慢性肺栓塞的外科治疗-宋云虎

慢性肺栓塞的外科治疗宋云虎柳志红阜外心血管病医院成人心脏外科中心肺血管病诊治中心1背景2慢性肺栓塞的概念形成机制决定治疗方案多样化Circulation，2006；113：2011－20传统观念：急性肺栓塞的转归之一现代观念：肺动脉血栓及内膜机化始动进行性肺动脉重构（remodeling)3

病理生理多数病人DVT、右心系统血栓等肺动脉反复栓塞，肺血管重构肺动脉高压右心衰竭、呼吸衰竭4诊断手段血气分析下肢静脉超声多谱勒超声心动图肺核素灌注扫描UFCT肺动脉造影5肺动脉造影与MRI肺动脉造影与CT6自然预后自然预后不佳，与平均动脉压有关>30mmHg,5年生存率30％>50mmHg,5年生存率10％Chest1982;81:151-87CTEPH治疗选择CurrentandFutureManagementofChronicThromboembolicPulmonaryHypertension:fromdiagnosistotreatmentresponse.ProcAmThoracSoc，2006(3)：601－607PEA失败药物治疗无效进行性肺小血管病变89资料与方法10CTEPH病人46例被选择行PEA1997年3月－2008年6月11阜外医院肺动脉栓塞病人的收治情况(1997-2008.6)共701例1213男：35例女：11例平均年龄:46.1岁平均病史:45.1月一般资料14临床表现气短44下肢水肿35晕厥7咯血13大量腹水1DVT3015双侧病变32例单侧病变14例16深低温、低流量或间断停循环清除血栓和机化内膜处理伴随心脏病变17TVP6CABG1PVP118ExposeRPAandRPAincisionExposeLPAandLPAincision19RPAincisionResectionplaneinitiated20Createresectionplane21222324结果25经适当处理均得以恢复2627女性,53岁,右肺动脉慢性栓塞28男性，53岁，右肺动脉慢性栓塞293031Case1:male,53yrsCase2:male,48yrs32随访结果

随访例数38随访时间(月)27.3（2-122）死亡4CTEPH相关入院1出血和血栓并发症1334例死亡原因34I

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术前002014术后2743035讨论3637Chest2004;126:63s-71s其他考虑的因素mPAP>40，外科水平，继发肺血管病变38Type病变位置例数死亡率1肺主动脉和叶动脉内新鲜血栓1872.1%2段以上动脉内膜增厚、纤维化2455.3%3病变仅位于远端段动脉605.0%4远端微血管病变，无肉眼可见血栓825%病变位置与死亡率关系JThoracCardiovascSurg2002;124:1203-121139术后PVRmortality<5000.9%>50030.6%术前PVRmortality<9004%900-120010%>120020%AssessmentofOperabilityinChronicThromboembolicPulmonaryHypertension

ProcAmThoracSoc2006;3:584-58840药物治疗Pre-PEA“Bridging”therapyPost-PEAtherapyMedicalTherapiesforChronicThromboembolicPulmonaryHypertension.AnEvolvingTreatmentParadigm.ProcAmThoracSoc2006;3:594-60041药物治疗抗凝药利尿剂等Advanceddrugs前列环素类似物：epoprostenol,iloprostET-R拮抗剂：bosentanPED-5抑制剂：sildenafilTraditionaldrugs42Pre-PEA“Bridging”therapyNYHAⅥMPAP>50CI<2.0PVR>1000血流动力学不稳定43Post-PEAtherapy目前尚需要指南决定WhenHowHowlongStoppingrules44再灌注肺水肿肺动脉高压所致右心功能衰竭Successfulextracorporealmembraneoxygenationsupportafterpulmonarythromboendarterectomy.AnnThoracSurg.2008Oct;86(4):1261-7.

用于脱机早期的循环呼吸障碍Berman报道：127例PEA中7例ECMO，5例脱机4546结论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例数死亡率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