机械循环支持在成人急性暴发性心肌炎合并心源性休克患者中的应用价值

摘要

目的 回顾性总结主动脉内球囊反搏(IABP)与体外膜肺氧合(ECMO)在成人急性暴发性心肌炎(AFM)合并心源性休克(CS)患者中的应用价值.方法 回顾性分析2011年2月至2017年2月首都医科大学附属北京安贞医院收治的12例AFM合并CS患者的病历资料,根据使用机械循环支持方式分为IABP组(8例)和ECMO组(4例),收集2组患者基线资料,各种药物治疗比例,临时起搏器、连续肾脏替代治疗及机械通气应用情况,入室至置入机械循环辅助装置时间及其辅助时间和住院期间预后,以及并发症发生情况等数据.结果 ECMO组左心室射血分数低于IABP组[(33±6)％比(42±8)％],差异有统计学意义(P=0.059);2组患者性别、年龄、心律失常、左心室舒张末期内径、左心室收缩末期内径、血流动力学指标和实验室指标水平比较差异均无统计学意义(均P＞0.1).ECMO组抗菌药物使用比例高于IABP组(3例比4例),差异有统计学意义(P =0.081);2组患者糖皮质激素、丙种球蛋白、正性肌力药物、抗病毒及保肝药物等应用比例比较差异均无统计学意义(均P＞0.1).2组患者临时起搏器、连续肾脏替代治疗、机械通气治疗比例比较差异均无统计学意义(均P＞0.1);ECMO组4例、IABP组3例患者应用有创机械通气治疗,2组有创机械通气治疗比例比较差异有统计学意义(P =0.081).IABP组入室到置入IABP时间及辅助时间、行紧急体外心肺复苏术和住院期间存活比例比较差异均无统计学意义(均P＞0.1).IABP组感染3例,其中肺部感染2例,深静脉置管相关感染1例;ECMO组肺部感染4例,其中2例合并穿刺置管部位感染;2组患者感染发生率比较差异有统计学意义(P =0.081);2组患者出血、下肢缺血及栓塞、急性肾损伤、神经系统损伤和多器官功能障碍综合征等并发症发生率比较差异均无统计学意义(均P＞0.1).结论 IABP或ECMO辅助均能为AFM合并CS患者提供有效的循环辅助,尽早主动应用ECMO效果好于被迫使用.%Objective To investigate the clinical values of intra-aortic balloon pump(IABP) and extracorporeal membrane oxygenation(ECMO) in acute fulminant myocarditis (AFM) patients with cardiogenic shock (CS).Methods Clinical data of 12 AFM patients with CS in Beijing Anzhen Hospital,Capital Medical University were retrospectively analyzed from February 2011 to February 2017.The patients were divided into IABP group(n =8) and ECMO group (n =4).Baseline information,medication,uses of temporary pacemaker,continuous renal replacement therapy and mechanical ventilation,time between admission and mechanical circulatory support,supporting time,in-hospital prognosis and complications were analyzed.Results Left ventricular ejection fraction in ECMO group was lower than that in IABP group [(33 ± 6) ％ vs (42 ± 8) ％] (P =0.059).Gender,age,arrhythmia,left ventricular end-diastolic diameter,left ventricular end-systolic diameter,hemodynamics and laboratory indicators were similar between groups(all P ＞ 0.1).Use rate of antibiotics in ECMO group was higher than that in IABP group(3 vs 4,P =0.081).There was no significant difference of use rates of glucocorticoids,gamma globulin,positive inotropic agents,antiviral and hepatoprotective drugs,temporary pacemaker,continuous renal replacement therapy and mechanical ventilation between groups(all P ＞ 0.1).There were 4 cases in ECMO group and 3 cases in IABP group treated with invasive mechanical ventilation(P =0.081).Admission to mechanical circulation time and mechanical supporting time,rates of emergency extracorporeal cardiopulmonary resuscitation and in-hospital survival showed no significant difference between groups (all P ＞ 0.1).There were 3 cases of infection including 2 cases of pulmonary infection and 1 case of deep vein catheterization related infection in IABP group,and 4 cases of pulmonary infection in ECMO group,including 2 cases complicated with infection of puncture site;incidence of infection showed a significant difference between groups (P =0.081).There was no significant difference of complications such as hemorrhage,lower limb ischemia and embolism,acute renal injury,nervous system injury and multiple organ dysfunction syndrome between groups (P ＞ 0.1).Conclusions IABP and ECMO can provide effective circulation support for AFM with CS patients.Application of ECMO as early as possible is better than forced use.