2019 年第 3 期 第 14 卷

年龄对成人心脏外科术后心源性休克患者体外膜肺氧合辅助治疗效果的影响

Impact of age on outcomes following extracorporeal membrane oxygenation implantation in adult patients with postcardiotomy cardiogenic shock

作者：崔永超杜中涛江春景江瑜杨峰邢智辰徐博郭冬邢家林缪娜赵岩岩郝星王红侯晓彤

英文作者：

单位：100029首都医科大学附属北京安贞医院成人心脏危重症中心北京市心肺血管疾病研究所

英文单位：

关键词：心源性休克；体外模式氧合；高龄

英文关键词：

• 摘要：

• 【摘要】目的    评价不同年龄心脏外科术后心源性休克（PCCS）患者行动静脉体外膜肺氧合（VA-ECMO）辅助治疗的临床效果。方法    回顾性分析2006年9月至2016年12月首都医科大学附属北京安贞医院收治的成人（年龄≥18岁）PCCS行VA-ECMO辅助患者496例，其中年龄18~<65岁354例（非老年组），≥65岁142例（老年组）。比较2组患者一般临床资料、合并疾病、外科手术操作情况和启动VA-ECMO辅助之前疾病严重程度、成功撤机率和出院存活率、VA-ECMO相关并发症发生率和术后恢复情况，分析患者住院死亡的影响因素。结果    老年组患者合并高血压、高脂血症、冠状动脉粥样硬化性心脏病以及接受主动脉内球囊反搏辅助和肺动脉栓塞取栓术比例均高于非老年组，身高低于非老年组，差异均有统计学意义（均P<0.05）。非老年组患者成功撤机率和出院存活率均高于老年组［62.4%（221/354）比49.3%（70/142）、42.4%（150/354）比21.8%（31/142）］，需连续肾脏替代治疗（CRRT）的肾功能衰竭发生率低于老年组［44.1%（156/354）比61.3%(87/142)］，差异均有统计学意义（χ2=12.013、20.786、11.376， P=0.007、<0.001、0.001）。2组患者术后恢复情况和感染、再次开胸止血、严重神经系统并发症和严重下肢缺血等并发症发生率比较差异均无统计学意义（均P>0.05）。多元Logistic回归分析结果显示高龄、肾功能衰竭需行CRRT、严重神经系统并发症和严重下肢缺血是成人PCCS患者进行VA-ECMO辅助住院死亡的影响因素（比值比=3.38、9.65、11.08、6.14，95%置信区间：1.49~8.10、2.75~21.20、3.69~25.79、2.48~16.51， P=0.015、<0.001、<0.001、<0.001）。结论    VA-ECMO能够为成人PCCS患者提供有效循环辅助，部分老年患者能够从中获益，高龄是VA-ECMO辅助患者住院死亡的影响因素。

• 【Abstract】Objective    To analyze the impact of age on outcomes in adult patients who underwent venoartieral extracorporeal membrane oxygenation(VA-ECMO) support for postcardiotomy cardiogenic shock(PCCS). Methods    Totally 496 adult patients with PCCS who were implanted with VA-ECMO from September 2006 to December 2016 in Beijing Anzhen Hospital, Capital Medical University were retrospectively analyzed. The patients were divided into non-elderly group(18-<65 years old, n=354) and elderly group(≥65 years old, n=142). Clinical characteristics, comorbidities, major cardiac procedures, pre-ECMO conditions, weaning and survival from VA-ECMO, ECMO-related complications and postoperative outcomes were assessed. Results    The elderly group had significantly higher prevalences of comorbidities including hypertension, hyperlipidemia, coronary heart disease, intra-aortic balloon pump support, surgical history of pulmonary embolism and lower body length(P<0.05). Weaning from VA-ECMO was achieved in 62.4%（221/354） of the non-elderly group and 49.3%（70/142） of the elderly group; survival to discharge was 42.4%（150/354） among the non-elderly group and 21.8%（31/142） among the elderly group; the elderly group had a higher incidence of renal function dysfunction requiring continuous renal replacement therapy（CRRT）［44.1%(156/354) vs 61.3%(87/142)］(χ2=12.013， 20.786， 11.376； P=0.007， <0.001， 0.001). Adverse events including infection, re-exploration for bleeding, severe neurologic complication and severe limb ischemia were comparable in both groups(P>0.05). Multivariable logistic regression identified that advanced age, renal function dysfunction requiring CRRT, severe neurologic complication and severe limb ischemia were risk factors of in-hospital mortality in adult PCCS patients supported by VA-ECMO（odds ratio=3.38, 9.65, 11.08, 6.14; 95% confidence interval： 1.49-8.10, 2.75-21.20, 3.69-25.79, 2.48-16.51; P=0.015, <0.001, <0.001, <0.001）. Conclusion    VA-ECMO support can be used in adult patients with PCCS with acceptable adverse events. Some elderly patients can benefit from VA-ECMO but advanced age is a risk factor of in-hospital mortality.