慢性栓塞性肺动脉高压外科治疗连续62例无死亡临床分析

目的 分析应用肺动脉血栓内膜剥脱术治疗慢性栓塞肺动脉高压的效果及诊治经验.方法 回顾性分析2002年10月至2008年9月于北京安贞医院手术治疗62例慢性栓塞性肺动脉高压患者的临床资料,按临床病理分型分为中央型组(46例)、外周型组(16例).全组均在深低温停循环下行肺动脉血栓内膜剥脱术.结果 围术期全组无死亡,围术期残余肺动脉高压15例,肺再灌注损伤23例,后者均经延长辅助呼吸支持治疗及体外膜肺治疗治愈.单因素分析显示外周型CTEPH是术后残余肺动脉高压的危险因子,中央型CTEPH是术后肺再灌注损伤的危险因子(P＜0.05).62例围术期生存患者术后72 h Swan-Ganz导管及血气指标较术前显著改善,肺动脉收缩压从(91 ±38) mm Hg 降至(53±21) mm Hg, 而肺循环阻力从(916±548) dyn·s·cm-5降至(368±302) dyn·s·cm-5(t=6.896,P=0.0001), 动脉血氧分压从 (51±7) mm Hg 升至(90±7) mm Hg, 动脉血氧饱和度从87.0%±3.9% 升至96.1%±3.3%,P＜0.01.随访期间无死亡.46例术后复查核素血流灌注通气扫描结果 显示,原灌注缺损部位恢复显像,或(及)肺动脉CT造影提示原不显影区充盈造影剂.2例患者于术后2年、3年再发双下肢静脉血栓,但因有下腔静脉滤网而未发肺动脉栓塞,全组术后3年免除再次栓塞率为96.7%±2.8%.发生出血并发症3例.全组抗凝相关出血线性发生率为2.47%患者年,再发下肢静脉栓塞线性发生率为1.64%患者年.术后长期生存62例患者中,心功能NYHA分级Ⅰ级38例、Ⅱ级20例、Ⅲ级2例、Ⅳ组2例.结论 肺动脉血栓内膜剥脱术治疗慢性肺动脉栓塞术后有较好围术期及中长期生存率,口服华法令抗凝相关的再发肺动脉栓塞、下肢静脉栓塞率、出血并发症线性发生率均在可接受范围.

Clinical analysis of 62 cases of chronic thromboembolic pulmonary hypertension treated with pulmonary thromboendarterectomy without early and late deaths

Objective To retrospectively evaluate the effects of pulmonary thromboendarterectomy (PTE) on chronic thromboembolic pulmonary hypertension (CTEPH).Methods Sixty-two cases of CTEPH operated with PTE from October 2002 to September 2008 at Anzhen Hospital were retrospectively reviewed and were assigned into either proximal CTEPH group (n=46)or distal CTEPH group(n=16).Result No early death was reported. 15 had residual pulmonary hypertension and 23 had pulmonary reperfusion injury postoperatively. And reperfusion injury was recovered with the support of ventilation or ECMO. Between pre and post-procedure, the pulmonary artery systolic pressure changed from 91 ±38 mm Hg to 53 ±21 mm Hg, the pulmonary vascular resistance from 916±548 dyn·s·cm-5 to 368 ±302 dyn·s·cm-5 (t=6.896,P=0.0001), and the arterial partial pressure of oxygen (PaO2) from 51±7 mm Hg to 90±7 mm Hg and the arterial oxygen saturation (SaO2) from 87.0%±3.9% to 96.1%±3.3%,P＜0.05.With the follow-up of (24.8±14.6) months (cumulative follow-up was 121.6 patient-years), there was no late death and 38 were in NYHA functional class Ⅰ, 20 class Ⅱ, 2 class Ⅲ and 2 class Ⅳ. According to Kaplan-Meier actuarial curve, the freedom from reembolism at 3 years was 96.7%±2.8%.The linear bleeding rate related to anticoagulation was 2.47% patient-years, and the linear thromboembolic rate related to anticoagulation is 1.64% patient-years.Conclusion The early and mid-long term survival rate of PTE procedure on CTEPH is acceptable and the complication rate related to anticoagulation with warfarin is relatively low.