Zhou Yating,Yi Min,Qiu Hongxiang,et al.Establishing a nomogram model for predicting postoperative mortality risk in children with complex congenital heart disease[J].Journal of Clinical Pediatric Surgery,2023,22(01):48-55.[doi:10.3760/cma.j.cn101785-202201026-010]
复杂先天性心脏病患儿术后死亡风险列线图预测模型的建立
- Title:
- Establishing a nomogram model for predicting postoperative mortality risk in children with complex congenital heart disease
- Keywords:
- Infant; Newborn; Heart Diseases; Mortality; Nomograms; Statistics
- 摘要:
- 目的 建立复杂先天性心脏病(complex congenital heart disease,CCHD)患儿术后死亡风险的列线图预测模型,并验证其预测效能。方法 回顾性分析2018年1月至2019年12月重庆医科大学附属儿童医院胸心外科收治并行体外循环下开胸手术的354例CCHD患儿临床资料。运用单因素分析、多因素Logistic回归分析筛选CCHD患儿术后死亡的独立危险因素。根据筛选结果建立列线图预测模型,并评价模型效能。结果 经单因素分析和多因素Logistic回归分析发现,正性肌力药物评分升高(OR=1.113,95%CI:1.055~1.175)、白细胞计数增多(OR=1.140,95%CI:1.044~1.245)、血红蛋白降低(OR=0.973,95%CI:0.949~0.998)、白蛋白减少(OR=0.907,95%CI:0.838~0.983)和术前有心肺复苏史(OR=36.656,95%CI:5.187~259.037)是CCHD患儿术后死亡的独立危险因素。以上述5项独立危险因素为输入变量建立列线图预测模型,输出变量为总分,总分值越大,死亡概率越大,反之越小;经计算该模型C-index为0.898,受试者工作特征曲线下面积(area under curve,AUC)为0.899(95%CI:0.821~0.976),校正曲线贴近于理想曲线,说明该列线图模型具有良好的预测效能,其最佳截取值为36分。结论 正性肌力药物评分高、白细胞计数增高、血红蛋白降低、白蛋白减少和有术前心肺复苏史是CCHD患儿术后死亡的独立危险因素,根据危险因素建立的列线图模型具有良好的预测效能。当患儿的列线图总分≥36分时应引起高度重视,采取更为积极的诊疗干预措施以改善患儿预后。
- Abstract:
- ObjectiveTo construct a nomogram model for predicting the mortality risk of postoperative in children with complex congenital heart disease (CCHD) and validate its predictive potence.MethodsFrom January 2018 to December 2019,a retrospective review was conducted for 354 CCHD children undergoing cardiopulmonary bypass (CPB) thoracotomy.And independent risk factors for postoperative mortality were screened by univariate and multivariate Logistic regression analyses and constructing a nomogram prediction model.ResultsThe independent postoperative mortality risk factors for CCHD children were as follows:inotropic score increased(IS,OR=1.113,95%CI:1.055-1.175),white blood cell increased(WBC,OR=1.140,95%CI:1.044-1.245),hemoglobin decreased(HB,OR=0.973,95%CI:0.949-0.998),albumin decreased(ALB,OR=0.907,95%CI:0.838-0.983) and cardiopulmonary resuscitation-preoperative (CPR-pre,OR=36.656,95%CI:5.187-259.037).A nomogram prediction model was constructed with the above risk factors as input variables and output variable was total score.The higher total scores,the greater of mortality and vice versa.This model verification showed that C-index and area under curve (AUC) were 0.898 and 0.899 respectively.And calibration curve was close to ideal,indicating decent prediction and discriminant validity.Also the optimal cut-off value was 36.ConclusionIS,WBC,HB,ALB and CPR-pre are independent postoperative mortality risk factors for CCHD children.The nomogram model constructed on the basis of five risk factors offers excellent predictive accuracy.Individuals with a total score ≥36 should raise a high alert and more aggressive intervention is required for a better prognosis.
参考文献/References:
[1] Krishna MR,Kumar RK.Diagnosis and management of critical congenital heart diseases in the newborn[J].Indian J Pediatr,2020,87(5):365-371.DOI:10.1007/s12098-019-03163-4.
[2] Go AS,Mozaffarian D,Roger VL,et al.Heart disease and stroke statistics-2014 update:a report from the American Heart Association[J].Circulation,2014,129(3):e28-e292.DOI:10.1161/01.cir.0000441139.02102.80.
[3] 罗雯懿,章雅青.儿童先天性心脏病术后心脏康复干预的研究进展[J].解放军护理杂志,2020,37(10):68-70.DOI:10.3969/j.issn.1008-9993.2020.10.017. Luo WY,Zhang YQ.Research progress on postoperative cardiac rehabilitation intervention for children with congenital heart disease[J].Nurs J Chin PLA,2020,37(10):68-70.DOI:10.3969/j.issn.1008-9993.2020.10.017.
[4] 李康明.5 kg以下先天性心脏病患儿体外循环手术危险因素分析[D].重庆:重庆医科大学,2020.DOI:10.27674/d.cnki.gcyku.2020.000070. Li KM.Analysis of surgical risk factors in children with congenital heart disease less than 5kg[D].Chongqing:Chongqing Medical University,2020.DOI:10.27674/d.cnki.gcyku.2020.000070.
[5] 郭小峰,陈兴澎,李斌.不同术前体质量先天性心脏病新生儿开胸术后早期死亡危险因素分析[J].安徽医学,2019,40(5):553-557.DOI:10.3969/j.issn.1000-0399.2019.05.024. Guo XF,Chen XP,Li B.Risk factors of early death after thoracotomy in neonates with congenital heart disease with different preoperative body mass[J].Anhui Med J,2019,40(5):553-557.DOI:10.3969/j.issn.1000-0399.2019.05.024.
[6] 崔晓征,沈冬炎,邹鹏,等.先天性心脏病患儿行体外循环心脏手术围术期死亡危险因素分析[J].疑难病杂志,2020,19(11):1084-1090.DOI:10.3969/j.issn.1671-6450.2020.11.002. Cui XZ,Shen DY,Zou P,et al.Analysis of perioperative mortality factors in children with congenital heart disease undergoing cardiopulmonary by-pass[J].Chin J Diffic Complicat Cases,2020,19(11):1084-1090.DOI:10.3969/j.issn.1671-6450.2020.11.002.
[7] Parikh CR,Greenberg JH,McArthur E,et al.Incidence of ESKD and mortality among children with congenital heart disease after cardiac surgery[J].Clin J Am Soc Nephrol,2019,14(10):1450-1457.DOI:10.2215/CJN.00690119.
[8] 任春年,吴春,潘征夏,等.儿童先天性心脏病手术后重症肺炎的风险预测研究[J].第三军医大学学报,2021,43(2):109-116.DOI:10.16016/j.1000-5404.202007232. Ren CN,Wu C,Pan ZX,et al.Risk prediction for severe pneumonia following congenital heart disease surgery in children[J].J Third Mil Med Univ,2021,43(2):109-116.DOI:10.16016/j.1000-5404.202007232.
[9] Xiong ZC,Deng GZ,Huang XJ,et al.Score for the survival probability in metastasis breast cancer:a nomogram-based risk assessment model[J].Cancer Res Treat,2018,50(4):1260-1269.DOI:10.4143/crt.2017.443.
[10] Mavrouois C,Backer CL.小儿心脏外科学[M].刘锦纷,孙彦隽,译.第4版.北京:世界图书出版公司,2014. Mavrouois C,Backer CL.Pediatric Cardiac Surgery[M].Liu JF,Sun YJ,Translated (4th Ed).Beijing:World Publishing Corporation,2014.
[11] Pollack MM,Patel KM,Ruttimann UE.PRISM III:an updated pediatric risk of mortality score[J].Crit Care Med,1996,24(5):743-752.DOI:10.1097/00003246-199605000-00004.
[12] 莫绪明.我国小儿先心病外科面临的挑战与思考[J].临床小儿外科杂志,2016,15(3):209-211.DOI:10.3969/j.issn.1671-6353.2016.03.001. Mo XM.Challenge and thinking of pediatric congenital heart disease surgery in China[J].J Clin Ped Sur,2016,15(3):209-211.DOI:10.3969/j.issn.1671-6353.2016.03.001.
[13] 龚书榕,张颖蕊,于荣国.小儿重症及复杂先天性心脏病术后急性呼吸窘迫综合征的危险因素分析[J].南方医科大学学报,2016,36(12):1660-1666.DOI:10.3969/j.issn.1673-4254.2016.12.12. Gong SR,Zhang YR,Yu RG.Risk factors for acute respiratory distress syndrome following surgeries for pediatric critical and complex congenital heart disease[J].J South Med Univ,2016,36(12):1660-1666.DOI:10.3969/j.issn.1673-4254.2016.12.12.
[14] Krishnamurthy G,Ratner V,Bacha E,et al.Comorbid conditions in neonates with congenital heart disease[J].Pediatr Crit Care Med,2016,17(8):S367-S376.DOI:10.1097/PCC.0000000000000832.
[15] 陶立元,张华,赵一鸣.列线图的制作要点及其应用[J].中华儿科杂志,2017,55(5):323.DOI:10.3760/cma.j.issn.0578-1310.2017.05.002. Tao LY,Zhang H,Zhao YM.The main points of making nomogram and its application[J].Chin J Pediatr,2017,55(5):323.DOI:10.3760/cma.j.issn.0578-1310.2017.05.002.
[16] 张婷婷,庄周颖,管咏梅,等.复杂型先天性心脏病患儿术后危重程度评分的初步构建探索[J].中国实用护理杂志,2016,32(2):86-90.DOI:10.3760/cma.j.issn.1672-7088.2016.02.002. Zhang TT,Zhuang ZY,Guan YM,et al.Exploration on the construction of severity of illness scoring systems in children with complex congenital heart disease after heart surgery[J].Chin J Prac Nurs,2016,32(2):86-90.DOI:10.3760/cma.j.issn.1672-7088.2016.02.002.
[17] 宋晓琪,杜欣为,王顺民,等.基于回归分析和机器学习的先天性心脏病患儿术后住院死亡预测模型的建立-单中心12年大数据汇总分析[J].中华胸心血管外科杂志,2020,36(2):65-73.DOI:10.3760/cma.j.issn.1001-4497.2020.02.001. Song XQ,Du XW,Wang SM,et al.Construction of patient-level prediction model for in-hospital mortality in congenital heart disease surgery:regression and machine learning analysis[J].Chin J Thorac Cardiovasc Surg,2020,36(2):65-73.DOI:10.3760/cma.j.issn.1001-4497.2020.02.001.
[18] Chang Junior J,Binuesa F,Caneo LF,et al.Improving preoperative risk-of-death prediction in surgery congenital heart defects using artificial intelligence model:a pilot study[J].PLoS One,2020,15(9):e0238199.DOI:10.1371/journal.pone.0238199.
[19] Scherer B,Moser EAS,Brown JW,et al.Vasoactive-ventilation-renal score reliably predicts hospital length of stay after surgery for congenital heart disease[J].J Thorac Cardiovasc Surg,2016,152(5):1423-1429.e1.DOI:10.1016/j.jtcvs.2016.07.070.
[20] 任洁.先天性心脏病术后患儿血管活性药物评分与预后关系[D].重庆:重庆医科大学,2018. Ren J.Vasoactive-inotropic score as a predictor of outcome in children after cardiac-surgury with bypass[D].Chongqing:Chongqing Medical University,2018.
[21] Haponiuk I,Jaworski R,Paczkowski K,et al.Postoperative kinetics of common inflammatory biomarkers after congenital heart defect procedures with extracorporeal circulation in children[J].Kardiol Pol,2018,76(6):968-973.DOI:10.5603/KP.a2018.0038.
[22] 吕瑛,李小兵,黄建成,等.低体重婴幼儿危重先心病合并肺部感染的外科治疗[J].河北医科大学学报,2020,41(12):1406-1411.DOI:10.3969/j.issn.1007-3205.2020.12.010. Lyu Y,Li XB,Huang JC,et al.Surgical treatment for severe acute congenital heart disease in low body weight infants with pulmonary infection[J].J Hebei Med Univ,2020,41(12):1406-1411.DOI:10.3969/j.issn.1007-3205.2020.12.010.
[23] Mukaida H,Matsushita S,Inotani T,et al.Continuous renal replacement therapy with a polymethyl methacrylate membrane hemofilter suppresses inflammation in patients after open-heart surgery with cardiopulmonary bypass[J].J Artif Organs,2018,21(2):188-195.DOI:10.1007/s10047-018-1025-6.
[24] Ly R,Compain F,Gaye B,et al.Predictive factors of death associated with infective endocarditis in adult patients with congenital heart disease[J].Eur Heart J Acute Cardiovasc Care,2021,10(3):320-328.DOI:10.1177/2048872620901394.
[25] Swartz MF,Makhija P,Rubenstein J,et al.Met-hemoglobin is a biomarker for poor oxygen delivery in infants following surgical palliation[J].World J Pediatr Congenit Heart Surg,2019,10(4):485-491.DOI:10.1177/2150135119852327.
[26] Duque-Sosa P,Martínez-Urbistondo D,Echarri G,et al.Perioperative hemoglobin area under the curve is an independent predictor of renal failure after cardiac surgery.Results from a Spanish multicenter retrospective cohort study[J].PLoS One,2017,12(2):e0172021.DOI:10.1371/journal.pone.0172021.
[27] Azhar AS,Aljefri HM.Predictors of extended length of hospital stay following surgical repair of congenital heart diseases[J].Pediatr Cardiol,2018,39(8):1688-1699.DOI:10.1007/s00246-018-1953-1.
[28] Shevell AH,Sahakian SK,Nguyen Q,et al.Associations between postoperative management in the critical care unit and adolescent developmental outcomes following cardiac surgery in infancy:an exploratory study[J].Pediatr Crit Care Med,2020,21(11):e1010-e1019.DOI:10.1097/PCC.0000000000002398.
[29] Goldberg JF,Shah MD,Kantor PF,et al.Prevalence and severity of anemia in children hospitalized with acute heart failure[J].Congenit Heart Dis,2016,11(6):622-629.DOI:10.1111/chd.12355.
[30] Arques S.Serum albumin and cardiovascular disease:state-of-the-art review[J].Ann Cardiol Angeiol (Paris),2020,69(4):192-200.DOI:10.1016/j.ancard.2020.07.012.
[31] Henry BM,Borasino S,Ortmann L,et al.Perioperative serum albumin and its influence on clinical outcomes in neonates and infants undergoing cardiac surgery with cardiopulmonary bypass:a multi-centre retrospective study[J].Cardiol Young,2019,29(6):761-767.DOI:10.1017/S1047951119000738.
[32] Schiller O,Goldshmid O,Mowassi S,et al.The utility of albumin level as a marker of postoperative course in infants undergoing repair of congenital heart disease[J].Pediatr Cardiol,2020,41(5):939-946.DOI:10.1007/s00246-020-02339-6.
[33] Kempny A,Diller GP,Alonso-Gonzalez R,et al.Hypoalbuminaemia predicts outcome in adult patients with congenital heart disease[J].Heart,2015,101(9):699-705.DOI:10.1136/heartjnl-2014-306970.
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黄金狮.新生儿胃肠穿孔78例诊治分析[J].临床小儿外科杂志,2010,9(02):0.
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备注/Memo
收稿日期:2022-01-12。
基金项目:重庆市科卫联合医学科研项目(2019MSXM006)
通讯作者:易敏,Email:744173239@qq.com