慢性肺栓塞的外科治疗宋云虎.ppt

FuwaiHospital,1,慢性肺栓塞的外科治疗,宋云虎柳志红,阜外心血管病医院成人心脏外科中心肺血管病诊治中心,FuwaiHospital,2,背景,FuwaiHospital,3,慢性肺栓塞的概念,形成机制决定治疗方案多样化,Circulation，2006；113：201120,传统观念：急性肺栓塞的转归之一,现代观念：肺动脉血栓及内膜机化始动进行性肺动脉重构（remodeling),FuwaiHospital,4,FuwaiHospital,5,诊断手段,血气分析下肢静脉超声多谱勒超声心动图肺核素灌注扫描UFCT肺动脉造影,FuwaiHospital,6,肺动脉造影与MRI,肺动脉造影与CT,FuwaiHospital,7,自然预后,自然预后不佳，与平均动脉压有关,30mmHg,5年生存率3050mmHg,5年生存率10,Chest1982;81:151-8,FuwaiHospital,8,CTEPH治疗选择,PEA:首选药物治疗肺移植球囊肺动脉成形术,CurrentandFutureManagementofChronicThromboembolicPulmonaryHypertension:fromdiagnosistotreatmentresponse.ProcAmThoracSoc，2006(3)：601607,不能行PEA手术的病人Pre-PEA“Bridging”therapy,PEA失败药物治疗无效进行性肺小血管病变,FuwaiHospital,9,FuwaiHospital,10,资料与方法,FuwaiHospital,11,CTEPH病人,病变位于手术可及部位无严重伴发症,46例被选择行PEA,1997年3月2008年6月,FuwaiHospital,12,阜外医院肺动脉栓塞病人的收治情况(1997-2008.6),共701例,FuwaiHospital,13,阜外医院近年PEA手术例数,FuwaiHospital,14,男：35例女：11例平均年龄:46.1岁平均病史:45.1月,一般资料,FuwaiHospital,15,临床表现,FuwaiHospital,16,双侧病变32例,单侧病变14例,FuwaiHospital,17,手术方法,深低温、低流量或间断停循环清除血栓和机化内膜处理伴随心脏病变,FuwaiHospital,18,平均体外循环时间:160.3min平均升主动脉阻断时间:72.2min平均停循环时间:44.6min同期手术如下表,FuwaiHospital,19,ExposeRPAandRPAincision,ExposeLPAandLPAincision,FuwaiHospital,20,RPAincision,Resectionplaneinitiated,FuwaiHospital,21,Createresectionplane,FuwaiHospital,22,FuwaiHospital,23,FuwaiHospital,24,FuwaiHospital,25,结果,FuwaiHospital,26,手术死亡率:8.7%(4/46)平均气管插管时间:75.2h肺水肿:10（21.7）术后早期严重肺动脉高压:6（13.0）神经系统并发症:7（15.2）,经适当处理均得以恢复,FuwaiHospital,27,FuwaiHospital,28,术前,术后7天,PEA术后UFCT改善,女性,53岁,右肺动脉慢性栓塞,FuwaiHospital,29,术前,术后1月,PEA术后UFCT改善,男性，53岁，右肺动脉慢性栓塞,术后1年,FuwaiHospital,30,术前,术后,FuwaiHospital,31,术前,术后,FuwaiHospital,32,PEA术后肺灌注改善,术前,术后3月,Case1:male,53yrs,术前,术后6月,Case2:male,48yrs,FuwaiHospital,33,随访结果,FuwaiHospital,34,4例死亡原因,1例，男性，49岁，术后30个月，脑出血1例，男性，47岁，出院回家路上，死因不祥1例，女性，58岁，术后24个月，白血病1例，女性，56岁，术后12个月，心力衰竭,FuwaiHospital,35,术前后心功能比较,FuwaiHospital,36,讨论,FuwaiHospital,37,PEA的手术适应症是什么?影响PEA术后效果的因素?,FuwaiHospital,38,PEA手术适应症,栓塞病变位于手术可及部位（亚段以上）PVR300dyne/sec/cm-5NYHAor级无严重伴发症,Chest2004;126:63s-71s,其他考虑的因素mPAP40，外科水平，继发肺血管病变,FuwaiHospital,39,病变位置与死亡率关系,JThoracCardiovascSurg2002;124:1203-1211,FuwaiHospital,40,PVR与手术死亡率相关,AssessmentofOperabilityinChronicThromboembolicPulmonaryHypertensionProcAmThoracSoc2006;3:584-588,FuwaiHospital,41,药物治疗,Pre-PEA“Bridging”therapyPost-PEAtherapy,MedicalTherapiesforChronicThromboembolicPulmonaryHypertension.AnEvolvingTreatmentParadigm.ProcAmThoracSoc2006;3:594-600,FuwaiHospital,42,药物治疗,抗凝药利尿剂等,Advanceddrugs,前列环素类似物：epoprostenol,iloprostET-R拮抗剂：bosentanPED-5抑制剂：sildenafil,Traditionaldrugs,FuwaiHospital,43,Pre-PEA“Bridging”therapy,NYHAMPAP50CI1000,血流动力学不稳定,医疗条件差，不能手术,FuwaiHospital,44,Post-PEAtherapy,用于术后残留持久性肺动脉高压的治疗PEA术后1015残留PH术后mPAP30,3年死亡率90,目前尚需要指南决定,WhenHowHowlongStoppingrules,FuwaiHospital,45,术后ECMO的运用,再灌注肺水肿肺动脉高压所致右心功能衰竭,Successfulextracorporealmembraneoxygenationsupportafterpulmonarythromboendarterectomy.AnnThoracSurg.2008Oct;86(4):1261-7.,用于脱机早期的循环呼吸障碍,Berman报道：127例PEA中7例ECMO，5例脱机,FuwaiHospital,46,FuwaiHospital,47,PEA是治疗CTEPH的安全而有效的方法，且具有良好的中远期结果。手术适应症与手术时机的判断影响手术疗效，也存在争议。,结论,FuwaiHospital,48,FuwaiHospital,49,PULMONARYTHROMBOENDARTERECTOMY,YUNHUSONG,CARDIACSURGERYDEPARTMENTFUWAIHOSPITAL,FuwaiHospital,50,BACKGROUND,FuwaiHospital,51,CONCEPTIONOFCTEPH,Formationmechanismrusultsindiversityoftreatment,Circulation，2006；113：201120,TRADIONAL:oneofturnoversofacutePE,MODERN:promotedbypulmonarythrombus,progressivepulmonaryarteryremodeling,FuwaiHospital,52,FuwaiHospital,53,DIAGNOSTICMETHODS,ABGDopplerultrasoundforlowerextremitiesUCGPulmonaryperfusionscanCTAPulmonaryangiography,FuwaiHospital,54,ANGIOGRAPHYANDMRI,ANGIOGRAPHYANDCT,FuwaiHospital,55,NATURALHISTORY,NaturalhistoryisassociatedwithmPAP,30mmHg,5-yearsurvival3050mmHg,5-yearsurvival10,Chest1982;81:151-8,FuwaiHospital,56,TREATMENTOFCHOICE,PEA:preferredmedicinePulmonarytransplantPulmonaryArteryBalloonAngioplasty,CurrentandFutureManagementofChronicThromboembolicPulmonaryHypertension:fromdiagnosistotreatmentresponse.ProcAmThoracSoc，2006(3)：601607,FuwaiHospital,57,FuwaiHospital,58,DATAANDMETHODS,FuwaiHospital,59,CTEPHPATIENTS,SURGICALACCESSIBLEWITHOUTSEVEREMOBIDITY,46UNDERGONEPEA,1997.32008.6,FuwaiHospital,60,PEinFUWAIHOSPITAL(1997-2008.6),701CASES,FuwaiHospital,61,PEAINFUWAIHOSPINRECENTYEARS,FuwaiHospital,62,male：35female：11Meanage:46.1yearsMeanhistory:45.1mon,GENERALINFORMATION,FuwaiHospital,63,CLINICALMANIFESTATION,FuwaiHospital,64,Bilateraldisease32cases,Unilateraldisease14cases,FuwaiHospital,65,OPERATIONMETHODS,deephypothermiccirculatoryarrestorlowflowthromboendarterectomyTreatassociatedcardiacdisorders,FuwaiHospital,66,MeanCPBtime:160.3minMeanAOCtime:72.2minMeancardiacarresttime:44.6minAssociatedmanagement,FuwaiHospital,67,ExposeRPAandRPAincision,ExposeLPAandLPAincision,FuwaiHospital,68,RPAincision,Resectionplaneinitiated,FuwaiHospital,69,Createresectionplane,FuwaiHospital,70,FuwaiHospital,71,FuwaiHospital,72,FuwaiHospital,73,RESULTS,FuwaiHospital,74,OPmortality:8.7%(4/46)Meanintubationtime:75.2hPulmonaryedema:10（21.7）Earlypostop-severePH:6（13.0）CNScomplication:7（15.2）,FuwaiHospital,75,FuwaiHospital,76,PRE-OP,7DAYSPOST-OP,CTAchanges,female,53yrs,CPEinRPA,FuwaiHospital,77,preop,1monpostop,male，53yrs，CPEinRPA,1yrpostop,CTAchanges,FuwaiHospital,78,preop,postop,FuwaiHospital,79,preop,postop,FuwaiHospital,80,Pulmonaryperfusionimprovedpostop,preop,3monpostop,Case1:male,53yrs,Case2:male,48yrs,preop,6monpostop,FuwaiHospital,81,FOLLOWUP,FuwaiHospital,82,Causesof4deathduringfollowup,1:male,49yrs,diedofCerebralHemorrhage30monthspostop2:male,47yrs,died15dayspostopwithunkownreason3:female,58yrs,diedofLeukemia24monthspostop4:female,56yrs,diedofheartfailure12monthspostop,FuwaiHospital,83,COMPARATIONOFCARDIACFUNCTIONBETWEENPRE-OPANDPOST-OP,FuwaiHospital,84,DISCUSSION,FuwaiHospital,85,INDICATIONOFPEA?FACTORSRELATEDTOPROGNOSISOFPEA?,FuwaiHospital,86,INDICATIONOFPEA,SurgicalaccessiblePVR300dyneNYHAorWithoutseveremorbidity,Chest2004;126:63s-71s,OtherconsiderationmPAP40，surgicalexpertise，advancedsecondaryarteriopathy,FuwaiHospital,87,Relationshiplocationofdiseaseandmortality,JThoracCardiovascSurg2002;124:1203-1211,FuwaiHospital,88,RELATIONSHIPBETWEENPVRANDMORTALITY,AssessmentofOperabilityinChronicThromboembolicPulmonaryHypertensionProcAmThoracSoc2006;3:584-588,FuwaiHospital,89,Medicaltreatmentcanimproveprognosis,Pre-PEA“Bridging”therapyPost-PEAtherapy,MedicalTherapiesforChronicThromboembolicPulmonaryHypertension.AnEvolvingTreatmentParadigm.ProcAmThoracSoc2006;3:594-600,FuwaiHospital,90,DRUGS,AnticoagulationdrugsDiuretics,etc,Advanceddrugs,Prostacyclinanalogues：epoprostenol,iloprostET-RAntagonists：bosentanPED-5inhibitors：sildenafil,Traditionaldrugs,FuwaiHospital,91,Pre-PEA“Bridging”therapy,NYHAMPAP50CI1000,Unstablehemodynamics,Unsatisfacto