慢性肺栓塞的外科治療-宋云虎

慢性肺栓塞的外科治療宋云虎柳志紅阜外心血管病醫(yī)院成人心臟外科中心肺血管病診治中心1背景2慢性肺栓塞的概念形成機(jī)制決定治療方案多樣化Circulation，2006；113：2011－20傳統(tǒng)觀念：急性肺栓塞的轉(zhuǎn)歸之一現(xiàn)代觀念：肺動(dòng)脈血栓及內(nèi)膜機(jī)化始動(dòng)進(jìn)行性肺動(dòng)脈重構(gòu)（remodeling)3

病理生理多數(shù)病人DVT、右心系統(tǒng)血栓等肺動(dòng)脈反復(fù)栓塞，肺血管重構(gòu)肺動(dòng)脈高壓右心衰竭、呼吸衰竭4診斷手段血?dú)夥治鱿轮o脈超聲多譜勒超聲心動(dòng)圖肺核素灌注掃描UFCT肺動(dòng)脈造影5肺動(dòng)脈造影與MRI肺動(dòng)脈造影與CT6自然預(yù)后自然預(yù)后不佳，與平均動(dòng)脈壓有關(guān)>30mmHg,5年生存率30％>50mmHg,5年生存率10％Chest1982;81:151-87CTEPH治療選擇CurrentandFutureManagementofChronicThromboembolicPulmonaryHypertension:fromdiagnosistotreatmentresponse.ProcAmThoracSoc，2006(3)：601－607PEA失敗藥物治療無效進(jìn)行性肺小血管病變89資料與方法10CTEPH病人46例被選擇行PEA1997年3月－2008年6月11阜外醫(yī)院肺動(dòng)脈栓塞病人的收治情況(1997-2008.6)共701例1213男：35例女：11例平均年齡:46.1歲平均病史:45.1月一般資料14臨床表現(xiàn)氣短44下肢水腫35暈厥7咯血13大量腹水1DVT3015雙側(cè)病變32例單側(cè)病變14例16深低溫、低流量或間斷停循環(huán)清除血栓和機(jī)化內(nèi)膜處理伴隨心臟病變17TVP6CABG1PVP118ExposeRPAandRPAincisionExposeLPAandLPAincision19RPAincisionResectionplaneinitiated20Createresectionplane21222324結(jié)果25經(jīng)適當(dāng)處理均得以恢復(fù)2627女性,53歲,右肺動(dòng)脈慢性栓塞28男性，53歲，右肺動(dòng)脈慢性栓塞293031Case1:male,53yrsCase2:male,48yrs32隨訪結(jié)果

隨訪例數(shù)38隨訪時(shí)間(月)27.3（2-122）死亡4CTEPH相關(guān)入院1出血和血栓并發(fā)癥1334例死亡原因34I

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術(shù)前002014術(shù)后2743035討論3637Chest2004;126:63s-71s其他考慮的因素mPAP>40，外科水平，繼發(fā)肺血管病變38Type病變位置例數(shù)死亡率1肺主動(dòng)脈和葉動(dòng)脈內(nèi)新鮮血栓1872.1%2段以上動(dòng)脈內(nèi)膜增厚、纖維化2455.3%3病變僅位于遠(yuǎn)端段動(dòng)脈605.0%4遠(yuǎn)端微血管病變，無肉眼可見血栓825%病變位置與死亡率關(guān)系JThoracCardiovascSurg2002;124:1203-121139術(shù)后PVRmortality<5000.9%>50030.6%術(shù)前PVRmortality<9004%900-120010%>120020%AssessmentofOperabilityinChronicThromboembolicPulmonaryHypertension

ProcAmThoracSoc2006;3:584-58840藥物治療Pre-PEA“Bridging”therapyPost-PEAtherapyMedicalTherapiesforChronicThromboembolicPulmonaryHypertension.AnEvolvingTreatmentParadigm.ProcAmThoracSoc2006;3:594-60041藥物治療抗凝藥利尿劑等Advanceddrugs前列環(huán)素類似物：epoprostenol,iloprostET-R拮抗劑：bosentanPED-5抑制劑：sildenafilTraditionaldrugs42Pre-PEA“Bridging”therapyNYHAⅥMPAP>50CI<2.0PVR>1000血流動(dòng)力學(xué)不穩(wěn)定43Post-PEAtherapy目前尚需要指南決定WhenHowHowlongStoppingrules44再灌注肺水腫肺動(dòng)脈高壓所致右心功能衰竭Successfulextracorporealmembraneoxygenationsupportafterpulmonarythromboendarterectomy.AnnThoracSurg.2008Oct;86(4):1261-7.

用于脫機(jī)早期的循環(huán)呼吸障礙Berman報(bào)道：127例PEA中7例ECMO，5例脫機(jī)4546結(jié)論47THEEND48PULMONARYTHROMBOENDARTERECTOMYYUNHUSONGCARDIACSURGERYDEPARTMENTFUWAIHOSPITAL49BACKGROUND50CONCEPTIONOFCTEPHFormationmechanismrusultsindiversityoftreatmentCirculation，2006；113：2011－20TRADIONAL:oneofturnoversofacutePEMODERN:promotedbypulmonarythrombus,progressivepulmonaryarteryremodeling51

PATHOPHYSIOLOYMosthaveDVTorrightheartthrombusRecurrentPE,pulmonaryremodelingPHRightheartfailure,respiratoryfailure52DIAGNOSTICMETHODSABGDopplerultrasoundforlowerextremitiesUCGPulmonaryperfusionscanCTAPulmonaryangiography53ANGIOGRAPHYANDMRIANGIOGRAPHYANDCT54NATURALHISTORYNaturalhistoryisassociatedwithmPAP>30mmHg,5-yearsurvival30％>50mmHg,5-yearsurvival10％Chest1982;81:151-855TREATMENTOFCHOICEPEA:preferredmedicinePulmonarytransplantPulmonaryArteryBalloonAngioplastyCurrentandFutureManagementofChronicThromboembolicPulmonaryHypertension:fromdiagnosistotreatmentresponse.ProcAmThoracSoc，2006(3)：601－6075657DATAANDMETHODS58CTEPHPATIENTSSURGICALACCESSIBLEWITHOUTSEVEREMOBIDITY46UNDERGONEPEA1997.3－2008.659PEinFUWAIHOSPITAL

(1997-2008.6)701CASES60PEAINFUWAIHOSPINRECENTYEARS61male：35female：11Meanage:46.1yearsMeanhistory:45.1monGENERALINFORMATION62CLINICALMANIFESTATIONEffortdyspnea44Lowerextremitesedema35syncope7hemoptysis13ascite1DVT3063Bilateraldisease32casesUnilateraldisease14cases64OPERATIONMETHODSdeephypothermiccirculatoryarrestorlowflowthromboendarterectomyTreatassociatedcardiacdisorders65MeanCPBtime:160.3minMeanAOCtime:72.2minMeancardiacarresttime:44.6minAssociatedmanagementTVP6CABG1PVP166ExposeRPAandRPAincisionExposeLPAandLPAincision67RPAincisionResectionplaneinitiated68Createresectionplane69707172RESULTS73OPmortality:8.7%(4/46)Meanintubationtime:75.2hPulmonaryedema:10（21.7％）Earlypostop-severePH:6（13.0％）CNScomplication:7（15.2％）7475PRE-OP7DAYSPOST-OPCTAchangesfemale,53yrs,CPEinRPA76preop

1monpostopmale，53yrs，CPEinRPA1yrpostopCTAchanges77preoppostop78preoppostop79Pulmonaryperfusionimprovedpostoppreop3monpostopCase1:male,53yrsCase2:male,48yrspreop6monpostop80FOLLOWUP

Casesfollowed38Followuptime(mon)27.3（2-122）death4CTEPHassociatedre-hospitalization1Bleedingandthrombolization181Causesof4deathduringfollowup1:male,49yrs,diedofCerebralHemorrhage30monthspostop2:male,47yrs,died15dayspostopwithunkownreason3:female,58yrs,diedofLeukemia24monthspostop4:female,56yrs,diedofheartfailure12monthspostop82timeI

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COMPARATIONOFCARDIACFUNCTIONBETWEENPRE-OPANDPOST-OP83DISCUSSION84INDICATIONOFPEA?FACTORSRELATEDTOPROGNOSISOFPEA?85INDICATIONOFPEASurgicalaccessiblePVR>300dyneNYHAⅢorⅣWithoutseveremorbidityChest2004;126:63s-71sOtherconsiderationmPAP>40，surgicalexpertise，advancedsecondaryarteriopathy86Typelocation例數(shù)死亡率1FreshthrombusinmainPAorlobularPA1872.1%2Thinkenedendotheliumabovesegementallevel2455.3%3DistalsegementalPA605.0%4Distalarteriopathy,withoutvisiblethrombis825%RelationshiplocationofdiseaseandmortalityJThoracCardiovascSurg2002;124:1203-121187RELATIONSHIPBETWEENPVRANDMORTALITYPost-opPVRmortality<5000.9%>50030.6%Pre-opPVRmortality<9004%900-120010%>120020%AssessmentofOperabilityinChronicThromboembolicPulmonaryHypertension

ProcAmThoracSoc2006;3:584-58888MedicaltreatmentcanimproveprognosisPre-PEA“Bridging”therapyPost-PEAtherapyMedicalTherapiesforChronicThromboembolicPulmonaryHypertension.AnEvolvingTreatmentParadigm.ProcAmThoracSoc2006;3:594-60089DRUGSAnticoagulationdrugsDiuretics,etcAdvanceddrugsProstacyclinanalogues：epoprostenol,iloprostET-RAntagonists

：bosentanPED-5inhibitors：sildenafilTraditionaldrugs90Pre-PEA“Bridging”therapyNYHAⅥMPAP>50CI<2.0PVR>1000UnstablehemodynamicsUnsatisfactoryhospitalcondition,unabletobeoperated91