静脉-动脉体外膜肺氧合和主动脉内球囊反搏联合辅助顺序对急性心肌梗死合并心源性休克患者的临床效果比较研究

doi:10.12114/j.issn.1007-9572.2023.0248

摘要/Abstract

摘要： 背景急性心肌梗死合并心源性休克（AMI-CS）病死率极高，及时有效的循环支持是挽救此类患者生命的关键。研究静脉-动脉体外膜肺氧合（VA-ECMO）和主动脉内球囊反搏（IABP）联合辅助顺序对AMI-CS患者的临床疗效、并发症和预后，具有重要的临床意义。目的观察VA-ECMO和IABP联合辅助下，二者辅助顺序对AMI-CS患者的治疗效果和预后影响，探讨相关指标变化原因及意义，对比并发症的发生率，分析预后影响因素，为AMI-CS患者寻求相对安全、有效的机械性循环辅助方式。方法回顾性纳入2021—2022年在郑州大学第二附属医院和阜外华中心血管病医院重症医学科接受VA-ECMO联合IABP治疗的AMI-CS患者为研究对象，患者均采用VA-ECMO与IABP联合辅助模式，根据VA-ECMO和IABP辅助的先后顺序分为两组：A组（先IABP后VA-ECMO辅助，n=42）；B组（先VA-ECMO后IABP或VA-ECMO与IABP同期辅助，n=40）。通过电子病历系统收集患者的基线资料、联合治疗前和治疗后24 h和72 h临床指标、治疗情况及相关并发症和预后情况。结果双因素重复测量方差分析结果显示，时间和组间对平均动脉压（MAP）、心指数（CI）、动脉血乳酸（Lac）、肌钙蛋白I（cTnI）存在交互作用（P<0.05），时间和组间对肾小球滤过率（GFR）、脑利钠肽（BNP）不存在交互作用（P>0.05），时间对MAP、CI、GFR、Lac、cTnI、BNP主效应显著（P<0.05），组间对CI、GFR主效应显著（P<0.05），组间对MAP、Lac、cTnI、BNP主效应不显著（P>0.05）。两组患者治疗后24、72 h的MAP、CI、GFR高于治疗前，Lac、cTnI、BNP低于治疗前（P<0.05），两组患者治疗后72 h的CI高于治疗后24 h，治疗后72 h的Lac、cTnI、BNP低于治疗后24 h（P<0.05）。B组患者治疗后24、72 h的MAP、CI、GFR高于A组，Lac、cTnI低于A组（P<0.05）。A组去甲肾上腺素、间羟胺使用比例高于B组（P<0.05）。A组急性肾损伤（AKI）比例高于B组，出院生存率低于B组（P<0.05）。结论相较于先IABP后VA-ECMO，先VA-ECMO后IABP（或ECMO与IABP同期）的联合辅助顺序在改善AMI-CS患者的血流动力学、心功能、肾功能和组织灌注水平更优，血管活性药物的使用比例更少，并发症AKI的发生率更低，出院生存率更高，改善了AMI-CS患者的临床结局。

关键词: 心肌梗死, 休克，心源性, 机械性循环辅助, 血管成形术，气囊，冠状动脉, 体外膜肺氧合, 预后

Abstract:

Background

The mortality of acute myocardial infarction complicated with cardiogenic shock (AMI-CS) is very high, timely and effective circulatory support is essential to save the lives of patients. It is important to explore the clinical efficacy, complications and prognosis of combined auxiliary sequence of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pumps (IABP) in patients with AMI-CS.

Objective

To observe the effect of the auxiliary sequence of VA-ECMO and IABP on the therapeutic effect and prognosis of patients with AMI-CS in the combination of VA-ECMO and IABP, explore the causes and significance of changes in relevant indicators, compare the incidence of complications, analyze the factors affecting prognosis, so as to find a relatively safe and effective mechanical circulatory support (MCS) method for patients with AMI-CS.

Methods

AMI-CS patients who received VA-ECMO combined with IABP in the Department of Intensive Care Medicine of the Second Affiliated Hospital of Zhengzhou University and Fuwai Central China Cardiovascular Hospital from 2021 to 2022 were retrospectively included as the study objects, and all patients were treated with the combined auxiliary mode of VA-ECMO and IABP, and divided into the group A (IABP followed by VA-ECMO, n=42) and group B (VA-ECMO followed by IABP or VA-ECMO combined with IABP at the same time, n=40). Baseline data, clinical indicators, treatment status, related complications and prognosis before, 24 h and 72 h after combination therapy were collected by the electronic medical record system.

Results

The results of two-factor repeated measures ANOVA showed that there were interactions of time and intergroup on mean arterial pressure (MAP), heart index (CI), arterial blood lactate (Lac), and troponin I (cTnI) (P<0.05). There was no interaction between time and groups on glomerular filtration rate (GFR) and brain natriuretic peptide (BNP) (P>0.05). The main effects of time on MAP, CI, GFR, Lac, cTnI and BNP were significant (P<0.05). The main intergroup effects on CI and GFR were significant (P<0.05) and not significant on MAP, Lac, cTnI and BNP (P>0.05). MAP, CI and GFR at 24 h and 72 h after treatment were higher than those before treatment, while Lac, cTnI and BNP were lower than those before treatment, the differences were statistically significant (P<0.05). CI at 72 h after treatment was higher than 24 h after treatment (P<0.05). Lac, cTnI and BNP at 72 h after treatment were lower than those at 24 h after treatment, the differences were statistically significant (P<0.05). MAP, CI and GFR of the group B were higher than those of group A at 24 h and 72 h after treatment, while Lac and cTnI were lower than those of group A, with significant differences (P<0.05). The proportions of norepinephrine and M-hydroxylamine use in group A were higher than group B (P<0.05). The proportion of acute kidney injury (AKI) in group A was higher than group B, with lower discharge survival rate (P<0.05) .

Conclusion

Compared to VA-ECMO followed by VA-ECMO, the combined auxiliary sequence of VA-ECMO followed by IABP (or the combination of ECMO and IABP at the same time) is superior in improving hemodynamics, cardiac function, renal function, and tissue perfusion levels, with less use of vasoactive drugs, lower incidence of complication of AKI, higher survival discharge rates, and improved clinical outcomes in patients with AMI-CS.

Key words: Myocardial infarction, Shock, cardiogenic, Mechanical circulatory suppor, Angioplasty, balloon, coronary, Extracorporeal membrane oxygenation, Prognosis

崔晓娜,冯瑞霞,韩雨澎,等. 静脉-动脉体外膜肺氧合和主动脉内球囊反搏联合辅助顺序对急性心肌梗死合并心源性休克患者的临床效果比较研究[J]. 中国全科医学, 2023, 26(35): 4439-4445. DOI: 10.12114/j.issn.1007-9572.2023.0248.
CUI Xiaona,FENG Ruixia,HAN Yupeng, et al. A Comparative Study on Clinical Effects of Combined Auxiliary Sequence of VA-ECMO and IABP on Acute Myocardial Infarction Complicated with Cardiogenic Shock[J]. Chinese General Practice, 2023, 26(35): 4439-4445. DOI: 10.12114/j.issn.1007-9572.2023.0248.

图/表 5

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项目	分值
年龄>73岁	1
脑卒中史	2
入院血糖水平>10.6 mmol/L	1
血肌酐水平>132.6 μmol/L	1
急诊PCI后TIMI血流分级<3级	2
血乳酸水平>5 mmol/L	2

项目	分值
年龄>73岁	1
脑卒中史	2
入院血糖水平>10.6 mmol/L	1
血肌酐水平>132.6 μmol/L	1
急诊PCI后TIMI血流分级<3级	2
血乳酸水平>5 mmol/L	2

组别	例数	性别（男/女）	年龄（岁）	BMI（kg/m²）	吸烟史〔例（%）〕	高血压史〔例（%）〕	糖尿病史〔例（%）〕	高脂血症史〔例（%）〕	脑卒中史〔例（%）〕	陈旧性心肌梗死史〔例（%）〕
A组	42	28/14	60.4±9.6	24.4±2.2	17（40.5）	20（47.6）	24（57.1）	10（23.8）	5（11.9）	6（14.3）
B组	40	26/14	62.7±8.7	24.4±2.7	14（35.0）	23（57.5）	17（42.5）	11（27.5）	7（17.5）	9（22.5）
χ²（t）值		0.025	-1.134^a	-0.087^a	0.261	0.802	1.757	0.146	0.513	0.925
P值		0.874	0.260	0.931	0.609	0.370	0.185	0.702	0.474	0.336

组别	例数	性别（男/女）	年龄（岁）	BMI（kg/m²）	吸烟史〔例（%）〕	高血压史〔例（%）〕	糖尿病史〔例（%）〕	高脂血症史〔例（%）〕	脑卒中史〔例（%）〕	陈旧性心肌梗死史〔例（%）〕
A组	42	28/14	60.4±9.6	24.4±2.2	17（40.5）	20（47.6）	24（57.1）	10（23.8）	5（11.9）	6（14.3）
B组	40	26/14	62.7±8.7	24.4±2.7	14（35.0）	23（57.5）	17（42.5）	11（27.5）	7（17.5）	9（22.5）
χ²（t）值		0.025	-1.134^a	-0.087^a	0.261	0.802	1.757	0.146	0.513	0.925
P值		0.874	0.260	0.931	0.609	0.370	0.185	0.702	0.474	0.336

组别	例数	MAP（mmHg）			CI〔L·min^-1·（m²）^-1〕			GFR（mL/min）
组别	例数	治疗前	治疗后24 h	治疗后72 h	治疗前	治疗后24 h	治疗后72 h	治疗前	治疗后24 h	治疗后72 h
A组	42	58.6±4.9	76.6±7.5^a	79.6±9.4^a	1.80±0.12	2.03±0.24^a	2.21±0.18^ab	55.1±8.7	65.7±12.9^a	67.9±19.7^a
B组	40	56.1±7.7	80.1±8.3^ac	84.3±10.5^ac	1.76±0.09	2.20±0.17^ac	2.31±0.15^abc	57.6±9.0	74.0±15.7^ac	77.0±16.6^ac
F值		F_时间=242.114，F_交互=5.057，F_组间=3.007			F_时间=307.275，F_交互=9.935，F_组间=7.838			F_时间=57.476，F_交互=2.533，F_组间=7.146
P值		P_时间<0.001，P_交互=0.009，P_组间=0.087			P_时间<0.001，P_交互<0.001，P_组间=0.006			P_时间<0.001，P_交互=0.086，P_组间=0.009
组别	Lac（mmol/L）			cTnI（μg/L）			BNP（ng/L）
组别	治疗前	治疗后24 h	治疗后72 h	治疗前	治疗后24 h	治疗后72 h	治疗前	治疗后24 h	治疗后72 h
A组	11.31±3.26	5.76±1.64^a	2.53±1.05^ab	31.53±12.46	13.68±5.38^a	1.32±0.40^ab	2 293.4±1 020.8	1 403.0±626.0^a	917.6±363.4^ab
B组	11.45±2.91	4.90±1.47^ac	2.09±0.88^abc	30.78±9.58	9.63±5.70^ac	0.78±0.37^abc	2 470.1±1 206.9	1 276.8±499.9^a	887.9±346.4^ab
F值	F_时间=542.804，F_交互=3.382，F_组间=1.103			F_时间=357.666，F_交互=4.301，F_组间=3.143			F_时间=113.153，F_交互=1.650，F_组间=0.001
P值	P_时间<0.001，P_交互=0.039，P_组间=0.297			P_时间<0.001，P_交互=0.017，P_组间=0.080			P_时间<0.001，P_交互=0.199，P_组间=0.980