超声心动图定量参数与急性心...MO早期撤机结局的关系探讨_桑园园.pdf

中国现代医学杂志China Journal of Modern MedicineVol.33 No.7Apr.2023第 33 卷 第 7 期2023 年 4 月超声心动图定量参数与急性心肌梗死患者ECMO早期撤机结局的关系探讨*桑园园1，王乔2，耿娟1（1.淮安市第二人民医院 心血管内科，江苏 淮安 223001；2.淮安市第五人民医院 心胸外科，江苏 淮安 223300）摘要：目的探讨超声心动图定量参数与急性心肌梗死患者体外膜氧合器（ECMO）早期撤机结局的关系。方法回顾性分析2020年2月2022年2月淮安市第二人民医院收治的82例采用ECMO救治的急性心肌梗死患者的临床资料。采用彩色多普勒超声诊断仪测量患者上机和撤机后的超声心动图参数，包括左室射血分数（LVEF）、二尖瓣侧壁瓣环收缩速度（Sa）、右室面积变化分数（RVFAC）和左室流出道速度-时间积分（LVOT-VTI）；统计患者撤机后28 d生存情况，比较死亡患者和生存患者上机和撤机后超声心动图参数的差值；采用一般多因素Logistic回归分析影响急性心肌梗死患者ECMO早期撤机结局的因素；绘制受试者工作特征（ROC）曲线分析超声心动图定量参数对急性心肌梗死患者ECMO早期撤机结局的预测效能。结果撤机后随访28 d，82例急性心肌梗死患者有24例死亡。死亡患者的多脏器功能衰竭占比、多支血管病变占比均高于生存患者（P 0.05）；死亡患者上机和撤机后LVEF差值、Sa差值、RVFAC差值、LVOT-VTI差值均低于生存患者（P 0.05）；一般多因素Logistic回归分析结果显示，多脏器功能衰竭 OR=3.367（95%CI：1.073，10.562）、LVEF OR=3.327（95%CI：1.060，10.436）、Sa OR=3.476（95%CI：1.108，10.906）、RVFAC OR=3.721（95%CI：1.186，11.673）、LVOT-VTI OR=3.931（95%CI：1.253，12.333）均是影响急性心肌梗死患者ECMO早期撤机后死亡的危险因素（P 0.05）；ROC曲线分析结果显示，上机后LVEF、Sa、RVFAC、LVOT-VTI的最佳截断值分别为22.18%、5.01 cm/s、26.87%和9.93 cm，联合检测的敏感性为79.17%（95%CI：0.578，0.929）、特异性为98.28%（95%CI：0.908，1.000）、AUC 为 0.927（95%CI：0.847，0.973）。结论超声心动图定量参数与急性心肌梗死患者ECMO早期撤机结局有关，可作为预测患者死亡的敏感指标。关键词：急性心肌梗死；超声心动图；体外膜氧合器；撤机中图分类号：R541.4文献标识码：ACorrelation of echocardiographic quantitative parameters with early ECMO weaning outcomes in patients with acute myocardial infarction*Sang Yuan-yuan1,Wang Qiao2,Geng Juan1(1.Department of Cardiovascular Medicine,Huaian Second Peoples Hospital,Huaian,Jiangsu 223001,China;2.Department of Cardiothoracic Surgery,Huaian Fifth Peoples Hospital,Huaian,Jiangsu 223300,China)Abstract:Objective To explore the correlation between echocardiographic quantitative parameters and early weaning outcomes of extracorporeal membrane oxygenerator(ECMO)in patients with acute myocardial infarction.Methods The data of 82 patients with acute myocardial infarction treated by ECMO in the hospital from 心肌梗死专题 论著DOI:10.3969/j.issn.1005-8982.2023.07.005文章编号：1005-8982（2023）07-0028-06收稿日期：2022-08-30*基金项目：江苏省自然科学基金项目（No：BK20190374）28第 7 期桑园园，等：超声心动图定量参数与急性心肌梗死患者ECMO早期撤机结局的关系探讨February 2020 to February 2022 were retrospectively analyzed,the Color Doppler ultrasound was used to measure the echocardiographic parameters of the patients after weaning and weaning,including left ventricular ejection fraction(LVEF),mitral sidewall annular systolic velocity(Sa),and right ventricular area fractional change(RVFAC)and left ventricular outflow tract velocity-time integral(LVOT-VTI),the 28-day survival of patients after weaning was counted.The difference of echocardiographic parameters after boarding and weaning between the dead patients and the surviving patients was compared.The factors affecting the outcome of early ECMO weaning in patients with acute myocardial infarction were analyzed,the receiver operating curve(ROC)was used to analyze the value of the difference of echocardiographic parameters after boarding and weaning in predicting the outcome of early ECMO weaning in patients with acute myocardial infarction.Results During the 28-day follow-up after weaning,24 of the 82 patients with acute myocardial infarction died.The proportions of multiple organ failure and multi-vessel disease in the dead patients were higher than those in the surviving patients(P 0.05).The difference of LVEF,Sa,RVFAC,and LVOT-VTI after boarding and weaning of the dead patients were lower than those of the surviving patients(P 0.05).Logistic multivariate regression analysis showed that multiple organ failure OR=3.367(95%CI:1.073,10.562),LVEF OR=3.327(95%CI:1.060,10.436),Sa OR=3.476(95%CI:1.108,10.906),RVFAC OR=3.721(95%CI:1.186,11.673),LVOT-VTI OR=3.931(95%CI:1.253,12.333)after boarding were the risk factors for death after early ECMO weaning in patients with acute myocardial infarction(P 0.05).ROC analysis showed that the best cut-off points of difference of LVEF,Sa,RVFAC,and LVOT-VTI after boarding and weaning were 22.18%,5.01 cm/s,26.87%and 9.93 cm,respectively,and the combined sensitivity,specificity and AUC were 79.17%(95%CI:0.578,0.929),98.28%(95%CI:0.908,1.000),0.927(95%CI:0.847,0.973),respectively.Conclusion Quantitative echocardiographic parameters are associated with early ECMO weaning outcomes in patients with acute myocardial infarction,and it can be used as a sensitive indicator for predicting patient mortality.Keywords:acute myocardial infarction;echocardiography;extracorporeal membrane oxygenerator;weaning急性心肌梗死是一种急危重症，具有发病率高、预后差的特点，3%10%的患者常伴有心脏骤停、心源性休克等，可导致全身性低灌注和多器官衰竭，死亡率高达 50%70%1。其中，急性心肌梗死并发心源性休克患者心脏泵血功能障碍，导致外周器官缺血、缺氧和组织灌注不足，而冠状动脉供血不足进一步加重心肌缺血，使心肌梗死面积扩大，形成恶性循环2。临床对急性循环障碍患者可采用机械循环支持部分替代心脏功能，以提高血流灌注，有助于心肌复苏3。体外膜氧合器（extracorporeal membrane oxygenerator，ECMO），又称体外膜肺，是机械循环支持的一种方法，越来越多地应用于急性心血管疾病的救治。ECMO具有呼吸和双心室支持、高流速及使用方便等优点4。ECMO可以将静脉血引流至体外，通过膜型人工肺进行氧合及排出二氧化碳后，再将血液泵回机体，其主要功能是使肺处于“休息”状态的情况下，提供氧合作用及排出二氧化碳，能够在短时间内替代肺和心脏5。临床研究发现，合适的撤机时间是ECMO治疗成功的关键，而临床监测心率、平均动脉压、血氧饱和度等血流动力学参数不能准确指导撤机时间6。超声心动图可以监测心脏功能，通过直观、动态地观察心脏腔室大小，准确反映心脏血流动力学状态，可以客观指导 ECMO 撤机的时机7。然而，超声心动图定量参数与急性心肌梗死患者ECMO早期撤机结局的关系尚不清楚。故本研究回顾性分析采用ECMO救治的急性心肌梗死患者的临床资料，探究