体外膜肺氧合治疗暴发性心肌炎患者的临床研究

doi:10.3877/cma.j.issn.1674-6880.2016.06.003

目的

探讨体外膜肺氧合（ECMO）对暴发性心肌炎（FM）患者的临床治疗效果。

方法

收集2009年9月至2015年10月入住杭州市第一人民医院危重病医学科的8例FM患者，所有患者均为常规治疗疗效不佳，遂立即行静脉-动脉模式ECMO（VA-ECMO）辅助治疗。观察患者疗效，并对患者治疗前后肌酸激酶、肌酸激酶同工酶（CKMB）、肌钙蛋白Ⅰ、天冬氨酸氨基转移酶（AST）、乳酸脱氢酶（LDH）、血肌酐、血乳酸、心胸比例及左室射血分数（LVEF）进行比较。并根据股动静脉置管法将所有患者分成外科手术组及超声组，每组4例，比较两组患者置管时间及并发症的发生情况。

结果

6例患者心功能恢复正常，成功撤机，2例患者由于心功能无法逆转最终死亡。ECMO辅助治疗后肌酸激酶[（586 ± 461）U/L vs.（90 ± 38）U/L，t = 2.721，P = 0.042]、血肌酐[（153 ± 70）μmol/L vs.（966 ± 20）μmol/L，t = 3.866，P = 0.012]、血乳酸[（6.25 ± 3.67）mmol/L vs.（1.23 ± 0.29）mmol/L，t = 3.236，P = 0.023]及LVEF[（0.21 ± 0.16）vs.（0.47 ± 0.05），t = 4.416，P = 0.007]较治疗前比较，差异均有统计学意义。同时，采用外科手术切开直视下股动静脉置管方法，所需时间为（72 ± 10）min，超声引导下紧急留置了股动静脉管，所需时间为（24 ± 5）min。两种方法比较，差异有统计学意义（t = 7.908，P = 0.004），且无其他不良反应及并发症发生。

结论

ECMO是抢救FM的一种有效机械辅助方法，且联合超声引导下的股动静脉置管技术救治效果更好。

关键词: 体外膜肺氧合, 心肌疾病, 暴发性心肌炎

Objective

To explore the clinical effect of the extracorporeal membrane oxygenation (ECMO) in patients with fulminant myocarditis (FM).

Methods

Observing 8 FM patients admitted to Critical Care Medicine in Hangzhou First People's Hospital from September 2009 to October 2015. All patients accepted vein-artery extracorporeal membrane oxygenation (VA-ECMO) after unsatisfactory results with conventional therapy. The levels of creatine kinase, creatine kinase isoenzyme MB (CK-MB), troponin Ⅰ (TNⅠ), aspartate aminotransferase (AST), actate dehydrogenase(LDH), serum creatinine, blood lactic acid, cardiothoracic ratio and left ventricular ejection fraction (LVEF) before and after VA-ECMO were compared. Meanwhile, all the patients were divided into the surgical group and ultraphonic group accroding to catheter of femoral arterio-venous, 4 patients in each group, and the time of insertion and the occurrence of complications were compared.

Results

Six patients were successfully weaned off and fully recovered cardiac function, while 2 patients eventually died because of heart function irreversible. The levels of creatine kinase [(586 ± 461) U/L vs. (90 ± 38) U/L, t = 2.721, P = 0.042], serum creatinine[(153 ± 70) μmol/L vs. (966 ± 20) μmol/L, t = 3.866, P = 0.012], blood lactic acid [(6.25 ± 3.67) mmol/L vs. (1.23 ± 0.29) mmol/L, t = 3.236, P = 0.023] and LVEF [(0.21 ± 0.16) vs. (0.47 ± 0.05), t = 4.416, P = 0.007] showed significant differences before and after VA-ECMO. The time of insertion in the ultraphonic group was much shorter than that in the surgical group [(24 ± 5) min vs. (72 ± 10) min, t = 7.908, P = 0.004], and no other adverse reactions and complications happened.

Conclusion

ECMO is one of the most effective mechanical circulation support devices, and combined with ultrasound can be better in FM patients.

Key words: Extracorporeal membrane oxygenation, Cardiomyopathies, Fulminant myocarditis

表1 8例暴发性心肌炎患者基本情况

编号	性别	年龄（岁）	并发症	治疗（μg·kg^-1·min^-1）
1	男	12	心源性休克+ Ⅲ度房室传导阻滞	多巴胺20 μg·kg^-1·min^-1 +多巴酚丁胺40 μg·kg^-1· min^-1
2	女	25	心源性休克+ MODS	多巴胺15 μg·kg^-1·min^-1 +多巴酚丁胺30 μg·kg^-1· min^-1
3	女	21	心源性休克+ Ⅲ度房室传导阻滞	多巴胺20 μg·kg^-1·min^-1 +多巴酚丁胺40 μg·kg^-1·min^-1 +肾上腺素2 μg·kg^-1·min^-1
4	男	18	心脏骤停	ECPR
5	男	21	心脏骤停	ECPR
6	男	58	心源性休克+ Ⅲ度房室传导阻滞	多巴胺20 μg·kg^-1·min^-1 +多巴酚丁胺40 μg·kg^-1·min^-1 +去甲肾上腺素2 μg·kg^-1· min^-1 + IABP
7	男	33	心源性休克+ MODS	多巴胺20 μg·kg^-1·min^-1 +多巴酚丁胺40 μg·kg^-1·min^-1 + IABP
8	女	51	心源性休克+ MODS心源性休克+Ⅲ度房室传导阻滞	多巴胺15 μg·kg^-1·min^-1 +肾上腺素1.6 μg·kg^-1·min^-1 +去甲肾上腺素1.12 μg·kg^-1·min^-1

表1 8例暴发性心肌炎患者基本情况

编号	性别	年龄（岁）	并发症	治疗（μg·kg^-1·min^-1）
1	男	12	心源性休克+ Ⅲ度房室传导阻滞	多巴胺20 μg·kg^-1·min^-1 +多巴酚丁胺40 μg·kg^-1· min^-1
2	女	25	心源性休克+ MODS	多巴胺15 μg·kg^-1·min^-1 +多巴酚丁胺30 μg·kg^-1· min^-1
3	女	21	心源性休克+ Ⅲ度房室传导阻滞	多巴胺20 μg·kg^-1·min^-1 +多巴酚丁胺40 μg·kg^-1·min^-1 +肾上腺素2 μg·kg^-1·min^-1
4	男	18	心脏骤停	ECPR
5	男	21	心脏骤停	ECPR
6	男	58	心源性休克+ Ⅲ度房室传导阻滞	多巴胺20 μg·kg^-1·min^-1 +多巴酚丁胺40 μg·kg^-1·min^-1 +去甲肾上腺素2 μg·kg^-1· min^-1 + IABP
7	男	33	心源性休克+ MODS	多巴胺20 μg·kg^-1·min^-1 +多巴酚丁胺40 μg·kg^-1·min^-1 + IABP
8	女	51	心源性休克+ MODS心源性休克+Ⅲ度房室传导阻滞	多巴胺15 μg·kg^-1·min^-1 +肾上腺素1.6 μg·kg^-1·min^-1 +去甲肾上腺素1.12 μg·kg^-1·min^-1

表2 暴发性心肌炎患者ECMO辅助治疗前后各指标的变化（±s）

组别	例数	肌酸激酶(U/L)	CK-MB(U/L)	肌钙蛋白Ⅰ(μg/L)	AST(U/L)	LDH(U/L)
治疗前	6	586 ± 461	74 ± 69	19.6 ± 18.8	744 ± 1 295	1 144 ± 1 745
治疗后	6	90 ± 38	6±3	0.5 ± 0.3	38 ± 19	379 ± 101
t值	?	2.721	2.449	2.519	1.330	1.056
P值	?	0.042	0.058	0.053	0.241	0.339
组别	例数	血肌酐(μmol/L)	乳酸(mmol/L)	心胸比例	LVEF
治疗前	6	153 ± 70	6.25 ± 3.67	0.428 ± 0.031	0.21 ± 0.16
治疗后	6	66 ± 20	1.23 ± 0.29	0.437 ± 0.020	0.47 ± 0.05
t值	?	3.866	3.236	0.496	4.416
P值	?	0.012	0.023	0.641	0.007

表2 暴发性心肌炎患者ECMO辅助治疗前后各指标的变化（±s）

组别	例数	肌酸激酶(U/L)	CK-MB(U/L)	肌钙蛋白Ⅰ(μg/L)	AST(U/L)	LDH(U/L)
治疗前	6	586 ± 461	74 ± 69	19.6 ± 18.8	744 ± 1 295	1 144 ± 1 745
治疗后	6	90 ± 38	6±3	0.5 ± 0.3	38 ± 19	379 ± 101
t值	?	2.721	2.449	2.519	1.330	1.056
P值	?	0.042	0.058	0.053	0.241	0.339
组别	例数	血肌酐(μmol/L)	乳酸(mmol/L)	心胸比例	LVEF
治疗前	6	153 ± 70	6.25 ± 3.67	0.428 ± 0.031	0.21 ± 0.16
治疗后	6	66 ± 20	1.23 ± 0.29	0.437 ± 0.020	0.47 ± 0.05
t值	?	3.866	3.236	0.496	4.416
P值	?	0.012	0.023	0.641	0.007

1	Ginsberg F,Parrillo JE. Fulminant myocarditis[J]. Crit Care Clin, 2013, 29(3): 465-483.
2	Vashist S,Singh GK. Acute myocarditis in children: current concepts and management[J]. Curr Treat Options Cardiovasc Med, 2009, 11(5): 383-391.
3	Lin KM,Li MH,Hsieh KS, et al. Impact of extracorporeal membrane oxygenation on acute fulminant myocarditis-related hemodynamic compromise arrhythmia in children[J]. Pediatr Neonatol, 2016, 57(6): 480-487.
4	Caldeira D,Lopes LR,Vaz-Carneiro A, et al. Cochrane corner: corticosteroids for viral myocarditis[J]. Rev Port Cardiol, 2015, 34(1): 65-67.
5	Isogai T,Yasunaga H,Matsui H, et al. Effect of intravenous immunoglobulin for fulminant myocarditis on inhospital mortality: propensity score analyses[J]. J Card Fail, 2015, 21(5): 391-397.
6	Shauer A,Gotsman I,Keren A, et al. Acute viral myocarditis: current concepts in diagnosis and treatment[J]. Isr Med Assoc J, 2013, 15(3): 180-185.
7	Schultheiss HP,Kuhl U,Cooper LT. The management of myocarditis[J]. Eur Heart J, 2011, 32(21): 2616-2625.
8	Ishida K,Wada H,Sakakura K, et al. Long-term follow-up on cardiac function following fulminant myocarditis requiring percutaneous extracorporeal cardiopulmonary support[J]. Heart Vessels, 2013, 28(1): 86-90.
9	Wu LL,Han B. Diagnosis and treatment of myocarditis[J]. Zhongguo Dang Dai Er Ke Za Zhi, 2014, 16(12): 1283-1288.
10	Lorusso R,Centofanti P,Gelsomino S, et al. Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: a 5-year multi-institutional experience[J]. Ann Thorac Surg, 2016, 101(3): 919-926.
11	Mody K P,Takayama H,Landes E, et al. Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock[J]. J Cardiovasc Transl Res, 2014, 7(2): 156-164.
12	洪军,孙仁华,屈百鸣. 经皮心肺辅助循环治疗重症心肌炎合并心源性休克七例[J/CD]. 中华危重症医学杂志：电子版, 2013, 6(1)：35-37.
13	Baughman KL. Diagnosis of myocarditis: death of Dallas criteria[J]. Circulation, 2006, 113(4): 593-595.
14	Cheng R,Hachamovitch R,Kittleson M, et al. Clinical outcomes in fulminant myocarditis requiring extracorporeal membrane oxygenation: a weighted meta-analysis of 170 patients[J]. J Card Fail, 2014, 20(6): 400-406.
15	den Uil CA,Lagrand WK,van der Ent M, et al. The effects of intra-aortic balloon pump support on macrocirculation and tissue microcirculation in patients with cardiogenic shock[J]. Cardiology, 2009, 114(1): 42-46.
16	Su TW,Tseng YH,Wu TI, et al. Extracorporeal life support in adults with hemodynamic collapse from fulminant cardiomyopathies: the chance of bridging to recovery[J]. ASAIO J, 2014, 60(6): 664-669.
17	Lunz D,Philipp A,Dolch M, et al. Veno-arterial extracorporeal membrane oxygenation. Indications, limitations and practical implementation[J]. Anaesthesist, 2014, 63(8-9): 625-635.
18	胡伟航,刘长文,胡炜, 等. 体外膜肺氧合治疗暴发性心肌炎5例分析[J/CD]. 中华危重症医学杂志：电子版, 2014, 7(5)：354-357.
19	Rajagopal SK,Almond CS,Laussen PC, et al. Extracorporeal membrane oxygenation for the support of infants, children, and young adults with acute myocarditis: a review of the extracorporeal Life Support Organization registry[J]. Crit Care Med, 2010, 38(2): 382-387.
20	Nakamura T,Ishida K,Taniguchi Y, et al. Prognosis of patients with fulminant myocarditis managed by peripheral venoarterial extracorporeal membranous oxygenation support: a retrospective single-center study[J]. J Intensive Care, 2015, 3(1): 5.
21	Chiu CW,Yen HH,Chiu CC, et al. Prolonged cardiac arrest: successful resuscitation with extracorporeal membrane oxygenation[J]. Am J Emerg Med, 2013, 31(11): 1627. e5-e6.
22	Hsu KH,Chi NH,Yu HY, et al. Extracorporeal membranous oxygenation support for acute fulminant myocarditis: analysis of a single center's experience[J]. Eur J Cardiothorac Surg, 2011, 40(3): 682-688.
23	Thiagarajan RR,Brogan TV,Scheurer MA, et al. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in adults[J]. Ann Thorac Surg, 2009, 87(3): 778-785.

[1]	赵洪峰, 王淑颖, 胡炜, 聂世姣, 费莹, 石尚世, 储华英, 王剑荣. 体外膜肺氧合相关血流感染危险因素及预测模型建立[J]. 中华危重症医学杂志(电子版), 2023, 16(02): 98-104.
[2]	陈娇, 王立伟, 孙斌, 张萌, 刘倩, 周美艳, 丁文平, 张伟. 体外膜肺氧合联合主动脉内球囊反搏在暴发性心肌炎救治中的应用[J]. 中华危重症医学杂志(电子版), 2023, 16(01): 6-12.
[3]	陈婧, 姚杨, 苗继荣, 丁格, 马青, 彭伊梦, 卢洲, 康凤尔, 王胜昱. 静脉-动脉体外膜肺氧合联合主动脉内球囊反搏对心源性疾病患者病死率的影响：Meta分析[J]. 中华危重症医学杂志(电子版), 2023, 16(01): 48-59.
[4]	张忠满, 朱轶, 李伟, 安迪, 邹乐, 夏雨, 丁涛, 时育彤, 陈旭锋. 行体外膜肺氧合患者脑出血危险因素分析[J]. 中华危重症医学杂志(电子版), 2022, 15(06): 454-459.
[5]	董亚玲, 邓超, 刘淼淼, 张颖, 郭锋伟, 阮骊韬, 陈红, 尚佳楠, 王飞, 武慧蓉, 师桃, 宋艳. 右心室心肌应变在静脉-动脉体外膜氧合辅助支持治疗暴发性心肌炎急性期中的价值[J]. 中华危重症医学杂志(电子版), 2022, 15(04): 300-303.
[6]	童洪杰, 陈琨, 潘飞艳, 倪红英. 俯卧位通气对静脉-静脉体外膜肺氧合支持的急性呼吸窘迫综合征患者病死率影响的Meta分析[J]. 中华危重症医学杂志(电子版), 2022, 15(04): 312-317.
[7]	康绍涛, 布祖克拉·阿布都艾尼, 李英杰, 拜合提尼沙·吐尔地. 体外膜肺氧合治疗脓毒症患者生存预后的Meta分析[J]. 中华危重症医学杂志(电子版), 2022, 15(01): 51-59.
[8]	张明光, 李斌飞, 吴少花. 婴幼儿颈部通路体外膜肺氧合相关性出血并发症分析[J]. 中华普通外科学文献(电子版), 2022, 16(04): 282-285.
[9]	滕鹏, 郑骏楠, 郭雷, 胡鹏, 倪程耀, 赵海格, 马量. 心脏移植术前体外膜肺氧合循环辅助桥接33例疗效分析[J]. 中华移植杂志(电子版), 2022, 16(06): 339-345.
[10]	惠姣洁, 梁锋鸣, 王逸峰, 王大鹏, 陈静瑜, 许红阳. 肺移植术后体外膜肺氧合流量不足处理经验[J]. 中华移植杂志(电子版), 2022, 16(04): 238-240.
[11]	梅喜平, 袁利学, 祝小梅, 袁法伟, 李炳奇, 叶俊伟, 刘栋, 王雪琴, 郑鲲, 冯辉斌. 体外膜肺氧合在危重症患者中的临床应用[J]. 中华肺部疾病杂志(电子版), 2022, 15(02): 206-208.
[12]	方可, 笪欢欢, 汪君, 孙瑞祥, 王涛, 李阳, 江海娇, 鲁卫华. ECMO联合肾上腺切除救治妊娠期嗜铬细胞瘤并儿茶酚胺心肌病一例并文献回顾[J]. 中华重症医学电子杂志, 2023, 09(03): 304-310.
[13]	高学慧, 邹晓静, 杨小博, 尚游. 甲磺酸萘莫司他在重症患者CRRT与ECMO中抗凝应用的研究进展[J]. 中华重症医学电子杂志, 2023, 09(02): 210-216.
[14]	尹承芬, 徐磊. 再议俯卧位通气的时机[J]. 中华重症医学电子杂志, 2023, 09(01): 9-13.
[15]	尹承芬, 徐磊. ARDS患者V-V ECMO支持期间机械通气设置的研究[J]. 中华重症医学电子杂志, 2022, 08(04): 378-383.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Clinical study of extracorporeal membrane oxygenation in patients with fulminant myocarditis

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Clinical study of extracorporeal membrane oxygenation in patients with fulminant myocarditis