心源性休克就的诊断和治疗.pptVIP

Left Ventricular Assist Devices The two left ventricular assist devices used in this study were the pulsatile-flow HeartMate XVE and the continuous-flow HeartMate II (both from Thoratec). These implanted pumps draw blood from the apex of the left ventricle and deliver it to the ascending aorta. Both are electrically driven by means of a percutaneous lead that connects the pump to an external system controller and power source (Fig. 1, and the animation16 available with the full text of this article at NEJM.org). The con- tinuous-flow left ventricular assist device has a volume of 63 ml and a weight of 390 g, as com- pared with 450 ml and 1250 g for the pulsatile- flow left ventricular assist device. Both devices are capable of a flow rate up to 10 liters per min- ute at a mean pressure of 100 mm Hg. Antithrom- botic management included aspirin for all pa- tients and warfarin (with a targeted international normalized ratio of 2.0 to 3.0) only for those with the continuous-flow device. 心源性休克的诊断和治疗 国家心血管病中心 阜外心血管病医院 心力衰竭中心 心衰监护病房 张 健 心原性休克 临床定义1 是在心脏充盈压足够大的时候心输出量降低、组织低灌注的综合征(HF导致的终末器官低灌注) - 明显而持续(30 min) 的低血压 SBP 90 mmHg或原有HT患者SBP降幅 ≥60 mmHg。平均动脉压降幅≥30 mmHg - 心指数降低 (2.2 L/min/M2) - 肺毛细血管楔压正常或升高 (15 mmHg) 2Hollenberg Ann Int Med 1999; 131:47-99 1Forrester JS et al 1976; 295:1404-13 3Circulation. 2008;117:686-697 NRMI STEMI Registry1 N=25,311 入选1995.1 - 2004.5的 293,633 STEMI 或新发的LBBB 美国775能够实施 PCI的医院 25,311 (8.6%) pts发展成为CS 心原性休克的频率 JAMA 2005 294:448 NEJM 1991; 325:1117 JACC 1995 26:668 CS 的发生率高 NRMI 注册研究1 Worcester Heart Attack Study2 1975-88 ? 7.5% CS Gusto-13 1995 ? 7.2% CS 病理生理 当左室心肌发生较大面积坏死时，心脏泵功能损害，SV和CO下降 心肌和冠状动脉灌注不良导致心动过速和低血压 LVEDP 增加，降低了冠脉灌注 LV 壁张力增加，增加心肌耗氧量 乳酸堆积，恶化了心肌能量代谢 心源性休克的常见病因 1. 心脏急性病变 (1) 急性心肌梗死 (2) 急性重症心肌炎 (3) 围生期心肌病 (4) 应激性心肌病 (5) 药物所致的心肌损伤，如抗肿瘤药物和毒物等 (6) 急性心脏瓣膜病变：感染性心内膜炎或创伤所致急性瓣膜大量返流 2.慢性心脏病急性加重 （1）缺血性心肌病 （2）非缺血性心肌病 （3）瓣膜性心脏病 （4）先天性心脏病 3.终末期心衰 4.急性大块肺栓塞 5.急性心包填塞 心源性休克的诱发因素 1.感染 2.血容量减少。出血如应激性溃疡等、大汗 3.不恰当