主动脉内球囊反搏的临床应用进展

主动脉内球囊反搏(IABP)作为一种机械循环支持方法最早应用于急性心肌梗死合并心源性休克的治疗,是目前抢救急危重症病人的有效手段,目前已广泛应用于临床.     

主动脉内球囊反搏在低射血分数患者非体外循环冠状动脉旁路移植术中应用的必要性探讨

目的探讨对低射血分数患者施行非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting, OPCAB)预防性应用主动脉内球囊反搏(intraaortic balloon pump, IABP)辅助的必要性. 方法 2001 年1 月～2004年10月对64例低射血分数(LVEF≤40%)施行OPCAB,将64例分为2组:术前或术中预防性应用IABP辅助者列为IABP组,共19例;未应用IABP者列为对照组,共45例. 结果 IABP组与对照组在术后并发症手术死亡、脑血管意外、肾功能衰竭衰血滤、围手术期心肌梗死等方面无显著差异(χ2=0.000,P=1.000).IABP组术后需要延长呼吸机带机时间(超过24 h)的比例显著高于对照组(IABP组8例,对照组3例; χ2=9.429,P=0.002);IABP组术后监护时间延长(超过48 h)的比例显著高于对照组(IABP组14例,对照组19例; χ2=4.110,P=0.043). 结论在无IABP辅助的情况下,为低射血分数患者实施OPCAB手术是可行的.     

主动脉内球囊反搏的护理

对主动脉内球囊反搏（IABP）的工作原理、应用指征、术前准备、术后及并发症的护理进行了综述,旨在保证IABP有效实施,提高其对心脏病患者的治疗效果,减少并发症的发生。     

主动脉内球囊反搏在冠状动脉旁路移植术中的应用

目的　为提高冠状动脉旁路移植术 (CABG)的手术疗效 ,总结 CABG围手术期主动脉内球囊反搏 (I-ABP)应用的临床经验。　方法　回顾性分析 4 6例 CABG围手术期行 IABP患者的临床资料及 IABP放置的原因、时间和预后。　结果　 34例康复出院 ,住院死亡 12例 ,主要死亡原因 :低心排血量综合征、肺部感染、多器官功能衰竭等。平均 IABP辅助时间 2 8.6± 18.2小时。IABP能使平均动脉压升高 ,心排血量增加 ,有助于心脏功能差的患者脱离体外循环和改善心脏不停跳冠状动脉旁路移植术 (OPCAB)中心脏对稳定器压迫的耐受性。　结论　 IABP是一种简单有效的循环辅助手段 ,心功能差的高危 CABG患者应及时放置 IABP。放置 IABP前应查明下肢血管情况 ,避免血管损伤。     

主动脉内球囊反搏的护理

对主动脉内球囊反搏(IABP)的工作原理、应用指征、术前准备、术后及并发症的护理进行了综述,旨在保证IABP有效实施,提高其对心脏病患者的治疗效果,减少并发症的发生.     

主动脉内球囊反搏在小儿中的应用

主动脉内球囊反搏(intraaortic balloon pump，IABP)已广泛应用于成年人心源性休克和围手术期低心排血量综合征的治疗，并取得良好的治疗效果，但在小儿中的应用仍较局限。现就有关IABP在小儿中的应用进行综述，着重分析IABP的适应证和影响在小儿中应用的技术困难和其他因素，介绍小儿IABP应用的技术要点，可能的并发症和治疗效果。在无体外膜式氧合器(ECMO)和左心辅助设备的情况下，小儿心脏直视手术后如不能脱离体外循环机或发生严重低心排血量综合征等，应用IABP治疗可收到较好的效果。     

主动脉内球囊反搏在心脏手术中的运用与护理

主动脉内球囊反搏(简称IABP)是心脏手术左心辅助循环方法之一.我科1999年2～12月,对7例体外循环术中不能脱机和/或低心排综合征行IABP辅助后顺利停机,现报告如下.     

主动脉内球囊反搏在高危患者非体外循环冠状动脉旁路移植术中的应用

目的分析行非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCAB)的高危患者术前应用主动脉内球囊反搏(intraaortic balloon pump,IABP)的治疗效果,总结IABP的应用及撤机指征。方法回顾性分析自2008年1月至2011年7月复旦大学附属中山医院102例高危冠心病患者[IABP组,男71例,女31例;年龄(63.0±8.2)岁]在OPCAB术前置入IABP治疗的临床资料,另外选择100例未于术前置入IABP的患者作为对照[对照组,男55例,女45例;年龄(64.1±9.5)岁]。监测两组患者手术后有创动脉收缩压(SABP)、有创平均动脉压(MABP)、机械辅助通气时间、住ICU时间、并发症发生情况、IABP辅助时间、围术期死亡等。术后3个月复查心脏超声心动图检测左心室射血分数(LVEF)。结果 IABP组患者术后SABP[(95.3±12.2)mm Hgvs(.80.1±11.7)mm Hg;t=8.440,P=0.000]、MABP[(78.9±13.5)mm Hg vs(.52.3±15.1)mm Hg;t=12.410,P=0.000]明显高于对照组;机械辅助通气时间、住ICU时间、正性肌力药物辅助时间较对照组短;室性心律失常、低心排血量、围术期心肌梗死和围术期肾功能不全血液透析的发生较对照组少;围术期死亡率低于对照组[5.9%(6/102)vs.17.0%(17/100),χ2=6.180,P=0.020]。IABP组随访96例,对照组随访83例,随访时间均为3个月。术后3个月时心脏超声心动图提示IABP组LVEF显著高于对照组(45.3%±12.0%vs.39.1%±8.2%,t=3.950,P=0.000)。结论对具有高危因素的OPCAB患者术前预防性置入IABP、且把握好撤机时机,可降低手术风险,明显提高手术效果,加快患者术后恢复,改善心功能,减少并发症的发生,降低围术期病死率。     

主动脉内球囊反搏在冠心病高危患者行非体外循环冠状动脉旁路移植手术中的应用

目的探讨主动脉内球囊反搏(IABP)在冠心病高危患者行非体外循环冠状动脉旁路移植术(OPCABG)中的应用时机。方法本文前瞻性随机研究,选择我院2007年1月至2010年1月行OPCABG的冠心病高危患者60例,均分为主动性植入IABP组(A组)和常规处理组(B组)。比较两组患者的临床资料及预后。结果 B组正性肌力药物辅助时间、IABP使用时间、机械通气时间、住ICU时间、围术期死亡率及围术期心肌梗死发生率明显高于A组(P<0.05);而术后1年生存率明显低于A组(P<0.05)。结论主动性植入IABP可改善冠心病高危患者行OPCABG的预后。     

Complications Related to Intra-aortic Balloon Pump in Cardiac Surgery: A Decade Later

BACKGROUND: Our centre in 1995 reported 26% of vascular complications in cardiac surgical patients treated with intra-aortic balloon pump (IABP). However, during the last decade there have been improvements in IABP technology and insertion techniques. We aimed to evaluate the impact of these changes on the incidence of IABP-related complications in cardiac surgery. METHODS: Demographics, indications, technique and complication rate in 186 consecutive patients treated with IABP from January 1994 to December 1998 (Group I) were compared with 323 consecutive patients treated with IABP from January 1999 to December 2003 (Group II) at our regional cardiothoracic centre. Data was variably expressed as mean with or without range and either standard deviation or range. Statistical significance was accepted at P<0.05. RESULTS: There were 121 (65%) and 194 (60%) males in Group I and II, respectively. The mean age was 66+/-12.1 (17-88) years and the mean duration of IAPB use was 43.5h (range 3-144 h). Overall complication rate was 10% in Group I and 2% in Group II whereas vascular complications accounted for 3% in Group-I and 1% in Group-II. Logistic regression analysis demonstrated cardiogenic shock being strongly correlated to in-hospital mortality (OR 4.68; P=0.004) followed by older age (OR 3.12; P=0.034) and ejection fraction <35% (OR 1.78; P=0.03). CONCLUSION: The study demonstrated a significant decrease in the IABP-related complications even though complexity of cases referred for surgery has increased. Henceforth, the risk of 1% vascular complications should play little influence on decision-making regarding the use of IABP.     

主动脉瓣重度狭窄伴左心室收缩功能受损患者的外科疗效分析

目的分析主动脉瓣置换术在治疗主动脉瓣重度狭窄伴左心室收缩功能受损患者中的疗效。方法回顾性分析2000年1月至2011年12月在第二军医大学长海医院接受手术治疗的主动脉瓣重度狭窄伴左心室收缩功能受损[左心室射血分数（LVEF）〈50％]患者的临床资料,排除二尖瓣狭窄患者。共纳入29例患者,男22例、女7例,年龄14～76（56.3±12．9）岁。将患者手术前后临床及心脏超声心动图相关指标进行比较,评价手术效果,并根据患者LVEF恢复情况,分析可能影响患者术后心脏功能恢复的危险因素。结果术后早期死亡1例。其余28例患者术后主动脉瓣跨瓣压差由（97．6±25．1）mmHg降至（25．0±9．7）mmHg,LVEF由41％±6％增加至56％±11％,左心室舒张／收缩期末直径／容积均较术前明显改善（P均〈0．001）。结论主动脉瓣膜置换术是主动脉瓣重度狭窄伴左心室收缩功能受损患者的有效治疗方法,术后左心室超声指标显著改善。术前左心室扩大程度较低可能更利于术后LVEF的恢复。     

无或伴有轻度主动脉瓣反流患者二尖瓣置换术后远期分析

目的 观察术前无或伴有轻度主动脉瓣反流(aortic valve regurgitation,AR)患者施行二尖瓣置换术后的远期结果,探讨二尖瓣置换术时是否需要同期处理所伴有的轻度AR. 方法 将1999年3月至2004年4月在四川大学华西医院行二尖瓣置换术(术前无或伴轻度AR)并随访5年或5年以上的88例患者纳入研究,按其术前超声心动图检查是否无或伴有轻度AR将患者分为两组,AR组:伴有轻度AR,35例,男7例,女28例;年龄49.26±11.87岁;术前心功能分级(NYHA):Ⅱ级4例,Ⅲ级26例,Ⅳ级5例.无AR组:无AR,53例,男7例,女46例;年龄48.59±10.22岁;术前NYHA:Ⅱ级7例,Ⅲ级39例,Ⅳ级7例.术后定期随访,术后5年完成超声心动图复查.结果 术后随访时间5～9年(6.39±1.26年), 两组患者性别、年龄、术前NYHA 、心律等比较差异无统计学意义(P=0.394,0.841,0.960,0.732).AR组患者术后NYHA构成、左心室射血分数(LVEF)和左心室缩短分数(LVFS)均较术前明显改善及增加(P<0.05);无AR组患者术后NYHA构成及LVEF亦较术前明显改善及增加(P<0.05),而术前、术后的LVFS比较差异无统计学意义(P>0.05).两组患者术前、术后左室径(LV)、主动脉内径(AO) 比较差异无统计学意义(P>0.05);AR组术前、术后发生AR的例数比较差异无统计学意义(P>0.05),而无AR组患者术前、术后发生AR的例数差异有统计学意义(P<0.05). 结论 术后5～9年术前伴有轻度AR的二尖瓣置换术患者术前、术后AR构成变化不明显,对二尖瓣置换术患者不需要同期预防性处理所伴有的轻度AR.     

Use of Intra-Aortic Balloon Pump Counterpulsation for Refractory Symptomatic Vasospasm

Delayed neurologic deficits secondary to vasospasm remain a vexing problem. Current treatments include: hypertensive hypervolemic hemodilution (Triple-H) therapy, angioplasty, and intra-arterial papaverine administration. Significant morbidity and mortality still result from vasospasm despite these therapies. We present two patients with symptomatic vasospasm who received intra-aortic balloon pump counterpulsation (IABP) to improve cerebral blood flow when they were unable to tolerate Triple-H therapy. One patient (L.T.) developed vasospasm after resection of a meningioma that encased the carotid and middle cerebral artery. The other patient (D.F.) suffered a subarachnoid hemorrhage (Fisher Grade III, Hunt/Hess Grade III) from a basilar tip aneurysm. Postoperatively, both patients developed vasospasm. Treatment with Triple-H therapy, angioplasty, and papaverine yielded modest results. When they experienced cardiac ischemia, Triple-H therapy was stopped, but their neurologic condition deteriorated markedly. Because of this, IABP was started. Both patients had an immediate improvement in cardiac function. IABP was able to reverse some of the neurologic deficits, and was weaned off after several days of support. Both patients had a substantial improvement in function, and are now capable of caring for themselves. We conclude that IABP may play an important role for improving cerebral blood flow in patients with vasospasm. It may be particularly useful in those patients with limited cardiac reserve.     

Evaluation of preoperative intra-aortic balloon pump support in high risk coronary patients

Objective: The intra-aortic balloon pump (IABP) is an established additional support to pharmacological treatment of the failing heart after myocardial infarction, unstable angina and cardiac surgery. The effect of preoperative IABP in high risk patients was evaluated. Methods: Between June 1994 and March 1996 all high risk patients for CABG (two or more of these criteria: Left ventricular ejection fraction (LVEF) ≤40%, left main stem stenosis ≥70%, REDO-CABG, unstable angina) were randomized into either of 3 groups: (1) IABP 1 day prior to surgery, (2) IABP 1–2 h prior to CPB and (3) no preoperative IABP, controls. Exclusion criteria: cardiogenic shock preoperatively. Fifty-two patients have entered the study—group 1 (13 patients), group 2 (19 patients) and group 3 (20 patients). Preoperative patient characteristics and operative data revealed no group differences. There were 56% REDO's, unstable angina 59%, LVEF≤40%, 87% (34.0±11.6%) and left main stem stenosis in 35%. Results: The CPB-time was shorter in groups 1 and 2 88.7±20.3 min than in group 3 105.5±26.8 min, P<0.001, while ischemia time did not differ. Hospital mortality was higher in group 3, 25% vs. 6% (groups 1 and 2). Postoperative low cardiac output was seen in 12 patients (60%) in group 3 vs. 6 patients (19%) in groups 1 and 2, P<0.05. Cardiac index increased significantly prior to CPB in groups 1 and 2. After CPB cardiac index was significantly higher in groups 1 and 2 compared to Group 3 and continued to increase. The IABP was removed after 3.1±1.0 days in group 3 vs. 1.3±0.6 days in groups 1 and 2, P<0.001. In group 3, 11 patients required IABP postoperatively compared to only 4 patients in groups 1 and 2. ICU stay was shorter in groups 1 and 2—2.3±0.9 days vs. 3.5±1.1 days for group 3, P=0.004. All patients received dopamin postoperatively, however in a lower dose in groups 1 and 2, 4.5 vs. 13.5 μg/kg/min. Dobutamine was added in 23% of the patients (group 1), 32% (group 2) and 95% (group 3). Adrenalin/amrinonum was required in 40% of the patients in group 3, 5% in group 2 and none in group 1. Group 1 patients had a better improvement of cardiac performance than group 2, while other parameters did not differ. Three months follow up of hospital survivors showed no group differences. Conclusions: The use of preoperative IABP in high risk patients lowers hospital mortality and shortens the stay in ICU, due to improved cardiac performance, compared to a controls. The procedure was cost-beneficial. One day preoperative IABP treatment improves cardiac performance more than 1–2 h preoperative IABP treatment, but does not significantly affect the outcome in terms of hospital mortality or postoperative morbidity.     

Balloon-pump-induced pulsatility improves coronary and carotid flows in an experimental model of BioMedicus left ventricular assistance

The aim of this study is to evaluate the benefit of the simultaneous use of a BioMedicus left ventricular assistance device (Medtronic, Minneapolis, MN, U.S.A.) and an intra-aortic balloon pump on regional blood flows, pressure, and pulsatility. Twelve pigs are studied. A BioMedicus pump was placed between the left atrium and the ascending aorta and an intra-aortic balloon pump was inserted through the left femoral artery. Blood flow and pressure were measured in the carotid, femoral, and coronary arteries and in the thoracic aorta below the intra-aortic balloon in the basal experimental condition with a full-flow BioMedicus pump and with a full-flow BioMedicus pump + intra-aortic balloon. The BioMedicus pump eliminates pulsatility in all sites and significantly decreases coronary and carotid blood flow. The adjunction of an intra-aortic balloon restores pulsatility to values comparable to those recorded in basal conditions. Coronary and carotid flows even increase to values higher than in the basal conditions. The simultaneous use of an intra-aortic balloon combined with the BioMedicus pump provides a pulsatile flow and increases coronary and carotid blood flows in pigs. An intra-aortic balloon can easily be combined with a BioMedicus pump whenever possible and may improve myocardial recovery in patients with postcardiotomy ventricular failure.     

Annuloaortic Repair in the Treatment of Aortic Regurgitation and Aortic Root Pathology

We developed a new technique of aortic root repair which may be able to eliminate the potential problem of leaflet damage, resulting from the direct contact of the aortic leaflets with synthetic vascular grafts during systole. This report describes our technique of annuloaortic repair and the operative results. Between February 1995 and October 1998, 13 patients underwent annuloaortic repair. The patients included 8 males and 5 females (mean age 50 years). Four patients had grade IV/IV aortic regurgitation (AR), 5 had III/IV AR, 2 had II/IV AR, and 1 had no AR preoperatively. Regarding the preoperative functional status, 1 patient was classified as New York Heart Association class IV, 5 were class III, 6 class II, and 1 class I. Concomitant cardiovascular procedures were performed in 12 cases. Aortic valvuloplasty or annuloplasty was performed in 7 patients. Both operative and short-term postoperative results with pre- and postoperative echocardiographic findings were studied retrospectively. The mean total cardiopulmonary bypass time was 212 min. The mean aortic cross-clamp time was 130 min. Circulatory arrest was induced in 5 patients. Postoperatively, 7 patients had no AR. Three patients had grade I/IV AR and 3 had grade II/IV AR. Perioperative changes in aortic annulus, mid-sinus portion, and sinotubular junction diameters were determined echocardiographically in 5 patients. The preoperative diameters were 2.7 +/- 0.4, 5.4 +/- 0.5, and 4.7 +/- 1.0 cm, respectively. The postoperative diameters were 2.3 +/- 0.5, 4.2 +/- 0.5, and 3.5 +/- 0.5cm, respectively. Ten patients were class I and 2 were class II. This technique of annuloaortic repair with or without aortic valvuloplasty is applicable to a certain subset of patients with aortic root disease and AR. Both the indications for this procedure and the long-term results should be confirmed.     

体外膜肺氧合在心脏移植术后早期移植物功能障碍中的应用

目的  分析体外膜肺氧合(ECMO)在心脏移植术后早期移植物功能障碍(EAD)中的应用效果。方法  回顾性分析614例心脏移植受者的临床资料,根据术后是否使用ECMO分为ECMO组(43例)和非ECMO组(571例)。总结ECMO组受者心脏移植术后ECMO支持治疗情况,比较两组受者的围手术期情况和远期预后。结果  43例ECMO支持受者中,17例因出血进行开胸探查,10例出现感染,4例出现下肢静脉血栓,1例出现脑卒中。26例受者成功脱离ECMO后康复出院,6例受者ECMO支持期间死亡,6例受者ECMO脱机后死亡,5例受者因无法脱离ECMO而接受再次移植,再次移植后仅1例存活。与非ECMO组比较,ECMO组术中体外循环时间较长,术后需要主动脉内球囊反搏(IABP)、肾功能不全需要透析、再次开胸止血、感染、机械通气时间≥96 h和气管切开比例较高,术后重症监护室(ICU)入住时间较长(均为P < 0.05)。ECMO组受者出院生存率和90 d生存率分别为63%和96%,低于非ECMO组的97%和100%,差异均有统计学意义(均为P < 0.05)。生存分析结果显示,ECMO组受者的远期生存率低于非ECMO组(P < 0.05); 当排除心脏移植术后90 d内死亡的受者后,两组之间的远期生存率差异无统计学意义(P > 0.05)。结论  ECMO是治疗心脏移植术后EAD有效的方法。使用ECMO的受者心脏移植术后的早期生存率低于不使用ECMO的受者,而顺利度过心脏移植术后90 d远期生存率差异无统计学意义。