经颅多普勒超声联合近红外光谱监测主动脉内球囊反搏治疗急性心肌梗死合并心源性休克患者脑血流灌注的价值

Value of transcranial Doppler ultrasound combined with near-infrared spectroscopy to the monitor of cerebral perfusion during intra-aortic balloon pulsation for acute myocardial infarction complicated with cardiogenic shock

目的探讨急性心肌梗死合并心源性休克患者行主动脉内球囊反搏治疗期间应用经颅多普勒超声联合近红外光谱监测脑血流灌注的价值。方法142例急性心肌梗死合并心源性休克患者均行急诊经皮冠状动脉介入治疗,其中经皮冠状动脉介入治疗前行主动脉内球囊反搏者71例为观察组,静脉持续泵注去甲肾上腺素者71例为对照组。比较2组发病至治疗时间、Killip分级等。记录2组主动脉内球囊反搏治疗前或应用去甲肾上腺素前(T_(0))、治疗后2h(T_(1))、12h(T_(2))、24h(T_(3))、48h(T_(4))、72h(T_(5))时局部脑氧饱和度(regional cerebral oxygen saturation,rSO_(2))、平均动脉压(mean arterial pressure,MAP),行经颅多普勒超声和近红外光谱监测,记录大脑中动脉平均血流速度(mean flow velocity,mFV)、舒张期血流速度(diastolic flow velocity,dFV),计算脑灌注压(cerebral perfusion pressure,CPP)。结果观察组发病至治疗时间、Killip分级、梗死部位及基础疾病与对照组比较差异均无统计学意义(P>0.05)。观察组T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时大脑中动脉mFV[(51.10±3.94)、(54.46±3.25)、(59.45±3.71)、(62.49±4.24)、(63.15±4.94)cm/s]、MAP[(55.61±5.73)、(64.65±6.90)、(73.69±7.54)、(80.30±6.05)、(79.11±7.66)mm Hg],T_(2)、T_(3)、T_(4)、T_(5)时大脑中动脉dFV[(42.68±4.71)、(45.14±4.61)、(47.06±4.90)、(46.76±4.05)cm/s]、CPP[(64.82±8.39)、(70.28±9.59)、(74.69±8.97)、(72.83±8.72)mm Hg]及T_(3)、T_(4)、T_(5)时rSO_(2)[(54.96±5.54)%、(60.15±5.22)%、(58.56±5.13)%]均高于对照组[mFV(48.65±4.21)、(49.86±4.44)、(54.10±5.09)、(57.37±4.50)、(56.85±4.51)cm/s,MAP(50.45±5.63)、(58.17±5.04)、(61.52±7.44)、(72.45±6.05)、(71.69±6.56)mm Hg,dFV(39.21±4.16)、(41.13±4.64)、(42.11±4.59)、(42.87±4.39)cm/s,CPP(60.25±8.43)、(61.08±8.48)、(66.27±8.78)、(68.31±8.03)mm Hg,rSO2(49.73±3.85)%、(53.07±4.15)%、(55.08±5.13)%](P<0.05),T0时大脑中动脉mFV、MAP,T0、T1时大脑中动脉dFV、CPP及T0、T1、T2时rSO2与对照组比较差异均无统计学意义(P>0.05)。观察组、对照组T1、T2、T3、T4、T5时大脑中动脉mFV、dFV、CPP、MAP及T3、T4、T5时rSO2均高于T0时(P<0.05),T1、T2时rSO2与T0时比较差异均无统计学意义(P>0.05)。结论经颅多普勒超声联合近红外光谱监测急性心肌梗死合并心源性休克患者脑血流灌注的价值较高,经皮冠状动脉介入治疗联合主动脉内球囊反搏改善急性心肌梗死合并心源性休克患者脑血流灌注优于经皮冠状动脉介入治疗联合去甲肾上腺素。

Objective To investigate the value of transcranial Doppler ultrasound(TCD)combined with near-infrared spectroscopy(NIRS)to the monitor of cerebral perfusion during intra-aortic balloon pulsation(IABP)for acute myocardial infarction(AMI)complicated with cardiogenic shock.Methods In 142patients with AMI complicated with cardiogenic shock,71patients received IABP(observation group)and 71patients received continuous norepinephrine pump injection(control group)besides primary percutaneous coronary intervention(PCI).The time from onset to treatment and Killip classification were recorded in two groups.The regional cerebral oxygen saturation(rSO2)and mean arterial pressure(MAP)were recorded before IABP or norepinephrine pump injection(T0),and 2h(T1),12h(T2),24h(T3),48h(T4)and 72h(T5)after treatment in two groups.TCD and NIRS were used to record the average blood flow velocity(mFV)and diastolic blood flow velocity(dFV)of the middle cerebral artery,and cerebral perfusion pressure(CPP)was calculated.Results There were no significant differences in the time from onset to treatment,Killip classification,area of infarction and underlying diseases between two groups(P>0.05).The mFVs[(51.10±3.94),(54.46±3.25),(59.45±3.71),(62.49±4.24),(63.15±4.94)cm/s]and MAPs[(55.61±5.73),(64.65±6.90),(73.69±7.54),(80.30±6.05),(79.11±7.66)mm Hg]at T1,T2,T3,T4and T5in observation group were higher than those in control group[(48.65±4.21),(49.86±4.44),(54.10±5.09),(57.37±4.50),(56.85±4.51)cm/s;(50.45±5.63),(58.17±5.04),(61.52±7.44),(72.45±6.05),(71.69±6.56)mm Hg](P<0.05),while the dFVs[(42.68±4.71),(45.14±4.61),(47.06±4.90),(46.76±4.05)cm/s]and CPPs[(64.82±8.39),(70.28±9.59),(74.69±8.97),(72.83±8.72)mm Hg]at T2,T3,T4and T5,as well as rSO2s[(54.96±5.54)%,(60.15±5.22)%,(58.56±5.13)%]at T3,T4and T5 were higher in observation group than those in control group[(39.21±4.16),(41.13±4.64),(42.11±4.59),(42.87±4.39)cm/s;(60.25±8.43),(61.08±8.48),(66.27±8.78),(68.31±8.03)mm Hg;(49.73±3.85)%,(53.07±4.15)%,(55.08±5.13)%](P<0.05).There were no significant differences in the mFV and MAP at T0,dFV and CPP at T0and T1,and rSO2s at T0,T1and T2 between two groups(P>0.05).The mFV,dFV,CPP and MAP at T1,T2,T3,T4and T5,as well as rSO2at T3,T4 and T5in both groups were higher than those at T0(P<0.05),and the rSO2in both groups showed no significant differences at T1and T2from those at T0(P>0.05).Conclusions TCD combined with NIRS has a certain value to the monitor of cerebral perfusion in patients with AMI complicated with cardiogenic shock.PCI combined with IABP is superior to PCI combined with norepinephrine injection in improving cerebral perfusion in patients with AMI complicated with cardiogenic shock.