体外膜肺氧合治疗暴发性心肌炎患者的临床研究

Clinical study of extracorporeal membrane oxygenation in patients with fulminant myocarditis

目的探讨体外膜肺氧合(ECMO)对暴发性心肌炎(FM)患者的临床治疗效果。方法收集2009年9月至2015年10月入住杭州市第一人民医院危重病医学科的8例FM患者,所有患者均为常规治疗疗效不佳,遂立即行静脉-动脉模式ECMO(VA-ECMO)辅助治疗。观察患者疗效,并对患者治疗前后肌酸激酶、肌酸激酶同工酶(CKMB)、肌钙蛋白Ⅰ、天冬氨酸氨基转移酶(AST)、乳酸脱氢酶(LDH)、血肌酐、血乳酸、心胸比例及左室射血分数(LVEF)进行比较。并根据股动静脉置管法将所有患者分成外科手术组及超声组,每组4例,比较两组患者置管时间及并发症的发生情况。结果 6例患者心功能恢复正常,成功撤机,2例患者由于心功能无法逆转最终死亡。ECMO辅助治疗后肌酸激酶[(586±461)U/L vs.(90±38)U/L,t=2.721,P=0.042]、血肌酐[(153±70)μmol/L vs.(966±20)μmol/L,t=3.866,P=0.012]、血乳酸[(6.25±3.67)mmol/L vs.(1.23±0.29)mmol/L,t=3.236,P=0.023]及LVEF[(0.21±0.16)vs.(0.47±0.05),t=4.416,P=0.007]较治疗前比较,差异均有统计学意义。同时,采用外科手术切开直视下股动静脉置管方法,所需时间为(72±10)min,超声引导下紧急留置了股动静脉管,所需时间为(24±5)min。两种方法比较,差异有统计学意义(t=7.908,P=0.004),且无其他不良反应及并发症发生。结论 ECMO是抢救FM的一种有效机械辅助方法,且联合超声引导下的股动静脉置管技术救治效果更好。

Objective To explore the clinical effect of the extracorporeal membrane oxygenation （ECMO） in patients with fulminant myocarditis （FM）. Methods Observing 8 FM patients admitted to Critical Care Medicine in Hangzhou First People＇s Hospital from September 2009 to October 2015. All patients accepted vein-artery extracorporeal membrane oxygenation （VA-ECMO） after unsatisfactory results with conventional therapy. The levels of creatine kinase, creatine kinase isoenzyme MB （CK-MB）, troponin I （TN I ）, aspartate aminotransferase （AST）, actate dehydrogenase （LDH）, serum creatinine, blood lactic acid, eardiothoracic ratio and left ventrieular ejection fraction （LVEF） before and after VA-ECMO were compared. Meanwhile, all the patients were divided into the surgical group and nltraphonie group accroding to catheter of femoral arterio-venous, 4 patients in each group, and the time of insertion and the occurrence of complications were compared. Results Six patients were successfully weaned off and fully recovered cardiac function, while 2 patients eventually died because of heart function irreversible. The levels of creatine kinase [（586 ± 461） U / L vs. （90 ± 38） U / L, t = 2.721, P = 0.042], serum creatinine [（153± 70） μmol / L vs. （966 ±20） μmol / L, t = 3.866, P= 0.012], blood lactic acid [（6.25 ± 3.67） mmol/ L vs. （1.23 ± 0.29） mmol / L, t = 3.236, P = 0.023] and LVEF [（0.21 ±0.16） vs. （0.47 ± 0.05）, t =4.416, P= 0.007] showed significant differences before and after VA- ECMO. The time of insertion in the ultraphonic group was much shorter than that in the surgical group [（24 ± 5） min vs. （72 ± 10） min, t = 7.908, P = 0.004], and no other adverse reactions and complications happened. Conclusion ECMO is one of the most effective mechanical circulation support devices, and combined with ultrasound can be better in FM patients.