重症急性左心收缩功能不全患者心脏超声评价及其与预后关系的研究

The echocardiographic evaluation and its predicted prognosis of acute left cardiac systolic dysfunction in critically ill patients

目的 通过评价重症急性左心收缩功能不全患者心脏超声表现,探讨其与预后的关系.方法 选2013年6月-2014年6月北京协和医院重症医学科收治的存在急性左心收缩功能不全患者,根据其心脏超声的不同表现分为全心弥漫抑制、左心弥漫抑制、冠状动脉相关节段抑制、非冠状动脉相关节段抑制,所有患者均进行规范的血流动力学治疗.记录患者使用强心药物时间、机械通气时间、住ICU时间及28 d病死率.结果 共纳入132例急性左心收缩功能不全患者,心脏超声表现为全心弥漫抑制者76例,左心弥漫抑制者21例,冠状动脉相关节段抑制者25例,非冠状动脉相关节段抑制者10例.冠状动脉相关节段抑制者基础冠心病的比例高（88.0％,22/25）.全心弥漫抑制者最常见的病因是全身性感染/感染性休克（63.2％,48/76）.28 d病死率全心弥漫抑制者为21.05％,左心弥漫抑制者为19.05％,冠状动脉相关节段抑制者为20.00％,非冠状动脉相关节段抑制者为1/10,差异有统计学意义（P＜0.001）.不同心脏超声表现者住ICU时间、机械通气时间、使用强心药物时间比较差异无统计学意义（P＞0.05）.有无基础左室舒张功能不全的全心弥漫抑制的急性左心收缩功能不全患者住ICU时间、机械通气时间、使用强心药物时间比较差异无统计学意义（P＞0.05）,合并基础左室舒张功能不全者病死率（5/7）高于未合并基础左室舒张功能不全者（15.94％）.结论 重症急性左心收缩功能不全患者不同心脏超声表现预后不同,需要建立包括左心收缩功能、左心舒张功能、有心功能评估的重症患者心功能评价体系,以进一步指导临床工作.

Objective The purpose of this study was to evaluate the significance of echocardiography for the prognosis of acute left c ardiac dysfunction in critically ill patients.Methods A prospective cohort study was conducted in patients with acute left cardiac dysfunction in the Department of Critical Care Medicine,Peking Union Medical College Hospital from June 2013 to June 2014.Patients were divided into four groups according to the echocardiographic manifestation,including biventricular failure,left ventricular failure,coronary related segmental movement disorder,non-coronary related segmental movement disorder.All patients were treated with standard hemodynamic therapy.The duration of cardiotonic drug use,the period of mechanical ventilation,the length of ICU stay and 28-day mortality rate were recorded.Results A total of 132 patients were retrospectively enrolled in this study.The incidence of coronary heart disease in the coronary related segmental movement disorder group （88.0%,22/25） was higher than that in the other three groups （P 〈 0.001）,while other general clinical information between groups at baseline was comparable （P 〉 0.05）.Sepsis or septic shock was the main cause of acute left cardiac systolic dysfunction.The 28-day mortality rate in biventricular failure group was 21.05%,19.05% in left ventricular failure group,20.00% in coronary related segmental movement disorder group,and 1/10 in non-coronary related segmental movement disorder group （P 〈 0.001）.However,the duration of cardiotonic drug use,the period of mechanical ventilation,and the length of ICU stay were similar in all groups （P 〉 0.05）.In biventricular failure group,previous history of left ventricular diastolic dysfunction significantly worsened the 28-day mortality rate （5/7,P 〈 0.001）.while diastolic dysfunction did not affect cardiotonic drug use,the period of mechanical ventilation and length of ICU stay （P 〉 0.05）.Conclusions The different echocardiographic features of acute left cardiac systolic dysfunction in critically ill patients predict the different prognosis.We need to setup an evaluation system including left cardiac systolic/diastolic function and right cardiac function,which may improve the process of workflow.