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主动脉球囊反搏在心脏危 重症中的临床应用 Intra Aortic Balloon Pump 张瑞岩 上海交通大学医学院附属瑞金医院心脏科 www.rjh.com.cn Case No.1 Male ,71y Acute STEMI, Cardiogenic Shock Coronary risk: Hypertension, smoking www.rjh.com.cn Immediate Coronary Angiography www.rjh.com.cn Primary PCI with IABP support www.rjh.com.cn Case No.2 • Female, 67y • Acute Non-STEMI, Cardiogenic Shock • Coronary risk: hypertension www.rjh.com.cn Coronary Angiography www.rjh.com.cn Immediate PCI with IABP Support www.rjh.com.cn History of IABP • 1952, Adrian and Arthur Kantrowitz: principle tested in experimental animals • 1962, Moulopoulos et al. developed an intraaortic device • 1968, Kantrowitz et al. reported the use of IABP in 2 pts with cardiogenic shock • 1980, Bregman et al. described percutaneous insertion of IABP www.rjh.com.cn Innovation in Industry KONTRON MODEL 10 IABP AVCO MODEL 7 IABP Prototype Pump ACAT® 1 PLUS IABP KAAT AND K 2000 IABPs TransAct® IABP www.rjh.com.cn Hemodynamic Principles of IABP A: cardiac diastole - inflation • Diastolic pressure↑ • Coronary artery flow↑ • Great vessel & renal artery flow↑ B: cardiac systole - deflation • Forward flow to the aorta and periphery↑ www.rjh.com.cn Hemodynamic Effects • Diastolic inflation---augmentation of DBP Increase coronary and systemic perfusion Increase in myocardial oxygen supply • Systolic deflation---afterload reduced Reduce LV wall stress Decrease myocardial oxygen demand Increase in cardiac output www.rjh.com.cn Device Components and Selection • • Components: (1) a double-lumen 8F~9.5F catheter with a 25~50ml balloon at its distal end; (2) a console with a pump to deliver gas to the balloon Selection of the balloon: fully expanded balloon diameter ≤85%~90% of the diameter of the patient’s descending thoracic aorta >183cm:50ml 163~183cm: 40ml 152~162cm:30ml <152cm: 25ml The tip of the catheter should be positioned 2~3cm distal to the origin of the LSA www.rjh.com.cn Triggers & Interpretation of IABP • Triggers: EKG waveform & systemic arterial pressure • Depending on the patient’s status (1:1, 1:2, 1:4,1:8) • Optimal arterial wave forms with IABP Peak diastolic augmentation should be greater than the unassisted systolic pressure The 2 assisted pressures should be less than the unassisted values www.rjh.com.cn Timing D>C; B+C>D+E www.rjh.com.cn Interpretations • Optimal arterial waveform Diastolic augmentation >unassisted systolic pressure 2 assisted pressures <the unassisted values www.rjh.com.cn Interpretations • Balloon inflation occurs too early (before aortic valve closure) LV afterload↑ Myocardial oxygen consumption↑ LV systolic function↓ www.rjh.com.cn Interpretations • Balloon inflation occurs too late (well after the beginning of diastole) Minimizing the diastolic augmentation www.rjh.com.cn Interpretations • Balloon deflation occurs too early (before the end of diastole) Diastolic pressure augmentation period↓ Transient decrease in aortic pressure may promote retrograde arterial flow from the carotid or coronary arteries www.rjh.com.cn Interpretations • Balloon deflation occurs too late (after the end of diastole) As early balloon inflation LV afterload↑ Myocardial oxygen consumption ↑ LV Systolic function↓ www.rjh.com.cn Indications for Use • Cardiogenic shock (complicated AMI, RV failure) • Cardiogenic shock due to VSR or papillary muscle rupture, with resultant mitral regurgitation (mechanical complications of AMI or trauma) • Intractable ventricular arrhythmias • Post-MI angina or unstable angina refractory to medical therapy • Severe CAD with hemodynamic compromise (left main disease) • Heart failure refractory to medical therapy • Hemodynamic support for “high-risk” coronary intervention • Hemodynamic support for high-risk CABG • Bridge to heart transplantation • Septic shock www.rjh.com.cn Shock Registry in-hospital mortality by IABP/Lytic use www.rjh.com.cn The use of IABP in patients with cardiogenic shock complicating AMI: data from the National Registry of Myocardial Infarction 2 • Retrospective analysis of 23,180 AMI patients complicated by cardiogenic shock • IABP was used in 7,268 patients Barron HV, et al. AHJ 2001;141:933 www.rjh.com.cn PAMI-2 Trial Study Design www.rjh.com.cn PAMI-2 Trial Conclusions • IABP was associated with fewer ischemic events, repeat interventions, re-infarction, and congestive heart failure episodes • The vascular complication rate was low in IABP group (2.2%) • No benefit of IABP was observed among low risk patients with AMI www.rjh.com.cn ACC/AHA IABP Practice Guidelines Clinical situation ACC/AHA recommendation Level of evidence IIa C I C I B IIb C IIa B Unstable angina (refractory to intensive medical care, for hemodynamic instability in pts pre- and post- coronary intervention) Recurrent ischemia/infarction (hemodynamic instability, poor LV function, or a large area of myocardium at risk) Cardiogenic shock (not quickly reversed with pharmacological therapy) CHF (w/ refractory pulmonary congestion) Polymorphic VT (refractory to medical management) www.rjh.com.cn ACC/AHA Guidelines for STEMI 2004 Treatment of low-output state/cardiogenic shock • Class I Fluids, inotropic support, IABP… Mechanical reperfusion with PCI or CABG if age<75y, early shock (<18hrs) Surgical correction of mechanical defects Fibrinolytic therapy if not suitable for invasive approach • Class IIa Early revasc. in selected patients >=75yrs old, if good prior functinal status and present early • Class III – not recommended or contraindicated Beta-blockers Calcium channel antagonists www.rjh.com.cn Contraindications to IABP • Aortic regurgitation • Suspected or known aortic dissection • Sizable abdominal aneurysm • Severe peripheral vascular disease • Uncontrolled septicemia or a bleeding diathesis www.rjh.com.cn Concomitant Medications, Weaning and Removal • UFH to maintain APTT 50s~70s • An immobile IABP should be removed within 30 minutes • Discontinue heparin >= 2 hours before removal • Periodically inflating IABP to prevent hemostasis and thrombosis • If a patient tolerates a 1:3 ratio, the IABP can be removed www.rjh.com.cn Complications of IABP • Vascular complications bleeding, systemic embolization, limb ischemia and amputation, aortic dissection • Mechanical complications balloon rupture, inadequate inflation, inadequate diastolic augmentation • Infection • Death www.rjh.com.cn Complication Frequency 7.00% 6.00% 4.00% 0.80% 0.90% limbthreatening ischemia 2.00% major bleeding 2.60% 0.10% limb amputation major total 0.00% 0.05% death 8.00% Age>=75y PVD DM Female BSA<1.65m2 www.rjh.com.cn Hematologic Effects • Hemoglobin and hematocrit often decrease modestly (hemolysis from mechanical damage to erythrocytes and bleeding at the vascular access site) • Thrombocytopenia (mechanical destruction of platelet, heparin administration) www.rjh.com.cn Daily Evaluation after IABP • • • • • • • • • Sepsis Thrombocytopenia Blood loss Hemolysis Vascular obstruction Thrombus Embolus Dissection APTT www.rjh.com.cn Conclusions • IABP is one of the most versatile support device used in the management of patients suffering from complications of acute cardiovascular disease • Relative ease and quick use of IABP leads to its application as a first line intervention among critically unstable patients • Improved risk-benefit ratio has achieved with the improvement in technology and refined percutaneous insertion techniques • IABP should probably be applied more often in certain clincal situations to enhance patient outcomes www.rjh.com.cn Thanks ! www.rjh.com.cn