慢性肺栓塞的外科治疗宋云虎.pptx

Fuwai 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 Hospital2背背 景景Fuwai 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 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 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 Hospital6肺肺动动脉脉造造影影与与MRI肺肺动动脉脉造造影影与与CTFuwai 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3050mmHg,5年生存率年生存率10Chest1982;81:151-8Fuwai Hospital8CTEPH治疗选择治疗选择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CurrentandFutureManagementofChronicThromboembolicPulmonaryHypertension:fromdiagnosistotreatmentresponse.ProcAmThoracSoc，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 Hospital9Fuwai Hospital10资资 料料 与与 方方 法法Fuwai 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无严重伴发症无严重伴发症46例被选择行例被选择行PEA1997年年3月月2008年年6月月Fuwai 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)共共701例例Fuwai Hospital13阜外医院近年阜外医院近年PEA手术例数手术例数Fuwai Hospital14男：男：35例例 女：女：11例例平均年龄平均年龄:46.1 岁岁平均病史平均病史:45.1 月月 一般资料一般资料Fuwai Hospital15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1DVT30Fuwai Hospital16双侧病变双侧病变 32 例例单侧病变单侧病变14 例例Fuwai 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 Hospital18平均体外循环时间平均体外循环时间: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平均停循环时间平均停循环时间:44.6 min同期手术如下表同期手术如下表TVP6CABG1PVP1Fuwai Hospital19Expose RPA and RPA incisionExpose LPA and LPA incisionFuwai Hospital20RPA incisionResection plane initiatedFuwai Hospital21Create resection planeFuwai Hospital22Fuwai Hospital23Fuwai Hospital24Fuwai Hospital25结结 果果Fuwai Hospital26手术死亡率手术死亡率:8.7%(4/46)平均气管插管时间平均气管插管时间:75.2 h肺水肿肺水肿:10（21.7）术后早期严重肺动脉高压术后早期严重肺动脉高压:6（13.0）神经系统并发症神经系统并发症:7（15.2）经适当处经适当处理均得以理均得以恢复恢复Fuwai Hospital27Fuwai Hospital28术前术前 术后术后7天天PEA术后术后UFCT 改善改善女性女性,53 岁岁,右肺动脉慢性栓塞右肺动脉慢性栓塞Fuwai Hospital29术前术前 术后术后1月月PEA术后术后UFCT 改善改善男性，男性，53 岁，右肺动脉慢性栓塞岁，右肺动脉慢性栓塞术后术后1年年Fuwai Hospital30术前术前术后术后Fuwai Hospital31术前术前术后术后Fuwai Hospital32PEA术后肺灌注术后肺灌注 改善改善术前术前 术后术后3月月Case 1:male,53 yrs术前术前术后术后6月月Case 2:male,48 yrsFuwai Hospital33随访结果随访结果 随访例数随访例数38随访时间随访时间(月月)27.3（2-122）死亡死亡4CTEPH相关入院相关入院1出血和血栓并发症出血和血栓并发症1Fuwai Hospital344例死亡原因例死亡原因1例，男性，例，男性，49岁，术后岁，术后30个月，脑出血个月，脑出血1例，男性，例，男性，47岁，出院回家路上，死因不祥岁，出院回家路上，死因不祥1例，女性，例，女性，58岁，术后岁，术后24个月，白血病个月，白血病1例，女性，例，女性，56岁，术后岁，术后12个月，心力衰竭个月，心力衰竭Fuwai Hospital35I I IIII IIIIII IVIV 术前术前002014术后术后27430 术前后心功能比较术前后心功能比较Fuwai Hospital36讨讨 论论Fuwai 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 Hospital38PEA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 dyne/sec/cm-5NYHA or 级级无严重伴发症无严重伴发症Chest2004;126:63s-71s其他考虑的因素其他考虑的因素mPAP40，外科水平，继发肺血管病变，外科水平，继发肺血管病变Fuwai Hospital39Type病变位置病变位置例数例数死亡率死亡率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1872.1%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2455.3%3病变仅位于远端段动脉病变仅位于远端段动脉605.0%4远端微血管病变，无肉眼可见血栓远端微血管病变，无肉眼可见血栓825%病变位置与死亡病变位置与死亡率关系率关系J Thorac Cardiovasc Surg2002;124:1203-1211Fuwai Hospital40PVR与手术死亡率相关与手术死亡率相关术后术后PVRmortality50030.6%术前术前PVRmortality120020%AssessmentofOperabilityinChronicThromboembolicPulmonaryHypertensionProcAmThoracSoc2006;3:584-588Fuwai Hospital41药物治疗药物治疗Pre-PEA“Bridging”therapyPost-PEA therapyMedicalTherapiesforChronicThromboembolicPulmonaryHypertension.AnEvolvingTreatmentParadigm.ProcAmThoracSoc2006;3:594-600Fuwai Hospital42药物治疗药物治疗抗凝药抗凝药利尿剂等利尿剂等pAdvanceddrugs前列环素类似物：前列环素类似物：epoprostenol,iloprostET-R 拮抗剂：拮抗剂：bosentanPED-5抑制剂：抑制剂：sildenafilpTraditionaldrugsFuwai Hospital43Pre-PEA“Bridging”therapyNYHA MPAP 50CI 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 Hospital44Post-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 术后术后1015残留残留PH术后术后mPAP 30,3年死亡率年死亡率90p目前尚需要指南决定目前尚需要指南决定WhenHowHow longStopping rulesFuwai Hospital45术后术后ECMO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Successfulextracorporealmembraneoxygenationsupportafterpulmonarythromboendarterectomy.AnnThoracSurg.2008Oct;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Fuwai Hospital46Fuwai Hospital47PEA是治疗是治疗CTEPH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 Hospital48Fuwai Hospital49PULMONARYTHROMBOENDARTERECTOMYYUNHUSONGCARDIACSURGERYDEPARTMENTFUWAIHOSPITALFuwai Hospital50BACKGROUNDFuwai Hospital51CONCEPTIONOFCTEPHFormationmechanismrusultsindiversityoftreatmentCirculation，2006；113：201120TRADIONAL:oneofturnoversofacutePEMODERN:promotedbypulmonarythrombus,progressivepulmonaryarteryremodelingFuwai Hospital52PATHOPHYSIOLOYMosthaveDVTorrightheartthrombusRecurrentPE,pulmonaryremodelingPHRightheartfailure,respiratoryfailureFuwai Hospital53DIAGNOSTICMETHODSABGDopplerultrasoundforlowerextremitiesUCGPulmonaryperfusionscanCTAPulmonaryangiographyFuwai Hospital54ANGIOGRAPHYANDMRIANGIOGRAPHYANDCTFuwai Hospital55NATURALHISTORYNaturalhistoryisassociatedwithmPAP30mmHg,5-yearsurvival3050mmHg,5-yearsurvival10Chest1982;81:151-8Fuwai Hospital56TREATMENTOFCHOICEPEA:preferredmedicinePulmonarytransplantPulmonaryArteryBalloonAngioplastyCurrentandFutureManagementofChronicThromboembolicPulmonaryHypertension:fromdiagnosistotreatmentresponse.ProcAmThoracSoc，2006(3)：601607Fuwai Hospital57Fuwai Hospital58DATAANDMETHODSFuwai Hospital59CTEPHPATIENTSSURGICALACCESSIBLEWITHOUTSEVEREMOBIDITY46UNDERGONEPEA1997.32008.6Fuwai Hospital60PEinFUWAIHOSPITAL(1997-2008.6)701CASESFuwai Hospital61PEAINFUWAIHOSPINRECENTYEARSFuwai Hospital62male：35female：11Meanage:46.1yearsMeanhistory:45.1monGENERALINFORMATIONFuwai Hospital63CLINICALMANIFESTATIONEffortdyspnea44Lowerextremitesedema35syncope7hemoptysis13ascite1DVT30Fuwai Hospital64Bilateraldisease32casesUnilateraldisease14casesFuwai Hospital65OPERATIONMETHODSdeephypothermiccirculatoryarrestorlowflowthromboendarterectomyTreatassociatedcardiacdisordersFuwai Hospital66MeanCPBtime:160.3minMeanAOCtime:72.2minMeancardiacarresttime:44.6minAssociatedmanagementTVP6CABG1PVP1Fuwai Hospital67Expose RPA and RPA incisionExpose LPA and LPA incisionFuwai Hospital68RPA incisionResection plane initiatedFuwai Hospital69Create resection planeFuwai Hospital70Fuwai Hospital71Fuwai Hospital72Fuwai Hospital73RESULTSFuwai Hospital74OPmortality:8.7%(4/46)Meanintubationtime:75.2hPulmonaryedema:10（21.7）Earlypostop-severePH:6（13.0）CNScomplication:7（15.2）Fuwai Hospital75Fuwai Hospital76PRE-OP7DAYSPOST-OPCTAchangesfemale,53yrs,CPEinRPAFuwai Hospital77preop 1 mon postopmale，53yrs，CPEinRPA1 yr postopCTAchangesFuwai Hospital78preoppostopFuwai Hospital79preoppostopFuwai Hospital80Pulmonaryperfusionimprovedpostoppreop3monpostopCase1:male,53yrsCase2:male,48yrspreop 6monpostopFuwai Hospital81FOLLOWUP Casesfollowed38Followuptime(mon)27.3（2-122）death4CTEPHassociatedre-hospitalization1Bleedingandthrombolization1Fuwai Hospital82Causesof4deathduringfollowup1:male,49yrs,diedofCerebralHemorrhage30monthspostop2:male,47yrs,died15dayspostopwithunkownreason3:female,58yrs,diedofLeukemia24monthspostop4:female,56yrs,diedofheartfailure12monthspostopFuwai Hospital83timeIIIIIIIVPRE002014POST27430 COMPARATIONOFCARDIACFUNCTIONBETWEENPRE-OPANDPOST-OPFuwai Hospital84DISCUSSIONFuwai Hospital85INDICATIONOFPEA?FACTORSRELATEDTOPROGNOSISOFPEA?Fuwai Hospital86INDICATIONOFPEASurgicalaccessiblePVR300dyneNYHAorWithoutseveremorbidityChest2004;126:63s-71sOtherconsiderationmPAP40，surgicalexpertise，advancedsecondaryarteriopathyFuwai Hospital87Typelocation例数例数死亡率死亡率1FreshthrombusinmainPAorlobularPA1872.1%2Thinkenedendotheliumabovesegementallevel2455.3%3DistalsegementalPA605.0%4Distalarteriopathy,withoutvisiblethrombis825%RelationshiplocationofdiseaseandmortalityJ Thorac Cardiovasc Surg2002;124:1203-1211Fuwai Hospital88RELATIONSHIPBETWEENPVRANDMORTALITYPost-op PVRmortality50030.6%Pre-op PVRmortality120020%AssessmentofOperabilityinChronicThromboembolicPulmonaryHypertensionProcAmThoracSoc2006;3:584-588Fuwai Hospital89Medical treatment can improve prognosisPre-PEA“Bridging”therapyPost-PEA therapyMedicalTherapiesforChronicThromboembolicPulmonaryHypertension.AnEvolvingTreatmentParadigm.ProcAmThoracSoc2006;3:594-600Fuwai Hospital90DRUGSAnticoagulationdrugsDiuretics,etcpAdvanceddrugsProstacyclinanalogues：epoprostenol,iloprostET-RAntagonists：bosentanPED-5inhibitors：sildenafilpTraditionaldrugsFuwai Hospital91Pre-PEA“Bridging”therapyNYHAMPAP50CI1000pUnstablehemodynamicspUnsatisfactoryhospitalcondition,unabletobeoperatedFuwai Hospital92Post-PEA therapyTreatment to residue PH residue PH observed in 10-15 PEA postopPostoperative mPAP 30,3 year mortality:90pGuidlineneededWhenHowHow longStopping rulesFuwai Hospital93ECMOReperfusionalpulmonaryedemaRightheartfailureduetoPHSuccessfulextracorporealmembraneoxygenationsupportafterpulmonarythromboendarterectomy.AnnThoracSurg.2008Oct;86(4):1261-7.Forcircularionorrespiratorydysfunctionpost-opBermanreported：7ECMOIN127PEA,5weaningsuccessfullyFuwai Hospital94CONCLUSIONFuwai Hospital95PEA is a safe and effective method to treat CTEPH and with satisfactory mid-and long-term resultspreop evaluation system supposed to be perfectedpostop treatment needs further exploration and standizationFuwai Hospital96