探讨内皮素-1水平与单纯行主动脉瓣置换术患者术后新发房颤的关系。

回顾性分析2017年6月至2019年6月于首都医科大学附属北京安贞医院结构性心脏病外科中心单纯行主动脉瓣置换术的119例患者的临床资料，根据患者术后是否新发房颤分为术后房颤组(n＝28)和无术后房颤组(n＝91)。2组患者均于全身麻醉成功后取仰卧位，常规消毒铺巾，作胸部正中切口并劈开胸骨。切开心包并悬吊，肝素化后升主动脉、右心房二阶梯引流管插管建立体外循环，转机、降温，阻断循环，切开主动脉，探查主动脉瓣病变情况，剪除病变主动脉瓣，选择合适大小的人工主动脉瓣(机械瓣或生物瓣)进行置换，全周间断缝合。关闭主动脉切口。复温、排气，开放循环。并行稳定后停止体外循环，拔出动静脉管路。常规止血关胸，结束手术。统计患者术前各项资料中最可能影响术后房颤发生的因素[性别、年龄、体重指数、内皮素-1水平、基础疾病、美国纽约心脏病协会(NYHA)心功能分级、超声心动图指标]、术中资料(术中体外循环时间、主动脉阻断时间)及术后资料[术后机械通气时间、术后住院时间、行开胸止血术例数、使用何种类型人工瓣膜(机械瓣或生物瓣)]。数据比较采用t检验、非参数检验、χ²检验；通过受试者工作特征(ROC)曲线确定内皮素-1预测术后新发房颤的截断值；采用单因素和多因素Logistic回归分析与术后新发房颤相关的危险因素。

(1)术后房颤组患者的年龄为(53.0±12.1)岁，高于无术后房颤组[(47.1±13.6)岁]，术前内皮素-1水平为0.43±0.19，高于无术后房颤组(0.27±0.14)，NYHA分级≥3级患者比例为14.3%(4/28)，高于无术后房颤组[4.4%(4/91)]，左心房直径为(40.6±4.8) mm，大于无术后房颤组[(36.7±5.2 ) mm]，主动脉瓣狭窄患者比例为39.3%(11/28)，低于无术后房颤组[60.4%(55/91)]，2组比较差异均有统计学意义(P<0.05)；其他术前资料比较差异均无统计学意义(P>0.05)。(2)术后房颤组患者术中体外循环时间为(113.9±41.7) min，主动脉阻断时间为(75.3±24.1) min，无术后房颤组患者术中体外循环时间为(108.6±46.3) min，主动脉阻断时间为(72.5±31.4) min，2组比较差异均无统计学意义(t＝－0.547、－0.432，P＝0.59、0.67)。(3)术后房颤组患者术后机械通气时间、术后住院时间分别为(24.7±14.3) h、(9.1±3.6) d，均大于无术后房颤组[(19.6±9.5) h、(7.6±2.9) d]；置换机械瓣患者比例为85.7%(24/28)，低于无术后房颤组[96.7%(88/91)]，置换生物瓣膜患者比例为14.3%(4/28)，高于无术后房颤组[3.3%(3/91)]，2组比较差异均有统计学意义(P<0.05)；术后房颤组患者术后行开胸止血术的比例为3.6%(1/28)，高于无术后房颤组[2.2%(2/91)]，2组比较差异无统计学意义(P>0.05)。(4)采用ROC曲线对内皮素-1预测术后新发房颤的价值进行分析可得，曲线下面积为0.76，95%CI：0.66～0.85，截断值0.265 pmol/L，特异度0.75，敏感度0.63。根据截断值将患者分为内皮素-1>0.265组(n＝55)和内皮素-1<0.265组(n＝64)，对2组患者术前、术中资料和术后资料进行比较，结果可得内皮素-1>0.265组患者左心房直径大于内皮素-1<0.265组患者，主动脉瓣狭窄患者比例低于内皮素-1<0.265组患者，术后新发房颤的发生率(38.2%)明显高于内皮素-1<0.265组(10.9%)，差异均有统计学意义(P<0.05)，其他各项比较差异均无统计学意义(P>0.05)。对收集到的患者资料进行单因素Logistic回归分析，发现年龄、NYHA分级≥3级、左心房直径、主动脉瓣狭窄、术后机械通气时间、置换生物瓣及内皮素-1>0.265 pmol/L均与术后新发房颤的发生相关；对以上指标进行多因素Logistic回归分析结果可得左心房直径、置换生物瓣和内皮素-1>0.265 pmol/L与患者术后新发房颤的发生呈独立相关。

在单纯行单纯主动脉瓣置换术的患者中，除左心房直径、置换生物瓣外，较高的内皮素-1水平也是患者发生术后新发房颤的独立危险因素。

To investigate the relationship between endothelin-1 level and new onset atrial fibrillation after isolated aortic valve replacement.

The clinical data of 119 patients who underwent isolated aortic valve replacement in the Structural Heart Surgery Center, Beijing Anzhen Hospital, Capital Medical University from June 2017 to June 2019 were retrospectively analyzed. According to whether the patients had postoperative new onset atrial fibrillation, they were divided into postoperative atrial fibrillation group (n=28) and non postoperative atrial fibrillation group (n=91). After the successful general anesthesia, the patients in both groups were taken to the supine position, routinely disinfected and covered with towels, a median chest incision was made and the sternum was split. The pericardium was cut and suspended. After heparinization, the ascending aorta and right atrium were intubated with two-step drainage tubes to establish extracorporeal circulation. The circulation was switched, cooled, blocked, the aorta was cut, the pathological condition of the aortic valve was explored, the pathological aortic valve was cut off, and the artificial aortic valve (mechanical valve or biological valve) of appropriate size was selected for replacement, and the whole week was sutured intermittently. After the aortic incision was closed, rewarmed, exhausted, and then the circulation was opened. After parallel stabilization, the cardiopulmonary bypass was stopped and the arteriovenous pipeline was pulled out. Routine hemostasis, chest closure, and the operation was end. The factors most likely to affect the occurrence of postoperative atrial fibrillation including the preoperative data [gender, age, body mass index, endothelin-1 level, basic diseases, New York Heart Association (NYHA) cardiac function classification, echocardiographic indicators], intraoperative data (intraoperative cardiopulmonary bypass time, aortic occlusion time), and postoperative data [postoperative mechanical ventilation time, postoperative hospital stay, number of cases undergoing thoracotomy hemostasis, and what type of artificial valve (mechanical valve or biological valve) was used] were collected. The data were compared by t test, nonparametric test and chi-square test; and the cut-off value of endothelin-1 for predicting postoperative new onset atrial fibrillation was determined by receiver operator characteristic (ROC) curve, univariate and multivariate Logistic regression were used to analyze the risk factors associated with postoperative new onset atrial fibrillation.

(1) The age of patients in the postoperative atrial fibrillation group was (53.0 ± 12.1) years old, higher than that in the non postoperative atrial fibrillation group [(47.1±13.6) years old], the preoperative endothelin-1 level was 0.43 ± 0.19, higher than that in the non postoperative atrial fibrillation group (0.27 ± 0.14), the proportion of patients with NYHA grade≥3 was 14.3%(4/28), higher than that in the non postoperative atrial fibrillation group [4.4%(4/91)], the left atrial diameter was (40.6±4.8) mm, higher than that in the non postoperative atrial fibrillation group [(36.7±5.2) mm], the proportion of patients with aortic stenosis was 39.3%(11/28), lower that that in the non postoperative atrial fibrillation group [60.4%(55/91)], the differences between the two groups were statistically significant (P<0.05); there was no atatistically significant differences in other preoperative data between the two groups (P> 0.05). (2) The intraoperative cardiopulmonary bypass time was (113.9±41.7) min and aortic blockade time was (75.3±24.1) min in postoperative atrial fibrillation group, and the intraoperative cardiopulmonary bypass time was (108.6±46.3) min and aortic blockade time was (72.5±31.4) min in non postoperative atrial fibrillation group, the differences were no statistically significant between the two groups (t=-0.547, -0.432; P=0.59, 0.67). (3) The postoperative mechanical ventilation time and postoperative hospitalization time of patients in the postoperative atrial fibrillation group were (24.7±14.3) h and (9.1±3.6) d respectively, which were higher than those in the non postoperative atrial fibrillation group [(19.6±9.5) h, (7.6±2.9) d]; the proportion of patients with mechanical valve replacement was 85.7%(24/28), lower than that in the non postoperative atrial fibrillation group [96.7%(88/91)], and the proportion of patients with biological valve replacement was 14.3% (4/28), higher than that in the non postoperative atrial fibrillation group [3.3% (3/91)], the differences between the two groups were statistically significant (P<0.05). The rate of postoperative hemostasis in the postoperative atrial fibrillation group was 3.6% (1/28), which was higher than that in the no postoperative atrial fibrillation group [2.2% (2/91)], and there was no statistically significant difference between the two groups (P>0.05). (4) ROC curve was used to analyze the value of endothelin-1 in predicting postoperative new onset atrial fibrillation after surgery, the area under the curve was 0.76, 95%CI: 0.66-0.85, the cut-off value was 0.265 pmol/L, the specificity was 0.75, and the sensitivity was 0.63. According to the cut-off value, patients were divided into endothelin-1>0.265 group (n=55) and endothelin-1<0.265 group (n=64). The preoperative, intraoperative and postoperative data of the two groups were compared, and the results showed that the left atrial diameter in the endothelin-1>0.265 group was larger than that in the endothelin-1<0.265 group, the proportion of patients with aortic valve stenosis was lower than that in the endothelin-1<0.265 group, and the incidence of postoperative atrial fibrillation in the endothelin-1>0.265 group (38.2%) was significantly higher than that in the endothelin-1< 0.265 group (10.9%), and the differences were statistically significant(P<0.05). And there was no significant difference in other comparisons (P>0.05). Univariate Logistic regression analysis was performed on the collected patient data and it was found that age, NYHA grade≥ 3, left atrial diameter, aortic valve stenosis, mechanical ventilation time, replacement of biological valve and endothelin-1 > 0.265 pmol/L were all associated with the occurrence of postoperative new onset atrial fibrillation; after multivariate regression Logistic analysis of the above indicators, it was found that only left atrial diameter, replacement biological valve and endothelin-1>0.265 pmol/L were independently related to the occurrence of postoperative new onset atrial fibrillation.

In patients undergoing isolated aortic valve replacement, in addition to left atrial diameter and replacement biological valve, high endothelin-1 level is also independent risk factor postoperative new onset atrial fibrillation.