感染性心内膜炎患者术后院内死亡危险因素分析及其预测价值

Analysis of risk factors for in-hospital mortality in patients with infective endocarditis after surgery and their predictive value

摘要:

目的 分析感染性心内膜炎（IE）患者术后院内死亡的危险因素，为临床提供改善疾病进程和预后的决策依据，同时进一步完善现有IE预后评估体系。方法 回顾性分析2019年1月—2021年3月在广东省人民医院确诊IE并行手术治疗的225例患者的临床资料，按照预后情况，分为死亡组12例和对照组213例。比较两组患者的术前因素、术中因素和术后因素；采用多因素向后逐步Logistic回归模型分析IE患者术后院内死亡的危险因素；绘制受试者工作特征（ROC）曲线。结果 225例IE患者术后院内死亡12例（5.3%）。血培养阳性51例（22.7%），均属革兰阳性菌，其中链球菌38例（74.5%）、葡萄球菌7例（13.7%）、肠球菌4例（7.8%）、缺陷乏氧菌1例（2.0%）、空气罗斯菌1例（2.0%）。死亡组与对照组的性别构成、年龄、体重、吸烟史占比、家族史占比、高血压占比、糖尿病占比、脑血管疾病占比、心外科手术史占比、入院前使用抗生素史占比、主动脉瓣周脓肿占比、合并先天性心脏病占比、血培养阳性占比、CRP水平、白细胞计数、中性粒细胞计数、CK-MB水平、赘生物直径、左室舒张期末直径、左室射血分数、主动脉阻断时间、使用人工瓣膜占比、赘生物培养阳性占比、抗生素使用时间、住院时间比较，差异均无统计学意义（P >0.05）。死亡组术前心力衰竭占比、术前BNP水平、术前PCT水平、二次IE手术占比、体外循环时间、累及多个瓣膜占比、肺部感染占比、CRRT占比、IABP辅助占比、重插管占比、呼吸机使用时间、ICU停留时间均高于对照组（P <0.05）。多因素向后逐步Logistic回归分析结果显示：累及多个瓣膜［O^R =3.216（95% CI：1.144，9.040）］、肺部感染［O^R =4.926（95% CI： 2.132，11.380）］、IABP辅助［O^R =2.112（95% CI：1.205，3.703）］、二次IE手术［O^R =1.870（95% CI： 1.007，3.474）］是IE术后院内死亡的独立危险因素（P <0.05）。建立回归方程：Logit（P） =-5.984+1.594×肺部感染+1.168×累及多个瓣膜+0.626×二次IE手术+0.748×IABP辅助；ROC曲线分析结果显示，该模型联合预测的曲线下面积为0.967（95% CI：0.913，1.000），敏感性为91.7%（95% CI：0.646，0.985），特异性为96.2%（95% CI：0.706，1.000）。结论 二次IE手术、手术累及多个瓣膜、术后肺部感染、术后需要IABP辅助治疗均为IE患者术后院内死亡的危险因素；对比单个预测因子，模型联合对IE患者术后院内死亡的预测价值更高。

Abstract:

Objective To analyze the predictive factors for in-hospital mortality after surgery in patients with infective endocarditis (IE) and provide healthcare professionals with opportunities to alter disease progression and improve prognosis. This study also aims to add value to existing factors known to affect the prognosis of IE.Methods A retrospective analysis was conducted on the clinical data of 225 patients diagnosed with IE and treated surgically at Guangdong Provincial People's Hospital from January 2019 to March 2021. Patients were divided into a death group (n = 12) and a control group (n = 213) based on their outcomes. Univariate analysis and multivariate logistic regression were used to identify risk factors for in-hospital mortality.Results Of the 225 IE patients, 12 (5.3%) died postoperatively. The median age was 49 years (range 35-59), and 180 patients (80%) were male. Blood cultures were positive in 51 cases (22.7%), all of which were Gram-positive bacteria, including 38 cases of streptococcus (74.5%), 7 cases of staphylococcus (13.7%), 4 cases of enterococcus (7.8%), 1 case of defective anaerobe (2.0%), and 1 case of Aeribacillus aerius (2.0%). Preoperative heart failure, preoperative BNP levels, preoperative PCT levels, reoperation for IE, cardiopulmonary bypass time, involvement of multiple valves, pulmonary infection, CRRT, IABP support, duration of ventilator use, reintubation, and ICU stay were significantly different between the death group and the control group (P < 0.05). These factors were higher in the death group compared to the control group. However, there were no significant differences in gender, age, smoking history, family history, weight, hypertension, diabetes, cerebrovascular disease, congenital heart disease, history of cardiac surgery, antibiotic use before admission, positive blood culture, CRP levels, white blood cell count, neutrophil count, CKMB levels, aortic root abscess, vegetation diameter, left ventricular ejection fraction, left ventricular end-diastolic diameter, aortic cross-clamp time, use of artificial valves, positive vegetation culture, and antibiotic use time (P > 0.05). Multivariate backward stepwise logistic regression analysis revealed that involvement of multiple valves [O^R = 3.216 (95% CI: 1.144, 9.040)], pulmonary infection [O^R = 4.926 (95% CI: 2.132, 11.380)], IABP support [O^R = 2.112 (95% CI: 1.205, 3.703)], and reoperation for IE [O^R = 1.870 (95% CI: 1.007,3.474)] were independent risk factors for in-hospital mortality after IE surgery (P < 0.05). The regression equation was Logit(P) = -5.984 + 1.594 × pulmonary infection + 1.168 × involvement of multiple valves + 0.626 × reoperation for IE + 0.748 × IABP support. The ROC curve showed that the combined prediction model had an AUC of 0.967 (95% CI: 0.931, 1.000) ,sensitivity of 0.917 (95% CI: 0.646, 0.985), and specificity of 0.962 (95% CI: 0.706, 1.000).Conclusion Reoperation for IE, involvement of multiple valves, postoperative pulmonary infection, and postoperative need for IABP support increase the risk of in-hospital mortality in patients with IE. Compared to individual predictors, the application value of the combined prediction model is higher in clinical practice.