Park Jung Bin, Kwak Jae Gun, Lim Hong-Gook, Kim Woong-Han, Lee Jeong Ryul, Kim Yong Jin
Seoul National University, Seoul, Korea.
Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea.
Korean Circ J. 2017 Jul;47(4):490-500. doi: 10.4070/kcj.2016.0320. Epub 2017 Jul 27.
Mechanical circulatory support with extracorporeal membrane oxygenation (ECMO) and ventricular assist device has always been the optimal choice for treating the majority of medically intractable low cardiac output case. We retrospectively investigated our institution's outcomes and variables associated with a high risk of mortality.
From 1999 to 2014, 86 patients who were of pediatric age or had grown-up congenital heart disease underwent mechanical circulatory support for medically intractable low cardiac output in our pediatric intensive care unit. Of these, 9 grown-up congenital heart disease patients were over 18 years of age, and the median age of the subject group was 5.82 years (range: 1 day to 41.6 years). A review of all demographic, clinical, and surgical data and survival analysis were performed.
A total of 45 (52.3%) patients were successfully weaned from the mechanical assist device, and 25 (29.1%) survivors were able to be discharged. There was no significant difference in results between patients over 18 years and under 18 years of age. Risk factors for mortality were younger age (<30 days), functional single ventricle anatomy, support after cardiac operations, longer support duration, and deteriorated pre-ECMO status (severe metabolic acidosis and increased levels of lactate, creatinine, bilirubin, or liver enzyme). The survival rate has improved since 2010 (from 25% before 2010 to 35% after 2010), when we introduced an upgraded oxygenator, activated heart transplantation, and also began to apply ECMO before the end-stage of cardiac dysfunction, even though we could not reveal significant correlations between survival rate and changed strategies associated with ECMO.
Mechanical circulatory support has played a critical role and has had a dramatic effect on survival in patients with medically intractable heart failure, particularly in recent years. Meticulous monitoring of acid-base status, laboratory findings, and early and liberal applications are recommended to improve outcomes without critical complication rates, particularly in neonates with single ventricle physiology.
体外膜肺氧合（ECMO）和心室辅助装置的机械循环支持一直是治疗大多数内科难治性低心排血量病例的最佳选择。我们回顾性研究了本机构的治疗结果以及与高死亡风险相关的变量。
1999年至2014年，86例儿科年龄或患有成人先天性心脏病的患者在我们的儿科重症监护病房接受了针对内科难治性低心排血量的机械循环支持。其中，9例成人先天性心脏病患者年龄超过18岁，研究对象组的中位年龄为5.82岁（范围：1天至41.6岁）。对所有人口统计学、临床和手术数据进行了回顾，并进行了生存分析。
共有45例（52.3%）患者成功脱离机械辅助装置，25例（29.1%）幸存者得以出院。18岁以上和18岁以下患者的结果无显著差异。死亡风险因素包括年龄较小（<30天）、功能性单心室解剖结构、心脏手术后的支持、较长的支持时间以及ECMO前状态恶化（严重代谢性酸中毒以及乳酸、肌酐、胆红素或肝酶水平升高）。自2010年以来生存率有所提高（从2010年前的25%提高到2010年后的35%），当时我们引入了升级的氧合器，启动了心脏移植，并且在心脏功能障碍终末期之前就开始应用ECMO，尽管我们未能揭示生存率与ECMO相关的改变策略之间的显著相关性。
机械循环支持发挥了关键作用，对内科难治性心力衰竭患者的生存产生了显著影响，尤其是近年来。建议对酸碱状态、实验室检查结果进行细致监测，并尽早且广泛地应用，以改善结局且无严重并发症发生率，特别是对于具有单心室生理特征的新生儿。
