Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.
Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.
Heart Rhythm. 2021 Jul;18(7):1106-1112. doi: 10.1016/j.hrthm.2021.03.014. Epub 2021 Mar 12.
The most severe form of arrhythmia-induced cardiomyopathy in adults- refractory cardiogenic shock requiring mechanical circulatory support-has rarely been reported.
The purpose of this study was to describe the management of critically ill patients admitted for acute, nonischemic, or worsening of previously known cardiac dysfunction and recent-onset supraventricular arrhythmia who developed refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO).
This study is a retrospective analysis of prospectively collected data.
Between 2004 and 2018, 35 patients received VA-ECMO for acute, nonischemic cardiogenic shock and recent supraventricular arrhythmia (77% atrial fibrillation [AF]). Cardiogenic shock was the first disease manifestation in 21 patients (60%). Characteristics at ECMO implantation [median (interquartile range)] were Sequential Organ Failure Assessment score 10 (7-13); inotrope score 29 (11-80); left ventricular ejection (LVEF) fraction 10% (10%-15%); and lactate level 8 (4-11) mmol/L. For 12 patients, amiodarone and/or electric cardioversion successfully reduced arrhythmia, improved LVEF, and enabled weaning off VA-ECMO; 11 had long-term survival without transplantation or long-term assist device. Eight patients experiencing arrhythmia-reduction failure underwent ablation procedures (7 atrioventricular node [AVN] with pacing, 1 atrial tachycardia) and were weaned off VA-ECMO; 7 survived. Of the remaining 15 patients without arrhythmia reduction or ablation, only the 6 bridged to heart transplantation or left ventricular (LV) assist device survived.
Arrhythmia-induced cardiomyopathy, mainly AF-related, is an underrecognized cause of refractory cardiogenic shock and should be considered in patients with nonischemic cardiogenic shock and recent-onset supraventricular arrhythmia. VA-ECMO support allowed safe arrhythmia reduction or rate control by AVN ablation while awaiting recovery, even among those with severe LV dilation.
成人中最严重的心律失常性心肌病形式——需要机械循环支持的难治性心源性休克——很少有报道。
本研究旨在描述因急性、非缺血性或先前已知心功能障碍恶化和新发室上性心律失常而导致难治性心源性休克需要静脉-动脉体外膜肺氧合（VA-ECMO）的危重症患者的管理。
这是一项回顾性分析前瞻性收集的数据的研究。
在 2004 年至 2018 年间，35 例患者因急性、非缺血性心源性休克和新发室上性心律失常（77%为心房颤动[AF]）接受 VA-ECMO 治疗。心源性休克是 21 例患者（60%）的首发疾病表现。ECMO 植入时的特征[中位数（四分位距）]为序贯器官衰竭评估评分 10（7-13）；正性肌力药物评分 29（11-80）；左心室射血分数（LVEF）为 10%（10%-15%）；乳酸水平 8（4-11）mmol/L。12 例患者通过胺碘酮和/或电复律成功降低心律失常、改善 LVEF，并成功脱离 VA-ECMO；11 例患者无移植或长期辅助设备存活。8 例因心律失常减少失败而接受消融治疗的患者（7 例房室结[AVN]起搏，1 例房性心动过速），并成功脱离 VA-ECMO；7 例患者存活。在其余 15 例无心律失常减少或消融的患者中，仅 6 例患者通过心脏移植或左心室（LV）辅助设备桥接存活。
心律失常性心肌病，主要与 AF 相关，是难治性心源性休克的一个未被充分认识的原因，对于非缺血性心源性休克和新发室上性心律失常的患者应考虑该病因。VA-ECMO 支持允许安全地降低心律失常或通过 AVN 消融控制心率，同时等待恢复，即使在那些有严重 LV 扩张的患者中也是如此。
