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Medicine

心原性ショックによる急性心筋梗塞における経皮性心室アシスト装置の利用

Published: June 12, 2021
doi:
10.3791/62110
, , ,
1Division of Cardiology,Loma Linda University Medical Center, 2Division of Cardiology,University of Nebraska, 3Division of Cardiology,Henry Ford Health System

Summary

急性心筋梗塞や心原性ショックを受けた患者では、経皮性心室補助装置がますます利用されています。ここでは、このようなデバイスの作用機序と血行力学的効果について議論する。また、これらの複雑なデバイスの移植、管理、および引き分けのためのアルゴリズムとベストプラクティスについても検討します。

Abstract

心原性ショックは、持続性低血圧と定義され、末端臓器低灌流の証拠を伴う。経皮性心室補助装置(PVAD)は、ヘモダイナミクスを改善するために心原性ショックの治療に使用されます。インペラは現在最も一般的なPVADであり、積極的に大大体に左心室から血液を送り出す。PVADは左心室をアンロードし、心拍出量を増加させ、冠状動脈灌流を改善する。PVADは、通常、可能であれば大腿動脈を介して蛍視的指導の下で心臓カテーテル検査室に配置される。重篤な末梢動脈疾患の場合、PVADは代替アクセスを介して移植することができる。本稿では、PVADの作用機序と、心因性ショックの治療におけるそれらの使用を支持するデータを要約する。

Introduction

心原性ショック(CS)は、持続性低血圧(収縮期血圧30分間、持続性低血圧と定義され、 または血管圧子またはイノトロープの必要性)、末端臓器低灌流(尿出力2 mmol/L)、肺鬱血(肺毛細血管ウェッジ圧(PCWP)15mmHg)≥、心臓性能低下(心臓 Equation 1 指数<2)1、原発性心疾患による2。急性心筋梗塞(AMI)はCS3の最も一般的な原因である。CSはAMIの5〜10%で発生し、歴史的に有意な死亡率3、4に関連付けられてきた。大動脈バルーンポンプ(IABP)、経皮性心室補助装置(PVAD)、体外膜酸素化(ECMO)および大動脈装置への経皮的左心房などの機械的循環支持(MCS)装置は、CS5患者に頻繁に使用される。IABPの日常的な使用は、AMI-CS1における臨床結果または生存率の改善を示していない。AMI-CSに関連する悪い結果、AMI-CSでの試験実施の難しさを考えると、AMI-CSにおけるIABP使用の否定的な結果を考えると、臨床医はますます他の形態のMCSに目を向けています。

PVADは、AMI-CS6の患者でますます利用されています。この記事では、現在使用されている最も一般的なPVADであるImpella CPに主に焦点を当てます 6.この装置は、左心室(LV)から昇順大動脈に血液を積極的かつ継続的に推進する軸流アルキメデススクリューポンプを利用する(図1)。装置は大腿動脈を介して蛍視的指導の下で心臓カテーテル検査室で最も頻繁に置かれる。あるいは、必要に応じて腋窩または経カバリーアクセスを通して移植することができます7,8.

Protocol

このプロトコルは、私たちの機関のケアの標準です。 1. PVADの挿入(例えば、インペラCP) 微小穿刺針9,10を用いて、大腿骨頭の下半分に対する大腿部の一般的なアクセスを、細小穿刺および超音波誘導で取得する。マイクロ穿刺鞘を位置付け、大腿動脈の血管造影を得て、適切な動脈開法位置11を確認す?…

Representative Results

表1はPVAD注入35、36、37、38、39、40の安全性と有効性を示す。 PVAD の結果の最適化PVADは、結果を最適化するために重要な経験と専門知識を必要とするリソースの重い介入です。次のベスト プラク?…

Discussion

PVADのリスクと複雑さを最小限に抑える(表 2)
PVADの血行力学的利点は、大出血および急性四肢虚血28,29のような大孔アクセスからの合併症が起こった場合に著しく中和することができる。したがって、デバイスのリスクと合併症を最小限に抑えることが不可欠です。

アクセス部位の合併症を減らし、アクセス試行?…

Disclosures

The authors have nothing to disclose.

Acknowledgements

何一つ

Materials

4 Fr-018-10 cm Silhouette Stiffened Micropuncture Set Cook G48002 Microvascular access
5 Fr Infiniti Pigtail Catheter Cordis 524-550S pigtail catheter
Impella CP Intra-cardiac Assist Catheter ABIOMED 0048-0003 Impella catheter kit
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Tags

Percutaneous Ventricular Assist DeviceAcute Myocardial InfarctionCardiogenic ShockImpella CatheterFemoral Arterial AccessVascular ComplicationsMicropuncture NeedleFluoroscopic GuidanceUltrasound GuidancePigtail CatheterPeripheral Artery DiseaseDilatorsPeel Away SheathHeparinLeft VentricleArchimedes Screw PumpMitral ChordaeMotor CurrentAortic WaveformVentricular Waveform
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Nandkeolyar, S., Velagapudi, P., Basir, M. B., Bharadwaj, A. S. Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock. J. Vis. Exp. (172), e62110, doi:10.3791/62110 (2021).
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