主动脉气囊反搏联合急诊经皮冠状动脉介入治疗急性心肌梗死合并心源性休克

目的研究主动脉气囊反搏（IABP）联合急诊经皮冠状动脉介入治疗（PCI）对急性心肌梗死合并心源性休克的疗效。方法比较36例患者急性心肌梗死合并心源性休克治疗前后的肺毛细血管楔压（PCWP）、心脏指数（CI）、中心静脉压（CVP）、平均动脉压（MAP）和每小时尿量变化。结果接受IABP联合PCI治疗后,患者的CVP、PCWP较治疗前明显降低,分别为（4．1±4．3）mmHgVS（10．4±6．8）mmHg,（10．5±7．1）mmHgVS（23．6±8．3）mmHg（P〈O．05）,而CI、MAP和每小时尿量均较治疗前明显增加,分别为（2．2±1．3）L·min-1·m-2 VS（1．3±0．9）L·min-1·m-2,（83．4±13．6）mm HgVS（56．8±15．2）mmHg,（44．5±14．9）ml／hVS（12．6±5．4）ml／h（P〈0．05）。结论对于急性心肌梗死并发心源性休克的患者,IABP联合急诊PCI治疗,疗效确切。这对不能开展急诊冠状动脉旁路手术的医院,IABP联合急诊PCI治疗具有特殊的临床意义。     

Optimal course of treatment in acute cardiogenic shock complicating myocardial infarction

Introduction: About 5% of patients with myocardial infarction suffer from cardiogenic shock as a complication, with a mortality of ≥30%. Primary percutaneous coronary intervention as soon as possible is the most successful therapeutic approach. Prognosis depends not only on the extent of infarction, but also – and even more – on organ hypoperfusion with consequent development of multiple organ dysfunction syndrome.

Areas covered: This review covers diagnostic, monitoring and treatment concepts relevant for caring patients with cardiogenic shock complicating myocardial infarction. All major clinical trials have been selected for review of the recent data.

Expert commentary: For optimal care, not only primary percutaneous intervention of the occluded coronary artery is necessary, but also best intensive care medicine avoiding the development of multiple organ dysfunction syndrome and finally death. On contrary, intra-aortic balloon pump – though used for decades – is unable to reduce mortality of patients with cardiogenic shock complicating myocardial infarction.     

Aortic counterpulsation in cardiogenic shock during acute myocardial infarction

Intra-aortic balloon counterpulsation is the most widely used form of mechanical hemodynamic support in the setting of cardiogenic shock due to ST-segment elevation myocardial infarction (STEMI). Intra-aortic balloon pump (IABP) is also strongly recommended (class 1b) in the current European guidelines for treatment of STEMI. The evidence of a possible benefit of IABP in this setting is based mainly on registry data and a few randomized trials. Cardiogenic shock and subsequent death due to STEMI result from three factors: hemodynamic deterioration, occurrence of multiorgan dysfunction and systemic inflammatory response. IABP does not cause an immediate improvement in blood pressure, but the recent SHOCK II trial shows positive effects on multiorgan dysfunction. Some experimental and clinical studies have indicated that IABP results in hemodynamic benefits as a result of afterload reduction and diastolic augmentation with improvement of coronary perfusion. However, the effect on cardiac output is modest and may not be sufficient to reduce mortality. Furthermore we can say that the use of IABP before coronary revascularization in the setting of STEMI complicated with cardiogenic shock may make the interventional procedure safer by improving left ventricular unloading. The purpose of the present review is to clarify the state of the art on this topic.     

心源性休克患者静脉-动脉体外膜肺氧合脱机结局影响因素

目的探讨心源性休克患者静脉-动脉体外膜肺氧合(V-A ECMO)脱机结局的影响因素。方法回顾性观察37例接受V-A ECMO辅助心源性休克患者,根据是否耐受脱机试验分为可耐受组及不耐受组;再据最终是否成功脱机将可耐受组患者分为成功脱机亚组(脱机且30天内存活)及脱机失败亚组,比较2亚组患者相关资料,以及脱机试验过程中最低流量水平下2亚组超声测得血流动力学参数。结果 37例中,32例可耐受脱机试验(可耐受组),5例无法耐受(不耐受组)。可耐受组患者年龄(P=0.04)及ECMO辅助中出血率(P<0.01)均低于不耐受组,2组患者性别、原发疾病等差异均无统计学意义(P均>0.05)。可耐受组32例中,22例成功脱机,7例脱机失败,3例死亡。脱机试验中最低流量水平下,脱机成功亚组静脉血氧饱和度(SvO₂)、左心室流出道速度-时间积分(LVOT-VTI)、左心室射血分数(LVEF)及二尖瓣环侧壁收缩期运动速度(Sa)均高于脱机失败亚组(P均<0.05)。结论 SvO₂、LVOT-VTI、LVEF及Sa均为V-A ECMO辅助心源性休...     

再灌注损伤在急性心肌梗死合并低血压及心源性休克中的临床意义和治疗对策

目的探讨再灌注损伤在急性心肌梗死(AMI)合并低血压状态(简称低血压)及心源性休克(CS)中的临床意义和治疗对策。方法观察AMI合并低血压及CS行急诊经皮冠状动脉介入治疗(PCI)患者131例,术中再灌注后出现或加重低血压及CS为治疗组(45例),其他为对照组(86例),观察两组再灌注损伤的临床表现及应用优化升压药配合主动脉内球囊反搏术(IABP)的序贯疗法支持下急诊PCI的疗效。结果术中再灌注后出现或加重的低血压及CS 45例(占34.35%,治疗组),对照组86例(占65.65%),两组发生再灌注心律失常共100例(76.34%),包括加速性室性自主心律43例,窦性心动过缓31例,室性早搏23例,室颤3例。治疗组病死率和心血管事件(左心心力衰竭)与对照组比较差异无统计学意义,但需要使用IABP的患者明显减少(P0.05)。结论再灌注损伤是AMI合并低血压及CS的重要原因之一,再灌注损伤导致的低血压和CS,用优化升压药配合IABP的序贯疗法配合急诊PCI是一种快捷、实用、安全的治疗方法。     

Fluid therapy and acute kidney injury in cardiogenic shock after cardiac arrest

Aim of the study

It has recently been suggested that acute kidney injury (AKI) may strongly be influenced by post-resuscitation disease and cardiogenic shock (CS), and may not just be a consequence of cardiac arrest and time without spontaneous circulation. AKI also has been suggested as a strong independent predictor of in-hospital mortality. Therefore the present study aimed at investigating the effect of fluid management on the incidence of AKI in patients with cardiogenic shock after cardiac arrest treated by mild therapeutic hypothermia.

Methods

Fluid therapy and the incidence of acute kidney injury (AKI) was retrospectively reviewed in 51 patients with cardiogenic shock after cardiac arrest comparing patients with and without hemodynamic (PPV, SVV) and volumetric (ELWI, GEDI) monitoring.

Results

There was no significant difference in baseline or cardiac arrest characteristics between hemodynamic monitored patients and conventional monitored patients. 28 patients were monitored by standard monitoring, in 23 patients monitoring was complemented by a PICCO system. In the first 24 h of treatment the total amount of fluid was significantly higher in patients under PICCO monitoring compared to conventional monitoring (4375 ± 1285 ml vs. 5449 ± 1438 ml, p = 0.007). This was associated with a significant reduction in the incidence of AKI (RIFLE ‘I’/‘F’: PICCO-group: 1 (4.3%) vs. conventional group 8 (28.6%), p = 0.03).

Conclusion

The presented data suggest that volume therapy guided by volumetric (ELWI, GEDI) and arterial waveform derived variables (PPV, SVV) can reduce the incidence of AKI in patients with cardiogenic shock after cardiac arrest treated with mild therapeutic hypothermia.     

基于冠状动脉CT血管造影深度神经网络模型检出和分类左前降支心肌桥

目的 观察基于冠状动脉血管造影（CCTA）构建左前降支（LAD）心肌桥检出和分类深度神经网络模型的应用价值。方法 回顾性分析726例因胸痛不适接受冠状动脉CTA患者,由2名影像科医师诊断心肌桥并分为浅表型或纵深型。分别按7 ∶ 3及1 ∶ 2比例将心肌桥患者及非心肌桥患者归入训练集和测试集。建立基于CCTA的深度神经网络残差-长短期记忆级联网络（Resnet-LSTM）模型,用于检测及分类LAD心肌桥。采用训练集对模型进行学习训练;以影像科医师诊断结果为标准,利用测试集数据检测模型性能。结果 CCTA显示,726例中,453例存在至少1处LAD心肌桥;共检出654处心肌桥,其中561处位于LAD、93处位于左回旋支及第一对角支等。561处LAD心肌桥中,503处为浅表型、58处为纵深型。训练集含333例心肌桥患者共406处LAD心肌桥（365处浅表型和41处纵深型）和91例非心肌桥患者;测试集含120例心肌桥患者共155处LAD心肌桥（138处浅表型和17处纵深型,139处位于LAD近、中段,16处位于LAD远段）和182例非心肌桥患者。针对测试集数据,Resnet-LSTM模型检出130例存在137处LAD心肌桥（含浅表型120处、纵深型17处）,误诊27例、漏诊17例,诊断敏感度为85.83%（103/120）,特异度为85.16%（155/182）,与医师诊断结果的一致性高（Kappa=0.70,P<0.05）;检出131处LAD近中段心肌桥,误诊2处、漏诊10处,诊断准确率为92.81%（129/139）;检出36处LAD远段心肌桥,误诊28处、漏诊8处,诊断准确率为50.00%（8/16）;将其中13处纵深型误诊为浅表型、9处浅表型误诊为纵深型,分类准确率为83.94%（115/137）。结论 基于CCTA的深度神经网络Resnet-LSTM模型用于检出和分类冠状动脉LAD心肌桥性能较好,具有一定临床应用价值。     

Endovascular treatment of an intramural aortic haematoma following cardiopulmonary resuscitation for myocardial ischemia with ventricular fibrillation

Cardiopulmonary resuscitation by manual cardiac compression can restore cardiocirculatory function but can also injure patients. Commonly reported are skeletal fractures of the rips and sternum, while injuries to the large thoracic vessels will frequently be lethal. We report the case of a 57-year-old male patient with sudden cardiac arrest because of myocardial ischemia with ventricular fibrillation, successful cardiopulmonary resuscitation, associated with an intramural haematoma (IMH) of the descending thoracic aorta treated by endovascular aortic repair. Secondary coronary angiography revealed a severe three vessel coronary disease with an occlusion of the proximal anterior descending branch and a subtotal stenosis of the first segmental branch of the left coronary artery (LCA) and a high-grade stenosis of the posterolateral segmental branch of the circumflex left coronary artery. Stenotic segments of coronary arteries were treated successfully by implantation of three drug-eluting stents followed by dual antiplatelet therapy. The patients recovered almost completely and was discharged for further rehabilitation after 3 weeks.     

冠状动脉介入治疗时代孤立性左主干狭窄病变患者的临床特征和预后分析

目的 回顾性分析孤立性左主干(left main coronary artery,LMCA)狭窄病变患者的临床特征和预后.方法 连续入选30例孤立性LMCA狭窄病变患者并分为两组:开口病变组(n=21)和非开口病变组(n=9).随访终点为主要心脑血管不良事件(major adverse cardiac or cereb...     

Inappropriate shock and percutaneous cardiac intervention: A lesson to learn in the cath lab

Coronary disease is a common condition in patients affected by heart failure with severely reduced ejection fraction (HFrEF). This condition represents an indication for implantable cardioverter defibrillator (ICD) in order to reduce the risk of sudden death related to arrhythmias. Nevertheless, inappropriate shocks are associated with worse quality of life, hospitalization, and death. We present the case of an inappropriate shock related to percutaneous coronary intervention during the insertion and advancement of the guidewire into the left anterior descending artery (LAD) in a patient with an ICD. Physicians’ awareness about the clinical implication of noise arising during a coronary procedure is very important in patients with an ICD or pacemaker, to avoid inappropriate shock or pacing inhibition and to raise the possibility of lead implantation in or helix protrusion into the coronary lumen.     

主动脉内球囊反搏支持下急性心肌梗死的急诊介入治疗

目的探讨主动脉内球囊反搏支持下的急性心肌梗死合并心源性休克患者行急诊介入治疗的可行性、安全性及疗效。方法回顾性分析浙江大学医学院附属第2医院2005年9月至2007年2月确诊急性心肌梗死合并心源性休克,在主动脉内球囊反搏支持下行急诊介入治疗的患者27例,观察血流动力学改变、急诊介入治疗特点、住院期间及术后1个月的病死率、主要心脏不良事件、心功能恢复状况。结果应用主动脉内球囊反搏30min后血流动力学即开始改善,2～6h达血流动力学稳定。27例患者在主动脉内球囊反搏支持下均成功完成急诊介入治疗,无术中死亡,住院期间死亡2例,随访1个月死亡1例。术后1个月的左室射血分数和室壁运动评分均较术后第1天显著改善。结论主动脉内球囊反搏支持下的急诊介入治疗能显著提高急性心肌梗死合并心源性休克患者的生存率,显著改善心肌梗死后的心功能状态。     

A case of de Winter syndrome presenting with chest tightness

de Winter syndrome, also termed anterior ST-segment elevation myocardial infarction (STEMI) equivalent, is estimated to be present in approximately 2% of patients with acute myocardial infarction, but is often under-recognized by clinicians. Therefore, de Winter syndrome is associated with increased morbidity and mortality. We report a 51-year-old man with typical chest tightness and a characteristic electrocardiographic pattern without classic ST-segment elevation, but with acute nearly total occlusion of the left anterior descending coronary artery. Although the patient presented as a non-STEMI case, the definite diagnosis of de Winter syndrome was made on the basis of clinical and electrocardiographic findings. The patient’s symptom of chest tightness was relieved immediately after acute percutaneous coronary intervention and the left ventricular ejection fraction had not deteriorated at 1 month of follow-up.     

主动脉内球囊反搏术在急性心肌梗死合并心源性休克行冠状动脉支架置入术中的临床评价

目的评价主动脉内球囊反搏术(IABP)在急性心肌梗死(AMI)合并心源性休克(CS)行经皮冠状动脉介入治疗(PCI)中的疗效。方法AMI合并CS的52例患者一经确诊即予急诊IABP循环支持治疗,与未经IABP治疗的48例患者(对照组)进行比较,两组均在常规用药基础上行PCI治疗。观察两组患者IABP前后的心功能指标、PCI术后1周内病死率及血管再闭塞事件发生率。结果治疗组进行IABP后桡动脉内测舒张压、平均动脉压(MAP)、心脏指数(CI)、心输出量(CO)、每搏输出量(SV)、射血分数(EF)较术前明显升高(P0.05或P0.01),而肺毛细血管楔压(PCWP)较术前明显降低(P0.05),治疗组病死率显著低于对照组(P0.05),治疗组血管再闭塞事件发生率显著低于对照组(P0.05)。结论IABP可显著改善心功能,降低AMI合并CS患者的死亡率及血管再闭塞发生率。     

两种途径冠状动脉介入治疗后并发症及患者舒适度的比较

目的对经桡动脉途径和经股动脉途径行冠状动脉介入治疗（percutaneous coronary intervention,PCI）的术后并发症及患者舒适度进行对照研究,观察两者差异情况。方法选择冠心病患者338例,随机分为桡动脉组153例和股动脉组185例,比较两组患者术后并发症和舒适度的情况。结果患者局部血肿、伤口出血、假性动脉瘤、迷走神经反射发生率及患者舒适度桡动脉组明显低于股动脉组（P〈0.01、P〈0.05、P〈0.01及P〈0.01）;动脉痉挛或闭塞发生率桡动脉组明显高于股动脉组（P〈0.01）,差异有统计学意义。结论桡动脉途径较股动脉途径PCI术后不易发生伤口出血、血肿、假性动脉瘤及迷走神经反射,且患者更加舒适,但应注意防止桡动脉痉挛的发生。     

主动脉内球囊反搏支持下介入治疗急性心肌梗死后休克的术后护理

目的探讨急性心肌梗死（acute myocardial infarction,AMI）后心源性休克经皮冠状动脉介入（percutaneous coronary intervention,PCI）及主动脉内球囊反搏（intra-aortic balloon pump,IABP）治疗的术后护理对策。方法回顾性分析1999-2009年67例行PCI及IABP治疗的AMI心源性休克患者的临床资料,总结抢救护理的经验。结果67例患者中,44例痊愈出院,23例死亡,病死率为34.33%。结论经PCI及IABP治疗AMI心源性休克的护理重点是加强观察,选择合适的体位,及时制止反搏泵停搏,根据患者的心功能进行输液管理,积极预防并发症。     

主动脉内球囊反搏支持下介入治疗急性心肌梗死后休克的术后护理

目的探讨急性心肌梗死（acute myocardial infarction,AMI）后心源性休克经皮冠状动脉介入（percutaneous coronary intervention,PCI）及主动脉内球囊反搏（intra-aortic balloon pump,IABP）治疗的术后护理对策。方法回顾性分析1999—2009年67例行PCI及IABP治疗的AMI心源性休克患者的临床资料,总结抢救护理的经验。结果67例患者中,44例痊愈出院,23例死亡,病死率为34．33％。结论经PCI及IABP治疗AMI心源性休克的护理重点是加强观察,选择合适的体位,及时制止反搏泵停搏,根据患者的心功能进行输液管理,积极预防并发症。     

修正休克指数和支架覆盖表面积对急性ST段抬高型心肌梗死患者冠状动脉介入术中无复流的影响

目的:探讨修正休克指数(modified shock index,MSI)和支架覆盖表面积(stent coverage surface area,SCSA)对急性ST段抬高型心肌梗死(ST-elevation myocardial infarction,STEMI)患者急诊经皮冠状动脉介入(percutaneous ...