本文選題：經(jīng)導(dǎo)管主動脈瓣置換術(shù) + 出血　； 參考：《浙江大學(xué)》2017年博士論文

【摘要】：第一部分:TAVR術(shù)后嚴重出血預(yù)測因子及預(yù)后的回顧性研究目的:探究經(jīng)導(dǎo)管主動脈瓣置換(Transcatheter Aortic Valve Replacement,TAVR)術(shù)后嚴重出血(SevereBleeding,SB)的獨立預(yù)測因子及SB對預(yù)后的影響。方法:本研究入選從2013年3月至2016年10月在浙江大學(xué)醫(yī)學(xué)院第二附屬醫(yī)院心血管內(nèi)科接受TAVR治療且隨訪期滿30天的重度主動脈瓣狹窄(Aortic Stenosis,AS)患者,搜集基線、化驗、檢查及操作相關(guān)因素的數(shù)據(jù)。使用Logistic回歸模型探索 TAVR 術(shù)后 30 天內(nèi) SB、致命出血(Life-Threatening Bleeding,LTB)、輸血的獨立預(yù)測因子,以比值比(Odds Ratio,OR)表示風(fēng)險大小。使用Cox回歸模型研究SB、LTB、輸血對30天及1年預(yù)后的獨立影響,以風(fēng)險比(Hazard Ratio,HR)表示死亡風(fēng)險大小。使用生存分析曲線呈現(xiàn)SB、LTB、輸血對1年及隨訪終點死亡率的影響,以Log-Rankp表示死亡率的差異。當(dāng)p0.05時考慮存在統(tǒng)計學(xué)意義。結(jié)果:本研究入選180例TAVR患者,其中SB、LTB、輸血的發(fā)生率分別為41.7%、9.4%、14.4%。SB的獨立預(yù)測因子有6個:其中外周動脈疾病(OR:4.80,p=0.002)、主動脈瓣嚴重鈣化(OR:3.14,p=0.013)、前期入選(OR:8.80,p0.001)可增加 SB 風(fēng)險;而高體重指數(shù)(OR:0.82,p=0.003)、貧血(OR:0.12,p0.001)、經(jīng)股動脈入路(OR:0.09,p=0.013)可降低SB風(fēng)險。LTB的獨立預(yù)測因子只有2個:其中前期入選(OR:4.20,p=0.041)可增加LTB風(fēng)險;而經(jīng)股動脈入路(OR:0.03,p=0.001)可降低LTB風(fēng)險。輸血的獨立預(yù)測因子只有1個:經(jīng)股動脈入路(OR:0.17,p=0.021)可降低輸血風(fēng)險。SB短期死亡風(fēng)險呈增加趨勢(HR:7.31,p=0.088);中期、隨訪終點預(yù)后均無顯著差異。LTB短期死亡風(fēng)險顯著增加(HR:27.78,p=0.001);中期死亡率雖增加(Log-Rankp0.001),但獨立死亡風(fēng)險未增加;隨訪終點死亡率增加(Log-Rankp0.001)。輸血短期(HR:8.28,p=0.036)、中期(Log-Rankp0.001)預(yù)后與LTB一致;但隨訪終點死亡率未增加。術(shù)后30天死亡獨立預(yù)測因子包括轉(zhuǎn)外科手術(shù)(HR:30.37,p=0.039)、血管并發(fā)癥(HR:15.77,p=0.037);1年死亡獨立預(yù)測因子包括年齡(HR:0.88,p=0.026)、局部麻醉(HR:0.167,p=0.030)、血管并發(fā)癥(HR:21.48,p=0.001)。結(jié)論:外周動脈疾病、主動脈瓣嚴重鈣化、前期入選可增加TAVR術(shù)后SB風(fēng)險,而高體重指數(shù)、貧血、經(jīng)股動脈入路可降低SB風(fēng)險。前期入選可增加LTB風(fēng)險,經(jīng)股動脈入路可降低LTB風(fēng)險。經(jīng)股動脈入路可降低輸血風(fēng)險。對于TAVR術(shù)后SB、輸血、LTB三種情況的整體預(yù)后,SB最佳,輸血次之,LTB最差。第二部分TAVR術(shù)后嚴重出血預(yù)測因子的薈萃分析目的:分析總結(jié)經(jīng)導(dǎo)管主動脈瓣置換(Transcatheter Aortic Valve Replacement,TAVR)相關(guān)研究中術(shù)后30天內(nèi)嚴重出血(SevereBleeding,SB)的預(yù)測因子的效應(yīng)估計值。方法:本研究對報道TAVR術(shù)后出血且包含感興趣預(yù)測因子的研究進行系統(tǒng)回顧及薈萃分析,并提取了研究、患者以及操作相關(guān)的數(shù)據(jù)。危險比(RiskRatio,RR)與95%置信區(qū)間用隨機效應(yīng)模型計算,p0.05則認為具有統(tǒng)計學(xué)意義。結(jié)果:本研究在包含65,209個患者的47個研究分析了 15個因素。SB中位發(fā)生率為11%。其中7個因素為TAVR術(shù)后早期SB的預(yù)測因子。年齡≥90(RR:1.17;p =0.008)、女性(RR:1.13;p = 0.01)與鞘管直徑19French(RR:1.19;p = 0.04)為弱預(yù)測因子。慢性腎臟病(Chronic Kidney Disease,CKD)(RR:1.94;p0.001)與經(jīng)心尖途徑(TransApical,TA)(RR:1.82;p0.001)為中等預(yù)測因子,幾乎與 2 倍風(fēng)險相關(guān)。血管并發(fā)癥(Vascular Complication,VC)(RR:2.97;p0.001)與循環(huán)支持(Circulatory Support,CS)(RR:3.39;p0.001)為強預(yù)測因子,幾乎與3倍風(fēng)險相關(guān)。其他8個因素,包括體重指數(shù)、糖尿病、心房顫動、冠心病、外周動脈疾病、貧血、雙聯(lián)抗血小板治療、經(jīng)鎖骨下途徑,與SB風(fēng)險均無顯著相關(guān)性。結(jié)論:本薈萃分析發(fā)現(xiàn),年齡、性別、CKD、TA、鞘管直徑、VC、CS均為TAVR術(shù)后早期SB的預(yù)測因子,為TAVR術(shù)后SB的預(yù)防與管理提供了一定的指導(dǎo)意義。
[Abstract]:Part one: a retrospective study of predictors and prognosis for severe hemorrhage after TAVR: To explore the independent predictors of severe hemorrhage (SevereBleeding, SB) after transcatheter aortic valve replacement (Transcatheter Aortic Valve Replacement, TAVR) and the effect of SB on prognosis. Methods: This study was selected from March 2013 to October 2016 in Zhejiang Province. The cardiovascular department of the Second Affiliated Hospital of Jiangu University of Medicine received TAVR treatment and patients with severe aortic valve stenosis (Aortic Stenosis, AS) who were followed up for 30 days to collect data on baseline, test, examination, and operation related factors. The Logistic regression model was used to explore SB, fatal hemorrhage (Life-Threatening Bleeding, LTB) within 30 days after TAVR. The independent predictor of blood transfusion, using the Odds Ratio (OR) to represent the risk size. Use the Cox regression model to study the independent effects of SB, LTB, blood transfusion on the 30 and 1 year prognosis, with the risk ratio (Hazard Ratio, HR) to represent the risk of death. Use the survival analysis curve to present SB, LTB, the effect of blood transfusion on 1 years and the mortality rate of follow-up endpoints, with Log-Ra NKP showed a difference in mortality. When P0.05 was considered statistically significant. Results: 180 cases of TAVR patients were enrolled in this study, of which SB, LTB, the incidence of blood transfusion was 41.7%, 9.4%, 14.4%.SB independent predictors of 6: peripheral artery disease (OR:4.80, p=0.002), aortic valve severe calcification (OR:3.14, p=0.013), early selection (OR:8.80, OR:8.80, P0.001) can increase the risk of SB; while OR:0.82 (p=0.003), anemia (OR:0.12, p0.001), only 2 independent predictors of SB risk.LTB can be reduced via the femoral artery approach (OR:0.09, p=0.013). There were only 1 independent predictors: OR:0.17 (p=0.021) could reduce the risk of blood transfusion in.SB (HR:7.31, p=0.088). In the medium term, there was no significant difference in the prognosis of.LTB short term death (HR:27.78, p=0.001) at the end point of follow-up (HR:27.78, p=0.001); the risk of independent death was no longer (Log-Rankp0.001), but the risk of independent death was not. Increased follow-up end point mortality increased (Log-Rankp0.001). Blood transfusion short-term (HR:8.28, p=0.036), intermediate (Log-Rankp0.001) prognosis was consistent with LTB; but the mortality rate at the end of follow-up did not increase. The 30 day postoperatively independent predictors of death included transthoracic surgery (HR:30.37, p=0.039), vascular complications (HR:15.77, p=0.037), and 1 year mortality independent predictors including Age (HR:0.88, p=0.026), local anesthesia (HR:0.167, p=0.030), vascular complications (HR:21.48, p=0.001). Conclusions: peripheral arterial disease, severe calcification of the aortic valve, and early entry of the aortic valve can increase the risk of SB after TAVR, while high body mass index, anemia, and femoral artery approach can reduce the risk of SB. Early admission can increase the risk of LTB and reduce the risk of LTB by femoral artery approach. Low LTB risk. Transfemoral approach can reduce the risk of blood transfusion. For the overall prognosis of SB, blood transfusion, and LTB three cases after TAVR, SB is the best, blood transfusion is the best, LTB is the worst. The meta analysis of the predictors of severe hemorrhage after the second part of TAVR: analysis and summary of transcatheter aortic valve replacement (Transcatheter Aortic Valve Replacement, TAVR) phase Effect estimates of the predictors of severe bleeding (SevereBleeding, SB) within 30 days of the study. Methods: a systematic review and meta-analysis of the study on TAVR postoperative bleeding and the inclusion of a predictive factor of interest was carried out, and the study, patients, and operation related data were extracted. The risk ratio (RiskRatio, RR) and the 95% confidence interval were extracted. With a random effect model, P0.05 was considered to be statistically significant. Results: in this study, 47 studies involving 65209 patients showed that the median incidence of.SB was 11%., of which 7 factors were predictors of early SB after TAVR. Age more than 90 (RR:1.17; P =0.008), women (RR:1.13; P = 0.01) and 19French (RR:1) sheath diameter (RR:1) .19; P = 0.04) is a weak predictor. Chronic renal disease (Chronic Kidney Disease, CKD) (RR:1.94; p0.001) and the apical pathway (TransApical, TA) (RR:1.82; p0.001) are medium predictors, almost 2 times the risk. 001) for strong predictors, almost 3 times the risk. Other 8 factors, including body mass index, diabetes, atrial fibrillation, coronary heart disease, peripheral artery disease, anemia, double antiplatelet therapy, and subclavian pathway, were not associated with SB risk. Conclusion: this meta-analysis shows that age, sex, CKD, TA, sheath diameter, VC, CS are TAVR Predictors of early postoperative SB provide guidance for prevention and management of SB after TAVR.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R654.2

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相關(guān)期刊論文 前1條

1 Xian-bao LIU;Ju-bo JIANG;Qi-jing ZHOU;Zhao-xia PU;Wei HE;Ai-qiang DONG;Yan FENG;Jun JIANG;Yong SUN;Mei-xiang XIANG;Yu-xin HE;You-qi FAN;Liang DONG;Jian-an WANG;;經(jīng)導(dǎo)管主動脈瓣置入術(shù)在中國人群二葉式主動脈瓣重度狹窄中的安全性和有效性評估(英文)[J];Journal of Zhejiang University-Science B(Biomedicine & Biotechnology);2015年03期

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本文編號：1897372