Clinical value and prognosis of arteriovenous extracorporeal membrane oxygenation in patients with refractory cardiogenic shock
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摘要: 目的 探讨动静脉体外膜肺氧合(VA-ECMO)支持治疗难治性心源性休克(RCS)患者的临床应用价值及其预后影响因素。方法 回顾性分析2022年1月—2023年4月于我院因RCS接受VA-ECMO行辅助治疗94例患者的临床资料，分析VA-ECMO辅助治疗前、后超声心动图参数变化，根据VA-ECMO撤机成功与否将其分为成功组(73例)和失败组(21例)，比较两组患者一般资料、血流动力学及生化指标结果，分析影响患者脱机的独立风险因素。结果 ① 不同病因间左室每搏量(LVSV)、左室射血分数(LVEF)、二尖瓣侧壁瓣环收缩速度(Sa)、主动脉瓣口前向血流速度(AV)、速度-时间积分(VTI)差异具有统计学意义(均P＜0.05)。与急性心肌缺血(AMI)组比较，暴发性心肌炎(FM)组、原发性心源性休克(CS)组的LVSV、LVEF、VTI测值更低(均P＜0.05)。②94例患者中73例患者成功撤机，21例撤机失败，成功组ECMO辅助时间明显小于失败组(P＜0.05)。③与ECMO建立前比较，成功组与失败组建立后的心率(HR)、LVESV、E/e′、血红蛋白(HGB)、血小板(PLT)及谷氨酸氨基转移酶(ALT)、LVSV、LVEF、三尖瓣瓣环收缩速度(S′)、Sa、AV、VTI、TAPSE、C反应蛋白(CRP)、血白细胞(WBC)存在组间差异(均P＜0.05)。与失败组比较，成功组在ECMO建立前、后血乳酸(Lac)、WBC、尿素/血肌酐(Urea/Crea)、休克指数(SI)、D-二聚体(D-dimer)、CRP、天冬氨酸氨基转移酶(AST)、ALT、PLT存在组间差异(均P＜0.05)。④多因素logistic回归分析结果显示S′、Lac、AST、ALT、Urea/Crea是影响RCS患者脱机成功的影响因素。结论 VA-ECMO治疗可显著改善RCS患者心脏功能，S′、Lac、AST、ALT、Urea/Crea是脱机成功的影响因素。Abstract: Objective To investigate the clinical value and prognostic factors of arteriovenous extracorporeal membrane oxygenation(VA-ECMO) support for the treatment of patients with refractory cardiogenic shock.Methods We retrospectively analyzed the clinical data of 94 patients who underwent VA-ECMO assisted treatment for refractory cardiogenic shock from January 2022 to April 2023, analyzed the changes of echocardiographic parameters of the patients before and after VA-ECMO assisted treatment, and classified them into the success group(73 cases) and the failure group(21 cases) according to the success of the withdrawal of VA-ECMO, and compared the general data, hemodynamic and biochemical parameters of the patients in the two groups, and analyze the independent risk factors affecting the clinical outcomes of patients.Results ① There were significant differences in left ventricular stroke volume(LVSV), left ventricular ejection fraction(LVEF), mitral annulus systolic velocity(Sa), aortic valve orifice forward flow velocity(AV) and velocity-time integral(VTI) among different etiological groups(all P < 0.05). Compared with the acute myocardial ischemia(AMI) group, the LVSV, LVEF, and VTI measurements were lower in the fulminant myocarditis(FM) group and the primary cardiogenic shock(CS) group(all P < 0.05). ②Among the 94 patients, 73 patients were weaned successfully and 21 patients failed. The time of ECMO assistance in the success group was significantly shorter than that in the failure group(P < 0.05). ③Compared with before ECMO, heart rate(HR), LVESV, E/e′, hemoglobin(HGB), platelets(PLT), and glutamate aminotransferase(ALT), LVSV, LVEF, tricuspid annulus peak systolic velocity(S′), Sa, AV, VTI, TAPSE, and C-reactive protein(CRP) and white blood cells(WBC) were significantly different between successful group and failed group(all P < 0.05). Compared with the failure group, there were significant differences in lactate(Lac), WBC, Urea/Crea, shock index(SI), D-dimer, CRP, aspartate aminotransferase(AST), ALT and PLT before and after ECMO in the success group(all P < 0.05). ④Multivariate logistic regression analysis showed that S′, Lac, AST, ALT and Urea/Crea were the influencing factors of weaning success in patients with refractory cardiogenic shock.Conclusion VA-ECMO treatment can significantly improve cardiac function in patients with refractory cardiogenic shock. The dynamic evaluations of S′, Lac, AST, ALT and Urea/Crea have certain value for the prognosis of patients.
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表 1 不同原因RCS患者ECMO治疗后超声多参数特征比较
Table 1. Comparison of echocardiography multi-parameter characteristics after ECMO treatment in patients with RCS of different causes
M(P25, P75) 指标 FM组(12例) AMI组(70例) CS组(12例) H值 P值 LVEDV/mL 137.50(101.75，165.00) 123.50(110.75，153.00) 121.00(98.00，142.50) 1.655 0.437 LVESV/mL 94.00(61.75，111.75) 69.50(58.75，91.50) 74.00(67.00，96.75) 2.556 0.279 LVSV/mL 48.50(28.50，55.5) 58.00(47.00，69.00) 42.00(29.00，47.25) 17.417 ＜0.001 LVEF 0.31(0.22，0.46) 0.43(0.39，0.48) 0.33(0.26，0.39) 19.01 ＜0.001 E/e′ 8.43(6.73，14.13) 10.51(7.88，14.59) 10.24(6.63，15.21) 0.818 0.664 Sa/(cm/s) 5.75(3.96，8.04) 6.20(4.99，7.11) 2.91(2.53，3.29) 29.464 ＜0.001 AV/(m/s) 0.58(0.50，0.95) 0.90(0.70，1.10) 0.70(0.60，0.90) 7.701 0.021 VTI/cm 10.90(7.05，15.88) 17.15(13.45，21.15) 12.75(10.13，16.75) 16.175 ＜0.001 S′/(cm/s) 8.53(7.37，10.92) 10.45(7.05，13.43) 8.65(6.93，13.83) 1.742 0.419 TAPSE/cm 1.35(1.20，1.58) 1.50(1.40，1.70) 1.40(0.85，1.68) 5.931 0.052 
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表 2 成功组与失败组一般临床资料比较
Table 2. Comparison of general clinical data between the two groups
X±S, M(P25, P75) 组别 例数 男/女/例 年龄/岁 病因/例 IABP/例 CRRT/例 ECMO辅助时间/h FM AMI CS 成功组 73 57/16 57.8±14.6 10 54 9 21 12 96(48，144) 失败组 21 16/5 57.7±10.7 2 16 3 9 6 144(96，192) χ2/t/Z值 0.034 0.037 0.018 0.042 0.000 1.490 0.866 -2.734 P值 0.854 0.970 0.893 0.837 1.000 0.222 0.352 0.008 注：IABP：主动脉内球囊反搏；CRRT：连续性肾脏替代治疗。
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表 3 两组患者在ECMO建立前、后主要血流动力学及生化参数变化
Table 3. Changes of main hemodynamic and biochemical parameters before and after the establishment of ECMO in two groups
M(P25, P75), X±S 项目 ECMO建立前 ECMO建立后 成功组(73例) 失败组(21例) 成功组(73例) 失败组(21例) HR/(次/min) 85.00(69.50，100.50) 95.00(69.00，120.00) 83.00(73.50，90.00)1) 90.00(78.00，95.50) SI 0.76(0.63，0.96) 0.78(0.62，1.17) 0.78(0.65，0.92) 0.98(0.72，1.11)4) SaO2/% 95.00(92.25，97.85) 97.6(90.80，99.30) 97.80(95.65，99.35)1) 95.20(94.10，99.25) LVEDV/mL 130.00(113.01，160.50) 141.00(105.86，166.50) 125.00(111.00，152.00) 125.00(106.00，162.00) LVESV/mL 80.37(67.55，106.00) 81.00(67.36，118.00) 73.00(61.50，95.00)1) 68.00(60.50，104.00) LVSV/mL 50.00(42.54，62.01) 43.79(35.00，55.50) 55.00(46.00，64.50)1) 45.00(42.50，70.00)2) LVEF 0.36±0.09 0.32±0.12 0.42±0.101) 0.39±0.132) E/e′ 10.45(7.10，15.41) 11.63(8.80，15.05) 9.85(6.96，14.29)1) 11.71(8.78，14.91)2) S′/(cm/s) 7.80(6.10，10.90) 6.70(4.81，9.69) 10.40(7.37，13.30)1) 8.50(6.15，10.75)2) Sa/(cm/s) 5.38±1.32 5.87±1.92 6.10±1.391) 5.64±1.50 AV/(m/s) 0.70(0.60，0.80) 0.70(0.60，0.90) 0.80(0.65，1.00)1) 0.80(0.70，1.05)2) VTI/cm 12.32±3.94 12.52±5.55 16.38±4.901) 14.43±5.962) TAPSE/cm 1.23±0.32 1.21±0.37 1.51±0.341) 1.41±0.312) cTnI/(ng/mL) 1.50(0.56，7.65) 1.70(0.42，8.46) 3.30(0.45，12.00) 3.70(0.59，14.00) CK-MB/(ng/mL) 33.00(6.30，95.00) 25.00(4.45，218.00) 26.00(7.95，104.00) 70.00(18.05，263.50) NT-proBNP/(pg/mL) 2 960.00(1 010.00，9 820.00) 3 920.00(1 300.00，7 693.00) 3 010.00(1 405.00，6 735.00) 4 450.00(2 024.50，9 385.00) D-dimer/(ng/mL) 858.00(547.00，3 408.00) 858.00(405.50，6 290.00) 1 290.00(688.50，4 005.00) 3 710.00(1 095.00，21 320.00)4) Lac/mmHg 2.00(1.35，3.65) 4.40(1.90，7.15)3) 2.10(1.50，3.25) 3.90(1.55，7.50)4) WBC/(×109/L) 10.20(7.16，14.52) 14.62(8.22，20.88)3) 11.67(9.02，14.97) 11.66(10.13，15.73)2) HGB/(g/L) 138.00(121.50，149.50) 127.00(118.50，153.50) 107.00(90.50，122.50)1) 91.00(71.00，123.50)2) PLT/(×109/L) 187.00(150.0，232.00) 220.00(163.00，277.00) 160.00(110.00，205.00)1) 129.00(80.50，169.00)2)4) CRP/(mg/L) 8.90(1.67，33.81) 6.60(1.97，35.65) 38.37(12.03，77.15)1) 64.62(44.49，114.55)2)4) AST/(U/L) 68.00(33.00，228.50) 85.00(30.00，464.00) 79.00(26.00，178.00) 162.00(50.50，619.00)4) ALT/(U/L) 46.00(26.00，89.50) 49.00(20.00，325.50) 41.00(17.50，71.50)1) 82.00(28.50，321.50)4) Urea/Crea 95.00(71.50，114.50) 76.00(55.50，99.50)3) 89.00(76.50，113.50) 69.00(53.00，109.00)4) TBIL/(mmol/L) 14.90(10.00，23.45) 14.60(11.55，19.90) 13.00(10.50，19.05) 17.70(11.90，26.25) 注：HR：心率；cTnI：肌钙蛋白I；CK-MB：肌酸激酶同工酶；NT-ProBNP：N末端B型利钠肽前体；D-dimer：D-二聚体；Lac：血乳酸；WBC：血白细胞；HGB：血红蛋白；PLT：血小板；CRP：C反应蛋白；AST：天冬氨酸氨基转移酶；ALT：谷氨酸氨基转移酶；Urea/Crea：尿素/血肌酐；TBIL：总胆红素。成功组建立后与建立前比较，1)P＜0.05；失败组建立后与建立前比较，2)P＜0.05；成功组与失败组比较：两组建立前比较，3)P＜0.05；建立后比较，4)P＜0.05。
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表 4 影响RCS患者脱机的多因素logistic回归分析
Table 4. Multifactor logistic regression analysis affecting clinical outcomes of RCS patients
变量 β Wald χ2 P OR(95%CI) S′ 0.446 4.214 0.040 1.562(1.020~2.391) Lac -1.105 4.421 0.035 0.331(0.118~0.928) AST -0.017 4.421 0.033 0.983(0.968~0.999) ALT 0.021 5.029 0.025 1.021(1.003~1.040) Urea/Crea 0.049 4.110 0.043 1.050(1.002~1.100)
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