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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,病例简介,?,患者，女性，,35,岁，既往史无殊。,?,主诉：发热,2,天伴寒战、肌痛。,?,体检：体温,39.1,，血压,95/60,（,72,）,mmHg,，心率,110 BPM,，呼吸,20,次,/,分，氧饱和度,100,（氧流量,2L/min,）。四肢冷，肺音清，心音听诊示心,动过速，未及第三、第四心音或摩擦音。,?,患者很快出现低血压状态，需静滴去甲肾上腺素（,12,g,Kg/min,）以维持,血压。,?,实验室检查：肌钙蛋白,3.89ng/mL,（正常范围,0-0.08ng/mL,），静脉乳酸,3.5mmol/L,（正常范围,0.50-2.20mmol/L,），白血细胞计数,17.0,10,9,/L,（正,常范围,3.5-9.1,10,9,/L,），血红蛋白,12.4g/dL,（正常范围,13.3-16.2g/dL,），,肝肾功能在正常范围。,第一页，编辑于星期二：二点 十分。,病例简介?患者，女性，35岁，既往史无殊。?主诉：发热2天伴,病例简介,?,心电图：窦性心动过速，下侧壁导联,ST,段抬高。,第二页，编辑于星期二：二点 十分。,病例简介?心电图：窦性心动过速，下侧壁导联ST段抬高。第二页,病史简介,?,胸部,CTA,：双侧胸腔少量积液，未示肺栓塞表现。,?,床旁经胸超声心动图：大量心包积液，下腔静脉扩张，右心房和,右心室（,RV,）舒张期塌陷。,LVEF,目测估计为,45,至,50,。,?,冠状动脉造影：正常。,第三页，编辑于星期二：二点 十分。,病史简介?胸部CTA：双侧胸腔少量积液，未示肺栓塞表现。?床,病例简介,?,左右侧心导管检查结果,(Table 1),第四页，编辑于星期二：二点 十分。,病例简介?左右侧心导管检查结果(Table 1)第四页，编辑,病例简介,?,由于大量心包积液导致的舒张期压力上升，尽管升压药物剂量快,速增加但患者仍然出现日益恶化的酸中毒，持续的低血压和心动,过速。于是病人被送往手术室行心包开窗术以治疗心包填塞。,?,尽管心包开窗术成功，但术中患者休克状态恶化，给予紧急安置,IABP,。随后患者在初诊后,24,小时内被转运至哥伦比亚大学医学中,心心血管科进一步诊治。,?,到达中心时患者血压,83/63,（,70,）,mmHg,，窦速,130bpm,，尽管,1,：,1IABP,支持下血压可充至,90mmHg,，并已给予米力农,0.25,g/Kg,min,和去甲肾上腺素,15,g/Kg,min,静滴，但,4,小时之前病,人的尿量已经减少到,15cm,3,/h,，留置的,Swan-Ganz,肺动脉漂浮导管,提示增高的充盈压和低心输出量,(Table 2),。,?,考虑给予机械辅助循环支持治疗。,第五页，编辑于星期二：二点 十分。,病例简介?由于大量心包积液导致的舒张期压力上升，尽管升压药物,病例简介,第六页，编辑于星期二：二点 十分。,病例简介第六页，编辑于星期二：二点 十分。,病例简介,第七页，编辑于星期二：二点 十分。,病例简介第七页，编辑于星期二：二点 十分。,病例简介,?,病人被送往手术室行,CentriMag BIVAD,植入，同时行心内膜心肌活,检送病理检查。术中经食道超声心动图显示小心腔，,LVEF50% with medical therapy (Class II; Level,of Evidence B),?,Current Recommendations for,MCS,第二十二页，编辑于星期二：二点 十分。,ACCF/AHA 2009 HF guidelines：?C,HFSA comprehensive HF practice guidelines,：,?,Patients awaiting heart transplantation who have become refractory,to all means of medical circulatory support should be considered for,an MCS device as a BTT (Level of Evidence B),?,Permanent mechanical assistance with an implantable LVAD may be,considered in highly selected patients with severe HF refractory to,conventional therapy who are not candidates for heart,transplantation, particularly those who cannot be weaned from,intravenous inotropic support at an experienced HF center (Level of,Evidence B),?,Current Recommendations for,MCS,第二十三页，编辑于星期二：二点 十分。,HFSA comprehensive HF practice,HFSA comprehensive HF practice guidelines,：,?,Patients with refractory HF and hemodynamic instability and/or,compromised end-organ function with relative contraindications to,cardiac transplantation or permanent MCS expected to improve with,time or restoration of an improved hemodynamic profile should be,considered for urgent MCS as a bridge to decision; these patients,should be referred to a center with expertise in the management of,patients with advanced HF (Level of Evidence C),?,Current Recommendations for,MCS,第二十四页，编辑于星期二：二点 十分。,HFSA comprehensive HF practice,Canadian HF guidelines,：,?,MCS may be offered to selected individuals with end-stage heart,failure who are inotrope dependent and do not meet the traditional,criteria for cardiac transplantation (Class IIb; Level of Evidence B),?,Current Recommendations for,MCS,第二十五页，编辑于星期二：二点 十分。,Canadian HF guidelines：?MCS ma,ESC guidelines 2008/2010,：,?,Current indications for LVADs and artificial hearts include bridging to,transplantation and managing patients with acute, severe,myocarditis (Class IIa; Level of Evidence C),?,Although experience is limited, these devices may be considered for,long-term use when no definitive procedure is planned (Class IIb;,Level of Evidence C),?,LVAD may be considered as destination treatment to reduce,mortality (Class IIa; Level of Evidence B),?,Current Recommendations for,MCS,第二十六页，编辑于星期二：二点 十分。,ESC guidelines 2008/2010：?Curr,
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