体外膜肺氧合与主动脉球囊反搏联合辅助救治心血管外科术后心原性休克:阜外医院单中心十一年经验总结
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摘要
目的:总结体外膜肺氧合(ECMO)与主动脉球囊反搏(IABP)联合辅助在心血管外科术后心原性休克(PCS)患者中的救治经验,分析影响疗效的因素。方法:回顾分析2006年2月至2017年3月阜外医院60例因PCS而接受ECMO与IABP联合辅助循环的患者临床资料。对比生存出院(成功脱机并存活出院)患者与非生存出院(撤机后院内死亡或未成功脱机)患者的临床特征,Logistic回归分析生存出院的独立预测因子。结果:38例(63.3%)患者于术中安装ECMO,22例(36.7%)患者于术后安装ECMO。38例(63.3%)患者ECMO与IABP同时安装。接受联合辅助患者的主要手术类型为心脏移植术23例(38.3%)和冠状动脉旁路移植术26例(43.3%)。ECMO成功脱机29例(48.3%),生存出院26例(43.3%)。生存出院患者的床边安装ECMO比例较非生存出院患者低(11.5%vs 41.2%, P=0.012),同期安装ECMO比例较非生存出院患者高(80.8%vs 50.0%, P=0.014)。Logistic回归分析显示,IABP同期安装ECMO是生存出院的独立预测因子(OR=0.177, 95%CI:0.044~0.718, P=0.015)。生存出院患者出现肾功能衰竭并发症比例(15.4%vs 58.8%, P=0.001)和多器官功能衰竭并发症比例(0%vs 29.4%, P=0.003)均较非生存出院患者低。生存出院患者远期随访发现,心脏移植术患者比其他手术患者有更好的远期生存率(P=0.0358)。结论:对于PCS患者,ECMO与IABP联合辅助是一种有效的短期生命支持治疗方法。同时安装IABP与ECMO进行循环辅助可能获得更好的短期临床结果。
Objectives: The aim of this study is to report the experience of combined application of extracorporeal membrane oxygenation(ECMO) with intra-aortic balloon pumping(IABP) in patients with postcardiotomy cardiac shock(PCS) in Fuwai hospital.Methods: A total of 60 consecutive patients who received both ECMO and IABP(concomitantly ≥ 24 hours) for PCS between February 2006 to March 2017 in Fuwai Hospital were included in this study. Clinical characteristics of the patients were collected retrospectively and compared between survivors and non-survivors. Logistic regression analysis was used for predictors for survival of discharge.Results: The mean age of patients was(51.4±12.7) years and 75.0% patients were males. ECMO was implanted intraoperatively in 38(63.3%) patients and post-operatively in 22(36.7%) patients. ECMO was implanted concurrently with IABP in38(63.3%) patients. Heart transplantation(38.3%) and coronary artery bypass graft(43.3%) were the main surgical procedures. ECMO was weaned successfully in 48.3% patients, and the rate of survival to discharge was 43.3%. Survivors received less bedside ECMO implantation(11.5% vs 41.2%, P=0.012) and more concurrent implantation of ECMO with IABP(80.8% vs 50.0%, P=0.014). Concurrent implantation of IABP with ECMO(OR=0.177, 95% CI: 0.044~0.718, P=0.015) was an independent predictor for survival to discharge. As for complications, the rate of renal failure(58.8% vs 15.4%, P=0.001) and multiple organ dysfunction syndrome(29.4% vs 0%, P=0.003) were significantly higher in non-survivors during hospitalization. Patients who had heart transplantation had a better long-term survival than patients with other surgeries(P=0.0358).Conclusions: ECMO combined with IABP, as a short-term mechanical life support, is an effective therapy option for patients with PCS. Concurrent implantation of ECMO with IABP provides better short-term outcome for patients with PCS.
Objectives: The aim of this study is to report the experience of combined application of extracorporeal membrane oxygenation(ECMO) with intra-aortic balloon pumping(IABP) in patients with postcardiotomy cardiac shock(PCS) in Fuwai hospital.Methods: A total of 60 consecutive patients who received both ECMO and IABP(concomitantly ≥ 24 hours) for PCS between February 2006 to March 2017 in Fuwai Hospital were included in this study. Clinical characteristics of the patients were collected retrospectively and compared between survivors and non-survivors. Logistic regression analysis was used for predictors for survival of discharge.Results: The mean age of patients was(51.4±12.7) years and 75.0% patients were males. ECMO was implanted intraoperatively in 38(63.3%) patients and post-operatively in 22(36.7%) patients. ECMO was implanted concurrently with IABP in38(63.3%) patients. Heart transplantation(38.3%) and coronary artery bypass graft(43.3%) were the main surgical procedures. ECMO was weaned successfully in 48.3% patients, and the rate of survival to discharge was 43.3%. Survivors received less bedside ECMO implantation(11.5% vs 41.2%, P=0.012) and more concurrent implantation of ECMO with IABP(80.8% vs 50.0%, P=0.014). Concurrent implantation of IABP with ECMO(OR=0.177, 95% CI: 0.044~0.718, P=0.015) was an independent predictor for survival to discharge. As for complications, the rate of renal failure(58.8% vs 15.4%, P=0.001) and multiple organ dysfunction syndrome(29.4% vs 0%, P=0.003) were significantly higher in non-survivors during hospitalization. Patients who had heart transplantation had a better long-term survival than patients with other surgeries(P=0.0358).Conclusions: ECMO combined with IABP, as a short-term mechanical life support, is an effective therapy option for patients with PCS. Concurrent implantation of ECMO with IABP provides better short-term outcome for patients with PCS.
引文
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[2] Ko WJ, Lin CY, Chen RJ, et al. Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenie shock[J].Ann Thorac Surg, 2002, 73(2):538-545. DOI:10. 1016/S0003-4975(01)03330-6.
[3] Zhong Z, Jiang C, Yang F, et al. Veno-arterial extracorporeal membrane oxygenation support in patients undergoing aortic surgery[J]. Artif Organs, 2017, 41(12):1113-1120. DOI:10. 1111/aor.12951.
[4] Rastan AJ, Dege A, Mohr M, et al. Early and late outcomes of 517consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock[J].J Thorac Cardiovasc Surg, 2010, 139(2):302-311. DOI:10. 1016/j.jtcvs. 2009. 10. 043.
[5] Doll N, Kiaii B, Borger M, et al. Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock[J]. Ann Thorac Surg-2004, 77(1):151-157. DOI:10. 1016/S0003-4975(03)01329-8.
[6] Wu MY, Lin PJ, Lee MY, et al. Using extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock:treatment strategies and predictors of short-term and midterm survival[J].Resuscitation, 2010,81(9):1111-1116. DOI:10.1016/j.resuscitation.2010. 04. 031.
[7] Petroni T, Harrois A, Amour J, et al. Intra-aortic balloon pump effects on macrocirculation and microcirculation in cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation[J]. Crit Care Med, 2014, 42(9):2075-2082. DOI:10.1097/CCM.0000000000000410.
[8] Brechot N, Demondion P, Santi F, et al. Intra-aortic balloon pump protects against hydrostatic pulmonary oedema during peripheral venoarterial-extracorporeal membrane oxygenation[J]. Eur Heart J Acute Cardiovasc Care, 2017, 7(1):62-69. DOI:2048872617711169.
[9] Yang F, Jia ZS, Xing JL, et al. Effects of intra-aortic balloon pump on cerebral blood flow during peripheral venoarterial extracorporeal membrane oxygenation support[J]. J Transl Med, 2014, 12:106.DOI:10. 1186/1479-5876-12-106.
[10] Acheampong B, Johnson JN, Stulak JM, et al. Postcardiotomy ECMO support after high-risk operations in adult congenital heart disease[J]. Congenit Heart Dis, 2016, 11(6):751-755. DOI:10. 1111/chd. 12396
[11]赵忠.体外膜肺氧合与心脏顿抑[J].中国循环杂志,1997(2):80-82.
[12] Gass A, Palaniswamy C, Aronow WS, et al. Peripheral venoarterial extracorporeal membrane oxygenation in combination with intraaortic balloon counterpulsation in patients with cardiovascular compromise[J]. Cardiology, 2014, 129(3):137-143. DOI:10.1159/000365138.
[13] Aso S,Matsui H,Fushimi K,et al. The effect of intraaortic balloon pumping under venoarterial extracorporeal membrane oxygenation on mortality of cardiogenic patients:an analysis using a nationwide inpatient database[J]. Crit Care Med, 2016, 44(11):1974-1979. DOI:10. 1097/CCM. 0000000000001828.
[14] Lin LY, Liao CW, Wang CH, et al. Effects of additional intra-aortic balloon counter-pulsation therapy to cardiogenic shock patients supported by extra-corporeal membranous oxygenation[J]. Sci Rep,2016, 6:23838. DOI:10. 1038/srep23838.
[15] Cheng R, Hachamovitch R, Makkar R, et al. Lack of survival benefit found with use of intraaortic balloon pump in extracorporeal membrane oxygenation:a pooled experience of 1517 patients[J].J Invasive Cardiol, 2015, 27(10):453-458. DOI:10. 1016/j.jacc.2014. 07. 096.
[16] Elsharkawy HA, Li L, Esa WA, et al. Outcome in patients who require venoarterial extracorporeal membrane oxygenation support after cardiac surgery[J]. J Cardiothorac Vase Anesth, 2010, 24(6):946-951. DOI:10. 1053/j. jvca. 2010. 03. 020.
[17] Mikus E, Tripodi A, Calvi S, et al. CentriMag venoarterial extracorporeal membrane oxygenation support as treatment for patients with refractory postcardiotomy cardiogenic shock[J]. ASAIO J,2013, 59(1):18-23. DOI:10. 1097/MAT. 0b013e3182768b68.
[18] Unosawa S, Sezai A, Hata M, et al. Long-term outcomes of patients undergoing extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock[J]. Surg Today, 2013, 43(3):264-270. DOI:10. 1007/s00595-012-0322-6.
[19] Wang JG, Han J, Jia YX, et al. Outcome of veno-arterial extracorporeal membrane oxygenation for patients undergoing valvular surgery[J]. PLoS One, 2013, 8(5):e63924. DOI:10. 1371/journal. pone. 0063924.
[20]龙村,胡盛寿,刘晋萍,等.体外膜肺氧合支持治疗39例心肺功能衰竭患者的临床经验[J].中国循环杂志,2007(5):373-376.
[2] Ko WJ, Lin CY, Chen RJ, et al. Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenie shock[J].Ann Thorac Surg, 2002, 73(2):538-545. DOI:10. 1016/S0003-4975(01)03330-6.
[3] Zhong Z, Jiang C, Yang F, et al. Veno-arterial extracorporeal membrane oxygenation support in patients undergoing aortic surgery[J]. Artif Organs, 2017, 41(12):1113-1120. DOI:10. 1111/aor.12951.
[4] Rastan AJ, Dege A, Mohr M, et al. Early and late outcomes of 517consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock[J].J Thorac Cardiovasc Surg, 2010, 139(2):302-311. DOI:10. 1016/j.jtcvs. 2009. 10. 043.
[5] Doll N, Kiaii B, Borger M, et al. Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock[J]. Ann Thorac Surg-2004, 77(1):151-157. DOI:10. 1016/S0003-4975(03)01329-8.
[6] Wu MY, Lin PJ, Lee MY, et al. Using extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock:treatment strategies and predictors of short-term and midterm survival[J].Resuscitation, 2010,81(9):1111-1116. DOI:10.1016/j.resuscitation.2010. 04. 031.
[7] Petroni T, Harrois A, Amour J, et al. Intra-aortic balloon pump effects on macrocirculation and microcirculation in cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation[J]. Crit Care Med, 2014, 42(9):2075-2082. DOI:10.1097/CCM.0000000000000410.
[8] Brechot N, Demondion P, Santi F, et al. Intra-aortic balloon pump protects against hydrostatic pulmonary oedema during peripheral venoarterial-extracorporeal membrane oxygenation[J]. Eur Heart J Acute Cardiovasc Care, 2017, 7(1):62-69. DOI:2048872617711169.
[9] Yang F, Jia ZS, Xing JL, et al. Effects of intra-aortic balloon pump on cerebral blood flow during peripheral venoarterial extracorporeal membrane oxygenation support[J]. J Transl Med, 2014, 12:106.DOI:10. 1186/1479-5876-12-106.
[10] Acheampong B, Johnson JN, Stulak JM, et al. Postcardiotomy ECMO support after high-risk operations in adult congenital heart disease[J]. Congenit Heart Dis, 2016, 11(6):751-755. DOI:10. 1111/chd. 12396
[11]赵忠.体外膜肺氧合与心脏顿抑[J].中国循环杂志,1997(2):80-82.
[12] Gass A, Palaniswamy C, Aronow WS, et al. Peripheral venoarterial extracorporeal membrane oxygenation in combination with intraaortic balloon counterpulsation in patients with cardiovascular compromise[J]. Cardiology, 2014, 129(3):137-143. DOI:10.1159/000365138.
[13] Aso S,Matsui H,Fushimi K,et al. The effect of intraaortic balloon pumping under venoarterial extracorporeal membrane oxygenation on mortality of cardiogenic patients:an analysis using a nationwide inpatient database[J]. Crit Care Med, 2016, 44(11):1974-1979. DOI:10. 1097/CCM. 0000000000001828.
[14] Lin LY, Liao CW, Wang CH, et al. Effects of additional intra-aortic balloon counter-pulsation therapy to cardiogenic shock patients supported by extra-corporeal membranous oxygenation[J]. Sci Rep,2016, 6:23838. DOI:10. 1038/srep23838.
[15] Cheng R, Hachamovitch R, Makkar R, et al. Lack of survival benefit found with use of intraaortic balloon pump in extracorporeal membrane oxygenation:a pooled experience of 1517 patients[J].J Invasive Cardiol, 2015, 27(10):453-458. DOI:10. 1016/j.jacc.2014. 07. 096.
[16] Elsharkawy HA, Li L, Esa WA, et al. Outcome in patients who require venoarterial extracorporeal membrane oxygenation support after cardiac surgery[J]. J Cardiothorac Vase Anesth, 2010, 24(6):946-951. DOI:10. 1053/j. jvca. 2010. 03. 020.
[17] Mikus E, Tripodi A, Calvi S, et al. CentriMag venoarterial extracorporeal membrane oxygenation support as treatment for patients with refractory postcardiotomy cardiogenic shock[J]. ASAIO J,2013, 59(1):18-23. DOI:10. 1097/MAT. 0b013e3182768b68.
[18] Unosawa S, Sezai A, Hata M, et al. Long-term outcomes of patients undergoing extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock[J]. Surg Today, 2013, 43(3):264-270. DOI:10. 1007/s00595-012-0322-6.
[19] Wang JG, Han J, Jia YX, et al. Outcome of veno-arterial extracorporeal membrane oxygenation for patients undergoing valvular surgery[J]. PLoS One, 2013, 8(5):e63924. DOI:10. 1371/journal. pone. 0063924.
[20]龙村,胡盛寿,刘晋萍,等.体外膜肺氧合支持治疗39例心肺功能衰竭患者的临床经验[J].中国循环杂志,2007(5):373-376.