左心輔助裝置的植入及其適應(yīng)癥孫寒松-課件幻燈（中英文）

左心輔助裝置的植入及其適應(yīng)癥孫寒松中國(guó)醫(yī)學(xué)科學(xué)院阜外心血管病醫(yī)院

中國(guó)協(xié)和醫(yī)科大學(xué) 阜外心血管病研究所心衰的流行病學(xué)人群流行病學(xué)研究顯示：中國(guó)共有447萬(wàn)心衰患者北京市有5萬(wàn)多心衰患者北京市心衰患者死亡率與惡性腫瘤死亡率相近心衰治療藥物治療：

?受體阻滯劑ACEI類藥物ARB類藥物藥物治療的效果有限，并沒(méi)有預(yù)想的好。心衰治療外科治療心臟移植搭橋，二尖瓣成型細(xì)胞移植心室成形機(jī)械輔助裝置臨床資料從2003年11月至今：共完成左心輔助裝置植入17例平均年齡：56.8±8.9y(39-68y)平均體重：72.3±12.6Kg(55–110Kg)臨床資料安裝時(shí)機(jī)：重癥患者選擇性安裝12例急癥搶救性安裝5例

臨床資料患者分組：心臟術(shù)后15例慢性進(jìn)行性心衰2例左室輔助裝置應(yīng)用類型

Medos

4例AB5000

1例BVS500012例插管方法1、引流管右上肺靜脈灌注管升主動(dòng)脈優(yōu)點(diǎn)：病人可活動(dòng)，適合長(zhǎng)期輔助10例2、引流管右上肺靜脈灌注管左股動(dòng)脈優(yōu)點(diǎn)：可以床旁撤管，短期輔助7例〔全為BVS〕·牛頸靜脈植入技術(shù)改進(jìn)植入技術(shù)改進(jìn)〔BVS5000〕：灌注管：股動(dòng)脈引流管：左房〔牛頸靜脈〕優(yōu)點(diǎn)：1.可床旁撤管；2.可防止出血〔可防止再次開(kāi)胸，劍突下小切口，管理容易〕缺點(diǎn)：病人活動(dòng)受限適用于恢復(fù)過(guò)渡時(shí)的短期應(yīng)用結(jié)果支持時(shí)間：9.6±10.7d(0.5d–43d)恢復(fù)過(guò)渡應(yīng)用15例成功脫機(jī)：70.5%出院：58.8%結(jié)果移植過(guò)渡2例1例移植成功，MEDOSLVAD支持26天1例在等待移植過(guò)程中死亡，BVS5000LVAD支持43天結(jié)果主要并發(fā)癥；腦栓塞出血感染多器官功能衰竭比較

LVADsECMO

植入技術(shù)復(fù)雜簡(jiǎn)單胸液少多輔助時(shí)間長(zhǎng)短心或肺輔助心兩者都有費(fèi)用多少管理簡(jiǎn)單復(fù)雜

小結(jié)適應(yīng)癥急診應(yīng)用：心衰失代償患者有猝死可能右室功能惡化心指數(shù)CI＜2L/min/㎡選擇性應(yīng)用不能脫離正性肌力藥物，LVEF<25%不適合心臟移植不能脫離體外循環(huán)機(jī)小結(jié)植入時(shí)機(jī)心臟術(shù)后長(zhǎng)時(shí)間的體外循環(huán)(超過(guò)一小時(shí))會(huì)降低生存率

進(jìn)行性心衰病情穩(wěn)定終末器官功能無(wú)明顯異常小結(jié)植入裝置的選擇和植入方法1.心臟術(shù)后連續(xù)支持至少48小時(shí)2慢性進(jìn)行性心衰中期或中長(zhǎng)期支持裝置，允許病人活動(dòng)國(guó)家藥監(jiān)局批準(zhǔn)原那么：有效，平安，廉價(jià)，簡(jiǎn)單小結(jié)最重要的預(yù)后決定因素：

置入時(shí)間

患者選擇恰當(dāng)選擇恰當(dāng)?shù)难b置和置入方式謝謝!IndicationandImplantationofLVAD

SUNHANSONG

DepartmentofCardiovascularSurgery,FuWaiHospital,PUMC&CAMSBeijing,ChinaEpidemiologyofHFPopulationbasedstudieshaveshown:InChina4.47millionHFpatientsInBeijingover50thousands

ThemortalityofHFinBeijingassameasthatofmalignanttumorTherapiesMedicinetreatment:?–blockerACEIARBTheresultsarenotsogoodasexpectedSurgicaltreatmentHearttransplantationCABGMVPCelltransplantationVentriculo--plastyMCSTherapiesClinicalData(1)11,2003.~LVADs:17casesMeanage：56.8±8.9y(39-68y)Meanweight:72.3±12.6Kg(55– 110Kg)ClinicalData(2)

FuWaihospitalTimingselection

Implantedinanelectivesetting: 12casesImplantedinurgentscenario: 5cases

ClinicalData(3)PatientselectionPostcardiotomy:15casesChronicprogressiveheartfailure:2cases

TypesofLVADs

Medos

4casesAB5000

1caseBVS5000

12casesMethodsofcannulation2、OutletcannulaRightsuperiorpulmonaryveinInletlcannulaFemoralartery Advantage：de-cannulabedside,7cases(allBVS).1.OutletcannulaRightsuperiorpulmonaryveinInletcannulaAscendingaorta

Advantage:Allowpatientmobility,10cases.

ImplantTechniqueModificationModification:(forBVS5000)Inletcannula:Femoralartery

Outletcannula:Bovinejugularveinleftatrial

Advantage:1.Bedsidedecannulation,2.Preventionbleeding

Disadvantage:Limitpatientmobility

Suitable:

Short-termassistforbridgetorecoveryAvoidre–sternotomySmallincisionbelowxiphoidEasymanagement·BovinejugularveinDe-airORICUextubationOutcome(1)SupportDuration:9.6±10.7d(0.5d–43d)Bridgetorecovery:15caseSuccessfulweanrate:70.5%Successfuldischargerate:58.8%

Outcome(2)

Bridgetotransplant:2cases 1patientsgotsuccessfullytransplantation

supportedbyMEDOSLVAD(26d)

1patientwaslostwhilewaitingfordonorheart

supportedbyBVS5000LVAD(43d)

Outcome(3)

Majorcomplications:CerebralembolismBleedingInfectionMOF

Comparison

LVADsECMOImplanttechniquecomplexsimpleChestdrainagelessmoreAssistdurationlongshortHeartorlungassistheartbothCostmorelessManagementsimplecomplex

Conclusion(1)

IndicationUrgentDecompensatedhearfailureRiskforsuddendeathDeteriorationinRVfunctionCI＜2L/min/㎡ElectiveInabilitytoweanfrominotropes,LVEF25%NotatransplantcandidateInabilitytoweanfromCPBConclusion(2)TimingofImplantPostcardiotomyProl