体外膜肺氧合治疗心脏术后难治性心室颤动的临床特点和中远期存活情况分析

Clinical characteristics and long-term survival in extracorporeal membrane oxygenation for adult patients with post-cardiotomy refractory ventricular fibrillation

目的:探讨应用体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)辅助治疗心脏术后难治性心室颤动(refractory ventricular fibrillation,RVF)的临床特点及病情转归,并行5年期随访,判断其应用价值和中远期疗效。方法:回顾性分析2015年1月至2017年12月,我院26例因心脏外科术中或术后24h内出现RVF,并应用静脉-动脉ECMO(venous-arterial ECMO,V-A ECMO)技术进行抢救治疗的患者资料,并于2023年1月对出院患者经行电话随访,了解患者出院后生存情况和心脏功能状态。结果:26例患者中的23例行体外循环心脏外科手术,因RVF于手术室中启动ECMO治疗,由体外循环中转为ECMO,另外3例不停跳旁路移植手术(off-pump coronary artery bypass grafting,OPCABG)患者于ICU发生难治性心室颤动,抢救性放置ECMO;26例均采用切开方式进行股动静脉插管,平均辅助时间(111.5±50.8)h。ECMO前电除颤7.5(5.8,9.3)次,辅助后自动转复16例(61.5%),电除颤转复8例(30.8%)。17例(65.4%)放置主动脉内球囊反搏(intra-aortic balloon pump,IABP),9例(34.6%)行连续性肾替代治疗(continuous renal replacement therapy,CRRT)治疗。患者术后第1日心肌酶学指标全部明显升高。本组病例数据与ELSO组织2021年公布的因心脏术后心源性休克采用ECMO治疗的多中心大样本注册研究数据进行统计对比,撤机成功率分别为88.5%(23/26)和56.4%(4051/7185),存活出院率分别为76.9%(20/26)和41.7%(2997/7185),本组病例撤机成功率和存活出院率明显高于ELSO组织的数据(P<0.001)。ICU平均住院(10.3±6.7)d,术后平均住院时间(18.4±8.0)天。失访1例,随访19例,1年存活率64.0%,5年存活率52.0%。目前存活11例,存活5.1~7.8年,NYHA心功能分级Ⅰ级1例,Ⅱ级7例,Ⅲ级3例。结论:应用ECMO技术治疗心脏术后RVF,撤机成功率和存活出院率较高,中远期生存情况良好。

Objective:To investigate the clinical characteristics and prognosis of post-cardiotomy refractory ventricular fibrillation treated with extracorporeal membrane oxygenation(ECMO),and to evaluate the long-term efficacy and application value through 5-year follow-up.Methods:From January 2015 to December 2017,the clinical data of 26 patients treated with venous-arterial ECMO(V-A ECMO)for refractory ventricular fibrillation during or within 24 hours after cardiac surgery were retrospectively analyzed.The discharged patients were followed up by telephone in January 2023 to understand their survival and cardiac function.Results:A total of 23 patients were converted from cardiopulmonary bypass to ECMO in the operating room.Three off-pump coronary artery bypass grafting(OPCABG)patients underwent ECMO implantation in ICU.Open cannula placement through femoral incision was chosen for all of the patients.The mean electric defibrillation time before ECMO was 7.5(5.8,9.3).16 cases(61.5%)were automatically converted during ECMO support,and 8 cases(30.8%)were converted from electric defibrillation.17 cases(65.4%)received intra-aortic balloon pump(IABP)and 9 cases(34.6%)received continuous renal replacement therapy(CRRT).On the first day after operation,the myocardial enzymology indexes were all significantly increased.Mean ECMO support time was(111.5±50.8)hours.23 cases(88.5%)were weaned successfully from ECMO and 20 cases(76.9%)survived to discharge which were higher than the published data from ELSO in 2021(P<0.001).The mean postoperative ICU day was(10.3±6.7)days,and the mean postoperative day was(18.4±8.0)days.One case missed follow-up and 19 cases were followed up.The 1-year survival rate was 64.0%and the 5-year survival rate was 52.0%.At present,11 cases have survived for 5.1 to 7.8 years.NYHA cardiac function classification is grade I in 1 case,grade II in 7 cases,and grade III in 3 cases.Conclusions:ECMO technology is used to treat refractory ventricular fibrillation after cardiac surgery,with higher success rate of weaning,survival and discharge rate,and good long-term survival rate.