慢性肺栓塞的外科治療課件

1、慢性肺栓塞的外科治療宋云虎 柳志紅阜外心血管病醫(yī)院成人心臟外科中心 肺血管病診治中心1Fuwai Hospital慢性肺栓塞的外科治療宋云虎 柳志紅阜外心血管病醫(yī)院1Fuw背 景2Fuwai Hospital背 景2Fuwai Hospital慢性肺栓塞的概念形成機制決定治療方案多樣化Circulation，2006；113：201120傳統(tǒng)觀念：急性肺栓塞的轉歸之一現(xiàn)代觀念：肺動脈血栓及內(nèi)膜機化始動進行性肺動脈重構（remodeling)3Fuwai Hospital慢性肺栓塞的概念形成機制決定治療方案多樣化Circulati 病理生理多數(shù)病人DVT、右心系統(tǒng)血栓等肺動脈反復栓塞，肺血管重構

2、肺動脈高壓右心衰竭、呼吸衰竭4Fuwai Hospital 病理生理多數(shù)病人DVT、右心系統(tǒng)血栓等肺動脈反復栓塞，肺診斷手段血氣分析下肢靜脈超聲多譜勒超聲心動圖肺核素灌注掃描UFCT肺動脈造影5Fuwai Hospital診斷手段血氣分析5Fuwai Hospital肺動脈造影與MRI肺動脈造影與CT6Fuwai Hospital肺動脈造影與MRI肺動脈造影與CT6Fuwai Hospi自然預后自然預后不佳，與平均動脈壓有關30mmHg, 5年生存率3050mmHg, 5年生存率10Chest 1982; 81: 151-87Fuwai Hospital自然預后自然預后不佳，與平均動脈壓有關3

3、0mmHg, 5年CTEPH治療選擇PEA: 首選藥物治療肺移植球囊肺動脈成形術Current and Future Management of Chronic Thromboembolic Pulmonary Hypertension: from diagnosis to treatment response. Proc Am Thorac Soc，2006(3) ：601607不能行PEA手術的病人Pre-PEA “Bridging” therapyPEA失敗藥物治療無效進行性肺小血管病變8Fuwai HospitalCTEPH治療選擇PEA: 首選Current and Fu9Fuwai

4、 Hospital9Fuwai Hospital資 料 與 方 法10Fuwai Hospital資 料 與 方 法10Fuwai HospitalCTEPH 病人病變位于手術可及部位 無嚴重伴發(fā)癥46 例被選擇行 PEA1997年3月2008年6月11Fuwai HospitalCTEPH 病人病變位于手術可及部位 46 例被選擇行 PE阜外醫(yī)院肺動脈栓塞病人的收治情況 (1997-2008.6)共701例12Fuwai Hospital阜外醫(yī)院肺動脈栓塞病人的收治情況 (1997-2008.6)阜外醫(yī)院近年PEA手術例數(shù)13Fuwai Hospital阜外醫(yī)院近年PEA手術例數(shù)13Fuwa

5、i Hospital男：35例 女：11例平均年齡: 46.1 歲平均病史: 45.1 月 一般資料14Fuwai Hospital男：35例 女：11例一般資料14Fuwai Ho臨床表現(xiàn)氣短44下肢水腫35暈厥7咯血13大量腹水1DVT3015Fuwai Hospital臨床表現(xiàn)氣短44下肢水腫35暈厥7咯血13大量腹水1DVT3雙側病變 32 例單側病變14 例16Fuwai Hospital雙側病變單側病變16Fuwai Hospital手術方法深低溫、低流量或間斷停循環(huán)清除血栓和機化內(nèi)膜處理伴隨心臟病變17Fuwai Hospital手術方法深低溫、低流量或間斷停循環(huán)17Fuwai

6、Hosp平均體外循環(huán)時間: 160.3 min平均升主動脈阻斷時間: 72.2 min平均停循環(huán)時間: 44.6 min同期手術如下表TVP6CABG1PVP118Fuwai Hospital平均體外循環(huán)時間: 160.3 minTVP6CABG1PVExpose RPA and RPA incisionExpose LPA and LPA incision19Fuwai HospitalExpose RPA and RPA incisionExpRPA incisionResection plane initiated20Fuwai HospitalRPA incisionResection

7、 plane inCreate resection plane21Fuwai HospitalCreate resection plane21Fuwai 22Fuwai Hospital22Fuwai Hospital23Fuwai Hospital23Fuwai Hospital24Fuwai Hospital24Fuwai Hospital結 果25Fuwai Hospital結 果25Fuwai Hospital手術死亡率: 8.7% (4/46)平均氣管插管時間: 75.2 h肺水腫: 10（21.7）術后早期嚴重肺動脈高壓: 6（13.0）神經(jīng)系統(tǒng)并發(fā)癥: 7（15.2）經(jīng)適當處理均

8、得以恢復26Fuwai Hospital手術死亡率: 8.7% (4/46)經(jīng)適當處理均得以恢復2627Fuwai Hospital27Fuwai Hospital術前 術后7天PEA術后UFCT 改善女性, 53 歲, 右肺動脈慢性栓塞28Fuwai Hospital術前 術后7天PEA術后UFCT 改善女性, 53 歲, 右術前 術后1月PEA術后UFCT 改善男性，53 歲，右肺動脈慢性栓塞術后1年29Fuwai Hospital術前 術后1月PEA術后UFCT 改善男性，53 歲，右肺動術前術后30Fuwai Hospital術前術后30Fuwai Hospital術前術后31Fuwa

9、i Hospital術前術后31Fuwai HospitalPEA術后肺灌注 改善術前 術后3月Case 1: male, 53 yrs術前術后6月Case 2: male, 48 yrs32Fuwai HospitalPEA術后肺灌注 改善術前 術后3月Case 1: male隨訪結果 隨訪例數(shù)38隨訪時間(月)27.3（2-122）死亡4CTEPH相關入院1出血和血栓并發(fā)癥133Fuwai Hospital隨訪結果 隨訪例數(shù)38隨訪時間(月)27.3（2-122）死4例死亡原因1例，男性，49歲，術后30個月，腦出血1例，男性，47歲，出院回家路上，死因不祥1例，女性，58歲，術后24個月

10、，白血病1例，女性，56歲，術后12個月，心力衰竭34Fuwai Hospital4例死亡原因1例，男性，49歲，術后30個月，腦出血34FuI II III IV 術前002014術后27430 術前后心功能比較35Fuwai HospitalI II III IV 術前002014術后27430 術前討 論36Fuwai Hospital討 論36Fuwai HospitalPEA的手術適應癥是什么?影響PEA術后效果的因素?37Fuwai HospitalPEA的手術適應癥是什么?37Fuwai HospitalPEA手術適應癥栓塞病變位于手術可及部位（亞段以上）PVR 300 dyne

11、/sec/cm-5NYHA or 級無嚴重伴發(fā)癥Chest 2004; 126: 63s-71s其他考慮的因素mPAP40，外科水平，繼發(fā)肺血管病變38Fuwai HospitalPEA手術適應癥栓塞病變位于手術可及部位（亞段以上）ChesType病變位置例數(shù)死亡率1肺主動脈和葉動脈內(nèi)新鮮血栓1872.1%2段以上動脈內(nèi)膜增厚、纖維化2455.3%3病變僅位于遠端段動脈605.0%4遠端微血管病變，無肉眼可見血栓825%病變位置與死亡率關系J Thorac Cardiovasc Surg 2002;124:1203-121139Fuwai HospitalType病變位置例數(shù)死亡率1肺主動脈和

12、葉動脈內(nèi)新鮮血栓187PVR與手術死亡率相關術后PVRmortality50030.6%術前PVRmortality120020%Assessment of Operability in Chronic Thromboembolic Pulmonary Hypertension Proc Am Thorac Soc 2006;3:584-58840Fuwai HospitalPVR與手術死亡率相關術后PVRmortality 50CI 1000血流動力學不穩(wěn)定醫(yī)療條件差，不能手術43Fuwai HospitalPre-PEA “Bridging” therapyNYHAPost-PEA the

13、rapy用于術后殘留持久性肺動脈高壓的治療PEA 術后1015殘留PH術后mPAP 30, 3年死亡率90目前尚需要指南決定WhenHowHow longStopping rules44Fuwai HospitalPost-PEA therapy用于術后殘留持久性肺動脈高壓術后ECMO的運用再灌注肺水腫肺動脈高壓所致右心功能衰竭Successful extracorporeal membrane oxygenation support after pulmonary thromboendarterectomy. Ann Thorac Surg. 2008 Oct;86(4):1261-7. 用

14、于脫機早期的循環(huán)呼吸障礙Berman報道：127例PEA中7例ECMO，5例脫機45Fuwai Hospital術后ECMO的運用再灌注肺水腫Successful extr46Fuwai Hospital46Fuwai HospitalPEA是治療CTEPH的安全而有效的方法，且具有良好的中遠期結果。手術適應癥與手術時機的判斷影響手術療效，也存在爭議。結 論47Fuwai HospitalPEA是治療CTEPH的安全而有效的方法，且具有良好的中遠期THE END48Fuwai HospitalTHE END48Fuwai HospitalPULMONARY THROMBOENDARTERECT

15、OMYYUNHU SONGCARDIAC SURGERY DEPARTMENT FUWAI HOSPITAL49Fuwai HospitalPULMONARY THROMBOENDARTERECTOMBACKGROUND50Fuwai HospitalBACKGROUND50Fuwai HospitalCONCEPTION OF CTEPHFormation mechanism rusults in diversity of treatmentCirculation，2006；113：201120TRADIONAL: one of turnovers of acute PEMODERN: pr

16、omoted by pulmonary thrombus, progressive pulmonary artery remodeling51Fuwai HospitalCONCEPTION OF CTEPHFormation m PATHOPHYSIOLOYMost have DVT or right heart thrombusRecurrent PE, pulmonary remodelingPHRight heart failure, respiratory failure52Fuwai Hospital PATHOPHYSIOLOYMost have DVT DIAGNOSTIC M

17、ETHODSABGDoppler ultrasound for lower extremitiesUCGPulmonary perfusion scanCTAPulmonary angiography53Fuwai HospitalDIAGNOSTIC METHODSABG53Fuwai ANGIOGRAPHY AND MRIANGIOGRAPHY AND CT54Fuwai HospitalANGIOGRAPHY AND MRIANGIOGRAPHYNATURAL HISTORYNatural history is associated with mPAP30mmHg, 5-year sur

18、vival 3050mmHg, 5-year survival 10Chest 1982; 81: 151-855Fuwai HospitalNATURAL HISTORYNatural historyTREATMENT OF CHOICEPEA:preferredmedicinePulmonary transplantPulmonary Artery Balloon AngioplastyCurrent and Future Management of Chronic Thromboembolic Pulmonary Hypertension: from diagnosis to treat

19、ment response. Proc Am Thorac Soc，2006(3) ：60160756Fuwai HospitalTREATMENT OF CHOICEPEA:preferr57Fuwai Hospital57Fuwai HospitalDATA AND METHODS58Fuwai HospitalDATA AND METHODS58Fuwai HospiCTEPH PATIENTSSURGICAL ACCESSIBLEWITHOUT SEVERE MOBIDITY46 UNDERGONE PEA1997.32008.659Fuwai HospitalCTEPH PATIEN

20、TSSURGICAL ACCESSPE in FUWAI HOSPITAL (1997-2008.6)701 CASES60Fuwai HospitalPE in FUWAI HOSPITAL (1997-20PEA IN FUWAI HOSP IN RECENT YEARS61Fuwai HospitalPEA IN FUWAI HOSP IN RECENT YEmale：35 female：11Mean age: 46.1 yearsMean history: 45.1 monGENERAL INFORMATION62Fuwai Hospitalmale：35 female：11GENER

21、AL ICLINICAL MANIFESTATIONEffort dyspnea44Lower extremites edema35syncope7hemoptysis13ascite1DVT3063Fuwai HospitalCLINICAL MANIFESTATIONEffort dBilateral disease 32 casesUnilateral disease14 cases64Fuwai HospitalBilateral diseaseUnilateral diOPERATION METHODSdeep hypothermic circulatory arrest or lo

22、w flowthromboendarterectomyTreat associated cardiac disorders65Fuwai HospitalOPERATION METHODSdeep hypotherMean CPB time: 160.3minMean AOC time: 72.2minMean cardiac arrest time: 44.6 minAssociated managementTVP6CABG1PVP166Fuwai HospitalMean CPB time: 160.3minTVP6CABExpose RPA and RPA incisionExpose

23、LPA and LPA incision67Fuwai HospitalExpose RPA and RPA incisionExpRPA incisionResection plane initiated68Fuwai HospitalRPA incisionResection plane inCreate resection plane69Fuwai HospitalCreate resection plane69Fuwai 70Fuwai Hospital70Fuwai Hospital71Fuwai Hospital71Fuwai Hospital72Fuwai Hospital72F

24、uwai HospitalRESULTS73Fuwai HospitalRESULTS73Fuwai HospitalOP mortality: 8.7% (4/46)Mean intubation time: 75.2 hPulmonary edema: 10（21.7）Early postop-severe PH: 6（13.0）CNS complication: 7（15.2）74Fuwai HospitalOP mortality: 8.7% (4/46)74Fuw75Fuwai Hospital75Fuwai HospitalPRE-OP 7 DAYS POST-OPCTA chan

25、gesfemale, 53 yrs, CPE in RPA76Fuwai HospitalPRE-OP 7 DAYS POST-OPCTA changpreop 1 mon postopmale，53 yrs， CPE in RPA1 yr postopCTA changes77Fuwai Hospitalpreop 1 mon postopmale，53 yrs，preoppostop78Fuwai Hospitalpreoppostop78Fuwai Hospitalpreoppostop79Fuwai Hospitalpreoppostop79Fuwai HospitalPulmonar

26、y perfusion improved postoppreop 3 mon postopCase 1: male, 53 yrsCase 2: male, 48 yrspreop 6 mon postop80Fuwai HospitalPulmonary perfusion improved pFOLLOWUP Cases followed38Followup time(mon)27.3（2-122）death4CTEPH associated re-hospitalization1Bleeding and thrombolization181Fuwai HospitalFOLLOWUP C

27、ases followed38FolloCauses 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 postop4: female, 56 yrs, died of heart failure 12 months postop82Fuwai HospitalCauses

28、 of 4 death during follotimeI II III IV PRE002014POST27430 COMPARATION OF CARDIAC FUNCTION BETWEEN PRE-OP AND POST-OP83Fuwai HospitaltimeI II III IV PRE002014POST2DISCUSSION84Fuwai HospitalDISCUSSION84Fuwai HospitalINDICATION OF PEA?FACTORS RELATED TO PROGNOSIS OF PEA?85Fuwai HospitalINDICATION OF P

29、EA?85Fuwai HosINDICATION OF PEASurgical accessiblePVR 300 dyneNYHA or Without severe morbidityChest 2004; 126: 63s-71sOther considerationmPAP40，surgical expertise，advanced secondary arteriopathy86Fuwai HospitalINDICATION OF PEASurgical acceTypelocation例數(shù)死亡率1Fresh thrombus in main PA or lobular PA187

30、2.1%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;124:1203-121187Fuwai HospitalTypelocation例數(shù)死亡率1Fresh thrombRELATIONSHIP BETWEEN PVR AND MOR

31、TALITYPost-op PVRmortality50030.6%Pre-op PVRmortality120020%Assessment of Operability in Chronic Thromboembolic Pulmonary Hypertension Proc Am Thorac Soc 2006;3:584-58888Fuwai HospitalRELATIONSHIP BETWEEN PVR AND MMedical treatment can improve prognosisPre-PEA “Bridging” therapyPost-PEA therapyMedic

32、al Therapies for Chronic Thromboembolic Pulmonary Hypertension. An Evolving Treatment Paradigm. Proc Am Thorac Soc 2006;3:594-60089Fuwai HospitalMedical treatment can improve DRUGSAnticoagulation drugsDiuretics, etcAdvanced drugsProstacyclin analogues ：epoprostenol, iloprostET-R Antagonists：bosentanPED-5 inhibitors：sildenafilTraditional drugs90Fuwai HospitalDRUGSAnticoagulation drugsAdvaPre