瓣膜置换术后心律失常危险因素分析

Risk Factors for Arrhythmia after Valve Replacement

摘要: 背景：目前瓣膜病已经成为严重危害人群健康的疾病，保守估计我国目前约2500万心脏瓣膜病患者。外科手术是解决病因的最佳途径。随着外科技术的日益发展，瓣膜病的外科治疗由20世纪70年代后期的闭式扩张分离术，至今，伴随着体外循环技术的发展，心脏停跳液的进步以及最重要的瓣膜的迭代，心脏瓣膜置换手术已然成为一项成熟的方式。不论是单个瓣膜的置换手术，还是联合瓣膜的手术，从手术数量以及死亡率来看，我国的瓣膜置换手术已然达到国际先进水平。然而，尽管目前心脏瓣膜置换手术技术越发成熟，手术死亡率显著降低。然而术后并发症的所带来的影响却不可忽视。心律失常是瓣膜置换手术最常见的并发症之一，轻者诸如房性早搏，还有大多数的心房颤动甚至可以自行转复，严重者诸如室性心动过速，室性颤动则是导致术后ICU住院时间延长，预后差，甚至是早期死亡的重要原因之一。目的：本研究的目的是通过比较正中开胸直视下瓣膜置换术术后发生心律失常与未发生心律失常的患者的相关指标，探讨能提示或导致术后心律失常危险因素，减少患者心律失常术后发生率。方法：回顾性分析194名自2021年1月1日起于我院行心脏瓣膜置换手术的患者(男80，女114)，按照是否发生瓣膜置换术后的心律失常，将其分为实验组(发生心律失常患者，80例，男37，女47，平均年龄63.0岁)及对照组(未发生心律失常患者，114例，男43，女67，平均年龄62.0岁)。比较两组临床资料，术后是否发生心律失常的单因素分析采用卡方检验以及秩和检验，而后对于P < 0.05的变量采用logistic回归模型进一步分析与术后心律失常的相关性。结果：心脏瓣膜置换术后新发心律失常80例，在本研究中，患者年龄、既往糖尿病史、高血压史、脑梗病史、既往开胸心脏手术史、术前肌酐、血钾、血镁、高敏肌钙蛋白、心超EF值、术前白蛋白、尿素氮、甘油三酯、乳酸，术中是否发生室颤、术后尿素氮、血镁、乳酸、血红蛋白值在实验组和对照组之间并无差异，而术前白细胞值(P = 0.025)、BMI (<0.001)、既往COPD史(0.036)、手术时间及主动脉夹闭时间(P < 0.001)、术后血钾(P < 0.001)、肌酐(P = 0.014)、术后白细胞(P = 0.019)在实验组与对照组之间差异具有统计学意义，为可能导致术后发生心率失常的危险因素。结论：术前注重把握手术适应症，对于术后心律失常高危患者尽早采取预防措施，术中注重患者心肌保护，减少不必要的手术操作，降低手术时间；术后关注患者生命体征及相关化验指标，及时进行抗炎治疗，注意维持患者电解质平衡，监护患者心律变化，及时处理病情。能有效改善患者心律失常发生率以及预后情况，降低手术死亡率。

Abstract: Background: At present, valvular disease has become a serious disease that endangers the health of the population, and it is conservatively estimated that there are currently about 25 million patients with valvular heart disease in China. Surgery is the best way to address the cause. With the increasing development of surgical technology, the surgical treatment of valvular disease has changed from closed dilation separation in the late 70s of the 20th century, and so far, with the development of cardiopulmonary bypass technology, the advancement of cardiac arrest fluid and the iteration of the most important valve, heart valve replacement surgery has become a mature method. Whether it is a single valve replacement surgery or a combined valve operation, from the perspective of the number of operations and mortality, China’s valve replacement surgery has reached the international advanced level. However, despite the current maturity of heart valve replacement surgery, surgical mortality has been significantly reduced. However, the impact of postoperative complications cannot be ignored. Arrhythmia is one of the most common complications of valve replacement surgery, mild such as atrial premature beats, and most atrial fibrillation can even be converted on its own, severe cases such as ventricular tachycardia, ventricular fibrillation is one of the important causes of prolonged postoperative ICU stay, poor prognosis, and even early death. Objective: The objective of this study is to reduce the incidence of arrhythmia in patients with arrhythmia after median open-eye valve replacement and patients without arrhythmia by comparing the relevant indicators of arrhythmia after median open-eye valve replacement with those without arrhythmia. Methods: A retrospective analysis was performed for 194 patients (80 males and 114 females) who underwent heart valve replacement surgery in our hospital since January 1, 2021, and they were divided into experimental group (80 patients with arrhythmia, 37 males, 47 females, average age 63.0 years) and control group (114 patients without arrhythmias, 43 males, 67 females, average age 62.0 years) according to whether arrhythmias occurred after valve replacement. The univariate analysis of whether arrhythmias occurred after surgery was compared between the two groups of clinical data, and the chi-square test and rank sum test were used for the variables with P < 0.05, and then the logistic regression model was used to further analyze the correlation with postoperative arrhythmias. Results: In this study, there were 80 new arrhythmias after heart valve replacement, and in this study, the age, previous diabetes history, hypertension history, cerebral infarction history, previous open heart surgery, preoperative creatinine, blood potassium, blood magnesium, high-sensitivity troponin, cardiac ultra-EF value, preoperative albumin, urea nitrogen, triglycerides, lactic acid, whether ventricular fibrillation, postoperative urea nitrogen, blood magnesium, lactic acid and hemoglobin values did not differ between the experimental and control groups, while the preoperative white blood cell value (P = 0.025), BMI (<0.001), previous COPD history (0.036), operation time and aortic clipping time (P < 0.001), postoperative potassium (P < 0.001), creatinine (P = 0.014), and postoperative leukocytes (P = 0.019) were statistically significant between the experimental and control groups, and were risk factors that may lead to arrhythmias after surgery. Conclusion: Preoperative attention should be paid to grasping the indications of surgery, preventive measures should be taken as soon as possible for patients at high risk of postoperative arrhythmia, and intraoperative attention should be paid to myocardial protection, so as to reduce unnecessary surgical operations and reduce the operation time. After surgery, pay attention to the patient’s vital signs and related laboratory indicators, timely carry out anti-inflammatory treatment, pay attention to maintaining the patient’s electrolyte balance, monitor the patient’s heart rhythm changes, and deal with the condition in time. It can effectively improve the incidence and prognosis of arrhythmia and reduce surgical mortality.