终末期肝病模型评分在肝功能衰竭中应用的研究进展

肝功能衰竭（hepatic failure，HF）是一切肝脏疾病重症化的共同结局，病情凶险，预后极差，据报道，其病死率高达60％-80％。准确评估HF患者的疾病严重程度，有助于预测病死率和指导选择治疗方案。终末期肝病模型（model for end-stage liver disease，MELD）评分是美国Mayo Clinic的Malinchoc和Kamath于2000年创立的一个判断终末期肝病病情的新分级方式，2002年被美国器官分配网络中心（United Network for Organ Sharing，UNOS）确立为等候肝移植患者生存率的独立预测指标。目前，国内外对MELD评分在重型肝炎／HF中的应用展开了广泛研究。现就MELD评分特点及国内外应用MELD评分研究重型肝炎／HF的相关新进展综述如下。     

吸入一氧化氮对老年急性大面积肺血栓栓塞症患者血浆心肌肌钙蛋白的影响

伴右心室功能衰竭的肺血栓栓塞症（PET）患者右心室功能障碍和衰竭的主要原因是右心室后负荷加重使右心室壁受损。心肌肌钙蛋白（cTn）是心肌早期受损的主要指标之一，其水平和心肌受损程度与PET的临床预后呈明显负相关。     

微创手术治疗慢性心功能衰竭

目的；探讨微创手术植入左心室心外膜起搏电极进行慢性心功能衰竭的再同步治疗的可行性、安全性和临床疗效。方法 按美国心脏病学会和美国心脏病学院（ACC／AHA）标准选择1例扩张性心肌病患者行再同步治疗，应用Medtrorile 5076心内膜起搏电极，通过心导管将右心房电极植入右心耳，右心室电极植入右宣流出道。通过微创手术经胸路径将Metronic 6945心外膜起搏电极植入左室侧后壁，电极经皮下隧道连至脉冲发生器。结果：三腔起搏电极均放置顺利。术后左心室同步性较前改善，患者恢复良好。结论：对于心导管径路左心室起搏电极放置失败的患者，微创手术植入左心室心外膜起搏电极是此类患者进行心脏再同步治疗的一种有效、可行和安全的方法。     

终末期心衰病人院外左心辅助Incor I治疗

目的评价终末期左心功能衰竭(ESHF)病人院外使用新型左心室辅助装置(LVAD)Incor I轴流泵辅助治疗的可行性。方法2002年6月~2004年1月对23例ESHF病人植入Incor I轴流泵辅助治疗。结果至2004年9月累计辅助治疗8 126d,平均辅助时间(353±44)d。2例(8.70%)在心功能恢复后成功撤离LVAD,11例(47.83%)接受心脏移植手术。现有辅助病例8例(34.78%),最长辅助治疗天数835d。死亡2例(8.70%)。结论Incor I辅助泵治疗的ESHF病人可出院等待心脏移植供体或心脏功能恢复,Incor I辅助泵也可作为永久辅助装置应用于不适合心脏移植的病人。     

终末期肾功能衰竭引起不安腿综合征21例分析

终末期肾功能衰竭引起的不安腿综合征（RLS）是一常见的中枢神经系统疾病，为进一步探讨其临床表现及治疗，对21例终末期。肾功能衰竭引起的RLS患者临床表现、治疗总结如下，     

俯卧位通气联合支气管镜肺泡灌洗成功治疗左心室辅助装置植入术后重症肺炎1例

左心室辅助装置(left ventricular assist device, LVAD)作为终末期心衰患者除心脏移植外又一有效治疗手段, 在国外应用已经有二三十年的历史。在国内的应用刚刚起步, 泰达国际心血管病医院自2009年开始和中国运载火箭技术研究院合作, 开始人工心脏的研发, 并于2020年正式开展多中心临床试验, 截止目前已成功完成50例临床试验目标。作为多中心研究组长单位, 本院共完成20例, 笔者对其中1例LVAD植入术后合并耐碳青霉烯肺炎克雷伯菌重症肺炎患者的救治过程进行回顾总结, 探讨俯卧位通气联合支气管镜肺泡灌洗在LVAD术后重症肺炎患者中的应用效果及可行性, 为临床此类患者的治疗提供经验参考。     

连续性肾脏替代治疗前后右心室功能改变的超声评价

［摘要］ 目的 应用彩色多普勒超声观察连续性肾脏替代治疗（Continuous Renal Replacement Therapy,CRRT）前后慢性肾功能衰竭患者右心室功能和容量的变化。方法 选择行连续性肾脏替代治疗的慢性肾功能衰竭患者71例，收集患者超声心动图参数，包括三尖瓣环收缩期纵向位移（TAPSE）、右室面积变化分数（FAC）、侧壁三尖瓣环收缩期峰速度（S’）、右室舒张末容积（RV EDV）、右室基底横径［RVDd（base）］。观察患者CRRT前后右心室参数的变化，探讨患者CRRT前TAPSE与CVP的相关性。结果 与CRRT前相比，CRRT后RV EDV和[RVDd（base）]降低，差异有统计学意义（P＜0.05）。CRRT前后S’之间无显著差异。CRRT前TAPSE为（15.37±4.45）mm，CRRT后TAPSE（16.89±5.01）mm增加，CRRT前FAC为（46.12±10.57）mm，CRRT后FAC（48.88±11.90）mm增加，差异有统计学意义（P＜0.05）。CRRT前TAPSE与CVP具有相关性（r=-0.592，P=0.000）。结论 TAPSE、FAC反映右心室收缩功能，CRRT可改善慢性肾功能衰竭患者右心室收缩功能。RV EDV、［RVDd（base）］反映右心室容积，提示CRRT可降低右心室容积。CVP随TAPSE的减低而增加，提示TAPSE可能成为反应容量的间接指标。     

糖尿病肾病的诊断与治疗

糖尿病肾病（didbefic nephropathy，DN）是糖尿病（diabetes mellitus，DM）常见的微血管合并症，约有30％～40％的DM会发展为DN，且会不断上升，最终成为终末期肾脏病（end-stage renal disease，ESRD）。DM患者一旦发生DN后，其进展至终末期肾功能衰竭的速度比一般肾脏病快，故DN在ESRD中比例必将不断增加，DN发展到终末期的过程是可以延缓却是不可逆的。因此对于DN的早期诊断，早期治疗，在一定程度上延缓其发病及缩短病程，延长患者生存时间，改善生活质量，降低医疗费用等意义重大。DN的自然病程开始于微量蛋白尿（VAE），发展为临床蛋白尿，贯穿整个肾功下降的过程。VAE是DN早期表现，是一个重要诊断指标。     

慢性心力衰竭患者血清尿酸、CA125、BNP的水平变化及意义

心力衰竭（heart failure ，HF）是心脏病发展的终末阶段，也是重要的死亡原因之一。HF临床表现复杂，合并症多，早期诊断有一定困难，而早期诊断对降低病死率非常重要。近年来研究显示尿酸、CA125和脑钠肽（BNP）水平对慢性充血性心力衰竭（chronic heart failure ，CHF）的诊断、疗效评价及预后有重要意义。本文通过检测78例不同原因引起心功能Ⅱ、Ⅲ、Ⅳ的CHF患者尿酸、CA125和BNP的水平，探讨其与心功能分级的关系，从而为临床CHF的诊断、治疗及预后提供参考。     

科素亚治疗糖尿病肾病的临床分析

糖尿病肾病（DN）是糖尿病（DM）的主要慢性并发症，亦是终末期肾功能衰竭的一个主要原因。近年来的研究表明，抑制血管紧张素Ⅱ（ATⅡ）的产生，并干扰其作用过程是治疗DN的关键。现就ATⅡ受体拮抗剂科素亚治疗DN的临床疗效进行分析。     

Continuous-flow left ventricular assist device and the right ventricle

Left ventricular assist devices (LVADs) have become accepted as treatment for heart failure as a result of improvements in diagnosing and treating left ventricular failure and limited donor availability. In the Pivotal Study of the HeartMate II in the bridge to transplantation population, the incidence of right ventricular failure without the implantation of a right ventricular assist device was 14%, with an additional 6% of the participants ill enough that they required implantation of a right ventricular assist device. This complication increases mortality, cost, and length of stay. This article reviews the screening of LVAD candidates for the probability of right ventricular failure postoperatively, the evaluation of right ventricular function in LVAD candidates, and the optimal management of the right ventricle during the perioperative care of LVAD patients.     

Anticoagulation and bleeding in patients with ventricular assist devices: walking the tightrope

A left ventricular assist device (LVAD) is a lifesaving therapy for end-stage heart failure, but it is associated with major complications such as bleeding and thrombosis. Anticoagulation is an important part of LVAD therapy; it requires meticulous management and monitoring for prevention of thromboembolic and bleeding events. Recommendations for thromboprophylaxis vary among pulsatile and nonpulsatile devices and require multiple pharmacological agents to achieve adequate anticoagulation. Patients expected to undergo LVAD implantation must have a comprehensive evaluation for underlying coagulopathies. During the perioperative period, all measures must be taken to prevent excessive bleeding and maintain hemostasis. Postoperative bleeding and thromboembolic episodes must be minimized to prevent significant complications of ventricular assist device therapy. Bleeding and thromboembolism are an impediment to a patient's quality of life as they can result in multiple hospitalizations, along with serious consequences such as death and permanent disability.     

Chronotropic incompetence and abnormal heart rate recovery early after left ventricular assist device implantation

Background: Chronotropic response to exercise and heart rate recovery immediately after exercise (HRR₁) are valid prognostic markers in patients with chronic heart failure (CHF). The aim of this study was to evaluate heart rate profile during and after exercise in CHF patients early after left ventricular assist device (LVAD) implantation. Methods: We enrolled seven stable consecutive CHF patients (five males, mean age: 45 ± 16 years) after 1 month of LVAD (HeartMate II; Thoratec Corp, Pleasanton, CA, USA) implantation, seven healthy subjects, and 14 patients with advanced HF (HF control group) who performed an incremental symptom‐limited cardiopulmonary exercise testing (CPET). CHF patients performed CPET at 1 and 3 months after LVAD. HRR₁ was defined as the HR difference from peak to 1 minute after exercise and chronotropic response to exercise as the chronotropic reserve ([CR, %]=[peak HR‐resting HR/220‐age‐resting HR]× 100). Results: LVAD patients 3 months after implantation had a significantly different HR profile during exercise compared to healthy controls, with significantly lower CR (57 ± 31 vs 90 ± 14, %, P < 0.001) and HRR₁ (14 ± 6 vs 28 ± 8, bpm, P < 0.01). HR profile during exercise did not significantly change 1 and 3 months after LVAD implantation. There was no statistical difference compared to HF control group and LVAD group regarding cardiopulmonary parameters. Conclusions: LVAD patients present an impaired CR and an abnormal HRR₁ after implantation, indicating significant cardiac autonomic abnormalities. These alterations seem to remain unaltered 3 months after LVAD implantation. (PACE 2011; 34:1607–1614)     

Twelve hours of sustained ventricular fibrillation supported by a continuous-flow left ventricular assist device

Left ventricular assist device (LVAD) therapy improves survival and quality of life by mechanically unloading the left ventricle and maintaining hemodynamics in patients with end-stage heart failure. LVADs can also be lifesaving by maintaining hemodynamics during ventricular arrhythmia. Continuous-flow LVADs have become the preferred LVAD technology. As presented here, a continuous-flow LVAD successfully provided hemodynamic support to a patient in sustained ventricular fibrillation for over 12 hours when the internal defibrillator was unable to terminate the arrhythmia. This case demonstrates that continuous-flow LVADs can be lifesaving in the setting of otherwise certain hemodynamic collapse from sustained ventricular fibrillation.     

A case of single-incision laparoscopic surgery for acute appendicitis with left ventricular assist device

A left ventricular assist device (LVAD) is used for patients with severe heart failure. We present a case of a 35-year-old man who had undergone LVAD implantation 2 years ago for dilated phase of hypertrophic cardiomyopathy. He had right lower abdominal pain and was diagnosed with acute appendicitis. Single-incision laparoscopic surgery for appendicitis was performed. We incised approximately 3 cm of the umbilicus carefully because the driveline of LVAD was passing just caudal to the umbilicus. LVAD is only available for patients waiting for cardiac transplantation in Japan, and the number of patients with LVAD has been increasing. Adequate anticoagulant therapy is necessary because device thrombosis often causes fatal complications, but during emergency cases, the surgeons have to be cautious of bleeding and injury to the driveline of LVAD.     

A longitudinal comparison of health-related quality of life in rural and urban recipients of left ventricular assist devices

Left ventricular assist devices (LVAD) are a common treatment for advanced heart failure (HF) to improve ventricular function, symptoms, and health-related quality of life (HRQOL). Many LVAD recipients travel long distances from rural areas for LVAD implantation and follow-up care. Individuals with HF in rural settings who have not undergone LVAD implantation have reported poor HRQOL. However, to date, no studies have compared HF-specific or generic HRQOL in rural and urban LVAD recipients. The purpose of this study was to compare generic and HF-specific HRQOL longitudinally from preimplantation to 1-, 3-, and 6- months postimplant in a cohort of rural and urban LVAD recipients (n = 95; rural n = 32 and urban n = 63). We measured generic HRQOL using the European Quality of Life Visual Analog Scale and HF-specific HRQOL with the quality of life domain of the Kansas City Cardiomyopathy Questionnaire (KCCQ). Latent growth curve modeling identified two phases of change in generic and HF-specific HRQOL: the initial response to LVAD between preimplantation and 1-month postimplant and the subsequent change between 1- and 6-months postimplant. Comparable improvements in generic HRQOL were noted in rural and urban LVAD recipients during both phases of change. Urban LVAD recipients had greater initial improvements in HF-specific HRQOL (KCCQ) compared with rural recipients (13.0 ± 5.6, p = .02), but subsequent improvements were similar among rural and urban recipients. Ongoing assessment of generic and HF-specific HRQOL is necessary during LVAD therapy.     

Laparoscopic gastrectomy for heart failure patients with left ventricular assist devices

Left ventricular assist devices (LVADs) currently play an important role in the treatment of patients with end-stage heart failure who require a bridge to heart transplantation. As the LVAD population increases, the incidence of cancer patients with an LVAD is assumed to be increasing as well. For gastric cancer patients with an LVAD, surgery may be the only curative treatment, especially as chemotherapy is scarcely available. However, we cannot perform an upper-middle incision in these patients because of the LVAD's location and driveline. Furthermore, to reduce the risk of driveline infection, minimally invasive surgery is desirable. Therefore, laparoscopic surgery is, where possible, suitable for achieving a secure approach to the abdominal cavity. However, laparoscopic surgery for patients with LVAD requires careful consideration not only for anesthetic management, but also for the technical procedure. We ingenuously performed laparoscopic gastrectomy for a gastric cancer patient with LVAD to preserve the device and obtain a good surgical view.     

Soluble ST2 in end‐stage heart failure,before and after support with a left ventricular assist device

Background

The interleukin‐33 (IL‐33)/suppressor of tumorigenicity 2 (ST2) pathway is suggested to play an important role in fibrosis, remodelling and the progression of heart failure (HF). Increased soluble (sST2) levels are associated with adverse outcome in the average HF population. Less is known about sST2 levels in end‐stage HF. Therefore, we studied sST2 levels in end‐stage HF and the effect of unloading by left ventricular assist device (LVAD) support on sST2 levels.

Method and results

Serial plasma measurements of sST2 were performed pre‐implantation and 1, 3 and 6 months after (LVAD) implantation in 38 patients. sST2 levels were elevated in end‐stage HF just prior to LVAD implantation (74.2 ng/mL [IQR 54.7‐116.9]; normal <35 ng/mL) and decreased substantially during LVAD support, to 29.5 ng/mL [IQR 24.7‐46.6](P < .001). Patients with INTERMACS profile I had significantly higher sST2 levels compared to patients in profile II and profile III. A moderate correlation was found between sST2 and C‐reactive protein (r = .580, P < .010).

Conclusion

Levels of sST2 are elevated in end‐stage HF patients with variability that suggests multiple inputs to a pro‐inflammatory and pro‐fibrotic pathway. Cardiogenic shock and increased C‐reactive protein levels are associated with higher sST2 levels. LVAD support results in a significant drop in sST2 levels with normalization within 3 months postimplantation. This suggests that LVAD support leads to lessening of fibrosis and inflammation, which might eventually be used to target medical policy: explantation of the LVAD versus permanent use or cardiac transplantation.     

Overcoming Electromagnetic Interference by LVADs on ICD Function by Shielding the ICD Programmer Wand and Extension Cable

Patients with end-stage cardiomyopathy and congestive heart failure are increasingly undergoing implantation with left ventricular assist devices (LVADs). In addition, implantable cardioverter-defibrillator (ICD) therapy has been proven to be an important part of the treatment for cardiomyopathy/congestive heart failure. Previous reports have noted a potential and dramatic electromagnetic interference from LVADs on ICDs that cause impaired telemetry communication between the ICD and ICD programmer. Such interference has necessitated explantation and generator replacement in order to resume communication between the ICD and programmer. We report two patients with advanced congestive heart failure and ICD programming impairment caused by a HeartMate II LVAD (Thoratec Corporation, Pleasanton, CA, USA) that was overcome by placing aluminum shielding around the ICD programmer wand and steel shielding around the extension cable during ICD interrogation.     

Acquired coagulopathy in patients with left ventricular assist devices

Summary

Chronic heart failure (HF) is a major emerging healthcare problem, associated with a high morbidity and mortality. Left ventricular assist devices (LVADs) have emerged as a successful treatment option for patients with end‐stage HF. Despite its great benefit, the use of LVAD is associated with a high risk of complications. Bleeding, pump thrombosis and thromboembolic events are frequently observed complications, with bleeding complications occurring in over a third of the patients. Although the design of the third‐generation LVAD has improved greatly, these hemostatic complications still occur. The introduction of an LVAD into the circulatory system results in an altered hematological balance as a consequence of blood–pump interactions, changes in hemodynamics, the rheology, and the concomitant need for anticoagulation while implanted with an LVAD. The majority, if not all, LVAD patients experience a form of platelet dysfunction and impaired von Willebrand factor activity, leading to acquired coagulopathy disorders. Different diagnostic tools and treatment strategies have been reported; however, they require validation in LVAD patients. The present review focuses on acquired coagulopathies, describing the incidence, impact and underlying mechanism of acquired coagulopathy disorders in patients supported by LVADs. In addition, we will discuss diagnostic and management strategies for these acquired coagulopathies.