影响冠状动脉旁路移植术手术死亡的危险因素分析

目的探讨影响我国冠状动脉旁路移植术(coronary artery bypass grafting,CABG)手术死亡的危险因素。方法选择北京阜外心血管病医院2002年1月1日至2003年12月31日(以手术日期为准)行CABG的冠心病患者2251例,确定潜在危险因素后,根据潜在危险因素从其临床资料中收集数据,对影响手术死亡的潜在危险因素进行单因素分析和logistic多因素回归分析,最终确立影响我国CABG手术死亡的危险因素,并对分析结果的校准度和分辨能力进行检验。结果全组手术死亡率为1.87%(42/2251),手术时年龄60.3±9.3岁,女性436例(19.4%)。logistic多因素回归分析结果:心源性休克、心律失常、左主干病变>50%、左心室射血分数(LVEF)、二尖瓣反流、肺动脉瓣反流、术前最后一次肌酐值、手术状态(非择期手术)、合并主动脉瘤手术等9个因素是本组CABG手术死亡的独立危险因素。受试者工作特征(Receiver-Operating Characteristic,ROC)曲线检验结果:曲线下面积为0.842。结论通过logistic多因素回归分析得出,心源性休克、心律失常、左主干病变>50%、LVEF、二尖瓣反流、肺动脉瓣反流、术前最后一次肌酐值、手术状态(非择期手术)、合并主动脉瘤手术等9个影响我国患者CABG手术死亡的危险因素。分析结果具有良好的校准度和分辨能力。     

冠状动脉旁路移植术后早期死亡的危险因素分析

目的 总结并分析冠状动脉旁路移植术(CABG)患者的特点和术后早期死亡的相关危险因素.方法 收集2005年1月至2007年12月接受CABG的全部310例患者的资料,并选择22个备选的死亡危险因素进行统计分析,其中术前指标15项,术中、术后指标7项.结果 单因素分析显示12项危险因素与CABG术后早期死亡相关,包括年龄、糖尿病、神经系统功能障碍、陈旧性心肌梗死、急性心肌梗死、射血分数、左主干病变、三支严重病变、急诊手术、转流时间、心肌阻断时间及术后机械通气时间.逐步Logistic回归分析显示CABG术后早期死亡的独市危险因素为:急诊手术、射血分数、年龄、转流时间和机械通气时间.结论 急诊手术、射血分数、年龄、转流时间和机械通气时间是本组CABG患者术后早期死亡的独立危险因素.     

心瓣膜置换术同期行冠状动脉旁路移植术患者长期预后的危险因素探讨

目的 探讨影响心瓣膜置换术同期行冠状动脉旁路移植术(CABG)患者长期预后的危险因素.方法 57例同期行心脏瓣膜置换术和冠状动脉旁路移植术的患者,同行CABG和主动脉手术13例,同行CABG和双瓣膜手术16例,同行CABG和二尖瓣手术28例;移植血管(1.97±1.36)支.通过随访获取数据,对潜在危险因素先用Cox比例风险模型进行单变量分析,再将有统计学意义(P＜0.05)的危险因素纳入Cox多变量回归.结果 失访2例,随访55例,平均随访时间(57.37±13.98)个月,随访期间共7例死亡;高龄(年龄＞70岁)、术前合并糖尿病、有心肌梗死史、慢性肺疾病和左心室射血分数≤40％为影响心瓣膜置换术和CABG同行患者长期预后的独立危险因素.结论 高龄、术前合并糖尿病、有心肌梗死史、有慢性肺疾病和左心室射血分数过低(≤40％)是影响两类手术同行患者长期预后的危险因素.     

低射血分数患者接受非体外循环冠状动脉旁路移植术的长期预后分析

目的总结低左心室射血分数(≤40%)冠心病患者行非体外循环冠状动脉旁路移植术(OPCAB)的手术疗效及预后相关因素。方法回顾性分析2001～2004年在北京大学人民医院行OPCAB的低射血分数患者顺利出院63例的随访临床资料,男48例,女15例;平均年龄(65.1±9.2)岁,左心室射血分数为33.8%±5.0%,对其长期随访,使用Kaplan-Meier法绘制生存曲线,采用单因素对数秩检验(log-rank test)和Cox回归模型分析影响患者长期预后的危险因素。结果随访时间3～107(71.3±24.4)个月,失访6例(9.5%)。随访期内死亡19例(30.2%),其中与心脏相关死亡10例(15.9%)。术后1年、3年、5年、8年的生存率分别为96.7%(61)、94.9%(60)、85.9%(55)、77.2%(53)。单因素分析表明,左心室射血分数≤30%、急性心肌梗死<30 d(急性心肌梗死发生30 d内即接受手术)是影响患者远期生存率的潜在危险因素(P<0.05)。Cox回归分析表明,左心室射血分数≤30%(RR=4.662,P<0.05)及心肌梗死<30 d(RR=5.544,P<0.05)是择期OPCAB患者术后发生心脏相关死亡的独立危险因素。结论低左心室射血分数冠心病患者行OPCAB治疗效果良好。左心室射血分数≤30%及急性心肌梗死<30 d是择期OPCAB患者术后发生心脏相关死亡的独立危险因素。     

糖尿病患者非心脏手术围术期心血管事件危险因素分析

目的 探讨糖尿病患者非心脏手术围术期心血管事件的危险因素.方法 择期行非心脏手术的糖尿病患者358例,记录术中、术后恶性心律失常、心肌缺血、不稳定性心绞痛、心肌梗死、心衰[射血分数(EF)＜50％]等心血管事件,根据有无发生心血管事件分为心血管事件组和无心血管事件组,比较两组年龄、血糖、血脂、血压等,并进行多因素非条件Logistic回归分析.结果 发生心血管事件组代谢紊乱情况明显,术前合并有冠心病、高血压,年龄、心衰、微量白蛋白尿增高、糖化血红蛋白增高的发生率均高于无心血管事件组,以上危险因素均与心血管事件发生呈正相关性(P＜0.05).结论 年龄、糖尿病合并症(冠心病、心衰、肾病)是非心脏手术围术期心血管事件的主要危险因素.     

大左心室心脏瓣膜病心瓣膜置换术后疗效及危险因素分析

目的探讨大左心室心脏瓣膜病心瓣膜置换术后疗效及危险因素,以提高手术疗效。方法回顾性分析2009年1月至2012年12月期间华中科技大学同济医学院附属协和医院144例大左心室心脏瓣膜病患者行心瓣膜置换术的临床资料,其中男116例、女28例,年龄15~69（44.9±11.9）岁;病程1个月~40年,平均病程（57.8±98.3）个月。风湿性心脏瓣膜病92例,退行性心脏瓣膜病28例,先天性心脏瓣膜病15例,感染性心内膜炎9例。对存活出院的137例患者进行随访,用t检验、卡方检验或Fisher′s精确概率法及logistic回归分析,探讨大左心室心脏瓣膜病患者行心瓣膜置换术后早期住院死亡、主要并发症发生及远期死亡的危险因素。采用寿命表生存率法计算术后远期生存率,并绘制生存曲线。结果术后早期主要并发症为低心排血量综合征19例（13.2%）,室性心律失常56例（38.9%）,人工瓣膜瓣周漏7例（4.9%）,胸腔积液33例（22.9%）,心包积液8例（5.6%）,肝功能不全23例（16.0%）,肾功能不全5例（3.5%）。术后早期住院死亡7例,死亡率4.9%。Logistic单因素分析显示：年龄〉50岁、风湿性心脏瓣膜病、术前心功能分级（NYHA）高（Ⅲ级或Ⅳ级）、病程长、术前左心功能低下[左心室射血分数（LVEF）〈40%]、双瓣膜置换术、合并其他心脏手术、体外循环及主动脉阻断时间长、术后低心排血量综合征和术后室性心律失常是大左心室心脏瓣膜病患者心瓣膜置换术后早期住院死亡的危险因素（P〈0.05）;Logistic多因素回归分析结果显示：年龄〉50岁、病程时间长、术前心功能分级（NYHA）高（Ⅳ级）、术前左心功能低下（LVEF〈40%）、双瓣膜置换术、体外循环时间长是术后早期住院死亡的危险因素（P〈0.05）。Logistic多因素回归分析结果显示：术前心功能分级（NYHA）高（Ⅲ级或Ⅳ级）、合并其他心脏手术、术前左心?     

冠状动脉手术前药物治疗:硝酸盐独立的预示死亡,β-受体阻滞剂预示存活

目的在于探讨冠脉搭桥(CABG)手术病人术前药物治疗与术后住院期间死亡率是否有关联。 病人包括行CABG术或同时行心脏或心血管手术者。术前心脏治疗药物持续至术日晨。在芬太尼、安氟醚全麻及低温体外循环下完成手术。术后连续监测ECG,不再常规用抗心绞痛药,抗高血压药则随病情确定。收集有关围术期死亡率危险因素的资料,根据室壁运动对左心室功能障碍分级:正常和轻、中、重度损害,     

心脏瓣膜置换术合并冠脉搭桥术的危险因素分析

目的分析影响心脏瓣膜置换术(HVR)合并冠脉搭桥术(CABG)患者预后的危险因素。方法 HVR合并CABG患者86例,分析患者术后近、中期的存活率、死亡率及并发症发生情况,比较术前、术后1周及术后3个月的心功能指标,包括左心房内径(LAD)、左心室舒张末径(LVEDD)、左心室射血分数(LVEF)、肺动脉压(PAP);对影响患者预后的相关因素进行Logistic单因素及多因素回归分析。结果院内病死率为4.65%(4/86),其中多器官衰竭2例,室颤1例,低心排综合征1例;除死亡患者外,存活率为95.35%(82/86),术后3个月随访82例患者,随访率为95.35%,平均随访时间(2.60±0.30)个月;严重并发症发生率为5.81%(5/86);随访期间,无死亡患者,患者术后心功能改善,术后1周和术后3个月患者的LAD、LVEDD及PAP与术前比较,均有明显改善(P0.05),而术后LVEF值与术前比较有所下降,但差异无统计学意义。Logistic单因素回归分析表明,年龄、心功能、瓣膜脓肿、移植血管桥数量、术后低心排、营养状态及IVEF是影响患者预后的危险因素;Logistic多因素回归分析显示,高龄、心功能NYHA分级(Ⅲ或Ⅳ级)、移植血管桥数量及术后低心排是影响患者预后的独立危险因素。结论 HVR合并CABG疗效确切,可改善患者的心功能;术后近、中期影响患者预后的危险因素具有多样性,高龄、心功能NYHA分级(Ⅲ或Ⅳ级)、移植血管桥数量、术后低心排及肺动脉高压是术后死亡或严重并发症发生的独立危险因素。     

心脏瓣膜置换手术死亡风险模型与体外膜肺氧合代替体外循环的适应证探讨

目的 建立心脏瓣膜病术前评估的死亡风险模型,并对手术病人进行评估,对体外膜肺氧合(ECMO)代体外循环的适应证进行初步探讨.方法 对4482例心脏瓣膜置换手术病人进行回顾性分析,选取性别,年龄,术前左心室射血分数(EF)、左心室舒张末径、肺动脉压、肾功能和是否合并冠心病7个临床指标作为住院死亡的可能影响因素.利用单因素分析进行筛选,用多因素Logistic回归确立死亡风险模型.根据模型,对此后的瓣膜病病人术前进行死亡风险评估,死亡概率≥10%的病例,随机分别给予常规手术或ECMO代替体外循环、术后转为心肺辅助.比较两种方法的手术病死率.采用SPSS11.5统计软件进行检验(α=0.05).结果 单因素分析除性别之外,其余6个因素均有统计学意义.Logistic回归建立死亡风险模型为Ln(P/1-P)=-4.3742+0.5192肾功能+0.1467年龄+0.3947EF+0.9390冠心病+0.5888肺动脉压+0.3287左室舒末径.此后常规手术52例,ECMO代体外循环术后转心肺辅助22例,两组性别、年龄、预计病死率构成比差异无统计学意义.两组预计病死率分别为(16.35±4.3)%和(16.21±5.19)%,差异无统计学意义(P<0.05).实际病死率分别为30.76%(16/52例)和9.09%(2/22例),差异有统计学意义(Pearson Chi-Square,P=0.047).结论 心脏瓣膜置换术前死亡风险评估,高龄、左心室低EF值、左室舒张末径过大或过小、肺动脉高压、肾功能不良、合并冠心病是危险因素,可以计算预计确切死亡概率.利用心脏瓣膜病死亡风险模型,对高风险(10%以上)病人进行ECMO代体外循环、术后转为心肺辅助,有利于降低手术病死率.     

老年髋部骨折患者术后心血管并发症的危险因素分析

目的探讨老年髋部骨折患者住院期间术后新发心血管并发症的危险因素。方法回顾性分析本院骨科2005年1月至2015年12月收治的髋部骨折患者693例,男257例,女436例,年龄65~103岁,BMI 16.5~33.1 kg/m2,ASAⅡ~Ⅳ级,分别收集患者的人口学资料、术前合并症、卧床时间、手术方式、麻醉方法、手术时间和出血量,采用多因素Logistic回归模型分析老年髋部骨折患者住院期间术后新发心血管并发症的危险因素。结果 46例患者(6.64%)在住院期间发生术后心血管并发症,包括心绞痛25例(3.61%)、心律失常19例(2.74%)、心力衰竭5例(0.72%)、心肌梗死4例(0.58%)和心源性猝死2例(0.29%)。单因素分析显示,年龄、心脏疾病、脑血管疾病、高血压、糖尿病、肾功能不全和全麻方式是老年髋部骨折患者住院期间新发术后心血管并发症的相关危险因素(P0.05)。多因素Logistic回归分析显示年龄(OR=1.11,95%CI 1.06~1.17,P0.001)、心脏疾病(OR=1.98,95%CI 1.02~3.85,P=0.045)、脑血管疾病(OR=2.14,95%CI 1.06~4.32,P=0.033)、高血压(OR=2.61,95%CI 1.23~5.51,P=0.012)、糖尿病(OR=2.06,95%CI 1.04~4.09,P=0.039)和肾功能不全(OR=17.42,95%CI 3.69~82.80,P0.001)是髋部骨折患者住院期间术后新发心血管并发症的独立危险因素。结论年龄、心脏疾病、脑血管疾病、高血压、糖尿病和肾功能不全可作为老年髋部骨折患者住院期间新发心血管并发症的预警因素。     

Coronary artery bypass grafting in patients with dialysis-dependent renal failure

This study identified preoperative characteristics of dialysis patients undergoing coronary artery bypass grafting (CABG) and determined the early and long-term results. We retrospectively analyzed the data of 60 patients (mean age 60.8 +/- 7.6 years) with end-stage renal disease who underwent CABG between 1982 and 1999. Seventeen (28%) patients underwent CABG for unstable angina, and 9 (15%) patients required preoperative intraaortic balloon pumping. The incidence of congestive heart failure (18%) and diseased aorta (42%) was higher in the dialysis group. In-hospital mortality in the dialysis group was 13% (8/60). The estimated survival rate at 5 and 10 years in the dialysis patients was 55.6 +/- 8.8% and 31.8 +/- 11.6%, respectively. The cardiac event-free rate, excluding the in-hospital mortality, was 62.5 +/- 9.9% at 5 years. Although the early and long-term results of CABG in dialysis patients were inferior to those of nondialysis patients, CABG in dialysis-dependent patients allows the patients to continue their dialysis therapy and to improve their functional status.     

冠状动脉旁路移植术后ICU监护时间延长的危险因素

目的 分析冠状动脉旁路移植术后ICU监护时间延长的危险因素.方法 1997年至2009年间单纯冠状动脉旁路移植术病人1318例,按ICU监护时间分2组,ICU监护时间≤72 h l113例,ICU监护时间＞72 h 205例.对两组病人术前多项指标进行单因素和多因素分析.结果 病人平均年龄(67.4±9.4)岁,男996例(75.6%),女322例(24.4%),两组病人的ICU监护时间分别为(40.1±22.5)h和(122.6±48.7)h,院内死亡分别占13.7%和1.2%.单因素分析显示,2组病人体外循环手术的比例、体外循环时间和阻断时间、远端吻合口数、术后升压药应用、呼吸机辅助时间和院内死亡方面差异有统计学意义.年龄、心功能(NYHA分级)Ⅲ～Ⅳ级,术前左室射血分数(LVEF)＜0.40、术前肾功能不全、脑血管和(或)周围血管病、慢性阻塞性肺疾病、近期心肌梗死、介入治疗病史、左主干和三支病变是ICU监护时间延长的危险因素.多因素分析显示,年龄、心功能(NYHA分级)Ⅲ～Ⅳ级的比例、LVEF、术前肾功能不全、慢性阻塞性肺疾病、近期心肌梗死、PCI病史和三支病变是ICU监护时间延长的危险因素.结论 LVEF＜0.40、近期心肌梗死、术前肾功能不全和慢性阻塞性肺疾病是术后ICU监护时问延长的主要高危因素.

Abstract：

Objective To describe the preoperative factors of prolonged intensive care unit length of stay after coronary artery bypass grafting. Methods From 1997 to 2009, 1318 patients underwent isolated CABG in our hospital. Retrospective analysis was performed on these cases. Univariate and multivariate analyses for preoperative risk factors were performed. Prolonged length of ICU stay was defined as initial admission to ICU exceeding 72 h. Results The mean age of patients ( 322women and 996 men) was (67.4±9.4) years. Of 1318 patients undergoing isolated CABG from 1997 to 2009, 205 experienced prolonged length of ICU stay. The length of ICU stay was (40.1 ± 22.5 ) hours and ( 122.6 ± 48.7 ) hours separately.Overall in-hospital mortality was higher among these 205 patients ( 13.7% vs. 1.2%, P ＜0.05 ). The overall mortality was 3.1%. In univariate analyses, there were statistically significant differences with respect to the percentage of CPB, total bypass time, cross-clamp time, number of distal anastomoses, use of pressor agent, use of intro-aortic balloon pump,time of ventilation and hospital mortality. The significant risk factors were age, NYHA class Ⅲ/Ⅳ, left ventricular ejection fraction(LVEF) ＜0.40, renal failure, cerebrovascular and/or peripheral vascular disease, chronic obstructive pulmonary disease, recent acute myocardial infarction, prior percutaneous coronary intervention, left main stenosi, three-vessels disease. The variables entered into the multivariate logistic regression were age, NYHA class Ⅲ/Ⅳ, LVEF ＜0.40, renal failure, chronic obstructive pulmonary disease, recent acute myocardial infarction, prior percutaneous coronary intervention, three-vessels disease. According to the outcome of multivariate logistic regression, we can conclude the model of probability forecast and create a new variable named Pre. The area under ROC curve of the new variable Pre was larger than other variables. Conclusion The main risk factors of prolonged ICU length of stay were LVEF ＜ 0.40, recent acute myocardial infarction, renal failure and chronic obstructive pulmorary disease. The AUC of variable Pre was higher than other' s , which indicated that new variable Pre combining each variable was more valuable than single variable with respect to prediction. A predicted probability of 0. 754 was used as cut-off point for the prognostic test.     

Determinants of stroke after coronary artery bypass grafting.

OBJECTIVES: Cerebrovascular accidents (CVA) after CABG are deleterious complications whose prevention remains poorly defined. The aim of this study was to identify the determinants for CVA after CABG. METHODS: Nine thousand nine hundred and sixteen patients underwent CABG at our institution from January 1992 to June 2002. Data were prospectively collected and univariate/multivariate analyses conducted. RESULTS: Two hundred and eight patients (2.1%) suffered perioperative CVA. Univariate analysis showed a higher risk profile in the CVA group including advanced age, depressed percent left ventricular ejection fraction (LVEF), unstable angina, diabetes mellitus (DM), chronic renal failure (CRF), redo surgery, peripheral vascular disease (PVD), previous CVA, and higher Parsonnet score (P<0.001). Furthermore, the CVA group had longer myocardial ischemia (CVA 56.2 +/-40.9 vs. Control 50.4+/-20.9 min, P=0.03) and cardiopulmonary bypass (CPB) times (CVA 87.4+/-30.0 min vs. Control 78.9 +/-25.9 min, P<0.0001), and lower off-pump surgery rate (CVA 1.4% vs. Control 4.7%, P=0.01). Multivariable analysis identified seven preoperative and two perioperative determinants for CVA: LVEF<30% (odds ratio (OR)=2.49), previous CVA (OR=2.15), DM (OR=1.78), redo (OR=1.76), PVD (OR=1.66), CRF (OR=1.55), age (OR=1.03), perioperative intra-aortic balloon pump (OR=1.83), and transfusion rate (OR=1.59). Perioperative mortality was higher in the CVA group (CVA 18.6% vs. Control 2.6%, P<0.0001). CONCLUSIONS: Although occurrence of CVA seems mainly related to preoperative comorbidities, perioperative surgical variables, such as off-pump surgery, myocardial ischemia and cardiopulmonary bypass time, do not seem to independently influence CVA rate after CABG. In this regard CVA prevention should be performed before posing an indication to CABG, and closer evaluation of patients' risk profiles and tailored clinical/surgical strategies for those patients at higher risk for CVA occurrence should be included.     

Predictors of stroke in the modern era of coronary artery bypass grafting: a case control study

BACKGROUND: Stroke is a rare but devastating complication after coronary artery bypass grafting (CABG) and its prevention remains elusive. We used a case control design to investigate the extent to which preoperative and perioperative factors were associated with occurrence of stroke in a cohort of consecutive patients undergoing myocardial revascularization. METHODS: From April 1996 to March 2001, data from 4,077 patients undergoing CABG were prospectively entered into a database. The association of preoperative and perioperative factors with stroke was investigated by univariate analyses. Factors observed to be significantly associated with stroke in these analyses were further investigated using multiple logistic regression to estimate the strength of the associations with the occurrence of stroke, after taking account of the other factors. RESULTS: During the study period, 4,077 patients underwent CABG and of these 923 (22.6%) had off-pump surgery. Forty-five patients suffered a perioperative stroke (1.1%). Overall there were 46 in-hospital deaths (1.1%), of whom 6 also suffered a stroke. Brain imaging of the stroke patients showed embolic lesions in 58%, watershed in 28%, and mixed in 14%. Multivariate regression analysis identified several preoperative factors as independent predictors of stroke, ie, age, unstable angina, serum creatinine greater than 150 mcg/ml, previous cerebrovascular accident (CVA), peripheral vascular disease (PVD), and salvage operation. When operative risk factors were added to the adjusted model, off-pump surgery was associated with a substantial, but not significant, protective effect against stroke (odds ratio = 0.56, 95% confidence interval 0.20 to 1.55). Survival for stroke patients was 93% and 78% at 1 and 5 years, respectively. CONCLUSIONS: Overall incidence of stroke is relatively low in our series. Age, unstable angina, previous CVA, PVD, serum creatinine greater than 150 mcg/ml, and salvage operation are independent predictors of stroke. These factors should be taken into account when informing each individual patient on the possible risk of stroke and in the decision-making process on the surgical strategy.     

Preoperative prediction of prolonged mechanical ventilation following coronary artery bypass grafting.

OBJECTIVE: Few studies have attempted to evaluate who would require prolonged mechanical ventilation following heart surgery. The objectives of this study were to identify predictors of prolonged ventilation in a large group of coronary artery bypass grafting (CABG) patients from a single institution. METHODS: One thousand, eight hundred and twenty-nine consecutive patients undergoing CABG were reviewed retrospectively and evaluated for preoperative predictors of prolonged ventilation which included: age, gender, ejection fraction (EF), renal function, diabetes, angina status, New York Heart Association Class, number of diseased vessels, urgency of the procedure, re-operation, chronic lung disease (COPD) and intraoperative variables such as IABP, inotropes, stroke and myocardial infarction. Prolonged ventilation was defined as > or = 24 h. Stepwise logistic regression analysis was performed. RESULTS: Patients were on average 65.4+/-10.6 years of age, 30% were diabetic, 80% had triple vessel disease and 93% were of functional class III/IV. The mean ejection fraction was 60+/-16 percent. Overall peri-operative mortality was 2.7%. There were 157 patients that required prolonged ventilation with a peri-operative mortality of 18.5% (P < 0.001). Preoperative independent predictors of prolonged ventilation were found to be: unstable angina (OR 5.6), EF < 50 (OR 2.3), COPD (OR 2.0), preop. renal failure (OR 1.9), female gender (OR 1.8) and age > 70 (OR 1.7). Based on these predictors, a model was created to estimate of the risk of prolonged ventilation in individual patients following CABG with results ranging from < or = 3% in patients without any risk factors to > or = 32% in patients with five or more independent risk factors.Certain intraoperative variables were strong predictors of prolonged ventilation and included: stroke (OR 12.3), re-operation for bleeding (OR 6.9) and perioperative MI (OR 5.8). CONCLUSION: We were able to create a stable model where several preoperative and intra-operative variables were shown to be predictive of prolonged ventilation after CABG surgery. The ability to identify patients at increased risk for prolonged ventilation may allow the development of pre-emptive strategies and more effective resource allocation.     

SinoSCORE对CABG术后死亡和并发症的预测价值

目的 评价中国冠状动脉旁路移植手术风险评估系统(SinoSCORE)对冠状动脉旁路移植(CABG)手术术后院内死亡及术后并发症的预测价值.方法 回顾性收集2007年1月至2008年12月期间行单纯CABG 手术的201例病人的围术期资料.应用 SinoSCORE模型(包含11个危险因素)预测术后院内病死率和主要并发症(胸部切口感染、肾衰、多肌器衰竭、围术期使用主动脉内球囊反搏等).评价其的校准度与分辨力评价模型的预测能力.Hosmer-Lemeshow拟合优度检验评价模型校准度,利用ROC曲线下面积评价模型的区分度,并用Youden指数确定SinoSCORE预测术后并发症的最佳诊断界值.结果 201例病人平均年龄(63.3±9.2)岁,其中24.4%(49/201例)为女性,总体院内病死率1.99%(4/201例).SinoSCORE模型预测病死率2.88%.SinoSCORE对术后院内死亡的发生有较好的校准度和区分度,Hosmer-Lemeshow拟合优度检验P=0.744(x2=4.304),ROC曲线下面积为0.81(95%置信区间0.687～0.932).SinoSCORE对术后肾衰、多脏器衰竭及围术期使用主动脉内球囊反搏(IABP)有较好的预测价值,Hosmer-Lemeshow拟合优度检验分别为P=0.75、P=0.75、P=1.00,ROC曲线下面积分别为0.768、0.832、0.737.SinoSCORE对上述3种并发症最佳诊断界值均为4.5.结论 SinoSCORE模型对CABG病人术后院内死亡和并发症具有较好的预测价值,适用于中国CABG手术风险的预测.

Abstract：

Objective To evaluate the performance of the Sino System for Coronary Operative Risk Evaluation ( SinoSCORE) on in-hospital mortality and postoperative complications in patients undergoing coronary artery bypass grafting (CABG) in a single heart center. Methods From January 2007 to December 2008, clinical information of 201 consecutive patients undergoing isolated CABG in our hospital was collected. The SinoSCORE was used to predict hospital mortality and major complications[sternal wound infection, postoperative renal failure, multiple organ dysfunction syndrome, perioperative intra-aortic balloon pumps ( IABP), etc.]after CABG among our study participants, which was initially designed as CBAG operative risk scoring system and included 11 risk factors. We estimated the predictable capability of SinoORE model by the means of analysing the calibration and discrimination characters of this risk scoring system. Calibration was evaluated with the method of Hosmer-Lemeshow goodness-of-fit test. Discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. The optimal cut-off point for SinoSCORE predicting major complications was obtained by the Youden index. Results Of all our study patients, the observed in-hospital mortality was 1.99% (4/201). The overall mean baseline age was ( 63.3 ± 9.2 ) years and 24.4% ( 49/201 ) were female. The predicted mortality cakulated by the SinoSCORE was 2.88% which was slightly higher than the actual mortality. SinoSCORE model slwed very high discriminatory ability and the good calibration power in predicting in-hospital mortality: Hosmer-Lemeshow calibration test:x2 =4. 304, P =0.744 and area under ROC was 0. 81 (95% CI: 0.687 -0.932). As for the major postoperative complications after CABG,SinoSCORE model still achieved a satisfactory performance with the good predictive value for the main complications risk evaluation such as postoperative renal failure, multiple organ dysfunction syndrome and IABP. Hosmer-Lemeshow: P =0.75, P =0. 75, P = 1.00; Areas under ROC respectively at was 0. 768 ( 95 % CI: 0.613 - 0. 924 ). 0. 832 ( 95 % CI: 0. 732 - 0. 932 )and 0. 737 (95% CI: 0. 607 -0. 867 ). The optimal cut-off points for SinoSCORE model predicting each of the above three major postoperative complications was ultimately determined to be 4.5. Conclusion In our patient database, the SinoSCORE model proved a good preoperative risk model in predicting both in-hospital mortality and major complications after CABG, which provides a realistic estimation of hospital death and post-operative complications risk for patients undergoing CABG. Sinoscore model is a suitable operative risk estimation system for Chinese CABG patients.     

Using biomarkers to improve the preoperative prediction of death in coronary artery bypass graft patients

The current risk prediction models for mortality following coronary artery bypass graft (CABG) surgery have been developed on patient and disease characteristics alone. Improvements to these models potentially may be made through the analysis of biomarkers of unmeasured risk. We hypothesize that preoperative biomarkers reflecting myocardial damage, inflammation, and metabolic dysfunction are associated with an increased risk of mortality following CABG surgery and the use of biomarkers associated with these injuries will improve the Northern New England (NNE) CABG mortality risk prediction model. We prospectively followed 1731 isolated CABG patients with preoperative blood collection at eight medical centers in Northern New England for a nested case-control study from 2003-2007. Preoperative blood samples were drawn at the center and then stored at a central facility. Frozen serum was analyzed at a central laboratory on an Elecsys 2010, at the same time for Cardiac Troponin T, N-Terminal pro-Brain Natriuretic Peptide, high sensitivity C-Reactive Protein, and blood glucose. We compared the strength of the prediction model for mortality using multivariable logistic regression, goodness of fit and tested the equality of the receiving operating characteristic curve (ROC) area. There were 33 cases (dead at discharge) and 66 randomly matched controls (alive at discharge).The ROC for the preoperative mortality model was improved from .83 (95% confidence interval: .74-.92) to .87 (95% confidence interval: .80-.94) with biomarkers (p-value for equality of ROC areas .09). The addition of biomarkers to the NNE preoperative risk prediction model did not significantly improve the prediction of mortality over patient and disease characteristics alone. The added measurement of multiple biomarkers outside of preoperative risk factors may be an unnecessary use of health care resources with little added benefit for predicting in-hospital mortality.     

Mortality risk factors in chronic renal failure patients after coronary artery bypass grafting

Perioperative risk during coronary artery bypass grafting (CABG) is high in patients with chronic renal disease. We aimed to determine postoperative two-year mortality and identify the preoperative risk factors of mortality during CABG surgery in hemodialysis (HD)-dependent and HD-non-dependent CRF patients. We included 102 CRF patients who underwent CABG in Baskent University Hospital between 2000 and 2005. There were 47 patients with CRF undergoing HD (Group I) and 55 CRF patients without dialysis requirement (Group II). We retrospectively retrieved demographic variables; clinical, operative, and echocardiographic data; and biochemical parameters at the time of the operation and six months postoperation. Postoperative HD requirement in Group II patients and infectious complications were recorded. In the second postoperative year, mortality rate was 27.7% in group I and 16.4% in group II (p > .05). When preoperative risk factors evaluated by univariate Cox analysis, only age (RR = 1.06, p = .04) was a significant determinant of survival in Group I patients. Among the operative and postoperative risk factors of mortality such as duration of operation, numbers of coronary vessel bypass, HD requirement, and infection were investigated in Group I and II patients. Rate of infectious complication (including mediastinitis) was found to be a major determinant of mortality by multivariate Cox analyses in both group I (RR = 4.42, p 相似文献   

Gender and mortality risk on the waiting list for coronary artery bypass grafting.

OBJECTIVE: There are gender differences in clinical presentation, treatment and outcome of patients with coronary artery disease. We investigated whether there is also a gender difference in terms of mortality risk on the waiting list in patients accepted for coronary artery bypass grafting (CABG). METHODS: All our patients accepted for elective CABG 1995-1999 (1303 women and 4561 men) were included. Prospectively registered preoperative characteristics and mortality were compared between men and women. Hazard functions for death on the waiting list were calculated using Poisson regression. RESULTS: At acceptance, women were older (68+/-9 vs 65+/-9 years, P<0.001), had a higher Cleveland risk score (2.4+/-1.8 vs 1.8+/-1.8, P<0.001) and a better left ventricular ejection fraction (60+/-14 vs 57+/-14%, P<0.001). More women had unstable angina pectoris (33 vs 20%, P<0.001), diabetes mellitus (23 vs 17%, P<0.001), chronic obstructive pulmonary disease (8 vs 5%, P<0.001), hypertension (47 vs 37%, P<0.001) and planned concomitant aortic valve surgery (13 vs 4%, P<0.001) while more men had three vessel disease (70 vs 66%, P=0.001). Median waiting time (55 vs 54 days, P=0.19) and unadjusted mortality (1.4 vs 1.0%, P=0.25) on the waiting list did not differ significantly between men and women but in a multivariate hazard analysis, female gender was associated with a lower risk than men of death on the waiting list (risk ratio 0.42, 95% confidence interval 0.19-0.93, P=0.032). CONCLUSIONS: Women have a lower risk of death on the waiting list for CABG, in spite of more advanced age, more co-morbidity, and a higher percentage of unstable angina pectoris.     

Outcome of non-elective coronary artery bypass grafting without cardio-pulmonary bypass.

OBJECTIVES: There is limited experience in the use of beating heart coronary artery bypass grafting (CABG) in emergency and urgent cases. The aim of this study was to retrospectively assess the safety and efficacy of this technique when used in a non-elective setting. METHODS: We retrospectively reviewed all urgent and emergency cases of coronary artery bypass grafting performed without cardiopulmonary bypass (CPB) from July 1999 to February 2000. There were 35 patients in total. The mean age was 64.8+/-11.9. Twenty-six (74.3%) patients had Canadian Cardiovascular Society grade 4 angina. Twenty-six patients (74.3%) had triple vessel disease. Eleven patients (31.4%) were on preoperative IV nitrates and nine patients (25.7%) had a preoperative IABP (intra aortic balloon pump). Three patients (8.6%) had suffered a preoperative cardiac arrest during coronary angiography. Other associated significant risk factors were smoking (60%), hypertension (40%), hypercholesterolemia (57.1%) and previous Q wave myocardial infarction (31.4%). RESULTS: Twenty-two patients (62.9%) were classified as being urgent and 13 patients (37.1%) were classified as emergencies. The mean number of anastomoses performed were 2.8+/-0.8 (range 1-4) with 68.6% of patients under going triple or quadruple vessel grafting. All patients (100%) received at least one arterial graft. There was no conversion to cardiopulmonary bypass. The main postoperative complications were--supraventricular arrhythmias eight (22.9%), low cardiac output seven (20%) and postoperative HF/dialysis two (5.7%). The median postoperative intensive care unit (ICU) stay was 27.5 h. The mean postoperative hospital stay was 8.3+/-3.1 days.One patient died (2.9%) at the eighth day after surgery due to postoperative myocardial infarction, multi-organ failure secondary to the septicaemia and ventricular arrest. CONCLUSION: Non-elective CABG without CPB is feasible and safe with modern cardiac stabilization devices.