Stanford A型主动脉夹层院内死亡风险的简易床旁评估模型
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摘要
目的分析Stanford A型主动脉夹层风险因素为院内死亡风险,建立一个简单而有效的床旁风险评估模型。方法纳入2010年1月至2015年12月我院血管病中心收治的999例Stanford A型主动脉夹层患者,其中男745例、女254例,平均年龄(49.8±12.0)岁。急性夹层837例。在急诊科药物治疗或等待外科治疗的术前患者182例(18.22%),获外科手术治疗的817例(81.78%)。运用多因素回归模型确立院内死亡风险因素,并量化评分院内死亡的风险值用于预测每例患者的院内死亡率。结果总体院内死亡率25.93%。多因素逻辑回归分析中,以下独立变量增加了院内死亡率:增加的年龄[OR=1.04,95%CI(1.02,1.05),P<0.000 1],急性主动脉夹层[OR=2.49,95%CI(1.30,4.77),P=0.006 1],晕厥[OR=2.76,95%CI(1.15,6.60),P=0.022 8],下肢麻木/疼痛[OR=7.99,95%CI(2.71,23.52),P=0.000 2],De BakeyⅠ型[OR=1.72,95%CI(1.05,2.80),P=0.030 5],头壁血管受累[OR=2.25,95%CI(1.20,4.24),P=0.011 7],急性肝功能不全[OR=2.60,95%CI(1.46,4.64),P=0.001 2],白细胞总数>15×10~9个/L[OR=1.87,95%CI(1.21,2.89),P=0.004 9]以及中大量心包积液[OR=4.34,95%CI(2.45,7.69),P<0.000 1]。根据多因素分析结果建立一个简易有效的床旁风险评估模型。结论主动脉A型夹层患者的不同临床表现和影像学特征预示着院内死亡的风险程度。简易快捷的床旁风险评估能有效协助临床医师识别高风险患者。
Objective To investigate predictors for mortality among patients with Stanford type A acute aortic dissection(AAD) and to establish a predictive model to estimate risk of in-hospital mortality. Methods A total of 999 patients with Stanford type A AAD enrolled between 2010 and 2015 in our hospital were included for analysis. There were745 males and 254 females with a mean age of 49.8±12.0 years. There were 837 patients with acute dissection and 182 patients(18.22%) were preoperatively treated or waiting for surgery in the emergency department and 817(81.78%) were surgically treated. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality.Significant risk factors for in-hospital death were used to develop a prediction model. Results The overall in-hospital mortality was 25.93%. In the multivariable analysis, the following variables were associated with increased in-hospital mortality: increased age(OR=1.04, 95% CI 1.02 to 1.05, P<0.000 1), acute aortic dissection(OR=2.49, 95% CI 1.30 to 4.77,P=0.006 1), syncope(OR=2.76, 95% CI 1.15 to 6.60, P=0.022 8), lower limbs numbness/pain(OR=7.99, 95% CI 2.71 to23.52, P=0.000 2), type Ⅰ De Bakey dissection(OR=1.72, 95% CI 1.05 to 2.80, P=0.030 5), brachiocephalic vessels involvement(OR=2.25, 95% CI 1.20 to 4.24, P=0.011 7), acute liver insufficiency(OR=2.60, 95% CI 1.46 to 4.64, P=0.001 2),white blood cell count(WBC)>15×10~9 cells/L(OR=1.87, 95% CI 1.21 to 2.89, P=0.004 9) and massive pericardial effusion(OR=4.34, 95% CI 2.45 to 7.69, P<0.000 1). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed. Conclusion Different clinical manifestations and imaging features of patients with Stanford type A AAD predict the risk of in-hospital mortality. This model can be used to assist physicians to quickly identify high risk patients and to make reasonable treatment decisions.
Objective To investigate predictors for mortality among patients with Stanford type A acute aortic dissection(AAD) and to establish a predictive model to estimate risk of in-hospital mortality. Methods A total of 999 patients with Stanford type A AAD enrolled between 2010 and 2015 in our hospital were included for analysis. There were745 males and 254 females with a mean age of 49.8±12.0 years. There were 837 patients with acute dissection and 182 patients(18.22%) were preoperatively treated or waiting for surgery in the emergency department and 817(81.78%) were surgically treated. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality.Significant risk factors for in-hospital death were used to develop a prediction model. Results The overall in-hospital mortality was 25.93%. In the multivariable analysis, the following variables were associated with increased in-hospital mortality: increased age(OR=1.04, 95% CI 1.02 to 1.05, P<0.000 1), acute aortic dissection(OR=2.49, 95% CI 1.30 to 4.77,P=0.006 1), syncope(OR=2.76, 95% CI 1.15 to 6.60, P=0.022 8), lower limbs numbness/pain(OR=7.99, 95% CI 2.71 to23.52, P=0.000 2), type Ⅰ De Bakey dissection(OR=1.72, 95% CI 1.05 to 2.80, P=0.030 5), brachiocephalic vessels involvement(OR=2.25, 95% CI 1.20 to 4.24, P=0.011 7), acute liver insufficiency(OR=2.60, 95% CI 1.46 to 4.64, P=0.001 2),white blood cell count(WBC)>15×10~9 cells/L(OR=1.87, 95% CI 1.21 to 2.89, P=0.004 9) and massive pericardial effusion(OR=4.34, 95% CI 2.45 to 7.69, P<0.000 1). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed. Conclusion Different clinical manifestations and imaging features of patients with Stanford type A AAD predict the risk of in-hospital mortality. This model can be used to assist physicians to quickly identify high risk patients and to make reasonable treatment decisions.
引文
1Hagan PG,Nienaber CA,Isselbacher EM,et al.The International Registry of Acute Aortic Dissection(IRAD):new insights into an old disease.JAMA,2000,283(7):897-903.
2楚军民,卫金花,常谦,等.Stanford A型主动脉夹层术后死亡和严重并发症的危险因素.中国胸心血管外科临床杂志,2017,24(3):211-216.
3Pape LA,Awais M,Woznicki EM,et al.Presentation,diagnosis,and outcomes of acute aortic dissection:17-year trends from the international registry of acute aortic dissection.J Am Coll Cardiol,2015,66(4):350-358.
4Lee TC,Kon Z,Cheema FH,et al.Contemporary management and outcomes of acute type A aortic dissection:An analysis of the STSadult cardiac surgery database.J Card Surg,2018,33(1):7-18.
5Trimarchi S,Eagle KA,Nienaber CA,et al.Role of age in acute type A aortic dissection outcome:report from the International Registry of Acute Aortic Dissection(IRAD).J Thorac Cardiovasc Surg,2010,140(4):784-789.
6Geirsson A,Szeto WY,Pochettino A,et al.Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection:outcomes and need for additional revascularizations.Eur J Cardiothorac Surg,2007,32(2):255-262.
7Conzelmann LO,Weigang E,Mehlhorn U,et al.Mortality in patients with acute aortic dissection type A:analysis of pre-and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A(GERAADA).Eur J Cardiothorac Surg,2016,49(2):e44-e52.
8Lio A,NicolòF,Bovio E,et al.Total arch versus hemiarch replacement for type a acute aortic dissection:a single-center experience.Tex Heart Inst J,2016,43(6):488-495.
9Tolenaar JL,Froehlich W,Jonker FH,et al.Predicting in-hospital mortality in acute type B aortic dissection:evidence from International Registry of Acute Aortic Dissection.Circulation,2014,130(11 Suppl 1):S45-S50.
10Trimarchi S,Nienaber CA,Rampoldi V,et al.Contemporary results of surgery in acute type A aortic dissection:The International Registry of Acute Aortic Dissection experience.JThorac Cardiovasc Surg,2005,129(1):112-122.
11Rylski B,Hoffmann I,Beyersdorf F,et al.Acute aortic dissection type A:age-related management and outcomes reported in the German Registry for Acute Aortic Dissection Type A(GERAADA)of over 2000 patients.Ann Surg,2014,259(3):598-604.
12Di Eusanio M,Patel HJ,Nienaber CA,et al.Patients with type Aacute aortic dissection presenting with major brain injury:Should we operate on them?J Thorac Cardiovasc Surg,2013,145(3 Suppl):S213-S221.
13Rampoldi V,Trimarchi S,Eagle KA,et al.Simple risk models to predict surgical mortality in acute type A aortic dissection:the International Registry of Acute Aortic Dissection score.Ann Thorac Surg,2007,83(1):55-61.
14Mussa FF,Horton JD,Moridzadeh R,et al.Acute aortic dissection and intramural hematoma:a systematic review.JAMA,2016,316(7):754-763.
15Sun L,Qi R,Zhu J,et al.Total arch replacement combined with stented elephant trunk implantation:a new"standard"therapy for type a dissection involving repair of the aortic arch?Circulation,2011,123(9):971-978.
16Rylski B,Milewski RK,Bavaria JE,et al.Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection.J Thorac Cardiovasc Surg,2014,148(6):2981-2985.
17Pape LA,Tsai TT,Isselbacher EM,et al.Aortic diameter>5.5 cm is not a good predictor of type A aortic dissection observations from the International Registry of Acute Aortic Dissection(IRAD). Circulation,2007,116:1120-1127.
18Tieu BC,Lee C,Sun H,et al.An adventitial IL-6/MCP1 amplification loop accelerates macrophage-mediated vascular inflammation leading to aortic dissection in mice.J Clin Invest, 2009,119(12):3637-3651.
19Kurihara T,Shimizu-Hirota R,Shimoda M,et al.Neutrophil-derived matrix metalloproteinase 9 triggers acute aortic dissection.Circulation,2012,126(25):3070-3080.
2楚军民,卫金花,常谦,等.Stanford A型主动脉夹层术后死亡和严重并发症的危险因素.中国胸心血管外科临床杂志,2017,24(3):211-216.
3Pape LA,Awais M,Woznicki EM,et al.Presentation,diagnosis,and outcomes of acute aortic dissection:17-year trends from the international registry of acute aortic dissection.J Am Coll Cardiol,2015,66(4):350-358.
4Lee TC,Kon Z,Cheema FH,et al.Contemporary management and outcomes of acute type A aortic dissection:An analysis of the STSadult cardiac surgery database.J Card Surg,2018,33(1):7-18.
5Trimarchi S,Eagle KA,Nienaber CA,et al.Role of age in acute type A aortic dissection outcome:report from the International Registry of Acute Aortic Dissection(IRAD).J Thorac Cardiovasc Surg,2010,140(4):784-789.
6Geirsson A,Szeto WY,Pochettino A,et al.Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection:outcomes and need for additional revascularizations.Eur J Cardiothorac Surg,2007,32(2):255-262.
7Conzelmann LO,Weigang E,Mehlhorn U,et al.Mortality in patients with acute aortic dissection type A:analysis of pre-and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A(GERAADA).Eur J Cardiothorac Surg,2016,49(2):e44-e52.
8Lio A,NicolòF,Bovio E,et al.Total arch versus hemiarch replacement for type a acute aortic dissection:a single-center experience.Tex Heart Inst J,2016,43(6):488-495.
9Tolenaar JL,Froehlich W,Jonker FH,et al.Predicting in-hospital mortality in acute type B aortic dissection:evidence from International Registry of Acute Aortic Dissection.Circulation,2014,130(11 Suppl 1):S45-S50.
10Trimarchi S,Nienaber CA,Rampoldi V,et al.Contemporary results of surgery in acute type A aortic dissection:The International Registry of Acute Aortic Dissection experience.JThorac Cardiovasc Surg,2005,129(1):112-122.
11Rylski B,Hoffmann I,Beyersdorf F,et al.Acute aortic dissection type A:age-related management and outcomes reported in the German Registry for Acute Aortic Dissection Type A(GERAADA)of over 2000 patients.Ann Surg,2014,259(3):598-604.
12Di Eusanio M,Patel HJ,Nienaber CA,et al.Patients with type Aacute aortic dissection presenting with major brain injury:Should we operate on them?J Thorac Cardiovasc Surg,2013,145(3 Suppl):S213-S221.
13Rampoldi V,Trimarchi S,Eagle KA,et al.Simple risk models to predict surgical mortality in acute type A aortic dissection:the International Registry of Acute Aortic Dissection score.Ann Thorac Surg,2007,83(1):55-61.
14Mussa FF,Horton JD,Moridzadeh R,et al.Acute aortic dissection and intramural hematoma:a systematic review.JAMA,2016,316(7):754-763.
15Sun L,Qi R,Zhu J,et al.Total arch replacement combined with stented elephant trunk implantation:a new"standard"therapy for type a dissection involving repair of the aortic arch?Circulation,2011,123(9):971-978.
16Rylski B,Milewski RK,Bavaria JE,et al.Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection.J Thorac Cardiovasc Surg,2014,148(6):2981-2985.
17Pape LA,Tsai TT,Isselbacher EM,et al.Aortic diameter>5.5 cm is not a good predictor of type A aortic dissection observations from the International Registry of Acute Aortic Dissection(IRAD). Circulation,2007,116:1120-1127.
18Tieu BC,Lee C,Sun H,et al.An adventitial IL-6/MCP1 amplification loop accelerates macrophage-mediated vascular inflammation leading to aortic dissection in mice.J Clin Invest, 2009,119(12):3637-3651.
19Kurihara T,Shimizu-Hirota R,Shimoda M,et al.Neutrophil-derived matrix metalloproteinase 9 triggers acute aortic dissection.Circulation,2012,126(25):3070-3080.