在2016年中原心脏病学大会中，来自中国医学科学院阜外医院外科术后恢复中心 的陈祖君教授带来了题为“围手术期心衰的管理”的精彩报告
一
发生于什么病人？
◆It often occurs in patients with underlying chronic heart failure;
◆However, it may occasionally present in patients with preserved left ventricular ejection fraction and possibly left ventricular diastolic dysfunction .
◆With such prevalence and complexity, acute perioperative heart failure management is a major challenge for physicians
EPIDEMIOLOGY AND OUTCOME
◆Based on recent American Heart Association statistics, incidence of heart failure has remained stable over the past several decades with more than 650 000 new cases of heart failure diagnosed annually.
◆Approximately, more than 5 million persons in the USA clinically manifest heart failure and the prevalence continues to rise .
◆Hence, the number of patients with heart failure presenting for surgery is growing significantly.
围手术期心衰的发生率？
◆Incidence of major cardiac complications after major noncardiac surgery is between 2 and 3.5% .
◆In cardiac surgery, the incidence rises to 20% or more.
◆Contemporary data showed that the cumulative total mortality rate of acute heart failure at 1 year was between 24 and 33% .
DEFINITION AND CAUSE OF ACUTE PERIOPERATIVE HEART FAILURE
◆Heart failure is a complex clinical syndrome that results from various structural or functional impairment of ventricular filling or ejection of blood
◆Acute heart failure presents frequently as pulmonary oedema, or left/right/biventricular congestive heart failure, sometimes as cardiogenic shock .
◆The majority of acute perioperative heart failure occurs in patients who have decreased cardiovascular reserve prior to surgery.
◆Cardiac surgery may lead to some unique causes of heart failure.
◆Indeed, mechanical complications including spasm or occlusion of a coronary graft, prosthetic paravalvular regurgitation, cardiac tamponade, and pneumo or hemothorax may be seen after cardiac surgery
DIAGNOSIS AND MONITORING
◆For years, the diagnosis of acute heart failure was based on clinical signs and was confirmed by echocardiography.
◆Recently, the use of plasma biomarkers (mainly natriuretic peptides) has shown great diagnostic value.
左-呼吸，右-恶心
◆The diagnosis of acute perioperative heart failure is still principally based on history and clinical findings.
◆In the perioperative setting, acute heart failure patients present with orthopnea related to increased left-sided filling pressures, and abdominal discomfort, nausea and vomiting caused by rightsided overload.
体检发现：
The physical examination may demonstrate signs of heart failure severity: hypotension, tachycardia, dyspnea, hepatic congestion, oliguria, cyanosis, mottling and disorder of consciousness.
心源性休克
◆The association of low cardiac output and tissue hypoxia in the absence of hypovolemia define cardiogenic shock.
◆The diagnosis can be supported by appropriate investigations such as electrocardiogram, chest radiograph, echocardiography, pulmonary artery catheter and biomarkers.
诱发因素
◆In the perioperative period, patients may be faced with numerous triggers of acute heart failure, including hypertension, tachyarrhythmias, anemia, hypercoagulability, inappropriate fluid management, pain, surgical stress and myocardial ischaemia.
◆Other possible causes of perioperative heart failure include acute or chronic valvular heart disease, pulmonary or fat emboli, which can be presented as acute right ventricular failure.
TOE的诊断重要性
◆Intraoperative and postoperative transoesophageal echocardiography (TOE) and postoperative transthoracic echocardiography should be performed as early as possible in patients suspected of perioperative heart failure.
◆Echocardiography quickly provides data on regional or global, right and/or left ventricular dysfunction, the presence of tamponade,cardiac thrombi, valvular dysfunction and preload estimation.
TOE--帮助评估最佳容量状态
◆The role of TOE is important for perioperative haemodynamic monitoring and the assessment of the optimal volume status.
◆Preload estimation through the measurement of left ventricular end diastolic area, and estimation of fluid responsiveness by dynamic indicators enables real time guidance for volume therapy.
肺动脉导管的作用
◆Although the role of pulmonary artery catheterization is contentious, it can be very useful for explaining a complex perioperative haemodynamic situation.
◆The diagnosis of severe acute heart failure is suspected by the association of low cardiac index (<2.2 l/min/m2), low mixed venous saturation (<60%) and elevated pulmonary capillary wedge pressure (>18 mmHg).
血生化指标--钠尿肽的诊断作用
◆Biomarkers are very useful in less severe acute heart failure when the mechanism of postoperative acute dyspnea is unclear, and when there is an urgent need to discriminate pulmonary infection and pulmonary oedema.
◆Currently, the diagnostic role of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) in the perioperative period remains to be demonstrated.
◆These biomarkers have the potential to strengthen the diagnosis of acute perioperative heart failure when used in conjunction with history, physical exam and other diagnostic tools.
MANAGEMENT OF PERIOPERATIVE HEART FAILURE
Management of acute heart failure in the perioperative period requires rapid diagnosis and treatment to prevent further myocardial and organ dysfunction.
对病人进行危险分层(risk stratification）的作用
◆Patients identifiedRisk stratification may be a valuable tool in the setting of acute perioperative heart failure.
◆At high risk may benefit from aggressive optimization of drug or device therapy, avoiding known triggers of acute heart failure, and identifying the appropriate postoperative care setting.
二
如何发现高危病人?
The goals of preoperative evaluation in noncardiac surgery are to gather information concerning the risk for cardiac events pertaining to surgery (urgency, type, magnitude, duration and blood loss), the functional capacity measured in metabolic equivalents (METs)
李改良心脏风险指数
◆心脏风险指数能准确预测非心脏手术患者围手术期心血管事件风险
◆修订心脏风险指数（Revised Cardiac risk index，RCRI）常被广泛应用于预测患者围手术期的心血管事件和死亡风险
◆Five independent clinical determinants of major perioperative cardiac events:
—a history of ischaemic heart disease
—heart failure,
—cerebrovascular disease
—insulin-dependent diabetes
—mellitus and impaired renal function.
欧洲心脏病学会(ESC）指南
According to the 2009 ESC guidelines,noninvasive testing of ischaemic heart disease (physiological exercise, stress echocardiography and myocardial perfusion imaging) are indicated before noncardiac surgery in patients with a stable cardiac condition scheduled for an intermediate or high-risk surgery, with a poor functional capacity (MET ≤ 4) and a Lee Index of at least 3.
没有诱发心肌缺血的病人
◆Patients without stress-induced ischaemia can proceed with the planned surgical procedure.
◆It is recommended that statin therapy and a titrated low-dose β-blocker regimen be initiated.
诱发心肌缺的病人
◆In patients with extensive stress-induced ischaemia, as assessed by noninvasive testing, individualized perioperative management is recommended, taking into consideration the potential benefit of the proposed surgical procedure compared with the predicted adverse outcome.
◆Also, the effect of medical therapy and/or coronary revascularization must be assessed.
EuroSCORE
◆The European system for cardiac operation risk evaluation (EuroSCORE) is widely used for predicting in-hospital mortality after cardiac surgery.
◆EuroSCORE II is better calibrated than the original model yet preserves powerful discrimination.
NT,BNP
◆In addition to noncardiac and cardiac surgery scoring systems, BNP and NT-pro-BNP levels at admission could be an additional risk stratification factor.
◆In coronary artery bypass graft surgery patients, increased perioperative BNP concentrations independently associate with heart failure hospitalization or heart failure death during the 5 years after surgery.
◆In another study including patients undergoing emergency noncardiac procedures, preoperative NT-pro-BNP ≥ 1740 pg/ml was associated with a 6.9-fold univariate relative risk (95% CI: 3.5–13.4) for in-hospital major adverse cardiac events, but did not remain significant in a multivariate logistic regression model .
◆In a recent systematic review and meta-analysis in noncardiac surgery patients, increased postoperative BNP and NT-pro-BNP are independently associated with increased risk of mortality, myocardial infarction (MI), and cardiac failure at 30 days and more than 180 days after surgery .
General considerations
◆In the perioperative acute heart failure, a differential diagnosis for the cause must be established as resuscitation measures are initiated.
◆Indeed, the good aetiologic diagnosis may allow definitive treatment through the use of specific therapies.
三
特别治疗
◆For example, patients with perioperative acute heart failure secondary to an acute MI, reperfusion via angioplasty, stenting or bypass grafting will be necessary.
◆Acute mitral regurgitation from a MI causing acute heart failure might require urgent surgical repair.
急性心衰黄金抢救时机
◆At the same time, appropriate resuscitation measures must be undertaken.
◆The concept of the golden hour for acute heart failure management is essential, and drugs administration must be started within minutes of diagnosis.
为手术期心衰抢救要点：
◆Develop differential diagnosis for cause, treat repairable lesions.
◆Initiate resuscitation measures: maximize oxygenation/ventilation, control postoperative pain/tachycardia, correct acid-base and electrolyte abnormalities.
◆Evaluate and optimize preload, afterload, contractility, heart rate and rhythm
◆Utilize mechanical assistance for patients resistant to above measures.
前、后负荷收缩性、心律心率调整
◆Preload – volume load vs. diuresis based on evaluation of volume status
◆Afterload – if high, consider dilation with nitrogycerine, sodium nitroprusside; if low consider augmentation with norepinephrine
◆Contractility – utilize inotropic agent
◆Establish stable heart rate and rhythm.
预–容积负荷与利尿的基础上体积状态评估•负荷–如果高，考虑扩张nitrogycerine，硝普钠；如果低考虑用去甲肾上腺素增强•收缩–使用正性肌力药建立稳定的心率和节奏。
THERAPEUTIC APPROACHES
◆正心肌力药
◆In the setting of the failing ventricle with clear clinical and pathological signs of low cardiac output, inotropes often act as the first-line agents to improve contractility and haemodynamics.
在失败的心室的设置明确临床和病理体征低心输出量、强心药物常作为第一线药物，以改善收缩性和血流动力学。
多巴酚丁胺反而增加死亡率
Although the use of inotropes is a mainstay of treatment in acute heart failure, a recent metaanalysis, including 14 studies with 673 participants, found that dobutamine was not associated with improved mortality in patients with acute heart failure, and a trend towards an increase in mortality with use of dobutamine compared with placebo or standard care,although this did not reach statistical significance.
虽然正性肌力药物的使用在急性心力衰竭治疗的中流砥柱，最近的一项荟萃分析，包括14个研究的673名参与者，发现dobutamine没有改善患者死亡率的急性心力衰竭有关，和对在用多巴酚丁胺与安慰剂或标准治疗相比，死亡率增加的趋势，虽然这并没有达到统计学意义
钙增敏剂左西孟坦levosimendan
◆In another recent meta-analysis evaluating the effects of levosimendan on mortality and hospitalization, data from 45 randomized clinical trials were analyzed in 5480 cardiac surgery, cardiology and septic patients.
◆The overall mortality rate was 17.4% among levosimendan treated patients and 23.3% in the control group [risk ratio 0.80 (0.72; 0.89), P < 0.001].
◆Reduction in mortality was confirmed in studies with placebo [risk ratio 0.82 (0.69; 0.97), P = 0.02] or dobutamine [risk ratio 0.68 (0.52–0.88); P = 0.003] as a comparator.
◆This meta-analysis suggests that the use of levosimendan in lieu of usual therapies is associated with a significant reduction in mortality mainly in cardiac surgery patients.
数据进行分析5480心脏手术，心脏病和脓毒症患者。总死亡率为17.4% levosimendantreated患者和23.3%例对照组[风险比（0.72；0.89）在0.80，P <0 0.001 ]。
死亡率降低被证实与安慰剂组[风险比为0.82（0.69；0.97），P = 0.02 ]或多巴酚丁胺[风险比为0.68（0.52–0.88）；P = 0.003 ]作为一个比较器。这项荟萃分析表明，在常规治疗的场所使用左西孟旦是主要在心脏手术患者的死亡率显著下降。
机械支持
◆In situations in which the use of pharmacologic therapy alone is insufficient and catecholamines have to be used at a high dose to improve ventricular performance, mechanical support is an appropriate option.
◆Currently, three methods are employed: the intra-aortic balloon pump (IABP), percutaneous cardiopulmonary bypass system and mechanical assist devices.Most of these techniques are restricted to use in specialized cardiac surgery centres.
◆Many review articles of the currently available devices for mechanical support, their indications, outcomes and complications were recently published.
在这情况下，药物治疗单独使用不足和儿茶酚胺有用于高剂量改善心室功能，机械的支持是一个合适的选择。目前采用三种方法：主动脉内球囊泵（IABP）、经皮体外循环系统和机械辅助装置，这些技术大部分都限于使用在专业心脏外科中心。许多评论文章的现有设备的机械支撑，其适应证、治疗效果及并发症最近公布的。
IABP主动脉内球囊反搏(Intra-aortic balloon pump)
◆In the IABP-SHOCK II Trial, a randomized controlled study involving patients with cardiogenic shock complicating MI for whom early revascularization was planned, IABP support did not reduce 30-day mortality.
◆Indeed, 119 patients in the IABP group (39.7%) and 123 patients in the control group (41.3%) died (relative risk with IABP, 0.96; 95% CI, 0.79–1.17; P = 0.69).
◆There were no significant differences in secondary end points or in process-of-care measures, including the time to hemodynamic stabilization, the length of stay in the ICU, serum lactate levels, the dose and duration of catecholamine therapy, and renal function .
◆The authors concluded that the results of the study cannot be generalized to the subgroup of patients with the most severe form of cardiogenic shock that are most likely to receive benefit from IABP support.
在iabp-shock II试验，随机对照研究包括心源性休克合并心肌梗死的早期血运重建计划之病人，IABP支持不降低30天死亡率。的确，在IABP组119例（39.7%），对照组中有123例（41.3%）死亡（相对风险与IABP，0.96；95% CI，0.79–1.17；P = 0.69）。有次要终点或过程的护理措施无显著性差异，包括时间的血流动力学稳定，在ICU逗留期间，血清乳酸水平，儿茶酚胺治疗剂量和持续时间，和肾功能[ 20 ]。作者得出结论，研究结果不能推广到与心源性休克是最有可能接受IABP支持受益最严重的患者。
biventricular pacing双室起搏
◆In patients with atrioventricular block, right ventricular versus biventricular pacing was assessed.
◆Curtis et al.[21] investigated whether biventricular pacing might reduce mortality, morbidity and adverse left ventricular remodelling in patients who had indications for pacing with atrioventricular block, New York Heart Association class I, II, or III heart failure, and a left ventricular ejection fraction of 50% or less.
房室阻滞患者，右心室和双心室起搏的评估。柯蒂斯等研究了▪双心室起搏能否降低死亡率、发病率和不良的左心室重构患者的指征和房室传导阻滞起搏，纽约心脏协会心功能分级I、II、III或心力衰竭和左室射血分数小于或等于50%。患者接受心脏再同步起搏器或植入式心律转复除颤器（ICD）和随机分配到标准右心室起搏或双心室起搏。初级终点是任何原因引起的死亡的时间，因心力衰竭需要静脉治疗急诊治疗，或在左心室收缩末期容积指数增加15%以上。双心室起搏患者的发病率明显低于主要的结果比那些分配到右心室起搏（风险比，0.74；95% CI，0.60–0.90）。
◆Patients received a cardiac-resynchronization pacemaker or implantable cardioverter-defibrillator (ICD) and were randomly assigned to standard right ventricular pacing or biventricular pacing.
◆The primary outcome was the time to death from any cause, an urgent care visit for heart failure that required intravenous therapy, or an increase in the left ventricular end-systolic volume index of 15% or more.
◆Biventricular pacing patients had a significantly lower incidence of the primary outcome over time than did those assigned to right ventricular pacing (hazard ratio, 0.74; 95% CI, 0.60–0.90).
房室阻滞患者，右心室和双心室起搏的评估。柯蒂斯等]研究了▪双心室起搏能否降低死亡率、发病率和不良的左心室重构患者的指征和房室传导阻滞起搏，纽约心脏协会心功能分级I、II、III或心力衰竭和左室射血分数小于或等于50%。患者接受心脏再同步起搏器或植入式心律转复除颤器（ICD）和随机分配到标准右心室起搏或双心室起搏。初级终点是任何原因引起的死亡的时间，因心力衰竭需要静脉治疗急诊治疗，或在左心室收缩末期容积指数增加15%以上。双心室起搏患者的发病率明显低于主要的结果比那些分配到右心室起搏（风险比，0.74；95% CI，0.60–0.90）。
◆It was concluded that biventricular pacing provided a significant clinical benefit over right ventricular pacing in patients with left ventricular dysfunction and atrioventricular block who require ventricular pacing.
◆More trials are needed to support the use of biventricular pacing in the perioperative setting, mainly in cardiac surgery patients.
认为双心室起搏提供显著的临床效益超过右心室起搏患者左心室功能障碍和房室传导阻滞患者需要心室起搏。需要更多的试验，支持双心室起搏在围手术期使用，主要是在心脏手术患者。
四
超滤重要性
◆Ultrafiltration may be useful for diuretic-refractory patients who have acute heart failure, and some investigators have advocated its early and more widespread use.
◆Potential advantages of ultrafiltration include adjustable fluid-removal volume and neutral effect on serum electrolytes.
◆Two recent studies raise concerns about the efficacy and safety of using ultrafiltration as a rescue strategy in acute heart failure patients with persistent congestion and renal failure.
超滤可以利尿治急性心力衰竭是有用的，而一些学者主张早期和更广泛的使用。潜在优势包括可调液超滤去除量和中性对血清电解质的影响。最近的两项研究提高关注的有效性和安全性，采用超滤作为一种急性心力衰竭患者的救援策略和持续性充血和肾功能衰竭。
◆In an observational study, Patarroyo et al. evaluated the outcome of 63 patients with acute heart failure and refractory congestion undergoing slow continuous ultrafiltration.
◆Although 48 h of ultrafiltration improved haemodynamic parameters, renal function did not improve in this high-risk population, and 59% required hemodialysis during their hospitalization.
超滤可以利尿治急性心力衰竭是有用的，而一些学者主张早期和更广泛的使用。潜在优势包括可调液超滤去除量和中性对血清电解质的影响。最近的两项研究提高关注的有效性和安全性，采用超滤作为一种急性心力衰竭患者的救援策略和持续性充血和肾功能衰竭。
◆The Cardiorenal Rescue Study in acute Decompensated Heart Failure (CARRESS-HF trial) randomly assigned 188 patients with acute heart failure, worsened renal function and persistant congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients).
◆Ultrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 h after enrolment (P = 0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group.
◆In addition, a higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72 vs. 57%, P = 0.03)
超滤可以利尿治急性心力衰竭是有用的，而一些学者主张早期和更广泛的使用。潜在优势包括可调液超滤去除量和中性对血清电解质的影响。最近的两项研究提出了关于使用急性失代偿性心力衰竭心肾救援研究的疗效和安全性的担忧（这项研究）随机分配188例急性心脏衰竭，肾功能恶化和持续拥塞策略阶梯药物治疗（94例）或超滤（94例）。超滤不如药物治疗相对于二元端点的变化，血清肌酐水平和体重96 h后报名（P = 0.003），这主要是由于在超滤组肌酐水平增加。此外，比在药物治疗组的严重不良事件的一个更高的超滤组患者的比例（72比57%，P = 0.03）
现任阜外医院术后恢复中心副主任，成人外科恢复室主任。
1999年毕业于同济医科大学，同年工作于武汉亚洲心脏病医院，2004年至2006年就读于华中科技大学同济医学院研究生院。2012年至今工作于北京阜外心血管病医院。
参加专著2部，参与多次全国重症医学大会，已发表的文章：《体外循环冠状动脉旁路移植术后低氧血症的危险因素分析》（中国综合临床2011年3期），《腺苷蛋氨酸治疗体外循环心脏术后急性肝功能损害疗效观察》（中国当代医药2010年10月）。
