静脉-动脉体外膜氧合支持患者的左心减负

doi:10.3877/cma.j.issn.2096-1537.2020.02.005

静脉-动脉体外膜氧合(V-A ECMO)可为顽固性心源性休克患者提供完全的循环支持，在临床上得到了越来越多的应用。但外周插管型V-A ECMO在运行过程中显著增加左心室后负荷，可能导致左心增大、心内血栓形成、心肌缺血加重、顽固性心律失常和肺水肿等左心室扩张的不良后果，也不利于心功能恢复。近年来研究人员对左心减负的认知和干预越来越关注。本文主要介绍V-A ECMO应用过程中各种无创和有创左心减负的策略。

关键词: 静脉-动脉体外膜氧合, 左心室扩张, 减压

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) provides complete circulatory support for patients with refractory cardiogenic shock and has been increasingly used in clinical practice. However, V-A ECMO using peripheral cannulation significantly increases the left ventricular afterload, results in many adverse consequences associated with left ventricular distension such as left ventricular enlargement, thrombosis, myocardial ischemia aggravation, refractory arrhythmia, and pulmonary edema, and is not conducive to the recovery of cardiac function. Therefore, in recent years, researchers have paid more and more attention to the investigation and application of left ventricular decompression. The present paper reviews various strategies for noninvasive and invasive left ventricular decompression in V-A ECMO.

Key words: Veno arterial extracorporeal membrane oxygenation, Ventricular dysfunction, left, Decompression

图1 以床旁即时超声评估为导向的左心室扩张管理流程　通过床旁即时超声的评估，预防并及时发现左心室扩张的程度以及是否需要处理，进而实施程序化的策略选择，给予ECMO流量及容量优化、药物管理（血管扩张剂、正性肌力药、利尿剂等）、经皮微创机械辅助、开放手术机械辅助等左心减负的方法，来降低左心室负荷，从而解决V-A ECMO辅助引起的左心室扩张问题

图2 采用满足目标平均动脉压的最小V-A ECMO血流量的超声图　图a为血流量为4.1 L/min时，左心室流出道无明显血流，脉压差为0，提示左心室无有效射血，图b为降低V-A ECMO流量至2.5 L/min时，脉压差增大，左心室流出道血流明显增多，左心室有射血，自身射血+ECMO血流可维持平均动脉压达标，认为该ECMO血流量更优

图3 顽固性心源性休克患者V-A ECMO支持的超声图　图a、b示左心室射血功能极低下、主动脉瓣无法开放、心内血流淤滞，有左心室扩张风险，图c、d示加用多巴酚丁胺（5 μg/kg?min）强心后，可见收缩增强、主动脉瓣开放，心内血流淤滞现象消失

图4 V-A ECMO辅助过程中，联合主动脉内球囊反搏可增加左心输出量、降低左心充盈压　图a、b为当主动脉内球囊反搏暂停后，输出量减少（速度时间积分为9.28 cm），E/e′为6.56（提示左心充盈增加）；图c、d为当主动脉内球囊反搏运行时，输出量增多（速度时间积分为12.5cm），E/e′为5.57（提示左心充盈下降）

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Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation

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Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation