慢性肺栓的外科治疗宋云虎

1、fuwai hospitalfuwai hospital1慢性肺栓塞的外科治疗慢性肺栓塞的外科治疗宋云虎宋云虎 柳志红柳志红阜外心血管病医院阜外心血管病医院成人心脏外科中心成人心脏外科中心 肺血管病诊治中心肺血管病诊治中心fuwai hospitalfuwai hospital2背背 景景fuwai hospitalfuwai hospital3慢性肺栓塞的概念慢性肺栓塞的概念形成机制决定治疗方案多样化形成机制决定治疗方案多样化circulation，2006；113：201120传统观念：急性肺栓塞的转归之一传统观念：急性肺栓塞的转归之一现代观念：现代观念：肺动脉血栓及内膜机化始动肺动脉血栓

2、及内膜机化始动进行性肺动脉重构（进行性肺动脉重构（remodeling)fuwai hospitalfuwai hospital4 病理生理病理生理多数病人多数病人dvt、右心系统血栓等、右心系统血栓等肺动脉反复栓塞，肺血管重构肺动脉反复栓塞，肺血管重构肺动脉高压肺动脉高压右心衰竭、呼吸衰竭右心衰竭、呼吸衰竭fuwai hospitalfuwai hospital5诊断手段诊断手段血气分析血气分析下肢静脉超声多谱勒下肢静脉超声多谱勒超声心动图超声心动图肺核素灌注扫描肺核素灌注扫描ufct肺动脉造影肺动脉造影fuwai hospitalfuwai hospital6肺动脉造影与肺动脉造影与mri

3、肺动脉造影与肺动脉造影与ctfuwai hospitalfuwai hospital7自然预后自然预后自然预后不佳，与平均动脉压有关自然预后不佳，与平均动脉压有关 30mmhg, 5年生存率年生存率30 50mmhg, 5年生存率年生存率10chest 1982; 81: 151-8fuwai hospitalfuwai hospital8ctephcteph治疗选择治疗选择pea: pea: 首选首选药物治疗药物治疗肺移植肺移植球囊肺动脉成形术球囊肺动脉成形术current and future management of chronic thromboembolic pulmonary h

4、ypertension: from diagnosis to treatment response. proc am thorac soc，2006(3) ：601607不能行不能行pea手术的病人手术的病人pre-pea “bridging” therapypea失败失败药物治疗无效药物治疗无效进行性肺小血管病变进行性肺小血管病变fuwai hospitalfuwai hospital9fuwai hospitalfuwai hospital10资资 料料 与与 方方 法法fuwai hospitalfuwai hospital11cteph 病人病人病变位于手术可及部位病变位于手术可及部位

5、 无严重伴发症无严重伴发症46 例被选择行例被选择行 pea19971997年年3 3月月20082008年年6 6月月fuwai hospitalfuwai hospital12阜外医院肺动脉栓塞病人的收治情况阜外医院肺动脉栓塞病人的收治情况 (1997-2008.6)(1997-2008.6)共共701701例例fuwai hospitalfuwai hospital13阜外医院近年阜外医院近年peapea手术例数手术例数fuwai hospitalfuwai hospital14男：男：3535例例 女：女：1111例例平均年龄平均年龄: 46.1 : 46.1 岁岁平均病史平均病史:

6、45.1 : 45.1 月月 一般资料一般资料fuwai hospitalfuwai hospital15临床表现临床表现气短气短下肢水肿下肢水肿晕厥晕厥咯血咯血大量腹水大量腹水dvt4435713130fuwai hospitalfuwai hospital16双侧病变双侧病变 32 32 例例单侧病变单侧病变14 14 例例fuwai hospitalfuwai hospital17手术方法手术方法 深低温、低流量或间断停循环深低温、低流量或间断停循环 清除血栓和机化内膜清除血栓和机化内膜 处理伴随心脏病变处理伴随心脏病变fuwai hospitalfuwai hospital18 平均体

7、外循环时间平均体外循环时间: 160.3 min: 160.3 min 平均升主动脉阻断时间平均升主动脉阻断时间: 72.2 min: 72.2 min 平均停循环时间平均停循环时间: 44.6 min: 44.6 min 同期手术如下表同期手术如下表tvptvpcabgcabgpvppvp6 61 11 1fuwai hospitalfuwai hospital19expose rpa and rpa incisionexpose lpa and lpa incisionfuwai hospitalfuwai hospital20rpa incisionresection plane ini

8、tiatedfuwai hospitalfuwai hospital21create resection planefuwai hospitalfuwai hospital22fuwai hospitalfuwai hospital23fuwai hospitalfuwai hospital24fuwai hospitalfuwai hospital25结结 果果fuwai hospitalfuwai hospital26 手术死亡率手术死亡率: : 8.7% (4/46)8.7% (4/46) 平均气管插管时间平均气管插管时间: : 75.275.2 h h 肺水肿肺水肿: : 10 10（

9、21.721.7） 术后早期严重肺动脉高压术后早期严重肺动脉高压: : 6 6（13.013.0） 神经系统并发症神经系统并发症: : 7 7（15.215.2）经适当处经适当处理均得以理均得以恢复恢复fuwai hospitalfuwai hospital27fuwai hospitalfuwai hospital28术前术前 术后术后7 7天天peapea术后术后ufct ufct 改善改善女性女性, 53 , 53 岁岁, , 右肺动脉慢性栓塞右肺动脉慢性栓塞fuwai hospitalfuwai hospital29术前术前 术后术后1 1月月peapea术后术后ufct ufct 改

10、善改善男性，男性，53 53 岁，右肺动脉慢性栓塞岁，右肺动脉慢性栓塞术后术后1 1年年fuwai hospitalfuwai hospital30术前术前术后术后fuwai hospitalfuwai hospital31术前术前术后术后fuwai hospitalfuwai hospital32peapea术后肺灌注术后肺灌注 改善改善术前术前 术后术后3 3月月case 1: male, 53 yrscase 1: male, 53 yrs术前术前术后术后6 6月月case 2: male, 48 yrscase 2: male, 48 yrsfuwai hospitalfuwai ho

11、spital33随访结果随访结果 随访例数随访例数随访时间随访时间( (月月) )死亡死亡ctephcteph相关入院相关入院出血和血栓并发症出血和血栓并发症383827.327.3（2-1222-122）4 41 11 1fuwai hospitalfuwai hospital344 4例死亡原因例死亡原因1 1例，男性，例，男性，4949岁，术后岁，术后3030个月，脑出血个月，脑出血1 1例，男性，例，男性，4747岁，出院回家路上，死因不祥岁，出院回家路上，死因不祥1 1例，女性，例，女性，5858岁，术后岁，术后2424个月，白血病个月，白血病1 1例，女性，例，女性，5656岁，术

12、后岁，术后1212个月，心力衰竭个月，心力衰竭fuwai hospitalfuwai hospital35术前术前术后术后i i 0 02727iiii 0 04 4iiiiii 20203 3iviv 14140 0 术前后心功能比较术前后心功能比较fuwai hospitalfuwai hospital36讨讨 论论fuwai hospitalfuwai hospital37pea的手术适应症是什么的手术适应症是什么?影响影响pea术后效果的因素术后效果的因素?fuwai hospitalfuwai hospital38peapea手术适应症手术适应症栓塞病变位于手术可及部位（亚段以上）栓

13、塞病变位于手术可及部位（亚段以上）pvr 300 pvr 300 dyne/sec/cm-5nyha nyha or or 级级无严重伴发症无严重伴发症chest 2004; 126: 63s-71s其他考虑的因素其他考虑的因素mpap40，外科水平，继发肺血管病，外科水平，继发肺血管病变变fuwai hospitalfuwai hospital39typetype病变位置病变位置例数例数死亡率死亡率1 1肺主动脉和叶动脉内新鲜血栓肺主动脉和叶动脉内新鲜血栓1871872.1%2.1%2 2段以上动脉内膜增厚、纤维化段以上动脉内膜增厚、纤维化2452455.3%5.3%3 3病变仅位于远端段动

14、脉病变仅位于远端段动脉60605.0%5.0%4 4远端微血管病变，无肉眼可见血栓远端微血管病变，无肉眼可见血栓8 825%25%病变位置与死亡病变位置与死亡率关系率关系j thorac cardiovasc surg 2002;124:1203-1211fuwai hospitalfuwai hospital40pvrpvr与手术死亡率相关与手术死亡率相关术后术后pvrpvrmortalitymortality50050050030.6%30.6%术前术前pvrpvrmortalitymortality9001200120020%20%assessment of operability in

15、 chronic thromboembolic pulmonary hypertension proc am thorac soc 2006;3:584-588fuwai hospitalfuwai hospital41药物治疗药物治疗pre-pea “bridging” therapypre-pea “bridging” therapypost-pea therapypost-pea therapymedical therapies for chronic thromboembolic pulmonary hypertension. an evolving treatment paradig

16、m. proc am thorac soc 2006;3:594-600fuwai hospitalfuwai hospital42药物治疗药物治疗抗凝药抗凝药利尿剂等利尿剂等padvanced drugs前列环素类似物：前列环素类似物：epoprostenol, iloprostepoprostenol, iloprostet-r et-r 拮抗剂：拮抗剂：bosentanbosentanped-5ped-5抑制剂：抑制剂：sildenafilsildenafilptraditional drugsfuwai hospitalfuwai hospital43pre-pea “bridging

17、” therapypre-pea “bridging” therapynyha nyha mpap 50mpap 50ci 2.0ci 1000pvr 1000p血流动力学不稳定血流动力学不稳定p医疗条件差，不能手术医疗条件差，不能手术fuwai hospitalfuwai hospital44post-pea therapypost-pea therapy用于术后残留持久性肺动脉高压的治疗用于术后残留持久性肺动脉高压的治疗pea pea 术后术后10101515残留残留phph术后术后mpap 30, 3mpap 30, 3年死亡率年死亡率9090p目前尚需要指南决定目前尚需要指南决定whe

18、nwhenhowhowhow longhow longstopping rulesstopping rulesfuwai hospitalfuwai hospital45术后术后ecmoecmo的运用的运用再灌注肺水肿再灌注肺水肿肺动脉高压所致右心功能衰竭肺动脉高压所致右心功能衰竭successful extracorporeal membrane oxygenation support after pulmonary thromboendarterectomy. ann thorac surg. 2008 oct;86(4):1261-7. 用于脱机早期的循环呼吸障碍用于脱机早期的循环呼吸障

19、碍berman报道：报道：127例例pea中中7例例ecmo，5例脱机例脱机fuwai hospitalfuwai hospital46fuwai hospitalfuwai hospital47peapea是治疗是治疗ctephcteph的安全而有效的方的安全而有效的方法，且具有良好的中远期结果。法，且具有良好的中远期结果。手术适应症与手术时机的判断影响手术手术适应症与手术时机的判断影响手术疗效，也存在争议。疗效，也存在争议。结结 论论fuwai hospitalfuwai hospital48fuwai hospitalfuwai hospital49pulmonary thromboen

20、darterectomyyunhu songcardiac surgery department fuwai hospitalfuwai hospitalfuwai hospital50backgroundfuwai hospitalfuwai hospital51conception of ctephformation mechanism rusults in diversity of treatmentcirculation，2006；113：201120tradional: one of turnovers of acute pemodern: promoted by pulmonary

21、 thrombus, progressive pulmonary artery remodelingfuwai hospitalfuwai hospital52 pathophysioloymost have dvt or right heart thrombusrecurrent pe, pulmonary remodelingphright heart failure, respiratory failurefuwai hospitalfuwai hospital53diagnostic methodsabgdoppler ultrasound for lower extremitiesu

22、cgpulmonary perfusion scanctapulmonary angiographyfuwai hospitalfuwai hospital54angiography and mriangiography and ctfuwai hospitalfuwai hospital55natural historynatural history is associated with mpap 30mmhg, 5-year survival 30 50mmhg, 5-year survival 10chest 1982; 81: 151-8fuwai hospitalfuwai hosp

23、ital56treatment of choicepea:preferredmedicinepulmonary transplantpulmonary artery balloon angioplastycurrent and future management of chronic thromboembolic pulmonary hypertension: from diagnosis to treatment response. proc am thorac soc，2006(3) ：601607fuwai hospitalfuwai hospital57fuwai hospitalfu

24、wai hospital58data and methodsfuwai hospitalfuwai hospital59cteph patientssurgical accessiblewithout severe mobidity46 undergone pea1997.31997.32008.62008.6fuwai hospitalfuwai hospital60pe in fuwai hospital (1997-2008.6)701 casesfuwai hospitalfuwai hospital61pea in fuwai hosp in recent yearsfuwai ho

25、spitalfuwai hospital62male：35 female：11mean age: 46.1 yearsmean history: 45.1 mongeneral informationfuwai hospitalfuwai hospital63clinical manifestationeffort dyspnealower extremites edemasyncopehemoptysisascitedvt4435713130fuwai hospitalfuwai hospital64bilateral disease 32 casesunilateral disease14

26、 casesfuwai hospitalfuwai hospital65operation methods deep hypothermic circulatory arrest or low flow thromboendarterectomy treat associated cardiac disordersfuwai hospitalfuwai hospital66 mean cpb time: 160.3min mean aoc time: 72.2min mean cardiac arrest time: 44.6 min associated managementtvpcabgp

27、vp611fuwai hospitalfuwai hospital67expose rpa and rpa incisionexpose lpa and lpa incisionfuwai hospitalfuwai hospital68rpa incisionresection plane initiatedfuwai hospitalfuwai hospital69create resection planefuwai hospitalfuwai hospital70fuwai hospitalfuwai hospital71fuwai hospitalfuwai hospital72fu

28、wai hospitalfuwai hospital73resultsresultsfuwai hospitalfuwai hospital74 op mortality: 8.7% (4/46) mean intubation time: 75.2 h pulmonary edema: 10（21.7） early postop-severe ph: 6（13.0） cns complication: 7（15.2）fuwai hospitalfuwai hospital75fuwai hospitalfuwai hospital76pre-op 7 days post-opcta chan

29、gesfemale, 53 yrs, cpe in rpafuwai hospitalfuwai hospital77preoppreop 1 mon postop1 mon postopmale，53 yrs， cpe in rpa1 yr postop1 yr postopcta changesfuwai hospitalfuwai hospital78preoppostopfuwai hospitalfuwai hospital79preoppostopfuwai hospitalfuwai hospital80pulmonary perfusion improved postoppre

30、op 3 mon postopcase 1: male, 53 yrscase 2: male, 48 yrspreop 6 mon postopfuwai hospitalfuwai hospital81followup cases followedfollowup time(mon)deathcteph associated re-hospitalizationbleeding and thrombolization3827.3（2-122）411fuwai hospitalfuwai hospital82causes of 4 death during followup1: male,

31、49 yrs, died of cerebral hemorrhage 30 months postop2: male, 47 yrs, died 15 days postop with unkown reason3: female, 58 yrs, died of leukemia 24 months postop4: female, 56 yrs, died of heart failure 12 months postopfuwai hospitalfuwai hospital83timepreposti 027ii 04iii 203iv 140 comparation of card

32、iac function between pre-op and post-opfuwai hospitalfuwai hospital84discussionfuwai hospitalfuwai hospital85indication of pea?factors related to prognosis of pea?fuwai hospitalfuwai hospital86indication of peasurgical accessiblepvr 300 dynenyha or without severe morbiditychest 2004; 126: 63s-71soth

33、er considerationmpap40，surgical expertise，advanced secondary arteriopathyfuwai hospitalfuwai hospital87typelocation例数例数死亡率死亡率1fresh thrombus in main pa or lobular pa1872.1%2thinkened endothelium above segemental level2455.3%3distal segemental pa605.0%4distal arteriopathy, without visible thrombis825

34、%relationship location of disease and mortalityj thorac cardiovasc surg 2002;124:1203-1211fuwai hospitalfuwai hospital88relationship between pvr and mortalitypost-op post-op pvrpvrmortalitymortality50050050030.6%30.6%pre-op pre-op pvrpvrmortalitymortality9001200120020%20%assessment of operability in

35、 chronic thromboembolic pulmonary hypertension proc am thorac soc 2006;3:584-588fuwai hospitalfuwai hospital89medical treatment can improve medical treatment can improve prognosisprognosispre-pea “bridging” therapypre-pea “bridging” therapypost-pea therapypost-pea therapymedical therapies for chroni

36、c thromboembolic pulmonary hypertension. an evolving treatment paradigm. proc am thorac soc 2006;3:594-600fuwai hospitalfuwai hospital90drugsanticoagulation drugsdiuretics, etcpadvanced drugsprostacyclin analogues ：epoprostenol, iloprostet-r antagonists：bosentanped-5 inhibitors：sildenafilptraditional drugsfuwai hospitalfuwai hospital91pre-pea “bridging” therapynyha mpap 50ci 1000punstable hemodynamicspunsatisfactory hospital conditio