合併使用ECMO和Drotrecogin alfa於急性重症心肌炎病人的成功經驗

前言，急性心肌炎併發心衰竭可能因為對藥物和動脈汽球幫浦反應不佳而死於心因性休克，目前許多文獻支持使用體外循環機維持身體的機能，度過危險期，然而，再合併使用具抗發炎與抗凝血作用的「蛋白質C」製劑，提高急性心肌炎併發心衰竭的療效則仍有待觀察。本文描述四例病毒性心肌炎治療情形，藉以探討體外循環機合併「蛋白質C」製劑的療效。方法：2003年以來，本院陸續有四例病毒性心肌炎病人因為併發心衰竭而接受重症加護單位住院治療，分別是二男二女，平均年齡37.2歲，發病前分別都有數天類流感症，如發燒、胸痛和呼吸困難等，住院時胸部X光都呈現心臟擴大和兩側肺野浸潤，雖然心電圖顯示ST上升，但是心導管攝影都排除心肌梗塞的可能，心臟超音波的左心室功能嚴重受損，住院初期雖然使用多種強心劑，病人仍併發呼吸衰竭和其他器官衰竭，其中兩位病人接受體外循環機合併「蛋白質C」製劑的治療，另一男性只接受「蛋白質C」製劑的治療，以及一女性只接受體外循環機的治療。結果：所有接受「蛋白質C」製劑治療的三位病人都順利脫離體外循環機和呼吸器，左心室功能也都恢復正常，出院後追蹤並無發現任何神經學或其他後遺症，具中只接受體外循環機治療的女性因為紅斑性狼瘡併發症和感染而死亡；血清學證實其中三位為Parvovirus B19感染所致心肌炎，四例初期血液細菌培養，顯現陰性。結論：對於瀕臨死亡的急性心肌炎併發心衰竭的病患，特別是病毒性的致病源，合併「蛋白質C」製劑和體外循環機的治療似乎有正面的意義
INTRODUCTION. Acute fulminant myocarditis with dilated cardiomyopathy may present with cardiogenic shock refractory to the maximum dose of inortropics and intra-aortic balloon pumping (IABP). The benefits of extracorporeal membrane oxygenation (ECMO) support for patients with acute life-threatening myocarditis has been established. The effectiveness of combination with the circulatory support (ECMO or IABP) and activated protein C (drotrecogin alfa, Xigris(superscript )) in managing acute myocarditis with dilated cardiomyopathy has to be defined. METHODS. Four patients (2 males, 2 females, mean age 37.2 years) presented with congestive heart failure 3 to 4 days after flu-like symptoms (intermittent fever 38-40℃, dyspnea and chest tightness). Chest roentgenograms showed cardiomegaly and bilateral pulmonary infiltrates. EKG revealed non-specific ST wave changes. 2-D echocardiograms demonstrated severe myocardial dysfunction with LVEF, measured between 18.4 to 27% (mean 19.5%). Coronary angiography was performed in each patient and excluded ischemic heart disease. Acute decompansation with more than 2 organ failure (heart and lungs) and unresponsive to more than 2 inortropics and acute respiratory therapy were indications for the use of circulatory support by IARP (3 pts) and/or ECMO (3 pts) as well as activated protein C (3 pts). RESULTS. Three patients having been treated with the combination of circulatory support (ECMO or IABP) and activated protein C were weaned. Follow-up LVEF measured were 39.9%, 43%, 53% and 55%, respectively. However, one patient died a month later because the deterioration of her SLE condition and repeated infection. There were no neurologic sequelae in the rest 3 survivors. Serological test and myocardial biopsy for Parvovirus Bi 9 was positive in out of 4 patients. CONCLUSION. Use of circulatory support and activated protein C is an effective alternative for acute life threatening myocarditis with dilated cardiomyopathy.