肺动脉栓塞外科治疗的围术期及中长期效果分析

目的探讨提高外科治疗肺动脉栓塞（pulmonary thromboembolism，PTE）的围术期和中长期疗效的方法。方法回顾性分析1994年10月至2007年10月北京安贞医院手术治疗57例PTE的临床资料，其中47例慢性PTE患者在深低温停循环（22例）或不停循环下（心脏停搏21例，心脏不停跳4例）行肺动脉血栓内膜剥脱术；10例急性PTE患者在中低温体外循环下行肺动脉切开取栓术。结果围术期慢性PTE患者死亡6例（12．8％），急性PTE患者死亡4例（40．0％，P=0．030）。术后发生残余肺动脉高压15例，出现重度肺组织再灌注损伤25例。41例慢性PTE患者术后72h肺动脉收缩压和肺血管阻力较术前降低（52．9±26．1mmHgvs．91．2±37．4mmHg；410．3±345．6dyn·s／cm^5vs．921．3±497．8dyn·s／cm^5）；动脉血氧饱和度和动脉血氧分压较术前增高（94．8％±2．7％vs．86．7％±4．3％；84．4±5．4mmHgvs．51．8±6．4mmHg，P〈0．05）。随访47例，随访时间44．6±39．3个月，累积随访时间为160．1人年。晚期死亡5例，其中慢性PTE4例，急性PTE1例。慢性PTE患者术后5年Kaplan—Meier生存曲线生存率为89．43％±5．80％，而急性PTE患者术后1～5年为83．33％±15．21％（Log rank=1．57，P=0．2103）。全组抗凝相关出血线性发生率为1．25％病人年，再发PTE线性发生率为0．62％病人年。中长期生存的42例患者中，心功能分级（NYHA）Ⅰ级29例、Ⅱ级10例、Ⅲ级3例。logistic回归分析发现，急性PTE（OR=3．28）、外周型PTE（OR=2．45）、未采用深低温停循环（OR=2．86）为早期死亡的危险因素；外周型PTE（OR=2．69）、术前下肢水肿（OR=2．79）为晚期死亡的危险因素。结论急性PTE患者围术期死亡率显著高于慢性PTE，两者术后均有较好的中长期生存率，差异无统计学意义。口服华法林抗凝相关的再发PTE、出血并发症线性发生率均较低，在可接受?

The Early and Middle-long Term Clinical Outcome of Surgical Treatment of Pulmonary Embolism

Objective To investigate the early and middle-long term clinical outcome of surgical treatment for pulmonary thromboembolism（PTE）. Methods The data of 57 cases of surgical treatment for pulmonary embolism from October 1994 to October 2007 in Anzhen Hospital were analyzed retrospectively, of which 47 cases were chronic PTE done with pulmonary thromboendarterectomy, and 10 were acute PTE done with pulmonary embolectomy. Results There were 6（12. 8%） perioperative deaths in chronic PTE and 4 （40. 0%）deaths in acute PTE（P= 0. 030）. Fifteen cases suffered with residual pulmonary hypertension and 25 cases with severe pulmonary reperfusion injury. The pulmonary artery systolic pressure （PASP） and the pulmonary vascular resistance （PVR） of 41 cases with chronic PTE at 72 hours after surgery were lowered significantly than those before surgery （52.9±26.1 mmHg vs. 91.2±37.4 mmHg;410.3±345.6 dyn·s/cm^5vs. 921.3±497.8dyn·s/cm^5）. The arterial oxygen saturation （SaO2）and the arterial partial pressure of oxygen （PaO2） at 72 hours after surgery were higher significantly than those before surgery （94.8%±2.7% vs. 86.7%±4.3% 84.4±5.4mmHg vs. 51.8±6.4mmHg, P〈0.05）. With the follow-up of 44. 6±39. 3 months （cumulative follow-up was 160. 1 patient-years） of the 47 perioperative survivors, there were 5 late deaths, of which 4 chronic PTE and 1 acute PTE. According to Kaplan-Meier survival curve, the 5 years survival rate was 89.43%±5.80% for chronic PTE and 83.33%±15. 21% for acute PTE（Log rank test=1. 57,P=0. 2103）. The lineal bleeding rate related to anticoagulation was 1.25% patient-years, and the lineal thromboembolic rate related to anticoagulation was 0. 62% patient-years. And of the 42 mid-long term survivor, the heart function in 29 cases was New York Heart Association （NYHA） class Ⅰ, 10 cases NYHA class Ⅱ, 3 cases NYHA class Ⅲ. According to logistic regression, the risk factors for the early death were acute PTE （OR=3.28, peripheral type of PTE （OR= 2