急性心肌梗死合并心原性休克患者应用VA-ECMO联合IABP的时机探索  

Impact of VA-ECMO combined with IABP and timing on outcome of patients with acute myocardial infarction complicated with cardiogenic shock

作　　者：潘晨亮[1] 赵晶[1] 胡思雄 雷鹏[1] 赵存瑞 苏昱润 蔡玮婷 张珊珊 闫志杰 卢安东 张博[1] 白明[1] Pan Chenliang;Zhao Jing;Hu Sixiong;Lei Peng;Zhao Cunrui;Su Yurun;Cai Weiting;Zhang Shanshan;Yan Zhijie;Lu Andong;Zhang Bo;Bai Ming(Heart Center,the First Hospital of Lanzhou University,Gansu Key Laboratory for Cardiovascular Diseases of Gansu Province,Lanzhou 730000,China)

机构地区：[1]兰州大学第一医院心脏中心、甘肃省心血管病临床医学研究中心,兰州730000

出　　处：《中华心血管病杂志》2023年第8期851-858,共8页Chinese Journal of Cardiology

基　　金：甘肃省科技重点研发计划项目(21YF5FA118);甘肃省青年科技基金计划项目(21JR7RA385)。

摘　　要：目的探讨急性心肌梗死合并心原性休克(AMICS)患者应用动脉-静脉体外膜肺氧合(VA-ECMO)联合主动脉内球囊反搏泵(IABP)的不同时机对患者预后的影响。方法本研究为前瞻性队列研究,纳入中国体外生命支持学会注册数据库中2019年3月至2022年3月于兰州大学第一医院心脏中心入组接受VA-ECMO支持的AMICS患者,根据是否联合IABP及联合时机,分为VA-ECMO单独组、VA-ECMO+IABP同期组和VA-ECMO+IABP非同期组。收集3组患者的人口学特征、危险因素、心电图和超声心动图检查结果、病情危重特点、冠状动脉介入手术结果及VA-ECMO相关参数及并发症等。主要临床终点为全因死亡事件,机械循环支持的安全性指标包括血红蛋白下降大于50 g/L、消化道出血、菌血症、下肢缺血、下肢血栓、急性肾损伤、肺水肿及卒中。采用Kaplan-Meier生存曲线分析3组患者随访30 d内的生存结局,以VA-ECMO+IABP同期组作为参考,采用多因素Cox回归模型评估AMICS患者VA-ECMO+IABP不同时机联合对30 d内预后的影响。结果本研究纳入68例应用VA-ECMO支持的AMICS患者,其中女性12例(17.6%),所有患者年龄(59.8±10.8)岁。VA-ECMO单独组19例,VA-ECMO+IABP同期组34例,VA-ECMO+IABP非同期组15例。VA-ECMO+IABP同期组ECMO撤机成功率明显高于VA-ECMO单独组及VA-ECMO+IABP非同期组(P均<0.05)。与VA-ECMO+IABP非同期组比较,其余两组ECMO支持时间较短、发生急性肾损伤并发症比例更低(P均<0.05),单独VA-ECMO组发生肺水肿的并发症比例更低(P<0.05)。院内存活患者在VA-ECMO+IABP同期组为28例,明显高于VA-ECMO单独组(9例)及VA-ECMO+IABP非同期组(7例)(P均<0.05);随访30 d内存活患者在VA-ECMO+IABP同期组为26例,明显高于VA-ECMO单独组(9例)及VA-ECMO+IABP非同期组(4例)(P均<0.05)。多因素Cox回归模型分析提示相较于VA-ECMO+IABP同期使用,单独VA-ECMO(HR=2.801,P=0.036)及VA-ECMO+IABP非同期使用(HR=2.985,P=0.033)与AMICS�Objective To investigate the impact of combined use and timing of arterial-venous extracorporeal membrane oxygenation(VA-ECMO)with intra-aortic balloon pump(IABP)on the prognosis of patients with acute myocardial infarction complicated with cardiogenic shock(AMICS).Methods This was a prospective cohort study,patients with acute myocardial infarction and cardiogenic shock who received VA-ECMO support from the Heart Center of Lanzhou University First Hospital from March 2019 to March 2022 in the registration database of the Chinese Society for Extracorporeal Life Support were enrolled.According to combination with IABP and time point,patients were divided into VA-ECMO alone group,VA-ECMO+IABP concurrent group and VA-ECMO+IABP non-concurrent group.Data from 3 groups of patients were collected,including the demographic characteristics,risk factors,ECG and echocardiographic examination results,critical illness characteristics,coronary intervention results,VA-ECMO related parameters and complications were compared among the three groups.The primary clinical endpoint was all-cause death,and the safety indicators of mechanical circulatory support included a decrease in hemoglobin greater than 50 g/L,gastrointestinal bleeding,bacteremia,lower extremity ischemia,lower extremity thrombosis,acute kidney injury,pulmonary edema and stroke.Kaplan-Meier survival curves were used to analyze the survival outcomes of patients within 30 days of follow-up.Using VA-ECMO+IABP concurrent group as reference,multivariate Cox regression model was used to evaluate the effect of the combination of VA-ECMO+IABP at different time points on the prognosis of AMICS patients within 30 days.Results The study included 68 AMICS patients who were supported by VA-ECMO,average age was(59.8±10.8)years,there were 12 female patients(17.6%),19 cases were in VA-ECMO alone group,34 cases in VA-ECMO+IABP concurrent group and 15 cases in VA-ECMO+IABP non-concurrent group.The success rate of ECMO weaning in the VA-ECMO+IABP concurrent group was significantly hi

关 键 词：心肌梗死 心原性休克 动脉-静脉体外膜肺氧合 主动脉内球囊反搏泵 联合时机 

分 类 号：R542.22[医药卫生—心血管疾病] R541.64[医药卫生—内科学]