长期植入式心室辅助装置成功救治急性心梗心源性休克合并心包填塞1例

Long-term implantable ventricular assist device successfully saves a case of acute myocardial infarction cardiogenic shock combined with cardiac tamponade

目的 探讨长期可植入式心室辅助救治急性心梗难治性心源性休克的可行性经验。方法 中国医学科学院阜外医院深圳医院2019年11月对1例急性心梗心源性休克合并心包填塞进行卵圆孔未闭修补术、冠状动脉旁路移植术和心室辅助装置CH-VAD血泵植入术治疗,术后早期观察血流动力学和器官灌注监测指标。出院后长期随访,应用经胸超声心动图、NYHA心功能分级、6分钟步行距离、心肺运动试验来评估心脏和活动耐量康复过程。结果 术中切开心包后有暗红色血性心包积液150 ml,左心室心尖部显著变薄,周围组织水肿,3点位置有陈旧性血栓形成。手术体外循环时间为120 min,主动脉阻断时间为55 min,主动脉侧壁阻断时间为10 min。术后早期CH-VAD血泵转速在2500~2900 r/min调整,流量为3.5~4.5 L/min,有创平均动脉压为65~75 mm Hg (1 mm Hg=0.133 k Pa),血乳酸、c Tn I和c Tn T分别术后当天和第7天恢复至正常水平。术后26 h拔除气管插管,术后第7~15天出现反复短阵室速和室颤,期间反复非同步除颤100~200 J,术后第8天再次气管插管,术后90 d顺利携带CH-VAD血泵出院,泵转速为2800 r/min,流量为3.9 L/min。患者术后12个月超声提示:LVEDD为60 mm,LVEF为29%,主动脉瓣与心动周期开放比恢复到1:1, NYHAⅠ级,6分钟步行距离为490 m。驱动线缆伤口每天换药1次,无伤口红肿、积液、脓性分泌物等异常。目前已携带CH-VAD血泵生存32个月,生活质量良好。结论 长期可植入式VAD对于急性心肌梗死合并难治性心源性休克患者是一种有效治疗策略,应尽早考虑。

Objective Explore the feasibility and experience of using long-term implantable ventricular assist devices to treat intractable cardiogenic shock caused by acute myocardial infarction.Methods In November 2019,the Shenzhen Hospital of Fuwai Hospital treated a case of acute myocardial infarction,cardiogenic shock,and cardiac tamponade with oval foramen repair surgery.The patient underwent coronary artery bypass grafting,and implantation of the CH-VAD ventricular assist device.Early postoperative observations included hemodynamic and organ perfusion monitoring indicators.Long-term follow-up after discharge included transthoracic echocardiography,NYHA cardiac function classification,6-minute walk distance,and cardiopulmonary exercise testing to assess the recovery process of cardiac function and exercise tolerance.Results During the surgery,150 ml of dark,red,bloody pericardial effusion was found after opening the pericardium.The apex of the left ventricle was significantly thinned,and the surrounding tissue was edematous.An old thrombus had formed at the 3 o'clock position.The cardiopulmonary bypass time was 120 min,the aortic cross-clamp time was 55 min,and the time for clamping the aortic sidewall was 10 min.Early postoperative CH-VAD pump speed was adjusted to between 2500 and 2900 rpm,with a flow rate of between 3.5 and 4.5 L/min.The invasive mean arterial pressure was maintained between 65 and 75 mmHg,and blood lactate,cTnI,and cTnT levels returned to normal on the day of surgery and on the 7th day postoperatively.The endotracheal tube was removed 26 h after surgery,and episodes of short bursts of ventricular tachycardia and ventricular fibrillation occurred between the 7th and 15th days postoperatively.During this period,asynchronous defibrillation was repeatedly performed at 100~200 J,and the endotracheal tube was reinserted on the 8th day after the surgery.The patient was smoothly discharged with the CH-VAD pump on the 90th day after the operation,with a pump speed of 2800 rpm and a flow of 3.9 L/min.Twelve months after the surgery,the patient's ultrasound indicated an LVEDD of 60 mm,an LVEF of 29%,restoration of the aortic valve and cardiac cycle opening ratio to 1∶1,NYHA ClassⅠ,and a 6-minute walk distance of 490 m.The dressing on the driveline cable wound was changed once a day,with no abnormalities such as wound redness,effusion,or purulent secretions.The dressing on the driveline cable wound was changed once a day,with no abnormalities such as wound redness,effusion,or purulent secretions.Conclusion Long-term implantable VAD is an effective treatment strategy for patients with acute myocardial infarction combined with intractable cardiogenic shock and should be considered as early as possible.