体外膜肺氧合技术在心脏移植不同时期的应用

目的 探讨体外膜肺氧合技术(ECMO)在心脏移植术前辅助、术中替代体外循环及术后辅助治疗的临床应用效果.方法 对心脏移植术前过渡、术中代替常规体外循环以及术后心功能衰竭辅助治疗中使用ECMO技术患者的临床资料进行回顾分析.结果 3例等待心脏移植的患者术前应用ECMO 5～8 d,其中2例患者在等待供心的过程中发生多器官功能衰竭而死亡;1例患者成功接受心脏移植,术后顺利撤除了ECMO.12例在心脏移植术中应用了ECMO代替常规体外循环技术,均顺利完成手术,术后持续应用ECMO辅助的时间平均为(38±14)h,1例患者因发生多器官功能衰竭死亡,其余11例患者均痊愈,顺利出院,无患者发生右心功能衰竭和三尖瓣返流等心脏移植术后常见的并发症.心脏移植术后由于严重右心功能衰竭接受ECMO辅助治疗的患者有10例,起始时间为返回监护室后2 h至2 d,持续时间为43～176 h,其中7例患者痊愈,顺利出院,1例因发生严重感染而死亡,2例因发生多器官功能衰竭而死亡.以上死亡患者的死亡原因均与ECMO的出血或血栓形成等并发症无关.结论 尽早应用ECMO可以使等待心脏移植的心功能衰竭患者有效地过渡到心脏移植;术中应用ECMO替代常规体外循环技术可以更好地保护供心,有利于缺血时间较长供心的功能恢复,提高心脏移植手术成功率;术后患者出现右心功能衰竭时,应用ECMO有良好的辅助治疗效果.

Abstract：

Objective To investigate the clinical results of extracorporeal membrane oxygenation (ECMO) technique during the peri-operative heart transplantation. Methods The clinical data of heart transplantations supported by the ECMO were retrospectively analyzed, including during the bridge to transplant, working as routine bypass in the operation room, and supporting the heart failure after surgery. Results Three 3 cases were supported with ECMO to extend the waiting time: 2cases died of multi organ failure during the waiting, and the third one received the heart transplant and the ECMO was successfully removed. Totally 12 cases of heart transplantation received the modified open style ECMO techniques replacing the routine bypass. The ECMO was removed after assistance for (38 ± 14) h. All the recipients except one death recovered well without right ventricular failure or obvious tricuspid regurgitation which was common after heart transplantation. Ten cases received ECMO support for the heart failure after the transplant. The initial application time ranged from 2 h to 2 days and lasted 43～176 h. One died of infection and two died of multi organ failure nothing to do with ECMO application and other 7 discharged with NYHA Ⅰ/Ⅱ cardiac function. Conclusion Early use of ECMO could safely bridge the heart failure patients to the transplant. Replacing the routine with ECMO techniques in the heart transplantation could get good myocardial protection results even with long cold ischemic time and improve the cardiac function recovery. For the heart failure patients after the surgery the ECMO could afford good support effect.     

体外膜肺氧合辅助后高胆红素血症的临床意义

Objective The incidence of post-operative hyperbilimbinemia, which is associated with poor outcomes in patients, was reported to be increased in recent years though it has been a rare complication for cardiac operations. Post-opera-tive impairment of liver function is highlighted. We evaluated the incidence and prognosis of post-operative hyperbiliruhinemia in adult patients who underwent cardiotomy with extracorporeal membrane oxygenation (ECMO) support. Methods Sixty-five adult patients who had received ECMO support after cardiac surgery from 2004 to 2008 were enrolled and evaluated retrospec-tively. Post-oporative hypethilirubinemia was defined as the serum level of the total bilirubin more than 51.3 μmol/L during postoperative period. Demographic and clinical data included gender, age, types of surgery, perioperative hemodynamic param-eters, biochemical variables, duration of the ventilation support, ICU stay and outcomes. Results The mean age of the pa-tients was (50.1 ± 13.9) years, forty-six patients(70.8%) were male. The main cardiac procedures were heart transplanta-tion for 9 patients, coronary artery bypass grafting and/or valve operations for 47 patients, congenital heart disease correction for 4 patients and other operations for 5 patients. Among all patients, fifty-one patients(78.5%) were weaned from ECMO succeas-fully and thirty-thrce patients were discharged from hospital. The overall mortality rate was 49.2%. Overall incidence of post-operative hyperbilirubinemia was 55.4%. In patients with postoperative hyperbilirubinemia, the mean peak value for serum to-tal bilirubin was 104.8 (68.5-156.7) μmol/l. The hospital mortality in the hyperbilirubinemia group was significantly higher than that in the non-hyperbilirubinemia group(66.7% vs. 27.6%, P <0.01). Moreover, postoperative hypethilirubinemia (adds ratio = 3. 895, 95% confidence interval, 1.088 - 13.947 ; P = 0.037) and SOFA score (odds ratio = 1.214, 95% confidence interval, 0.987 - 1.494, P = 0.047) and APACHE Ⅲ score (odds ratio = 1.096, 95% confidence interval, 1.028 - 1.169 ; P = 0.004) were associated with hospital mortality after adjusting for preoperative levels of the total bilirubin, direct bilirubin, gender and age. Conclusion Postoperative hyperbilirubinemia is one of the complications in adult patients who undergo cardiotomy with ECMO support, and is associated with increased hospital mortality.     

体外膜肺氧合辅助后高胆红素血症的临床意义

Objective The incidence of post-operative hyperbilimbinemia, which is associated with poor outcomes in patients, was reported to be increased in recent years though it has been a rare complication for cardiac operations. Post-opera-tive impairment of liver function is highlighted. We evaluated the incidence and prognosis of post-operative hyperbiliruhinemia in adult patients who underwent cardiotomy with extracorporeal membrane oxygenation (ECMO) support. Methods Sixty-five adult patients who had received ECMO support after cardiac surgery from 2004 to 2008 were enrolled and evaluated retrospec-tively. Post-oporative hypethilirubinemia was defined as the serum level of the total bilirubin more than 51.3 μmol/L during postoperative period. Demographic and clinical data included gender, age, types of surgery, perioperative hemodynamic param-eters, biochemical variables, duration of the ventilation support, ICU stay and outcomes. Results The mean age of the pa-tients was (50.1 ± 13.9) years, forty-six patients(70.8%) were male. The main cardiac procedures were heart transplanta-tion for 9 patients, coronary artery bypass grafting and/or valve operations for 47 patients, congenital heart disease correction for 4 patients and other operations for 5 patients. Among all patients, fifty-one patients(78.5%) were weaned from ECMO succeas-fully and thirty-thrce patients were discharged from hospital. The overall mortality rate was 49.2%. Overall incidence of post-operative hyperbilirubinemia was 55.4%. In patients with postoperative hyperbilirubinemia, the mean peak value for serum to-tal bilirubin was 104.8 (68.5-156.7) μmol/l. The hospital mortality in the hyperbilirubinemia group was significantly higher than that in the non-hyperbilirubinemia group(66.7% vs. 27.6%, P <0.01). Moreover, postoperative hypethilirubinemia (adds ratio = 3. 895, 95% confidence interval, 1.088 - 13.947 ; P = 0.037) and SOFA score (odds ratio = 1.214, 95% confidence interval, 0.987 - 1.494, P = 0.047) and APACHE Ⅲ score (odds ratio = 1.096, 95% confidence interval, 1.028 - 1.169 ; P = 0.004) were associated with hospital mortality after adjusting for preoperative levels of the total bilirubin, direct bilirubin, gender and age. Conclusion Postoperative hyperbilirubinemia is one of the complications in adult patients who undergo cardiotomy with ECMO support, and is associated with increased hospital mortality.     

美多巴治疗早期非创伤性股骨头坏死的近期疗效观察

Objective To observe the preliminary effects of the treatment for early non-traumatic osteonecrosis of the femoral head with Madopar. Methods Thirty-one patients with 48 hips of early stage (Ficat Ⅰ,Ⅱ) non-traumatic necrosis of the femoral head were treated with oral administration of Madopar since 2002. The disease was associated with consumption of alcohol in 16 cases with 27 hips; use of steroids in 10 cases with 13 hips; both consumption of alcohol and use of steroids in 2 cases with 4 hips; the remaining 3 cases, the condition was idiopathic. According to the criteria of Ficat et al., there were 4 hips in stage Ⅰ; 40 in stage Ⅱa and 4 in stage Ⅱb. Eighteen patients had received madopar for 10-28 months; 13 patients had been receiving the drug until now. Follow-up examinations were made by radiography, MRI and Charnley modified Merle d'Aubigne score. Results All patients were followed up for 12-84 months (average 27.8 months). The clinical symptoms improved in all cases. X-ray films showed that the bone density increased in nearly all the femoral heads, and 68.75%(33/48) of them maintained their shapes. The follow-up MRI showed their necrotic indices had decreased. The rate of clinical satisfaction was 91.67%(44/48), and the successful rate of treatment was 72.92%(35/48), and the collapse rate of early stage necrosis of the femoral head is 27.08%(13/48). Conclusion The preliminary results showed that madopar could prevent or delay collapse of the femoral head in early stage of osteonecrosis.     

美多巴治疗早期非创伤性股骨头坏死的近期疗效观察

Objective To observe the preliminary effects of the treatment for early non-traumatic osteonecrosis of the femoral head with Madopar. Methods Thirty-one patients with 48 hips of early stage (Ficat Ⅰ,Ⅱ) non-traumatic necrosis of the femoral head were treated with oral administration of Madopar since 2002. The disease was associated with consumption of alcohol in 16 cases with 27 hips; use of steroids in 10 cases with 13 hips; both consumption of alcohol and use of steroids in 2 cases with 4 hips; the remaining 3 cases, the condition was idiopathic. According to the criteria of Ficat et al., there were 4 hips in stage Ⅰ; 40 in stage Ⅱa and 4 in stage Ⅱb. Eighteen patients had received madopar for 10-28 months; 13 patients had been receiving the drug until now. Follow-up examinations were made by radiography, MRI and Charnley modified Merle d'Aubigne score. Results All patients were followed up for 12-84 months (average 27.8 months). The clinical symptoms improved in all cases. X-ray films showed that the bone density increased in nearly all the femoral heads, and 68.75%(33/48) of them maintained their shapes. The follow-up MRI showed their necrotic indices had decreased. The rate of clinical satisfaction was 91.67%(44/48), and the successful rate of treatment was 72.92%(35/48), and the collapse rate of early stage necrosis of the femoral head is 27.08%(13/48). Conclusion The preliminary results showed that madopar could prevent or delay collapse of the femoral head in early stage of osteonecrosis.     

ICGR15在肝癌切除术前评估肝脏储备功能的作用

Objective To evaluate the role of ICGR15 in assessment of hepatic functional reserve before hepateetomy for hepatocellular carcinoma.Methods From August 2005 to October 2007, six-ty-six patients with hepatocellular carcinoma were treated in our hospital.The patients were random-ized into Child-Pugh grading group (32 cases) and ICGR15 detection group (34 cases).Preoperative preparation,operative procedures and postoperative management were the same in all the 66 patients.The morbidity and mortality were compared and the relationship between Child-Pugh grading and ICGR15 in assessment of hepatic functional reserve was determined.Results The incidence of hepatic failure after hepatectomy in ICGR15 detection group(23.50%) was significanly lower than that in Child-Pugh grading group(34.4%).ICGR15 (14.38 ±8.2)% in patients with tumor of Child-Pugh grading B was higher than ICGR15 (7.84 ± 4.8)% in those with tumor of Child-Pugh grading A.Conclusion ICGR15 valuecan be more sensitive in evaluating hepatic functional reserve than Child-Pugh grading, but some correlation can be observed between them.ICGR15 is useful in assessing the range of liver resection and prognosis before hepatectomy for hepatocellular carcinoma.     

ICGR15在肝癌切除术前评估肝脏储备功能的作用

Objective To evaluate the role of ICGR15 in assessment of hepatic functional reserve before hepateetomy for hepatocellular carcinoma.Methods From August 2005 to October 2007, six-ty-six patients with hepatocellular carcinoma were treated in our hospital.The patients were random-ized into Child-Pugh grading group (32 cases) and ICGR15 detection group (34 cases).Preoperative preparation,operative procedures and postoperative management were the same in all the 66 patients.The morbidity and mortality were compared and the relationship between Child-Pugh grading and ICGR15 in assessment of hepatic functional reserve was determined.Results The incidence of hepatic failure after hepatectomy in ICGR15 detection group(23.50%) was significanly lower than that in Child-Pugh grading group(34.4%).ICGR15 (14.38 ±8.2)% in patients with tumor of Child-Pugh grading B was higher than ICGR15 (7.84 ± 4.8)% in those with tumor of Child-Pugh grading A.Conclusion ICGR15 valuecan be more sensitive in evaluating hepatic functional reserve than Child-Pugh grading, but some correlation can be observed between them.ICGR15 is useful in assessing the range of liver resection and prognosis before hepatectomy for hepatocellular carcinoma.     

ICGR15在肝癌切除术前评估肝脏储备功能的作用

Objective To evaluate the role of ICGR15 in assessment of hepatic functional reserve before hepateetomy for hepatocellular carcinoma.Methods From August 2005 to October 2007, six-ty-six patients with hepatocellular carcinoma were treated in our hospital.The patients were random-ized into Child-Pugh grading group (32 cases) and ICGR15 detection group (34 cases).Preoperative preparation,operative procedures and postoperative management were the same in all the 66 patients.The morbidity and mortality were compared and the relationship between Child-Pugh grading and ICGR15 in assessment of hepatic functional reserve was determined.Results The incidence of hepatic failure after hepatectomy in ICGR15 detection group(23.50%) was significanly lower than that in Child-Pugh grading group(34.4%).ICGR15 (14.38 ±8.2)% in patients with tumor of Child-Pugh grading B was higher than ICGR15 (7.84 ± 4.8)% in those with tumor of Child-Pugh grading A.Conclusion ICGR15 valuecan be more sensitive in evaluating hepatic functional reserve than Child-Pugh grading, but some correlation can be observed between them.ICGR15 is useful in assessing the range of liver resection and prognosis before hepatectomy for hepatocellular carcinoma.     

小儿体外膜肺氧合支持治疗8例

目的 总结小儿先天性心脏病术后严重心力衰竭和暴发型心肌炎应用体外膜肺氧合(ECMO)支持治疗的经验.方法 8例中术后不能脱离CPB 7例、暴发型心肌炎1例.均使用离心泵,全部静脉-动脉模式;采用中心插管、右房-升主动脉7例,周围大血管插管、股静脉-股动脉模式1例.辅助65～498 h,辅助流量80～120ml·min-1·kg-1.结果 死亡5例;出院3例,生存率38%.并发症包括出血5例、血栓形成2例、溶血1例、DIC 1例、肝衰竭1例、营养不良2例、机械故障2例.结论 先心病术后无残余解削畸形,而出现严重心衰病例,往往因合并左、右心室并伴肺功能不全,宜及时施行ECMO支持治疗,而取代肺脏气体交换功能,减少呼吸器使用中的高浓度氧气和气道压的肺损伤,降低总体病死率;注意及时补充新鲜血小板、血浆等血制品;合理应用血管活性药物和肝素,根椐出血部位及量采用针对性措施,维持内环境稳定;加用超滤,减少机体特别是出血的并发症.应选用长期使用的肝素涂层膜肺,监测膜前后压力,注意血浆渗漏,减少机械并发症.

Abstract：

Objective The use of extracorporeal membrane oxygenation (ECMO) as a treatment for the failure of cardiopulmonary function after cardiac surgery is increasing and has been reported to be 3% to 5% in the cases with congenital heart disease. We reviewed our experience with ECMO in children who received heart surgery for congenital heart disease and complicated with severe heart failure postoperatively. Methods Eight patients received ECMO, seven was due to the failure to wean from bypass and one had fulminant myocarditis. Import membrane oxygenator,veno-arterial mode ECMO and right atriumascending aortic cannulation were used in 7 cases and peripheral cannulation via femoral veno-artery route was used in 1 case.Supportive intervention persisted from 65 to 498 hours, with flow rate maintained at 80 to 120 ml per minute per kilogram body weight. Results Five patients died, with a mortality of 62.5%, and 3 cases discharged, with a survival rate of 38%. Bleeding occurred in 5 cases, thrombosis occurred in 2 cases, hemolysis was identified in 1 case and DIC was observed in 1 case.One case had liver failure and 2 cases had malnutrition. Oxygenator plasma leakage occurred in 2 cases. Mean arterial blood pressure increased significantly after the establishment of ECMO as compared with that before the procedure [( 60.2 ± 7.8 )mmHg vs. (48. 1 ± 5.2 ) mmHg, P≤0.05]. The arterial concentration of lactate decreased significantly, from (5. 1 ± 0. 8 )mmol per liter before ECMO to ( 3.6 ±0. 5 )mmol per liter after ECMO, P ＜0.05. Conclusion For patients who survived the congenital heart surgery and no residual anatomic deformity, ECMO can be used as early as possible as a treatment for severe heart failure which resulted from coexistent of left and right ventricular and pulmonary insufficiency. An overall mortality may be decreased by ECMO technique as it plays a substitution role for gas exchange in the lung. As a result, the concentration of oxygen and the airway pressure used during ventilation, and the resultant lung injury can be reduced. Appropriate strategies involve transfusion of fresh platelet and packed red blood cells, replacement of frozen plasma and blood products, as well as rational use of vasoactive drugs and heparin, and maintaining a stable internal environment. Following strategies are also recommended: using continuous arterio-venous hemofiltration and durable heparin-coated membrne oxygenator, reducing hemorrhagic complications, monitoring pressure on both side of the film, identifying plasma leakage carefully and reducing the mechanical complications.     

ICGR15在肝癌切除术前评估肝脏储备功能的作用

Objective To evaluate the role of ICGR15 in assessment of hepatic functional reserve before hepateetomy for hepatocellular carcinoma.Methods From August 2005 to October 2007, six-ty-six patients with hepatocellular carcinoma were treated in our hospital.The patients were random-ized into Child-Pugh grading group (32 cases) and ICGR15 detection group (34 cases).Preoperative preparation,operative procedures and postoperative management were the same in all the 66 patients.The morbidity and mortality were compared and the relationship between Child-Pugh grading and ICGR15 in assessment of hepatic functional reserve was determined.Results The incidence of hepatic failure after hepatectomy in ICGR15 detection group(23.50%) was significanly lower than that in Child-Pugh grading group(34.4%).ICGR15 (14.38 ±8.2)% in patients with tumor of Child-Pugh grading B was higher than ICGR15 (7.84 ± 4.8)% in those with tumor of Child-Pugh grading A.Conclusion ICGR15 valuecan be more sensitive in evaluating hepatic functional reserve than Child-Pugh grading, but some correlation can be observed between them.ICGR15 is useful in assessing the range of liver resection and prognosis before hepatectomy for hepatocellular carcinoma.