主動(dòng)脈內(nèi)球囊反搏

主動(dòng)脈內(nèi)球囊反搏主動(dòng)脈內(nèi)球囊反搏概念：

主動(dòng)脈內(nèi)球囊反搏（IABP）intra-aorticballooncounterpulsation

心臟輔助裝置IABP為主動(dòng)脈內(nèi)球囊反搏泵的簡(jiǎn)稱，IABP是一種機(jī)械循環(huán)輔助方法，通過(guò)在左鎖骨下動(dòng)脈開(kāi)口遠(yuǎn)端和腎動(dòng)脈開(kāi)口上方的降主動(dòng)脈內(nèi)植入一根帶氣囊的導(dǎo)管，在心臟舒張期氣囊充氣，在心臟收縮前氣囊放氣，達(dá)到輔助心臟功能的作用。IABP可增加冠狀動(dòng)脈血流，改善外周循環(huán)，減少主動(dòng)脈內(nèi)舒張末容量及心臟收縮時(shí)左室后負(fù)荷,減少心肌耗氧，增加心肌收縮力，改善心功能。其有利因素為：左室舒張末壓降低，心肌耗氧量降低，心輸出量增加10%~40%，冠狀動(dòng)脈峰值血流速度增加。IABP適應(yīng)證1.各種原因引起的心臟功能衰竭。（1）急性心肌梗死并發(fā)心源性休克。（2）冠狀動(dòng)脈旁路移植圍術(shù)期發(fā)生的心肌梗死。（3）體外循環(huán)心臟手術(shù)后低心排。（4）心臟挫傷。（5）中毒性休克。（6）病毒性心肌炎。IABP適應(yīng)證2.急性心肌梗死后發(fā)生機(jī)械并發(fā)癥。（1）室間隔穿孔。（2）乳頭肌斷裂致二尖瓣關(guān)閉不全。（3）冠心病合并大室壁瘤。IABP適應(yīng)證3.內(nèi)科治療無(wú)效的不穩(wěn)定型心絞痛。4.心肌缺血而致的心律失常。5.進(jìn)展性心肌梗死。6.嚴(yán)重心肌缺血病人作冠脈造影，PTCA、溶栓。高危重癥病人作心導(dǎo)管檢查。IABP適應(yīng)證7.心臟移植前的輔助治療。8.人工心臟的過(guò)渡治療。9.手術(shù)中產(chǎn)生搏動(dòng)性血流。IABP的禁忌癥主動(dòng)脈瓣關(guān)閉不全。主動(dòng)脈竇瘤破裂。腹部或胸部的主動(dòng)脈瘤或夾層動(dòng)脈瘤。嚴(yán)重動(dòng)脈壁的鈣化或外周血管瘤。不可逆的腦損傷或腦出血。慢性心臟病的晚期。IABP應(yīng)用指征多巴胺用量>15ug/Kg/min,或應(yīng)用兩種升壓藥難以維持血壓。CI<2.0L/min/m2。動(dòng)脈收縮壓<80mmHg。左房壓>20mmHg。CVP>15cmH2O。尿量<0.5mL/Kg/h。末梢循環(huán)差，手足涼。IABP輔助有效的指標(biāo)升壓藥的用量逐漸減少。CO增加。血壓逐漸回升。心率（律）恢復(fù)正常。尿量增加。末梢循環(huán)改善，手足變暖。IABP停用指征多巴胺用量<5ug/Kg/min。CI>2.5L/min/m2。平均動(dòng)脈壓>80mmHg。尿量>1mL/Kg/h。末梢循環(huán)好，手足暖。減慢反搏頻率時(shí)，上述指標(biāo)穩(wěn)定。IABP在心外手術(shù)中的應(yīng)用IABP對(duì)于衰竭的心臟是一種強(qiáng)有力的輔助措施，目前療效優(yōu)于藥物。其輔助原理是心臟舒張期，氣囊迅速充氣，主動(dòng)脈舒張壓升高，冠狀動(dòng)脈流量增加，心肌供氧增加；心臟收縮前，氣囊迅速排氣，主動(dòng)脈壓力下降，心臟后負(fù)荷下降，心臟射血阻力減少，心肌耗氧下降。故IABP雖對(duì)各種心臟病術(shù)后的低心排都有效，但以冠心病效果最好。Evidencefromthismeta-analysissupporttheuseofpreoperativeIABPinhigh-riskpatientstoreducehospitalmortality.JCardSurg2008;23:79-86國(guó)外相關(guān)研究顯示使用IABP可以顯減少CABG術(shù)后病人死亡率，住院天數(shù)，術(shù)后低心排綜合癥以及CBP使用時(shí)間Theuseofthepreoperativeintraaorticballoonpump(IABP)inpatientswithsevereleftventriculardysfunctionorunstableanginawithcriticalcoronaryanatomyisbecomingmorefrequentassurgicalcasemixchanges.TheaimofthisstudywastodeterminetheimpactofpreoperativeIABPuseonsurvivalinhigh-riskpatientshavingopenheartsurgery.AnnThoracSurg.2001Jul;72(1):54-7.groupA(preoperativeIABPforhigh-risknonemergentcases),groupB(preoperativeIABPforemergentcases),andgroupC(intra/postoperativeIABP).highrisk,”onthebasisofpoorleftventricularfunctionorcriticallyischemicheartssuchasleftmainlesionsorreoperativecasesThepredictedversusactualhospitalmortalityratewas20%versus5.7%ingroupA,32.1%versus47.6%ingroupB,and12.6%versus22.2%ingroupCRisk-adjustedmortalitywassignificantlylowerinhigh-riskcaseswithpreoperativeIABPscomparedwithemergentcasesandintraoperative/postoperativeIABPs.WeencouragetheuseofpreoperativeIABPsinselectedhigh-riskpatients.Risk-adjustedmortalitywassignificantlylowerinhigh-riskcaseswithpreoperativeIABPscomparedwithemergentcasesandintraoperative/postoperativeIABPs.WeencouragetheuseofpreoperativeIABPsinselectedhigh-riskpatients.InteractCardiovascThoracSurg.2008May;7(3):389-95.Epub2008Feb6.Intraaorticballoonpumpreplacement(IABP)isthemostwidelyusedcirculatoryassistdevicetodayandisutilizedinawiderangeofseriouscardiovascularconditions.Weexaminedtheeffectsonmortalityofpre-,intra-,orpostoperativeIABPsupportinpatientsundergoingcardiacsurgerycomparedtohigh-riskpatientswithoutIABPsupport.First,themean

EuroSCOREpredictedmortalityandtheactualmortalityrates

donotstatisticallydifferamongpatientswithpreoperative

IABPinsertion.Second,patientswithoutpreoperativeIABPinsertion

haveahigheractualmortalitythanpredicted.Third,theactual

mortalityamongpatientswithintra-andpostoperativeIABP

usealsoprovedtobesignificantlyhigherthanpredictedby

theEuroSCORE.

patientswithoutpreoperativeIABPplacementhadthehighest

overallactualmortalityandnon-emergencypatientsperformed

significantlyworsethanpredicted.Thisfindingadvocatesan

earlypreoperativeIABPinsertiontoreducemortality,atleast

tothepredictedvalue.

Thereisnoacceptedconsensusonthedefinitionofhigh-riskpatientswhomaybenefitfromtheuseofintraaorticballoonpump(IABP)incoronaryarterybypassgrafting(CABG).Theaimofthisstudywastodevelopariskmodeltoidentifyhigh-riskpatientsandpredicttheneedforIABPinsertionduringCABG.AnnThoracSurg.Authormanuscript;availableinPMC2011February1.ResultsofUnivariateAnalysis

Threeriskgroupswereidentified:low-risk(IABPscore0to6),medium-risk(IABPscore7to13),andhigh-riskscore(IABPscore>14).TheincidenceofIABPinsertionandmortalitywere,respectively,0.9%and0.7%inthelow-riskgroup,7.2%and2.8%inthemedium-riskgroup,and36.4%and9.1%inthehigh-riskgroupRelationshipbetweenriskscoreandprobabilityofintraoperativeorpostoperativeintraaorticballoonpump(IABP)insertion.

Specifically,patientsinthehigh-risk(score>14)medium-risk(score7to13),andlow-riskgroup(score<6)had36.4%,10.6%,and1.7%probabilityofIABPinsertion,respectively

high-riskpatientswhomaybenefitfromelectiveinsertionofIABPduringCABGDislocationsoftheheartrequiredforexposureandconstructionofdistalanastomosesoftenproducehemodynamicinstabilitywhenperformingcoronaryarteryrevascularizationwithoutusingcardiopulmonaryperfusion(OPCAB).Wereportourearlyexperiencewithelectiveintraaorticballooncounterpulsation(IABP)toenableandfacilitateselectedhigh-riskpatientstoundergoOPCAB.AnnThoracSurg2001;71:1220-1223ThisstudysoughttheprotectiveeffectofIABPinreducingthesusceptibilityofacuteperioperativestressesonaninjuredheartcausedbydisplacementduringOPCABbysupportinghemodynamicstabilityandreducingitsmyocardialoxygendemand.Thisbenefitisofparticularvalueforheartsthataremorevulnerablebecauseofsevereproximalmultivesselcoronarydisease,ventricularhypertrophy,anddysfunction.webelievethisstrategyinusingIABPselectivelycanallowsurgeonstosafelyextendthebenefitsofOPCABprocedurestohigh-riskpatientsandavoiddangeroushemodynamicinstabilitythatotherwise,oftenoccurs.國(guó)內(nèi)也有報(bào)道，在術(shù)前預(yù)防性的放置IABP對(duì)重癥冠心病患者的預(yù)后有很大改善我們對(duì)安貞醫(yī)院近1年來(lái)重癥冠心病的35位患者進(jìn)行跟蹤調(diào)查，其中18例（51.4%）的患者在術(shù)中或者術(shù)后24小時(shí)內(nèi)行IABP輔助治療，放置IABP患者的心功能均較未放置IABP組的患者有明顯好裝，并且ICU住院時(shí)間和呼吸機(jī)輔助時(shí)間均有所減少。重癥冠心病患者的概念是嚴(yán)重的左主干病變，EF≤35％或術(shù)前有心源性休克的患者以及復(fù)雜冠心病外科治療患者(如一些需處理心梗后機(jī)械并發(fā)癥的手術(shù)患者，包括室壁瘤切除、室間隔穿孔修補(bǔ)、二尖瓣腱索斷裂的瓣膜置換)這些重癥患者的特點(diǎn)是術(shù)前心功能差，心肌收縮功能受損，術(shù)中不耐受搬動(dòng)，術(shù)后可能伴有心臟結(jié)構(gòu)變化及左室容量減少，使這些患者在術(shù)后心臟創(chuàng)傷期都要經(jīng)歷一個(gè)心臟低排的過(guò)程，故術(shù)前應(yīng)用IABP幫助心臟度過(guò)創(chuàng)傷期是十分必要的，可降低術(shù)后低心排的發(fā)生率。IABP并發(fā)癥及意外下肢缺血穿刺部位滲血血小板減少機(jī)器故障球囊破損（囊內(nèi)血栓形成）感染主動(dòng)脈撕裂球囊誤入股靜脈球囊誤入對(duì)側(cè)股動(dòng)脈導(dǎo)絲嵌頓導(dǎo)管置入困難接頭漏氣Theintra-aorticballoonpump(IABP)iswidelyusedtoprovidecirculatorysupportforpatientsexperiencinghemodynamicinstabilityduetomyocardialinfarction,cardiogenicshock,orinveryhighriskpatientsundergoingangioplastyorcoronaryarterybypassgrafting.JournaloftheAmericanCollegeofCardiologyVolume38,Issue5，1November2001,Pages1456-1462Themajorfindingofthisstudyisthattheincidenceofmajorballoon-relatedcomplicationsisencouraginglylow(2.8%).Advancessuchaspercutaneousinsertionandsmaller-diametercathetershaveconsiderablyreducedthe