上海交通大学学报（医学版）

上海交通大学学报（医学版） ›› 2026, Vol. 46 ›› Issue (9): 1242-1251.doi: 10.3969/j.issn.1674-8115.2026.09.009

• 论著 · 临床研究 • 上一篇    

双联合标志物对肥厚型梗阻性心肌病改良扩大Morrow术后早期风险的预测价值

石亚强1, 白晓宇1, 姜勇杰1, 刘俊2, 祁泉1,3()   

  1. 1.兰州大学第一临床医学院，兰州 730030
    2.同济大学附属东方医院心脏大血管外科，上海 200120
    3.兰州大学第一医院心外科，兰州 730030
  • 收稿日期:2025-12-29 接受日期:2026-03-16 出版日期:2026-09-09 发布日期:2026-09-09
  • 通讯作者: 祁　泉，主任医师，博士；电子信箱：quanqi@126.com。
  • 基金资助:
    甘肃省自然科学基金(23JRRA0923);甘肃省卫生健康行业科研项目(GSWSKY2020-49);兰州大学第一医院院内基金(ldyyyn2019-04)

Predictive value of combined biomarkers for early postoperative risk following the modified extended Morrow procedure for hypertrophic obstructive cardiomyopathy

Shi Yaqiang1, Bai Xiaoyu1, Jiang Yongjie1, Liu Jun2, Qi Quan1,3()   

  1. 1.The First School of Clinical Medical College, Lanzhou University, Lanzhou 730030, China
    2.Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University, Shanghai 200120, China
    3.Department of Cardiac Surgery, The First Hospital of Lanzhou University, Lanzhou 730030, China
  • Received:2025-12-29 Accepted:2026-03-16 Online:2026-09-09 Published:2026-09-09
  • Contact: Qi Quan, E-mail: quanqi@126.com.
  • Supported by:
    Natural Science Foundation of Gansu Province(23JRRA0923);Health Industry Scientific Research Project of Gansu Province(GSWSKY2020-49);Science Foundation of The First Hospital of Lanzhou University(ldyyyn2019-04)

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摘要：

目的·探讨肥厚型梗阻性心肌病（hypertrophic obstructive cardiomyopathy，HOCM）患者术前D-二聚体水平联合N末端B型利钠肽前体（N-terminal pro-B-type natriuretic peptide，NT-proBNP）比值对改良扩大Morrow术后早期主要不良心血管事件（major adverse cardiovascular event，MACE）的预测价值。方法·纳入2015年1月—2025年6月于兰州大学第一医院接受改良扩大Morrow术的HOCM患者。收集患者基线资料［人口统计学指标、症状与功能状态、既往病史、术前血液生物标志物水平（D-二聚体与NT-proBNP，计算后者经年龄-性别校正的比值）及术前超声心动图参数］和围术期资料。研究的主要结局为患者术后30 d内的MACE。采用Logistic回归构建临床基础变量模型、临床基础变量+NT-proBNP比值模型、临床基础变量+D-二聚体模型及临床基础变量联合双标志物（NT-proBNP比值与D-二聚体）模型4个预测模型。采用受试者操作特征曲线下面积、净重分类改善指数与综合判别改善指数评价模型效能，以校准曲线、Brier分数及决策曲线分析评估模型的校准度、预测准确性与临床适用性。根据NT-proBNP比值与D-二聚体的最佳截断值对患者进行风险分层，比较患者围术期风险与临床结局。结果·在最终纳入分析的83例患者中，共有21例于术后30 d内发生MACE，发生率为25.30%。联合双标志物模型展现出最优预测效能，其曲线下面积为0.935，优于临床基础变量模型及临床基础变量+任一单一标志物模型。与临床基础变量模型相比，联合双标志物模型的净重分类改善指数和综合判别改善指数分别为1.390及0.366（均P<0.001），校准度最佳（Hosmer‑Lemeshow检验P=0.767，Brier分数0.080），且决策曲线分析显示其在大部分阈值范围内净获益最高。根据NT-proBNP比值与D-二聚体最佳截断值划分的“双低”“单高”“双高”3组患者，其MACE发生率呈现显著风险梯度。此外，“双高”组患者的围术期临床过程更为复杂，其体外循环时间、主动脉阻断时间、术后机械通气时间及术后住院时长均长于“双低”组（均P<0.05）。结论·术前联合经年龄-性别校正的NT-proBNP比值与D-二聚体水平可构建高效、稳健的术后早期MACE风险预测模型。该策略在区分度、校准度及临床适用性方面均表现优异，能有效识别极高危患者，为个体化围术期管理提供客观依据。

关键词: 肥厚型梗阻性心肌病, D-二聚体, N末端B型利钠肽前体, 改良扩大Morrow术, 不良心血管事件

Abstract:

Objective ·To investigate the predictive value of the combination of preoperative D-dimer levels and the N-terminal pro-B-type natriuretic peptide (NT-proBNP) ratio for early major adverse cardiovascular events (MACE) following the modified extended Morrow procedure in patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods ·Patients with HOCM who underwent the modified extended Morrow procedure in the First Hospital of Lanzhou University between January 2015 and June 2025 were enrolled. Baseline data and perioperative data were collected for all patients. Baseline data included demographic indicators, symptoms and functional status, medical history, preoperative levels of blood biomarkers (D-dimer and NT-proBNP, with the latter calculated as an age- and sex-adjusted ratio), and preoperative echocardiographic parameters. The primary outcome was MACE within 30 days postoperatively. Four predictive models were constructed using Logistic regression: a model based on clinical baseline variables, a model combining clinical baseline variables with the NT-proBNP ratio, a model combining clinical baseline variables with D-dimer levels, and a model combining clinical baseline variables with two biomarkers (the ratio of NT-proBNP and the levels of D-dimer). Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Calibration accuracy, prediction accuracy, and clinical applicability were assessed using calibration curves, the Brier score, and decision curve analysis (DCA). Risk stratification of patients was performed using the optimal cut-off values for the NT-proBNP ratio and D-dimer, and perioperative risks and clinical outcomes were compared. Results ·Among the 83 patients included in the final analysis, 21 (25.30%) experienced MACE within 30 days postoperatively. The combined dual-biomarker model demonstrated the best predictive performance, with an AUC of 0.935, superior to the model based on clinical baseline variables and to any model combining clinical baseline variables with a single biomarker. Compared to the clinical baseline variable model, the combined dual-biomarker model showed an NRI of 1.390 and an IDI of 0.366 (both P<0.001). It also exhibited the best calibration (Hosmer-Lemeshow test P=0.767, Brier score 0.080), and DCA indicated the highest net benefit across a wide range of threshold probabilities. Patients were stratified into three groups (“dual-low”, “single-high”, and “dual-high”) based on the optimal cut-off values of the NT-proBNP ratio and D-dimer, revealing a significant risk gradient in MACE incidence. Furthermore, patients in the “dual-high” group had a more complex perioperative course, with significantly longer cardiopulmonary bypass time, aortic cross-clamp time, postoperative mechanical ventilation time, and postoperative hospital stay compared to those in the “dual-low” group (all P<0.05). Conclusion ·The preoperative combination of an age- and sex-adjusted NT-proBNP ratio and D-dimer levels can be used to construct an efficient and robust risk prediction model for early postoperative MACE. This strategy demonstrates excellent performance in discrimination, calibration, and clinical applicability, effectively identifying patients at extremely high risk and providing an objective basis for individualised perioperative management.

Key words: hypertrophic obstructive cardiomyopathy (HOCM), D-dimer, N-terminal pro-B-type natriuretic peptide (NT-proBNP), modified extended Morrow procedure, major adverse cardiovascular event (MACE)

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