A De Gasperis Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Milan, Italy.
J Thorac Cardiovasc Surg. 2010 Dec;140(6):1416-21. doi: 10.1016/j.jtcvs.2010.07.083. Epub 2010 Oct 8.
Cardiogenic shock still carries a very high mortality. We adopted veno-arterial extracorporeal membrane oxygenation using the Levitronix centrifugal pump (Levitronix LLC, Waltham, Massachusetts) as a first-line treatment of cardiogenic shock in a "bridge to decision" strategy. This article provides our experience of this clinical approach.
Since 1988, 160 ventricular assist devices have been implanted at our hospital for heart failure. Since 2005, 15 consecutive patients have been treated with veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock. Veno-arterial extracorporeal membrane oxygenation has been implanted either centrally or peripherally.
Mean age was 44.7 ± 20.0 years (2-78 years). There were 5 women. Veno-arterial extracorporeal membrane oxygenation was implanted peripherally in 8 cases (53.4%) and centrally in the remaining 7 (46.6%). Mean veno-arterial extracorporeal membrane oxygenation duration was 11.5 ± 8.1 days (range, 1-30). No patient experienced any neurologic event or vascular complication at the cannulation site. Twelve patients (80%) were weaned from veno-arterial extracorporeal membrane oxygenation or bridged to either a long-term left ventricular assist device or heart transplantation. Three patients died during veno-arterial extracorporeal membrane oxygenation support secondary to multi-organ failure. Seven patients (46.6%) were discharged from the hospital, with a 100% survival at follow-up. The survivors include 2 patients affected by fulminant myocarditis, who were bridged to recovery, and 5 patients who were bridged to heart transplantation. Survivors were younger than nonsurvivors (mean age, 28.5 vs 58.8 years, respectively).
In our experience, the use of veno-arterial extracorporeal membrane oxygenation as bridge to decision has been effective to promptly restore adequate systemic perfusion, allowing further time to evaluate myocardial recovery or candidacy for ventricular assist device or heart transplantation. Younger patients, with no or mild end-organ injury, had the best outcomes. Peripheral cannulation decreases the surgical trauma and makes emergency implantation possible, even in the intensive care unit.
心源性休克仍然具有很高的死亡率。我们采用 Levitronix 离心泵（Levitronix LLC，马萨诸塞州沃尔瑟姆）进行静脉-动脉体外膜肺氧合，作为一种“桥接决策”策略，用于治疗心源性休克。本文提供了我们对这种临床方法的经验。
自 1988 年以来，我院共植入 160 台心室辅助装置治疗心力衰竭。自 2005 年以来，连续 15 例难治性心源性休克患者采用静脉-动脉体外膜肺氧合治疗。静脉-动脉体外膜肺氧合可在中心部位或外周部位植入。
平均年龄为 44.7 ± 20.0 岁（2-78 岁）。其中 5 例为女性。8 例（53.4%）患者外周静脉-动脉体外膜肺氧合，7 例（46.6%）患者中心静脉-动脉体外膜肺氧合。静脉-动脉体外膜肺氧合时间平均为 11.5 ± 8.1 天（1-30 天）。无患者在插管部位出现任何神经事件或血管并发症。12 例（80%）患者成功脱离静脉-动脉体外膜肺氧合，或桥接至长期左心室辅助装置或心脏移植。3 例患者因多器官衰竭在静脉-动脉体外膜肺氧合支持期间死亡。7 例（46.6%）患者出院，随访时存活率为 100%。幸存者包括 2 例暴发性心肌炎患者，他们成功康复，5 例患者成功桥接心脏移植。幸存者比非幸存者年轻（平均年龄分别为 28.5 岁和 58.8 岁）。
根据我们的经验，将静脉-动脉体外膜肺氧合作为桥接决策的方法，可有效地迅速恢复充分的全身灌注，从而有更多的时间来评估心肌恢复或是否适合心室辅助装置或心脏移植。无或轻度终末器官损伤的年轻患者的预后最好。外周插管可减少手术创伤，并可在重症监护病房进行紧急植入。
