成人暴发性心肌炎体外生命支持治疗9例临床分析

Fulminant myocarditis with multiple organ dysfunction treated by extracorporeal life support in ICU:report of 9 adult cases

目的总结在重症监护病房(ICU)使用体外机械生命支持治疗成人暴发性心肌炎合并多脏器功能损害(MODS)的临床经验。方法回顾性分析2019年1月至2020年10月厦门大学附属第一医院ICU连续收治的9例暴发性心肌炎患者的临床资料、患者转归和并发症情况。结果共纳入9例符合诊断标准的暴发性心肌炎患者,在糖皮质激素等免疫调节基础上,给予体外膜肺氧合(ECMO)和/或主动脉内球囊反搏(IABP)支持治疗。其中,6例患者给予IABP+静脉-动脉体外膜肺氧合(VA-ECMO)支持,1例患者IABP治疗。使用ECMO的6例患者,使用后第5天血氧饱和度[(100.0±0)%]、中心静脉血氧饱和度[(78.7±3.9)%]、超敏肌钙蛋白I[10.0(2.2,31.8)mg/ml]、氧合指数[437.0(326.5,450.8)]、乳酸[(1.5±0.5)mmol/L]、碱剩余(-1.1±1.9)、左心室射血分数[(53.5±12.6)%]较使用前[(98.0±1.4)%、(61.9±4.3)%、27.1(16.6,50.0)mg/ml、159.7(70.3,190.9)、(6.4±3.4)mmol/L、(-10.3±4.6)、(29.0±11.1)%]明显好转(t=-3.46、-9.74,Z=-1.99、-4.89,t=3.63、-5.84、-3.33;均P<0.05)。8例患者治愈出院,1例死亡。结论暴发性心肌炎发病迅速,在ICU中以体外机械生命支持治疗为依托、免疫调节治疗为核心的综合治疗可以改善患者预后。

Objective To summarize the clinical experience in the treatment of fulminant myocarditis with multiple organ dysfunction using extracorporeal life support in the ICU.Methods Clinical data of 9 adult cases of fulminant myocarditis complicated with multiple organ dysfunction admitted in ICU from January 2019 to October 2020 were retrospectively analyzed.Results All patients received immunoregulatory and antiviral therapy;mechanical ventilation and renal replacement treatment were performed.Extracorporeal life support was also applied,including 1 case receiving intra-aortic balloon pump(IABP)support,and 6 cases receiving IABP and venous-arterial extracorporeal membrane oxygenation(VA-ECMO).In 6 cases with ECMO,the SpO2(100.0±0)%,ScvO2(78.7±3.9)%,hsTnI[10.0(2.2,31.8)mg/ml],oxygenation index[437.0(326.5,450.8)],lactic acid[(1.5±0.5)mmol/L],BE(-1.1±1.9)and LVEF(53.5±12.6)%were significantly improved 5 days after treatment compared with before[(98.0±1.4)%,(61.9±4.3)%,27.1(16.6,50.0)mg/ml,159.7(70.3,190.9),(6.4±3.4)mmol/L,(-10.3±4.6),(29.0±11.1)%](t=-3.46,-9.74;Z=-1.99,-4.89;t=3.63,-5.84,-3.33;P<0.05).Eight patients were discovered and discharged,and one patient died.Conclusion Fulminant myocarditis develops rapidly,integrated treatment based on extracorporeal mechanical life support and immunomodulatory therapy can improve the outcome of patients in the ICU.