心源性休克的诊断和治疗.ppt

*LeftVentricularAssistDevicesThetwoleftventricularassistdevicesusedinthisstudywerethepulsatile-flowHeartMateXVEandthecontinuous-flowHeartMateII(bothfromThoratec).Theseimplantedpumpsdrawbloodfromtheapexoftheleftventricleanddeliverittotheascendingaorta.Bothareelectricallydrivenbymeansofapercutaneousleadthatconnectsthepumptoanexternalsystemcontrollerandpowersource(Fig.1,andtheanimation16availablewiththefulltextofthisarticleatNEJM.org).Thecon-tinuous-flowleftventricularassistdevicehasavolumeof63mlandaweightof390g,ascom-paredwith450mland1250gforthepulsatile-flowleftventricularassistdevice.Bothdevicesarecapableofaflowrateupto10literspermin-uteatameanpressureof100mmHg.Antithrom-boticmanagementincludedaspirinforallpa-tientsandwarfarin(withatargetedinternationalnormalizedratioof2.0to3.0)onlyforthosewiththecontinuous-flowdevice.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3Circulation.2008;117:686-697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(30min)的低血压SBP90mmHg或原有HT患者SBP降幅≥60mmHg。平均动脉压降幅≥30mmHg - 心指数降低(2.2L/min/M2) - 肺毛细血管楔压正常或升高(15mmHg)2HollenbergAnnIntMed1999;131:47-991ForresterJSetal1976;295:1404-13CS的发生率高NRMISTEMIRegistry1N=25,311入选1995.1-2004.5的293,633STEMI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JAMA2005294:448NEJM1991;325:1117JACC199526:668NRMI注册研究1WorcesterHeartAttackStudy21975-88?7.5%CSGusto-131995?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01心肌和冠状动脉灌注不良导致心动过速和低血压02LVEDP增加，降低了冠脉灌注03LV壁张力增加，增加心肌耗氧量04乳酸堆积，恶化了心肌能量代谢05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.急性心包填塞感染血容量减少。出血如应激性溃疡等、大汗不恰当