体外膜肺氧合救治心血管术后心原性休克患者的研究
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摘要
目的:分析静脉-动脉体外膜肺氧合(VA-ECMO)对心血管术后心原性休克(PCS)的疗效及其影响因素。方法:回顾分析阜外医院2005年1月1日至2017年12月31日152例因PCS接受VA-ECMO辅助循环的成人患者临床资料。对比生存出院(成功脱机并存活出院)患者(n=73)与非生存出院(撤机后院内死亡和未成功脱机)患者(n=79)的临床特征,采用多因素Logistic回归分析法分析生存出院的独立预测因子。结果:49例(32.2%)患者在安装VA-ECMO同时启动了主动脉内球囊反搏(IABP)辅助,28例(18.4%)患者在安装VA-ECMO前后启动了IABP辅助。VA-ECMO的总体脱机率为56.6%,院内死亡率为52.0%(79/152)。生存出院患者与非生存出院患者相比,术前合并高血压比例(15.1%vs 35.4%)、ECMO安装前二次开胸比例(19.2%vs 39.2%)、ECMO安装前心跳骤停或心室颤动发生率(11.0%vs 34.2%)、床旁ECMO安装比例(11.0%vs 41.8%)均较低,而心脏移植手术(45.2%vs 20.3%)和同时启动IABP比例(41.1%vs 24.1%)均较高(P均<0.05)。多因素Logistic回归分析显示,同时启动IABP是生存出院的唯一独立保护因素(OR=0.375,95%CI:0.146～0.963,P=0.041)。同时启动ECMO和IABP者与单用ECMO者相比,需要持续血滤治疗的比例(30.6%vs 49.3%)和神经系统并发症发生率(8.2%vs 22.7%)均较低,但血栓形成发生率增高(18.4%vs 2.7%),差异均有统计学意义(P均<0.05)。结论:在接受ECMO治疗的PCS患者中,同时联合IABP辅助可以带来更好的生存获益,而且可以减少由于外周灌注不足引起的肾脑并发症。
Objectives: Veno-arterial extracorporeal membrane oxygenation(VA-ECMO) is widely used in postcardiotomy cardiac shock(PCS). In this study, we analyzed the outcomes, predictive factors and complications of ECMO use for PCS.Methods: A total of 152 consecutive adult patients, who received VA-ECMO(>24 hours) for PCS in Fuwai Hospital,were included. We retrospectively collected data including the baseline characteristics, outcomes and complications from these patients. Baseline characteristics were compared between survivors(n=73) with non-survivors(n=79), and logistic regression was performed to identify predictive factors for in-hospital mortality.Results: The mean age of the subjects was(49.5±14.1) years, with a male-dominancy of 73.7%. Intra-aortic balloon pumping(IABP) was initiated concurrently with ECMO in 32.2% subjects and sequentially in 18.4% subjects. The ECMO weaning rate was 56.6%, and the in-hospital mortality was 52.0%. When compared with non-survivors, survivors had less hypertension(15.1% vs 35.4%, P=0.004), pre-ECMO secondary thoracotomy(19.2% vs 39.2%, P=0.007), pre-ECMO cardiac arrest/ventricular fibrillation(11.0% vs 34.2%, P=0.001), bedside implantation of ECMO(11.0% vs 41.8%, P<0.001), and more transplant procedure(45.2% vs 20.3%, P=0.001), and concurrent IAPB initiation with ECMO(41.1% vs 24.1%, P=0.025).Multivariate Logistic regression indicated concurrent IABP initiation with ECMO was the only independent protective factor for in-hospital mortality(OR=0.375, P=0.041, 95% CI: 0.146-0.963). Concurrent IABP initiation with ECMO had less need for continuous renal replacement therapy(30.6% vs 49.3%, P=0.039) and less neurological complications(8.2% vs 22.7%, P=0.035),but more thrombosis complications(18.4% vs 2.7%, P=0.007).Conclusions: Concurrent initiation of IABP with ECMO is associated with better short-term survival and reduced hypoperfusion-induced renal and cerebral complications for PCS in this patient cohort.
Objectives: Veno-arterial extracorporeal membrane oxygenation(VA-ECMO) is widely used in postcardiotomy cardiac shock(PCS). In this study, we analyzed the outcomes, predictive factors and complications of ECMO use for PCS.Methods: A total of 152 consecutive adult patients, who received VA-ECMO(>24 hours) for PCS in Fuwai Hospital,were included. We retrospectively collected data including the baseline characteristics, outcomes and complications from these patients. Baseline characteristics were compared between survivors(n=73) with non-survivors(n=79), and logistic regression was performed to identify predictive factors for in-hospital mortality.Results: The mean age of the subjects was(49.5±14.1) years, with a male-dominancy of 73.7%. Intra-aortic balloon pumping(IABP) was initiated concurrently with ECMO in 32.2% subjects and sequentially in 18.4% subjects. The ECMO weaning rate was 56.6%, and the in-hospital mortality was 52.0%. When compared with non-survivors, survivors had less hypertension(15.1% vs 35.4%, P=0.004), pre-ECMO secondary thoracotomy(19.2% vs 39.2%, P=0.007), pre-ECMO cardiac arrest/ventricular fibrillation(11.0% vs 34.2%, P=0.001), bedside implantation of ECMO(11.0% vs 41.8%, P<0.001), and more transplant procedure(45.2% vs 20.3%, P=0.001), and concurrent IAPB initiation with ECMO(41.1% vs 24.1%, P=0.025).Multivariate Logistic regression indicated concurrent IABP initiation with ECMO was the only independent protective factor for in-hospital mortality(OR=0.375, P=0.041, 95% CI: 0.146-0.963). Concurrent IABP initiation with ECMO had less need for continuous renal replacement therapy(30.6% vs 49.3%, P=0.039) and less neurological complications(8.2% vs 22.7%, P=0.035),but more thrombosis complications(18.4% vs 2.7%, P=0.007).Conclusions: Concurrent initiation of IABP with ECMO is associated with better short-term survival and reduced hypoperfusion-induced renal and cerebral complications for PCS in this patient cohort.
引文
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[4] Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure:the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC)developed with the special contribution of the Heart Failure Association(HFA)of the ESC[J]. Eur Heart J, 2016, 37(27):2129-2200. DOI:10.1093/eurheartj/ehw128.
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[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] Sugiura A, Abe R, Nakayama T, et al. Predictors of successful weaning from veno-arterial extracorporeal membrane oxygenation after coronary revascularization for acute myocardial infarction complicated by cardiac arrest:a retrospective multicenter study[J/OL]. Shock,(2018-08-03)[2019-02-24]. https://insights.ovid.com/crossref?an=00024382-900000000-97770. DOI:10.1097/SHK.0000000000001220.
[8] Chen SW, Tsai FC, Lin YS, et al. Long-term outcomes of extracorporeal membrane oxygenation support for postcardiotomy shock[J]. J Thorac Cardiovasc Surg, 2017, 154(2):469-477 e2. DOI:10.1016/j.jtcvs.2017.02.055.
[9] Khorsandi M, Dougherty S, Bouamra O, et al. Extra-corporeal membrane oxygenation for refractory cardiogenic shock afteradult cardiac surgery:a systematic review and meta-analysis[J]. J Cardiothorac Surg, 2017, 12:55. DOI:10.1186/s13019-017-0618-0.
[10] Slottosch I,Liakopoulos O, Kuhn E,et al. Outcomes after peripheral extracorporeal membrane oxygenation therapy for postcardiotomy cardiogenic shock:a single-center experience[J]. J Surg Res, 2013,181(2):e47-e55.DOI:10.1016/j.jss.2012.07.030.
[11] 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.
[12] Bakhtiary F, Keller H, Dogan S, et al. Venoarterial extracorporeal membrane oxygenation for treatment of cardiogenic shock:clinical experiences in 45 adult patients[J]. J Thorac Cardiovasc Surg, 2008,135(2):382-388. DOI:10.1016/j.jtcvs.2007.08.007.
[13] Saxena P, Neal J, Joyce LD, et al. Extracorporeal membrane oxygenation support in postcardiotomy elderly patients:the Mayo Clinic experience[J]. Ann Thorac Surg, 2015, 99(6):2053-2060.DOI:10.1016/j.athoracsur.2014.11.075.
[14] 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.
[15] 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.
[16] 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.
[17] 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.
[2] Smith C, Bellomo R, Raman JS, et al. An extracorporeal membrane oxygenation-based approach to cardiogenic shock in an older population[J]. Ann Thorac Surg, 2001, 71(5):1421-1427. DOI:10.1016/S0003-4975(00)02504-2.
[3] Abrams D, Combes A, Brodie D. Extracorporeal membrane oxygenation in cardiopulmonary disease in adults[J]. J Am Coll Cardiol, 2014, 63(25):2769-2778. DOI:10.1016/j.jacc.2014.03.046.
[4] Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure:the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC)developed with the special contribution of the Heart Failure Association(HFA)of the ESC[J]. Eur Heart J, 2016, 37(27):2129-2200. DOI:10.1093/eurheartj/ehw128.
[5] McCarthy FH, McDermott KM, Kini V, et al. Trends in U.S.extracorporeal membrane oxygenation use and outcomes:2002-2012[J]. Semin Thorac Cardiovasc Surg,2015,27(2):81-88. DOI:10.1053/j.semtcvs.2015.07.005.
[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] Sugiura A, Abe R, Nakayama T, et al. Predictors of successful weaning from veno-arterial extracorporeal membrane oxygenation after coronary revascularization for acute myocardial infarction complicated by cardiac arrest:a retrospective multicenter study[J/OL]. Shock,(2018-08-03)[2019-02-24]. https://insights.ovid.com/crossref?an=00024382-900000000-97770. DOI:10.1097/SHK.0000000000001220.
[8] Chen SW, Tsai FC, Lin YS, et al. Long-term outcomes of extracorporeal membrane oxygenation support for postcardiotomy shock[J]. J Thorac Cardiovasc Surg, 2017, 154(2):469-477 e2. DOI:10.1016/j.jtcvs.2017.02.055.
[9] Khorsandi M, Dougherty S, Bouamra O, et al. Extra-corporeal membrane oxygenation for refractory cardiogenic shock afteradult cardiac surgery:a systematic review and meta-analysis[J]. J Cardiothorac Surg, 2017, 12:55. DOI:10.1186/s13019-017-0618-0.
[10] Slottosch I,Liakopoulos O, Kuhn E,et al. Outcomes after peripheral extracorporeal membrane oxygenation therapy for postcardiotomy cardiogenic shock:a single-center experience[J]. J Surg Res, 2013,181(2):e47-e55.DOI:10.1016/j.jss.2012.07.030.
[11] 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.
[12] Bakhtiary F, Keller H, Dogan S, et al. Venoarterial extracorporeal membrane oxygenation for treatment of cardiogenic shock:clinical experiences in 45 adult patients[J]. J Thorac Cardiovasc Surg, 2008,135(2):382-388. DOI:10.1016/j.jtcvs.2007.08.007.
[13] Saxena P, Neal J, Joyce LD, et al. Extracorporeal membrane oxygenation support in postcardiotomy elderly patients:the Mayo Clinic experience[J]. Ann Thorac Surg, 2015, 99(6):2053-2060.DOI:10.1016/j.athoracsur.2014.11.075.
[14] 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.
[15] 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.
[16] 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.
[17] 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.