Challenges to rescuing patients in cardiogenic shock
Challenges to rescuing patients in cardiogenic shock
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心源性休克患者的抢救面临的挑战
DOI：
10.1093/ejcts/ezac005
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发表时间：
2022
影响因子：
3.4
通讯作者：
Fukushima Satsuki
中科院分区：
文献类型：
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作者：
Fujita Tomoyuki;Fukushima Satsuki
耐用的左心室辅助装置(LVAD)作为桥接疗法或终点疗法的长期结果已得到改善[1]。几个国家心脏分配标准的变化，例如美国的器官共享联合网络，已经优先考虑心脏移植患者接受临时机械循环支持(MCS)[2]。因此，现在更重要的是将心源性休克合并多器官衰竭的患者安全地桥接到持久的LVAD或使用各种临时MCS途径的心脏移植。多器官衰竭的发生是由于低心输出量和高后负荷引起的终末器官循环停滞，导致终末器官血流量减少。短期MCS的目的是为终末器官提供充足的血液供应和减少后遗症。对于左心衰竭患者来说，旁冠状LVAD是一种理想的系统，因为如果患者没有选择持久的LVAD，它可以通过其强大的泵实现这两个目的，而且据报道其结果是合理的[3]。然而，在双心室衰竭的患者中，它变得更加复杂。静脉动脉体外膜氧合(ECMO)可以提供双肺支持，但可能会增加肺楔压，导致肺水肿。因此，它经常与经皮经腹主动脉LVAD(Impella，Abied Inc.，Daners，MA，USA)或主动脉内球囊反搏相结合，导致比单独静脉动脉ECMO更高的存活率[4，5]。我们最近发表了一篇文章，描述了几种临时性双心室辅助装置(BVAD)的配置，其中包括(I)从右心房和左心室心尖部引流血液的中央ECMO，(Ii)从右和左心房引流血液的中央ECMO，以及(Iii)有或没有ECMO的左心辅助装置和连续流动的右室辅助装置的组合[6]。这些使用Impella、连续流泵和ECMO的治疗方法侵入性较小，不需要进行大手术；然而，在耐用性方面存在问题。从终末器官衰竭中恢复的时间有时比预期的要长，在患者康复之前，可能会发生严重的不良事件，如感染或血液相容性相关事件。因此，如果患者有合理的呼吸功能，使用耐用的副心脏辅助装置的BVAD是一个合理的策略。Michel等人[7]报道了80名心源性休克(Intermacs 1)患者使用脉冲式副心脏辅助装置(柏林心脏Excorvr，德国柏林)进行双室支持治疗的结果。在这篇报道中，在左心支持的基础上需要右室支持的患者是病情最严重的患者。事实上，大多数患者在桥接到BVAD之前需要短期的MCS。严重的肾功能衰竭和肝功能衰竭是常见的。在这些患者中，37名患者(46%)成功地桥接到心脏移植，其余患者死亡。在不良事件方面，41名患者接受了再次开胸手术，16名患者发生了中风。正如讨论中所述，这些数据与其他战略的数据具有可比性或有利。BVAD支持的平均持续时间为63天，最长支持持续时间为487天。其他短期MCS无法支持如此长的时间。治疗后肾、肝功能恢复较好。因此，BVAD配合搏动的心脏辅助装置的优点是(I)强大的VAD有足够的流量，(Ii)充分降低左右房内压，(Iii)改善微循环的搏动性和(Iv)耐用性。这些功能预计将支持…
The long-term outcomes of durable left ventricular assist device (LVAD) as a bridging therapy or destination therapy have been improved [1]. Changes in heart allocation criteria in several countries, such as the United Network for Organ Sharing in the United States, have given prioritized patients on temporary mechanical circulatory support (MCS) for heart transplantation [2]. Therefore, it is now more important to bridge patients in cardiogenic shock with multi-organ failure safely to durable LVAD or heart transplantation using various temporary MCS approaches. Multiorgan failure occurs due to a decrease in blood flow in end organs as a result of low cardiac output and circulatory stasis in end organs caused by high afterload. The purpose of short-term MCS is to provide sufficient blood supply to and reduce afterload in end organs. Paracorporeal LVAD is an ideal system in patients with left ventricular failure because it can achieve both purposes with its powerful pump if patients are not indicated for durable LVAD, and its outcomes have been reported to be reasonable [3]. However, it becomes more complicated in patients with biventricular failure. Venoarterial extracorporeal membrane oxygenation (ECMO) can provide biventricular support but possibly increase pulmonary wedge pressure to cause pulmonary oedema. Thus, it is often combined with percutaneous transaortic LVAD (Impella, Abiomed Inc, Danvers, MA, USA) or intra-aortic balloon pump and leads to better survival rates than venoarterial ECMO alone [4, 5]. We recently published an article that described several temporary biventricular assist device (BVAD) configurations, which included (i) central ECMO that drained blood from right atrium and left ventricular apex,(ii) central ECMO that drained blood from right and left atrium and (iii) the combination of LVAD and a continuous-flow right ventricular assist device, with or without ECMO [6]. These treatments using Impella, a continuous-flow pump, and ECMO are less invasive and do not require major surgery; however, there is a problem with respect to durability. It sometimes takes longer to recover from end-organ failure than expected, and serious adverse events, such as infection or hemocompatibility-related events, may occur until patient recovery. Thus, BVAD using durable paracorporeal devices is a reasonable strategy if patients have reasonable respiratory function.Michel et al.[7] report the outcomes of 80 patients with cardiogenic shock (Intermacs 1) treated with biventricular support using a pulsatile paracorporeal assist device (Berlin Heart ExcorVR, Berlin, Germany). The patients who required right ventricular support on top of left ventricular support presented in this report were the sickest patients. In fact, most patients required short-term MCS before bridging to BVAD. Severe kidney and liver failure were common. Of these, 37 patients (46%) were successfully bridged to heart transplantation and the remaining patients died. Regarding adverse events, 41 patients experienced re-thoracotomy and 16 patients experienced stroke. These data were comparable or favourable to those from other strategies as they described in the discussion. The mean duration of BVAD support was 63 days, and the longest duration of support was 487days. Other short-term MCSs cannot support such a long time. Kidney and liver functions recovered fairly well following this treatment. Consequently, the advantages of BVAD with a pulsatile paracorporeal assist device are (i) sufficient flow with powerful VAD,(ii) sufficient reduction of the right and left atrial pressure,(iii) improving microcirculation with pulsatility and (iv) durability. These features are expected to …