超声对急性暴发性心肌炎患者静脉-动脉体外膜肺氧合支持下血流动力学评估的初步研究

Quantitative evaluation of hemodynamic parameter changes by echocardiography in patients with acute fulminant myocarditis supported by venousarterial extracorporeal membrane oxygenation

目的探讨经胸超声心动图(TTE)对急性暴发性心肌炎(AFM)患者静脉-动脉体外膜肺氧合(V-A ECMO)辅助前、中、后期心脏血流动力学监测中的应用价值。方法纳入28例AFM并接受V-A ECMO支持的患者,根据V-A ECMO脱机成功与否将其分为成功组(20例)和失败组(8例),筛选影响脱机的独立风险因素,比较两组患者在不同V-A ECMO状态下血流动力学参数结果。结果年龄、肌酸激酶-同工酶(CK-MB)、血清肌钙蛋白-I(cTnI)、ECMO建立后第24 h乳酸含量与能否成功脱机密切相关(OR=0.064,95%CI:0.008-0.527,P=0.011;OR=1.004,95%CI:1.002-1.108,P=0.039;OR=3.635,95%CI:1.320-9.740,P=0.020;OR=1.075,95%CI:1.045-1.286,P=0.013)。①V-A ECMO成功组中,建立后第1 d最大流量下与建立前相比,右侧桡动脉平均压(MAP)、外周组织血氧饱和度(StO2)明显增高(均P<0.05),而中心静脉压(CVP)及三尖瓣前向血流流速(TVDV)明显减低(均P<0.05)。②撤机后与建立前相比,MAP、StO2、左室射血分数(LVEF)、左室流出道速度-时间积分(LVOT-VTI)、二尖瓣环侧壁收缩期运动速度(Lat Sa)、舒张期运动速度(Late)峰值明显增高(均P<0.05)。③撤机后,成功组较失败组MAP、StO2及LVEF、LVOT-VTI、LatSa明显增高(均P<0.05),左室舒张末期容积(LVEDV)显著减低(P<0.05)。结论超声在ECMO前、中及后期均具有重要的应用价值,是监测心脏血流动力学变化的主要方法之一。

Objective To investigate the application value of transthoracic echocardiography in monitoring hemodynamics changes of acute fulminant myocarditis(AFM)supported by venous-arterial extracorporeal membrane oxygenation(V-A ECMO).Methods A total of 28 patients with AFM supported by V-A ECMO were enrolled and divided into the weaning group(n=20)and no weaning group(n=8).The clinical data and hemodynamic parameters under different ECMO states were compared between the two groups.Results Age,the peak of creatine kinase-MB levels(CK-MB),cardiac troponin I levels(cTnI),and 24 h lactic acid level after V-A ECMO were closely related to the ECMO from weaning(OR=0.064,95%CI:0.008-0.527,P=0.011;OR=1.004,95%CI:1.002-1.108,P=0.039;OR=3.635,95%CI:1.320-9.740,P=0.020;OR=1.075,95%CI:1.045-1.286,P=0.013).In the weaning group,compared with pre-ECMO,mean arterial pressure(MAP)and peripheral tissue oxygen saturation(StO2)were significantly increased at maximum flow on the first day during ECMO(all P<0.05),while the value of central venous pressure(CVP)and flow velocity of tricuspid valve orifice(TVDV)were significantly decreased(all P<0.05).The values of MAP,StO2,left ventricular ejection fraction(LVEF),velocity-time integral of left ventricular outflow tract(LVOT-VTI),velocity of mitral annulus in systolic(LatSa)and diastolic(Late)after V-A ECMO weaning were significantly increased compared with the pre-ECMO(all P<0.05).Compared with the no weaning group,MAP,StO2,LVEF,LVO-TVTI and LatSa increased significantly in the weaning group(all P<0.05),and the left ventricular end diastolic volume(LVEDV)decreased obviously after ECMO weaning(P<0.05).Conclusions Echocardiography plays an important role in monitoring hemodynamic parameters in AFM patient supported by V-A ECMO.