Mount Sinai Medical Center, New York, NY 10029, USA.
Eur J Cardiothorac Surg. 2013 Aug;44(2):213-6. doi: 10.1093/ejcts/ezt014. Epub 2013 Jan 30.
Recently, the initial therapy for refractory cardiogenic shock has largely been based on use of short-term mechanical devices with later conversion to durable options. The premise is that such patients cannot tolerate cardiopulmonary bypass and the extended surgery needed for implantable left ventricular assist device (LVAD) placement. We have adopted an alternative strategy to implant long-term LVADs as the initial device therapy in such patients.
Over a 3 year period, we used implantable LVADs (Jarvik 2000, one; Ventrassist, one; Heartmate XVE, two; and Heartmate II, nine) in 13 patients (11 men and two women; mean age 54 years) with postmyocardial infarction shock without prior use of a short-term LVAD. The median time interval from myocardial infarction to LVAD implantation was 3.5 days. Eight patients were on a ventilator, two had unknown neurological status and four had suffered cardiac arrest in the preceding 24 h. Two had prior coronary artery bypass graft. Nine had received dual antiplatelet therapy postmyocardial infarction. The mean laboratory value of creatinine was 1.5 mg/dl, alanine aminotransferase 748 U/l, international normalized ratio 1.5 and lactate 3.2 mmol/l. One procedure was carried out off pump; for the others, the mean cardiopulmonary bypass time was 72 min. Right ventricular assist devices were used in two cases and were later explanted.
One patient died of progressive multiorgan failure. All others survived to hospital discharge. There were no re-explorations for bleeding or major infectious complications; two patients had perioperative stroke. The median duration of mechanical ventilation, intensive care unit stay and hospital stay was 3, 9 and 18 days, respectively. At 1 year, of the 12 survivors, eight have since had heart transplant, one patient underwent device explant, two remained alive on support and one died 7 months post-LVAD.
Our data challenge the notion that patients in refractory cardiogenic shock are too ill to tolerate immediate placement of implantable LVADs. Despite the surgical challenges, a one-stop implantable LVAD approach for cardiogenic shock is feasible and may offer unique advantages over the bridge-to-bridge approach because it avoids the incremental costs, hospitalization and morbidity associated with repeated interventions.
近来，难治性心源性休克的初始治疗主要基于短期机械装置的使用，随后转为持久选择。前提是这些患者不能耐受体外循环和植入式左心室辅助装置（LVAD）所需的延长手术。我们采取了一种替代策略，即在这些患者中作为初始设备治疗植入长期 LVAD。
在 3 年期间，我们在 13 名患有心肌梗死后休克且既往未使用短期 LVAD 的患者中使用了植入式 LVAD（Jarvik 2000，1 个；Ventrassist，1 个；Heartmate XVE，2 个；Heartmate II，9 个）。心肌梗死至 LVAD 植入的中位时间间隔为 3.5 天。8 名患者使用呼吸机，2 名患者神经状态未知，4 名患者在过去 24 小时内发生心脏骤停。2 名患者既往接受过冠状动脉旁路移植术。9 名患者在心肌梗死后接受双联抗血小板治疗。肌酸酐的平均实验室值为 1.5mg/dl，丙氨酸氨基转移酶 748U/l，国际标准化比值 1.5，乳酸 3.2mmol/l。1 例手术在体外循环下进行；其余病例的平均体外循环时间为 72 分钟。2 例患者使用右心室辅助装置，随后被取出。
1 名患者死于进行性多器官衰竭。所有其他患者均存活至出院。无因出血或重大感染并发症而再次探查；2 例患者发生围手术期卒中。机械通气、重症监护病房和住院的中位时间分别为 3 天、9 天和 18 天。在 1 年时，12 名幸存者中，8 人随后进行了心脏移植，1 名患者进行了设备取出，2 人在支持下存活，1 人在 LVAD 后 7 个月死亡。
我们的数据挑战了这样一种观点，即难治性心源性休克患者病得太重，无法耐受立即植入植入式 LVAD。尽管存在手术挑战，但对心源性休克进行一站式植入式 LVAD 方法是可行的，并且可能与桥接桥接方法相比具有独特的优势，因为它避免了与重复干预相关的增量成本、住院和发病率。
