体外膜肺氧合联合急诊经皮冠状动脉介入治疗抢救急性心肌梗死后心脏骤停患者的临床疗效及其影响因素分析

Effect of Extra-corporeal Membrane Cxygenation Combined With Percutaneous Coronary Intervention on Cardiac Arrest Patients due to Acute Myocardial Infarction

目的:探讨体外膜肺氧合(ECOM)联合急诊经皮冠状动脉(冠脉)介入治疗(PCI)抢救急性心肌梗死(AMI)后心脏骤停患者的临床疗效及临床结局的影响因素。方法:回顾性分析2015-01至2017-01期间于我院植入ECMO联合急诊PCI治疗AMI后心脏骤停患者37例的临床资料,男性28例(75.7%)。根据患者的生存情况分为存活组(n=17)和死亡组(n=20),比较两组的临床资料,分析影响患者预后的危险因素。结果:37例患者手术成功率100%,存活率45.9%(17/37)。两组患者的冠脉病变血管支数、罪犯血管的分布比较,差异均有统计学意义(P均<0.05),其中存活组的罪犯血管以右冠脉比例最高(52.94%),死亡组以左前降支比例最高(60.00%)。与死亡组比较,存活组患者的传统心肺复苏时间[(54.6±25.7)min vs(31.4±5.2)min]、发生心脏骤停至ECMO植入时间[(93.6±60.5)h vs(47.5±19.5)h]较短,心肺监护病房住院时间较长[16.0(8.7,32.6)d vs 4.0(2.0,12.0)d];植入ECMO 24 h、48 h后,存活组的平均动脉压[(89.6±21.9)mm Hg、(87.9±19.4)mm Hg,1 mm Hg=0.133k Pa]显著高于死亡组[(71.8±19.3)mm Hg、(63.7±18.6)mm Hg],差异均有统计学意义(P<0.05)。多因素非条件Logistic回归分析显示,左前降支(OR=0.723,95%CI:0.516~0.947)、病变血管支数(OR=1.638,95%CI:1.107~1.729)、更长的心肺复苏时间(OR=0.712,95%CI:0.436~0.973)和发生心脏骤停至ECMO植入时间(OR=0.698,95%CI:0.411~0.859)可能加重患者死亡的风险,而植入ECMO复苏后48 h的较高的平均动脉压(OR=0.672,95%CI:0.326~0.693)可能减少患者死亡的风险(P均<0.05)。结论:ECMO联合急诊PCI治疗AMI后心脏骤停,患者存活率高,且安全性较好。

Objectives： To investigate the clinical efficacy and influencing factors on clinical outcome of extracorporeal membrane oxygenation（ECMO） combined with percutaneous coronary intervention（PCI） on cardiac arrest patients due to acute myocardial infarction（AMI）.Methods： The clinical data of 37 cardiac arrest patients post AMI who underwent ECMO combined with emergency PCI therapy strategies from January 2015 to January 2017 were retrospectively analyzed. The clinical data of the surviving group（17 cases） and the death group（20 cases） were compared and the outcome determinants were investigated. Results： 37 patients were successfully treated with emergency PCI with the help of ECMO device, and the successful operation rate was 100%. The survival rate was 45.9%（17/37）. There was no significant difference in gender, age and past history between the two groups（P〈0.05）. The proportion of right coronary artery lesion was the highest（47.06%） in the surviving group, and the percent of the left anterior descending coronary artery lesion was the highest（60.00%） in the death group. Most patients（70.0%） inthe death group had three vessel lesions and around half the patients（52.9%） in the surviving group had two-vessel lesions. The time of traditional cardiopulmonary resuscitation（[31.4±5.2] min vs [54.6±25.7] min）,the time from cardiac arrest to ECMO（[47.5±19.5] h vs [93.6±60.5] h） were significantly shorter, while CCU time（16.0[8.7, 32.6] d vs 4.0[2.0, 12.0] d） was significantly longer in the surviving group compared to the death group（all P〈0.05）. The mean arterial pressure at 24 h and 48 h after ECMO was significantly higher in the surviving group（89.6±21.9,87.9±19.4） than in the death group（71.8±19.3, 63.7±18.6）（both P〈0.05）. Unconditional logistic regression analysis showed that left anterior descending artery lesion（OR=0.723, 95%CI：0.516-0.947）, higher lesion vessel number（OR=1.638,95%CI：1.107-1.729）, longer cardiopulmonary resuscitation time（OR=0.712, 95%CI：0.436-0.973）, prolonged cardiac arrest to ECMO placement time（OR=0.698, 95%CI：0.411-0.859） were risk factors of death, and the higher MBP at 48 h after ECMO（OR=0.672,95%CI：0.326-0.693） was the protective factor of death（all P〈0.05） in this patient cohort.Conclusions： ECMO combined with emergency PCI is safe and can improve the success rate of rescue in patients with cardiac arrest after acute myocardial infarction.