V-A ECMO联合血液灌流治疗急性心肌梗死合并心源性休克的临床效果

Clinical effect of V-A ECMO combined with hemoperfusion in the treatment of acute myocardial infarction with cardiogenic shock

目的探讨静脉-动脉体外膜肺氧合联合血液灌流治疗急性心肌梗死合并心源性休克的临床效果。方法选取本院自2021年1月至2023年4月期间收治的需要体外生命支持的急性心肌梗死合并心源性休克的成人患者52例,根据是否联合应用血液灌流治疗随机分为对照组和观察组,每组26例。对照组采用常规治疗及静脉-动脉体外膜肺氧合治疗,观察组在对照组治疗方案的基础上联合血液灌流治疗。比较治疗前后两组患者的APACHEⅡ评分、正性肌力药物评分、乳酸及IL-6水平。采用单因素分析和Logistic回归分析对ECMO撤机成功率及撤机后14d存活率的影响因素进行研究,并评价联合血液灌流治疗对患者预后的影响。结果与治疗前相比,治疗后7d、14d两组患者APACHEⅡ评分、正性肌力药物评分均有所下降,且观察组下降水平高于对照组(P<0.05);与治疗前相比,治疗后1d、3d两组患者乳酸水平均有所下降,且观察组下降水平高于对照组(P<0.05);IL-6水平在对照组中呈现上升趋势,在观察组中呈现下降趋势,且治疗后1d和3d均为观察组显著低于对照组(P<0.05)。观察组中两两比较可知,IL-6水平在治疗后3d显著低于治疗前,但其余时间两两比较无差异(P>0.05)。ECMO撤机成功率与患者是否联合血液灌流(偏回归系数:-1.719,OR=0.179,95%CI:0.047~0.687,P=0.012)及患者是否为ECPR(偏回归系数:-1.678,OR=0.187,95%CI:0.047~0.735,P=0.016)有关,联合血液灌流的患者及ECMO上机前未发生心脏骤停的非ECPR患者撤机成功率显著升高(P<0.05)。ECMO撤机后14d患者存活率与是否联合血液灌流无关(P>0.05)。结论与单纯应用静脉-动脉体外膜肺氧合治疗相比,联合血液灌流治疗急性心肌梗死合并心源性休克能够降低炎症反应,加快乳酸水平下降,减少正性肌力药物使用,提高ECMO撤机成功率,改善短期预后,但不能改善远期预后。

Objective To investigate the clinical effect of veno-arterial extracorporeal membrane oxygenation(V-A ECMO)combined with hemoperfusion in the treatment of acute myocardial infarction with cardiogenic shock(AMICS).Methods 52 adult patients who were suffering from AMICS and treated with extracorporeal life support in our hospital from January 2021 to April 2023 were selected and randomly divided into control group and observation group,with 26 cases in each group.The control group was treated with routine treatment and V-A ECMO,while the observation group was treated with hemoperfusion on the basis of the control group.The acute physiology and chronic health scoreⅡ(APACHEⅡscore),vasoactive-inotropic score(VIS),the serum levels of lactic acid and interleukin-6(IL-6),were compared between the two groups before and after treatment.While the influence factors of the achievement ratio of ECMO weaning and the 14-day survival rate after ECMO weaning were analyzed by univariate analysis and Logistic regression analysis to evaluate the effect of combined hemoperfusion therapy on the prognosis of patients.Results Compared with the level before treatment,APACHEⅡscore and VIS in control group and observation group were both decreased on the 7th day and 14th day after treatment,and the decrease degree in observation group was higher than that in control group(P<0.05).The serum levels of lactic acid decreased on the 1st day and 3rd day after treatment,and the decreased degree in observation group was higher than that in control group compared with those before treatment(P<0.05).The level of IL-6 increased in the control group and decreased in the observation group,and the observation group was significantly lower than the control group on the 1st day and 3rd day after treatment(P<0.05).Pairwise comparison in the observation group showed that the level of IL-6 was significantly lower at the 3rd day after treatment than that before.The remaining pairwise comparison between groups were not statistically significant(P>0.05).The achievement ratio of ECMO weaning was related to whether the hemoperfusion(partial regression coefficient:-1.719,OR=0.179,95%CI:0.047~0.687,P=0.012)and ECPR(partial regression coefficient:-1.678,OR=0.187,95%CI:0.047~0.735,P=0.016)were performed.The achievement ratio of ECMO weaning was significantly higher in patients treated with hemoperfusion and significantly lower in patients treated with ECPR patients(P<0.05).The 14-day survival rate after ECMO weaning was not related to whether the hemoperfusion was performed(P>0.05).Conclusions Compared with V-A ECMO alone,the combination of hemoperfusion in the treatment of AMICS can reduce inflammatory response,accelerate the decline of lactic acid level,reduce the use of positive inotropic drugs,raise the achievement ratio of ECMO weaning and improve short-term prognosis,but cannot improve long-term prognosis.