【作者】 郭慧；

【导师】 谢立；

【作者基本信息】 中南大学 ， 临床医学（专业学位）， 2023， 硕士

【摘要】 背景:成人先天性心脏病(ACHD)人群近年来在心血管外科手术占比越来越多,心脏术后院内死亡是一种少见但极其严重的结局,成人先心病术前风险评分表的应用可以给患者围术期治疗和预后评估提供指导。目的:本研究的目的是评估围术期成人先心病评分表(PEACH score)预测单中心成人先心病术后死亡风险的准确性,排除不适用的风险因素,确定额外的危险因素,并通过调整后的预测模型预测本中心成人先心病手术后的院内死亡率。方法:回顾性分析中南大学湘雅二医院心脏大血管外科2019年01月至2022年12月在接受先天性心脏手术且≥18岁患者的围手术期临床资料。计算每位患者的风险变量衍生的PEACH评分,利用单因素回归分析调整风险因素内容,并通过计算受试者工作特征曲线下面积(AUC)和Hosmer-Lemeshow拟合优度检验评价调整前后风险模型对术后死亡率和常见并发症的预测能力。结果:本研究共纳入464例成人先心病患者,其中死亡患者9例。所有患者根据PEACH score风险因素情况分成三个等级,其中低危组285例,中危组166例,高危组13例。手术类型以房、室间隔缺陷修补合并其他畸形同期矫治最常见,占比63.3%,复杂紫绀性先心病占比6.1%,包含主动脉瓣置换的手术占比16.4%,先天性心脏病合并同期行冠脉搭桥手术占比3.0%。PEACH score模型对本中心术后死亡率的区分能力和预测能力较好,AUC:0.884(95%CI:0.852-0.906),Hosmer-Lemeshow拟合优度检验:χ~2=6.978,P=0.713。通过单因素分析排除“急诊手术”风险因素,纳入“血氧饱和度”风险因素,调整其他风险因素临界值。调整后的成人先心病人群术后死亡率预测评分表内容包括:1.NYHA心功能分级为Ⅲ级或Ⅳ级;2.血氧饱和度<90%;3.活动性心内膜炎;4.既往开胸手术≥1次;5.ACHS手术评分≥1分;6.血红蛋白≥180g/L或者<100g/L;7.内生肌酐清除率<60ml/min,调整后预测术后死亡率AUC:0.929(95%CI:0.908-0.959),χ~2=5.746,P=0.988。结论:调整后的PEACH评分对本中心的成人先心病患者术后死亡率的预测效能更加良好,对术后心率失常的发生率也有一定的预测价值,能成为本中心术后死亡率的术前风险预测模型。图4幅,表7个,参考文献56篇更多还原

【Abstract】 Background: The population of adult congenital heart disease(ACHD)is increasing,and in-hospital death after cardiac surgery is a rare but extremely serious outcome.The application of preoperative risk score for adult congenital heart disease can provide guidance for perioperative treatment and prognosis assessment.Objective: The objective of this study was to evaluate the accuracy of PEACH score in predicting the postoperative mortality risk of adult congenital heart disease in single-center,and then exclude unapplicable risk factors,identify additional risk factors,and predict in-hospital mortality after surgery for congenital heart disease in adults through the adjusted predictive model.Methods: This study retrospectively analyzed the perioperative clinical data of patients aged over 18-year-old who underwent congenital heart surgery from January 2019 to December 2022 in the Department of Cardiac and Macrovascular Surgery,Second Xiangya Hospital of Central South University.The PEACH score derived from the risk variables of each patient was calculated,the risk factor content was adjusted by univariate regression analysis,and the prediction ability of the risk model before and after adjustment for postoperative mortality and complications was evaluated by calculating the area under the receiver operating characteristic curve(AUC)and the Hosmer-Lemeshow goodness-of-fit test.Results: A total of 464 patients were enrolled in this study,of which9 patients died.All patients were divided into three grades according to the risk factors of PEACH score,including 285 in the low-risk group,166 in the intermediate-risk group,and 13 in the high-risk group.The types of surgery were atrial and ventricular septal defect repair combined with simultaneous correction of other malformations,accounting for 63.3%,complex cyanotic congenital heart disease accounted for 6.1%,surgery including aortic valve replacement accounted for 16.4%,and congenital heart disease combined with coronary artery bypass grafting surgery accounted for 3.0%.The PEACH score model had good discrimination and prediction ability for postoperative mortality in this center,AUC:0.884(95% CI: 0.852-0.906),Hosmer-Lemeshow goodness-of-fit test: χ2= 6.978,P=0.713.Univariate analysis excluded a risk factor as emergency surgery,included a risk factor as oxygen saturation,and adjusted other risk factors by cut-off values.The adjusted postoperative mortality prediction score for adult congenital heart disease includes: 1.NYHA cardiac function is graded as grade Ⅲ or Ⅳ;2.Blood oxygen saturation<90%;3.Active endocarditis;4.previous open-heart surgery≥1time;5.ACHS surgery score≥1 points;6.Hemoglobin≥180g/L or<100g/L;7.Endogenous creatinine clearance < 60ml/min,adjusted AUC for inpatient death: 0.929(95% CI: 0.908-0.959),χ2=5.746,P=0.988.Conclusion: The adjusted PEACH score has a better predictive effect on the postoperative mortality of adult congenital heart disease patients,and can also predict the incidence of postoperative arrhythmia.The adjusted PEACH score can be used as a preoperative risk prediction model for postoperative mortality in our center.更多还原