JoVE Journal > Medicine
Summary
Abstract
Introduction
Protocol
Results
Discussion
Disclosures
Acknowledgements
Materials
References
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使用经皮心室辅助装置/左心房至股动脉旁路系统治疗心源性休克

Published: August 16, 2021
doi:
10.3791/62140
, , , ,
1University of Nebraska Medical Center, 2Keele Cardiovascular Research Group,Keele University, 3University of Chicago Medicine, 4Virginia Heart/Inova Heart and Vascular Institute

Summary

以下文章描述了在心源性休克（CS）中放置装置（例如串联心动）的逐步程序，该装置是经皮左心室辅助装置（pLVAD）和左心房到股动脉旁路（LAFAB）系统，该系统绕过并支持CS中的左心室（LV）。

Abstract

左心房至股动脉旁路术 （LAFAB） 系统是一种用于心源性休克 （CS） 的机械循环支持 （MCS） 装置，通过从左心房 （LA） 引流血液并通过股动脉将其返回到体循环，从而绕过左心室。它可以提供2.5-5升/分钟的流量，具体取决于套管的大小。在这里，我们讨论了LAFAB的作用机制，可用的临床数据，其在心源性休克中的应用适应症，植入步骤，术后护理以及与使用该装置及其管理相关的并发症。

我们还提供了器械治疗程序组件的简短视频，包括预置准备，在超声心动图指导下通过经隔穿刺对器械进行经皮置入以及器械参数的术后管理。

Introduction

心源性休克（CS）是一种组织灌注不足的状态，伴有或不伴有低血压，其中心脏无法提供足够的血液和氧气来满足身体的需求，导致器官衰竭。心血管血管造影和干预学会（SCAI）将其分为A至E期：A期 – 有CS风险的患者;B期 – CS开始阶段的患者低血压或心动过速，无低灌注;C期 – 经典CS，具有冷湿表型，需要正性肌力药物/血管加压药或机械支持以维持灌注;D级 – 当前医疗或机械支持恶化，需要升级到更先进的设备;和 E 期 – 包括循环衰竭和难治性心律失常患者，这些患者积极经历心脏骤停并持续进行心肺复苏1。CS 最常见的病因是急性心肌梗死 （AMI），在最近报告的分析中占病例的 81%2，以及急性失代偿性心力衰竭 （ADHF）。CS 的典型特征是充血和灌注受损，表现为充盈压力升高（肺毛细血管楔形压 [PCWP]、左心室舒张末压 [LVEDP]、中心静脉压 [CVP] 和右心室舒张末压 [RVEDP]）、心输出量 （CO）、心脏指数 （CI）、心功率输出量 （CPO） 和终末器官功能障碍3.过去，对于并发 CS 的 AMI，唯一可用的治疗方法是早期血运重建和使用正性肌力药物和/或血管加压药进行药物治疗4。最近，随着机械循环支持（MCS）装置的出现以及血管加压药升级与死亡率增加相关的认识，AMI和ADHF相关CS5，6的治疗发生了范式转变。

在当前经皮心室辅助装置 （pVAD） 时代，有许多 MCS 装置平台/配置可用，可提供单室或双心室循环和心室支持，无论是否具有氧合作用能力7。尽管使用pVADs治疗AMI和ADHF CS的人数稳步增加，但死亡率基本保持不变5。随着越来越多的证据表明，AMI8 中左心室 （LV） 的早期卸载和 AMI CS9 中早期使用 MCS 可能具有临床益处，MCS 的使用继续增加。

左心房至股动脉旁路术（LAFAB）MCS装置通过从左心房（LA）引流血液并通过股动脉将其返回到全身动脉循环来绕过左心室（图1）。它由外部离心泵提供支持，该离心泵提供每分钟2.5-5.0升（L / m）流量（新一代泵，指定为LifeSPARC，能够高达8 L / m流量），具体取决于插管的大小。一旦血液通过经室静脉套管从LA中提取，它就会通过外部离心泵，离心泵通过放置在股动脉中的动脉套管将血液再循环回患者体内。

Figure 1
图 1：拉斐设置。 图片由LivaNova US Inc.的全资子公司TandemLife提供 ，请点击此处查看此数字的放大版本。

Protocol

该程序和协议已获得机构审查委员会和美国食品和药物管理局（FDA）的批准。 1. 患者标准 包括 SCAI 共识声明1 所定义的 CS B 期及以上患者。 包括作为移植的桥梁或D期心力衰竭的持久左心室辅助系统。 包含在由 CS 复杂化的 AMI 中作为恢复的桥梁。 排除全身性抗凝治疗的禁忌证。 排除预期寿命<6个月（活动性恶性肿瘤）?…

Representative Results

拉斐设备的临床应用经皮经心房左心室旁路系统的技术和可行性由Dennis等人于20世纪60年代首次描述，11，12。然而，经隔穿刺最初并未被广泛采用，因为隔膜造口术技术存在并发症。在过去十年中，随着经皮介入治疗领域的进步，操作员积累了房间隔造口术的经验，这导致了经隔心室辅助装置或LAFAB装置的复兴。 从 2…

Discussion

拉法博装置的血流动力学：
LAFAB设备的血流动力学特征与其他pVAD不同。通过直接从LA引流血液并将其返回股动脉，该装置完全绕过左心室。在此过程中，它减少了左心室终末舒张容积和压力，有助于改善左心室几何形状，从而减少左心室冲程工作。然而，通过将血液返回髂动脉/降主动脉，后负荷增加。这导致左心室收缩末压 （LVESP） 升高导致左心室负荷。总体而言，?…

Disclosures

The authors have nothing to disclose.

Acknowledgements

致LifeSparc的TandemHeart团队。

Materials

For LAFAB (TandemHeart)
Factory Supplied Equipment for circuit connections. TandemLife
ProtekSolo 15 Fr or 17 Fr Arterial Cannula  TandemLife
ProtekSolo 62 cm or 72 cm Transseptal Cannula  TandemLife
TandemHeart Controller  TandemLife For adjusting flows/RPM
TandemHeart Pump  LifeSPARC Centrifugal pump
For RAPAB (ProtekDuo)
Factory Supplied Equipment to complete the circuit.  TandemLife
ProtekDuo  29 Fr or 31 Fr Dual Lumen Cannula  TandemLife
TandemHeart Controller  TandemLife For adjusting flows/RPM
TandemHeart Pump  LifeSPARC Centrifugal pump
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Tags

Percutaneous Ventricular Assist DeviceLeft Atrium To Femoral Artery BypassCardiogenic ShockTandem HeartMechanical Circulatory SupportLV ThrombusAortic StenosisPercutaneous ImplantationController SetupPriming TrayPump Drive LineOxygenatorTransesophageal EchocardiogramTEE Probe
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Sundaravel, S., Velagapudi, P., Mamas, M., Nathan, S., Truesdell, A. Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock. J. Vis. Exp. (174), e62140, doi:10.3791/62140 (2021).
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