EuroSCORE Ⅱ在心脏手术患者风险预测中的应用进展

介绍新版欧洲心脏手术风险评分系统EuroSCORE Ⅱ的发展及评估内容,从心脏手术患者术后死亡风险预测、手术后并发症及ICU住院时间预测方面综述其临床应用进展,并提出提高预测效能的针对性措施,旨在为心脏手术后患者制订预防性治疗和护理措施,减少术后并发症和病死率提供参考。     

欧洲心脏手术风险评估系统预测中国人心瓣膜手术后并发症的发生及预后

目的评估欧洲心脏手术风险评估系统(EuroSCORE)能否有效预测中国人心瓣膜手术后重症监护(ICU)时间延长、死亡以及主要并发症的发生。方法将2004年1月至2006年1月北京阜外心血管病医院连续收治的后天性心瓣膜病患者2 218例纳入研究,其中男1 047例,女1 171例;年龄49.26±11.10岁。所有患者均行心瓣膜手术。将EuroSCORE的logistic模型和additive模型应用于所有患者,评估两种方法预测心瓣膜手术后患者死亡I、CU时间延长以及重要并发症的发生。模型的区分能力采用受试者工作特征曲线(ROC曲线)评价,校正能力采用Hosmer-Lemeshow拟合优度检验评价。结果 EuroSCORE的logistic模型和additive模型预测术后死亡的ROC曲线面积分别为0.710和0.690,ICU时间延长为0.670和0.660,心力衰竭为0.650和0.640,呼吸功能衰竭为0.720和0.710,肾功能衰竭为0.700和0.740,二次开胸止血为0.540和0.550;其中肾功能衰竭和心力衰竭两种模型的ROC曲线下面积差异有统计学意义(P0.05)。EuroSCORE预测术后死亡、心力衰竭、肾功能衰竭、二次开胸止血以及ICU时间延长的Hosmer-Lemeshow拟合优度欠佳,但logistic模型预测术后呼吸功能衰竭的拟合优度良好(P=0.120)。结论 EuroSCORE预测中国人心瓣膜手术后死亡I、CU时间延长以及重要并发症发生的预测效果较差,但logistic模型可用来预测术后呼吸功能衰竭。     

不同心脏手术风险预测评分系统对中国冠状动脉旁路移植术后患者早期死亡的预测

目的 评价STS评分系统[the Society of Thoracic Surgeons(STS)2008 Cardiac Surgery Risk Models]、欧洲心脏手术风险评估系统(EuroSCORE)、Parsonnet评分系统和美国心脏病学院/美国心脏协会(American College of Car...     

高手术风险冠状动脉旁路移植术早期临床结果分析

目的采用心脏手术风险评估欧洲系统（European System for Cardiac Operative Risk Evaluation，EuroSCORE）评估高手术风险冠状动脉旁路移植术（CABG）患者的早期临床结果。方法将2004年2～9月在我科行CABG的84例患者按EuroSCORE评分分为高手术风险组（≥6,40例）和中低手术风险组（0～5,44例）；记录两组手术方案、术后并发症发生情况；在手术后应用急性生理学和慢性健康状况评分Ⅲ（APACHEⅢ）和序贯器官衰竭评估（SOFA）对患者进行危重症评估。分析比较两组患者早期临床结果。结果高手术风险组的手术死亡率、需长时间重症监护治疗比率、术后并发症发生率和危重程度均高于中低手术风险组。在总体水平上A0，A1，Amax和S1，Smax均与standard EuroSCORE（P〈0．01）和logistic EuroSCORE（P〈0．05）分别呈正相关；在不同风险度比较时，仅在高手术风险组中standard EuroSCORE与A1，Anax，S1和Smax呈正相关（P〈0．05）；logistic EuroSCORE仅与Amax相关（P〈0．05）。结论EuroSCORE系统在总体上能够很好地评估心脏手术风险，对高危患者更敏感。术前准确对患者状况进行评估，术中完善心肌保护、有效的心肌供血重建和彻底心内畸形矫正，术后及时正确的处理可以改善高手术风险患者的预后。     

术前心脏检测对冠心病非心脏手术并发症评估

心脏意外事件是非胸手术围手术期的主要死亡原因之一,现就当今国内外非胸手术前心脏风险评估的主要技术和方法作一综述,包括心电图Holter监测、运动心电图试验、潘生丁试验、左心射血分数测定、多巴酚丁胺超声心动图负荷试验、冠状动脉造影。     

美国克利夫兰大学急性肾衰竭风险评分系统在我国成人心脏手术患者中的应用

目的探讨美国克利夫兰大学急性肾衰竭风险评分系统(the Clinical Score to Predict Acute Renal Failure,简称Cleveland评分系统)预测中国心脏手术患者术后发生急性肾衰竭(ARF)行肾脏替代治疗(RRT)及患者院内死亡的应用价值。方法将2005年1月至2009年12月期间上海交通大学医学院附属仁济医院收治的所有成人心脏手术患者2 153例纳入研究,其中男1 267例,女886例;年龄58.70(18～99)岁。术前按Cleveland评分分值将所有患者分层:0～2分(n=979),3～5分(n=1 116),6～8分(n=54),9～13分(n=4),比较各组间术后发生ARF行RRT的发生率、多器官功能衰竭(MOSF)的发生率及病死率。应用受试者工作特征(ROC)曲线评价该评分预测术后发生ARF行RRT、患者院内死亡的准确性。结果 0～2分、3～5分、6～8分、9～13分组术后发生ARF行RRT的发生率分别为0.92%、1.88%、12.96%和25.00%(χ2=55.635,P=0.000),MOSF发生率分别为1.23%、1.88%、3.70%和25.00%(χ2=16.080,P=0.001),病死率分别为0.92%、4.21%、25.93%和50.00%(χ2=71.470,P=0.000),4组差异均有统计学意义。Cleveland评分预测术后行RRT的ROC曲线下面积(AUC)为0.775[95%CI(0.713,0.837),P=0.000],预测院内死亡AUC为0.764[95%CI(0.711,0.817),P=0.000]。结论 Cleveland评分系统可有效预测中国成人心脏手术后发生ARF需RRT治疗的风险,为及早对高危人群采取有效的预防措施提供依据。     

Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients

Objective: To assess risk factors for mortality in cardiac surgical adult patients as part of a study to develop a European System for Cardiac Operative Risk Evaluation (EuroSCORE). Methods: From September to November 1995, information on risk factors and mortality was collected for 19030 consecutive adult patients undergoing cardiac surgery under cardiopulmonary bypass in 128 surgical centres in eight European states. Data were collected for 68 preoperative and 29 operative risk factors proven or believed to influence hospital mortality. The relationship between risk factors and outcome was assessed by univariate and logistic regression analysis. Results: Mean age (± standard deviation) was 62.5±10.7 (range 17–94 years) and 28% were female. Mean body mass index was 26.3±3.9. The incidence of common risk factors was as follows: hypertension 43.6%, diabetes 16.7%, extracardiac arteriopathy 2.9%, chronic renal failure 3.5%, chronic pulmonary disease 3.9%, previous cardiac surgery 7.3% and impaired left ventricular function 31.4%. Isolated coronary surgery accounted for 63.6% of all procedures, and 29.8% of patients had valve operations. Overall hospital mortality was 4.8%. Coronary surgery mortality was 3.4% In the absence of any identifiable risk factors, mortality was 0.4% for coronary surgery, 1% for mitral valve surgery, 1.1% for aortic valve surgery and 0% for atrial septal defect repair. The following risk factors were associated with increased mortality: age (P=0.001), female gender (P=0.001), serum creatinine (P=0.001), extracardiac arteriopathy (P=0.001), chronic airway disease (P=0.006), severe neurological dysfunction (P=0.001), previous cardiac surgery (P=0.001), recent myocardial infarction (P=0.001), left ventricular ejection fraction (P=0.001), chronic congestive cardiac failure (P=0.001), pulmonary hypertension (P=0.001), active endocarditis (P=0.001), unstable angina (P=0.001), procedure urgency (P=0.001), critical preoperative condition (P=0.001) ventricular septal rupture (P=0.002), non-coronary surgery (P=0.001), thoracic aortic surgery (P=0.001). Conclusion: A number of risk factors contribute to cardiac surgical mortality in Europe. This information can be used to develop a risk stratification system for the prediction of hospital mortality and the assessment of quality of care.     

An adjusted EuroSCORE model for high-risk cardiac patients

Objective: To verify the accuracy and precision of the logistic European system for cardiac operative risk evaluation (EuroSCORE) in high-risk cardiac surgery patients and to develop and externally validate a new system of recalibration. Methods: The development series included 4279 high-risk patients who had undergone cardiac operations at the IRCCS Policlinico S. Donato. Performance, accuracy, and precision of the logistic EuroSCORE were assessed in this series, using a deciles-based comparison between expected and observed mortality rates, a receiver operating characteristic analysis, and a Hosmer–Lemeshow test for calibration. Differences between predicted and observed mortality rates were mathematically evaluated to develop an adjusted logistic EuroSCORE. This adjusted risk score was subsequently validated with the same approach on an external series of 1459 high-risk patients who had undergone cardiac operations at the Siena hospital. Results: The adjusted logistic EuroSCORE was based on five different correction factors applied to the crude logistic EuroSCORE depending on its value. At the external validation, this model provided a good performance, with observed mortality rates not significantly different from the expected in 8 out of 10 deciles of risk distribution. The adjusted EuroSCORE had the same moderate balanced accuracy of the crude logistic EuroSCORE (area under the curve: 0.695), with a better precision (Hosmer–Lemeshow calibration test: χ²: 3.6, p = 0.891). Conclusions: Recalibration of the logistic EuroSCORE in high-risk patients is needed due to its tendency to overestimate the mortality risk. The application of a variable correction factor results in a better performance, increased precision, with unaltered balanced accuracy.     

糖尿病肾脏病维持性血液透析患者心脏瓣膜钙化易发因素分析

目的通过检测糖尿病肾脏病(diabetic kidney disease,DKD)患者心脏瓣膜钙化(cardiac valve calcifieation,CVC)情况,对其相关因素进行分析,探讨DKD的易发因素。方法选择2013年1月至2015年12月在我院血液净化中心行维持性血液透析的患者118例,其中DKD患者57例(DKD组),非DKD患者61例(非DKD组),观察2组吸烟比率及年龄有无统计学差异,完善超声心动图、血压、血三酰甘油、血钙、血磷、C反应蛋白、血白蛋白的检测,比较2组之间有无差异,并对DKD组透析时间、血磷、C反应蛋白进行单因素分析。结果 DKD组发生瓣膜钙化44例(占77.2%),非DKD组发生瓣膜钙化24例(占39.3%),2组比较差异有统计学意义(P0.01)。2组患者中单纯主动脉瓣钙化共24例(占20.3%),DKD组17例(占29.8%),非DKD组7例(占11.4%);单纯二尖瓣膜钙化17例(占14.4%),DKD组10例(占17.5%),非DKD组7例(占11.4%);主动脉瓣加二尖瓣同时钙化27例(占22.9%),DKD组17例(占29.8%),非DKD组10例(占16.4%)。2组患者吸烟比率比较差异无统计学意义(P=0.89),2组年龄比较无统计学差异。2组收缩压、舒张压、透析时间、血钙、血磷、钙磷乘积、血三酰甘油比较,差异有统计学意义(P0.05);DKD组收缩压高于非DKD组,舒张压低于非DKD组,透析时间明显短于非DKD组;DKD组血钙、血磷、钙磷乘积明显低于非DKD组,血三酰甘油、C反应蛋白均高于非DKD组,体质量指数、血白蛋白无统计学差异。DKD组CVC的危险因素结果提示透析时间、血磷升高是发生CVC的主要危险因素。结论血钙、钙磷乘积不是DKD瓣膜钙化的预测因子,血磷、血脂、透析时间等是影响瓣膜钙化的独立危险因素。     

Simultaneous operation for cardiac disease and gastrointestinal malignancy

AIM: To investigate the safety of performing simulta-neous cardiac surgery and a resection of a gastrointes-tinal malignancy. METHODS: Among 3664 elective cardiac operations performed in adults at Kagoshima University Hospi-tal from January 1991 to October 2009, this study reviewed the clinical records of the patients who un-derwent concomitant cardiac surgery and a gastroin-testinal resection. Such simultaneous surgeries were performed in 15 patients between January 1991 and October 2009. The cardiac diseases included 8 cases of coronary artery disease and 7 cases with valvular heart disease. Gastrointestinal malignancies included 11 gas-tric and 4 colon cancers. Immediate postoperative andlong-term outcomes were evaluated. RESULTS: Postoperative complications occurred in 5 patients(33.3%), including strokes(n = 1), respiratory failure requiring re-intubation(n = 1), hemorrhage(n = 2), hyperbilirubinemia(n = 1) and aspiration pneu-monia(n = 1). There was 1 hospital death caused by the development of adult respiratory distress syndrome after postoperative surgical bleeding followed aortic valve replacement plus gastrectomy. There was no car-diovascular event in the patients during the follow-up period. The cumulative survival rate for all patients was 69.2% at 5 years. CONCLUSION: Simultaneous procedures are accept-able for the patients who require surgery for both car-diac diseases and gastrointestinal malignancy. In par-ticular, the combination of a standard cardiac operation, such as coronary artery bypass grafting or an isolated valve replacement and simple gastrointestinal resection, such as gastrectomy or colectomy can therefore be safely performed.     

EuroSCORE和SinoSCORE在预测成人心脏病术后死亡率中的应用回顾和展望

随着现心血管外科中高危病人的比例明显增加。心血管外科医师需要量化的评估体系对患者围手术期危险性进行术前评估。目前国际影响较大的风险预测模型是欧洲心血管手术危险因素评分系统（European system for cardiac operative risk evaluation,EuroSCORE）。中国心血管外科注册登记研究的数据表明,EuroSCORE不能很好地预测我国心血管外科患者的手术风险。因此,中国心血管外科注册登记研究协作组应用最新的心血管外科病例数据建立我国首个冠状动脉旁路移植手术风险评估系统（Sinosystem for coronary operative risk evaluation,SinoSCORE）,目前正广泛应用于临床。我们结合文献对EuroSCORE和 SinoSCORE两个指标在预测成人心脏病术后死亡率中的应用进行回顾和展望。     

169例动脉调转手术治疗大动脉转位的早、中期结果

目的 探讨大动脉调转手术(ASO)治疗完全性大动脉转位(TGA)的早、中期结果,分析其随访死亡、术后主动脉瓣反流及肺动脉狭窄的危险因素.方法 2004年1月至2007年12月,169例行动脉调转术病儿入选,其中男129例,女40例,平均年龄(11.7±26.3)个月.病儿分两组:Ⅰ组为室间隔完整组(56例),Ⅱ组为室间隔缺损组(113例).所有术后生存病儿均进行超声随访,平均随访时间(27.7±14.6)个月.危险因素采用Logistic回归模型分析.结果 全组住院死亡19例(11.24%),两组间差异无统计学意义.随着整体治疗水平的提高,住院病死率由2004年的16.67%下降到2007年的3.92%.1、3及5年生存率分别为94.00%、91.33%及91.33%,两组间差异无统计学意义.Logistic回归分析发现,ASO术后随访死亡的危险因素为手术年龄大于6个月;术后主动脉瓣反流的危险因素为合并室间隔缺损、年龄大于6个月、术后新主动脉瓣Z值>1;术后肺动脉狭窄的危险因素为手术年龄小于1个月和肺动脉采用补片成形.结论 ASO手术具有良好的早、中期结果,是治疗完全性大动脉转位的理想术式.TGA病儿应该尽早手术治疗,手术年龄大于6个月是随访死亡及主动脉瓣反流的重要危险因素;新主动脉根部与主动脉远端不匹配是术后主动脉瓣反流的危险因素;病儿的生长发育与肺动脉成形材料无生长特性的矛盾是导致术后肺动脉狭窄的危险因素.     

比较additive EuroSCORE,logistic EuroSCORE,EuroSCOREⅡ风险评分系统在评估中国心脏外科手术患者中的应用

【摘要】 目的 评价additive EuroSCORE,logistic EuroSCORE 及EuroSCOREⅡ风险评分系统在预测中国心脏外科患者行心脏手术住院死亡率准确性中的作用。方法 回顾性收集中山大学孙逸仙纪念医院心胸外科于2006年1月至2012年10月接受心脏手术的594例成人患者的临床资料,其中男348例,女246例;平均年龄57.59±14.27岁。分别按additive EuroSCORE,logistic EuroSCORE及 EuroSCOREⅡ计算每例患者的预测死亡率,按预测死亡率把患者分6组(Ⅰ组0~1.99%,Ⅱ组2%~3.99%,Ⅲ组4%~5.99%,Ⅳ组6%~7.99%,Ⅴ组8%~9.99%,Ⅵ组大于10%),比较每组实际住院死亡率与预测死亡率。预测模型的区分度使用受试者工作特征(receiver operating characteristic, ROC)曲线下面积进行检验,校准度使用Hosmer-Lemeshow拟和优度检验。结果 594例患者住院死亡31例,实际住院死亡率5.22%,additive EuroSCORE预测死亡率3.46%±2.62%,logistic EuroSCORE预测死亡率 3.61%±4.32%,EuroSCOREⅡ预测死亡率2.81%±4.26%。EuroSCOREⅡ低估了Ⅱ、Ⅳ、Ⅴ组住院死亡率,但在其余各组中均较好预测住院死亡率。EuroSCOREⅡ较additive/logistic EuroSCORE区分度好(AUC 0.727 vs. 0.704, 0.715),除logistic EuroSCORE的Hosmer-Lemeshow拟和优度检验(P<0.05)外其余两种方法校准度均较好(P>0.05)。结论 EuroSCOREⅡ评分系统较适用于预测本中心心脏手术患者的住院死亡风险。     

小儿心脏手术促红细胞生成素治疗和术前自体献血的临床研究

目的探讨促红细胞生成素和硫酸亚铁治疗用于小儿心脏手术的术前自体献血(AHT).方法观察组30例患儿术前3周连续用促红细胞生成素(EPO)治疗,每周3次皮下注射100 U/kg,并口服硫酸亚铁60 mg/d,采2次血备术中用;对照组按目前常规备血,监测红细胞(RBC),血红蛋白(Hb)、红细胞压积(Hct)、白细胞(WBC)和血小板(Plt).结果观察组28例输用自体血,其中3例输了同种血,对照组24例输同种血.结论小儿心脏手术采用促红细胞生成素治疗和AHT,降低了同种血暴露的危险.     

双调转术(Double-Switch手术)的临床应用

目的 探讨Double-Switch手术方法的临床应用。方法 采用Double-Switch手术方法纠治房室连接和心室大动脉连接不一致的复杂先天性心脏病病儿3例，其中1例为纠正型大血管错位、室间隔缺损、肺动脉狭窄伴轻度三尖瓣反流，2例为房室连接不一致、右心室双出口、肺动脉狭窄、室间隔缺损、三尖瓣轻一中度反流。心房内采用Senning术，心室内采用Rastelli术的方法，从解剖上彻底予以纠治。结果 手术均取得成功，恢复顺利，分别术后11d、18d和21d出院。术后随访心电图窦性节律，超声检查示心功能正常，腔静脉、肺静脉血流通畅，同种带瓣管道和心内隧道血流无梗阻。结论 对房室连接和心室大动脉连接不一致病例，特别是解剖右心室功能不全和三尖瓣反流者，应首选Double-Switch手术。