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1、Fuwai Hospital,1,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,Fuwai Hospital,2,背 景,Fuwai Hospital,3,慢性肺栓塞的概念,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,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),Fuwai Hospital,4,Fuwai Hospital,5,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,Fuwai Hospita
2、l,6,肺动脉造影与MRI,肺动脉造影与CT,Fuwai Hospital,7,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,Chest 1982; 81: 151-8,Fuwai Hospital,8,CTEPH治疗选择,PEA: 首选 药物治疗 肺移植 球囊肺动脉成形术,Current and Future Management of Chronic Thromboembolic Pulmonary Hypertension: from diagnosis to treatment response. Proc Am Thorac
3、 Soc，2006(3) ：601607,不能行PEA手术的病人 Pre-PEA “Bridging” therapy,PEA失败 药物治疗无效 进行性肺小血管病变,Fuwai Hospital,9,Fuwai Hospital,10,资 料 与 方 法,Fuwai Hospital,11,CTEPH 病人,病变位于手术可及部位 无严重伴发症,46 例被选择行 PEA,1997年3月2008年6月,Fuwai Hospital,12,阜外医院肺动脉栓塞病人的收治情况 (1997-2008.6),共701例,Fuwai Hospital,13,阜外医院近年PEA手术例数,Fuwai Hospit
4、al,14,男：35例 女：11例 平均年龄: 46.1 岁 平均病史: 45.1 月,一般资料,Fuwai Hospital,15,临床表现,Fuwai Hospital,16,双侧病变 32 例,单侧病变 14 例,Fuwai Hospital,17,手术方法,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,Fuwai Hospital,18,平均体外循环时间: 160.3 min 平均升主动脉阻断时间: 72.2 min 平均停循环时间: 44.6 min 同期手术如下表,Fuwai Hospital,19,Expose RPA and RPA incision,Exp
5、ose LPA and LPA incision,Fuwai Hospital,20,RPA incision,Resection plane initiated,Fuwai Hospital,21,Create resection plane,Fuwai Hospital,22,Fuwai Hospital,23,Fuwai Hospital,24,Fuwai Hospital,25,结 果,Fuwai Hospital,26,手术死亡率: 8.7% (4/46) 平均气管插管时间: 75.2 h 肺水肿: 10（21.7） 术后早期严重肺动脉高压: 6（13.0） 神经系统并发症: 7（1
6、5.2）,经适当处理均得以恢复,Fuwai Hospital,27,Fuwai Hospital,28,术前,术后7天,PEA术后UFCT 改善,女性, 53 岁, 右肺动脉慢性栓塞,Fuwai Hospital,29,术前,术后1月,PEA术后UFCT 改善,男性，53 岁，右肺动脉慢性栓塞,术后1年,Fuwai Hospital,30,术前,术后,Fuwai Hospital,31,术前,术后,Fuwai Hospital,32,PEA术后肺灌注 改善,术前,术后3月,Case 1: male, 53 yrs,术前,术后6月,Case 2: male, 48 yrs,Fuwai Hospi
7、tal,33,随访结果,Fuwai Hospital,34,4例死亡原因,1例，男性，49岁，术后30个月，脑出血 1例，男性，47岁，出院回家路上，死因不祥 1例，女性，58岁，术后24个月，白血病 1例，女性，56岁，术后12个月，心力衰竭,Fuwai Hospital,35,术前后心功能比较,Fuwai Hospital,36,讨 论,Fuwai Hospital,37,PEA的手术适应症是什么? 影响PEA术后效果的因素?,Fuwai Hospital,38,PEA手术适应症,栓塞病变位于手术可及部位（亚段以上） PVR 300 dyne/sec/cm-5 NYHA or 级 无严重伴
8、发症,Chest 2004; 126: 63s-71s,其他考虑的因素 mPAP40，外科水平，继发肺血管病变,Fuwai Hospital,39,病变位置与死亡率关系,J Thorac Cardiovasc Surg 2002;124:1203-1211,Fuwai Hospital,40,PVR与手术死亡率相关,Assessment of Operability in Chronic Thromboembolic Pulmonary Hypertension Proc Am Thorac Soc 2006;3:584-588,Fuwai Hospital,41,药物治疗,Pre-PEA “
9、Bridging” therapy Post-PEA therapy,Medical Therapies for Chronic Thromboembolic Pulmonary Hypertension. An Evolving Treatment Paradigm. Proc Am Thorac Soc 2006;3:594-600,Fuwai Hospital,42,药物治疗,抗凝药 利尿剂等,Advanced drugs,前列环素类似物：epoprostenol, iloprost ET-R 拮抗剂：bosentan PED-5抑制剂：sildenafil,Traditional dr
10、ugs,Fuwai Hospital,43,Pre-PEA “Bridging” therapy,NYHA MPAP 50 CI 1000,血流动力学不稳定,医疗条件差，不能手术,Fuwai Hospital,44,Post-PEA therapy,用于术后残留持久性肺动脉高压的治疗 PEA 术后1015残留PH 术后mPAP 30, 3年死亡率90,目前尚需要指南决定,When How How long Stopping rules,Fuwai Hospital,45,术后ECMO的运用,再灌注肺水肿 肺动脉高压所致右心功能衰竭,Successful extracorporeal membr
11、ane 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,Berman报道：127例PEA中7例ECMO，5例脱机,Fuwai Hospital,46,Fuwai Hospital,47,PEA是治疗CTEPH的安全而有效的方法，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疗效，也存在争议。,结 论,Fuwai Hospital,48,Fuwai Hospital,49,PULMONARY THROMBO
12、ENDARTERECTOMY,YUNHU SONG,CARDIAC SURGERY DEPARTMENT FUWAI HOSPITAL,Fuwai Hospital,50,BACKGROUND,Fuwai Hospital,51,CONCEPTION OF CTEPH,Formation mechanism rusults in diversity of treatment,Circulation，2006；113：201120,TRADIONAL: one of turnovers of acute PE,MODERN: promoted by pulmonary thrombus, pro
13、gressive pulmonary artery remodeling,Fuwai Hospital,52,Fuwai Hospital,53,DIAGNOSTIC METHODS,ABG Doppler ultrasound for lower extremities UCG Pulmonary perfusion scan CTA Pulmonary angiography,Fuwai Hospital,54,ANGIOGRAPHY AND MRI,ANGIOGRAPHY AND CT,Fuwai Hospital,55,NATURAL HISTORY,Natural history i
14、s associated with mPAP,30mmHg, 5-year survival 30 50mmHg, 5-year survival 10,Chest 1982; 81: 151-8,Fuwai Hospital,56,TREATMENT OF CHOICE,PEA:preferred medicine Pulmonary transplant Pulmonary Artery Balloon Angioplasty,Current and Future Management of Chronic Thromboembolic Pulmonary Hypertension: fr
15、om diagnosis to treatment response. Proc Am Thorac Soc，2006(3) ：601607,Fuwai Hospital,57,Fuwai Hospital,58,DATA AND METHODS,Fuwai Hospital,59,CTEPH PATIENTS,SURGICAL ACCESSIBLE WITHOUT SEVERE MOBIDITY,46 UNDERGONE PEA,1997.32008.6,Fuwai Hospital,60,PE in FUWAI HOSPITAL (1997-2008.6),701 CASES,Fuwai
16、Hospital,61,PEA IN FUWAI HOSP IN RECENT YEARS,Fuwai Hospital,62,male：35 female：11 Mean age: 46.1 years Mean history: 45.1 mon,GENERAL INFORMATION,Fuwai Hospital,63,CLINICAL MANIFESTATION,Fuwai Hospital,64,Bilateral disease 32 cases,Unilateral disease 14 cases,Fuwai Hospital,65,OPERATION METHODS,deep
17、 hypothermic circulatory arrest or low flow thromboendarterectomy Treat associated cardiac disorders,Fuwai Hospital,66,Mean CPB time: 160.3min Mean AOC time: 72.2min Mean cardiac arrest time: 44.6 min Associated management,Fuwai Hospital,67,Expose RPA and RPA incision,Expose LPA and LPA incision,Fuw
18、ai Hospital,68,RPA incision,Resection plane initiated,Fuwai Hospital,69,Create resection plane,Fuwai Hospital,70,Fuwai Hospital,71,Fuwai Hospital,72,Fuwai Hospital,73,RESULTS,Fuwai Hospital,74,OP mortality: 8.7% (4/46) Mean intubation time: 75.2 h Pulmonary edema: 10（21.7） Early postop-severe PH: 6（
19、13.0） CNS complication: 7（15.2）,Fuwai Hospital,75,Fuwai Hospital,76,PRE-OP,7 DAYS POST-OP,CTA changes,female, 53 yrs, CPE in RPA,Fuwai Hospital,77,preop,1 mon postop,male，53 yrs， CPE in RPA,1 yr postop,CTA changes,Fuwai Hospital,78,preop,postop,Fuwai Hospital,79,preop,postop,Fuwai Hospital,80,Pulmon
20、ary perfusion improved postop,preop,3 mon postop,Case 1: male, 53 yrs,Case 2: male, 48 yrs,preop,6 mon postop,Fuwai Hospital,81,FOLLOWUP,Fuwai Hospital,82,Causes of 4 death during followup,1: male, 49 yrs, died of Cerebral Hemorrhage 30 months postop 2: male, 47 yrs, died 15 days postop with unkown
21、reason 3: female, 58 yrs, died of Leukemia 24 months postop 4: female, 56 yrs, died of heart failure 12 months postop,Fuwai Hospital,83,COMPARATION OF CARDIAC FUNCTION BETWEEN PRE-OP AND POST-OP,Fuwai Hospital,84,DISCUSSION,Fuwai Hospital,85,INDICATION OF PEA? FACTORS RELATED TO PROGNOSIS OF PEA?,Fu
22、wai Hospital,86,INDICATION OF PEA,Surgical accessible PVR 300 dyne NYHA or Without severe morbidity,Chest 2004; 126: 63s-71s,Other consideration mPAP40，surgical expertise，advanced secondary arteriopathy,Fuwai Hospital,87,Relationship location of disease and mortality,J Thorac Cardiovasc Surg 2002;12
23、4:1203-1211,Fuwai Hospital,88,RELATIONSHIP BETWEEN PVR AND MORTALITY,Assessment of Operability in Chronic Thromboembolic Pulmonary Hypertension Proc Am Thorac Soc 2006;3:584-588,Fuwai Hospital,89,Medical treatment can improve prognosis,Pre-PEA “Bridging” therapy Post-PEA therapy,Medical Therapies fo
24、r Chronic Thromboembolic Pulmonary Hypertension. An Evolving Treatment Paradigm. Proc Am Thorac Soc 2006;3:594-600,Fuwai Hospital,90,DRUGS,Anticoagulation drugs Diuretics, etc,Advanced drugs,Prostacyclin analogues ：epoprostenol, iloprost ET-R Antagonists ：bosentan PED-5 inhibitors：sildenafil,Traditi
25、onal drugs,Fuwai Hospital,91,Pre-PEA “Bridging” therapy,NYHA MPAP 50 CI 1000,Unstable hemodynamics,Unsatisfactory hospital condition, unable to be operated,Fuwai Hospital,92,Post-PEA therapy,Treatment to residue PH residue PH observed in 10-15 PEA postop Postoperative mPAP 30, 3 year mortality: 90,G
26、uidline needed,When How How long Stopping rules,Fuwai Hospital,93,ECMO,Reperfusional pulmonary edema Right heart failure due to PH,Successful extracorporeal membrane oxygenation support after pulmonary thromboendarterectomy. Ann Thorac Surg. 2008 Oct;86(4):1261-7.,For circularion or respiratory dysf
27、unction post-op,Berman reported：7 ECMO IN 127 PEA, 5 weaning successfully,Fuwai Hospital,94,CONCLUSION,Fuwai Hospital,95,PEA is a safe and effective method to treat CTEPH and with satisfactory mid- and long-term results preop evaluation system supposed to be perfected postop treatment needs further exploration and standization,Fuwai Hospital,96,