Bonacchi Massimo, Vannini Andrea, Harmelin Guy, Batacchi Stefano, Bugetti Marco, Sani Guido, Peris Adriano
Department of Cardiac Surgery, Experimental and Clinical Medicine, University of Florence, Florence, Italy
Department of Cardiac Surgery, Experimental and Clinical Medicine, University of Florence, Florence, Italy.
Interact Cardiovasc Thorac Surg. 2015 Mar;20(3):365-71. doi: 10.1093/icvts/ivu421. Epub 2014 Dec 21.
The sequelae of severe poly-trauma may include myocardial dysfunction followed by acute heart failure and death. Inverted-Takotsubo cardiomyopathy (ITC) is a variant of stress cardiomyopathy, characterized by a contractile abnormality with extensive left ventricular circumferential dyskinesia or akinesia with a hyperkinetic apex. We report our experience with refractory cardiogenic shock and/or cardiac arrest, treated with extracorporeal life support.
From June 2008 to December 2011, we treated 4 adult poly-trauma patients (3 men, 1 woman, mean age: 27.7 ± 13.5 years, mean ISS score 53.2 ± 15.9) with veno-arterial (V-A) extracorporeal life support for cardiopulmonary failure/cardiac arrest refractory to conventional treatment, due to inverted-Takotsubo cardiomyopathy. We used a miniaturized extracorporeal life support (ECLS) device.
ITC myocardial dysfunction appeared 15.4 ± 11.6 h after intensive care unit admission and rapidly evolved to refractory cardiopulmonary failure and cardiac arrest (within 4.8 ± 2.5 h of the onset). At ECLS, initiation median pH was 7.12 ± 0.14 (6.91-7.25), median lactate was 6.7 ± 2.8 (4-10) mmol/l and median vasoactive-inotropic score was 192.1 ± 50.6 µg/kg/min. Tissue perfusion improved significantly within 4 h on ECLS. Cardiac function improved gradually but consistently. Initial median ejection fraction was 14.2 ± 4.7% and median global longitudinal strain test was -7.4 ± 4.7. At complete cardiac recovery, they were 62.73 ± 7.8 and -18.43 ± 2.4%, respectively. After that, 2 patients survived and were sent to neurological rehabilitation before hospital discharge. In the other 2 cases, post-traumatic cerebral death occurred and they underwent organ explantation.
Rapid heparin-free ECLS may improve outcome in the most severe cases of poly-traumatized patients demonstrating refractory inverted-Takotsubo cardiomyopathy.
严重多发伤的后遗症可能包括心肌功能障碍，继而发展为急性心力衰竭甚至死亡。倒T波型应激性心肌病（ITC）是应激性心肌病的一种变体，其特征为收缩异常，伴有广泛的左心室圆周运动障碍或运动不能，心尖部运动亢进。我们报告了应用体外生命支持治疗难治性心源性休克和/或心脏骤停的经验。
2008年6月至2011年12月，我们对4例成年多发伤患者（3例男性，1例女性，平均年龄：27.7±13.5岁，平均损伤严重度评分53.2±15.9）因ITC导致常规治疗难治的心肺功能衰竭/心脏骤停，采用静脉-动脉（V-A）体外生命支持治疗。我们使用了小型体外生命支持（ECLS）设备。
ITC心肌功能障碍在重症监护病房入院后15.4±11.6小时出现，并迅速发展为难治性心肺功能衰竭和心脏骤停（发病后4.8±2.5小时内）。在开始ECLS时，中位pH值为7.12±0.14（6.91 - 7.25），中位乳酸水平为6.7±2.8（4 - 10）mmol/L，中位血管活性药物-正性肌力药物评分192.1±50.6μg/kg/min。在ECLS治疗4小时内组织灌注显著改善。心脏功能逐渐但持续改善。初始中位射血分数为14.2±4.7%，中位整体纵向应变检测为-7.4±4.7。心脏完全恢复时，分别为62.73±7.8和-18.43±2.4%。此后，2例患者存活，出院前被送去进行神经康复治疗。另外2例发生创伤后脑死亡，接受了器官摘除。
快速无肝素ECLS可能改善多发伤患者中表现为难治性倒T波型应激性心肌病的最严重病例的预后。
