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摘要: 目的 分析机器人心脏外科手术的安全性及有效性，探讨术后急性肾功能损伤(CSA-AKI)的危险因素。方法 回顾性分析陆军军医大学大坪医院2016年7月—2022年6月147例机器人体外循环(CPB)下心脏外科手术患者的资料，统计其人口学资料及相关临床资料。按患者术后是否发生CSA-AKI，将其分为CSA-AKI组(37例)与非CSA-AKI组(109例)，1例患者因术后早期死亡未纳入分组。对两组围术期危险因素进行单因素分析，再将筛选出的有意义的变量纳入多因素logistic回归分析。结果 147例机器人心脏外科术后发生CSA-AKI 37例，发生率为25.34%，1期CSA-AKI 28例(19.18%)，2期CSA-AKI 6例(4.11%)，3期CSA-AKI 3例(2.05%)，肾功能衰竭透析1例(0.68%)，院内死亡1例(0.68%)。CSA-AKI组与非CSA-AKI组年龄、性别、肥胖分级、高血压、吸烟、饮酒、NYHA分级、左房前后径(LAD)、甘油三酯(TG)、高密度脂蛋白胆固醇(HDL-C)、丙氨酸氨基转移酶(ALT)、手术时间、主动脉阻断时间、CPB时间及手术类型均差异有统计学意义(均P < 0.05)。多因素logistic回归分析提示，术前TG(OR=1.756，95%CI：1.058~2.914，P=0.029)与手术时间≥300 min(OR=3.649，95%CI：1.061~12.553，P=0.04)是机器人心脏外科术后CSA-AKI的独立危险因素。CSA-AKI组术后气管带管时间、监护室停留时间、术后住院时间明显延长，术后肺部感染、肝功能损伤及低蛋白血症发生率明显增加，术后大剂量输血事件明显增加(均P < 0.05)。结论 术前TG、手术时间≥300 min是机器人心脏外科术后CSA-AKI的独立危险因素；CSA-AKI患者术后气管带管时间、监护室停留时间、术后住院时间明显延长，术后肺部感染、肝功能损伤、低蛋白血症发生率明显增加，术后大剂量输血事件显著增加。Abstract: Objective To analyze the safety and efficacy of robotic cardiac surgery, and to explore the risk factors of postoperative acute kidney injury(CSA-AKI).Methods The data of 147 patients who underwent cardiac surgery under robotic cardiopulmonary bypass(CPB) from July 2016 to June 2022 in Daping Hospital of Army Medical University were retrospectively analyzed, and their demographic data and related clinical data were statistically analyzed. The patients were divided into the CSA-AKI group(n=37) and the non-CSA-AKI group(n=109) according to whether CSA-AKI occurred after operation, and 1 patient died in the early postoperative period and was not included in the group. Univariate analysis was performed for perioperative risk factors in both groups, followed by multivariate logistic regression analysis for variables selected to be more significant.Results Thirty-seven of 147 patients(25.34%) developed CSA-AKI after robotic cardiac surgery, 28(19.18%) had stage 1 CSA-AKI, 6(4.11%) had stage 2 CSA-AKI, 3(2.05%) had stage 3 CSA-AKI, 1(0.68%) had renal failure dialysis, and 1(0.68%) died in the hospital. There were significant differences in age, gender, obesity class, hypertension, smoking, alcohol consumption, NYHA class, left atrial anteroposterior diameter(LAD), triglyceride(TG), high-density lipoprotein cholesterol(HDL-C), alanine aminotransferase(ALT), operation time, aortic cross-clamp time, CPB time, and operation type in CSA-AKI group and non-CSA-AKI group(all P < 0.05). Multivariate logistic regression analysis suggested that preoperative TG(OR=1.756, 95%CI: 1.058-2.914, P=0.029) and operation time ≥ 300 min(OR=3.649, 95%CI: 1.061-12.553, P=0.04) were independent risk factors for CSA-AKI after robotic cardiac surgery. In the CSA-AKI group, the postoperative tracheal intubation time, intensive care unit stay, and postoperative hospital stay were significantly prolonged, the incidence of postoperative pulmonary infection, liver function injury, and hypoproteinemia was significantly increased, and postoperative high-dose transfusion events were significantly increased(all P < 0.05).Conclusion Preoperative TG and operation time ≥ 300 min were independent risk factors of CSA-AKI after robotic cardiac surgery. In patients with postoperative CSA-AKI, postoperative tracheal intubation time, intensive care unit stay, and postoperative hospital stay were significantly prolonged, the incidence of postoperative pulmonary infection, liver function injury, and hypoproteinemia are significantly increased, and postoperative high-dose blood transfusion events are significantly increased.
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Key words:
- robotic surgery /
- cardiac surgery /
- cardiopulmonary bypass /
- acute kidney injury /
- risk factors
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表 1 患者术前一般资料
Table 1. Preoperative general data
例(%), X±S 项目 非CSA-AKI组(109例) CSA-AKI组(37例) χ2/t P 年龄/岁 41.19±13.10 47.84±11.53 7.530 0.007 男性 34(31.19) 21(56.76) 8.005 0.005 身高/cm 160.77±7.72 161.29±7.78 0.293 0.589 体重/kg 57.30±11.13 61.35±11.89 3.529 0.062 BMI/(kg·m-2) 22.12±3.60 23.42±3.77 3.510 0.063 BSA/m2 1.59±0.17 1.62±0.18 2.936 0.089 肥胖分级 6.172 0.014 偏瘦 14(12.84) 3(8.11) 正常 66(60.55) 15(40.54) 超重及肥胖 29(26.61) 19(51.35) 糖尿病 1(0.09) 2(5.41) 2.779 0.098 高血压 10(9.17) 8(21.62) 4.014 0.047 吸烟 15(13.76) 13(35.14) 8.504 0.004 饮酒 12(11.01) 15(40.54) 17.701 < 0.001 NYHA分级 6.668 0.011 Ⅰ级 2(1.83) 0(0) Ⅱ级 77(70.64) 18(48.64) Ⅲ级 30(27.53) 19(48.66) LVFS/% 36.53±4.71 36.49±4.59 0.003 0.959 LVEF/% 66.28±6.51 66.38±5.21 0.006 0.937 LAD/mm 34.28±6.54 37.51±7.32 6.329 0.013 LVDs/mm 42.51±6.97 43.78±6.69 0.935 0.335 RAD/mm 37.88±7.91 36.95±6.72 0.414 0.521 RVDs/mm 28.11±8.84 26.72±6.41 1.358 0.246 三尖瓣跨瓣压差/mmHg 26.26±12.38 29.24±11.22 1.682 0.197 SPAP/mmHg 35.34±15.49 37.32±13.17 0.487 0.486 注：LAD：左房前后径；LVDs：左室前后径；RAD：右房横径；RVDs：右室前后径。 
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表 2 患者术前检验资料
Table 2. Preoperative examination data
X±S 项目 非CSA-AKI组(109例) CSA-AKI组(37例) χ2/t P TC/(mmol·L-1) 3.92±0.93 3.96±1.09 0.031 0.861 TG/(mmol·L-1) 1.15±0.71 1.62±1.13 9.002 0.003 LDL/(mmol·L-1) 2.37±0.64 2.45±0.71 0.338 0.562 HDL/(mmol·L-1) 1.27±0.41 1.12±0.33 4.336 0.039 ALT/(U·L-1) 19.40±11.71 24.62±17.04 4.301 0.040 AST/(U·L-1) 22.63±7.78 23.41±10.32 0.230 0.632 TBIL/(μmol·L-1) 14.25±7.23 13.76±6.22 0.133 0.716 DBIL/(μmol·L-1) 2.77±1.71 2.91±2.38 0.132 0.717 ALB/(g·L-1) 41.44±4.19 41.25±3.82 0.062 0.804 PA/(mg·L-1) 224.62±42.93 232.66±64.99 0.733 0.393 SCr/(μmol·L-1) 60.82±13.28 65.79±17.11 3.329 0.070 GFR/% 144.94±34.87 142.79±45.02 0.090 0.764 UA/(μmol·L-1) 322.29±92.65 340.92±76.86 1.211 0.273 HGB/(g·L-1) 136.67±25.66 136.65±16.47 0.000 0.996 PLT/(×109·L-1) 226.47±67.92 225.49±56.53 0.096 0.757 RDW/% 43.41±4.16 43.64±3.68 0.091 0.763 NE/(×109·L-1) 3.34±1.31 3.84±1.43 3.849 0.052 LY/(×109·L-1) 1.88±0.68 1.81±0.52 0.415 0.520 注：TC：总胆固醇；TG：甘油三酯；LDL-C：低密度脂蛋白胆固醇；HDL-C：高密度脂蛋白胆固醇；ALT：丙氨酸氨基转移酶；AST：天门冬氨酸氨基转移酶；TBIL：总胆红素；DBIL：直接胆红素；ALB：白蛋白；PA：前白蛋白；GFR：肾小球滤过率；UA：尿酸；HGB：血红蛋白；PLT：血小板；RDW：红细胞宽度；NE：中性粒细胞计数；LY：淋巴细胞计数。
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表 3 患者手术资料
Table 3. Operation data
例(%), X±S 项目 非CSA-AKI组(109例) CSA-AKI组(37例) χ2/t P 手术时间≥300 min 48(44.04) 29(78.38) 14.983 < 0.001 CPB时间/min 123.49±74.08 181.01±89.36 14.948 < 0.001 主动脉阻断时间/min 69.58±56.04 112.32±70.28 14.058 < 0.001 术中红细胞悬液输入量≥800 mL 10(9.17) 8(21.62) 4.891 0.029 术中血浆输入量≥800 mL 4(3.67) 4(10.81) 3.983 0.048 手术类型 9.168 0.003 瓣膜置换或成形术 69(63.31) 14(37.84) 先心病矫正术 14(12.84) 5(13.51) 心脏良性肿瘤切除术 26(23.85) 18(48.65)
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表 4 患者术后资料
Table 4. Postoperative data
例(%), X±S 项目 非CSA-AKI组(109例) CSA-AKI组(37例) χ2/t P值 术后第1天引流量/mL 337.34±313.91 398.11±312.84 1.037 0.310 气管带管时间/h 12.33±6.25 18.23±8.89 19.597 < 0.001 监护室停留时间/h 53.22±18.64 64.72±25.93 8.516 0.004 术后住院时间/d 9.06±3.24 11.35±5.14 10.055 0.002 术后大剂量输血≥800 mL 10(9.17) 11(29.73) 9.997 0.002 肺部感染 29(26.61) 17(45.95) 4.883 0.029 心律失常 14(12.84) 9(24.32) 2.757 0.099 肝功能损伤 14(12.84) 10(27.03) 4.104 0.045 胆红素代谢异常 68(62.39) 27(72.97) 1.356 0.246 低白蛋白血症 55(50.46) 28(75.68) 7.427 0.007 低前白蛋白血症 17(15.59) 9(24.32) 1.432 0.233
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表 5 CSA-AKI危险因素的多因素logistic回归分析
Table 5. Risk factors of CSA-AKI analyzed by multivariate logistic regression analysis
危险因素 β SE P OR(95%CI) 年龄 0.034 0.020 0.090 1.034(0.995~1.076) 男性 -0.116 0.558 0.835 0.890(0.298~2.661) 吸烟 0.287 0.765 0.707 1.333(0.298~5.970) 饮酒 1.312 0.712 0.065 3.715(0.920~15.009) TG 0.563 0.258 0.029 1.756(1.058~2.914) 手术时间≥300 min 1.295 0.630 0.040 3.649(1.061~12.553) CPB时间 -0.007 0.009 0.406 0.993(0.976~1.010) 主动脉阻断时间 0.011 0.010 0.279 1.011(0.991~1.032) 常量 -5.566 1.700 0.001
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[1] Girdauskas E, Pausch J, Harmel E, et al. Minimally invasive mitral valve repair for functional mitral regurgitation[J]. Eur J Cardiothorac Surg, 2019, 55(Suppl 1): i17-i25.
[2] Darr C, Cheufou D, Weinreich G, et al. Robotic thoracic surgery results in shorter hospital stay and lower postoperative pain compared to open thoracotomy: a matched pairs analysis[J]. Surg Endosc, 2017, 31(10): 4126-4130. doi: 10.1007/s00464-017-5464-6
[3] Yanagawa F, Perez M, Bell T, et al. Critical Outcomes in Nonrobotic vs Robotic-Assisted Cardiac Surgery[J]. JAMA Surg, 2015, 150(8): 771-777. doi: 10.1001/jamasurg.2015.1098
[4] 许李力, 李平, 徐屹, 等. 机器人心脏外科手术早期随访的安全性及有效性研究[J]. 机器人外科学杂志(中英文), 2021, 2(6): 421-430. https://www.cnki.com.cn/Article/CJFDTOTAL-JQRW202106004.htm
[5] Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury[J]. Crit Care, 2007, 11(2): R31. doi: 10.1186/cc5713
[6] Palomba H, de Castro I, Neto A L, et al. Acute kidney injury prediction following elective cardiac surgery: AKICS Score[J]. Kidney Int, 2007, 72(5): 624-631. doi: 10.1038/sj.ki.5002419
[7] Haines RW, Kirwan CJ, Prowle JR. Continuous renal replacement therapy: individualization of the prescription[J]. Curr Opin Crit Care, 2018, 24(6): 443-449. doi: 10.1097/MCC.0000000000000546
[8] Nifong LW, Chitwood WR, Pappas PS, et al. Robotic mitral valve surgery: a United States multicenter trial[J]. J Thorac Cardiovasc Surg, 2005, 129(6): 1395-1404. doi: 10.1016/j.jtcvs.2004.07.050
[9] Cerny S, Oosterlinck W, Onan B, et al. Robotic cardiac surgery in Europe: Status 2020[J]. Front Cardiovasc Med, 2021, 8: 827515.
[10] Gillinov AM, Mihaljevic T, Javadikasgari H, et al. Early results of robotically assisted mitral valve surgery: Analysis of the first 1000 cases[J]. J Thorac Cardiovasc Surg, 2018, 155(1): 82-91. doi: 10.1016/j.jtcvs.2017.07.037
[11] Hu J, Chen R, Liu S, et al. Global Incidence and Outcomes of Adult Patients With Acute Kidney Injury After Cardiac Surgery: A Systematic Review and Meta-Analysis[J]. J Cardiothorac Vasc Anesth, 2016, 30(1): 82-89. doi: 10.1053/j.jvca.2015.06.017
[12] Vandenberghe W, Gevaert S, Kellum J A, et al. Acute Kidney Injury in Cardiorenal Syndrome Type 1 Patients: A Systematic Review and Meta-Analysis[J]. Cardiorenal Med, 2016, 6(2): 116-128. doi: 10.1159/000442300
[13] Nadim MK, Forni LG, Bihorac A, et al. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI(Acute Disease Quality Initiative) Group[J]. J Am Heart Assoc, 2018, 7(11): e008834. doi: 10.1161/JAHA.118.008834
[14] Lassnigg A, Schmidlin D, Mouhieddine M, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study[J]. J Am Soc Nephrol, 2004, 15(6): 1597-1605. doi: 10.1097/01.ASN.0000130340.93930.DD
[15] Helgason D, Helgadottir S, Ahlsson A, et al. Acute kidney injury after acute repair of type A aortic dissection[J]. Ann Thorac Surg, 2021, 111(4): 1292-1298. doi: 10.1016/j.athoracsur.2020.07.019
[16] Fu HY, Chou NK, Chen YS, et al. Risk factor for acute kidney injury in patients with chronic kidney disease receiving valve surgery with cardiopulmonary bypass[J]. Asian J Surg, 2021, 44(1): 229-234. doi: 10.1016/j.asjsur.2020.05.024
[17] Reazaul KH, Yunus M, Dey S. A retrospective comparison of preoperative estimated glomerular filtration rate as a predictor of postoperative cardiac surgery associated acute kidney injury[J]. Ann Card Anaesth, 2020, 23(1): 53-58. doi: 10.4103/aca.ACA_156_18
[18] Wang J, Gu C, Gao M, et al. Preoperative Statin Therapy and Renal Outcomes After Cardiac Surgery: A Meta-analysis and Meta-regression of 59, 771 Patients[J]. Can J Cardiol, 2015, 31(8): 1051-1060. doi: 10.1016/j.cjca.2015.02.034
[19] Wittlinger T, Maus M, Kutschka I, et al. Risk assessment of acute kidney injury following cardiopulmonary bypass[J]. J Cardiothorac Surg, 2021, 16(1): 4. doi: 10.1186/s13019-020-01382-x
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| 引用本文: |
吴文军, 丁任重, 陈建明, 等. 机器人心脏外科术后急性肾功能损伤的危险因素分析[J]. 临床心血管病杂志, 2023, 39(1): 51-56. doi: 10.13201/j.issn.1001-1439.2023.01.010
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| Citation: |
WU Wenjun, DING Renzhong, CHEN Jianming, et al. Risk factors of acute kidney injury after robotic cardiac surgery[J]. J Clin Cardiol, 2023, 39(1): 51-56. doi: 10.13201/j.issn.1001-1439.2023.01.010
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