体外膜肺氧合治疗老年心原性休克患者预后和影响因素分析

Extracorporeal membrane oxygenation in treating elderly patients with acute myocardial infarction complicated with cardiogenic shock: analysis of prognosis and risk factors

目的比较体外膜肺氧合(ECMO)治疗老年急性心肌梗死合并心原性休克(CS)患者的短期效果和影响因素。方法回顾性分析2011年1月至2018年7月河南省胸科医院收治的55例老年急性心肌梗死合并心原性休克患者的临床资料。根据预后分为存活组(41例)和死亡组(14例)。分析两组的基线资料,比较两组住院期间的预后情况,包括临时起搏器、连续肾脏替代治疗、机械通气应用和并发症。单因素和多因素Logistic回归评估影响病死率的危险因素。结果55例患者中,男性30例(54.5%),平均为(67.2±5.3)岁。从入急诊室到置入ECMO时间为(8.6±6.3)h,辅助时间为(143.2±61.7)h。死亡组患者病情重,两组的糖尿病、血流动力学指标、肾功能、肌钙蛋白、B型利钠肽、乳酸水平和急性生理与慢性健康评分(APACHEⅡ)评分均差异有统计学意义(均P<0.05)。住院期间,死亡组去甲肾上腺素、多巴酚丁胺等血管活性药应用量、连续肾脏替代治疗、有创机械通气和主动脉内球囊反搏应用率明显高于存活组(均P<0.05)。并发症方面,死亡组的急性肾损伤、感染和多脏器功能不全综合征的发生率均高于存活组(均P<0.05)。多因素Logistic回归分析结果显示,高龄、低左心室射血分数、急性肾损伤、感染和多脏器功能不全综合征是影响病死率的危险因素(均P<0.05)。结论老年急性心肌梗死合并心原性休克患者的预后差,ECMO可显著改善患者的血流动力学,但对生存预后无明显影响。高龄、低左心室射血分数、急性肾损伤、感染和多脏器功能不全综合征是影响病死率的危险因素。

Objective To investigate the short-term clinical effect of extracorporeal membrane oxygenation(ECMO)for elderly patients with acute myocardial infarction(AMI)complicated with cardiogenic shock and to analyze its risk factors. Methods Clinical data of 55 elderly patients with AMI complicated with cardiogenic shock admitted into Henan Provincial Chest Hospital from January 2011 to July 2018 were retrospectively analyzed.According to the prognosis, patients were divided into the survival group(n=41)and the death group(n=14). Baseline characteristics were compared between the two groups.The short-term prognosis during hospitalization including use of temporary pacemaker, continuous renal replacement therapy and ventilation treatment and complications were compared.Univariate and multivariate logistic regression analysis were used to assess the risk factors for mortality. Results Of the 55 patients, 30 patients were male(54.5%), with a mean ±SD age of(67.2±5.3)years.The time from admission to ECMO insertion was(8.6±6.3)h, and the support time was(143.2±61.7)h.There were significant differences in diabetes incidence, hemodynamic indexes, renal function, troponin, B-type natriuretic peptide, lactate levels and the Acute Physiology and Chronic Health Enquiry(APACHE-Ⅱ)score between the two groups(P<0.05). The dosage of norepinephrine, dobutamine and other vasoactive agents, and the application frequency of continuous renal replacement therapy, invasive ventilation treatment and intra-aortic balloon counterpulsation during hospitalization were increased in the death group compared with the survival group(P<0.05). Incidence rates of complications including acute kidney injury, infection and multiple organ dysfunction syndrome were higher in death group than in survival group(P<0.05). Multiple logistic regression analysis showed that advanced age, low left ventricular ejection fraction(LVEF), acute kidney injury, infection and multiple organ dysfunction syndrome were risk factors for the short-term mortality(P<0.05). Conclusions The prognosis of elderly patients with AMI complicated with cardiogenic shock are poor.ECMO can significantly improve the hemodynamic indexes, but has no effect on the survival time in elderly patients with AMI complicated with cardiogenic shock.The advanced age, low LVEF, acute kidney injury, infection and multiple organ dysfunction syndrome are risk factors for the short-term mortality.