Atrial fibrillation after cardiac surgery - A major morbid event?
Atrial fibrillation after cardiac surgery - A major morbid event?
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DOI：
10.1097/00000658-199710000-00011
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发表时间：
1997-10-01
影响因子：
9
通讯作者：
Hammermeister, KE
中科院分区：
文献类型：
--
作者：
Almassi, GH;Schowalter, T;Hammermeister, KE
本研究的目的是调查与术后房颤（AF）相关的发病率、预测因素、发病率和死亡率及其对退伍军人事务部（VA）心脏手术患者重症监护室（ICU）和术后住院时间的影响。这种心律失常的病因和导致其发生的因素尚不清楚，其对术后手术结果的影响仍存在争议。这个特殊的子研究的目的是阐明术后AF的发病率和相关因素与其发展，以及AF对手术outcome.MethodsThe研究人群的影响，包括3855例患者进行了心脏直视手术1993年9月至1996年12月在14 VA医疗中心。另外329例患者因缺乏完整数据或术前存在AF而被排除，其中3794例（98.4%）为男性，平均年龄为63.7 ± 9.6岁。手术方式包括冠状动脉旁路移植术（CABG）3126例（81%），+ AVR（主动脉瓣置换术）（228，5.9%）、CABG + MVR（二尖瓣置换术）（35，0.9%）、AVR（231，6%）、MVR（41，1.06%）、CABG +其他（95，2.46%）和其他（99，2.5%）。术后房颤发生率为29.6%。对单变量分析中发现有意义的因素进行多变量logistic回归分析，结果显示术后AF的预测因素如下：术前患者风险预测因素：年龄增长（比值比[OR] 1.61，95%置信区间[CI] 1.48-1.75，p < 0.001），慢性阻塞性肺疾病（OR 1.37，95% CI 1.12-1.66，p < 0.001），术前2周内使用地高辛（OR 1.37，95% CI 1.10-1.70，p < 0.003），低静息脉率120（OR 1.19，95% CI 1.02-1.40，p < 0.026），术中护理过程预测因素：经右上级肺静脉心脏通气（OR 1.42，95% CI 1.21-1.67，p < 0.0001），二尖瓣修复术（OR 2.86，95% CI 1.72-4.73，p < 0.0001）和置换（OR 2.33，95% CI 1.55-3.55，p < 0.0001），未使用局部冰沙（OR 1.29，95% CI 1.10-1.49，p < 0.0009），心肺转流终止后使用正性肌力药物超过30分钟（OR 1.36，95% CI 1.16-1.59，p < 0.0001）。术后ICU平均住院时间（3.6天AF vs. 2天无AF，p < 0.001）和住院时间AF患者的发病率、住院死亡率和B月死亡率显著高于AF患者（10天AF vs 7天无AF，p < 0.001）。（p < 0.001）：ICU再入院13% AF vs 3.9%无AF，围手术期心肌梗死7.41% AF vs 3.36%无AF，持续性充血性心力衰竭4.57% AF vs 1.4%无AF，再次插管10.59% AF vs. 2.47%无AF，卒中5.26% AF vs. 2.44%无AF，住院死亡率5.95% AF vs. 2.95%无AF，6个月死亡率9.36% AF vs. 4.17%结论心脏手术后房颤发生在大约三分之一的患者中，并且与所有患者中不良事件的增加有关。医疗保健的可衡量结果，增加了医院资源的使用，因此，医疗保健的成本。降低心脏手术后AF发生率的策略应能有利地影响手术结局，减少资源利用，从而降低护理成本。
ObjectiveThe purpose of the study was to investigate the incidence, predictors, morbidity, and mortality associated with postoperative atrial fibrillation (AF) and its impact on intensive care unit (ICU) and postoperative hospital stay in patients undergoing cardiac surgery in the Department of Veterans Affairs (VA).Summary Background DataPostoperative AF after open cardiac surgery is rather common. The etiology of this arrhythmia and factors responsible for its genesis are unclear, and its impact on postoperative surgical outcomes remains controversial. The purpose of this special substudy was to elucidate the incidence of postoperative AF and the factors associated with its development, as well as the impact of AF on surgical outcome.MethodsThe study population consisted of 3855 patients who underwent open cardiac surgery between September 1993 and December 1996 at 14 VA Medical Centers. Three hundred twenty-nine additional patients were excluded because of lack of complete data or presence of AF before surgery, and 3794 (98.4%) were male with a mean age of 63.7 +/- 9.6 years. Operations included coronary artery bypass grafting (CABG) (3126, 81%), CABG. + AVR (aortic valve replacement) (228, 5.9%), CABG + MVR (mitral valve replacement) (35, 0.9%), AVR (231, 6%), MVR (41, 1.06%), CABG + others (95, 2.46%), and others (99, 2.5%). The incidence of postoperative AF was 29.6%. Multivariate logistic regression analysis of factors found significant on univariate analysis showed the following predictors of postoperative AF: preoperative patient risk predictors: advancing age (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.48-1.75, p < 0.001), chronic obstructive pulmonary disease (OR 1.37, 95% Cl 1.12-1.66, p < 0.001), use of digoxin within 2 weeks before surgery (OR 1.37, 95% Cl 1.10-1.70, p < 0.003), low resting pulse rate 120 (OR 1.19, 95% Cl 1.02-1.40, p < 0.026), intraoperative process of care predictors: cardiac venting via right superior pulmonary vein (OR 1.42, 95% Cl 1.21-1.67, p < 0.0001), mitral valve repair (OR 2.86, 95% Cl 1.72-4.73, p < 0.0001) and replacement (OR 2.33, 95% Cl 1.55-3.55, p < 0.0001), no use of topical ice slush (OR 1.29, 95% Cl 1.10-1.49, p < 0.0009), and use of inotropic agents for greater than 30 minutes after termination of cardiopulmonary bypass (OR 1.36, 95% Cl 1.16-1.59, p < 0.0001). Postoperative median ICU stay (3.6 days AF vs. 2 days no AF, p < 0.001) and hospital stay (10 days AF vs. 7 days no AF, p < 0.001) were higher in AF. Morbid events, hospital mortality, and B-month mortality were significantly higher in AF (p < 0.001): ICU readmission 13% AF vs. 3.9% no AF, perioperative myocardial infarction 7.41% AF vs. 3.36% no AF, persistent congestive heart failure 4.57% AF vs. 1.4% no AF, reintubation 10.59% AF vs. 2.47% no AF, stroke 5.26% AF vs. 2.44% no AF, hospital mortality 5.95% AF vs. 2.95% no AF, 6-month mortality 9.36% AF vs. 4.17% no AF.ConclusionsAtrial fibrillation after cardiac surgery occurs in approximately one third of patients and is associated with an increase in adverse events in all measurable outcomes of care and increases the use of hospital resources and, therefore, the cost of care. Strategies to reduce the incidence of AF after cardiac surgery should favorably affect surgical outcomes and reduce utilization of resources and thus lower cost of care.