emcardioНеотложная кардиология и кардиоваскулярные рискиEmergency Cardiology and Cardiovascular Risks journal2616-633XБелорусский государственный медицинский университет10.51922/2616-633X.2025.9.1.2459emcardio-123Research ArticleОригинальные научные публикацииOriginal Scientific Research«Вабк или не вабк?» – вот в чем вопрос. Прогнозирование оптимального метода механической поддержки кровообращения у пациентов с посткардиотомным шоком«Iabp or not iabp?» – that is the question. Predicting the optimal method of mechanical circulatory support in patients with postcardiotomy shockЯрошР. Г.YaroshR. G.

Минск 

Minsk

doc_pomka@mail.ruШестаковаЛ. Г.ShestakovaL. G.

Минск 

Minsk

doc_pomka@mail.ruОстровскийЮ. П.OstrovskyY. P.

Минск 

Minsk

doc_pomka@mail.ruГУ «Республиканский научно-практический центр «Кардиология»Scientific and Practical Center “Cardiology”2025110920259124592466Copyright © Ярош Р.Г., Шестакова Л.Г., Островский Ю.П., 20252025Ярош Р.Г., Шестакова Л.Г., Островский Ю.П.Yarosh R.G., Shestakova L.G., Ostrovsky Y.P.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://emcardio.bsmu.by/jour/article/view/123Цель

Цель. Определить критерии выбора оптимального метода механической поддержки кровообращения (МПК): внутриаортальной баллонной контрапульсации (ВАБК) или экстракорпоральной мембранной оксигенации (ЭКМО), необходимой для пациентов с посткардиотомным шоком.

Методы

Методы. Проведено ретроспективное исследование в Республиканском научно-практическом центре «Кардиология» за 2012–2020 гг. Критериями включения в исследование были пациенты в возрасте 18–80 лет, перенесших операцию на сердце в условиях искусственного кровообращения (ИК), у которых интраоперационно развился посткардиотомный шок, рефрактерный к медикаментозной терапии. В связи с невозможностью отлучения пациента от ИК потребовалось подключение МПК. Были отобраны пациенты, которым проводилась ЭКМО (n = 28) и успешно выписавшиеся из стационара. Методом псевдорандомизации на основании алгоритма «ближайшего соседа» (kNN – Nearest Neighbours), в пропорции 1:1 были подобраны выжившие пациенты с ВАБК (n = 28). Таким образом, в исследование было включено 56 пациентов. На основе анализа логистической регрессии были определены критерии выбора оптимального метода МПК. Интенсивность инотропной и вазопрессорной поддержки (ВИП) определялась в баллах (Vasoactive Inotrope Score), на основании следующей формулы: ВИП (баллы) = добутамин (мкг/кг/мин) + допамин (мкг/кг/мин) + 100 × норэпинефрин (мкг/кг/мин) + + 100 × эпинефрин (мкг/кг/мин) + 10 × милринон (мкг/кг/мин) + 10,000 ×× вазопрессин (ед/кг/мин) + 50 × левосимендан (мкг/кг/мин) [1].

Результаты

Результаты. Были определены критерии определяющие необходимость подключения ЭКМО: клиника отека легких ОШ = 23,4 [95% ДИ 4,52 – 119,7], р = 0,001; лактат артериальной крови > 4 ммоль/л (Sn = 68%, Sp = 68%), ОШ = 7,7 [95% ДИ 2,32 – 25,74], р = 0,001; кислотность крови pH < 7,34 (Sn = 66,3%, Sp = 66,4%), ОШ = 3,8 [95% ДИ 1,25 – 11,55], р = 0,031; дефицит оснований ВЕ > –4,3 (Sn = 75%, Sp = 70,4%), ОШ = 7,15 [95% ДИ 2,16 – 23,42], р = 0,001, вазоактивная и инотропная поддержка более 35 (Sn = 57,1%, Sp = 75%) баллов ОШ = 4,45 [95% ДИ 1,45 – 13,68], р = 0,015. Разработана прогностическая модель определения оптимальной МПК на основании сатурации артериальной крови, значения лактата крови, длительность ИК, значения вазоактивной и инотропной поддержки.

Заключение

Заключение. Посткардиотомный шок является тяжелым осложнением в кардиохирургии и характеризуется высокой госпитальной летальностью ввиду развития синдрома полиорганной недостаточности. Применение инотропных и вазопрессорных препаратов обеспечивает лишь временное улучшение показателей гемодинамики, в то время как увеличение их дозировки вызывает развитие лактат-ацидоза, который влечет за собой ослабление эффективности катехоламинов и приводит к еще большей эскалации фармакологической поддержки. Своевременное подключение необходимого варианта МПК на основании разработанной модели позволит рационально использовать ресурсы кардиохирургических центров, снизить частоту развития полиорганной недостаточности и госпитальной летальности.

Aim

Aim. To determine the criteria for selecting the optimal method of mechanical circulatory support (MCS): intra-aortic balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO), needed for patients with post-cardiotomy shock.

Methods

Methods. A retrospective study was conducted at the Republican Scientific and Practical Center “Cardiology” for the period 2012–2020. Inclusion criteria for the study were patients aged 18-80 years who underwent heart surgery under cardiopulmonary bypass (CPB), and who have intraoperatively developed postcardiotomy shock refractory to drug therapy. As it was impossible to disconnect the patient from CPB, the use of mechanical circulatory support (MCS) was required. The patients selected were those who underwent ECMO (n = 28) and were successfully discharged from the hospital. Using the pseudorandomization method based on “the nearest neighbour” algorithm (kNN – Nearest Neighbours), in a 1:1 ratio the surviving patients with IABP (n = 28) were selected. Thus, 56 patients were included in the study. Based on the analysis of logistic regression, the criteria for choosing the optimal MCS method were determined. The intensity of inotropic and vasopressor therapy was determined in points (Vasoactive Inotrope Score), based on the following formula: VIS (points) = dobutamine (mcg/kg/min) + dopamine (mcg/kg/min) + 100 × norepinephrine (mcg/kg/ min) + 100 × epinephrine (mcg/kg/min) + 10 × milrinone (mcg/kg/min) + + 10,000 × vasopressin (units/kg/min) + 50 × levosimendan (mcg/kg/min) [1].

Results

Results. The criteria determining the need for ECMO were defined: clinical presentation of pulmonary edema OR = 23,4 [95% CI 4,52 – 119,7], p = 0.001; arterial blood lactate > 4 mmol/L (Sn = 68%, Sp = 68%), OR = 7,7 [95% CI 2,32 – 25,74], p = 0.001; pH < 7,34 (Sn = 66,3%, Sp = 66,4%), OR = 3,8 [95% CI 1,25 – 11,55], р = 0,031; ВЕ > –4,3 (Sn = 75%, Sp = 70,4%), OR = = 7,15 [95% CI 2,16 – 23,42], р = 0,001; vasoactive and inotropic support more than 35 points (Sn = 57,1%, Sp = 75%), OR = 4,45 [95% CI 1,45 – 13,68], p = 0,015. A prognostic model was developed to determine the optimal MCS based on arterial blood saturation, blood lactate values, the duration of CPB, and the values of vasoactive and inotropic support.

Conclusion

Conclusion. Postcardiotomy shock is a severe complication in cardiac surgery characterized by high in-hospital mortality due to the development of multiple organ failure syndrome. The use of inotropic and vasopressor drugs leads to temporary hemodynamic improvement. Increasing vasoactive support causes lactate acidosis, which entails a weakening of the catecholamines effectiveness and leads to greater escalation of pharmacological support. Timely connection of the necessary MCS option based on the developed model will make it possible to efficiently use the resources of cardiac surgery centers, reduce the incidence of multiple organ failure and in-hospital mortality.

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The authors declare that there are no conflicts of interest present.