Long-term outcome after pulmonary thromboendarterectomy.

This study evaluated long-term outcome of pulmonary thromboendarterectomy (PTE) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Survival, functional status, quality of life, health care utilization, and relationships between these parameters and postoperative pulmonary hemodynamics were assessed. Questionnaires were mailed to 420 patients who were more than 1 yr post-PTE; 308 responded (mean age, 56 yr [range, 19-89 yr]; mean years since PTE, 3.3 [range, 1- 16]). Survival after PTE was 75% at > 6 yr. After surgery, symptoms were markedly reduced. Median distance walked was 5,280 ft; 56 patients could walk "indefinitely." Of the working population, 62% of patients unemployed before PTE returned to work. Post-PTE patients scored several quality of life components of the Rand SF-36 slightly lower than reported normals but significantly higher than did pre-PTE patients. Ten percent of patients used oxygen. Ninety-three percent were in NYHA Class I or II. Disease-related hospitalizations/ER visits were minimal. A relationship was shown between 48 h postoperative pulmonary vascular resistance (PVR) and walking and stair-climbing ability, NYHA class, dyspnea scores, and the physical function and general health quality of life components. These data indicate that PTE offers most CTEPH patients substantial improvement in survival, function, and quality of life, with minimal disease-related health care utilization.     

肺动脉血栓内膜剥脱术的远期疗效

目的　观察肺动脉血栓内膜剥脱术 (PTE)对慢性栓塞性肺动脉高压 (CTEPH )患者的远期疗效。方法　 1997年 3月～ 2 0 0 2年 6月 ,共对 15例CTEPH患者行PTE ,14例存活出院。其中 13例随访时间平均 4 0 (17～ 77)个月 ,1例失访 ;随访项目包括心功能状态、血气分析和通过超声心动图测量肺动脉收缩压。结果　随访期内 13例患者均存活 ,其术前心功能NYHA分级均为Ⅲ、Ⅳ级 ;术后 12例患者心功能NYHA分级Ⅰ级、1例Ⅲ级 ;动脉血氧分压 (PaO2 )由术前的 (5 8 1± 8 6 )mmHg上升至(90 8± 6 0 )mmHg (P <0 0 1) ;动脉血氧饱和度由术前的 (90± 5 ) %上升至 (96± 1) % (P <0 0 5 ) ;肺动脉收缩压由术前的 (97 1± 2 2 4 )mmHg下降至 (4 2 6± 10 7)mmHg (P <0 0 1)。结论　肺动脉血栓内膜剥脱术对慢性栓塞性肺动脉高压患者具有很好的远期疗效 ,它能显著改善患者的心肺功能 ,提高其生活质量     

肺动脉血栓内膜剥脱术后再灌注肺水肿的进展

肺血栓栓塞症是一种常见、多发且病死率和致残率高的疾病。大多数急性肺动脉血栓栓塞经及时的溶栓抗凝等治疗和 (或 )自身的纤溶系统能将血栓不同程度地溶解 ,另有0 1%～ 0 2 %的患者因血栓在急性期未能溶解或栓塞反复发生进而发展成慢性栓塞性肺动脉高压。慢性栓塞性肺动脉高压溶栓无效 ,抗凝、扩血管治疗效果不佳 ,其病理过程多呈进行性加重或稳定一段时间后再次加重 ,自然预后差。肺动脉平均压 >3 0ｍｍＨｇ(1ｍｍＨｇ =0 13 3ｋＰａ)的慢性栓塞性肺动脉高压患者 5年生存率为 3 0 % ,肺动脉平均压 >5 0ｍｍＨｇ者仅为 10 %。肺动脉血…     

Reperfusion pulmonary edema after pulmonary artery thromboendarterectomy

Pulmonary artery thromboendarterectomy (PAT) is a potentially curative procedure in chronic, major vessel thromboembolic pulmonary hypertension. However, postoperative reperfusion pulmonary edema (RPE) has been a serious complication, often requiring prolonged mechanical ventilation. This entity has been described only anecdotally in the past. To characterize it more fully, we retrospectively analyzed the course and potential determinants of RPE after thromboendarterectomy in 22 patients who had PAT at our institution from 1969 through 1984. Particular attention was directed to clinical data, thrombus location, areas operated, postoperative roentgenograms, and preoperative and postoperative hemodynamic data. In all patients but 1, RPE developed within 72 h after surgery, corresponding to anatomic locations distal to vessels subjected to PAT. Regions of lung not reperfused at surgery were uniformly spared. Pulmonary capillary wedge and/or left atrial pressures preoperatively and postoperatively were not elevated. None of the preoperative data predicted which patients would develop more persistent RPE. These observations suggest that the phenomenon of RPE is a peculiar, focal form of pulmonary edema, the basis for which remains to be defined.     

Gas exchange in chronic thromboembolism after pulmonary thromboendarterectomy

Thromboendarterectomy is the treatment of choice for chronic large vessel thromboembolic pulmonary hypertension. To identify the mechanisms responsible for the improvement in gas exchange following thromboendarterectomy, we studied nine patients with chronic thromboembolic pulmonary hypertension before and eight to 18 months after surgery using the multiple inert gas elimination technique. Preoperatively, all subjects had pulmonary hypertension and were hypoxemic or had an elevated P(A-a)O2. The VA/Q distribution was widened with an elevated VD/VT and a low cardiac index. After thromboendarterectomy, significant improvement had occurred. The VA/Q distribution had narrowed to near normal, and the cardiac index increased. It was concluded that thromboendarterectomy improved gas exchange both by improving VA/Q relationships and by increasing cardiac output.     

Early changes of right heart geometry after pulmonary thromboendarterectomy

To determine the changes in right heart hemodynamics and geometry early after surgery for chronic pulmonary hypertension due to large vessel thromboembolic occlusion, 30 patients were evaluated 8 +/- 8 days (mean +/- SD) before and 6 +/- 4 days after pulmonary thromboendarterectomy by two-dimensional echocardiography and right heart catheterization. Surgery resulted in an early significant improvement in hemodynamic variables including mean pulmonary artery pressure (48 +/- 12 to 28 +/- 8 mm Hg, p less than 0.001), right ventricular systolic pressure (76 +/- 20 to 47 +/- 15 mm Hg, p less than 0.001), pulmonary vascular resistance (935 +/- 620 to 278 +/- 252 dynes.s.cm-5, p less than 0.001) and cardiac index (2.0 +/- 0.5 to 2.9 +/- 0.6 liters/min per m2, p less than 0.001). Similarly, echocardiographic variables of right heart structures, which were well outside the normal range preoperatively, improved significantly early after thromboendarterectomy. These included diameters of the pulmonary artery (2.8 +/- 0.3 to 2.4 +/- 0.4 cm, p less than 0.001), inferior vena cava (2.9 +/- 0.6 to 2.2 +/- 0.4 cm, p less than 0.001) and right atrium (6.8 +/- 1.5 to 5.9 +/- 1.5 cm, p less than 0.001) as well as right ventricular short axis (4.5 +/- 0.8 to 3.7 +/- 0.8 cm, p less than 0.001) and long axis (8.7 +/- 0.9 to 8.1 +/- 0.9 cm, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

21例肺动脉血栓内膜剥脱术预后影响因素分析

目的:肺动脉血栓内膜剥脱术(PTE),对于慢性肺动脉栓塞患者是一种有效的治疗方法。本文拟通过对施行PTE患者围手术期预后影响因素进行分析,以期通过围术期临床常见检测手段来为此类患者提供预后判断。方法:择期21例患者单纯施行PTE术,记录ICU入住天数为因变量,以患者年龄(AGE),病程(Course,year),体外循环的时间(TCPB)和ASA分级,术前平均肺动脉压(mPAPPRE),术前右心室/左心室容积比(RV/LVPRE),术后右心室/左心室容积比(RV/LVPOST),术前左心室射血分数(LVEFPRE)和术后左心室射血分数(LVEFPOST)为自变量;采用多因素线性回归分析模型评价各影响因素的作用大小。结果:施行PTE患者的围手术期预后影响因素包括ASA分级、mPAPPRE、RV/LVPRE、TCPB和LVEFPOST。结论:本研究提示在PTE手术的临床监测指标中,患者的一般状况(ASA分级)、术前平均肺动脉压、术前右心室/左心室容积比、体外循环时间和术后LVEFPOST与预后转归密切相关。     

Effects of nitric oxide inhalation after pulmonary thromboendarterectomy for chronic pulmonary thromboembolism

STUDY OBJECTIVES: To examine the hypothesis that nitric oxide (NO) inhalation improves hemodynamics and gas exchange in patients with chronic pulmonary thromboembolism after pulmonary thromboendarterectomy. DESIGN: Prospective crossover clinical study. SETTING:: Surgical ICU in a national education and research hospital. PATIENTS:: Seven patients (mean age +/- SD, 54 +/- 11 years) who underwent elective pulmonary thromboendarterectomy for chronic pulmonary thromboembolism. INTERVENTIONS: Patients breathed 20 parts per million of NO gas for 30 min at 12-h intervals until extubation of the trachea. MEASUREMENTS AND RESULTS: Hemodynamics and arterial blood gas levels were analyzed before, during, and after NO inhalation. Waveform of pulmonary artery pressure (PAP) was evaluated using fractional pulse pressure (PPf): (systolic PAP - diastolic PAP)/mean PAP. After surgery, pulmonary vascular resistance decreased, PPf decreased, and cardiac index increased significantly. At the first trial, NO inhalation resulted in a slight improvement in arterial oxygen tension (from 173 +/- 33 to 196 +/- 44 mm Hg; p < 0.05), while hemodynamics did not change significantly. Twelve hours later, NO inhalation decreased pulmonary vascular resistance index (from 312 +/- 98 to 277 +/- 93 dyne.s. cm(-5)/m(2); p < 0.01), while the change in oxygenation was not significant. CONCLUSIONS: Immediately after pulmonary thromboendarterectomy for chronic pulmonary thromboembolism, NO inhalation improved oxygenation; at 12 h after surgery, NO inhalation resulted in decreased pulmonary vascular resistance, although both changes were small.     

Increase in thrombomodulin concentrations after pulmonary thromboendarterectomy in chronic thromboembolic pulmonary hypertension

STUDY OBJECTIVES: The objectives of the study were as follows: (1) to identify differences in endothelial dysfunction and altered hemostasis in patients with chronic thromboembolic pulmonary hypertension (CTEPH) compared with patients with acute pulmonary thromboembolism (APTE) uncomplicated by pulmonary arterial hypertension, by measuring the concentrations of thrombomodulin (TM), a receptor for thrombin and a major anticoagulant proteoglycan on the endothelial membrane, and other plasma factors of coagulation and fibrinolysis; and (2) to examine the effects of thromboendarterectomy on TM levels as a parameter of endothelial cell injury leading to abnormal hemostasis as well as to examine the clinical significance of TM as a marker of endothelial injury. DESIGN: Prospective comparison of concentrations of TM and other plasma parameters among patients with CTEPH or APTE and control subjects. PARTICIPANTS: We studied 22 healthy subjects (ie, control subjects), 22 patients who had been clinically stabilized after APTE, and 44 patients with CTEPH. In 21 of the patients with CTEPH, measurements were repeated after they had undergone pulmonary thromboendarterectomy. MEASUREMENTS AND RESULTS: Plasma concentrations of soluble TM in patients with CTEPH were measured and compared with those in patients with APTE. The mean (+/- SD) TM concentration in the CTEPH group (2.5 +/- 0.7 ng/mL) was significantly lower than that in the control group (4.0 +/- 0.6 ng/mL; p < 0.05). In contrast, the mean plasma TM concentration in the APTE group (4.6 +/- 1.9 ng/mL) was similar to that in the control group. After patients underwent pulmonary thromboendarterectomy, the mean TM concentration increased from 2.0 +/- 0.4 to 2.9 +/- 0.7 ng/mL (p < 0.05). In the CTEPH group, the plasma TM concentration was negatively correlated with mean pulmonary arterial pressure and total pulmonary resistance (p < 0.05). CONCLUSIONS: A decreased plasma TM concentration may reflect pulmonary vascular endothelial dysfunction leading to altered anticoagulant and fibrinolytic function in CTEPH, which rarely develops after APTE. Plasma TM measurements may be useful in distinguishing CTEPH with severe pulmonary hypertension from recurrent APTE.     

The influence of fractional pulse pressure on the outcome of pulmonary thromboendarterectomy.

Although pulmonary thromboendarterectomy is an effective modality for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), the mortality in patients with severe haemodynamic disease is still high. Recently it was reported that fractional pulse pressure (pulmonary arterial pulse pressure/mean pulmonary arterial pressure) was higher in CTEPH than in primary pulmonary hypertension (PPH). It was hypothesized that fractional pulse pressure might be low in CTEPH with inaccessible distal thrombi and/or secondary pulmonary hypertensive change, resulting to the high operative mortality. To determine the influence of fractional pulse pressure to the outcome of surgery, 32 patients with CTEPH who had thromboendarterectomy between 1985 and 1998 were studied. Pulmonary haemodynamics and fractional pulse pressure were compared between survivors (n=26) and nonsurvivors (n=6) postoperatively. Those parameters in PPH (n=18) and large vessel pulmonary arteritis (n=6) were also analysed. Fractional pulse pressure in CTEPH (1.23+/-0.21) was significantly higher than in PPH (0.93+/-0.22; p=0.0017) and lower than in pulmonary arteritis (1.69+/-0.32; p=0.03). Fractional pulse pressure in survivors (1.26+/-0.21) was significantly higher than in nonsurvivors (1.06+/-0.16; p=0.03). Fractional pulse pressure is a significant predictor for mortality in patients with high pulmonary vascular resistance >1100 dynes.sec.cm(-5). To conclude fractional pulse pressure in addition to pulmonary vascular resistance might be useful in predicting for the outcome of surgery, especially in patients with severe haemodynamic impairment.     

CT scan findings in chronic thromboembolic pulmonary hypertension: predictors of hemodynamic improvement after pulmonary thromboendarterectomy

STUDY OBJECTIVES: The aim was to correlate CT scan findings with hemodynamic measurements in patients who had undergone pulmonary thromboendarterectomy (PTE) and to evaluate whether CT scan findings can help to predict surgical outcome.Patients and method: Sixty patients who underwent PTE and preoperative helical CT scanning were included. Preoperative and postoperative hemodynamics were correlated with preoperative CT imaging features. RESULTS: The diameter of the main pulmonary artery (PA) and the ratio of the PA and the diameter of the ascending aorta correlated with preoperative mean pulmonary artery pressure (PAP) [r = 0.42; p < 0.001; and r = 0.48; p < 0.0001, respectively]. There was a significant correlation of subpleural densities with preoperative pulmonary vascular resistance (PVR) [r = 0.44; p < 0.001] and of the number of abnormal perfused lobes with preoperative PAP (r = 0.66; p < 0.0001) and PVR (r = 0.76; p < 0.0001). Postoperative PVR correlated negatively with the presence and extent of central thrombi (r = -0.36; p = 0.007) and dilated bronchial arteries (p = 0.03) seen on preoperative CT scans. Sixty percent of patients (3 of 5 patients) without visible central thromboembolic material on CT scans had an inadequate hemodynamic improvement in contrast to 4% of patients (2 of 51 patients) with central thrombi (p = 0.003). Preoperative PVR (r = 0.31; p = 0.018) and the extent of abnormal lung perfusion (r = 0.37; p = 0.007) and of subpleural densities (r = 0.32; p = 0.017) were positively correlated with postoperative PVR. CONCLUSIONS: In patients with thromboembolic pulmonary hypertension, CT scan findings can help to predict hemodynamic improvement after PTE. The absence of central thrombi is a significant risk factor for inadequate hemodynamic improvement.     

Pathophysiology of impaired right and left ventricular function in chronic embolic pulmonary hypertension: changes after pulmonary thromboendarterectomy

STUDY OBJECTIVES: This study sought to evaluate the pathophysiology of left and right heart failure in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who were hospitalized to undergo pulmonary thromboendarterectomy (PTE). DESIGN: Thirty-nine patients (16 women and 23 men; mean +/- SD age, 55+/-12 years) with severe CTEPH were examined before and 13+/-8 days after PTE by way of transthoracic echocardiography and right heart catheterization. MEASUREMENTS AND RESULTS: Examination results confirmed in all cases that before surgery the right ventricles were enlarged and systolic function was impaired. Moderate to severe tricuspid valve regurgitation was observed. Left ventricular eccentricity indexes reflected a leftward displacement of the interventricular septum. End-diastolic left ventricular size and systolic function had decreased, and the left ventricular filling pattern showed impaired diastolic function. After surgery, mean pulmonary artery pressure was significantly lower (48+/- 10 mm Hg vs. 25+/-7 mm Hg; p<0.05). The calculated end-diastolic and end-systolic right ventricular areas had decreased: 30+/-7 cm(2) vs 21 +/-5 cm(2) (p<0.05) and 24+/-6 cm(2) vs. 14+/-4 cm(2) (p<0.05), respectively. Right ventricular fractional area change had increased (20+/-7% vs. 33+/-8%; p<0.05). Most of the patients exhibited a marked decrease in the severity of tricuspid regurgitation. Septal motion, left ventricular systolic function, and diastolic filling pattern returned to normal values (early to late diastolic left ventricular inflow ratio, 0.70+/-0.33 vs. 1.35+/-0.51; p<0.05). The mean cardiac index also improved (2.7+/-0.6 L/min/m(2) vs. 3.7+/-0.8 L/min/m(2)). CONCLUSIONS: In CTEPH, functions are impaired in the right as well as the left ventricles of the heart. Improved lung perfusion and the reduction of right ventricular pressure overload are direct results of PTE, which in turn bring a profound reduction of right ventricular size and a recovery of systolic function. Normalization of interventricular septal motion as well as improved venous return to the left atrium lead to a normalization of left ventricular diastolic and systolic function, and the cardiac index improves.     

球囊肺动脉成形术治疗肺动脉血栓内膜剥脱术后残余/复发肺动脉高压的疗效和安全性研究

目的:对球囊肺动脉成形术(BPA)治疗慢性血栓栓塞性肺动脉高压(CTEPH)患者肺动脉血栓内膜剥脱术(PEA)术后残余/复发肺动脉高压的有效性和安全性进行评估。方法:本研究为单中心病例对照研究。采用非随机抽样的方法纳入2004年11月至2021年12月于首都医科大学附属北京朝阳医院行PEA的CTEPH患者76例,其中发...