本文選題：一站式雜交手術(shù)　切入點：心臟術(shù)后急性腎損傷　出處：《北京協(xié)和醫(yī)學(xué)院》2015年博士論文

【摘要】：第一部分：一站式冠狀動脈再血管化手術(shù)與非體外循環(huán)下冠狀動脈移植術(shù)對術(shù)后腎功能及術(shù)后出血量的比較研究研究目的一站式冠狀動脈雜交手術(shù)給冠心病多支病變患者提供了微創(chuàng)、安全、方便的治療方法。左側(cè)乳內(nèi)動脈至前降支的搭橋保障了左室壁的血管供應(yīng),乳內(nèi)動脈作為橋血管的優(yōu)勢在于長久性和血管的通暢性。其次內(nèi)科介入支架植入術(shù)減少外科血管吻合口,創(chuàng)傷小,患者更加容易接受。但是一站式雜交手術(shù)患者術(shù)中要接受大量造影劑,再加上圍術(shù)期特殊的抗血小板凝集藥物的應(yīng)用,一站式雜交手術(shù)患者術(shù)后急性腎損傷以及出血量成為臨床醫(yī)生的擔(dān)憂。本研究的目的就是通過對比一站式雜交手術(shù)患者以及同期非體外循環(huán)下冠狀動脈移植術(shù)患者的術(shù)后出血量以及肌酐值,探索一站式雜交手術(shù)在術(shù)后出血量以及腎損傷方面的安全性。為臨床工作中患者選擇提供依據(jù)。研究方法本研究回顧性的收集了2007年6月至2011年1月期間阜外醫(yī)院實施的一站式冠狀動脈雜交手術(shù)患者共141例。通過傾向性評分收集同期手術(shù)的非體外循環(huán)下冠狀動脈移植術(shù)患者共141例。通過病史采集,收集術(shù)前可能影響預(yù)后的臨床變量,記錄術(shù)后肌酐值變化,術(shù)后出血量以及一般臨床預(yù)后變量。最后通過統(tǒng)計學(xué)方法對兩組數(shù)據(jù)進(jìn)行分析統(tǒng)計。結(jié)果與非體外循環(huán)下冠狀動脈移植術(shù)相比,一站式雜交手術(shù)患者術(shù)后12小時出血量以及總出血量明顯低于對照組,P值分別為0.04和P0.001。同時,一站式雜交組患者術(shù)后血液輸注率明顯低于非體外循環(huán)下冠狀動脈移植術(shù)患者(P=0.001)。一站式雜交手術(shù)患者術(shù)后急性腎損傷的發(fā)生率略高于非體外循環(huán)下冠狀動脈移植術(shù)患者,但是沒有達(dá)到統(tǒng)計學(xué)差異(25.2% vs 17.6%,p=0.13)。術(shù)后轉(zhuǎn)歸方面,一站式雜交組患者術(shù)后血流動力學(xué)更加穩(wěn)定,血管活性藥物的使用更少,呼吸系統(tǒng)并發(fā)癥更少,機(jī)械通氣時間以及ICU住院時長都顯著低于對照組。結(jié)論與非體外循環(huán)下不停跳冠狀動脈移植術(shù)相比,一站式雜交手術(shù)有明顯的優(yōu)勢,主要體現(xiàn)在術(shù)后出血量更少,輸血率更低,而且并不明顯增加術(shù)后腎損傷的幾率。一站式雜交手術(shù)是安全、可靠的冠狀動脈再血管化治療方式。第二部分：血小板計數(shù),急性腎損傷以及冠狀動脈移植術(shù)后中長期死亡率的研究研究背景體外循環(huán)下,血小板激活以及聚集可能是術(shù)后終末器官缺血性并發(fā)癥的主要原因。血小板在術(shù)后急性中風(fēng)以及心肌梗塞中的作用已經(jīng)被研究證實過,但是血小板與心臟術(shù)后急性腎損傷的關(guān)系的研究并不明確。研究目的本研究主要目的在于探索非免疫性血小板減少癥與冠狀動脈移植術(shù)術(shù)后急性腎損傷以及術(shù)后中長期死亡率之間的關(guān)系研究方法我們回顧性收集了4201例冠狀動脈移植術(shù)病人資料。同時記錄患者術(shù)后10日內(nèi)每日血小板的最低值作為連續(xù)性變量,分析血小板低值(連續(xù)性變量)與術(shù)后急性腎損傷以及死亡率之間的關(guān)系。再者,我們將術(shù)后血小板計數(shù)處于整體患者血小板計數(shù)10%的患者作為觀察組,即血小板計數(shù)10%低限組,并將此作為二分類變量進(jìn)行統(tǒng)計。最后進(jìn)行單因素和多因素分析,探索術(shù)后血小板計數(shù)(連續(xù)性變量以及二分類變量)與術(shù)后急性腎損傷以及死亡率之間的聯(lián)系。研究結(jié)果術(shù)后血小板低值的平均值為121x109/L.術(shù)后急性腎損傷(KDIGO標(biāo)準(zhǔn))發(fā)生率為50%,其中1.6% (34例)患者為AKIⅡ級,2%(42例)為AKIⅢ級。術(shù)后血小板計數(shù)每升高30x109/L,其術(shù)后急性腎損傷的風(fēng)險下降約7%(OR,0.93；95%CI,0.89-0.98；P=0.003),更重要的是,術(shù)后30天死亡率下降約46%(OR，，0.54；95% CI,0.41-0.69；P0.0001)。術(shù)后血小板計數(shù)處于整體患者人群最低10%的患者,其術(shù)后進(jìn)展到更加級別的急性腎損傷的幾率增加3.5倍,血小板計數(shù)10%低限組的患者其術(shù)后30天以及長期死亡率明顯高于剩余的患者。OR值分別為術(shù)后30天OR 4.34；95%CI,2.46-7.58；p0.0001,統(tǒng)計調(diào)整后術(shù)后長期死亡率OR值為1.33；95%CI,1.12 to 1.59;P=0.001。結(jié)論我們的研究發(fā)現(xiàn)術(shù)后血小板計數(shù)與術(shù)后急性腎損傷以及死亡率有顯著性相關(guān)。第三部分：負(fù)荷劑量阿托伐他汀對冠狀動脈旁路移植術(shù)后腎臟保護(hù)作用及炎性反應(yīng)調(diào)節(jié)作用的研究-前瞻性隨機(jī)雙盲研究研究背景阿托伐他汀不僅有明確的降脂作用,近年來他汀類藥物的抗炎、抗氧化應(yīng)激、增加內(nèi)皮細(xì)胞功能等降脂外作用成為很多臨床疾病的有效預(yù)防和治療替代方法。他汀類藥物在冠心病介入治療患者中顯示有明顯的抗炎、保護(hù)術(shù)后腎功能作用。甚至單次負(fù)荷劑量術(shù)前給藥都顯示了令人滿意的腎臟保護(hù)作用。但是在外科圍術(shù)期應(yīng)用中,大多數(shù)回顧性研究的結(jié)果不一致,目前缺少前瞻性負(fù)荷劑量他汀類治療的臨床證據(jù)。研究目的本研究希望通過前瞻性隨機(jī)雙盲設(shè)計對負(fù)荷劑量他汀藥物在冠狀動脈移植術(shù)中的應(yīng)用,探索他汀類藥物對體外循環(huán)手術(shù)患者的潛在腎臟保護(hù)作用以及炎癥調(diào)節(jié)作用。研究方法經(jīng)阜外醫(yī)院倫理委員會審核后,本研究納入患者96例,其中92例患者完成隨訪(阿托伐他汀組47例,安慰劑組45例)�；颊呷脒x后,根據(jù)隨即數(shù)字表,隨機(jī)分為阿托伐他汀組和安慰劑組。阿托伐他汀組術(shù)前12小時給予阿托伐他汀80mmg,術(shù)前2小時加服阿托伐他汀40mmg,安慰劑組患者服用同等劑量安慰劑。在術(shù)中以及術(shù)后抽取血液樣本并記錄相關(guān)臨床變量并統(tǒng)計分析。研究結(jié)果研究結(jié)果顯示兩組患者術(shù)前基線資料基本平齊,阿托伐他汀組術(shù)后NGAL值顯著低于安慰劑組,但術(shù)后兩組之間肌酐值沒有顯著差異。在本研究中阿托伐他汀有抑制Th1細(xì)胞相關(guān)因子傾向,而兩組之間Th2細(xì)胞相關(guān)因子含量無明顯差異。術(shù)后臨床轉(zhuǎn)歸比較中,兩組之間急性腎損傷的發(fā)生率無明顯差異。術(shù)后房顫、呼吸系統(tǒng)并發(fā)癥、輸血率、機(jī)械通氣時間和ICU住院時間等均無明顯差異。但阿托伐他汀組患者術(shù)后中風(fēng)發(fā)生率低于安慰劑組,但未達(dá)統(tǒng)計學(xué)顯著差異。研究結(jié)論本研究結(jié)果顯示,體外循環(huán)下冠狀動脈移植術(shù)患者術(shù)前負(fù)荷劑量阿托伐他汀是有效、安全的。阿托伐他汀有保護(hù)心臟手術(shù)后腎功能的作用,同時對于體外循環(huán)下的免疫調(diào)節(jié)作用可能是降低術(shù)后并發(fā)癥的原因之一。
[Abstract]:The first part: the safety of one-stop coronary revascularization procedures with off-pump coronary artery bypass grafting on the amount of bleeding and postoperative renal function after surgery and the comparative study of the research objective of one-stop hybrid coronary artery surgery for multivessel coronary heart disease patients with minimally invasive, easy treatment method. The left internal mammary bypass artery to the anterior descending branch of the left ventricular wall to protect the blood supply, the internal mammary artery as vascular bridge has the advantage of long term patency and vascular interventional stent implantation. Secondly reduce surgical trauma, vascular anastomosis, were easier to accept. But the one-stop hybrid surgery to accept a large number of contrast agent, plus the application of antiplatelet drug special peri operation period, acute kidney injury of one-stop hybrid surgery patients with postoperative bleeding and becoming the concern. The purpose of this study is to By comparing the one-stop hybrid surgery patients and the same amount of bleeding and creatinine values under extracorporeal circulation in patients with coronary artery transplantation after operation, explore the one-stop hybrid operating safety and the amount of bleeding in the postoperative renal damage. Provide the basis for the selection of patients in clinical practice. This study retrospectively collected from June 2007 to January 2011 in Fuwai Hospital during the implementation of one-stop hybrid coronary artery surgery in 141 cases. The propensity score of off-pump surgery collected patients undergoing coronary artery bypass grafting in 141 cases. Through history collection, collection of preoperative clinical variables may influence prognosis, postoperative creatinine changes, surgery after bleeding and general clinical prognostic variables. Finally, through the statistical analysis of the statistical method to the data of the two groups were compared. Results with off-pump coronary artery bypass grafting, Significantly lower than the control group and the total amount of bleeding amount of bleeding in 12 hours of one-stop hybrid surgery patients, P = 0.04 and P0.001. at the same time, a one-stop hybrid group of patients after blood infusion rate was significantly lower than that of off-pump coronary artery bypass grafting patients (P=0.001). The one-stop hybrid surgery after the occurrence of acute kidney injury rate is slightly higher than that of off-pump coronary artery bypass grafting patients, but did not reach statistical significance (25.2% vs 17.6%, p=0.13). The outcome after operation, one stop hybrid group were more stable hemodynamics, blood vessel active drug use fewer respiratory complications, less mechanical ventilation time and ICU stay were significantly lower than the control group. Conclusion with off-pump off-pump coronary artery transplantation compared to the one-stop hybrid procedure has obvious advantages, mainly reflected in the amount of postoperative bleeding more Less, lower transfusion rates, but does not significantly increase the probability of renal injury after operation. One stop hybrid operation is safe and reliable for coronary artery revascularization. The second part: the platelet count, and acute kidney injury after coronary artery bypass grafting in long-term mortality research background of extracorporeal circulation, platelet activation and may be gathered after end organ ischemic complications have been studied. The main reason of platelets demonstrated in acute stroke and myocardial infarction after operation, but the research on the relationship between platelet and acute kidney injury after cardiac surgery is not clear. The purpose of the study the main purpose of this study is to research the relation between long-term mortality between exploration non immune thrombocytopenia and coronary artery transplantation after acute kidney injury and postoperative we retrospectively collected 4201 cases of coronary artery graft Implantation of patient data were recorded at the same time. After 10 days the daily minimum value of platelets as a continuous variable, analysis of platelet low value (continuous variables) and the relationship between postoperative acute kidney injury and mortality. Furthermore, we will postoperative platelet count in patients with overall platelet counts of 10% patients as observation group that is, low platelet counts of 10% groups, and will carry out the statistics as two classification variables. Finally, single factor and multi factor analysis, explore the postoperative platelet count (continuous variables and two variables) and postoperative acute kidney injury and mortality. The average results of postoperative platelet low value for acute kidney injury after 121x109/L. (KDIGO) incidence rate was 50%, of which 1.6% (34 cases) of patients with AKI grade II, 2% (42 cases) for the AKI grade. Postoperative platelet count per 30x109/L increase in acute kidney after operation The risk of injury decreased by about 7% (OR, 0.93; 95%CI, 0.89-0.98; P=0.003), more importantly, a decrease of about 46% 30 day postoperative mortality (OR, 0.54; 95% CI, 0.41-0.69; P0.0001). Postoperative platelet count in patients with the lowest overall population in 10% of patients, the postoperative risk of progression to acute renal injury level increased 3.5 times more, low platelet counts of 10% group of patients within 30 days of surgery and long-term mortality was significantly higher than that of the rest of the patients with.OR respectively after 30 days OR 4.34; 95%CI, 2.46-7.58; P0.0001, the adjusted statistical postoperative long-term mortality OR value is 1.33; 95%CI, 1.12 to 1.59; our study conclusion P=0.001. found postoperative platelet count and postoperative acute kidney injury and mortality were significantly related. The third part: the loading dose of atorvastatin on renal protection and regulation of inflammatory response after coronary artery bypass grafting The study of prospective randomized double-blind study background of atorvastatin not only have lipid-lowering effect clear, in recent years, statins, anti-inflammatory, anti oxidative stress, increase endothelial cells function in the pleiotropic effects become effective in the prevention and treatment of many alternative approaches to clinical disease. Statin intervention patients showed obvious anti-inflammatory in coronary heart disease, renal function protection after operation. Even a single loading dose of preoperative administration showed renal protective effect satisfactory. But in surgery, most retrospective studies are not consistent at the lack of prospective clinical evidence of loading dose of statin therapy. The purpose of this study hope the prospective randomized double-blind design of loading dose of statins in coronary artery bypass grafting in the exploration of statins in patients with cardiopulmonary bypass Potential regulation protect renal function and inflammation. Research methods by the ethics committee of Fuwai Hospital after the examination, this study included 96 patients, including 92 patients completed follow-up (atorvastatin group 47 cases, 45 patients in the placebo group). Patients were enrolled, according to the random number table, randomly divided into atorvastatin group and placebo group atorvastatin group were given atorvastatin 12 hours before 80mmg, 2 hours prior to surgery plus atorvastatin 40mmg, placebo group were given the same dose of placebo. The intraoperative and postoperative blood samples and record the relevant clinical variables and statistical analysis. Results: the results showed that two groups of patients with baseline information the basic level of atorvastatin group after NGAL was significantly lower than that of the placebo group, but the postoperative creatinine values between the two groups were no significant difference. In this study, atorvastatin can inhibit Th1 cells by Guan Yin Sub tendency, but there was no significant difference between the two groups of Th2 cell related cytokines content. The postoperative clinical outcome in comparison between the two groups, the incidence of acute kidney injury. No significant differences in postoperative atrial fibrillation, respiratory complications, blood transfusion rate, duration of mechanical ventilation and ICU stay were no significant difference of stroke. But the effect of atorvastatin in patients with statin group was lower than that of the placebo group, but there was no significant difference. Conclusion the results of this study show that under cardiopulmonary bypass in patients undergoing coronary artery transplantation preoperative loading dose of atorvastatin is effective and safe. A supporting lovastatin protect renal function after cardiac surgery, at the same time under extracorporeal circulation for the immune regulatory effect is one of the reduction of postoperative complications.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R654.2;R692

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

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本文編號：1666738