Teirstein P S, Vogel R A, Dorros G, Stertzer S H, Vandormael M G, Smith S C, Overlie P A, O'Neill W W
Scripps Clinic and Research Foundation, Division of Cardiovascular Diseases, La Jolla, California 92037.
J Am Coll Cardiol. 1993 Mar 1;21(3):590-6. doi: 10.1016/0735-1097(93)90089-j.
Data from a national registry of 23 centers using cardiopulmonary support (CPS) were analyzed to compare the risks and benefits of prophylactic CPS versus standby CPS for patients undergoing high risk coronary angioplasty.
Early data from the CPS registry documented a high angioplasty success rate as well as a high procedural morbidity rate. Because of this increased morbidity some high risk patients were placed on standby CPS instead of prophylactic CPS.
Patients in the prophylactic CPS group had 18F or 20F venous and arterial cannulas inserted and cardiopulmonary bypass initiated. Patients in the standby CPS group were prepared for institution of cardiopulmonary bypass, but bypass was not actually initiated unless the patient sustained irreversible hemodynamic compromise.
There were 389 patients in the prophylactic CPS group and 180 in the standby CPS group. The groups were comparable with respect to most baseline characteristics, except that left ventricular ejection fraction was lower in the prophylactic CPS group. Thirteen of the 180 patients in the standby CPS group sustained irreversible hemodynamic compromise during the angioplasty procedure. Emergency institution of CPS was successfully initiated in 12 of these 13 patients in < 5 min. Procedural success was 88.7% for the prophylactic and 84.4% for the standby CPS group (p = NS). Major complications did not differ between groups. However, 42% of patients in the prophylactic CPS group sustained femoral access site complications or required blood transfusions, compared with only 11.7% of patients in the standby CPS group (p < 0.01). Among patients with an ejection fraction < or = 20%, procedural morbidity remained significantly higher in the prophylactic CPS group (41% vs. 9.4%, p < 0.01), but procedural mortality was higher in the standby group (4.8% vs. 18.8%, p < 0.05).
Patients in the standby and prophylactic CPS groups had comparable success and major complication rates, but procedural morbidity was higher in the prophylactic group. When required, standby CPS established immediate hemodynamic support during most angioplasty complications. For most patients, standby CPS was preferable to prophylactic CPS during high risk coronary angioplasty. However, patients with extremely depressed left ventricular function (ejection fraction < 20%) may benefit from institution of prophylactic CPS.
分析来自23个使用心肺支持（CPS）中心的国家注册数据，以比较接受高风险冠状动脉血管成形术患者预防性CPS与备用CPS的风险和益处。
CPS注册的早期数据记录了较高的血管成形术成功率以及较高的手术发病率。由于这种发病率的增加，一些高风险患者被置于备用CPS而非预防性CPS。
预防性CPS组患者插入18F或20F动静脉插管并启动体外循环。备用CPS组患者做好体外循环准备，但除非患者出现不可逆的血流动力学损害，否则不实际启动体外循环。
预防性CPS组有389例患者，备用CPS组有180例患者。除预防性CPS组左心室射血分数较低外，两组在大多数基线特征方面具有可比性。备用CPS组的180例患者中有13例在血管成形术过程中出现不可逆的血流动力学损害。这13例患者中有12例在<5分钟内成功启动了CPS紧急支持。预防性CPS组的手术成功率为88.7%，备用CPS组为84.4%（p=无显著性差异）。两组的主要并发症无差异。然而，预防性CPS组42%的患者出现股动脉穿刺部位并发症或需要输血，而备用CPS组仅为11.7%（p<0.01）。在射血分数≤20%的患者中，预防性CPS组的手术发病率仍然显著更高（41%对9.4%，p<0.01），但备用组的手术死亡率更高（4.8%对18.8%，p<0.05）。
备用和预防性CPS组患者的成功率和主要并发症发生率相当，但预防性组的手术发病率更高。在需要时，备用CPS在大多数血管成形术并发症期间建立了即时血流动力学支持。对于大多数患者，在高风险冠状动脉血管成形术期间备用CPS优于预防性CPS。然而，左心室功能极度低下（射血分数<20%）的患者可能从预防性CPS中获益。
