慢性肺栓塞的外科治療宋云虎柳志紅阜外心血管病醫院成人心臟外科中心肺血管病診治中心1背景2慢性肺栓塞的概念形成機制決定治療方案多樣化Circulation，2006；113：2011－20傳統觀念：急性肺栓塞的轉歸之一現代觀念：肺動脈血栓及內膜機化始動進行性肺動脈重構（remodeling)3

病理生理多數病人DVT、右心系統血栓等肺動脈反復栓塞，肺血管重構肺動脈高壓右心衰竭、呼吸衰竭4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5肺動脈造影與MRI肺動脈造影與CT6自然預后自然預后不佳，與平均動脈壓有關>30mmHg,5年生存率30％>50mmHg,5年生存率10％Chest1982;81:151-87CTEPH治療選擇CurrentandFutureManagementofChronicThromboembolicPulmonaryHypertension:fromdiagnosistotreatmentresponse.ProcAmThoracSoc，2006(3)：601－607PEA失敗藥物治療無效進行性肺小血管病變89資料與方法10CTEPH病人46例被選擇行PEA1997年3月－2008年6月11阜外醫院肺動脈栓塞病人的收治情況(1997-2008.6)共701例1213男：35例女：11例平均年齡:46.1歲平均病史:45.1月一般資料14臨床表現氣短44下肢水腫35暈厥7咯血13大量腹水1DVT3015雙側病變32例單側病變14例16深低溫、低流量或間斷停循環清除血栓和機化內膜處理伴隨心臟病變17TVP6CABG1PVP118ExposeRPAandRPAincisionExposeLPAandLPAincision19RPAincisionResectionplaneinitiated20Createresectionplane21222324結果25經適當處理均得以恢復2627女性,53歲,右肺動脈慢性栓塞28男性，53歲，右肺動脈慢性栓塞293031Case1:male,53yrsCase2:male,48yrs32隨訪結果

隨訪例數38隨訪時間(月)27.3（2-122）死亡4CTEPH相關入院1出血和血栓并發癥1334例死亡原因34I

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術前002014術后2743035討論3637Chest2004;126:63s-71s其他考慮的因素mPAP>40，外科水平，繼發肺血管病變38Type病變位置例數死亡率1肺主動脈和葉動脈內新鮮血栓1872.1%2段以上動脈內膜增厚、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JThoracCardiovascSurg2002;124:1203-121139術后PVRmortality<5000.9%>50030.6%術前PVRmortality<9004%900-120010%>120020%AssessmentofOperabilityinChronicThromboembolicPulmonaryHypertension

ProcAmThoracSoc2006;3:584-58840藥物治療Pre-PEA“Bridging”therapyPost-PEAtherapyMedicalTherapiesforChronicThromboembolicPulmonaryHypertension.AnEvolvingTreatmentParadigm.ProcAmThoracSoc2006;3:594-60041藥物治療抗凝藥利尿劑等Advanceddrugs前列環素類似物：epoprostenol,iloprostET-R拮抗劑：bosentanPED-5抑制劑：sildenafilTraditionaldrugs42Pre-PEA“Bridging”therapyNYHAⅥMPAP>50CI<2.0PVR>1000血流動力學不穩定43Post-PEAtherapy目前尚需要指南決定WhenHowHowlongStoppingrules44再灌注肺水腫肺動脈高壓所致右心功能衰竭Successfulextracorporealmembraneoxygenationsupportafterpulmonarythromboendarterectomy.AnnThoracSurg.2008Oct;86(4):1261-7.

用于脫機早期的循環呼吸障礙Berman報道：127例PEA中7例ECMO，5例脫機4546結論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例數死亡率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