体外膜肺氧合在心脏移植围术期的支持策略

目的回顾性分析总结体外膜肺氧合(ECMO)在心脏移植围术期的支持策略。方法自2008年9月至2014年7月武汉协和医院共行150例原位心脏移植术,其中1例为心肝联合移植。在围术期因严重心肺衰竭使用ECMO辅助11例,其中1例患者在等待供心期间急性左心衰行ECMO过渡后行心脏移植,4例边缘供心移植术中低心排中转ECMO辅助,5例心脏移植术后右心衰行ECMO辅助,1例移植术后左心衰行ECMO辅助。ECMO辅助主要采用静脉-动脉(VA)模式,温度维持在36~37℃,流量维持在2.5~3.5 L/min,全血激活凝固时间维持在160~180 s,转流过程中血流动力学和呼吸参数平稳。结果 11例心脏移植围术期ECMO辅助后8例脱机,脱机率72.7%。ECMO辅助时间15~1 532 h,平均315 h。ECMO期间患者血流动力学明显改善,正性肌力药物用量减少。ECMO期间1例出现插管远端肢体缺血,经远端血管插管供血后缓解。此外,出血2例,溶血1例,肾功能衰竭2例,经积极对应治疗后6例ECMO辅助患者痊愈出院。结论 ECMO能对心脏移植围术期的心肺功能衰竭提供强有效的支持治疗,并且提高"边缘供心"的使用成功率,扩大了供心来源。

The strategy of extracorporeal membrane oxygenation support in the peri-operative period of heart transplantation

Objective To summarize and analyze the clinical effect and experience of extracorporeal membrane oxygenation （ ECMO） support in the peri-operative period of heart transplant patients in Wuhan Union Hospital. Methods From September 2008 to May 2014, 150 orthotopic heart transplantations were performed in Wuhan Union Hospital, including one case with simultaneous heart-liver transplantation. Eleven patients with severe ventricular failure in the peri-operative period of heart transplant received ECMO support. One patient received ECMO support because of acute left heart failure during waiting for donor heart;four patients of marginal donor heart transplantation received ECMO support during operation because of low cardiac output after cardiopulmonary bypass;five patients because of right heart failure and one patient because of left heart failure after transplantation received ECMO support. ECMO was established in these patients by cannulation of VA model. Temperature was maintained between 36-37℃, active clotting time （ ACT） was maintained between 160-180 seconds, mean blood flow was 2.5-3.5 L/min during ECMO assistant period. The hemodynamic and respiratory parameters were maintained stabilization. Results ECMO was weaned off successfully in eight of eleven patients （72.7%）. The ECMO time was 15-1532 h and mean time was 315 h. The hemodynamic parameters of eleven patients were improved during ECMO and the dose of vasoactive drugs was decreased. One patient occurred catheter-associated ischemia in distal limb, and was treated by using the distal vascular intubation. In addition, there were hemorrhage in two patients, hemolysis in one patient and renal failure in two patients. All these six patients recovered after treatment and discharged successfully. Conclusion ECMO is an important extracorporeal method of life support for heart transplant patients with severe perioperative heart failure, and it can extend the use of marginal donor hearts, which is very important because of the shortage of donor he