非体外循环冠状动脉旁路移植术后机械通气时间延长的危险因素及预后分析

目的分析影响非体外循环冠状动脉旁路移植术（OPCABG）后机械通气时间延长（PMV）的因素，以及PMV对患者预后的影响。 方法回顾性分析2013年6月至2018年12月在首都医科大学附属北京安贞医院接受OPCABG的1 097例患者。根据术后气管插管的时间，分为对照组（术后气管插管时间≤ 24 h，972例）和PMV组（术后气管插管时间> 24 h，125例）。比较两组患者术前、术中及术后的临床资料，采用多因素Logistic回归分析筛选影响患者PMV的相关因素，探讨PMV对接受OPCABG患者预后的影响。 结果对照组及PMV组患者间纽约心脏病协会（NYHA）分级（ χ² = 34.138，P < 0.001）及左室舒张功能分级（ χ² = 215.175，P < 0.001）比较，差异均有统计学意义。同时，与对照组比较，PMV组患者年龄[（62 ± 9）岁vs.（67 ± 9）岁，t = 6.618，P < 0.001]、手术时间[（4.0 ± 1.2）h vs.（5.9 ± 2.5）h，t = 8.246，P < 0.001]、移植桥血管数目[（2.8 ± 0.6）支vs.（3.2 ± 0.9）支，t = 4.769，P < 0.001]、冠状动脉内膜剥脱术（CE）[4.0%（39 / 972）vs. 20.8%（26 / 125），χ² = 55.998，P < 0.001]及左心室成形术（SVR）[2.3%（22 / 972）vs. 12.8%（16 / 125），χ² = 36.771，P < 0.001]发生率均显著升高，而左室射血分数（LVEF）[（58 ± 6）% vs.（47 ± 7）%，t = 18.006，P < 0.001]水平则显著降低。将年龄、NYHA分级、LVEF、左室舒张功能分级、手术时间、移植桥血管数目、CE和SVR纳入多因素Logistic回归分析，结果显示，年龄[比值比（OR）= 1.881，95%置信区间（CI）（1.399，2.529），P < 0.001]、NYHA分级[OR = 1.476，95%CI（1.220，1.785），P < 0.001]、左室舒张功能分级[OR = 2.866，95%CI（1.712，4.799），P < 0.001]、手术时间[OR = 1.599，95%CI（1.068，2.394），P = 0.003]和SVR [OR = 2.334，95%CI（1.196，4.554），P < 0.001]是接受OPCABG的患者术后发生PMV的独立危险因素，而LVEF [OR = 0.287，95%CI（0.189，0.436），P = 0.009]是其保护因素。PMV组患者术后心律失常[29.6% （37 / 125）vs. 14.7%（143 / 972），χ² = 17.898，P < 0.001]、肺部感染[10.4% （13 / 125）vs. 2.3%（22 / 972），χ² = 26.281，P < 0.001]、胸腔积液[12.8%（16 / 125）vs. 3.0%（29 / 972），χ² = 27.131，P < 0.001]、血清肌酐[（114 ± 37）μmol / L vs.（81 ± 27）μmol / L，t = 9.547，P < 0.001]、脑血管事件[10.4%（13 / 125）vs. 3.2%（31 / 972），χ² = 14.957，P = 0.001]、胃肠道事件[17.6%（22 / 125）vs. 4.0%（39 / 972），χ² = 38.939，P < 0.001]、住ICU时间[（43 ± 20）h vs.（13 ± 8）h，t = 16.187，P < 0.001]、术后住院时间[（11 ± 9）d vs.（6 ± 3）d，t = 5.937，P < 0.001]和30 d病死率[8.8%（11 / 125）vs. 0.9%（9 / 972），χ² = 38.365，P < 0.001]均显著高于对照组。 结论年龄、NYHA分级、LVEF、左室舒张功能分级、手术时间及同期行SVR是影响患者OPCABG术后PMV的相关因素。预防PMV的发生可减少术后多种并发症的发生、缩短住院时间、降低患者30 d病死率。

Risk factors and prognosis of prolonged mechanical ventilation after off-pump coronary artery bypass grafting

ObjectiveTo analyze factors influencing prolonged mechanical ventilation (PMV) after off-pump coronary artery bypass grafting (OPCABG) and its effect on the prognosis of patients. MethodsA retrospective analysis of 1 097 patients receiving OPCABG were collected at Beijing Anzhen Hospital, Capital Medical University from June 2013 to December 2018. According to their postoperative tracheal intubation time, patients were divided into a control group (postoperative tracheal intubation time ≤ 24 h, n = 972) and a PMV group (postoperative tracheal intubation time > 24 h, n = 125). The clinical data before, during, and after operation were compared in the two groups. Multivariate Logistic regression analysis was used to screen relevant factors for PMV; then the effect of PMV on the prognosis of patients receiving OPCABG was explored. ResultsThe New York Heart Association (NYHA) classification ( χ² = 34.138, P < 0.001) and left ventricular diastolic function grade ( χ² = 215.175, P < 0.001) in the control group and PMV group both showed significant differences. Compared with the control group, the age [(62 ± 9) years vs. (67 ± 9) years, t = 6.618, P < 0.001], operation time [(4.0 ± 1.2) h vs. (5.9 ± 2.5) h, t = 8.246, P < 0.001], number of graft vessels [(2.8 ± 0.6) branches vs. (3.2 ± 0.9) branches, t = 4.769, P < 0.001], coronary endarterectomy (CE) [4.0% (39 / 972) vs. 20.8% (26 / 125), χ² = 55.998, P < 0.001], and surgical ventricular restoration (SVR) [2.3% (22 / 972) vs. 12.8% (16 / 125), χ² = 36.771, P < 0.001] in the PMV group were significantly higher, while the left ventricular ejection fraction (LVEF) [(58 ± 6)% vs. (47 ± 7)%, t = 18.006, P < 0.001] was significantly lower. Then the age, NYHA classification, LVEF, left ventricular diastolic function grade, operation time, number of graft vessels, CE, and SVR were included in multivariate regression analysis. The results showed that the age [odds ratio (OR) = 1.881, 95% confidence interval (CI) (1.399, 2.529), P < 0.001], NYHA classification [OR = 1.476, 95%CI (1.220, 1.785), P < 0.001], left ventricular diastolic function grade [OR = 2.866, 95%CI (1.712, 4.799), P < 0.001], operation time [OR = 1.599, 95%CI (1.068, 2.394), P = 0.003], and SVR [OR = 2.334, 95%CI (1.196, 4.554), P < 0.001] were independent risk factors for postoperative PMV in patients receiving OPCABG, whereas LVEF [OR = 0.287, 95%CI (0.189, 0.436), P = 0.009] was a protective factor. The arrhythmia [29.6% (37 / 125) vs. 14.7% (143 / 972), χ² = 17.898, P < 0.001], pulmonary infection [10.4% (13 / 125) vs. 2.3% (22 / 972), χ² = 26.281, P < 0.001], pleural effusion [12.8% (16 / 125) vs. 3.0% (29 / 972), χ² = 27.131, P < 0.001], serum creatinine [(114 ± 37) μmol / L vs. (81 ± 27) μmol / L, t = 9.547, P < 0.001], cerebrovascular events [10.4% (13 / 125) vs. 3.2% (31 / 972), χ² = 14.957, P = 0.001], gastrointestinal events [17.6% (22 / 125) vs. 4.0% (39 / 972), χ² = 38.939, P < 0.001], ICU stay [(43 ± 20) h vs. (13 ± 8) h, t = 16.187, P < 0.001], hospital stay [(11 ± 9) d vs. (6 ± 3) d, t = 5.937, P < 0.001], and 30-d mortality [8.8% (11 / 125) vs. 0.9% (9 / 972), χ² = 38.365, P < 0.001] after operation in the PMV group were significantly higher than those in the control group. ConclusionsThe age, NYHA classification, LVEF, left ventricular diastolic function grade, operation time, and concurrent SVR are related factors for PMV in patients undergoing OPCABG. Prevention of PMV can reduce the occurrence of multiple postoperative complications, shorten the hospital stay, and decrease the 30-d mortality of patients.