機(jī)械循環(huán)支持與心原性休克case

1、病例簡(jiǎn)介l 患者，女性，35歲，既往史無殊。l 主訴：發(fā)熱2天伴寒戰(zhàn)、肌痛。l 體檢：體溫39.1，血壓95/60（72）mmHg，心率 110 BPM，呼吸 20次/分，氧飽和度100（氧流量2L/min）。四肢冷，肺音清，心音聽診示心動(dòng)過速，未及第三、第四心音或摩擦音。l 患者很快出現(xiàn)低血壓狀態(tài)，需靜滴去甲腎上腺素（12gKg/min）以維持血壓。l 實(shí)驗(yàn)室檢查：肌鈣蛋白3.89ng/mL（正常范圍0-0.08ng/mL），靜脈乳酸3.5mmol/L（正常范圍0.50-2.20mmol/L），白血細(xì)胞計(jì)數(shù)17.0109/L（正常范圍3.5-9.1109/L），血紅蛋白12.4g/dL（正常

2、范圍13.3-16.2g/dL），肝腎功能在正常范圍。病例簡(jiǎn)介l 心電圖：竇性心動(dòng)過速，下側(cè)壁導(dǎo)聯(lián)ST段抬高。病史簡(jiǎn)介l 胸部CTA：雙側(cè)胸腔少量積液，未示肺栓塞表現(xiàn)。l 床旁經(jīng)胸超聲心動(dòng)圖：大量心包積液，下腔靜脈擴(kuò)張，右心房和右心室（RV）舒張期塌陷。LVEF目測(cè)估計(jì)為45至50。l 冠狀動(dòng)脈造影：正常。病例簡(jiǎn)介l 左右側(cè)心導(dǎo)管檢查結(jié)果(Table 1)病例簡(jiǎn)介l 由于大量心包積液導(dǎo)致的舒張期壓力上升，盡管升壓藥物劑量快速增加但患者仍然出現(xiàn)日益惡化的酸中毒，持續(xù)的低血壓和心動(dòng)過速。于是病人被送往手術(shù)室行心包開窗術(shù)以治療心包填塞。l 盡管心包開窗術(shù)成功，但術(shù)中患者休克狀態(tài)惡化，給予緊急安置IA

3、BP。隨后患者在初診后24小時(shí)內(nèi)被轉(zhuǎn)運(yùn)至哥倫比亞大學(xué)醫(yī)學(xué)中心心血管科進(jìn)一步診治。l 到達(dá)中心時(shí)患者血壓83/63（70）mmHg，竇速130bpm，盡管1：1IABP支持下血壓可充至90mmHg，并已給予米力農(nóng)0.25g/Kgmin和去甲腎上腺素15g/Kgmin靜滴，但4小時(shí)之前病人的尿量已經(jīng)減少到15cm3/h，留置的Swan-Ganz肺動(dòng)脈漂浮導(dǎo)管提示增高的充盈壓和低心輸出量(Table 2)。l 考慮給予機(jī)械輔助循環(huán)支持治療。病例簡(jiǎn)介病例簡(jiǎn)介病例簡(jiǎn)介l 病人被送往手術(shù)室行CentriMag BIVAD植入，同時(shí)行心內(nèi)膜心肌活檢送病理檢查。術(shù)中經(jīng)食道超聲心動(dòng)圖顯示小心腔，LVEF50%

4、with medical therapy (Class II; Level of Evidence B)Current Recommendations for MCSCurrent Recommendations for MCSHFSA comprehensive HF practice guidelines：l Patients awaiting heart transplantation who have become refractory to all means of medical circulatory support should be considered for an MCS

5、 device as a BTT (Level of Evidence B)l Permanent mechanical assistance with an implantable LVAD may be considered in highly selected patients with severe HF refractory to conventional therapy who are not candidates for heart transplantation, particularly those who cannot be weaned from intravenous

6、inotropic support at an experienced HF center (Level of Evidence B)Current Recommendations for MCSCurrent Recommendations for MCSHFSA comprehensive HF practice guidelines：l Patients with refractory HF and hemodynamic instability and/or compromised end-organ function with relative contraindications t

7、o cardiac transplantation or permanent MCS expected to improve with time or restoration of an improved hemodynamic profile should be considered for urgent MCS as a bridge to decision; these patients should be referred to a center with expertise in the management of patients with advanced HF (Level o

8、f Evidence C)Current Recommendations for MCSCurrent Recommendations for MCSCanadian HF guidelines：l MCS may be offered to selected individuals with end-stage heart failure who are inotrope dependent and do not meet the traditional criteria for cardiac transplantation (Class IIb; Level of Evidence B)

9、Current Recommendations for MCSCurrent Recommendations for MCSESC guidelines 2008/2010：l Current indications for LVADs and artificial hearts include bridging to transplantation and managing patients with acute, severe myocarditis (Class IIa; Level of Evidence C)l Although experience is limited, these devices may be considered for long-term use when no definitive procedure