Abstract:

Objective Explore the feasibility and experience of using long-term implantable ventricularassist devices to treat intractable cardiogenic shock caused by acute myocardial infarction. Methods In November 2019，the Shenzhen Hospital of Fuwai Hospital treated a case of acute myocardial infarction，cardiogenic shock，and cardiac tamponade with oval foramen repair surgery. The patient underwent coronary artery bypass grafting，and implantation of the CH-VAD ventricular assist device. Early postoperative observations included hemodynamic and organperfusion monitoring indicators. Long-term follow-up after discharge included transthoracic echocardiography，NYHAcardiac function classification，6-minute walk distance，and cardiopulmonary exercise testing to assess the recovery process of cardiac function and exercise tolerance. Results During the surgery，150 ml of dark，red，bloody pericardial effusionwas found after opening the pericardium. The apex of the left ventricle was significantly thinned，and the surrounding tissue was edematous. An old thrombus had formed at the 3 o'clock position. The cardiopulmonary bypass time was 120 min，the aortic cross-clamp time was 55 min，and the time for clamping the aortic sidewall was 10 min. Early postoperative CH-VAD pump speed was adjusted to between 2 500 and 2 900 rpm，with a flow rate of between 3.5 and 4.5 L/min. The invasive mean arterial pressure was maintained between 65 and 75 mmHg，and blood lactate，cTnI，and cTnT levels returned to normal on the day of surgery and on the 7th day postoperatively. The endotracheal tube was removed 26 h after surgery，and episodes of short bursts of ventricular tachycardia and ventricular fibrillation occurred between the 7th and 15th days postoperatively.During this period，asynchronous defibrillation was repeatedly performed at 100 ～ 200 J，and the endotracheal tube wasreinserted on the 8th day after the surgery. The patient was smoothly discharged with the CH-VAD pump on the 90th day after the operation，with a pump speed of 2 800 rpm and a flow of 3.9 L/min. Twelve months after the surgery，the patient's ultrasound indicated an LVEDD of 60 mm，an LVEF of 29%，restoration of the aortic valve and cardiac cycle opening ratio to 1 ∶ 1，NYHA Class Ⅰ，and a 6-minute walk distance of 490 m. The dressing on the driveline cable woundwas changed once a day，with no abnormalities such as wound redness，effusion，or purulent secretions. The dressing onthe driveline cable wound was changed onceaday，withnoabnormalities such aswoundredness，effusion，orpurulent secretions. ConclusionLong-termimplantableVADis aneffectivetreatmentstrategy forpatients with acute myocardialinfarction combined with intractable cardiogenicshockand should beconsidered as earlyas possible. 

Key words:

"> Ventricularassist device, Acute myocardial infarction, Cardiogenic shock, Blood pump

摘要：

目的 探讨长期可植入式心室辅助救治急性心梗难治性心源性休克的可行性经验。方法 中国医学科学院阜外医院深圳医院 2019 年 11 月对 1 例急性心梗心源性休克合并心包填塞进行卵圆孔未闭修补术、冠状动脉旁路移植术和心室辅助装置 CH-VAD 血泵植入术治疗，术后早期观察血流动力学和器官灌注监测指标。出院后长期随访，应用经胸超声心动图、NYHA 心功能分级、6 分钟步行距离、心肺运动试验来评估心脏和活动耐量康复过程。结果 术中切开心包后有暗红色血性心包积液 150 ml，左心室心尖部显著变薄，周围组织水肿，3 点位置有陈旧性血栓形成。手术体外循环时间为 120 min，主动脉阻断时间为 55 min，主动脉侧壁阻断时间为 10 min。术后早期 CH-VAD 血泵转速在 2500 ～ 2900 r/min 调整，流量为 3.5 ~ 4.5 L/min，有创平均动脉压为 65 ~ 75 mmHg（1 mmHg ＝ 0.133 kPa），血乳酸、cTnI 和 cTnT 分别术后当天和第 7 天恢复至正常水平。术后 26 h 拔除气管插管，术后第 7 ~ 15 天出现反复短阵室速和室颤，期间反复非同步除颤 100 ~ 200 J，术后第 8 天再次气管插管，术后 90 d 顺利携带 CH-VAD 血泵出院，泵转速为 2800 r/min，流量为 3.9 L/min。患者术后 12 个月超声提示：LVEDD 为 60 mm，LVEF 为 29%，主动脉瓣与心动周期开放比恢复到 1：1，NYHA Ⅰ级， 6 分钟步行距离为 490 m。驱动线缆伤口每天换药 1 次，无伤口红肿、积液、脓性分泌物等异常。目前已携带CH-VAD 血泵生存 32 个月，生活质量良好。结论 长期可植入式 VAD 对于急性心肌梗死合并难治性心源性 休克患者是一种有效治疗策略，应尽早考虑。 

关键词:

"> 心室辅助装置 , 急性心梗 , 心源性休克 , 血泵