心血管康復(fù)的特色技術(shù)：體外反搏

衛(wèi)生部輔助循環(huán)重點(diǎn)實(shí)驗(yàn)室ANovelModalityofCardiovascularRehabilitation:EnhancedExternalCounterpulsation2

伍貴富美國(guó)哈佛大學(xué)醫(yī)學(xué)院博士后、博士生

導(dǎo)師中山大學(xué)第一附屬醫(yī)院心內(nèi)科教授深圳市福田區(qū)人民醫(yī)院院長(zhǎng)中國(guó)體外反搏專業(yè)委員會(huì)副主任委員衛(wèi)生部輔助循環(huán)重點(diǎn)實(shí)驗(yàn)室主任國(guó)際體外反搏領(lǐng)域核心專家之一“國(guó)際體外反搏項(xiàng)目工作組”中國(guó)區(qū)總

負(fù)責(zé)人2010-2030中國(guó)CVD事件將發(fā)生警報(bào)性增長(zhǎng)（>50%)WHO疾病負(fù)擔(dān)項(xiàng)目Circulation.2011;124:314-323.Circulation.2011;124:278-279.中國(guó)心腦血管病防治面臨挑戰(zhàn)更為嚴(yán)峻！腦卒中死亡率冠心病死亡率4體外反搏技術(shù)的概念與發(fā)展心臟康復(fù)與體外反搏血管康復(fù)與體外反搏體外反搏技術(shù)的未來(lái)發(fā)展主要內(nèi)容5體外反搏是如何工作的？D/S比值>1.2執(zhí)行機(jī)構(gòu)電池閥（開(kāi)/關(guān)）管道（氣體傳輸）主機(jī)系統(tǒng)DS囊套（充氣/排氣）效果監(jiān)測(cè)信息反饋D/S比值心電圖調(diào)節(jié)氣泵壓力增強(qiáng)型體外反搏工作原理EnhancedExternalCounterpulsation,EECP7美國(guó)：1960年代研制成功液壓驅(qū)動(dòng)的體外反搏裝置（未推廣普及）體外反搏概念的提出與技術(shù)發(fā)展中國(guó)：中山大學(xué)領(lǐng)銜的課題組1970年代研制成功氣動(dòng)式四肢序貫式體外反搏裝置并在國(guó)內(nèi)推廣應(yīng)用（ECP）中國(guó)：1980年代研制成功增強(qiáng)型體外反搏裝置并在國(guó)內(nèi)推廣應(yīng)用（EECP）時(shí)間體外反搏發(fā)展的重要事件1980年代初增強(qiáng)型體外反搏裝置（EECP）誕生并進(jìn)入臨床應(yīng)用1990年代初EECP裝置獲美國(guó)FDA批準(zhǔn)，進(jìn)入美國(guó)并經(jīng)此進(jìn)入世界其他國(guó)家和地區(qū)1995-1997年

美國(guó)第一個(gè)體外反搏RCT（MUST-EECP）：哈佛大學(xué)、耶魯大學(xué)、哥倫比亞大學(xué)、紐約州立大學(xué)及加州州立大學(xué)等聯(lián)合攻關(guān)1998年第一個(gè)“國(guó)際EECP病人登記中心（IEPR）”（美國(guó)匹茲堡大學(xué)）2002年美國(guó)ACC/AHA冠心病穩(wěn)定型心絞痛治療指南2006年歐洲心臟病協(xié)會(huì)（ESC）冠心病心絞痛治療指南中華醫(yī)學(xué)會(huì)心血管病分會(huì)冠心病心絞痛治療指南2009年在中國(guó)老年學(xué)會(huì)的支持下，中國(guó)體外反搏專業(yè)委員會(huì)(EAC)成立各國(guó)指南對(duì)體外反搏的推薦10國(guó)外媒體給予體外反搏積極和正面的報(bào)道Bypassingthesurgeon(不需要外科的“心臟搭橋”！)11中東地區(qū)于2001年初開(kāi)始引進(jìn)體外反搏療法12體外反搏技術(shù)的概念與發(fā)展心臟康復(fù)與體外反搏血管康復(fù)與體外反搏體外反搏技術(shù)的未來(lái)發(fā)展主要內(nèi)容13增強(qiáng)型體外反搏工作原理EnhancedExternalCounterpulsation,EECP增加心輸出量DuplexechocardiographyDescendingAortaLawson,Hui:JofCriticalIllness2000;5:629-636

ControlEECP降低收縮期阻力負(fù)荷舒張期主動(dòng)脈根部血流增加增加CO增加靜脈回心血流增加心室舒張期充盈收縮期舒張期降低收縮期阻力負(fù)荷增加冠脈血流體外反搏對(duì)心臟血流的影響15BhavanandaT.Reddy,AndrewD.MichaelsJournalofGeriatricCardiology2010;7(2):67體外反搏與IABP比較的血流動(dòng)力學(xué)差異舒張壓主動(dòng)脈平均壓收縮壓冠脈平均流速舒張期冠脈流速HealthVolunteerAtherosclerotic10203010200Changeofbloodvelocity(%)收縮期流速舒張期平均流速-6.0%-19.3%*9.6%13.7%**3.2%23.6%***p<0.05,**p<0.01體外反搏對(duì)其它重要臟器的影響-眼底動(dòng)脈血流WernerD,etal:Graefe’sArchClinExpOphthalmol.239:599-6-2健康志愿者動(dòng)脈粥樣硬化頸動(dòng)脈

(n=35)腎動(dòng)脈

(n=18)ApplebaumRM,etal:AmHeartJ1997;133:611-5.102030022%19%p=0.001(%)p=0.0001血流速度積分變化率20406005640(cm/sec)舒張期平均流速體外反搏對(duì)其它重要臟器的影響-頸動(dòng)脈、腎動(dòng)脈1990年1991年1992年2年內(nèi)……7次PCI2次搭橋手術(shù)病例介紹NatClinPractCardiovascMed2006;3(11):623-32ChangeinAnginaFunctionalClassfromIEPR-1BaselineCCSanginalClassDistribution1-yearCCSanginalClassDistribution86%inClassIII/IV25%inClassIII/IV2719301960102030405060NoAnginaIIIIIIIV%ofpatientsineachCCSClass76%maintainedatleast1CCSclassimprovement0102030405060IIIIIIIV%ofpatientsineachCCSClassN=4,56529.718.427.817.96.20102030405060NoanginaIIIIIIIV2-yearCCSanginalClassDistribution24%inClassIII/IVAmJournalofCardiol2004;93:461-4643-yearCCSanginalClassDistribution0102030405060NoAnginaIIIIIIIV21%inClassIII/IV5%16%24.8%19.3%34.9%Clin.Cardiol2008;31,4:159-164ChangesinpatientswithLeftVentricularDysfunctionWithdiabetesmellitus(DM,n=36)versusnon-diabetes(Non-DM,n=27)6-minuteWalkNYHAClassification2.71.12.91.3p<0.001p<0.001p<0.001p<0.001Increase37%Increase30%NosignificantdifferenceintheincreaseinbothgroupPre-EECPPost-EECP7478731,0251,137(ft)AHA2008ChangesinpatientswithLeftVentricularDysfunctionWithdiabetesmellitus(DM,n=36)versusnon-diabetes(Non-DM,n=27)Cardiac

Output3.13.93.34.1p<0.001p<0.001Pre-EECPPost-EECP0510152025303540DMNon-DMEjectionFractionp<0.001p<0.001Increase21%Increase20%Nosignificantdifferenceintheincreaseinbothgroup29.829.936.235.9(%)(l/min)Increase25%Increase22%NosignificantdifferenceintheincreaseinbothgroupAHA2008CosteffectivenessPotentialCostSavingsScenario#HFptsTotal#HospitalVisitsAverageCostperHospitalVisitTotalCosttoHealthcareSystem/1,000ptsBeforeECP1,0003,000*$5,456$16,368,000AfterECP1,000500**$5,456$2,728,000ReductioninhospitalizationcostsaftertreatedwithECP$13,640,000CosttotreatwithECP$3,640,000Annualsavingstohealthcare$10,000,000Savingperpatient$10,000*Average#ofhospitalvisitsbeforeECPover12monthsis3.6**Average#ofhospitalvisitsafterECPover12monthsis0.5(Reductioninaveragecostofhospitalizations)EECPreducedERVisits&HospitalizationsinPatientswithLVDHospitalizationsCHF2007;13:36-4000.20.40.60.811.21.486%83%6-monthsPre-EECP6-monthsPost-EECPp<0.001p<0.001ERVisits6-monthsPre-EECP6-monthsPost-EECP

3.53.02.52.01.51.00.50體外反搏技術(shù)的概念與發(fā)展心臟康復(fù)與體外反搏血管康復(fù)與體外反搏體外反搏技術(shù)的未來(lái)發(fā)展主要內(nèi)容24EvolutionofCardiovascularDiseasesRiskFactorsHypertensionAtherogenicDyslipidemiaDiabetesMellitusAbdominalObesityProthromboticstateProinflammatorystateGeneticsEthnicPredispositionAgingHormonalimbalancePhysicalinactivitySmokingCommonFactors

Exercisecapacity

ArterialwallthickeningVascularStiffnessAtherosclerosisLV-contractility

LV-relaxationEndothelialDysfunctionInflammationCatabolismAtrophyEarlyfatigueSkeletalMuscleDysfunctionVentilatoryAbnormalitiesNeurohormonalactivationRenalSingleorgandysfunctionAnginaHeartAttackStrokeSilentIschemiaMultipleorgansdysfunctionHeartfailureRenalFailureCerebralPulmonaryDiseaseProgressionComplexfactorsthatdeterminetherateofprogressionfromrisktoorganfailureLinkingriskfactorstocardiovasculardiseaseisendothelialdysfunction血流切應(yīng)力與血管內(nèi)皮保護(hù)生理狀態(tài)的切應(yīng)力低切應(yīng)力狀態(tài)低血流切應(yīng)力和湍流區(qū)域是動(dòng)脈粥樣硬化斑塊高發(fā)區(qū)域血流切應(yīng)力與冠心病的臨床聯(lián)系ZhangY,etal:Circulation2007,116:526-34

流速切應(yīng)力體外反搏對(duì)豬頸總動(dòng)脈內(nèi)的血液流速和切應(yīng)力變化30體外反搏治療對(duì)實(shí)驗(yàn)性動(dòng)脈粥樣硬化豬冠脈內(nèi)膜的影響ZhangY,etal:Circulation2007,116:526-34x400x40正常組動(dòng)脈硬化組動(dòng)脈硬化組＋體外反搏體外反搏保護(hù)血管內(nèi)膜促進(jìn)冠狀動(dòng)脈血管重構(gòu)HE染色彈力纖微染色ZhangY,etal:Circulation2007,116:526-3432體外反搏降低冠脈前降支CRP和補(bǔ)體C3a表達(dá)ZhangY,etal:ATVB2010Cardiology2008;110:160-166CirculatingEndothelialProgenitorCells(CEPC)inpatientswithAnginaPectorisBaselinePost-treatmentAssessedbyflowactivatedcellsorterper105peripheralbloodmononuclearcellsNumberofCD34+/KDR+Cellsp=0.430p=0.049p=0.557p=0.010CEPCColonyFormingUnitperwellArterialStiffnessandMyocardialOxygenDemandResultsofarandomizedshamcontrolstudyAmJCardiol2011;107(10):1466-1472AorticAugmentationIndex(Alx)ChangeinAlx(%)*p<0.01??p<0.05?p<0.05**??????*WastedLeftVentricularEnergyEw(dynescm2sec)??p<0.05?p<0.05??????EECP(N=28)ShamControl(N=14)Pulse-WaveVelocityCarotid–FemoralCarotid-Femoral(m/sec)*p<0.05??p<0.05?p<0.05*??????*ChangesinExerciseCapacityResultsofarandomizedshamcontrolstudyAmJCardiol2011;107(10):1466-1472EECP(N=28)ShamControl(N=14)ExerciseTimeTreadmillExerciseTime(sec)*p<0.05??p<0.001?p<0.01*??????**??ModifiedNaughtonprotocolPeakTimetoAnginaPeakTimetoAngina(sec)*p<0.05??p<0.001?p<0.01*??????**??PeakOxygenUptakePeakOxygenUptake(ml/kg/min)*p<0.05??p<0.001?p<0.01*??????**??EECPimprovesendothelialfunctionArandomizedsham-controlledstudyBraith:Circulation2010;122:1612-1620EffectsonVasomotorFlow-MediatedDilation:BrachialArteryPercentChange(%)p<0.01

?

?ShamN=14,EECPN=28Pre-EECPPost-EECP2%

51%PercentChange(%)Flow-MediatedDilation:FemoralArtery

?

?p<0.013%

30%ChangeinPlasmaNOx

?

?p<0.01μmol/L2%

36%

ChangeinProstaglandin6-keto-PGF1α

?

?p<0.01pg/mL1%

71%

ChangeinEndothelin-1

?

?p<0.01pg/mL5%

25%EECPimprovesendothelialfunctionArandomizedsham-controlledstudyBraith:Circulation2010;122:1612-1620InflammatoryCytokinesandAdhesionMoleculesTumorNecrosisFactor-αShamN=14,EECPN=28Pre-EECPPost-EECPSolubleVascularCellAdhesionMolecule

??p<0.011%6%*?ng/mLHigh-sensitivityC-reactiveProtein

?

?p<0.015%32%*?mg/Lp<0.01

??12%16%*?pg/mLMonocytechemoattractantProtein-1

??p<0.010.2%13%pg/mL*?EECPimprovesendothelialfunctionArandomizedsham-controlledstudyPre-EECPPost-EECPShamN=14,EECPN=28Braith:Circulation2010;122:1612-1620FunctionalandExerciseCapacityCCSFunctionalClass

?

?p<0.001*?AnginaEpisodesperday

?

?p<0.01*?DailyNitrateUsage

?

?p<0.01*?1.01.00.90.2PeakTimetoangina

?

?p<0.01*?sec406449471645

?p<0.001PeakExerciseDuration

?*?secPeakOxygenConsumption

?

?p<0.001*?mL/kg/minute體外反搏研究：逐步占領(lǐng)學(xué)術(shù)的至高點(diǎn)（心血管領(lǐng)域）MichaelsAD,etal:Circulation2002;106;1237-1242;通過(guò)有創(chuàng)檢查證實(shí)體外反搏的即時(shí)血流動(dòng)力學(xué)效果ZhangY,etal:Circulation2007;116;526-534;通過(guò)慢性動(dòng)物試驗(yàn)論證體外反搏保護(hù)血管內(nèi)皮BraithRW,etal:Circulation.

2010;122:1612-16.通過(guò)臨床隨機(jī)研究論證體外反搏通過(guò)抑制炎癥因子保護(hù)血管內(nèi)皮YangDY,WUGF.IntJCardiol.2012May3.[Epubaheadofprint]全面綜述體外反搏機(jī)制研究的國(guó)內(nèi)外進(jìn)展，重點(diǎn)闡述體外反搏的細(xì)胞與分子機(jī)制與動(dòng)脈粥樣硬化病變的關(guān)系MartinJS

etal:ApplPhysiol.2012;112(5):868-76目的：研究體外反搏對(duì)糖耐量異?；颊邉?dòng)脈血管功能、糖耐量和肌肉形態(tài)組織學(xué)研究治療方案：7wks(351-hsessions)EECP或標(biāo)準(zhǔn)療法結(jié)果：FMD肱動(dòng)脈增加

27%,腘動(dòng)脈增加52%空腹血糖下降16.9±5.4mg/dl，2小時(shí)血糖下降28.3±7.3mg/dl胰島素抵抗降低31%股外側(cè)肌活檢：毛細(xì)血管密度增加結(jié)論：

體外反搏治療可以改善糖耐量異?；颊叩难悄土亢屯庵軇?dòng)脈血管的功能體外反搏與糖尿病治療Stroke.2012;43:00-00DOI:10.1161/STROKEAHA.112.659144Stroke2008;39;1340-1343;ConclusionEECPprovidesanewmethodofcerebralbloodflowaugmentationinischemicstrokebyelevationofbloodpressure.FlowaugmentationinducedbyECPsuggeststheimprovementofcerebralperfusionandcollateralsupplyfrominfarctipsilateralandcontralateralsides體外反搏與腦血管病防治AS進(jìn)展期斑塊破裂破裂斑塊修復(fù)體外反搏-

從動(dòng)脈粥樣硬化病變的早期開(kāi)始介入PeterLibby,Circulation2001;104;365-372斑塊形成體外反搏47血管內(nèi)皮切應(yīng)力“血管內(nèi)皮”：體外反搏作用的新靶點(diǎn)中國(guó)專家的觀點(diǎn)加速動(dòng)脈血流速度，提高血管內(nèi)皮的血流切應(yīng)力刺激改善血管內(nèi)皮功能，促進(jìn)內(nèi)皮修復(fù)抑制內(nèi)膜增生抑制動(dòng)脈粥樣硬化病變及相關(guān)基因表達(dá)Circulation,2007,116:526-534ATVB

2010;30(4):773-780.AJP-HeartCirc