1、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1FuwaiFuwai Hospital Hospital背背 景景2FuwaiFuwai Hospital Hospital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及内膜机化始动进行性肺动脉重构（进行性肺动脉重构（remo
2、deling)3FuwaiFuwai Hospital Hospital 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4FuwaiFuwai Hospital Hospital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5FuwaiFuwai Hospital Hospital肺动脉造影与肺动脉造影与MRI肺动脉造影与肺动脉造影与CT6FuwaiFuwai Hos
3、pital Hospital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;81:151-87FuwaiFuwai Hospital HospitalCTEPHCTEPH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 Hypertension:from diagnosis to treat
4、ment 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8FuwaiFuwai Hospital Hospital9FuwaiFuwai Hospital Hospital资资 料料 与与 方方 法法10FuwaiFuwai Hospital HospitalCTEPH 病人病人病变位于手术可及部位病变位于手术可及部位 无严重伴发症无严重伴发症46 例被例被选择行选择行 PEA19971997年年3
5、 3月月20082008年年6 6月月11FuwaiFuwai Hospital Hospital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12FuwaiFuwai Hospital Hospital阜外医院近年阜外医院近年PEAPEA手术例数手术例数13FuwaiFuwai Hospital Hospital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:45.1:45.1 月月 一般资料一般资料14FuwaiFuwai Hospital Ho
6、spital临床表现临床表现气短气短44下肢水肿下肢水肿35晕厥晕厥7咯血咯血13大量腹水大量腹水1DVT3015FuwaiFuwai Hospital Hospital双侧病变双侧病变 32 32 例例单侧病变单侧病变14 14 例例16FuwaiFuwai Hospital Hospital手术方法手术方法 深深低温、低流量或间断停循环低温、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17FuwaiFuwai Hospital Hospital 平均体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
7、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TVPTVP6 6CABGCABG1 1PVPPVP1 118FuwaiFuwai Hospital HospitalExpose RPA and RPA incisionExpose LPA and LPA incision19FuwaiFuwai Hospital HospitalRPA incisionResection plane initiated20FuwaiFuwai Hospital HospitalCreate resection
8、plane21FuwaiFuwai Hospital Hospital22FuwaiFuwai Hospital Hospital23FuwaiFuwai Hospital Hospital24FuwaiFuwai Hospital Hospital结结 果果25FuwaiFuwai Hospital Hospital 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（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（1
9、5.215.2）经适当处经适当处理均得以理均得以恢复恢复26FuwaiFuwai Hospital Hospital27FuwaiFuwai Hospital Hospital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,右右肺动脉慢性栓塞肺动脉慢性栓塞28FuwaiFuwai Hospital Hospital术前术前 术后术后1 1月月PEAPEA术后术后UFCT UFCT 改善改善男性，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29FuwaiFuwai Hospital Hospital术前术前术
10、后术后30FuwaiFuwai Hospital Hospital术前术前术后术后31FuwaiFuwai Hospital HospitalPEAPEA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 yrs32FuwaiFuwai Hospital Hospital随访结果随访结果 随访例数随访例数3838随访时间随访时间(月月)27.327.3（2-1222-122）死亡死亡4 4CTEPHCTEPH相关入院相关入院1
11、 1出血和血栓并发症出血和血栓并发症1 133FuwaiFuwai Hospital Hospital4 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，术后岁，术后1212个月，心力衰竭个月，心力衰竭34FuwaiFuwai Hospital HospitalI I IIII IIIIII IVIV 术前术前0 00 02020141
12、4术后术后2 27 74 43 30 0 术术前后心功能比较前后心功能比较35FuwaiFuwai Hospital Hospital讨讨 论论36FuwaiFuwai Hospital HospitalPEA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?37FuwaiFuwai Hospital HospitalPEAPEA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 级级无无严重伴发症严重伴发症Chest 2004;12
13、6:63s-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38FuwaiFuwai Hospital HospitalTypeType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 Thor
14、ac Cardiovasc Surg 2002;124:1203-121139FuwaiFuwai Hospital HospitalPVRPVR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 Chronic Thromboembolic Pulmonary Hypertension Proc Am Thorac Soc 2006;3:584-58840FuwaiFuwa
15、i Hospital Hospital药物治疗药物治疗Pre-PEA Pre-PEA“BridgingBridging”therapy therapyPost-PEA therapyPost-PEA therapyMedical Therapies for Chronic Thromboembolic Pulmonary Hypertension.An Evolving Treatment Paradigm.Proc Am Thorac Soc 2006;3:594-60041FuwaiFuwai Hospital Hospital药物治疗药物治疗抗凝药抗凝药利尿剂等利尿剂等pAdvanced
16、 drugs前列环素类似物：前列环素类似物：epoprostenolepoprostenol,iloprostiloprostET-R ET-R 拮抗剂：拮抗剂：bosentanbosentanPED-5PED-5抑制剂：抑制剂：sildenafilsildenafilpTraditional drugs42FuwaiFuwai Hospital HospitalPre-PEA Pre-PEA“BridgingBridging”therapy 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，
17、不能手术医疗条件差，不能手术43FuwaiFuwai Hospital HospitalPost-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mPAPmPAP 30,3 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WhenWhenHowHowHow longHow longStopping rulesStopping rules44FuwaiFuwai Hospital Hospital术后术后ECMOECMO的运用的运用再灌注
18、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碍Berman报道：报道：127例例PEA中中7例例ECMO，5例脱机例脱机45FuwaiFuwai Hospital Hospital46FuwaiFuwai Hospital HospitalPEAPEA是治疗是治
19、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47FuwaiFuwai Hospital Hospital48FuwaiFuwai Hospital HospitalPULMONARY THROMBOENDARTERECTOMYYUNHU SONGCARDIAC SURGERY DEPARTMENT FUWAI HOSPITAL49FuwaiFuwai Hospital HospitalBACKGROUND50Fuwa
20、iFuwai Hospital HospitalCONCEPTION OF CTEPHFormation mechanism rusults in diversity of treatmentCirculation，2006；113：201120TRADIONAL:one of turnovers of acute PEMODERN:promoted by pulmonary thrombus,progressive pulmonary artery remodeling51FuwaiFuwai Hospital Hospital PATHOPHYSIOLOYMost have DVT or
21、right heart thrombusRecurrent PE,pulmonary remodelingPHRight heart failure,respiratory failure52FuwaiFuwai Hospital HospitalDIAGNOSTIC METHODSABGDoppler ultrasound for lower extremitiesUCGPulmonary perfusion scanCTAPulmonary angiography53FuwaiFuwai Hospital HospitalANGIOGRAPHY AND MRIANGIOGRAPHY AND
22、 CT54FuwaiFuwai Hospital HospitalNATURAL HISTORYNatural history is associated with mPAP 30mmHg,5-year survival 30 50mmHg,5-year survival 10Chest 1982;81:151-855FuwaiFuwai Hospital HospitalTREATMENT OF CHOICEPEA:preferredmedicinePulmonary transplantPulmonary Artery Balloon AngioplastyCurrent and Futu
23、re Management of Chronic Thromboembolic Pulmonary Hypertension:from diagnosis to treatment response.Proc Am Thorac Soc，2006(3)：60160756FuwaiFuwai Hospital Hospital57FuwaiFuwai Hospital HospitalDATA AND METHODS58FuwaiFuwai Hospital HospitalCTEPH PATIENTSSURGICAL ACCESSIBLEWITHOUT SEVERE MOBIDITY46 UN
24、DERGONE PEA1997.31997.32008.62008.659FuwaiFuwai Hospital HospitalPE in FUWAI HOSPITAL(1997-2008.6)701 CASES60FuwaiFuwai Hospital HospitalPEA IN FUWAI HOSP IN RECENT YEARS61FuwaiFuwai Hospital Hospitalmale：35 female：11Mean age:46.1 yearsMean history:45.1 monGENERAL INFORMATION62FuwaiFuwai Hospital Ho
25、spitalCLINICAL MANIFESTATIONEffort dyspnea44Lower extremites edema35syncope7hemoptysis13ascite1DVT3063FuwaiFuwai Hospital HospitalBilateral disease 32 casesUnilateral disease14 cases64FuwaiFuwai Hospital HospitalOPERATION METHODS deep hypothermic circulatory arrest or low flow thromboendarterectomy
26、Treat associated cardiac disorders65FuwaiFuwai Hospital Hospital Mean CPB time:160.3min Mean AOC time:72.2min Mean cardiac arrest time:44.6 min Associated managementTVP6CABG1PVP166FuwaiFuwai Hospital HospitalExpose RPA and RPA incisionExpose LPA and LPA incision67FuwaiFuwai Hospital HospitalRPA inci
27、sionResection plane initiated68FuwaiFuwai Hospital HospitalCreate resection plane69FuwaiFuwai Hospital Hospital70FuwaiFuwai Hospital Hospital71FuwaiFuwai Hospital Hospital72FuwaiFuwai Hospital HospitalRESULTSRESULTS73FuwaiFuwai Hospital Hospital OP mortality:8.7%(4/46)Mean intubation time:75.2 h Pul
28、monary edema:10（21.7）Early postop-severe PH:6（13.0）CNS complication:7（15.2）74FuwaiFuwai Hospital Hospital75FuwaiFuwai Hospital HospitalPRE-OP 7 DAYS POST-OPCTA changesfemale,53 yrs,CPE in RPA76FuwaiFuwai Hospital Hospitalpreoppreop 1 1 monmon postoppostopmale，53 yrs，CPE in RPA1 yr 1 yr postoppostopC
29、TA changes77FuwaiFuwai Hospital Hospitalpreoppostop78FuwaiFuwai Hospital Hospitalpreoppostop79FuwaiFuwai Hospital HospitalPulmonary perfusion improved postoppreop 3 mon postopCase 1:male,53 yrsCase 2:male,48 yrspreop 6 mon postop80FuwaiFuwai Hospital HospitalFOLLOWUP Cases followed38Followup time(mo
30、n)27.3（2-122）death4CTEPH associated re-hospitalization1Bleeding and thrombolization181FuwaiFuwai Hospital HospitalCauses of 4 death during followup1:male,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
31、postop4:female,56 yrs,died of heart failure 12 months postop82FuwaiFuwai Hospital HospitaltimeI II III IV PRE002014POST27430 COMPARATION OF CARDIAC FUNCTION BETWEEN PRE-OP AND POST-OP83FuwaiFuwai Hospital HospitalDISCUSSION84FuwaiFuwai Hospital HospitalINDICATION OF PEA?FACTORS RELATED TO PROGNOSIS
32、OF PEA?85FuwaiFuwai Hospital HospitalINDICATION OF PEASurgical accessiblePVR 300 dyneNYHA or Without severe morbidityChest 2004;126:63s-71sOther considerationmPAP40，surgical expertise，advanced secondary arteriopathy86FuwaiFuwai Hospital HospitalTypelocation例数例数死亡率死亡率1Fresh thrombus in main PA or lob
33、ular PA1872.1%2Thinkened endothelium above segemental level2455.3%3Distal segemental PA605.0%4Distal arteriopathy,without visible thrombis825%Relationship location of disease and mortalityJ Thorac Cardiovasc Surg 2002;124:1203-121187FuwaiFuwai Hospital HospitalRELATIONSHIP BETWEEN PVR AND MORTALITYP
34、ost-op Post-op PVRPVRmortalitymortality50050050030.6%30.6%Pre-op Pre-op PVRPVRmortalitymortality9001200120020%20%Assessment of Operability in Chronic Thromboembolic Pulmonary Hypertension Proc Am Thorac Soc 2006;3:584-58888FuwaiFuwai Hospital HospitalMedical treatment can improve Medical treatment c
35、an improve prognosisprognosisPre-PEA Pre-PEA“BridgingBridging”therapy therapyPost-PEA therapyPost-PEA therapyMedical Therapies for Chronic Thromboembolic Pulmonary Hypertension.An Evolving Treatment Paradigm.Proc Am Thorac Soc 2006;3:594-60089FuwaiFuwai Hospital HospitalDRUGSAnticoagulation drugsDiu
36、retics,etcpAdvanced drugsProstacyclin analogues：epoprostenol,iloprostET-R Antagonists：bosentanPED-5 inhibitors：sildenafilpTraditional drugs90FuwaiFuwai Hospital HospitalPre-PEA“Bridging”therapyNYHA MPAP 50CI 1000pUnstable hemodynamicspUnsatisfactory hospital condition,unable to be operated91FuwaiFuw
37、ai Hospital HospitalPost-PEA therapyPost-PEA therapyTreatment to residue PH Treatment to residue PH residue PH observed in 10-15residue PH observed in 10-15 PEA PEA postoppostopPostoperative Postoperative mPAPmPAP 30,3 year mortality:30,3 year mortality:9090pGuidline needed WhenWhenHowHowHow longHow
38、 longStopping rulesStopping rules92FuwaiFuwai Hospital HospitalECMOReperfusional pulmonary edemaRight heart failure due to PHSuccessful extracorporeal membrane oxygenation support after pulmonary thromboendarterectomy.Ann Thorac Surg.2008 Oct;86(4):1261-7.For circularion or respiratory dysfunction p
39、ost-opBerman reported：7 ECMO IN 127 PEA,5 weaning successfully93FuwaiFuwai Hospital HospitalCONCLUSION94FuwaiFuwai Hospital HospitalPEA is a safe and effective PEA is a safe and effective method to treat CTEPH and with method to treat CTEPH and with satisfactory mid-and long-term satisfactory mid-and long-term resultsresultspreoppreop evaluation system evaluation system supposed to be perfectedsupposed to be perfectedpostoppostop treatment needs further treatment needs further exploration and exploration and standizationstandization95FuwaiFuwai Hospital Hospital96FuwaiFuwai Hospital Hospital
