急性心肌梗死合并心原性休克患者应用VA-ECMO联合IABP的时机探索

Impact of VA-ECMO combined with IABP and timing on outcome of patients with acute myocardial infarction complicated with cardiogenic shock

目的探讨急性心肌梗死合并心原性休克(AMICS)患者应用动脉-静脉体外膜肺氧合(VA-ECMO)联合主动脉内球囊反搏泵(IABP)的不同时机对患者预后的影响。方法本研究为前瞻性队列研究,纳入中国体外生命支持学会注册数据库中2019年3月至2022年3月于兰州大学第一医院心脏中心入组接受VA-ECMO支持的AMICS患者,根据是否联合IABP及联合时机,分为VA-ECMO单独组、VA-ECMO+IABP同期组和VA-ECMO+IABP非同期组。收集3组患者的人口学特征、危险因素、心电图和超声心动图检查结果、病情危重特点、冠状动脉介入手术结果及VA-ECMO相关参数及并发症等。主要临床终点为全因死亡事件,机械循环支持的安全性指标包括血红蛋白下降大于50 g/L、消化道出血、菌血症、下肢缺血、下肢血栓、急性肾损伤、肺水肿及卒中。采用Kaplan-Meier生存曲线分析3组患者随访30 d内的生存结局,以VA-ECMO+IABP同期组作为参考,采用多因素Cox回归模型评估AMICS患者VA-ECMO+IABP不同时机联合对30 d内预后的影响。结果本研究纳入68例应用VA-ECMO支持的AMICS患者,其中女性12例(17.6%),所有患者年龄(59.8±10.8)岁。VA-ECMO单独组19例,VA-ECMO+IABP同期组34例,VA-ECMO+IABP非同期组15例。VA-ECMO+IABP同期组ECMO撤机成功率明显高于VA-ECMO单独组及VA-ECMO+IABP非同期组(P均<0.05)。与VA-ECMO+IABP非同期组比较,其余两组ECMO支持时间较短、发生急性肾损伤并发症比例更低(P均<0.05),单独VA-ECMO组发生肺水肿的并发症比例更低(P<0.05)。院内存活患者在VA-ECMO+IABP同期组为28例,明显高于VA-ECMO单独组(9例)及VA-ECMO+IABP非同期组(7例)(P均<0.05);随访30 d内存活患者在VA-ECMO+IABP同期组为26例,明显高于VA-ECMO单独组(9例)及VA-ECMO+IABP非同期组(4例)(P均<0.05)。多因素Cox回归模型分析提示相较于VA-ECMO+IABP同期使用,单独VA-ECMO(HR=2.801,P=0.036)及VA-ECMO+IABP非同期使用(HR=2.985,P=0.033)与AMICS患者30 d内死亡率增加相关。结论AMICS患者应用VA-ECMO时,同期联合IABP可提高患者ECMO撤机率、存活出院率及30 d内的生存率,且没有明显增加额外并发症。

Objective To investigate the impact of combined use and timing of arterial-venous extracorporeal membrane oxygenation(VA-ECMO)with intra-aortic balloon pump(IABP)on the prognosis of patients with acute myocardial infarction complicated with cardiogenic shock(AMICS).Methods This was a prospective cohort study,patients with acute myocardial infarction and cardiogenic shock who received VA-ECMO support from the Heart Center of Lanzhou University First Hospital from March 2019 to March 2022 in the registration database of the Chinese Society for Extracorporeal Life Support were enrolled.According to combination with IABP and time point,patients were divided into VA-ECMO alone group,VA-ECMO+IABP concurrent group and VA-ECMO+IABP non-concurrent group.Data from 3 groups of patients were collected,including the demographic characteristics,risk factors,ECG and echocardiographic examination results,critical illness characteristics,coronary intervention results,VA-ECMO related parameters and complications were compared among the three groups.The primary clinical endpoint was all-cause death,and the safety indicators of mechanical circulatory support included a decrease in hemoglobin greater than 50 g/L,gastrointestinal bleeding,bacteremia,lower extremity ischemia,lower extremity thrombosis,acute kidney injury,pulmonary edema and stroke.Kaplan-Meier survival curves were used to analyze the survival outcomes of patients within 30 days of follow-up.Using VA-ECMO+IABP concurrent group as reference,multivariate Cox regression model was used to evaluate the effect of the combination of VA-ECMO+IABP at different time points on the prognosis of AMICS patients within 30 days.Results The study included 68 AMICS patients who were supported by VA-ECMO,average age was(59.8±10.8)years,there were 12 female patients(17.6%),19 cases were in VA-ECMO alone group,34 cases in VA-ECMO+IABP concurrent group and 15 cases in VA-ECMO+IABP non-concurrent group.The success rate of ECMO weaning in the VA-ECMO+IABP concurrent group was significantly higher than that in the VA-ECMO alone group and the VA-ECMO+IABP non-concurrent group(all P<0.05).Compared with the ECMO+IABP non-concurrent group,the other two groups had shorter ECMO support time,lower rates of acute kidney injury complications(all P<0.05),and lower rates of pulmonary edema complications in the ECMO alone group(P<0.05).In-hospital survival rate was significantly higher in the VA-ECMO+IABP concurrent group(28 patients(82.4%))than in the VA-ECMO alone group(9 patients)and VA-ECMO+IABP non-concurrent group(7 patients)(all P<0.05).The survival rate up to 30 days of follow-up was also significantly higher surviving patients within were in the ECMO+IABP concurrent group(26 cases)than in VA-ECMO alone group(9 patients)and VA-ECMO+IABP non-concurrent group(4 patients)(all P<0.05).Multivariate Cox regression analysis showed that compared with the concurrent use of VA-ECMO+IABP,the use of VA-ECMO alone and non-concurrent use of VA-ECMO+IABP were associated with increased 30-day mortality in AMICS patients(HR=2.801,P=0.036;HR=2.985,P=0.033,respectively).Conclusions When VA-ECMO is indicated for AMICS patients,combined use with IABP at the same time can improve the ECMO weaning rate,in-hospital survival and survival at 30 days post discharge,and which does not increase additional complications.