急性心肌梗死合并心源性休克的處理課件

1、AMI合并心源性休克的診斷及治療Cardiogenic Shock 由于心臟泵血功能?chē)?yán)重受損，不能維持最低限度心輸出量，導(dǎo)致血壓下降，重要臟器和組織供血不足，引起全身性微循環(huán)功能障礙，從而出現(xiàn)一系列缺血、缺氧、代謝障礙及重要臟器損害為特征的病理生理過(guò)程，是心泵衰竭的最嚴(yán)重的表現(xiàn)形式病因急性心肌梗死大面積心梗小面積心梗但既往心功能不全梗死延展機(jī)械并發(fā)癥急性二尖瓣關(guān)閉不全游離壁破裂室間隔穿孔急性失代償性心衰流出道梗阻心包填塞心臟驟停后頓抑SIRS時(shí)的心肌抑制心臟挫傷左心泵衰竭是AMI合并CS最常見(jiàn)的原因Adapted From Sanborn T. et al, JACC. 2000泵衰竭74.5

2、%急性二尖瓣返流8.3%室間隔穿孔4.6%孤立性右室心梗3.4%心臟破裂1.7%其他7.5%心源性休克是急性心肌梗死直接PCI后早期死亡的最主要原因宋雷、楊躍進(jìn)等，中華心血管病雜志，2012年，40（7），554-58心源性休克的發(fā)生率-NRMI注冊(cè)研究293,633例STEMI患者775家美國(guó)中心心源性休克25311例，8.6%發(fā)生率7-10%，且每年變化不大CAMI 2013年統(tǒng)計(jì)：心源性休克發(fā)生率 4.2%Babaev et al JAMA 2005 294：448預(yù)后很差：30天死亡率高USIK 1995, USIC 2000, FAST-MI France National Regi

3、stry 2005Aissaoui et al. Eur Heart J 2012; 33:25352543Sandhu A, McCoy l, Negi S, et al. Use of Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention; Insights from the National Cardiovascular Data Registry. Circulation, 2015;132:1243-1251 Acute Cardiac Assist Repor

4、t, Health Research International August 2015Jeger, et al. Ann Intern Med. 2008N = 23,696US AMI/CGS cases per year1,2死亡率下降趨勢(shì)不明顯AMI合并心源性休克血運(yùn)重建比例及住院死亡率Mayo Clin Proc Innov Qual Outcomes. 2017 Jun 8;1(1):26-36.NRMI注冊(cè)數(shù)據(jù)Goldberg et al. NEJM 1999; Hochman et al. NEJM 1999; Sjauw, Henriques et al. NHJ 2012Z

5、eymer et al. Eurointervention 2011; Thiele NEJM 2012Primary PCI IABPThrombolysispre-ThrombolysisAMC1997-2005AMC1999SHOCK TrialEuro Heart Survey2005-2008IABP-SHOCK 22009-2012心源性休克死亡率在介入時(shí)代有所下降心源性休克的死亡率中國(guó)急性心肌梗死注冊(cè)研究（CAMI）2013年統(tǒng)計(jì)：心源性休克患者住院死亡率36.4%（227/623）是否存在心臟驟停與預(yù)后相關(guān)Cardiogenic Shock (+)Cardiogenic Sho

6、ck ()Cardiac Arrest(+)184 PatientsIn-hospital Mortality: 47.3%1 Year Mortality: 51.6%317 PatientsIn-hospital Mortality: 20.2%1 Year Mortality: 22.7%Cardiac Arrest()259 PatientsIn-hospital Mortality: 25.1%1 Year Mortality: 33.6%4157 PatientsIn-hospital Mortality: 1.7%1 Year Mortality: 5.5%心源性休克死亡預(yù)測(cè)因素

7、高齡女性L(fǎng)VEF35%慢性腎功能不全初始、最終TIMI血流1級(jí)收縮壓低 糖尿病曾有心梗史PCI延誤時(shí)間長(zhǎng)前降支完全閉塞二尖瓣返流多支血管病變心梗部位與休克的關(guān)系InferiorAnteriorPosteriorMultipleLocations55%46%21%50%Hochman Circ 1995; 91:873-81SHOCK Trial and Registry (N=1160)不同梗死相關(guān)血管所致休克距發(fā)作時(shí)間休克平均在心梗癥狀發(fā)作后6.2小時(shí)出現(xiàn)Webb JACC 2000; 36:1084 病生理機(jī)制臨床表現(xiàn)與診斷標(biāo)準(zhǔn)低血壓血壓正常者SBP80mmHg高血壓者SBP 1400 d

8、yn.s.cm-5排除其他原因所致血壓下降心律失常容量不足劇烈疼痛心肌抑制藥過(guò)敏感染出血性休克 Forrester JS et al 1976; 295:1404-13Hollenberg Ann Int Med 1999; 131:47-99臨床試驗(yàn)中的診斷標(biāo)準(zhǔn)關(guān)鍵血流動(dòng)力學(xué)指標(biāo)的意義CI (心臟指數(shù)）：反映每分鐘心臟搏血的供需關(guān)系，正常值約 3-7 L/(min.m2)PCWP (肺毛細(xì)血管楔壓）：肺毛細(xì)血管內(nèi)的壓力，通常近似于左房壓，是反映左心前負(fù)荷的重要指標(biāo)。正常值：0.801.60kPa (612mmHg)SVRI (全身血管阻力指數(shù)): 反映左心室后負(fù)荷大小根據(jù)血容量狀態(tài)和外周循環(huán)

9、將心源性休克分為四種類(lèi)型，其中2/3的心梗所致心源性休克是濕冷型濕冷暖干不同類(lèi)型心源性休克特點(diǎn)濕冷型最常見(jiàn)，約占AMI相關(guān)心源性休克的 2/3干冷型在對(duì)利尿劑尚有反應(yīng)的慢性心衰失代償期常見(jiàn)，但 28% AMI相關(guān)心源性休克也表現(xiàn)為干冷型。通常 PCWP 較低，無(wú)心梗史或慢性腎臟疾病史暖濕型可見(jiàn)于心肌梗死后全身炎癥反應(yīng)綜合征和血管舒張反應(yīng)后，體循環(huán)阻力較低，膿毒血癥和死亡的風(fēng)險(xiǎn)高血壓正常型心源性休克盡管 SBP 90 mmHg，但外周灌注不足，體循環(huán)血管阻力顯著升高右心室梗死型休克(5.3%)，特點(diǎn)是中心靜脈壓高心源性休克分期的專(zhuān)家共識(shí)SCAI/HFSAStage A: At riskA pat

10、ient ot currently experiencing signs or symptoms of CS but is at risk for its development.These patients may include those with NSTEMI, STEMI, acute or acute on chronic CHFPhysical ExamBiochem MarkersHemodynamics“Not Sick”Normal LabsNormotensiveNormal JVPNormal renal functionSBP 100 or normal for pt

11、Clear LungsNormal lactic acidIf Swan inWarm/ Well PerfusedCI 2.5Strong distal pulsesCVP 10Normal mentationPA Sat 65Stage B: Beginning CSA patient who has clinical evidence of relative hypotension or tachycardia Without hypoperfusionPhysical ExamBioxchem MarkersHemodynamics“Not Sick”Elevated BNPSBP 9

12、0 OR MAP30 mm drop from baselineElevated JVPMinimal renal dysfunctionPulse 100Normal Resp rateRales in Lung fieldsNormal lactic acidIf Swan inWarm/ Well PerfusedCI 2.2Strong distal pulsesCVP 10Normal mentationPA Sat 65Stage C: Classic cSA patient with hypoperfusion that requires interventions such a

13、s inotrope, pressor or perc. MCS other than ECMO to restore perfusionThese patients typically have relative hypotensionPhysical ExamMay Include any of:Bioxchem Markers: May Include any ofHemodynamics: May Include any of“Sick”, Looks unwell, panickedLactate 2SBP90 or MAP 30 mm drop from baseline AND

14、drugs/ device used to maintain BP above theseAshen, mottled, duskyCreatinine doubling or 50 % loss of GFRCI 1.8 or 2.2 on supportExtensive ralesIncreased LFTsPCW 15BiPAP or mechanical ventIncreased BNPRA / CVP 0.8Cold, clammyPAPI 1.85Acute alteration of mental statusCPI 0.6Stage D: Doom / Deteriorat

15、ingPatients similar to C but are getting worseThey have failure to respond to initial interventionsPhysical ExamMay Include any of:Bioxchem Markers: May Include any ofHemodynamics: May Include any of“Sick”, Looks unwell, panickedLactate 2SBP90 or MAP 30 mm drop from baselineAshen, mottled, duskyCrea

16、tinine doubling or 50 % loss of GFRCI 1.8 or 2.2 on supportExtensive ralesIncreased LFTsPCW 60 mmHgPCWP 2.2 L/min/m2 改善組織灌注Hgb 100 g/LSaO2 92%乳酸2.2 mmol/L保證尿量糾正器官功能不全改善肝腎功能指標(biāo)糾正腦病一般治療體位、體溫管理鎮(zhèn)靜止痛，呼吸支持容量管理常規(guī)監(jiān)護(hù)：心電、呼吸、血壓、CVP、SaO2、體溫等特殊監(jiān)測(cè)：漂浮導(dǎo)管、SvO2、CO2、乳酸、心臟超聲、床旁胸片心源性休克患者的監(jiān)護(hù)心源性休克患者的監(jiān)護(hù)肺動(dòng)脈漂浮導(dǎo)管血流動(dòng)力學(xué)監(jiān)測(cè)RARVPAP

17、CWP血流動(dòng)力學(xué)監(jiān)測(cè)顯著改善心源性休克患者預(yù)后ONeill WW, et al. Presented at ACC 2017Sotomi Y, et al. Int J Cardiol 2014;172:165172.p 100mmHg硝酸甘油 10-20 ug/min收縮壓70-100mmHg 無(wú)休克表現(xiàn)多巴酚丁胺 2-20 ug/kg/min收縮壓 70-100mmHg 伴休克表現(xiàn)多巴胺5-15 ug/kg/min收縮壓 70mmHg 伴休克表現(xiàn)去甲腎上腺素 1-30 ug/kg/minAntman, JACC, 2004;44:671Steg et al. Eur Heart J. 20

18、12;33:2569-2619可改善血流動(dòng)力學(xué)指標(biāo)，但不提高生存率臨床可合用血管擴(kuò)張劑IIaCCBIIaIIb血壓偏低時(shí)首選常用血管活性藥物作用及機(jī)制不同類(lèi)型CS，建議應(yīng)用不同藥物不同類(lèi)型CS，建議應(yīng)用不同藥物Three HighDose2%3%7.5%21%42%80%No InotropeLowDoseModerateDoseOne HighDoseTwo HighDosePre-ShockProfound ShockShockNo HemodynamicSupportNeeds Partial Hemodynamic SupportNeeds Full Hemodynamic Suppo

19、rtMortality Risk with Inotrope DosingAdapted from Samuels LE et al, J Card Surg. 1999 Jul-Aug;14(4):288-93藥物治療效果并不滿(mǎn)意Adapted from Samuels LE et al, J Card Surg. 1999;14(4):288-93血運(yùn)重建顯著改善CS患者Hochman et al NEJM 1999;341:625SHOCK研究SHOCK研究 (N=302)Randomization from Apr 1993 - Nov 1998急診早期血運(yùn)重建（n=152）藥物治療（

20、n=150）隨機(jī)后6小時(shí)內(nèi)PCI或CABG所有患者均建議應(yīng)用IABPIABP溶栓治療如果情況適合，隨機(jī)54小時(shí)后的延遲血運(yùn)重建主要終點(diǎn)：30天死亡率次要終點(diǎn)：6個(gè)月和1年死亡率Hochman et al. NEJM 1999;341:625SHOCK研究入選標(biāo)準(zhǔn)排除標(biāo)準(zhǔn)STEMI或新發(fā)LBBB合并心源性休克低血壓 收縮壓小于90mmg持續(xù)30分鐘或需要藥物維持血壓于90mmHg以上組織低灌注血流動(dòng)力學(xué)指標(biāo)心臟指數(shù)2.2L/min/m2PCWP15mmHg休克發(fā)作時(shí)間 0.53W = 71% survival Optimizing SupportCardiac Power Output=MAPx

21、CO451Increase vasopressor dose?Add vasopressor?Rhythm (Afib)?Adequate preload?RV function?PAPI = (PAs Pad)/RAUpgrade support?5.0 ImpellaECMOPredictors of Survival at 12-24 hours (N=75)LACTATECARDIAC POWER OUTPUT 0.644 0.663% Survival(n=5/8)30% Survival(n=3/10)80% Survival(n=8/10)96% Survival(n=45/47

22、)指南推薦的再灌注治療策略如無(wú)禁忌癥，對(duì)不適于PCI或CABG治療的STEMI合并心源性休克患者進(jìn)行靜脈溶栓對(duì)STEMI后泵功能衰竭導(dǎo)致的心源性休克患者采用PCI或CABG進(jìn)行急診血運(yùn)重建治療，不考慮距心梗發(fā)作的時(shí)間OGara PT, et al. Circulation 2013Steg et al. Eur Heart J. 2012;33:2569-2619 AMI合并CS溶栓治療再灌注成功率低主要用于無(wú)法介入/手術(shù)治療或有相關(guān)禁忌患者單純血流動(dòng)力學(xué)或代謝因素等不是溶栓禁忌首選方法，可有效降低近期及遠(yuǎn)期死亡率療效優(yōu)于溶栓治療多支病變者，對(duì)非梗死相關(guān)動(dòng)脈血運(yùn)重建可能改善預(yù)后合并嚴(yán)重多器官衰

23、竭者，PCI可能無(wú)效 AMI合并CS直接PCI% Patients with MV-CADAMI合并CS患者大多為多支病變多支病變血運(yùn)重建策略的選擇Cardiogenic shock?Culprit LesionOnlyCulprit lesiononly + Staged Revasc.ImmediateMV-PCICABG與僅處理罪犯病變相比，完全血運(yùn)重建長(zhǎng)期獲益更大DANAMI-3/PRIMULTI研究1Engstrm et al, Lancet 2015; 386: 66571Gerschlick et al. J Am Coll Cardiol 2015;65:96372CvLPRI

24、T研究2死亡/非致死MI/IRA血運(yùn)重建事件率（%）隨訪(fǎng)時(shí)間（月）隨機(jī)、開(kāi)放研究，入選627例除梗死相關(guān)動(dòng)脈外存在1個(gè)有臨床意義的冠脈狹窄的STEMI患者，在梗死相關(guān)動(dòng)脈成功完成PCI后，患者在出院前隨機(jī)接受或不接受完全血運(yùn)重建。隨訪(fǎng)1年，主要終點(diǎn)：全因死亡、非致死性再梗、缺血驅(qū)動(dòng)的非梗死相關(guān)動(dòng)脈的血運(yùn)重建。完全血運(yùn)重建：13%僅處理梗死相關(guān)動(dòng)脈：22%44%P=0.004HR 056 (038083) 主要不良心臟事件率（%）隨訪(fǎng)時(shí)間（月）完全血運(yùn)重建：10%55%P=0.009HR 045 (024084) 僅處理梗死相關(guān)動(dòng)脈：21.2%入選296例直接PCI患者，隨機(jī)給予完全血運(yùn)重建或僅

25、梗死相關(guān)動(dòng)脈血運(yùn)重建，隨訪(fǎng)12個(gè)月。主要終點(diǎn)：主要不良心臟事件，定義為全因死亡、再發(fā)心梗、心衰和缺血驅(qū)動(dòng)的血運(yùn)重建。出院前完全同期完全Kurt Huber Gilles MontalescotJan PiekHolger ThielePranas SerpytisJanina StepinskaChristiaan VrintsMarko NocKeith OldroydStefan WindeckerStefano SavonittoThiele et al. Am Heart J. 2016;172:160-169CULPRIT-SHOCK TrialInvestigator-initia

26、ted European multicenter trial; 1:1 randomizationCULPRIT-SHOCK 研究流程1075 patients with acute myocardial infarction (STEMI and NSTEMI) and cardiogenic shock screened 369 excluded706 randomized355 randomized to immediate multivessel PCI342 full informed consent344 full informed consent351 randomized to

27、 culprit lesion only PCI301 culprit lesion only PCI43 immediate multivessel PCI60 staged PCI1 staged CABG13 urgent PCI344 primary endpoint analysis341 primary endpoint analysis344 full informed consent351 randomized to culprit lesion only PCI301 culprit lesion only PCI43 immediate multivessel PCI60

28、staged PCI1 staged CABG13 urgent PCI344 full informed consent351 randomized to culprit lesion only PCI301 culprit lesion only PCI43 immediate multivessel PCI60 staged PCI1 staged CABG13 urgent PCI344 full informed consent351 randomized to culprit lesion only PCI344 primary endpoint analysis301 culpr

29、it lesion only PCI43 immediate multivessel PCI60 staged PCI1 staged CABG13 urgent PCI344 full informed consent351 randomized to culprit lesion only PCI310 immediate multivessel PCI32 culprit lesion only PCI 8 staged PCI 0 staged CABG 5 urgent PCI 341 with 30-day follow-up1 lost to follow-up341 prima

30、ry endpoint analysis344 primary endpoint analysis344 with 30-day follow-up301 culprit lesion only PCI43 immediate multivessel PCI60 staged PCI1 staged CABG13 urgent PCI344 full informed consent351 randomized to culprit lesion only PCIAllocationInformed consentRevascularizationFollow-upPrimary endpoi

31、nt analysisCULPRIT-SHOCK研究設(shè)計(jì)AMI合并心源性休克706例先處理罪犯血管分次血運(yùn)重建351例納入和排除知情同意隨機(jī)直接完全血運(yùn)重建355例主要終點(diǎn)：30天死亡和/或嚴(yán)重腎功能衰竭Am Heart J 2016;172:160-9. CULPRIT-SHOCK Trial 30-Day ResultsThiele et al. NEJM 2017; 377:2419-2432All-cause mortality 30 daysPrimary study endpoint 30 daysAll-cause mortality or renal replacement t

32、herapyBaseline VariableMultivessel PCICulprit lesion only PCIRelative Risk (95% CI)P Value for InteractionSexMale148/266 (55.6)109/257 (42.4)0.76 (0.64-0.91)0.11Female 41/75 (54.7) 48/86 (55.8)1.02 (0.77-1.35)Age75 years 72/99 (72.7) 70/115 (60.1)0.84 (0.69-1.01)DiabetesNo 116/218 (53.2) 93/235 (39.

33、6)0.74 (0.61-0.91)0.08Yes 66/116 (56.9) 59/102 (57.8)1.02 (0.81-1.28)HypertensionNo 68/129 (52.7) 65/139 (46.8)0.89 (0.70-1.13)0.47Yes114/205 (55.6) 88/200 (44.0)0.79 (0.65-0.97)Type of infarctionNSTEMI 54/97 (55.7) 45/98 (45.9)0.82 (0.62-1.09)0.96STEMI128/233 (54.9)108/237 (45.6)0.83 (0.69-0.99)STE

34、MI typeAnterior infarction 59/113 (52.2) 57/108 (52.8)1.01 (0.79-1.30)0.07Non-anterior infarction 48/92 (52.2) 34/97 (35.0)0.67 (0.48-0.94)Previous infarctionNo 154/281 (54.8)128/279 (45.9)0.84 (0.71-0.99)0.83Yes 28/53 (52.8) 25/60 (41.7)0.79 (0.53-1.17)Coronary artery disease2-vessel disease 64/124

35、 (51.6) 48/122 (39.3)0.76 (0.58-1.01)0.563-vessel disease124/215 (57.7)109/218 (50.0)0.87 (0.73-1.03)Chronic total occlusionNo 146/259 (56.4)131/267 (49.1)0.87 (0.74-1.02)0.26Yes 43/82 (52.4) 27/77 (35.1)0.67 (0.46-0.97)Culprit lesion only PCI betterMultivessel PCI better亞組分析多支病變合并心源性休克患者完全血運(yùn)重建策略的指南

36、推薦European and American Recommendations 2017IIIaIIbIIIIIIIIIIIICESCACC/AHA/SCAINo recommendationGuidelinesAppropriate Use CriteriaACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STSA (9)Ibanez et al. Eur Heart J 2018;39:119-177Levine et al. J Am Coll Cardiol 2016;67:1235-1250Patel et al. J Am Coll Cardiol 2017;69:5

37、70-5912018 ESC 心肌血運(yùn)重建指南更新概覽升級(jí)對(duì)于分叉病變PCI治療，推薦首先主支血管置入支架，對(duì)于分支行PROVISIONAL球囊成形術(shù)，側(cè)支血管根據(jù)情況決定是否置入支架對(duì)于院外心臟驟停，心電圖支持ST段抬高型心肌梗死患者，有條件應(yīng)立即行冠脈造影及血運(yùn)重建術(shù)所有患者需警惕造影劑引發(fā)的腎病推薦使用OCT幫助最優(yōu)化支架置入策略降級(jí)大隱靜脈橋病變患者，行PCI需使用遠(yuǎn)端保護(hù)裝置NSTE-ACS 患者，行PCI使用比伐盧定抗凝STEMI 患者，行PCI使用比伐盧定抗凝SYNTAX評(píng)分23，MVD合并糖尿病患者，推薦行PCI心臟手術(shù)中通過(guò)檢測(cè)血小板功能指導(dǎo)術(shù)前停用抗血小板藥物EuroSCO

38、RE 評(píng)分系統(tǒng)，評(píng)估冠狀動(dòng)脈旁路移植術(shù)（CABG）院內(nèi)死亡率如果考慮左主干或多支血管血運(yùn)重建，推薦使用SYNTAX評(píng)分橈動(dòng)脈是冠狀動(dòng)脈造影和PCI的標(biāo)準(zhǔn)入路方式藥物洗脫支架（DES）適用于任何PCI心肌血運(yùn)重建后需對(duì)患者進(jìn)行系統(tǒng)性的重新評(píng)估對(duì)于已經(jīng)穩(wěn)定的NSTE-ACS患者，推薦按穩(wěn)定性冠心病指南進(jìn)行血運(yùn)重建對(duì)于重度狹窄患者，推薦橈動(dòng)脈而非大隱靜脈作為移植血管對(duì)冠心病合并心衰、LVEF35%的患者行心肌血運(yùn)重建，優(yōu)先考慮冠狀動(dòng)脈旁路移植術(shù)（CABG）PCI 可作為CABG的替代治療當(dāng)考慮選擇CABG還是PCI時(shí)，完全血運(yùn)重建為首要考慮因素非瓣膜性房顫患者進(jìn)行抗凝和抗血小板治療時(shí)，新型口服抗凝藥

39、物（NOAC）優(yōu)于維生素K拮抗劑（VKA）行CABG時(shí)，如行開(kāi)放靜脈獲取術(shù)，注意使用無(wú)接觸血管技術(shù)左主干PCI術(shù)者年P(guān)CI不應(yīng)低于25例對(duì)于中度或重度慢性腎臟?。–KD）患者，如預(yù)估造影劑使用量超過(guò)100mL，術(shù)前術(shù)后需使用等滲鹽水進(jìn)行水化對(duì)于高?；颊撸\(yùn)重建后6個(gè)月需常規(guī)行非入侵性影像檢查進(jìn)行評(píng)估對(duì)于真性左主干分叉病變，DK crush 技術(shù)優(yōu)于Provisional T技術(shù)對(duì)于以往未應(yīng)用P2Y12受體抑制劑的患者，PCI術(shù)中推薦坎格雷洛對(duì)于以往應(yīng)用P2Y12受體抑制劑的ACS患者，PCI術(shù)中推薦GP b/a抑制劑PCI術(shù)后抗凝治療，與抗血小板藥物聯(lián)用時(shí)，達(dá)比加群150mg優(yōu)于110mg可

40、根據(jù)ACS患者血小板功能檢測(cè)結(jié)果進(jìn)行P2Y12受體抑制劑降級(jí)治療對(duì)于心肌梗死心源性休克的患者，不推薦在非罪犯動(dòng)脈行常規(guī)血運(yùn)重建新一代生物可吸收支架不推薦用于臨床試驗(yàn)以外的臨床實(shí)踐2018 ESC/EACTS Guidelines onmyocardial revascularization. European Heart Journal (2018) 00, 1-96. doi:10.1093/eurheartj/ehy394新增推薦推薦變化20142018PCI與CABG比較PCI與CABG生存率相似，但6個(gè)月的再次血運(yùn)重建率高GRACE研究中，PCI對(duì)于無(wú)保護(hù)左主干病變所致的STEMI合并

41、心源性休克患者是更好的選擇當(dāng)左主干為罪犯血管時(shí)，TIMI血流2且血流動(dòng)力學(xué)不穩(wěn)定時(shí)，PCI較CABG實(shí)施的速度更快理想的循環(huán)輔助裝置充分的血流動(dòng)力學(xué)支持足夠的心肌保護(hù)置入簡(jiǎn)單，所需時(shí)間短易于管理并發(fā)癥率低目前臨床應(yīng)用的循環(huán)輔助裝置Thiele et al. Eur Heart J 2015;36:1223-1230Blumenstein et al. EuroIntervention 2016;12:Suppl X.X61-X67主動(dòng)脈內(nèi)球囊反搏（IABP）優(yōu)勢(shì)提高冠脈灌注壓，降低后負(fù)荷及心肌耗氧量，增加心輸出量置入簡(jiǎn)單，管理方便并發(fā)癥相對(duì)較少可支持較長(zhǎng)時(shí)間價(jià)格便宜劣勢(shì)不改善冠脈狹窄遠(yuǎn)端心肌供

42、血單獨(dú)應(yīng)用不改善死亡率支持力度有限IABP-SHOCK II 研究隨機(jī)、前瞻性、開(kāi)放標(biāo)簽、多中心600名STEMI患者隨機(jī)分為 IABP組（301例） 對(duì)照組 （299例）入組患者均接受早期血運(yùn)重建（PCI或CABG）Thiele et al. N Engl J Med 2012;367:1287-96Thiele et al. NEJM 2012;367:1287-96結(jié)論：IABP不能降低死亡率30天時(shí)大出血、外周動(dòng)脈缺血并發(fā)癥、感染和卒中亦無(wú)顯著差異ESC Guidelines 2012-2018Windecker et al. Eur Heart J. 2014;35:2541-261

43、9Roffi et al. Eur Heart J. 2016;37:267-315IABP in cardiogenic shockESCClass IC IIb B III Ponikowski et al. Eur Heart J.2016;37:21292200Ibanez et al. Eur Heart J 2018;39:119-177Neumann et al. Eur Heart J 2018;epubShah et al. Clin Res Cardiol 2018;107:287-303US Registry: 144.254 patients with cardioge

44、nic shockIABP + Other Devices Use IABP-SHOCK II 研究的局限單純死亡作為主要終點(diǎn)效力不足入選休克患者偏輕10%的非IABP組患者cross-over到IABP組大部分患者在PCI術(shù)后才置入IABP否定IABP的作用？No，但應(yīng)該注意患者和時(shí)機(jī)的選擇所有休克患者無(wú)區(qū)別的常規(guī)置入IABP并不推薦雖然研究多為中性結(jié)果，但基于中國(guó)國(guó)情臨床不得不用可使部分患者獲得進(jìn)一步救治機(jī)會(huì)否定IABP的作用？IABP-TIMING in CS102例患者的單中心研究評(píng)價(jià)IABP時(shí)機(jī)對(duì)預(yù)后的影響主要終點(diǎn)：全因死亡率Lessons Learned.Basir M, Schr

45、eiber T, Grines C, et al. Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock. Am. J. of Cardiology, 20164 hrsTandemHeart 股靜脈入路穿刺房間隔從左房引出氧合血，注入股動(dòng)脈與IABP對(duì)照，TandemHeart 組CI顯著增加Holger T. European Heart Journal (2005) 26, 12761283Impella (2.5/5.0)Inflow(ventricle

46、)Outflow(aortic root)aorticvalve Coronary Perfusion Microvascular ResistanceLVEDP and LVEDV O2 DemandUnloading to Myocardial Recovery O2 Supply Mechanical Work Wall Tension Cardiac Power Output FlowEnd Organ Perfusion MAPFincke J, et al. Am Coll Cardiol 2004den Uil CA, et al. Eur Heart J 2010Mendoza

47、 DD, et al. AMJ 2007Torgersen C, et al. Crit Care 2009Torre-Amione G, et al. J Card Fail 2009Suga H. et al. Am J Physiol 1979Suga H, et al. Am J Physiol 1981Burkhoff D. et al. Am J Physiol Heart Circ 2005Burkhoff D. et al. Mechanical Properties Of The Heart And Its Interaction With The Vascular Syst

48、em. (White Paper) 2011Sauren LDC, et al. Artif Organs 2007Meyns B, et al. J Am Coll Cardiol 2003 Remmelink M, et al. atheter.Cardiovasc Interv 2007Aqel RA, et al. J Nucl Cardiol 2009Lam K,. et al. Clin Res Cardiol 2009Reesink KD, et al. Chest 2004Valgimigli M, et al.Catheter Cardiovasc Interv 2005Re

49、mmelink M. et al. Catheter Cardiovasc Interv 2010 Naidu S. et al. Novel Circulation.2011Weber DM, et al. Cardiac Interventions Today Supplement Aug/Sep 2009HCS-PMA-PP00229-017 rHImpella (2.5/5.0)ONeill, et. al. J Interven Cardiol, 2013隨機(jī), 26例Impella 2.5 與 IABP比較Impella組CO和MAP顯著升高Impella組乳酸的濃度明顯減低死亡、下肢缺血和出血兩組無(wú)明顯差異ISAR-SHOCKImpella vs. IABP的隨機(jī)對(duì)照研究Seyfarth et al. J Am Coll Cardiol 2008;52:15848血流動(dòng)力學(xué)改善明顯，但30天死亡率無(wú)顯著差異Change in Cardiac IndexUSpella registry盡早應(yīng)用Impella可以改善預(yù)后Oneill W et al; J Int Car 2013盡早應(yīng)用Impella可以提高住院期間的生存率Support Strategy (N=154)IABP Pre-PCI(N=53)No support