主动脉内球囊反搏

主动脉内球囊反搏主动脉内球囊反搏概念：

主动脉内球囊反搏（IABP）intra-aorticballooncounterpulsation

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。CI<2.0L/min/m2。动脉收缩压<80mmHg。左房压>20mmHg。CVP>15cmH2O。尿量<0.5mL/Kg/h。末梢循环差，手足凉。IABP辅助有效的指标升压药的用量逐渐减少。CO增加。血压逐渐回升。心率（律）恢复正常。尿量增加。末梢循环改善，手足变暖。IABP停用指征多巴胺用量<5ug/Kg/min。CI>2.5L/min/m2。平均动脉压>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。Evidencefromthismeta-analysissupporttheuseofpreoperativeIABPinhigh-riskpatientstoreducehospitalmortality.JCardSurg2008;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Theuseofthepreoperativeintraaorticballoonpump(IABP)inpatientswithsevereleftventriculardysfunctionorunstableanginawithcriticalcoronaryanatomyisbecomingmorefrequentassurgicalcasemixchanges.TheaimofthisstudywastodeterminetheimpactofpreoperativeIABPuseonsurvivalinhigh-riskpatientshavingopenheartsurgery.AnnThoracSurg.2001Jul;72(1):54-7.groupA(preoperativeIABPforhigh-risknonemergentcases),groupB(preoperativeIABPforemergentcases),andgroupC(intra/postoperativeIABP).highrisk,”onthebasisofpoorleftventricularfunctionorcriticallyischemicheartssuchasleftmainlesionsorreoperativecasesThepredictedversusactualhospitalmortalityratewas20%versus5.7%ingroupA,32.1%versus47.6%ingroupB,and12.6%versus22.2%ingroupCRisk-adjustedmortalitywassignificantlylowerinhigh-riskcaseswithpreoperativeIABPscomparedwithemergentcasesandintraoperative/postoperativeIABPs.WeencouragetheuseofpreoperativeIABPsinselectedhigh-riskpatients.Risk-adjustedmortalitywassignificantlylowerinhigh-riskcaseswithpreoperativeIABPscomparedwithemergentcasesandintraoperative/postoperativeIABPs.WeencouragetheuseofpreoperativeIABPsinselectedhigh-riskpatients.InteractCardiovascThoracSurg.2008May;7(3):389-95.Epub2008Feb6.Intraaorticballoonpumpreplacement(IABP)isthemostwidelyusedcirculatoryassistdevicetodayandisutilizedinawiderangeofseriouscardiovascularconditions.Weexaminedtheeffectsonmortalityofpre-,intra-,orpostoperativeIABPsupportinpatientsundergoingcardiacsurgerycomparedtohigh-riskpatientswithoutIABPsupport.First,themean

EuroSCOREpredictedmortalityandtheactualmortalityrates

donotstatisticallydifferamongpatientswithpreoperative

IABPinsertion.Second,patientswithoutpreoperativeIABPinsertion

haveahigheractualmortalitythanpredicted.Third,theactual

mortalityamongpatientswithintra-andpostoperativeIABP

usealsoprovedtobesignificantlyhigherthanpredictedby

theEuroSCORE.

patientswithoutpreoperativeIABPplacementhadthehighest

overallactualmortalityandnon-emergencypatientsperformed

significantlyworsethanpredicted.Thisfindingadvocatesan

earlypreoperativeIABPinsertiontoreducemortality,atleast

tothepredictedvalue.

Thereisnoacceptedconsensusonthedefinitionofhigh-riskpatientswhomaybenefitfromtheuseofintraaorticballoonpump(IABP)incoronaryarterybypassgrafting(CABG).Theaimofthisstudywastodevelopariskmodeltoidentifyhigh-riskpatientsandpredicttheneedforIABPinsertionduringCABG.AnnThoracSurg.Authormanuscript;availableinPMC2011February1.ResultsofUnivariateAnalysis

Threeriskgroupswereidentified:low-risk(IABPscore0to6),medium-risk(IABPscore7to13),andhigh-riskscore(IABPscore>14).TheincidenceofIABPinsertionandmortalitywere,respectively,0.9%and0.7%inthelow-riskgroup,7.2%and2.8%inthemedium-riskgroup,and36.4%and9.1%inthehigh-riskgroupRelationshipbetweenriskscoreandprobabilityofintraoperativeorpostoperativeintraaorticballoonpump(IABP)insertion.

Specifically,patientsinthehigh-risk(score>14)medium-risk(score7to13),andlow-riskgroup(score<6)had36.4%,10.6%,and1.7%probabilityofIABPinsertion,respectively

high-riskpatientswhomaybenefitfromelectiveinsertionofIABPduringCABGDislocationsoftheheartrequiredforexposureandconstructionofdistalanastomosesoftenproducehemodynamicinstabilitywhenperformingcoronaryarteryrevascularizationwithoutusingcardiopulmonaryperfusion(OPCAB).Wereportourearlyexperiencewithelectiveintraaorticballooncounterpulsation(IABP)toenableandfacilitateselectedhigh-riskpatientstoundergoOPCAB.AnnThoracSurg2001;71:1220-1223ThisstudysoughttheprotectiveeffectofIABPinreducingthesusceptibilityofacuteperioperativestressesonaninjuredheartcausedbydisplacementduringOPCABbysupportinghemodynamicstabilityandreducingitsmyocardialoxygendemand.Thisbenefitisofparticularvalueforheartsthataremorevulnerablebecauseofsevereproximalmultivesselcoronarydisease,ventricularhypertrophy,anddysfunction.webelievethisstrategyinusingIABPselectivelycanallowsurgeonstosafelyextendthebenefitsofOPCABprocedurestohigh-riskpatientsandavoiddangeroushemodynamicinstabilitythatotherwise,oftenoccurs.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，EF≤35％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Theintra-aorticballoonpump(IABP)iswidelyusedtoprovidecirculatorysupportforpatientsexperiencinghemodynamicinstabilityduetomyocardialinfarction,cardiogenicshock,orinveryhighriskpatientsundergoingangioplastyorcoronaryarterybypassgrafting.JournaloftheAmericanCollegeofCardiologyVolume38,Issue5，1November2001,Pages1456-1462Themajorfindingofthisstudyisthattheincidenceofmajorballoon-relatedcomplicationsisencouraginglylow(2.8%).Advancessuchaspercutaneousinsertionandsmaller-diametercathetershaveconsiderablyreducedthe