体外膜肺氧合在循环衰竭中的应用治疗体会

目的总结循环衰竭患者实施体外膜肺氧合（extracorporeal membrane oxygenation,EC-MO）支持的方法和效果。方法对3例患者实施ECMO支持,年龄17～32岁,体质量45～60 kg。3例患者中,2例为急性暴发性重症心肌炎;另一例为法洛氏四联症矫治术后低心排综合征。采用静脉-动脉转流,辅助流量40～70 ml/（kg.min）,间断检测活化凝血时间（activated coagulation time,ACT）150～200 s。结果 ECMO支持时间96～135 h,均成功脱机,康复出院。结论 ECMO支持是抢救危重循环衰竭的有效方法。     

Novel multi-functional life support system

Concepts of cardiopulmonary support (CPS), extracorporeal membrane oxygenation (ECMO), and ventricular support (VS) have been thoroughly studied and refined. These perfusion adjuncts often require multiple devices, skill sets, and significant financial burden to purchase, maintain, deploy, and use. We describe a novel system that is rapidly deployable, user-friendly, portable, safe, and economical. Over a 1-year period we have used a multi-functional life support system (MLS) in the cardiac catheterization laboratory, cardiovascular intensive care unit, and cardiac surgical suites. Further, we have conducted multiple transports within the hospital and one to an alternate facility. Applications have included ECMO, cardiopulmonary resuscitation-supported cardiogenic shock, high risk percutaneous coronary intervention (PCI), valvuloplasty, right ventricular assist device transition to ECMO post cardiotomy, left ventricular assist device transition to ECMO, ventricular septal defect closure, and ECMO transition to conventional cardiopulmonary bypass (CPB). Duration of support has ranged from approximately 39 minutes to several days. Keywords: extracorporeal membrane oxygenation (ECMO), percutaneous ventricular assist device, cardiopulmonary support, portable cardiopulmonary life support, ventricular assist.     

Impact of temporary mechanical circulatory support for early graft failure on post–heart transplantation outcomes

Although temporary mechanical circulatory support (tMCS) for hemodynamic failure following heart transplantation is associated with increased early morbidity and mortality, the impact of etiology of graft dysfunction and long-term clinical implications are less well known. The objective of our study was to evaluate outcomes in patients who required venoarterial extracorporeal membrane oxygenation (VA ECMO) or temporary right ventricular assist device (RVAD) support for either primary or secondary early graft dysfunction. Hospital mortality in 27 patients who required tMCS following heart transplantation at our institution between 2007 and 2017 was 56%, 30% in patients with right ventricular dysfunction secondary to increased afterload, 60% in patients with primary graft dysfunction, and 100% in patients with graft failure secondary to coagulopathy with intraoperative bleeding or overwhelming sepsis. Conditional 1-year and 5-year survival was comparable between patients with, and without, the need for post-transplantation support with tMCS (98% and 89%; 92% and 65% at 1 and 5 years, P = .21). Etiology of early graft failure plays an important part in determining the short-term post–heart transplantation outcome. Although complications associated with tMCS use, such as renal dysfunction and infection, extend beyond index transplant hospitalization, long-term conditional survival is not compromised.     

Extracorporeal life support in lung and heart–lung transplantation for pulmonary hypertension in adults

After bilateral lung and heart–lung transplantation in adults with pulmonary hypertension, hemodynamic and oxygenation deficiencies are life‐threatening complications that are increasingly managed with extracorporeal life support (ECLS). The primary aim of this retrospective study was to assess 30‐day and 1‐year survival rates in patients managed with vs without post‐operative venoarterial ECLS in 2008–2013. The secondary endpoints were the occurrence rates of nosocomial infection, bleeding, and acute renal failure. Of the 93 patients with pulmonary hypertension who received heart‐lung (n=29) or bilateral lung (n=64) transplants, 28 (30%) required ECLS a median of 0 [0–6] hours after surgery completion and for a median of 3.0 [2.0–8.5] days. Compared to ECLS patients, controls had higher survival at 30 days (95.0% vs 78.5%; P=.02) and 1 year (83% vs 64%; P=.005), fewer nosocomial infections (48% vs 79%; P=.0006), and fewer bleeding events (17% vs 43%; P=.008). The need for renal replacement therapy was not different between groups (11% vs 17%; P=.54). Venoarterial ECLS is effective in treating pulmonary graft dysfunction with hemodynamic failure after heart‐lung or bilateral lung. However, ECLS use was associated with higher rates of infection and bleeding.     

Mechanical cardiopulmonary resuscitation for venoarterial ECMO implantation in pulmonary embolism complicated by type B aortic dissection and retroperitoneal hemorrhage

A patient with acute pulmonary embolism suffered cardiac arrest, received manual and mechanical cardiopulmonary resuscitation and tissue plasminogen activator before extracorporeal cardiopulmonary resuscitation was initiated. She suffered a type B aortic dissection and retroperitoneal hemorrhage secondary to resuscitation measures. This case report describes high-risk anticoagulation management for contradicting treatment goals in preparation for pulmonary embolectomy on cardiopulmonary bypass.     

A novel approach to delivery of extracorporeal support using a modified continuous flow ventricular assist device in a mid‐volume congenital heart program

Extracorporeal life support (ECLS) is an essential component of a modern congenital cardiac surgery program. The circuit components and bedside management team may, however, vary among institutions. Here, we evaluate our initial experience with a modified ventricular assist device—based ECLS circuit primarily managed by the bedside nurse. We hypothesize that our outcomes are comparable to Extracorporeal Life Support Organization (ELSO) registry data. All patients who received ECLS from January 1, 2016 to December 31, 2019 at a single institution were included. Primary outcomes were survival to ECLS decannulation and discharge or transfer. Secondary outcomes included complications from ECLS. Data were compared to available ELSO registry data. Thirty‐seven patients underwent 44 ECLS runs during the study period. Forty percent of patients had single ventricle physiology. Nearly 46% of patients received ECLS as part of extracorporeal cardiopulmonary resuscitation (eCPR). Survival to ECLS decannulation (68.2%) and survival to discharge or transfer (61.4%) did not differ from overall ELSO outcomes (69.7%, P = .870 and 50.7%, P = .136), as well as survival to discharge or transfer in a comparable cohort of ELSO centers (53.1%, P = .081). Patients with complications had a lower rate of survival to discharge or transfer but this did not reach statistical significance (47.7% vs. 75.0%, P = .455). Neurologic (50.0%), hemorrhagic (45.5%), and renal complications (31.8%) were most common in this cohort. A modified ventricular assist device‐based ECLS circuit with primary management by the bedside nurse can provide comparable support in a neonatal and pediatric cardiac surgery population. Cost analyses and further delineation of the complication profile are necessary for a complete characterization of this system.     

胸腔镜下室间隔缺损修补术

目的　探讨胸腔镜下室间隔缺损修补术。　方法　 16例先天性心脏病 (男 10例 ,女 6例 )。年龄 (6～ 2 7)岁。 (14± 7)岁 ,体重 (17～ 6 7)kg ,(38 5± 16 8)kg。采用股动静脉插管 ,在患者右侧第四肋间胸骨旁、第四肋间腋中线、第七肋间腋中线各打一个直径 1cm～ 3cm的孔 ,经第四肋间腋中线插入上腔静脉插管 ,建立体外循环 ,阻闭升主动脉 ,冠脉冷灌 ,心脏停搏 ,切开并悬吊右心房 ,显露三尖瓣及室间隔缺损 ,缝合室间隔缺损 ,缝合右心房切口 ,开放升主动脉。　结果　 16例手术均获成功 ,主动脉阻闭时间 (2 7～ 6 7)min ,(43± 13)min。体外循环时间 (6 6～ 16 8)min ,(95± 33)min。术后心脏杂音消失 ,心脏超声检查示无心内分流。　结论　胸腔镜下可完成室间隔缺损修补术的全部心内操作。也为室间隔缺损修补术提供了另一种选择。     

Right ventricular end–systolic pressure–volume relation during propofol infusion

The effects of propofol on right ventricular function were studied in 11 ICU patients who needed sedation for acute respiratory failure or neurological diseases. Right ventricular function was studied using a thermodilution method at patients' bedside. Right ventricular ejection fraction (RVEF), cardiac output (CO), right ventricular end–diastolic volume (RVEDV), right ventricular end–systolic volume (RVESV), right ventricular end–systolic pressure (RVESP) and pulmonary capillary wedge pressure (PCWP) were obtained from a modified Swan–Ganz catheter. Calculation of right ventricular end–systolic pressure–volume relation (ESPVR) allowed to assess changes in right ventricular inotropic state. A baseline ESPVR was obtained before propofol infusion: RVESP = 0.21 RVESV + 2.4, r = 0.83, P < 0.0001. Then, patients were given an induction dose of 1 to 2.5 mg kg^-1 propofol over 1 min followed by a continuous infusion of 3 mg kg^-1 h^-1. During propofol infusion heart rate, mean arterial pressure, PCWP, CO, systemic vascular resistance and RVEF significantly decreased. No change in RVEDV and RVESV was observed. ESPVR was significantly altered with a dramatic decrease in the slope of the relation: RVESP = 0.12 RVESV + 6.9 ( P < 0.001 from baseline). Dobutamine was used in five patients with clinically significantly cardiac dysfunction and restored the slope of the ESPVR to the baseline value: RVESP = 0.22 RVESV + 6.3 (NS from baseline). In the study patients, propofol altered the inotropic state of the right ventricle.     

Generation of microbubbles in extracorporeal life support and assessment of new elimination strategies

Occurrence of microbubbles (MB) is a major problem during venoarterial extracorporeal life support (ECLS) with partially severe clinical complications. The aim of this study was to establish an in vitro ECLS setup for the generation and detection of MB. Furthermore, we assessed different MB elimination strategies. Patient and ECLS circuit were simulated using reservoirs, a centrifugal pump, a membrane oxygenator, and an occluder (modified roller pump). The system was primed with a glycerin solution of 44%. Three different revolution speeds (2500, 3000, and 3400 rpm) were applied. For MB generation, the inflow line of the pump was either statically or dynamically (15 rpm) occluded. A bubble counter was used for MB detection. The effectiveness of the oxygenator and dynamic bubble traps (DBTs) was evaluated in regard to MB elimination capacities. MB generation was highly dependent on negative pressure at the inflow line. Increasing revolution speeds and restriction of the inflow led to increased MB activity. The significant difference between inflow and outflow MB volume identified the centrifugal pump as a main source. We could show that the oxygenator’s ability to withhold larger MB is limited. The application of one or multiple DBTs leads to a significant reduction in MB count and overall gas volume. The application of DBT can significantly reduce the overall gas volume, especially at high flow rates. Moreover, large MB can effectively be broken down for faster absorption. In general, the incidence of MBs is significantly dependent on pump speed and restriction of the inflow. The centrifugal pump was identified as a major source of MB generation.     

Outcomes of congenital heart surgery patients after extracorporeal life support at Texas Children's Hospital

The objective of this study was to investigate the outcomes of children with heart failure of various etiologies requiring temporary use of currently available technology in the U.S.A. after extracorporeal life support (ECLS) [left ventricular assist device (LVAD) or extracorporeal membrane oxygenation (ECMO)] at Texas Children's Hospital. Between July of 1995 and October of 2002, 2847 patients underwent congenital heart surgical repairs with the aid of cardiopulmonary bypass at Texas Children's Hospital. During this period, 17 patients required chronic mechanical circulatory assistance with Biomedicus centrifugal pump (n=8) or Thoratec LVAD (n=4), and ECMO (n=5). Six out of 17 patients required ECLS for postcardiotomy heart failure. Seven of the 17 patients had congenital heart disease, six had cardiomyopathy, three had late acute rejection following heart transplantation, and one had myocardial infarction. Twelve patients survived and five patients expired. Six of 12 survivors recovered sufficient cardiac function to allow device removal; and the remaining six patients underwent heart transplantation. Three out of five deaths were ECMO patients. The need for ECLS following repair of congenital heart disease is extremely rare in our institution. The requirement for the use of ECMO confers a significantly higher mortality presumably because of associated combined cardiopulmonary failure. Congenital heart disease appears to be associated with significantly higher mortality.     

Assessed value of high-sensitivity cardiac troponin T for cardiovascular disease among CKD patients

Objective To analyze the relationship between serum high-sensitivity cardiac troponin T (hs-cTnT) and cardiovascular disease (CVD) among non-dialysis chronic kidney disease (CKD) patients, and to further explore its value of evaluating and predicting CVD in this population. Methods Five hundred and fifty-seven non-dialysis CKD patients were involved in this cross-sectional study. The relationship between serum hs-cTnT and CVD was analyzed using comparison between groups and regression analysis, and its value on assessing cardiac structure and function was evaluated by ROC curves. Results Median level of hs-cTnT was 13 (7–29) ng/L, with 1.7% undetectable, 46.4% greater than 99th percentile of the general population. Multivariate analysis suggested that compared with the lowest quartile of hs-cTnT, the highest quartile was approximately six times as likely to develop into LVH (OR, 6.515; 95% CI, 3.478–12.206, p?<?0.05) and 18 times as likely to progress to left ventricular diastolic dysfunction(OR, 18.741; 95% CI, 2.422–145.017, p?<?0.05). And Ln cTnT level had a more modest association with LVEF (OR, ?1.117; 95% CI, ?5.839 to ?0.594; p?<?0.05). When evaluated as a screening test, the area under the curve of ROC curves for hs-cTnT was 0.718, 0.788 and 0.736, respectively (p?<?0.05). With a specificity of 90% as a diagnostic criterion, the value of hs-cTnT to evaluate LVH, LVEF?Conclusions In CKD non-dialysis population, hs-cTnT and NT-proBNP were valuable for evaluating LVH, left ventricular systolic dysfunction and left ventricular diastolic dysfunction.