1、机械循环支持与心原性休克演示文稿（优选）机械循环支持与心原性休克病例简介l 患者，女性，35岁，既往史无殊。l 主诉：发热2天伴寒战、肌痛。l 体检：体温39.1，血压95/60（72）mmHg，心率 110 BPM，呼吸 20次/分，氧饱和度100（氧流量2L/min）。四肢冷，肺音清，心音听诊示心动过速，未及第三、第四心音或摩擦音。l 患者很快出现低血压状态，需静滴去甲肾上腺素（12gKg/min）以维持血压。l 实验室检查：肌钙蛋白3.89ng/mL（正常范围0-0.08ng/mL），静脉乳酸3.5mmol/L（正常范围0.50-2.20mmol/L），白血细胞计数17.0109/L（正
2、常范围3.5-9.1109/L），血红蛋白12.4g/dL（正常范围13.3-16.2g/dL），肝肾功能在正常范围。病例简介l 心电图：窦性心动过速，下侧壁导联ST段抬高。病史简介l 胸部CTA：双侧胸腔少量积液，未示肺栓塞表现。l 床旁经胸超声心动图：大量心包积液，下腔静脉扩张，右心房和右心室（RV）舒张期塌陷。LVEF目测估计为45至50。l 冠状动脉造影：正常。病例简介l 左右侧心导管检查结果(Table 1)病例简介l 由于大量心包积液导致的舒张期压力上升，尽管升压药物剂量快速增加但患者仍然出现日益恶化的酸中毒，持续的低血压和心动过速。于是病人被送往手术室行心包开窗术以治疗心包填塞。
3、l 尽管心包开窗术成功，但术中患者休克状态恶化，给予紧急安置IABP。随后患者在初诊后24小时内被转运至哥伦比亚大学医学中心心血管科进一步诊治。l 到达中心时患者血压83/63（70）mmHg，窦速130bpm，尽管1：1IABP支持下血压可充至90mmHg，并已给予米力农0.25g/Kgmin和去甲肾上腺素15g/Kgmin静滴，但4小时之前病人的尿量已经减少到15cm3/h，留置的Swan-Ganz肺动脉漂浮导管提示增高的充盈压和低心输出量(Table 2)。l 考虑给予机械辅助循环支持治疗。病例简介病例简介病例简介l 病人被送往手术室行CentriMag BIVAD植入，同时行心内膜心肌
4、活检送病理检查。术中经食道超声心动图显示小心腔，LVEF50%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 sh
5、ould be considered for an MCS 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
6、be weaned from intravenous 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 re
7、lative contraindications to 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
8、with advanced HF(Level of 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 II
9、b;Level of Evidence B)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 experien
10、ce is limited,these devices may be considered for long-term use when no definitive procedure is planned(Class IIb;Level of Evidence C)l LVAD may be considered as destination treatment to reduce mortality(Class IIa;Level of Evidence B)Current Recommendations for MCSCurrent Recommendations for MCS2014
11、中国心力衰竭诊断和治疗指南：急性心衰l 主动脉内球囊反搏(IABP)：可有效改善心肌灌注，又降低心肌耗氧量和增加心输出量。适应证（I类，B级）：AMI或严重心肌缺血并发心源性休克，且不能由药物纠正；伴血液动力学障碍的严重冠心病（如AMI伴机械并发症）；心肌缺血或急性重症心肌炎伴顽固性肺水肿；作为左心室辅助装置(LVAD)或心脏移植前的过渡治疗。对其他原因的心源性休克是否有益尚无证据。l 心室机械辅助装置（a类，B级）：急性心衰经常规药物治疗无明显改善时，有条件的可应用该技术。此类装置有体外模式人工肺氧合器(ECMO)、心室辅助泵（如可置人式电动左心辅助泵、全人工心脏）。根据急性心衰的不同类型，可选择应用心室辅助装置，在积极纠治基础心脏疾病的前提下，短期辅助心脏功能，也可作为心脏移植或心肺移植的过渡。ECMO可以部分或全部代替心肺功能。临床研究表明，短期循环呼吸支持（如应用ECMO）可明显改善预后。
