长期机械循环辅助在终末期心力衰竭患者中的应用与展望

doi:10.3877/cma.j.issn.2096-1537.2025.04.001

以左心室辅助装置（LVAD）为代表的长期机械循环辅助（dMCS）在终末期心力衰竭患者的治疗中发挥重要作用。悬浮技术的引入（磁悬浮或液力悬浮）极大地改善了LVAD的血液相容性及生存率，进一步改变了LVAD的治疗理念（终点治疗比例增加）。未来全植入型LVAD将会进一步提高患者的生活质量，符合生理特性的搏动泵也将进一步提高血液相容性。本文就dMCS在终末期心力衰竭患者中的应用作一综述，并重点介绍LVAD的现状、适应证与手术时机以及未来发展方向。

关键词: 长期机械循环辅助, 终末期心力衰竭, 左心室辅助装置, 全人工心脏

Durable mechanical circulatory support, represented by the left ventricular assist device (LVAD), plays an important role in the treatment of patients with end-stage heart failure. The introduction of levitation technologies (magnetic or hydraulic) has substantially improved the hemocompatibility and survival of LVAD, further transforming the therapeutic philosophy for LVAD (evidenced by increased proportion of destination therapy). In the future, fully implantable LVADs will further improve patients' quality of life, while physiologically adaptive pulsatile pumps are expected to achieve even greater improvements in hemocompatibility. This article provides a review of the application of durable mechanical circulatory support (dMCS) in patients with end-stage heart failure, focusing on the current status of LVAD, its indications and timing of surgery, as well as future development directions.

Key words: Durable mechanical circulatory support, End-stage heart failure, Left ventricular assist device, Total artificial heart

表1 国内正在使用的LVAD产品参数及上市时间

产品参数	CH-VAD	Heart-Con	CorHeart 6	EVA-Pulsar^TM	HeartMate 3
制造商	苏州同心医疗	航天泰心	深圳核心医疗	重庆永仁心医疗	美国雅培
轴承原理	全磁悬浮	磁液悬浮	全磁悬浮	液力悬浮	全磁悬浮
泵体直径（mm）	47	50	33	51	50.3
泵体高度（mm）	25	22	26	67.5	33.8
重量（g）	186	184	90	262	200
出血管直径（mm）	10	10	12	14	14
转速（转/min）	1000~4200	2000~3400	2200~4300	1600~2400	3000~9000
功耗（W）	5~8	2~6	1.5~7	3~6	3~4
最大流量（L/min）	10	10	10	20	10
中国获批时间	2021年11月	2022年7月	2023年6月	2024年2月	2024年7月

表1 国内正在使用的LVAD产品参数及上市时间

产品参数	CH-VAD	Heart-Con	CorHeart 6	EVA-Pulsar^TM	HeartMate 3
制造商	苏州同心医疗	航天泰心	深圳核心医疗	重庆永仁心医疗	美国雅培
轴承原理	全磁悬浮	磁液悬浮	全磁悬浮	液力悬浮	全磁悬浮
泵体直径（mm）	47	50	33	51	50.3
泵体高度（mm）	25	22	26	67.5	33.8
重量（g）	186	184	90	262	200
出血管直径（mm）	10	10	12	14	14
转速（转/min）	1000~4200	2000~3400	2200~4300	1600~2400	3000~9000
功耗（W）	5~8	2~6	1.5~7	3~6	3~4
最大流量（L/min）	10	10	10	20	10
中国获批时间	2021年11月	2022年7月	2023年6月	2024年2月	2024年7月

表2 LVAD的适应证及禁忌证

适应证	禁忌证
适应证	相对	绝对
因心力衰竭频繁住院	年龄＞80岁	不可逆的肝、肾或神经系统功能不全
最大剂量药物治疗情况下仍表现为NYHA心功能分级ⅢB~Ⅳ级	未治疗的恶性肿瘤	依从性差
无法耐受神经内分泌拮抗剂	不愿意终止的药物滥用	严重的社会心理学障碍
利尿剂剂量增加	活动性感染或长期气管插管
心脏再同步化治疗后仍存在心力衰竭症状	重度肥胖或营养不良
强心药依赖	严重的周围血管疾病
最大摄氧量下降[VO2max＜14～16 ml/（kg•min）]	影响术后康复的肌肉骨骼疾病
低心输出量导致终末器官功能不全	未治疗的精神疾病、认知功能障碍或社会家庭支持不足

表2 LVAD的适应证及禁忌证

适应证	禁忌证
适应证	相对	绝对
因心力衰竭频繁住院	年龄＞80岁	不可逆的肝、肾或神经系统功能不全
最大剂量药物治疗情况下仍表现为NYHA心功能分级ⅢB~Ⅳ级	未治疗的恶性肿瘤	依从性差
无法耐受神经内分泌拮抗剂	不愿意终止的药物滥用	严重的社会心理学障碍
利尿剂剂量增加	活动性感染或长期气管插管
心脏再同步化治疗后仍存在心力衰竭症状	重度肥胖或营养不良
强心药依赖	严重的周围血管疾病
最大摄氧量下降[VO2max＜14～16 ml/（kg•min）]	影响术后康复的肌肉骨骼疾病
低心输出量导致终末器官功能不全	未治疗的精神疾病、认知功能障碍或社会家庭支持不足

表3 I NEED HELP工具

首字母	英文	中文
I	IV inotropes	静脉正性肌力药物
N	NYHA ⅢB/Ⅳ or persistently elevated natriuretic peptides	NYHA ⅢB/Ⅳ级，或BNP 持续升高
E	End-organ dysfunction	终末器官功能不全
E	EF≤35%	EF≤35%
D	Defibrillator shocks	ICD放电
H	Hospitalizations ＞1	住院大于1次
E	Edema despite escalating diuretics	利尿剂不断增加，水肿持续存在
L	Low blood pressure，high heart rate	血压低、心率快
P	Progressive intolerance or down titration of GDMT	不能耐受或下调指南导向的药物治疗

表3 I NEED HELP工具

首字母	英文	中文
I	IV inotropes	静脉正性肌力药物
N	NYHA ⅢB/Ⅳ or persistently elevated natriuretic peptides	NYHA ⅢB/Ⅳ级，或BNP 持续升高
E	End-organ dysfunction	终末器官功能不全
E	EF≤35%	EF≤35%
D	Defibrillator shocks	ICD放电
H	Hospitalizations ＞1	住院大于1次
E	Edema despite escalating diuretics	利尿剂不断增加，水肿持续存在
L	Low blood pressure，high heart rate	血压低、心率快
P	Progressive intolerance or down titration of GDMT	不能耐受或下调指南导向的药物治疗

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