Fayad Georges, Larrue Benoît, Modine Thomas, Azzaoui Richard, Regnault Alexi, Koussa Mohammad, Gourlay Terry, Fourrier François, Decoene Christophe, Warembourg Henri
Clinique de Chirurgie Cardiovasculaire, Hôpital Cardiologique, CHRU de Lille, France.
J Extra Corpor Technol. 2007 Jun;39(2):112-6.
Pregnancy is a common decompensation factor for women with post-rheumatic mitral disease. However, valvular heart diseases causing severe acute respiratory distress are rare. Use of extracorporeal membrane oxygenation (ECMO) early in the event of cardiorespiratory failure after cardiac surgery may be of benefit. Indeed, ECMO cardiopulmonary bypass (CPB) support could help pulmonary recovery if the mitral pathology is involved. A 31-year-old female patient at 30 weeks of amenorrhea was admitted to the obstetrics department with 40 degrees C hyperthermia and New York Heart Association (NYHA) class 4 dyspnea. The patient's medical history included a post-rheumatic mitral stenosis. Blood gases showed severe hypoxemia associated with hypocapnia. The patient needed to be rapidly intubated and was placed on ventilatory support because of acute respiratory failure. Transesophageal echocardiography showed a severe mitral stenosis, mild mitral insufficiency, and diminished left ventricular function, hypokinetic, dilated right ventricle, and a severe tricuspid regurgitation. An urgent cesarean section was performed. Because of the persistent hemodynamic instability, a mitral valvular replacement and tricuspid valve annuloplasty were performed. In view of the preoperative acute respiratory distress, we decided, at the beginning of the operation, to carry on circulatory support with oxygenation through an ECMO-type CPB at the end of the operation. This decision was totally justified by the unfeasible CPB weaning off. ECMO use led to an efficient hemodynamic state without inotropic drug support. The surgical post-operative course was uneventful. Early use of cardiorespiratory support with veno-arterial ECMO allows pulmonary and right heart recovery after cardiac surgery, thus avoiding the use of inotropic drugs and complex ventilatory support.
妊娠是风湿性二尖瓣疾病女性患者常见的失代偿因素。然而，导致严重急性呼吸窘迫的瓣膜性心脏病却很罕见。心脏手术后发生心肺衰竭时早期使用体外膜肺氧合（ECMO）可能有益。事实上，如果二尖瓣病变累及，ECMO心肺转流（CPB）支持有助于肺部恢复。一名停经30周的31岁女性患者因体温40摄氏度及纽约心脏协会（NYHA）4级呼吸困难入住产科。患者既往有风湿性二尖瓣狭窄病史。血气分析显示严重低氧血症伴低碳酸血症。由于急性呼吸衰竭，患者需要迅速插管并接受通气支持。经食管超声心动图显示严重二尖瓣狭窄、轻度二尖瓣关闭不全、左心室功能减退、运动减弱、右心室扩张以及严重三尖瓣反流。紧急实施了剖宫产。由于持续存在血流动力学不稳定，进行了二尖瓣置换和三尖瓣环成形术。鉴于术前急性呼吸窘迫，我们在手术开始时决定在手术结束时通过ECMO式CPB进行氧合循环支持。因CPB撤机不可行，这一决定完全合理。使用ECMO导致血流动力学状态良好，无需使用血管活性药物支持。手术术后过程顺利。早期使用静脉 - 动脉ECMO进行心肺支持可使心脏手术后肺部和右心恢复，从而避免使用血管活性药物和复杂的通气支持。
