Udnyttelse af vinkelrette ventrikulære hjælpeenheder i akut myokardieinfarkt kompliceret af kardiogen shock
Summary
Vinkelrette ventrikulære hjælpeanordninger bliver i stigende grad udnyttet hos patienter med akut myokardieinfarkt og kardiogent chok. Heri diskuterer vi virkningsmekanismen og de hæmodynamiske virkninger af sådanne anordninger. Vi gennemgår også algoritmer og bedste praksis for implantation, styring og fravænning af disse komplekse enheder.
Abstract
Kardiogent chok er defineret som vedvarende hypotension, ledsaget af tegn på end organ hypo-perfusion. Vinkelrette ventrikulære hjælpeanordninger (PVADs) bruges til behandling af kardiogen chok i et forsøg på at forbedre hæmodynamik. Impella er i øjeblikket den mest almindelige PVAD og aktivt pumper blod fra venstre ventrikel ind i aorta. PVADs losse venstre ventrikel, øge hjerte output og forbedre koronar perfusion. PVAD’er placeres typisk i laboratoriet for hjertekateterisation under fluoroskopisk vejledning via lårpulsåren, når det er muligt. I tilfælde af alvorlig perifer arteriel sygdom kan PVAD’er implanteres gennem en alternativ adgang. I denne artikel opsummerer vi PVAD’s virkningsmekanisme og de data, der understøtter deres anvendelse til behandling af kardiogenchok.
Introduction
Kardiogent chok (CS) defineres som vedvarende hypotension (systolisk blodtryk 30 minutter eller behovet for vasopressorer eller inotroper), hypomafusion i end organet (urinudgang 2 mmol/L), lungepropper (lungekapillær kiletryk (PCWP) ≥ 15 mmHg) og nedsat hjerteydelse (hjerteindeks <2.2 
)1, 2 på grund af en primær hjertesygdom. Akut myokardieinfarkt (AMI) er den mest almindelige årsag til CS3. CS forekommer i 5-10 % af AMI og har historisk set været forbundet med betydeligdødelighed 3,4. Mekaniske kredsløbshjælpemidler (MCS) enheder såsom intra-aorta ballonpumpe (IABP), vinkelrette ventrikulære hjælpeanordninger (PVAD), ekstrakorporal membran iltning (ECMO) og perkutan venstre atrie til aorta enheder bruges ofte til patienter med CS5. Rutinemæssig brug af IABP har ikke vist nogen forbedring i kliniske resultater eller overlevelse i AMI-CS1. I betragtning af de dårlige resultater forbundet med AMI-CS, vanskelighederne med at gennemføre forsøg i AMI-CS, og de negative resultater af IABP brug i AMI-CS, klinikere er i stigende grad ser til andre former for MCS.
PVAD’er anvendes i stigende grad hos patienter med AMI-CS6. I denne artikel vil vi primært fokusere vores diskussion på Impella CP, som er den mest almindelige PVAD, der bruges i øjeblikket6. Denne enhed anvender en aksial flow Arkimedes-skrue pumpe, som aktivt og kontinuerligt driver blod fra venstre ventrikel (LV) ind i stigende aorta (Figur 1). Enheden er oftest placeret i hjertekateterisation laboratorium under fluoroskopisk vejledning via lårpulsåren. Alternativt kan det implanteres gennem en aksillær eller transkaval adgang, når det er nødvendigt7,8.
Protocol
Representative Results
Discussion
Minimering af risici og komplikationer ved PVAD (tabel 2)
De hæmodynamiske fordele ved PVAD kan neutraliseres betydeligt, hvis der opstår komplikationer fra storboring, såsom større blødning og akut lemmer iskæmi28,29. Det er derfor vigtigt at minimere enhedens risiko og komplikationer.
For at mindske komplikationer på adgangsstedet og reducere antallet af adgangsforsøg bør ultralyds- og fluoroskopisk vejle…
Disclosures
The authors have nothing to disclose.
Acknowledgements
Ingen
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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