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警惕，心脏也患“肥胖病”
　　　　一位患者因胸闷、胸痛、气急从睡梦中惊醒，醒来后休息片刻未见缓解，且有加重的趋势。医生检查发现，他的心电图提示心肌缺血伴左心室肥厚，眼底动脉硬化，胸部X线显示心脏扩大，血压160／100mmHG，医生诊断：高血压心肌肥厚病。　　高血压“压”出来的心室肥胖　　人体的血液循环和血液供应，都是由左心室来完成的。患有高血压的病人，常伴有动脉硬化，血管阻力增大，左心室只有增加做功，才能泵出足量的血液以供心脏自身和全身组织脏器的需要，这样无形中就增加了左心室的负担。左心室在长期重负荷下，再加上心室长期受到高血压的冲击，左心室心肌纤维就会发生变性肥厚，从而患上“肥胖病”。左心室肥厚，可导致心肌细胞缺血缺氧，电生理传导障碍，容易引起心肌梗死，室性心律紊乱，充血性心力衰竭及心脏猝死等危急重症，这也是高血压心脏病最严重的后果，必须高度重视。　　生活“低姿态”降压又护心　　高血压心脏病所致的心肌肥厚，除了有效的用药物控制血压外，还要降低日常生活“标准”。　　降低膳食脂肪及热量：高脂肪、高胆固醇、高热量类食物，是诱发和加重高血压动脉硬化、心脑血管病的主要原因，所以要控制动物性食物和主食热量的摄取。适当地多吃些粗粮、蔬菜和水果，有计划地吃些大豆类、菌菇类、海藻类食物。　　减低饮食摄盐量：钠盐的摄入量与高血压的发生和发展密切相关，健康成人每天摄盐量不得超过10克，高血压及心脑肾病人应控制在4克以下，严重病患者则应食用无盐饮食。　　调低好强好胜心：精神情绪经常处于高度紧张状态中，可致神经内分泌功能紊乱，从而大大地增加了高血压发生的危险性，高度精神紧张还可加重高血压及其并发症的病情。因此，要正确地对待生活中一切不如意的事，消除精神情绪的紧张状态，保持轻松自如的良好心态。　　进行适量的锻炼：适宜的运动，能降低和稳定血压，尤其是对早期高血压效果更为明显，运动还可维护和增强心脏功能，提高身体素质和抗病能力。　　省武警总医院&&汤建武　　作者简介　　汤建武&&心内科主任医师，从事心血管病和老年病专业30余年，对冠心病、高血压、高脂血症、心肌病、顽固性心衰、病窦综合征、复杂性心律失常等疾病及老年病有独特的诊疗方法，发表医学论文近40篇，获武警部队科技成果奖两项，获国家发明专利1项，荣立三等功1次。
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主动脉内球囊反搏技术 (1)
官方公共微信左心室辅助装置在高危冠状动脉介入治疗中的应用
张斌, 马墩亮. 左心室辅助装置在高危冠状动脉介入治疗中的应用. 循证医学, ): 326-329ZHANG Bin, MA Dunliang. Left Ventricular Assist for High-Risk Percutaneous Coronary Intervention. Journal of Evidence-Based Medicine,): 326-329&&
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左心室辅助装置在高危冠状动脉介入治疗中的应用
广东省人民医院、广东省医学科学院、广东省心血管病研究所心内科, 广州510080
作者简介:张斌（1965-）,男,江西宜春人,主任医师,医学博士,主要研究方向为冠心病的介入治疗。
左心室辅助装置;
经皮冠状动脉介入治疗
中图分类号:R318.1;R541.405
文献标识码:A
Left Ventricular Assist for High-Risk Percutaneous Coronary Intervention
ZHANG Bin,
MA Dunliang
Authors’ address： Department of Cardiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences,Guangdong Provincial Cardiovascular Institute, Guangzhou 510080, China
Key words:
left ventricular assist;
percutaneous coronary intervention
经皮冠状动脉介入治疗（percutaneous coronary intervention,PCI） 技术越来越成熟,已在越来越多的高危患者中应用。同时,对于无保护的左主干患者、多支病变患者、最后存留血管患者、左心室功能受损者以及持续性缺血症状发作的患者,介入心血管医生通常应用各种经皮辅助装置来降低术中的风险。PCI高危患者的定义也因各临床试验的结果而不断更改。而目前尚无关于左心室辅助装置的明确的临床证据,预防性地置入也未被证明是一项有益的临时措施。本文主要就主动脉内球囊反搏术（intra-aortric balloon pump,IABP）、轴流泵（Impella 2.5）、左心房-股动脉分流术（串联心）及体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）在高危PCI患者中的应用作一述评。1 主动脉内球囊反搏术IABP技术在临床应用已有50年,是目前最多用于冠脉及全身循环支持的设备。IABP置入的部位接近降主动脉部,主要起到的作用包括：提高冠脉血流及血压,提高脑及终末器官的灌注,提高系统灌注压,降低后负荷从而减少肌肉耗氧量、每搏量增高至前负荷降低、心输出量增加对二尖瓣返流及室间隔运动障碍有所改善。打入及抽空氦气的过程使得球囊充气及放气。而球囊充放气时间取决于主动脉压力波形及心电图。IABP有效的原理在于球囊的同步反搏,这是IABP的核心作用机制。在主动脉瓣关闭后球囊即刻充气,而球囊放气刚好在主动脉瓣打开之前。球囊的充气及放气有两方面的作用：舒张期充气使得血液尽量流向主动脉,从而增加冠脉血流;而收缩期放气利用了装置中抽真空的作用,减少主动脉内血液容积,减轻了后负荷。IABP 可迅速使心源性休克患者病情稳定。使心指数得到最大改善,并改善急性心肌梗死并发功能性障碍,如二尖瓣返流或室缺等患者的肺毛细血管楔压[]。IABP并非是一种孤立的治疗心源性休克的方法,必须结合病因治疗,如进行血管重建等。虽然IABP可迅速稳定病情,但在非纤维蛋白溶解的ST段抬高心肌梗死患者中,并不能降低其死亡率。由于目前缺乏随机对照研究以及适应证选择的偏倚,关于纤维蛋白溶解者中降低死亡率的临床证据仍非常有限[,,]。1.1 高危PCI患者部分观察性的研究发现,IABP装置的置入可降低死亡率及PCI术后的主要并发症[,]。球囊反搏辅助的冠脉介入研究（BCIS-1）是唯一提出在高危PCI患者中,术前选择性置入IABP装置可减少不良心脑血管事件的前瞻性、随机临床研究[]。此研究对比了应用预防性置入IABP临时使用（如高危患者的PCI术中突然出现血流动力学不稳定）与不应用的临床获益。高危PCI患者的界定为,存在左心室功能受损（左心室射血分数<30%）及广泛的多支病变,严重左主干狭窄,或目标血管存在侧支循环来代偿另一支闭塞血管,因而供应40%以上的心肌供血。此研究中复合主要终点事件无差异,其包括了死亡、急性心肌梗死、脑血管事件或再次行血管成形术。值得注意的是,12%的患者由于血流动力学不稳定,而临时采取置入IABP的措施。此研究虽然并不主张PCI术前常规预防性置入IABP装置,但此研究中,患者因病情评估而交叉到临时器械辅助组的发生率提示,操作者应做好紧急情况下置入IABP的准备。有临床中心常规在对侧股动脉置入4F鞘管以备紧急需要。1.2 难治性心绞痛各种临床研究报道了IABP反搏术对冠脉血流的不同影响,从无改变到冠脉血流明显增加等[,,,]。其中一项研究直接在应用了IABP反搏的心源性休克及不稳定心绞痛患者中同时测量冠脉血流,结果发现IABP可提高近端冠脉血流速度[]。此外,IABP已被证实对心电图诊断的急性冠脉综合征患者有益[,]。1.3 并发症一项关于17 000名患者的观察研究中,入选年置入IABP装置的病例,发现并发症发生率为2.8%[]。2 轴流泵Impella 2.5Impella 2.5是一种以微创的导管为基础的心脏辅助装置,可通过股总动脉内置13F的鞘管递送,且经过主动脉瓣逆行进入左心室。有一旋转泵最大转速可达51 000 rpm,将左心室血液泵入升主动脉内。此类13F推进装置可使心输出量最多达到5 L/分,减轻心肌负荷并降低耗氧量,增加了冠脉及终末器官的灌注。关于推进器的机理,可应用压力-容量环解释其血流动力学及与IABP的比较。PV曲线经常用于描述一个完整心动周期中心室的血流动力学变化。舒张末期左心室压力及容积减小而排空,压力-容量环消失,左心室做功减少。2.1 高危PCI部分研究报道了在继发于急性心肌梗死后出现心源性休克的患者中应用Impella 2.5的可行性[,,]。ProtectⅡ研究是一项关于评价高危PCI患者应用Impella 2.5与IABP效果对比的随机研究[]。高危PCI的定义为：左主干病变狭窄,左心室射血分数≤35%,或三支病变及左心室射血分数<30%。主要终点事件包括死亡、急性心肌梗死、卒中、二次血管重建术、严重高血压、心肺复苏术或室性心动过速、肢体缺血、主动脉瓣关闭不全加重、急性肾功能衰竭。在第30天及90天时,患者应用Impella 2.5效果与IABP对比差异无统计学意义,而值得注意的是,亚组分析发现,配备Impella 2.5装置的冠脉旋磨术患者,需要行二次血管重建术的几率较低。此外,心脏做功作为反映心脏泵功能的一项指标,可用来评估血流动力学效应。Impella 2.5已被证实可使血流动力学得到明显改善,且此研究证明了Impella 2.5与IABP比较的非劣性。Impella 2.5可应用于需要更多血流动力学支持的患者。ISAR-SHOCK研究比较了26名急性心肌梗死引起的心源性休克患者,应用Impella 2.5效果与IABP的对比[]。主要终点事件为心指数从基线到置入后30分钟的变化。在30分钟时观察,发现Impella 2.5可明显提高心指数。然而,在其他最长至30小时时间段内观察,心指数变化相似。两组30天死亡率相同。此研究结果证明,Impella 2.5对急性心肌梗死引起的心源性休克可起到快速稳定患者病情的作用,但其效果并不能持续。2.2 禁忌证包括主动脉瓣关闭不全,主动脉瓣换瓣术后, 主动脉夹层,严重主动脉或外周血管疾病,左心室或左心房血栓,出血倾向以及败血症。3 串联心串联心是一类主动脉-股动脉旁路系统,其套管系统由21F穿房间隔的插管、15-17F的动脉插管、离心血泵组成。静脉插管由股静脉为入路后经房间隔进入左心房。另一插管由股动脉入路并置于髂动脉内。离心泵可使流体速度达到4.0 L/分,最高速度达7 500 rpm。血流从左心房改道直接入体循环,从而减轻左心室负荷。3.1 高危PCI对于左主干无保护或严重左心室功能受损的高危PCI患者而言,串联心的使用只在部分小型临床研究中有报道,并且证明了其可行性[,,]。然而其临床受益并未被明确阐明。一项随机试验观察了串联心及IABP在急性心肌梗死并发心源性休克的患者中行血管重建术的使用[]。主要终点事件为血流动力学的改善,具体评价指标为置入2小时后的心指数。虽然左心房-股动脉分流组患者的血流动力学参数有所改善,但其发生出血事件及血管相关并发症的比例偏高。至今,与IABP相比,尚无可信服临床证据支持串联心在心源性休克患者中的使用。3.2 禁忌证包括主动脉瓣返流,主动脉夹层,外周血管病变,严重周围血管病变,出血倾向,不可控制的败血症。4 体外膜肺氧合经皮心肺支持技术提供了完整的心肺支持,类似于心外科的体外分流术。而对于新一代的ECMO技术,可使患者得到完全的心脏支持长达几日至数周。静-动脉ECMO包括了静股动脉进入的双孔导管,一条置于主动脉,另一条置于右心房。由静脉导管流出的血液泵入热交换器及氧合器,作用后经动脉导管回到体内动脉系统。ECMO通过人工膜的作用可将二氧化碳去除并在静脉血中加入氧气,从而分流了部分肺循环。ECMO可用于预防或作为高危PCI手术的备用设备。一项23个中心的注册研究中,调查了569名高危PCI患者预防性使用以及备用的经皮穿刺心肺循环支持。389名患者为预防使用组（即PCI手术开始前置入并使用装置）,180名进入备用组（装置已配备,但PCI术前未开启使用）。高危PCI定义为,左心室射血分数<25%,和/或需行血管重建的目标血管供应超过50%的大面积心肌。结果发现,预防组穿刺点并发症及输血事件明显增高,而两组手术成功率并无差异。值得注意的是,在左心室射血分数<20%的患者中,预防性使用组的手术死亡率高于备用组。因此备用经皮心脏辅助仪器可在减少穿刺位点并发症的基础上,提高手术的成功率。在左心室功能极度不良的情况下,预防性使用左心室辅助技术可降低患者死亡率。ECMO使用的禁忌证包括主动脉瓣返流,严重的外周血管疾病, 出血倾向,近期出现卒中或头部外伤史以及不可控制的败血症。5 展 望在行高危PCI的同时,往往伴随着左心室功能衰竭。左心室辅助装置可提供血流动力学的稳定。高危PCI患者术中选用的左心室辅助装置应具备以下优点：首先,装置需易于操作,可快速插入体内;其次,置入装置相关并发症的发生率低,在辅助装置开启过程中,应有效减少高危PCI术中相关并发症;最后,对于所有类型的冠脉血管损伤的PCI手术均具有效的辅助作用。ECMO及其导管的实用性虽已被证实,但其在高危PCI中的应用证据仍然不足。在IABP与Impella的选择上,目前无论大型临床研究或单中心试验,均支持Impella的优越性。其功能与患者自身左心室功能损伤程度无关,因此在循环障碍发生时,可保证心输出量及大脑灌注。与Impella相比,由于IABP将心律的稳定性考虑在内,并得以更加优化左心室功能,故是一种较为稳定的左心室辅助仪器。我们建议,首先,谨慎评估冠脉解剖并正确预测术中可能出现的困难。严重的钙化病变、分叉病变可能需要血管旋磨术及多种支架的准备。循环系统的支持措施对此类手术尤为重要。其次,评估左心室功能,左心室射血分数小于35%者,和/或重度二尖瓣返流者,则考虑轴流推进泵装置辅助,以使心输出量增加。此外,评估是否有周围血管狭窄、钙化、迂曲,以便在需要时行周围血管重建术。若条件允许,对侧放置股动脉鞘管,以便依病情变化需要临时置入辅助装置。对于IABP或Impella的选择方面,在于目的是需要控制缺血（IABP）还是增加心输出量（Impella）。最后,术后正确并快速移除辅助装置才使得整个应用过程完整。一般推荐采用穿刺口缝合的办法以达到最佳止血效果。总之,左心室辅助装置在高危PCI患者中的应用越来越多,其临床证据有待更多多中心临床研究支持,且对心肌重塑影响的病理及病理生理学证据尚不足。操作快捷、并发症发生率低已成为评价高危PCI手术选用左心室辅助装置的两大必要条件。
The authors have declared that no competing interests exist.
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... 使心指数得到最大改善,并改善急性心肌梗死并发功能性障碍,如二尖瓣返流或室缺等患者的肺毛细血管楔压[1] ...
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Anderson RD, Ohman EM, Holmes DR Jr, et al.
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... 球囊反搏辅助的冠脉介入研究（BCIS-1）是唯一提出在高危PCI患者中,术前选择性置入IABP装置可减少不良心脑血管事件的前瞻性、随机临床研究[7] ...
Port SC, Patel S, Schmidt DH.
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Kern MJ, Aguirre FV, Tatineni S, et al.
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... 其中一项研究直接在应用了IABP反搏的心源性休克及不稳定心绞痛患者中同时测量冠脉血流,结果发现IABP可提高近端冠脉血流速度[11] ...
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surgery[J].
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... 8%[14] ...
Dixon SR, Henriques JPS, Mauri L, et al.
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... 5与IABP效果对比的随机研究[18] ...
Seyfarth M, Sibbing D, Bauer I, et al.
A rand omized clinical trial to evaluate the safety and
efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction[J].
ObjectivesThe aim of this study was to test whether the left ventricular assist device (LVAD) Impella LP2.5 (Abiomed Europe GmbH, Aachen, Germany) provides superior hemodynamic support compared with the intra-aortic balloon pump (IABP).BackgroundCardiogenic shock caused by left ventricular failure is associated with high mortality in patients with acute myocardial infarction (AMI). An LVAD may help to bridge patients to recovery from left ventricular failure.MethodsIn a prospective, randomized study, 26 patients with cardiogenic shock were studied. The primary end point was the change of the cardiac index (CI) from baseline to 30 min after implantation. Secondary end points included lactic acidosis, hemolysis, and mortality after 30 days.ResultsIn 25 patients the allocated device (n = 13 IABP, n = 12 Impella LP2.5) could be safely placed. One patient died before implantation. The CI after 30 min of support was significantly increased in patients with the Impella LP2.5 compared with patients with IABP (Impella: ΔCI = 0.49 & 0.46 l/min/m2; IABP: ΔCI = 0.11 & 0.31 l/min/m2; p = 0.02). Overall 30-day mortality was 46% in both groups.ConclusionsIn patients presenting with cardiogenic shock caused by AMI, the use of a percutaneously placed LVAD (Impella LP 2.5) is feasible and safe, and provides superior hemodynamic support compared with standard treatment using an intra-aortic balloon pump. (Efficacy Study of LV Assist Device to Treat Patients With Cardiogenic Shock [ISAR-SHOCK]; )
... 5效果与IABP的对比[19] ...
Aragon J, Lee MS, Kar S, et al.
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Cardiovascular Intervention Center, Division of Cardiology, Cedars-Sinai Medical Center, University of California, Los Angeles School of Medicine, Los Angeles, California&br/&&sup&*&/sup&Cardiovascular Intervention Center, Cedars-Sinai Medical Center, 8631 W. Third Street, Room 415E, Los Angeles, CA 90048
>Patients undergoing percutaneous coronary intervention (PCI) with severely compromised left ventricular systolic function and complex coronary lesions, including multivessel disease, left main disease, or bypass graft disease, are at higher risk of adverse outcomes from hemodynamic collapse. The TandemHeart percutaneous ventricular assist device may provide circulatory support during high-risk PCI. We implanted the TandemHeart device in eight patients who underwent high-risk PCI. The patients were considered to be at exceptionally high risk for decompensation due to procedural complexity combined with underlying LV dysfunction. The mean ejection fraction was 30% & 9% and five patients were turned down for surgical revascularization. Seven patients underwent multivessel PCI, including three patients who underwent unprotected left main coronary artery PCI. There was 100% procedural success. The TandemHeart was removed immediately post-PCI with no groin complications. Six patients are event- and symptom-free at 189 & 130 one patient died 10 days post-PCI after lower extremity bypass surgery and another developed acute renal failure postprocedure, requiring hemodialysis. Our initial clinical experience with the TandemHeart ventricular assist device demonstrates that hemodynamic support can be rapidly achieved percutaneously during high-risk PCI, with excellent procedural success in highly complex and critically ill patients. & 2005 Wiley-Liss, Inc.
... 一项随机试验观察了串联心及IABP在急性心肌梗死并发心源性休克的患者中行血管重建术的使用[23] ...
左心室辅助装置在高危冠状动脉介入治疗中的应用
[张斌, 马墩亮]}