机械循环支持与心原性休克case

1、病例简介l 患者，女性，35岁，既往史无殊。l 主诉：发热2天伴寒战、肌痛。l 体检：体温39.1，血压95/60（72）mmHg，心率 110 BPM，呼吸 20次/分，氧饱和度100（氧流量2L/min）。四肢冷，肺音清，心音听诊示心动过速，未及第三、第四心音或摩擦音。l 患者很快出现低血压状态，需静滴去甲肾上腺素（12gKg/min）以维持血压。l 实验室检查：肌钙蛋白3.89ng/mL（正常范围0-0.08ng/mL），静脉乳酸3.5mmol/L（正常范围0.50-2.20mmol/L），白血细胞计数17.0109/L（正常范围3.5-9.1109/L），血红蛋白12.4g/dL（正常

2、范围13.3-16.2g/dL），肝肾功能在正常范围。病例简介l 心电图：窦性心动过速，下侧壁导联ST段抬高。病史简介l 胸部CTA：双侧胸腔少量积液，未示肺栓塞表现。l 床旁经胸超声心动图：大量心包积液，下腔静脉扩张，右心房和右心室（RV）舒张期塌陷。LVEF目测估计为45至50。l 冠状动脉造影：正常。病例简介l 左右侧心导管检查结果(Table 1)病例简介l 由于大量心包积液导致的舒张期压力上升，尽管升压药物剂量快速增加但患者仍然出现日益恶化的酸中毒，持续的低血压和心动过速。于是病人被送往手术室行心包开窗术以治疗心包填塞。l 尽管心包开窗术成功，但术中患者休克状态恶化，给予紧急安置IA

3、BP。随后患者在初诊后24小时内被转运至哥伦比亚大学医学中心心血管科进一步诊治。l 到达中心时患者血压83/63（70）mmHg，窦速130bpm，尽管1：1IABP支持下血压可充至90mmHg，并已给予米力农0.25g/Kgmin和去甲肾上腺素15g/Kgmin静滴，但4小时之前病人的尿量已经减少到15cm3/h，留置的Swan-Ganz肺动脉漂浮导管提示增高的充盈压和低心输出量(Table 2)。l 考虑给予机械辅助循环支持治疗。病例简介病例简介病例简介l 病人被送往手术室行CentriMag BIVAD植入，同时行心内膜心肌活检送病理检查。术中经食道超声心动图显示小心腔，LVEF50%

4、with medical therapy (Class II; Level of Evidence B)Current Recommendations for MCSCurrent Recommendations for MCSHFSA comprehensive HF practice guidelines：l Patients awaiting heart transplantation who have become refractory to all means of medical circulatory support should be considered for an MCS

5、 device as a BTT (Level of Evidence B)l Permanent mechanical assistance with an implantable LVAD may be considered in highly selected patients with severe HF refractory to conventional therapy who are not candidates for heart transplantation, particularly those who cannot be weaned from intravenous

6、inotropic support at an experienced HF center (Level of Evidence B)Current Recommendations for MCSCurrent Recommendations for MCSHFSA comprehensive HF practice guidelines：l Patients with refractory HF and hemodynamic instability and/or compromised end-organ function with relative contraindications t

7、o cardiac transplantation or permanent MCS expected to improve with time or restoration of an improved hemodynamic profile should be considered for urgent MCS as a bridge to decision; these patients should be referred to a center with expertise in the management of patients with advanced HF (Level o

8、f Evidence C)Current Recommendations for MCSCurrent Recommendations for MCSCanadian HF guidelines：l MCS may be offered to selected individuals with end-stage heart failure who are inotrope dependent and do not meet the traditional criteria for cardiac transplantation (Class IIb; Level of Evidence B)

9、Current Recommendations for MCSCurrent Recommendations for MCSESC guidelines 2008/2010：l Current indications for LVADs and artificial hearts include bridging to transplantation and managing patients with acute, severe myocarditis (Class IIa; Level of Evidence C)l Although experience is limited, these devices may be considered for long-term use when no definitive procedure