小儿心脏机械辅助循环设备的临床应用及选择

Clinical application and choice of mechanical circulatory support devices in children

目的探讨机械辅助循环设备在心力衰竭患儿中的临床使用及辅助方式的选择。方法回顾性分析上海儿童医学中心2005年1月至2015年12月使用离心泵心室辅助（VAD）和体外膜肺氧合（ECMO）的临床资料及使用经验。共使用机械辅助设备60例，其中先天性心脏畸形手术后54例，暴发性心肌炎6例，所有患儿都因为循环功能衰竭或心律失常使用机械辅助。其中，使用VAD患儿32例（VAD组），ECMO支持26例（ECMO组），使用VAD后转为ECMO（VAD-ECMO组）2例。结果VAD组机械辅助时间3-458h，成功脱离支持22例，出院20例（62．50％）；ECMO组辅助时间26-498h，成功撤离的16例，出院14例（53．85％）；VAD-ECMO组出院0例。60例患儿主要的死亡原因是出血（8例）和神经系统并发症（5例）。左冠状动脉异常起源于肺动脉（ALCAPA）患儿是VAD组中最主要的病种，其存活率达81．82％（9／11）。结论心力衰竭患儿可以选择VAD和ECMO进行心脏功能支持。ALCAPA患儿使用VAD效果满意。各类畸形使用机械辅助循环的效果无明显差异。对于VAD和ECMO的选择，先天性心脏畸形患儿应根据其心脏畸形特点，左、右心室功能，呼吸功能及年龄因素来进行判断，同时应兼考虑并发症及医疗费用的问题；暴发性心肌炎的患儿以ECMO为宜。

Objective To explore the clinical application of centrifugal ventricular assist device （VAD） and extracorporeal membrane oxygenation （ECMO） at Shanghai Children＇s Medical Center and summarize the experiences of selecting an ideal method of mechanical circulatory support （MCS） in pediatric cases. Methods From January 2005 to December 2015, 60 Eases were support by MCS devices. There were congenital heart defects （n = 56） and acute myocarditis （n = 4）. The mechanical circulatory support devices were used for supporting circulatory functions because of heart failure or arrhythmia. Thirty-two cases were supported with centrifugal VAD （VAD group） and 26 with ECMO （ECMO group） and other 2 cases were started by VAD then transferred to ECMO （VAD-ECMO group）. Results The duration for VAD was from 3 to 458 hours. Twenty-two cases were weaned and 20（62. 50%） were successfully discharged. The duration of ECMO was from 26 to 498 hours. Sixteen cases were weaned and 14 （53. 85%） successfully discharged. None survived in VAD-ECMO group. Bleeding and neurological complications were two major mortal causes. ALCAPA （anomalous origin of coronary artery from pulmonary artery） cases had the biggest ratio in VAD group and the survival rate was 81.82%. Conclusions Pediatric patients with cardiac failure are suitable for VAD and ECMO supports. Cardiac function, respiratory function, age, complications and costs should be considered for selecting from these two methods.