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Application of Intra-aortic Balloon Pump for High-risk Patients before Off-pump Coronary Artery Bypass Grafting

Abstract： Objective To analyze clinical outcomes of intra-aortic balloon pump （IABP） application for high-risk　 patients before undergoing off-pump coronary artery bypass grafting （OPCAB）， and summarize our experience and weaning indications of IABP. Methods We retrospectively analyzed clinical data of 102 high-risk patients with coronary artery disease who underwent IABP implantation before OPCAB from January 2008 to July 2011 in Zhongshan Hospital of Fudan University. There were 71 male patients and 31 female patients with their average age of 63.0±8.2 years in this IABP group. We also chose another 100 patients without IABP implantation before undergoing OPCAB as the control group， including 55 male patients and 45 female patients with their average age of 64.1±9.5 years. Postoperative systolic arterial blood pressure （SABP）， mean arterial blood pressure （MABP）， mechanical ventilation time， length of intensive care unit（ICU） stay， morbidity， duration of IABP treatment and in-hospital mortality of two groups were compared. Left ventricular　 ejection fraction （LVEF） was evaluated with echocardiography 3 months after surgery. Results Postoperative SABP （95.3±12.2 mm Hg vs. 80.1±11.7 mm Hg；t=8.440， P=0.000） and MABP （78.9±13.5 mm Hg vs. 52.3±15.1 mm Hg； t=12.410， P=0.000） of the IABP group were significantly higher than those of the control group. Mechanical ventilation time， length of ICU stay and duration of inotropic support of the IABP group were significantly shorter than those of the control group. The incidence of ventricular arrhythmia， low cardiac output syndrome， perioperative myocardial infarction and dialysis-requiring acute kidney failure of the IABP group were significantly lower than those of the control group. In-hospital mortality of the IABP group was significantly lower than that of the control group ［5.9% （6/102） vs. 17.0% （17/100）， χ 2 =6.180， P=0.020］. Ninety-six patients in the IABP group and 83 patients in the control group were followed up for 3 months. Three months after surgery， echocardiography showed that LVEF of the IABP group was significantly higher than that of the control group（45.3%±12.0% vs. 39.1%±8.2%， t=3.950， P=0.000）. Conclusion Preoperative prophylactic IABP implantation and optimal timing of weaning from IABP support can not only significantly reduce surgical risk and improve surgical outcomes and postoperative recovery of high-risk patients undergoing OPCAB， but also considerably ameliorate patient heart function and reduce perioperative morbidity and mortality.

外科治疗心脏电风暴三例

Application of Intra-aortic Balloon Pump in Patients with Mild or Mild to Moderate Aortic Regurgitation

Abstract： Objective To estimate the effectiveness and safety of intra-aortic balloon pump （IABP）in the patients with mild or mild to moderate aortic regurgitation. Methods A total of 15 patients with mild or mild to moderate aortic regurgitation and low left ventricular ejection fraction (LVEF＜ 40.00%) including 11 males and 4 females, who underwent IABP application after cardiac surgery between September 2006 and January 2011, were included in this study. Their age ranged from 50 to 74 years with an average age of 63.60 years. There were 9 patients with mild aortic regurgitation and 6 patients with mild to moderate aortic regurgitation, all with LVEF ＜ 40.00%. IABP catheters were inserted before operation and IABP worked after heart the recovery of heart beat. Mean aortic pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), pulmonary vascular resistance index (PVRI), LVEF , and aortic regurgitation volume before the use of IABP and after stopping use of it were compared. Results The total mortality was zero. The patients’ CI significantly improved from 1.99±0.23 L/(min.m2) to 3.30±0.29 L/(min.m2) after IABP （t =48.30，P=0.00）. Their LVEFs were significantly improved after use of IABP (37.20%±1.37% versus 42.60%±2.87%， t =11.34，P=0.00）. Their SVRI improved significantly (2 347.00±190.00 dyn·s/(cm5·m2) versus 2 128.00±204.00 dyn·s/(cm5 · m2)，t=20.60, P=0.00）after use of IABP. However, their aortic regurgitation volume were not significantly increased（χ2=0.60, P=0.44）. Conclusion Application of IABP in patients with mild or mild to moderate aortic regurgitation and low LVEF can obtain good circulation support after operation without increasing their aortic regurgitation.

新型主动脉旁与主动脉内球囊反搏对羊重度急性心力衰竭辅助的实验研究

Objective To compare the assisting function between a new paraaortic counterpulsation device (PACD) and the intraaortic balloon pump (IABP) in acute severe heart failure in sheep. Methods Eight healthy adult small fattailed sheep were chosen in our study. The selfmade PACD (with a stroke volume of 55 ml) was anastomosed to the descending aorta through a valveless graft, and an intraaortic balloon (with a stroke volume of 40 ml) was placed in the descending aorta for the purpose of counterpulsation assisting. Acute severe heart failure model was established by snaring coronary artery branches. The hemodynamic changes of both devices were recorded during, before and after the counterpulsation assisting. Results Eight heart failure sheep models were successfully set up. Cardiac output (CO), pulmonary capillary wedge pressure (PCWP), mean arterial pressure (MAP) and left ventricular end diastolic presssure (LVEDP) after the heart failure were significantly different compared with basic value (t=-8.466, 34.083, 25.767, -5.219, P=0.000). After IABP and PACD assisting, the mean aortic diastolic pressure (MADP) didn’t significantly or did increase (38.34±7.13 mm Hg vs. 38.42±6.81 mm Hg, P=0.418; 38.34±7.13 mm Hg vs.54.14±10.13 mm Hg, P=0.001), and the degree of increasing between the two methods showed a significant difference (P=0.010); LVEDP didn’t significantly decrease (7.43±2.54 mmHg vs. 7.32±2.14 mm Hg, P=0.498; 7.43±2.54 mm Hg vs. 6.53±1.91 mm Hg, P=0.821), and there was no significant difference between the two methods in the change (P=0.651); the coronary sinus flow (CSF) didn’t significantly or did increase (86.63±7.71 ml/min vs. 87.04±6.53 ml/min, P=0.981; 86.63±7.71 ml/min vs. 110.52±11.03 ml/min, P=0.000), and there was a significant difference in the change of CSF between the two methods (P=0.000). IABP didn’t significantly decrease the left carotid artery flow (LCAF) (131.07±21.26 ml/min vs. 128.36±20.38 ml/min, P=0.689), while PACD increased it (131.07±21.26 ml/min vs. 151.29±18.37 ml/min, P=0.008), and there was a significant difference in the change of pressure waveform between the two methods (P=0.002). The thrombus, thrombosis and ischemic necrosis were not found in the hematosac of PACD, artificial blood vessels, heart, lung, liver or kidney of the animal. No apparent abnormalities of the pathohistological sections were detected under optical microscope. Conclusion IABP has no assisting function for the heart of animal with severe heart failure. However, PACD can improve hemodynamic parameters like MADP, returned blood volume in the coronary artery and perfusion volume into the brain, which may become a promising implantable device for severe heart failure.

IABP辅助下非体外循环冠状动脉旁路移植术治疗冠心病合并严重左心室功能不全

目的 总结严重左心室功能低下的冠心病患者行主动脉内球囊反搏(IABP)辅助下非体外循环冠状动脉旁路移植术（offpump CABG）的临床经验，以提高手术的成功率。 方法 66例严重左心室功能低下的冠心病患者，男48例，女18例；年龄68.4±10.3岁；左心室射血分数（LVEF）29.6%±5.3%。所有患者均在选择性IABP辅助下行offpump CABG。根据IABP置入的时间不同，将66例患者分为两组，术前IABP置入组：34例，于术前麻醉诱导后置入IABP；术后IABP置入组：32例，在手术完成后置入IABP。回顾分析其临床资料、手术资料、手术结果。结果  66例患者中每例移植血管3.4±0.7支，采用乳内动脉（IMA）66例，且全部吻合于左前降支，采用大隐静脉（SV）64例，桡动脉（RA）5例，吻合于除左前降支以外的所有冠状动脉。于术后15~48 h均顺利停用IABP；围术期死亡1例，于术后29 d发生低心排血量综合征合并肾功能衰竭，死于多器官功能衰竭。所有患者应用IABP后血流动力学和血气指标明显改善，连续心排血量（CCO）、心脏指数（CI）、混合静脉血氧饱和度（SvO2）、有创动脉收缩压（SABP）、有创平均动脉压（MABP）较术前明显升高，而毛细血管楔压（PCWP）较术前明显降低（Plt;0.05）。术前置入IABP组术后住ICU时间、室性心律失常和低心排血量发生率短于或低于术后置入组（Plt;0.05）。随访60例，随访时间1个月~3年，失访5 例。随访期间无心绞痛复发，无心肌梗死发生，心功能分级（NYHA）Ⅰ~Ⅱ级51例，Ⅲ级9例。无晚期死亡。 结论 合理使用IABP，使严重左心室功能低下的冠心病患者施行off-pump CABG有良好的近期效果，该方法是可行的。

心瓣膜置换术后早期心肌顿抑致低心排血量综合征的诊治经验

目的 探讨心瓣膜置换术后早期心肌顿抑的识别、诊断，以及由此导致严重低心排血量综合征（LCOS）的治疗方法，以提高诊断、治疗水平。 方法 回顾分析我科2004年9月至2006年9月期间4例心瓣膜置换术后早期出现心肌顿抑导致LCOS患者的临床资料，4例均为女性，年龄35～54岁，平均年龄46-75岁。术前左心室大小、收缩功能均基本正常，左心室舒张期末内径（LVEDD)3.5～6.3 cm，射血分数(EF)49%～61%；2例行二尖瓣、主动脉瓣置换术，1例行二尖瓣置换术，1例行主动脉瓣置换术。 结果 4例患者均在术后早期（14～40 h、平均26 h）出现无明确原因的LCOS，给予大剂量肾上腺素［0.10～0.15 μg/(min·kg）］治疗无效而改行主动脉内球囊反搏（IABP）治疗，4例患者IABP支持时间为7～12 d（平均8.5 d），3例痊愈，1例因肺部感染于术后28 d死于多器官功能衰竭。2例出现急性肾功能不全，1例7 d后肾功能恢复正常，1例经腹膜透析治疗2周后痊愈。 结论 心肌顿抑可出现在术前心功能良好，手术经过顺利的心瓣膜置换术患者，由心肌顿抑导致的术后早期LCOS，及时应用IABP可以减轻心脏负荷，增加冠状动脉灌注，改善重要脏器循环，有助于左心室渡过心肌顿抑期，恢复收缩功能，是成功救治的重要手段。

主动脉内球囊反搏在冠状动脉旁路移植术围术期的应用

目的 探讨主动脉内球囊反搏（IABP）在冠状动脉旁路移植术（CABG）围术期的应用效果。 方法 在CABG围术期，对急性心肌梗死（2例）、术中停体外循环困难（16例）、停体外循环后发生低心排血量（7例）和发生恶性心律失常、心跳骤停行心肺复苏后（3例）患者经皮股动脉穿刺置入IABP进行循环辅助。结果 IABP辅助时间36h~7d(74.16±31.64h)，住ICU时间为4~27d。围术期死亡3例，死亡率为10.7%（3/28）；其余患者均存活。使用IABP后舒张压从48.7±3.1mmHg升至68.0±8.8mmHg(t=4.504 ,Plt;0.01），平均动脉压从52.0±8.8 mmHg上升至73.0±9.5mmHg（t=6.060,Plt;0.01），多巴胺用量由12.8±2.6mmol/L降至8.5±1.3mmol/L（t=3.490,Plt;0.01）。随访25例，随访时间6个月，25例患者心功能均恢复良好，无1例发生并发症。 结论 在CABG围术期使用IABP可明显改善危重患者的心功能，掌握好IABP的使用指征和时机是救治危重患者成功的关键。

主动脉内球囊反搏在冠状动脉旁路移植术中的应用

目的 为提高冠状动脉旁路移植术(CABG)的手术疗效, 总结CABG围手术期主动脉内球囊反搏(IABP)应用的临床经验. 方法 回顾性分析46例CABG围手术期行IABP患者的临床资料及IABP放置的原因、时间和预后. 结果 34例康复出院,住院死亡12例,主要死亡原因:低心排血量综合征、肺部感染、多器官功能衰竭等.平均IABP辅助时间28.6±18.2小时.IABP能使平均动脉压升高,心排血量增加,有助于心脏功能差的患者脱离体外循环和改善心脏不停跳冠状动脉旁路移植术(OPCAB)中心脏对稳定器压迫的耐受性. 结论 IABP是一种简单有效的循环辅助手段,心功能差的高危CABG患者应及时放置IABP.放置IABP前应查明下肢血管情况,避免血管损伤.

主动脉内球囊反搏救治心脏手术后室性心律失常的疗效观察

目的　评价主动脉内球囊反搏(IABC)治疗心脏手术后室性心律失常的效果。　方法　对33例因心脏手术后出现室性心律失常使用IABC的病例进行分析，观察心律恢复情况、ST段转复情况、监测桡动脉和主动脉压力波形，记录血管活性药物用量。　结果　所有患者在应用IABC后1～2小时室性心律失常由原来的Ⅱ～Ⅴ级恢复到0～Ⅰ级(Lown分级)。ST段的抬高或降低在30分钟～1小时后恢复正常。所有患者在应用IABC后，桡动脉压的基础收缩压均在早期有所下降，从90±19mmHg下降到78±21mmHg(P＜0.05)；基础舒张压从71±16mmHg上升到131±25mmHg(P＜0.01)；平均动脉压增加。多巴胺用量由8±2μg/mlh下降至3±2μg/mlh。　结论　IABC能够有效地控制体外循环手术后室性心律失常的发生，为治疗心脏手术后室性心律失常的一种新方法。

急性心肌梗死伴心源性休克患者应用主动脉内球囊反搏治疗的观察及护理

【摘要】 目的 探讨使用主动脉内球囊反搏治疗过程中护理措施对改善患者预后的影响。 方法 选择我科2008年9月〖CD3/5〗2009年5月使用主动脉内球囊反搏治疗急性心肌梗死伴心源性休克的9例患者,对治疗过程进行了观察及全面合理的护理。 结果 主动脉内球囊反搏治疗患者,取得了满意的效果。 结论 主动脉内球囊反搏患者病情复杂危重,使用过程中需辅以全面合理的护理措施,防止并发症发生,对改善患者预后有益。