心室輔助裝置治療

心力衰竭復(fù)旦大學(xué)附屬中山醫(yī)院心外科王春生

心臟輔助裝置是將心臟內(nèi)的一部分血液引流到輔助裝置中,并通過(guò)VAD提供的機(jī)械動(dòng)力重新注入動(dòng)脈,從而取代一部分心室的泵血功能。心室輔助裝置

(Ventricularassistdevices,VADs)心室輔助的目的降低心臟負(fù)荷增加心肌氧供維持組織及器官的灌注急性心梗后心源性休克的傳統(tǒng)治療強(qiáng)心藥（Inotrope）IABPOthersforacutecoronarysyndromes:

Thrombolytics EmergencyPTCA/PCI EmergencyCABG住院死亡率高達(dá)60%InotropeScoreSamuelsetal,AnnThoracSurg2001;71:S67-72

HospitalMortalityInotropeLevelIABPScoreParameters: Points:腎上腺素用量>0.5mcg/kg/min 2左房壓>15mmHg 1尿量<100ml/hr 1SV02<60%

1Range:0-5pointsHausmannetal,Circulation2002;106:I203-6IABPScore86%57.5%52.2%30%8.3%0%Hausmannetal,Circulation2002;106:I203-6012345Points

survivalPointsBottomLinewithAcute-CS任何原因?qū)е碌闹旅缘男脑葱孕菘舜髣┝繌?qiáng)心藥無(wú)效單用IABP無(wú)法維持循環(huán)穩(wěn)定MechanicalSupportisAppropriate

VAD分類非搏動(dòng)性體外裝置：

體外膜肺（ECMO）等搏動(dòng)性體外裝置：AbiomedBVS5000等，用于左心輔助、右心輔助或雙心輔助搏動(dòng)性植入裝置：Heartmate等非搏動(dòng)性植入裝置：

ImpellaLD等臨床應(yīng)用短期過(guò)渡支持：

AbiomedBVS5000，AB5000，ImpellaLD等；移植前過(guò)渡：

HeartMateLVAS(IP)氣動(dòng)搏動(dòng)型泵，不需正規(guī)抗凝；NovacorLVAS,電動(dòng),正規(guī)抗凝

長(zhǎng)期支持治療：

HeartMateVE等ABIOMED循環(huán)支持系統(tǒng)CirculatorySupportSystemABIOMEDSystemcomponents:AtrialandarterialcannulaeSingleorDualchamberedbloodpumpPneumaticdriveconsoleAbiomed心室輔助產(chǎn)品BVS5000AB5000AB5000BVS控制臺(tái)血泵AbiomedBVS5000PumpingChamberConsoleBVSImplantsCumulativeBVS&AB5000–Apical“Sleeve”EasytoputinBVS&AB5000–PreservationofLVApexEasytotakeoutAB5000RegistryOutcomes86%Post-CardiotomyCardiogenicShockMyocarditisAMI(HeartAttack)CardiogenicShock75%67%Survival43%57%42%%RecoveryoftheSurvivors*RepresentsallpatientsfromallUSAB5000centerssupportedfromOct2003throughJune2005RealWorld:AllUS*Data,notselectedcentersorbestpracticesImpellaLP2.5catheter.

ImpellaLD當(dāng)前最小的軸流泵，移動(dòng)和攜帶方便

驅(qū)動(dòng)裝置30cm×30cm,重約3kg軸葉輪直徑6.4mm,流量可達(dá)5～6L/min左心輔助：通過(guò)主動(dòng)脈瓣插入左心室完成泵血功能，最長(zhǎng)輔助7d右心輔助：插入右心房并通過(guò)一段PTFE人工管道(8mm)與肺動(dòng)脈連接ImpellaLP2.5可通過(guò)經(jīng)皮股動(dòng)脈穿剌完成臨床應(yīng)用進(jìn)展AcuteCardiogenicShockAlgorithmAcuteCardiogenicShock

LowOutput2HighDoseInotropesInotropesIABPPrecardiotomyPostcardiotomyWithin30minof1stattempttoweanfromCPBWithin1hourof1stattempttoweanfromCPBIABPoptionalifconditionwarrantsdirectVADinsertion

checkCVPandPAPcheckEchoLVADRVADBi-VADIfRVfailsafterLVADinsertionIfLVfailsafterRVADinsertionSamuelsetal.Ann.OfThorac.Surg2001;71:S82-85Within6-24hrsofMIWithin1-6hr