1、主动脉内球囊反搏在心脏外科中的应用,北京安贞医院来永强,主动脉内球囊反搏,概念： 主动脉内球囊反搏（IABP）intra-aortic balloon counterpulsation 心脏辅助装置,IABP为主动脉内球囊反搏泵的简称，IABP是一种机械循环辅助方法，通过在左锁骨下动脉开口远端和肾动脉开口上方的降主动脉内植入一根带气囊的导管，在心脏舒张期气囊充气，在心脏收缩前气囊放气，达到辅助心脏功能的作用。,IABP可增加冠状动脉血流，改善外周循环，减少主动脉内舒张末容量及心脏收缩时左室后负荷,减少心肌耗氧，增加心肌收缩力，改善心功能。其有利因素为：左室舒张末压降低，心肌耗氧量降低，心输出量
2、增加 10%40%，冠状动脉峰值血流速度增加。,IABP适应证,1.各种原因引起的心脏功能衰竭。（1）急性心肌梗死并发心源性休克。（2）冠状动脉旁路移植围术期发生的心肌梗死。（3）体外循环心脏手术后低心排。（4）心脏挫伤。（5）中毒性休克。（6）病毒性心肌炎。,IABP适应证,2.急性心肌梗死后发生机械并发症。（1）室间隔穿孔。（2）乳头肌断裂致二尖瓣关闭不全。（3）冠心病合并大室壁瘤。,IABP适应证,3. 内科治疗无效的不稳定型心绞痛。4. 心肌缺血而致的心律失常。5. 进展性心肌梗死。6. 严重心肌缺血病人作冠脉造影，PTCA、溶栓。高危重症病人作心导管检查。,IABP适应证,7. 心脏
3、移植前的辅助治疗。8. 人工心脏的过渡治疗。9. 手术中产生搏动性血流。,IABP的禁忌症,主动脉瓣关闭不全。主动脉窦瘤破裂。腹部或胸部的主动脉瘤或夹层动脉瘤。严重动脉壁的钙化或外周血管瘤。不可逆的脑损伤或脑出血。慢性心脏病的晚期。,IABP应用指征,多巴胺用量15ug/Kg/min,或应用两种升压药难以维持血压。CI20mmHg。CVP15cmH2O。尿量80mmHg。尿量1mL/Kg/h。末梢循环好，手足暖。减慢反搏频率时，上述指标稳定。,IABP在心外手术中的应用,IABP对于衰竭的心脏是一种强有力的辅助措施，目前疗效优于药物。其辅助原理是心脏舒张期，气囊迅速充气，主动脉舒张压升高，冠状
4、动脉流量增加，心肌供氧增加；心脏收缩前，气囊迅速排气，主动脉压力下降，心脏后负荷下降，心脏射血阻力减少，心肌耗氧下降。故IABP虽对各种心脏病术后的低心排都有效，但以冠心病效果最好。,Evidence from this meta-analysis support the use of preoperative IABP in high-risk patients to reduce hospital mortality.,J Card Surg 2008;23:79-86,国外相关研究显示使用IABP可以显减少CABG术后病人死亡率，住院天数，术后低心排综合症以及CBP使用时间,The us
5、e of the preoperative intraaortic balloon pump (IABP) in patients with severe left ventricular dysfunction or unstable angina with critical coronary anatomy is becoming more frequent as surgical casemix changes. The aim of this study was to determine the impact of preoperative IABP use on survival i
6、n high-risk patients having open heart surgery.,Ann Thorac Surg.2001 Jul;72(1):54-7.,group A (preoperative IABP for high-risk nonemergent cases), group B (preoperative IABP for emergent cases), and group C (intra/postoperative IABP).high risk,” on the basis of poor left ventricular function or criti
7、cally ischemic hearts such as left main lesions or reoperative cases,The predicted versus actual hospital mortality rate was 20% versus 5.7% in group A, 32.1% versus 47.6% in group B, and 12.6% versus 22.2% in group CRisk-adjusted mortality was significantly lower in high-risk cases with preoperativ
8、e IABPs compared with emergent cases and intraoperative/postoperative IABPs. We encourage the use of preoperative IABPs in selected high-risk patients.,Risk-adjusted mortality was significantly lower in high-risk cases with preoperative IABPs compared with emergent cases and intraoperative/postopera
9、tive IABPs. We encourage the use of preoperative IABPs in selected high-risk patients.,Interact Cardiovasc Thorac Surg.2008 May;7(3):389-95. Epub 2008 Feb 6.,Intraaortic balloon pump replacement (IABP) is the most widely used circulatory assist device today and is utilized in a wide range of serious
10、 cardiovascular conditions. We examined the effects on mortality of pre-, intra-, or postoperative IABP support in patients undergoing cardiac surgery compared to high-risk patients without IABP support.,First, the mean EuroSCORE predicted mortality and the actual mortality rates do not statisticall
11、y differ among patients with preoperative IABP insertion. Second, patients without preoperative IABP insertion have a higher actual mortality than predicted. Third, the actual mortality among patients with intra- and postoperative IABP use also proved to be significantly higher than predicted by the
12、 EuroSCORE.,patients without preoperative IABP placement had the highest overall actual mortality and non-emergency patients performed significantly worse than predicted. This finding advocates an early preoperative IABP insertion to reduce mortality, at least to the predicted value.,There is no acc
13、epted consensus on the definition of high-risk patients who may benefit from the use of intraaortic balloon pump (IABP) in coronary artery bypass grafting (CABG). The aim of this study was to develop a risk model to identify high-risk patients and predict the need for IABP insertion during CABG.,Ann
14、 Thorac Surg. Author manuscript; available in PMC 2011 February 1.,Results of Univariate Analysis,Three risk groups were identified: low-risk (IABP score 0 to 6), medium-risk (IABP score 7 to 13), and high-risk score (IABP score 14). The incidence of IABP insertion and mortality were, respectively,
15、0.9% and 0.7% in the low-risk group, 7.2% and 2.8% in the medium-risk group, and 36.4% and 9.1% in the high-risk group,Relationship between risk score and probability of intraoperative or postoperative intraaortic balloon pump (IABP) insertion.,Specifically, patients in the high-risk (score 14) medi
16、um-risk (score 7 to 13), and low-risk group (score 6) had 36.4%, 10.6%, and 1.7% probability of IABP insertion, respectively high-risk patients who may benefit from elective insertion of IABP during CABG,Dislocations of the heart required for exposure and construction of distal anastomoses often pro
17、duce hemodynamic instability when performing coronary artery revascularization without using cardiopulmonary perfusion (OPCAB). We report our early experience with elective intraaortic balloon counterpulsation (IABP) to enable and facilitate selected high-risk patients to undergo OPCAB.,Ann Thorac S
18、urg 2001;71:1220-1223,This study sought the protective effect of IABP in reducing the susceptibility of acute perioperative stresses on an injured heart caused by displacement during OPCAB by supporting hemodynamic stability and reducing its myocardial oxygen demand. This benefit is of particular va
19、lue for hearts that are more vulnerable because of severe proximal multivessel coronary disease,ventricular hypertrophy, and dysfunction.,we believe this strategy in using IABP selectively can allow surgeons to safely extend the benefits of OPCAB procedures to high-risk patients and avoid dangerous
20、hemodynamic instability that otherwise, often occurs.,国内也有报道，在术前预防性的放置IABP对重症冠心病患者的预后有很大改善,我们对安贞医院近1年来重症冠心病的35位患者进行跟踪调查，其中18例（51.4%）的患者在术中或者术后24小时内行IABP辅助治疗，放置IABP患者的心功能均较未放置IABP组的患者有明显好装，并且ICU住院时间和呼吸机辅助时间均有所减少。,重症冠心病患者的概念是严重的左主干病变，EF35或术前有心源性休克的患者以及复杂冠心病外科治疗患者(如一些需处理心梗后机械并发症的手术患者，包括室壁瘤切除、室间隔穿孔修补、二尖
21、瓣腱索断裂的瓣膜置换),这些重症患者的特点是术前心功能差，心肌收缩功能受损，术中不耐受搬动，术后可能伴有心脏结构变化及左室容量减少，使这些患者在术后心脏创伤期都要经历一个心脏低排的过程，故术前应用IABP帮助心脏度过创伤期是十分必要的，可降低术后低心排的发生率。,IABP并发症及意外,下肢缺血穿刺部位渗血血小板减少机器故障球囊破损（囊内血栓形成）感染主动脉撕裂球囊误入股静脉球囊误入对侧股动脉导丝嵌顿导管置入困难接头漏气,The intra-aortic balloon pump (IABP) is widely used to provide circulatory support forpa
22、tients experiencing hemodynamic instability due to myocardial infarction, cardiogenicshock, or in very high risk patients undergoing angioplasty or coronary artery bypass grafting.,Journal of the American College of Cardiology Volume 38, Issue 5，1 November 2001, Pages 1456-1462,The major finding of
23、this study is that the incidence ofmajor balloon-related complications is encouragingly low (2.8%). Advances such as percutaneous insertion and smaller-diameter catheters have considerably reduced the incidence of serious vascular complications. In addition,the incidence of unsuccessful IABP due to
24、balloon leak, poor inflation, poor augmentation or insertion difficulty was extremely low (2.3%), and to our knowledge, no previous study has examined this issue.,我们对2007年1月1日至2009年10月1日在安贞医院放置IABP的患者232例通过回顾性病例分析，探讨主动脉内球囊反搏（IABP）应用前、后血小板计数的变化规律。 并分析IABP相关血小板减少症的发生和患者疾病转归之间的联系。,血小板减少症诊断标准为血小板总体计数小于1
25、00,000/mm3；和/或IABP放置期间患者血小板计数值较其基础值降低大于50%。,统计结果显示术前放置组血小板减少症的发生率明显低于术中放置组和术后放置组（P0.01）。而术中放置组和术后放置组之间并无明显差别（P0.05）。,对于在围术期的不同时段放置IABP的患者，其放置IABP后血小板减少症的发生率存在差异，术前放置组血小板减少症的发生率明显低于术中放置组和术后放置组。这提示术前预防性使用IABP可减少IABP相关血小板减少症的发生。原因可能是术前预防性应用IABP可以使患者围术期期间血流动力学更加平稳，降低严重低血压和术后低心排的发生率，有利于患者整体恢复，而术中和术后放置IABP多在被迫情况下，患者生命体征多不平稳，病情危重，血小板减少症发生率相应也较高。,谢 谢,
