Hata M, Shiono M, Orime Y, Yagi S Y, Yamamoto T, Okumura H, Kimura S I, Nakata K I, Kashiwazaki S, Choh S, Negishi N, Sezai Y
The Second Department of Surgery, Nihon University School of Medicine, Tokyo, Japan.
Artif Organs. 2000 Aug;24(8):636-9. doi: 10.1046/j.1525-1594.2000.06597.x.
We evaluated the efficacy and problems of circulatory support with percutaneous cardiopulmonary support (PCPS) for severe cardiogenic shock and discussed our strategy of mechanical circulatory assist for severe cardiopulmonary failure. We also described the effects of an alternative way of PCPS as venoarterial (VA) bypass from the right atrium (RA) to the ascending aorta (Ao), which was used recently in 3 patients. Over the past 9 years, 30 patients (20 men and 10 women; mean age: 61 years) received perioperative PCPS at our institution. Indications of PCPS were cardiopulmonary bypass weaning in 13 patients, postoperative low output syndrome (LOS) in 14 patients, and preoperative cardiogenic shock in 3 patients. Approaches of the PCPS system were the femoral artery to the femoral vein (F-F) in 21 patients, the RA to the femoral artery (RA-FA) in 5 patients, the RA to the Ao (RA-Ao) in 3 patients, and the right and left atrium to the Ao in 1 patient. Seventeen (56.7%) patients were weaned from mechanical circulatory support (Group 1) and the remaining 13 patients were not (Group 2). In Group 1, PCPS running time was 33.1 +/- 13.6 h, which was significantly shorter than that of Group 2 (70.6 +/- 44.4 h). Left ventricular ejection fraction was improved from 34.8 +/- 12.0% at the pump to 42.5 +/- 4.6% after 24 h support in Group 1, which was significantly better than that of Group 2 (21.6 +/- 3.5%). In particular, it was 48.6 +/- 5.7% in the patients with RA-Ao, which was further improved. Two of 3 patients with RA-Ao were discharged. Thrombectomy was carried out for ischemic complication of the lower extremity in 5 patients with F-F and 1 patient with RA-FA. One patient with F-F needed amputation of the leg due to necrosis. Thirteen patients (43.3%) were discharged. Hospital mortality indicated 17 patients (56.7%). Fifteen patients died with multiple organ failure. In conclusion, our alternate strategy of assisted circulation for severe cardiac failure is as follows. In patients with postcardiotomy cardiogenic shock or LOS, PCPS should be applied first under intraaortic balloon pumping (IABP) assist for a maximum of 2 or 3 days. In older aged patients particularly, the RA-Ao approach of PCPS is superior to control flow rate easily, with less of the left ventricular afterload and ischemic complications of the lower extremity. If native cardiac function does not recover and longer support is necessary, several types of ventricular assist devices should be introduced, according to end-organ function and the expected support period.
我们评估了经皮心肺支持（PCPS）用于严重心源性休克的循环支持疗效及问题，并讨论了我们针对严重心肺功能衰竭的机械循环辅助策略。我们还描述了一种替代的PCPS方式，即从右心房（RA）到升主动脉（Ao）的静脉 - 动脉（VA）旁路，最近我们对3例患者采用了这种方法。在过去9年中，我们机构有30例患者（20例男性和10例女性；平均年龄：61岁）接受了围手术期PCPS。PCPS的适应证为13例患者用于体外循环脱机，14例患者用于术后低心排血量综合征（LOS），3例患者用于术前心源性休克。PCPS系统的途径为21例患者采用股动脉到股静脉（F - F），5例患者采用RA到股动脉（RA - FA），3例患者采用RA到Ao（RA - Ao），1例患者采用左右心房到Ao。17例（56.7%）患者成功脱离机械循环支持（第1组），其余13例患者未成功脱离（第2组）。在第1组中，PCPS运行时间为33.1±13.6小时，明显短于第2组（70.6±44.4小时）。第1组患者左心室射血分数在开始使用泵时为34.8±12.0%，在支持24小时后提高到42.5±4.6%，明显优于第2组（21.6±3.5%）。特别是采用RA - Ao途径的患者中这一数值为48.6±5.7%，且进一步得到改善。采用RA - Ao途径的3例患者中有2例出院。5例采用F - F途径和1例采用RA - FA途径的患者因下肢缺血并发症进行了血栓切除术。1例采用F - F途径的患者因坏死需要截肢。13例患者（43.3%）出院。医院死亡率为17例患者（56.7%）。15例患者死于多器官功能衰竭。总之，我们针对严重心力衰竭的辅助循环替代策略如下。对于心脏手术后的心源性休克或LOS患者，应首先在主动脉内球囊反搏（IABP）辅助下应用PCPS，最长使用2至3天。特别是老年患者，PCPS的RA - Ao途径在轻松控制流速方面更具优势，左心室后负荷更小，下肢缺血并发症更少。如果自身心脏功能未恢复且需要更长时间的支持，则应根据终末器官功能和预期支持时间引入几种类型的心室辅助装置。
