背景:心包切除术是缩窄性心包炎围手术期死亡的主要原因。我们调查了相关的风险因素和后果。
方法:我们选择了2013年1月至2021年1月接受孤立性心包切除术的缩窄性心包炎患者。术后低心输出量被定义为需要机械循环支持或一个以上的肌力剂以保持心脏指数>2.2L•min-1•m-2且无灌注不足。尽管有足够的填充状态。使用单变量和多变量分析来确定与低心输出量相关的因素。Cox回归用于确定与住院时间相关的因素。
结果:在具有完整数据的212例患者中,55(25.9%)在术后第1天(四分位数1和2)出现低心输出量,导致9例围手术期死亡中的7例。房性心律失常的发生率,肾功能不全,低蛋白血症,中度至重度低钠血症,缩窄性心包炎引起的高胆红素血症占9.4%,12.3%,49.1%,10.4%,和81.6%。术前平均中心静脉压和心脏指数为18±5cmH2O和1.87±0.45L•min-1•m-2。单变量分析显示低心输出量患者的房性心律失常发生率较高(OR3.32[1.35,8.17],P=0.007),肾功能不全(OR4.24[1.94,9.25],P<0.001),低蛋白血症(OR1.99[1.06,3.73],P=0.031)和低钠血症(OR6.36[2.50,16.20],P<0.001),E峰值速度变化更大(差2.8[0.7,5.0],P=0.011),较高的中心静脉压(差3[2,5]cmH2O,P<0.001)和较低的心脏指数(差异-0.27[-0.41,-0.14]L•min-1•m-2,P<0.001)。多因素回归分析显示房性心律失常(OR4.04[1.36,12.02],P=0.012),肾功能不全(OR2.64[1.07,6.50],P=0.035),低钠血症(OR3.49[1.19,10.24],P=0.023),中心静脉压高(OR1.17[1.08,1.27],P<0.001),和低心脏指数(OR0.36[0.14,0.92],P=0.032)与低心输出量相关(AUC0.79[0.72-0.86],P<0.001)。Cox回归分析显示高胆红素血症(HR0.66[0.46,0.94],P=0.022),肾功能不全(HR0.51[0.33,0.77],P=0.002),和低心输出量(HR0.42[0.29,0.59],P<0.001)与住院时间有关。
结论:低钠血症的早期识别和处理,肾功能不全,体液潴留,高胆红素血症可能对缩窄性心包炎患者心包切除术后获益。
BACKGROUND: Low cardiac output is the main cause of perioperative death after pericardiectomy for constrictive pericarditis. We investigated the associated risk factors and consequences.
METHODS: We selected constrictive pericarditis patients undergoing isolated pericardiectomy from January 2013 to January 2021. Postoperative low cardiac output was defined as requiring mechanical circulatory support or more than one inotrope to maintain a cardiac index > 2.2 L •min-1 •m-2 without hypoperfusion, despite adequate filling status. Uni- and multivariable analysis were used to identify factors associated with low cardiac output. Cox regression was used to identify factors associated with length of hospital stay.
RESULTS: Among 212 patients with complete data, 55 (25.9%) developed low cardiac output within postoperative day 1 (quartiles 1 and 2), which caused seven of the nine perioperative deaths. The rates of atrial arrhythmia, renal dysfunction, hypoalbuminemia, modest-to-severe hyponatremia, and hyperbilirubinemia caused by constrictive pericarditis were 9.4%, 12.3%, 49.1%, 10.4%, and 81.6%. The mean preoperative central venous pressure and cardiac index were 18 ± 5 cmH2O and 1.87 ± 0.45 L•min-1•m-2. Univariable analysis showed that low cardiac output patients had higher rates of atrial arrhythmia (OR 3.32 [1.35, 8.17], P = 0.007), renal dysfunction (OR 4.24 [1.94, 9.25], P < 0.001), hypoalbuminemia (OR 1.99 [1.06, 3.73], P = 0.031) and hyponatremia (OR 6.36 [2.50, 16.20], P < 0.001), greater E peak velocity variation (difference 2.8 [0.7, 5.0], P = 0.011), higher central venous pressure (difference 3 [2,5] cmH2O, P < 0.001) and lower cardiac index (difference - 0.27 [- 0.41, - 0.14] L•min-1•m-2, P < 0.001) than patients without low cardiac output. Multivariable regression showed that atrial arrhythmia (OR 4.04 [1.36, 12.02], P = 0.012), renal dysfunction (OR 2.64 [1.07, 6.50], P = 0.035), hyponatremia (OR 3.49 [1.19, 10.24], P = 0.023), high central venous pressure (OR 1.17 [1.08, 1.27], P < 0.001), and low cardiac index (OR 0.36 [0.14, 0.92], P = 0.032) were associated with low cardiac output (AUC 0.79 [0.72-0.86], P < 0.001). Cox regression analysis showed that hyperbilirubinemia (HR 0.66 [0.46, 0.94], P = 0.022), renal dysfunction (HR 0.51 [0.33, 0.77], P = 0.002), and low cardiac output (HR 0.42 [0.29, 0.59], P < 0.001) were associated with length of hospital stay.
CONCLUSIONS: Early recognition and management of hyponatremia, renal dysfunction, fluid retention, and hyperbilirubinemia may benefit constrictive pericarditis patients after pericardiectomy.