Emergent Percutaneous Coronary Intervention under Extracorporeal Membrane Oxygenation Support for a Patient with Inferior St Elevation Myocardial Infarction and Refractory Shock: A Case Report and Lit

在體外膜氧合支援下的緊急經皮冠狀動脈介入來治療下壁ST段升高心肌梗塞合併頑固性休克的病人：一病例報告及文獻回顧

宋立勤(Li-Chin Sung) ； 陳郁志(Yu-Chih Chen) ； 張比嵩(Bee-Song Chang)

《重症醫學雜誌》 10卷3期 (2009/09) Pp. 248-255

摘要

主動脈內氣球幫浦支持下的早期緊急血管再通術對於急性心肌梗塞合併心因性休克的病人是必要的。我們報告一個急性心肌梗塞導致心因性休克病人的經驗，其對於傳統的治療，包括主動脈內氣球幫浦無效且無法進行後續的血管再通術。我們使用體外膜氣合來當做進一步血行動力支持，並且施行成功的血管再通術。然而這病人術後並無法脫離體外膜氧合，五天後我們觀察到疑似乳頭肌斷裂所引起的重度二尖瓣膜逆流。這個病人後來接受二尖瓣膜置換而成功地存活且出院。故使用體外膜氧合可做血行動力支持以利血管再通及回復休克所引起的器官傷害。當這類已接受成功血管再通後的下後壁心肌梗塞病人，其血行動力仍不穩定時，我們必須想到是二尖瓣膜逆流所引起的休克及心衰竭。我們另外討論急性下壁心肌梗塞合併二尖瓣膜逆流及頑固性休克的處理。

關鍵字

急性心肌梗塞 ； 心因性休克 ； 體外膜氧合 ； 重度二尖瓣膜逆流

並列摘要

Early emergency revascularization with intra-aortic balloon pump (IABP) support is mandatory for patients with acute myocardial infarction (AMI) and concomitant cardiogenic shock. We report our experience with a patient of cardiogenic shock caused by an AMI refractory to conventional therapies including IABP that impede subsequent revascularization procedures. We used extracorporeal membrane oxygenation (ECMO) to provide further hemodynamic support and performed successful revascularization. However, the patient failed to wean from ECMO and severe mitral regurgitation with suspected papillary muscle rupture was observed 5 days later. The patient later underwent mitral valve replacement, survived and was discharged from the hospital. The use of ECMO can support hemodynamics for revascularization and reverse shock-induced organ damage. The shock and heart failure caused by mitral regurgitation should be considered in patients with inferoposterior AMI after successful revascularization, who are still hemodynamically unstable. We also discuss the management regarding inferior AMI with mitral regurgitation and refractory shock.

並列關鍵字

Acute myocardial infarction ； Cardiogenic shock ； Extracorporeal membrane oxygenation ； Severe mitral regurgitation