Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
Section of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
J Am Soc Echocardiogr. 2018 Feb;31(2):169-179. doi: 10.1016/j.echo.2017.09.004. Epub 2017 Nov 1.
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been proved to effectively rescue patients from refractory cardiogenic shock. The role of the right ventricle in VA-ECMO has been emphasized, but quantitative right ventricular (RV) analysis in this population has been lacking. Three-dimensional echocardiography (3DE) is currently suggested for RV volumetric analysis. The aims of this study were to assess 3DE-derived RV ejection fraction (RVEF) in patients with refractory cardiogenic shock stabilized by VA-ECMO and to explore the association between 3DE-derived RVEF and weaning success as well as the prognosis after the first intent of decannulation.
Three-dimensional echocardiographic data sets before the first intent of decannulation were retrospectively selected and analyzed in 46 patients who underwent VA-ECMO for refractory acute circulatory collapse.
Twenty-eight of the 46 patients had protocol-defined success in weaning from VA-ECMO. In the success group, both ventricles were smaller and had better pumping function. By stepwise multivariate linear regression, RV free wall strain, left ventricular ejection fraction, RV fractional area change, and central venous pressure were found to be independently associated with RVEF. Receiver operating characteristic curve analysis showed that RVEF had the highest area under the curve (0.90, P < .001) for weaning success with a cutoff value of 24.6%. Worse RVEF (≤24.6%) was also associated with poor prognosis in terms of all-cause mortality within 30 days (hazard ratio, 15.86; 95% CI, 3.56-70.73; P < .001).
Three-dimensional echocardiography-derived RVEF might represent the composite results of RV contractility, left ventricular performance, and fluid status. Under mechanical circulatory support of VA-ECMO, RVEF > 24.6% was associated with higher weaning success and lower 30-day mortality after the first intent of decannulation.
体外膜肺氧合（VA-ECMO）已被证明可有效抢救难治性心源性休克患者。右心室（RV）在 VA-ECMO 中的作用已得到强调，但该人群中 RV 的定量分析尚缺乏。目前建议使用三维超声心动图（3DE）进行 RV 容积分析。本研究旨在评估接受 VA-ECMO 稳定治疗的难治性心源性休克患者的 3DE 衍生 RV 射血分数（RVEF），并探讨 3DE 衍生 RVEF 与撤机成功以及首次拔管意向后的预后之间的关系。
回顾性选择 46 例接受 VA-ECMO 治疗难治性急性循环衰竭患者的 3DE 数据集，并进行分析。
46 例患者中有 28 例符合撤机标准。在撤机成功组中，左右心室均更小，泵血功能更好。通过逐步多元线性回归，RV 游离壁应变、左心室射血分数、RV 节段面积变化和中心静脉压被发现与 RVEF 独立相关。受试者工作特征曲线分析显示，RVEF 对撤机成功的曲线下面积最高（0.90，P < 0.001），截断值为 24.6%。更差的 RVEF（≤24.6%）也与 30 天内全因死亡率的预后不良相关（危险比，15.86；95%置信区间，3.56-70.73；P < 0.001）。
3DE 衍生的 RVEF 可能代表 RV 收缩力、左心室功能和液体状态的综合结果。在 VA-ECMO 的机械循环支持下，RVEF > 24.6%与撤机成功率更高和首次拔管意向后 30 天死亡率更低相关。
