早期血运重建及体外膜肺氧合支持治疗急性心肌梗死合并心原性休克的疗效观察及影响因素分析

Effects and Related Factors of Early Revascularization and Extracorporeal Membrane Oxygenation Support on the In-hospital Outcome of Acute Myocardial Infarction Patients Combined With Cardiogenic Shock

目的:探讨早期血运重建及体外膜肺氧合(ECMO)治疗急性心肌梗死合并心原性休克患者的疗效,并分析影响其预后的因素。方法:回顾2018年1月至2019年12月郑州大学人民医院早期血运重建及ECMO救治的急性心肌梗死合并心原性休克66例患者的临床资料。收集并分析患者一般情况、临床特征、合并症、冠状动脉病变特点,ECMO前后血流动力学变化及应用时长、并发症及疗效,是否应用主动脉球囊反搏(IABP)及院内临床转归等。结果:66例患者平均年龄(56.6±11.7)岁,其中男性46例。患者入院均行早期血运重建:5例行冠状动脉旁路移植术(CABG);61例行经皮冠状动脉介入治疗(PCI),其中44例行入院即刻早期血运重建,17例行院内延迟早期血运重建;其中42例患者为多支冠状动脉病变。所有患者均应用ECMO辅助,其中39例使用了IABP。ECMO治疗后患者平均动脉压、中心静脉压、血乳酸水平及pH值均得到显著改善(P均<0.05)。66例患者中38例成功撤机,30例存活出院,36例死亡;并发症分别为20例肾功能不全或急性肾功能衰竭、11例消化道出血、5例脑出血、1例肺出血、9例下肢血栓及3例下肢缺血。多因素Logistic回归分析显示高血压,多脏器功能衰竭,发生至少2次呼吸心脏骤停、意识丧失及恶性心律失常事件为患者院内死亡的高危因素(P<0.05),应用IABP对院内结局无显著影响。结论:早期血运重建及ECMO用于救治急性心肌梗死合并心原性休克的患者是可行的。

Objectives:To investigate the efficacy of early revascularization and extracorporeal membrane oxygenation(ECMO)in the treatment of patients with acute myocardial infarction and cardiogenic shock,and to analyze the factors associated with the outcome.Methods:Patients with acute myocardial infarction complicating cardiac shock and treated with early revascularization and ECMO in our hospital between January 2018 and December 2019 were analyzed retrospectively.General data,clinical features,complications,characteristics of coronary artery,hemodynamic data changes before and after ECMO,ECMO complications and efficacy,intra-aortic balloon pump(IABP)use and in-hospital clinical outcome were collected and analyzed.Patients were divided into survival group and non-survival group according to their in-hospital outcomes.Results:The mean age of 66 enrolled patients was(56.6±11.7)years,and 46 of them were male.All patients underwent early revascularization:5 underwent coronary artery bypass grafting(CABG);61 patients underwent percutaneous coronary intervention(PCI),among which 44 underwent immediate early revascularization on admission and 17 underwent delayed early revascularization during hospitalization.42 patients had multiple coronary artery lesions.All patients were treated with ECMO,and IABP was applied in 39 patients during hospitalization.After ECMO support,the mean arterial pressure,central venous pressure,lactate level and PH of the patients were significantly improved compared with those before ECMO support(P<0.05).A total of 38 patients were successfully weaned from ECMO,30 were discharged alive,and 36 died.As for the complications,there were 20 cases of renal insufficiency or acute renal failure,11 cases of gastrointestinal bleeding,5 cases of cerebral hemorrhage,1 case of pulmonary hemorrhage,9 cases of lower limb venous thrombosis,and 3 cases critical limb ischemia.Multivariate logistic regression analysis showed that hypertension,multiple organ failure,respiratory cardiac arrest≥2,loss of consciousness and malignant arrhythmia were the independent risk factors of in-hospital death(P<0.05),while IABP had no significant impact on the in-hospital outcome.Conclusions:Our study found that early revascularization in combination with extracorporeal membrane oxygenation is a feasible way to treat patients with acute myocardial infarction complicated with cardiogenic shock.Randomized controlled studies with large sample sizes are needed to validate the efficacy of this therapy option for patients with acute myocardial infarction complicated with cardiogenic shock.