主動(dòng)脈內(nèi)球囊反搏

1、主動(dòng)脈內(nèi)球囊反搏在心臟外科中的應(yīng)用,北京安貞醫(yī)院來(lái)永強(qiáng),主動(dòng)脈內(nèi)球囊反搏,概念： 主動(dòng)脈內(nèi)球囊反搏（IABP）intra-aortic balloon counterpulsation 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。,

2、,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。

3、（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

4、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。CI20mmHg。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

5、。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

6、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。,,Evidence from this meta-analysis support the use of preoperative IABP in high-risk patients to reduce hospital mortality.,J Card Surg 2008;23:79

7、-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,,The use of the preoperative intraaortic balloon pump (IABP) in patients with severe left ventricular dysfunction or unstable angina with critical coronary anatom

8、y is becoming more frequent as surgical casemix changes. The aim of this study was to determine the impact of preoperative IABP use on survival in high-risk patients having open heart surgery.,Ann Thorac Surg.2001 Jul;72

9、(1):54-7.,,group A (preoperative IABP for high-risk nonemergent cases), group B (preoperative IABP for emergent cases), and group C (intra/postoperative IABP).high risk,” on the basis of poor left ventricular function

10、or critically ischemic hearts such as left main lesions or reoperative cases,,The predicted versus actual hospital mortality rate was 20% versus 5.7% in group A, 32.1% versus 47.6% in group B, and 12.6% versus 22.2% in g

11、roup CRisk-adjusted mortality was significantly lower in high-risk cases with preoperative IABPs compared with emergent cases and intraoperative/postoperative IABPs. We encourage the use of preoperative IABPs in selecte

12、d high-risk patients.,,Risk-adjusted mortality was significantly lower in high-risk cases with preoperative IABPs compared with emergent cases and intraoperative/postoperative IABPs. We encourage the use of preoperative

13、IABPs in selected high-risk patients.,,Interact Cardiovasc Thorac Surg.2008 May;7(3):389-95. Epub 2008 Feb 6.,Intraaortic balloon pump replacement (IABP) is the most widely used circulatory assist device today and is uti

14、lized in a wide range of serious cardiovascular conditions. We examined the effects on mortality of pre-, intra-, or postoperative IABP support in patients undergoing cardiac surgery compared to high-risk patients withou

15、t IABP support.,,,First, the mean EuroSCORE predicted mortality and the actual mortality rates do not statistically differ among patients with preoperative IABP insertion. Second, patients without preoperative IABP inser

16、tion have a higher actual mortality than predicted. Third, the actual mortality among patients with intra- and postoperative IABP use also proved to be significantly higher than predicted by the EuroSCORE.,,patients with

17、out preoperative IABP placement had the highest overall actual mortality and non-emergency patients performed significantly worse than predicted. This finding advocates an early preoperative IABP insertion to reduce mort

18、ality, at least to the predicted value.,,There is no accepted consensus on the definition of high-risk patients who may benefit from the use of intraaortic balloon pump (IABP) in coronary artery bypass grafting (CABG). T

19、he aim of this study was to develop a risk model to identify high-risk patients and predict the need for IABP insertion during CABG.,Ann Thorac Surg. Author manuscript; available in PMC 2011 February 1.,Results of Univar

20、iate Analysis,,,,Three risk groups were identified: low-risk (IABP score 0 to 6), medium-risk (IABP score 7 to 13), and high-risk score (IABP score >14). The incidence of IABP insertion and mortality were, respective

21、ly, 0.9% and 0.7% in the low-risk group, 7.2% and 2.8% in the medium-risk group, and 36.4% and 9.1% in the high-risk group,Relationship between risk score and probability of intraoperative or postoperative intraaortic ba

22、lloon pump (IABP) insertion.,,Specifically, patients in the high-risk (score >14) medium-risk (score 7 to 13), and low-risk group (score <6) had 36.4%, 10.6%, and 1.7% probability of IABP insertion, respectively

23、 high-risk patients who may benefit from elective insertion of IABP during CABG,,Dislocations of the heart required for exposure and construction of distal anastomoses often produce hemodynamic instability when perfo

24、rming coronary artery revascularization without using cardiopulmonary perfusion (OPCAB). We report our early experience with elective intraaortic balloon counterpulsation (IABP) to enable and facilitate selected high-ris

25、k patients to undergo OPCAB.,Ann Thorac Surg 2001;71:1220-1223,,,This study sought the protective effect of IABP in reducing the susceptibility of acute perioperative stresses on an injured heart caused by displacement d

26、uring OPCAB by supporting hemodynamic stability and reducing its myocardial oxygen demand. This benefit is of particular value for hearts that are more vulnerable because of severe proximal multivessel coronary disease,v

27、entricular hypertrophy, and dysfunction.,,we believe this strategy in using IABP selectively can allow surgeons to safely extend the benefits of OPCAB procedures to high-risk patients and avoid dangerous hemodynamic inst

28、ability that otherwise, often occurs.,,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，E

29、F≤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

30、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,,The intra-aortic balloon pump (IABP) is widely used to provide circulatory support forpatients experiencing hemodynamic instability due to myocar

31、dial infarction, cardiogenicshock, or in very high risk patients undergoing angioplasty or coronary artery bypass grafting.,Journal of the American College of Cardiology Volume 38, Issue 5，1 November 2001, Pages 1456-14

32、62,,,,The major finding of this study is that the incidence ofmajor balloon-related complications is encouragingly low (2.8%). Advances such as percutaneous insertion and smaller-diameter catheters have considerably red

33、uced the incidence of serious vascular complications. In addition,the incidence of unsuccessful IABP due to balloon leak, poor inflation, poor augmentation or insertion difficulty was extremely low (2.3%), and to our kno

34、wledge, no previous study has examined this issue.,,我們對(duì)2007年1月1日至2009年10月1日在安貞醫(yī)院放置IABP的患者232例通過(guò)回顧性病例分析，探討主動(dòng)脈內(nèi)球囊反搏（IABP）應(yīng)用前、后血小板計(jì)數(shù)的變化規(guī)律。 并分析IABP相關(guān)血小板減少癥的發(fā)生和患者疾病轉(zhuǎn)歸之間的聯(lián)系。,,血小板減少癥診斷標(biāo)準(zhǔn)為血小板總體計(jì)數(shù)小于100,000/mm3；和/或IABP放置期間患者血小板計(jì)數(shù)值

35、較其基礎(chǔ)值降低大于50%。,,,統(tǒng)計(jì)結(jié)果顯示術(shù)前放置組血小板減少癥的發(fā)生率明顯低于術(shù)中放置組和術(shù)后放置組（P﹤0.01）。而術(shù)中放置組和術(shù)后放置組之間并無(wú)明顯差別（P﹥0.05）。,,對(duì)于在圍術(shù)期的不同時(shí)段放置IABP的患者，其放置IABP后血小板減少癥的發(fā)生率存在差異，術(shù)前放置組血小板減少癥的發(fā)生率明顯低于術(shù)中放置組和術(shù)后放置組。這提示術(shù)前預(yù)防性使用IABP可減少I(mǎi)ABP相關(guān)血小板減少癥的發(fā)生。原因可能是術(shù)前預(yù)防性應(yīng)用IABP可以使患