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Medicina

经皮心室辅助装置治疗急性心肌梗死并发心源性休克

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

经皮心室辅助装置越来越多地用于急性心肌梗死和心源性休克患者。在本文中，我们讨论了这些装置的作用机制和血流动力学效应。我们还审查了这些复杂设备的植入，管理和断奶的算法和最佳实践。

Abstract

心源性休克被定义为持续性低血压，伴有终末器官灌注不足的证据。经皮心室辅助装置 （PVAD） 用于治疗心源性休克，以改善血流动力学。Impella是目前最常见的PVAD，并主动将血液从左心室泵入主动脉。PVAD可卸下左心室，增加心输出量并改善冠状动脉灌注。在可行的情况下，通常将 PVAD 放置在心导管插入实验室，通过股动脉进行荧光镜引导。在严重外周动脉疾病的情况下，PVAD可以通过替代通道植入。在本文中，我们总结了PVAD的作用机制以及支持其在治疗心源性休克中的应用的数据。

Introduction

心源性休克 （CS） 定义为持续性低血压（收缩压 30 分钟，或需要血管加压药或正性肌力药物）、终末器官灌注不足（尿量 2 mmol/L）、肺淤血（肺毛细血管楔形压 （PCWP） ≥ 15 mmHg）和心脏功能下降（心脏指数 <2.2） Equation 1 1， 2.由于原发性心脏疾病。急性心肌梗死（AMI）是CS3的最常见病因。CS 发生在 5-10% 的 AMI 中，历史上与显著的死亡率相关3、4。机械循环支持 （MCS） 装置，如主动脉内球囊泵 （IABP）、经皮心室辅助装置 （PVAD）、体外膜肺氧合 （ECMO） 和经皮左心房到主动脉装置，常用于 CS5患者。常规使用IABP显示AMI-CS1的临床结局或生存率没有改善。鉴于与AMI-CS相关的不良结局，在AMI-CS中进行试验的困难以及在AMI-CS中使用IABP的阴性结果，临床医生越来越多地寻求其他形式的MCS。

PVAD 越来越多地用于 AMI-CS6患者。在本文中，我们将主要讨论Impella CP，这是目前最常用的PVAD6。该装置利用轴流阿基米德螺杆泵，该泵主动且连续地将血液从左心室（LV）推入升主动脉（图1）。该装置最常放置在心导管插入实验室，通过股动脉进行透视引导。或者，可以在必要时通过腋窝或经腔通道植入7，8。

Protocol

该协议是我们机构的护理标准。 1. 插入PVAD（例如，Impella CP） 在荧光透视和超声引导下，使用微穿刺针9、10获得股骨头下半部分的普通股骨通路。定位微穿刺鞘并获取股动脉血管造影以确认适当的动脉切开术位置11。 在股动脉中插入6 Fr鞘。 如果担心髂股疾病，在腹主动脉下部插入尾纤导管?…

Representative Results

表1显示了PVAD植入的安全性和有效性35、36、37、38、39、40。 优化 PVAD 结果PVAD是一种资源密集型干预措施，需要大量的经验和专业知识来优化结果。应考虑以下最佳做法： 1. 在休…

Discussion

尽量减少PVAD的风险和并发症（表2）
如果发生大口径通路的并发症，例如大出血和急性肢体缺血28，29，PVAD的血流动力学益处可以显着中和。因此，必须最大限度地降低设备的风险和并发症。

为了减少进入部位并发症并减少进入尝试的次数，在获得股动脉通路时应使用超声和透视引导10，30。<sup class…

Declarações

The authors have nothing to disclose.

Acknowledgements

没有

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

Keywords: 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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