老年冠状动脉钙化患者冠状动脉旋磨术中并发症及术后短期主要不良心血管事件的影响因素.pdf

临床研究老年冠状动脉钙化患者冠状动脉旋磨术中并发症及术后短期主要不良心血管事件的影响因素周杨1,李超1,梁丽2(宜宾市第三人民医院:1心血管内科,2胸外普外科,四川 宜宾 644000)【摘 要】目的 探讨老年冠状动脉钙化(CAC)患者冠状动脉旋磨(RA)术中并发症及术后短期(12 个月内)主要不良心血管事件(MACE)的影响因素。方法 收集 2017 年 1 月至 2020 年 12 月于宜宾市第三人民医院行 RA 的老年 CAC 患者 188 例,参照冠状动脉内旋磨术中国专家共识进行手术,随访术后 12 个月内 MACE 发生情况,按照 12 个月内是否发生 MACE 分为试验组和对照组。采用 SPSS 25.0 软件进行统计分析。根据数据类型组间比较采用 t 检验或2检验。采用多因素 logistic 回归分析术中并发症和术后12 个月内 MACE 的影响因素。结果 术中并发症和术后12 个月内 MACE 的发生率分别为17.02%(32/188)和 18.62%(35/188),发生术中并发症组和未发生术中并发症组患者体质量指数、吸烟史、心力衰竭史、高血压史、既往心肌梗死史、病变血管、SYNTAX 评分、凝血酶原时间、糖化血红蛋白(HbA1c)、最小管腔直径(MLD)、管腔横切面积和旋磨头血管内径比比较,差异均有统计学意义(P0.05)。多因素分析显示:心力衰竭史、病变血管(双支、三支、左主干支相对于单支)、SYNTAX 评分、MLD 及旋磨头血管内径比是术中并发症的影响因素OR=0.518,(1.660、2.311 和 3.089),3.893,0.794,0.641;均 P 0.05;术后 12 个月 MACE 的影响因素有心力衰竭史、高血压史、SYNTAX 评分、HbA1c 和 MLD(OR=0.481,0.812,2.777,0.762,0.721;均 P0.05)。结论 旋磨术中并发症可能与患者心力衰竭史、病变血管、SYNTAX 评分、MLD 及旋磨头血管内径比有关,而心力衰竭史、高血压史、SYNTAX 评分、HbA1c 和 MLD 则可能是术后短期发生 MACE 的独立预测因素。【关键词】冠状动脉旋磨术;冠状动脉钙化;并发症;主要不良心血管事件;影响因素【中图分类号】R543.3;R541.4 【文献标志码】A 【DOI】10.11915/j.issn.1671-5403.2023.10.156收稿日期:2023-02-15;接受日期:2023-03-22基金项目:四川省卫健委科研项目(18PJ549)通信作者:梁丽,E-mail:5161711 Influencing factors of intraoperative complications and short-term postoperative major adverse cardiovascular events in rotational atherectomy among elderly patients with coronary artery calcificationZhou Yang1,Li Chao1,Liang Li2(1Department of Cardiology,2Department of Extrathoracic General Surgery,Third Peoples Hospital of Yibin,Yibin 644000,Sichuan Province,China)【Abstract】Objective To explore the influencing factors of intraoperative complications and short-term postoperative major adverse cardiovascular events(MACE)in rotational atherectomy(RA)among the elderly patients with coronary artery calcification(CAC).Methods From January 2017 to December 2020,188 elderly CAC patients who underwent RA in the Third Peoples Hospital of Yibin were collected.The operation was performed according to the Chinese Expert Consensus on Rotational Atherectomy.The patients were followed up for MACEs for 12 months after operation and were divided into study group and control group based on the occurrence of MACEs within 12 months.SPSS 25.0 was used for statistical analysis.Comparison between groups was made using t-test or chi-square test according to the data type.Multivariate logistic regression was used to analyze the influencing factors of the intraoperative complica-tions and postoperative MACE within 12 months.Results The incidence was 17.02%(32/188)for the intraoperative complications and 18.62%(35/188)for MACE within 12 months after the operation.There were statistically significant differences between MACE and non-MACE patients in body mass index,history of smoking,history of heart failure,history of hypertension,history of previous myocardial infarction,diseased vessels,SYNTAX score,prothrombin time,glycosylated hemoglobin A1c(HbA1c),minimum lumen diameter(MLD),cross section area(CSA),and ratio of rotary burr to vessel diameter(P0.05 for all).Multivariate analysis showed that the history of heart failure,angiopathic vessels(double,triple vessels and left main branch compared with single vessel),737中华老年多器官疾病杂志 2023年10月28日 第22卷 第10期 Chin J Mult Organ Dis Elderly,Vol.22,No.10,Oct 28,2023SYNTAX score,MLD,and ratio of rotary burr to vessel diameter were the influencing factors of intraoperative complicationsOR=0.518,(1.660,2.311 and 3.089),3.893,0.794,0.641;all P0.05.The influencing factors of MACE within 12 months after operation were the history of heart failure,history of hypertension,SYNTAX score,HbA1c and MLD(OR=0.481,0.812,2.777,0.762,0.721;all P180;(3)冠状动脉狭窄程度级及以上;(4)患者知情同意。排除标准:(1)支架内再狭窄;(2)急性完全闭塞及其他 PCI 禁忌证;(3)凝血功能异常。本研究经宜宾市第三人民医院医学伦理委员会审批通过(2019YBLL009)。1.2 方法1.2.1 手术方法按照中国经皮冠状动脉介入治疗指南(2016)6做好 PCI 基本术前准备,常规服用抗血小板凝集药物,术中采用 RotablatorTM冠状动脉内旋磨仪(美国波士顿科学公司)根据血管内超声(intravascular ultrasound imaging,IVUS)测得不同冠状动脉内径选择旋磨头、入路和指引导管(旋磨头直径1.75 mm 则通过股动脉入路,指引导管用 7F 或 8F),旋磨转速 150000180000 转/min,单次时长 1520s,两次旋磨间隔 3060s,术中采用肝素钠(80100 U/kg)抗凝治疗,旋磨完成后根据造影和 IVUS 结果选择合适的球囊进行扩张,扩张完成后按常规 PCI 方法植入雷帕霉素药物洗脱支架,再次 IVUS 观察管腔及扩张情况。以上手术均由经验丰富的高年资医师按指南操作完成。1.2.2 影响因素收集入院后收集患者一般情况年龄、性别、体质量指数(body mass index,BMI)等、既往史(吸烟、饮酒)、家族史(高脂血症、高血压、冠心病等家族史)、疾病史(心力衰竭、糖尿病、高血压、高尿酸血症、血脂异常、周围血管病及脑卒中等)、既往手术史(PCI 及冠状动脉旁路移植术等)、术前检查(生化检查指标、IVUS 指标及心功能指标)和手术过程(旋磨头大小的选择、旋磨头与血管内径比、扩张球囊种类等),登记术前、术中及术后抗凝药物使用情况。1.2.3 研究终点事件(1)术中并发症,包括房室传导阻滞(度)、严重心动过缓(40 次/min)、旋磨头嵌顿、低血压收缩压90 mmHg(1 mmHg=0.133kPa)或舒张压60 mmHg、冠状动脉夹层或穿孔、支架贴壁不良、血管穿孔和慢血流/无复流(溶栓后血流分级2 级)。以发生术中并发症为并发症组,未发生并发症为非并发症组。(2)术后12 个月内 MACE,包括新发严重心律失常、再发心绞痛、再发心力衰竭、再次血运重建、支架内狭窄、心肌梗死和心源性死亡。以 12 个月内发生 MACE 为试验组,以未发生 MACE 为对照组。1.3 统计学处理 采用 SPSS 25.0 统计软件进行数据分析。符合正态分布的计量资料用均数标准差(xs)表示,采用t 检验;计数资料用例数(百分率)表示,采用2检验。837中华老年多器官疾病杂志 2023年10月28日 第22卷 第10期 Chin J Mult Organ Dis Elderly,Vol.22,No.10,Oct 28,2023根据是否发生研究终点事件将研究对象分为 2 组,按病例对照研究设计方案比较组间影响因素的差异,将有意义的影响因素采用前进法进一步行多因素logistic 回归分析。P0.05 为差异有统计学意义。2 结 果2.1 终点事件发生情况 术中并发症总发生 32 例,发生率为 17.02%,其中房室传导阻滞 3 例、严重心动过缓 2 例、旋磨头嵌顿 4 例、低血压 3 例、冠状动脉夹层或穿孔 3 例、支架贴壁不良 7 例、慢血流/无复流 9 例、血管穿孔1 例。术后 12 个月内 MACE 发生 35 例,发生率为18.62%,其中新发严重心律失常 3 例、再发心绞痛5 例、再发心力衰竭 2 例、再次血运重建 13 例、支架内狭窄 8 例、心肌梗死 3 例和心源性死亡 1 例。2.2 术中并发症影响因素的单因素分析 并发症组患者 32 例,非并发症组患者 156 例。2 组患者 BMI、吸烟史、心力衰竭史、高血压史、既往心肌梗死史、病变血管、SYNTAX 评分、凝血酶原时间(prothrombin time,PT)、糖化血红蛋白(glycosy-lated hemoglobin A1c,HbA1c)、最小管腔直径(mini-mum lumen diameter,MLD)、管腔横切面积(cross section area,CSA)和旋磨头血管内径比比较,差异均有统计学意义(均 P0.05);其余指标比较,差异均无统计学意义(表 1)。2.3 术中并发症影响因素的多因素分析 用前进法行多因素 logistic 回归分析,结果发现:心力衰竭史、病变血管、SYNTAX 评分、MLD 及旋磨头血管内径比是 RA 术中并发症的影响因素(均 P0.05;表 2)。2.4 术后 12 个月 MACE 影响因素的单因素分析 12 个月内发生 MACE 患者 35 例(试验组),未发生 MACE 的患者 153 例(对照组)。2 组 BMI、吸烟史、心力衰竭史、糖尿病史、高血压史等 12 项指标比较,差异均有统计学意义(均 P0.05;表 3)。2.5 术后 12 个月 MACE 影响因素的二元 logisitic回归分析 多因素 logistic 回归显示:心力衰竭史、高血压史、SYNTAX 评分、HbA1c 和 MLD 是术后 12 个月发生 MACE 的影响因素(均 P0.05;表 4)。表 1 术中并发症影响因素的单因素分析Table 1 Analysis of influencing factors of intraoperative complicationsFactorComplication group(n=32)Non-complication group(n=156)t/2P valueBMI(kg/m2,xs)24.832.1723.792.242.4050.017History of smokingn(%)16(50.00)44(28.21)5.8050.022History of heart failuren(%)12(37.50)20(12.82)11.4510.003History of diabetes mellitusn(%)20(62.50)70(44.87)3.3070.082History of hypertensionn(%)23(71.88)71(45.51)7.3810.011History of acute coronary syndromen(%)6(18.75)14(8.97)2.6690.117History of hyperlipidemian(%)13(40.63)39(25.00)3.2400.084History of miocardial infarctionn(%)7(21.88)9(5.77)8.8460.008History of PCIn(%)3(6.25)4(2.56)3.4360.097History of CABGn(%)4(12.50)6(3.85)3.9480.069Angiopathyn(%)9.0100.029 Single12(37.50)86(55.13)Double9(28.14)45(28.85)Triple7(21.88)21(13.46)Left main branch4(12.50)4(2.56)Target vesseln(%)0.2960.862 Left anterior descending branch17(53.13)91(58.33)Right coronary artery10(31.24)43(27.56)Left circumflex branch5(15.63)22(14.11)SYNTAX score(points,xs)27.53.025.63.33.0110.003PT(s,xs)14.063.0312.493.572.3210.021HbA1c(%,xs)7.100.946.530.773.6680.001MLD(mm,xs)1.280.091.350.103.6660.001CSA(mm2,xs)1.290.121.430.145.2710.001Ratio of rotary burr to vessel diameter(xs)0.640.080.600.072.8720.005Stenosis degree of target vessel lumen(%,xs)75.34.973.65.21.7010.091BMI:body mass index;PCI:percutaneous coronary intervention;CABG:coronary artery bypass grafting;PT:prothrombin time;HbA1c:glycosylated hemoglobin A1c;MLD:minimum lumen diameter;CSA:cross section area.937中华老年多器官疾病杂志 2023年10月28日 第22卷 第10期 Chin J Mult Organ Dis Elderly,Vol.22,No.10,Oct 28,2023表 2 术中并发症影响因素的二元 logistic 回归分析Table 2 Logistic regression of influencing factors of intraoperative complicationsFactorBSEWald2P valueOR(95%CI)History of heart failure-0.6580.17813.6650.0000.518(0.365-0.734)Angiopathy(compared with single vessel)Double0.5070.2215.2630.0171.660(1.077-2.560)Triple0.8370.3296.4720.0072.311(1.212-4.401)Left main branch1.1280.33211.5440.0003.089(1.612-5.922)SYNTAX score1.3590.4917.6610.0023.893(1.487-10.190)MLD-0.2310.0975.6710.0130.794(0.656-0.960)Ratio of rotary burr to vessel diameter-0.4450.13710.5510.0000.641(0.490-0.838)MLD:minimum lumen diameter.表 3 术后 12 个月内 MACE 影响因素的单因素分析Table 3 Analysis of influencing factors of MACE after operation for 12 monthsFactorStudy group(n=35)Control group(n=153)t/2P valueBMI(kg/m2,xs)24.762.3423.792.072.4400.016History of smokingn(%)17(48.57)40(26.14)6.7820.014History of heart failuren(%)13(37.14)19(12.42)12.3280.002History of diabetes mellitusn(%)23(65.71)67(43.79)5.4860.024History of hypertensionn(%)24(75.00)70(45.75)5.9330.024SYNTAX score(points,xs)27.43.125.63.03.1830.002PT(s,xs)14.013.1212.473.052.6830.008CK-MB(IU/L,xs)33.976.7631.486.232.0990.037HbA1c(%,xs)7.020.916.540.852.9740.003MLD(mm,xs)1.300.101.350.092.9030.004CSA(mm2,xs)1.310.141.430.125.1690.6 可能诱发血管夹层或穿孔。PCI 患者术后 MACE 与多种因素有关,本研究发现:心力衰竭史、高血压史、SYNTAX 评分、HbA1c和 MLD 是术后 12 个月内 MACE 的影响因素。高血压是手术并发症的独立危险因素,而心力衰竭和手术并发症则是患者住院期间 MACE 的影响因素17。Safarian 等18认为 SYNTAX 评分可作为预测 PCI 术后患者发生 MACE 的重要指标,韩风杰等19认为RA+切割球囊能获得更好的管腔直径,从而降低术后 2 年内 MACE 的发生,提示 MLD 与 MACE 有关,原因可能是因为更大的 MLD 能保证血流通畅及心脏血液供应,降低 MACE 的发生。本研究还发现高血压史和 HbA1c 是 12 个月内发生 MACE 的独立危险因素,高血压可能会损伤血管内皮,促进血栓形成,从而诱发心肌梗死、心力衰竭等不良心血管事件20。关于糖尿病在 PCI 术后 MACE 和临床结局方面的研究结论不太一致,国内相关研究中发现HbA1c7.0%是 PCI 术后 1 年内发生 MACE 的独立预测因素21,本研究结果与这些结论接近。综上,RA 是重度 CAC 介入治疗的重要手段,旋磨并发症可能与患者心力衰竭史、SYNTAX 评分、MLD 及旋磨头血管内径比有关,而心力衰竭史、高血压史、SYNTAX 评分、HbA1c 和 MLD 则可能是术后 12 个月内发生 MACE 的独立预测因素。【参考文献】1 Gallinoro E,Monizzi G,Candreva A,et al.Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsyJ.Int J Cardiol,2022,352:27-32.DOI:10.1016/j.ijcard.2022.01.066.2 Liang B,Gu N.High-speed rotational atherectomy in coronary artery calcification:the randomized ROTAXUS and PREPARE-CALC trialsJ.Catheter Cardiovasc Interv,2022,100(1):61-71.DOI:10.1002/ccd.30119.3 Rheude T,Fitzgerald S,Allali A,et 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