Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany.
J Thorac Cardiovasc Surg. 2010 Feb;139(2):302-11, 311.e1. doi: 10.1016/j.jtcvs.2009.10.043.
Adult postcardiotomy cardiogenic shock potentially requiring mechanical circulatory support occurs in 0.5% to 1.5% of cases. Risk factors influencing early or long-term outcome after extracorporeal membrane oxygenation implantation are not well described.
Between May 1996 and May 2008, 517 adult patients received extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock. Procedures were isolated coronary artery bypass grafting (37.4%), isolated valve surgery (14.3%), coronary artery bypass grafting plus valve surgery (16.8%), thoracic organ transplantation (6.5%), and other combinations (25.0%). Fifty-four preoperative and 42 procedural risk factors concerning in-hospital mortality were evaluated by logistic regression analyses.
Mean age was 63.5 years, 71.5% were male, ejection fraction was 45.9% +/- 17.6%, logistic EuroSCORE was 21.6% +/- 20.7%. Extracorporeal membrane oxygenation was established through thoracic (60.8%) or extrathoracic (39.2%) cannulation. Extracorporeal membrane oxygenation support was 3.28 +/- 2.85 days. Intra-aortic balloon pumps were implanted in 74.1%. Weaning from extracorporeal membrane oxygenation was successful for 63.3%, and 24.8% were discharged. Cerebrovascular events occurred in 17.4%, gastrointestinal complications in 18.8%, and renal replacement therapy in 65.0%. Risk factors for hospital mortality were age older than 70 years (odds ratio, 1.6), diabetes (odds ratio, 2.5), preoperative renal insufficiency (odds ratio, 2.1), obesity (odds ratio, 1.8), logistic EuroSCORE greater than 20% (odds ratio, 1.8), operative lactate greater than 4 mmol/L (odds ratio, 2.2). Isolated coronary artery bypass grafting (odds ratio, 0.44) was protective. Cumulative survivals were 17.6% after 6 months, 16.5% after 1 year, and 13.7% after 5 years.
Extracorporeal membrane oxygenation support is an acceptable option for patients with postcardiotomy cardiogenic shock who otherwise would die and is justified by good long-term outcome of hospital survivors. Because of high morbidity and mortality, extracorporeal membrane oxygenation must be decided by individual risk profile.
成人心脏手术后心源性休克需要机械循环支持的发生率为 0.5%至 1.5%。体外膜肺氧合（ECMO）植入后影响早期或长期预后的风险因素尚不清楚。
1996 年 5 月至 2008 年 5 月，517 例成人心脏手术后心源性休克患者接受 ECMO 支持。手术方式为单纯冠状动脉旁路移植术（37.4%）、单纯瓣膜手术（14.3%）、冠状动脉旁路移植术+瓣膜手术（16.8%）、胸部器官移植（6.5%）和其他组合（25.0%）。通过逻辑回归分析评估了 54 项术前和 42 项与院内死亡率相关的手术风险因素。
平均年龄 63.5 岁，71.5%为男性，射血分数 45.9%+/-17.6%，逻辑欧洲心脏手术风险评分（EuroSCORE）为 21.6%+/-20.7%。ECMO 通过胸内（60.8%）或胸外（39.2%）插管建立。ECMO 支持时间为 3.28+/-2.85 天。主动脉内球囊反搏（IABP）植入率为 74.1%。ECMO 成功撤机 63.3%，出院 24.8%。发生脑血管事件 17.4%，胃肠道并发症 18.8%，肾脏替代治疗 65.0%。院内死亡的危险因素为年龄大于 70 岁（比值比[OR]，1.6）、糖尿病（OR，2.5）、术前肾功能不全（OR，2.1）、肥胖（OR，1.8）、逻辑欧洲心脏手术风险评分大于 20%（OR，1.8）、手术时乳酸大于 4mmol/L（OR，2.2）。单纯冠状动脉旁路移植术（OR，0.44）是保护性因素。6 个月、1 年和 5 年的累积生存率分别为 17.6%、16.5%和 13.7%。
对于其他情况下会死亡的心脏手术后心源性休克患者，ECMO 支持是一种可接受的选择，并且医院幸存者的长期预后良好。由于高发病率和死亡率，ECMO 的应用必须根据个体风险状况决定。
