30例肺动脉血栓内膜剥脱术临床结果

Outcomes of Pulmonary Thromboendarterectomy: Results of 30 Cases

目的:报告肺动脉血栓内膜剥脱术(PTE)治疗慢性栓塞性肺动脉高压的结果。方法:回顾性总结连续30例肺动脉血栓内膜剥脱术的手术要点、围术期处理以及近中期结果。结果:共行PTE术30例,男24例,女6例,平均年龄45．7岁,平均病史48．0个月。术前心功能为纽约心功能协会分级标准(NYHA)Ⅳ级者12例,Ⅲ级者18例。手术均在深低温间断停循环下完成肺动脉血栓及机化内膜剥脱术。围术期死亡1例(死亡率为3．3％)。死亡原因为感染性休克。术后出现神经系统并发症4例(13．3％),再灌注肺水肿7例(23．3％),肺内出血1例(3．3％)。平均体外循环时间191．1 min,平均主动脉阻断时间95．1 min,平均停体外循环时间47．7 min。术后平均拔除气管插管时间85．1 h。肺动脉收缩压由术前的91．4 mmHg(1 mmHg=0．133 kPa)降至术后的48．3 mmHg、动脉血氧分压由56．2 mmHg升至88．9 mmHg、动脉血氧饱和度由0．90升至0．97(P均<0．01-0．05),均有显著改善。随访26例,平均随访时间36．8个月,心功能NYHA分级Ⅰ级22例,Ⅱ级3例,Ⅲ级1例,生活质量明显改善。结论:PTE术是治疗慢性栓塞性肺动脉高压的有效手段,其关键在于选择合适病例,彻底剥离肺动脉血栓和机化内膜,正确预防和治疗各种并发症。

Objective： To investigate the clinical outcomes of pulmonary thromboendarterectomy （PFE） for chronic thromboembolic pulmonary hypertension （CTEPH）. Methods： Between March 1997 and April 2005, a total of 30 cases of PTE were performed in Fuwai Hospital. There were 24 men and 6 women with an average age of 45.7 years and an disease history of average 48.0 months. The patients had NYHA class Ⅳ （n ： 12） or class Ⅲ （n = 18）. The thrombolic sites originated in the right or left pulmonary artery （ RPA or LPA） and extended to lobar and segmental pulmonary arteries. Eleven had unilateral （ 10 with RPA and 1 with LPA） and 19 had bilateral lesions. They underwent PTE under deep hypothermia and intermittent circulation arrest. The procedures included tricuspid valve annuloplasty （ n = 3 ）, coronary artery bypass grafting （ n = 1 ）, and pulmonary valve annuloplasty （ n = 1 ）. Results： One patient died of infective shock postoperatively （3.3%）. Complication of central nervous system occurred in 4 （ 13.3% ） ,and reperfusion pulmonary edema in 7 （23.3%）. The mean cardiopulmonary bypass time was 191. 1 minutes, the mean aortic clamping time was 95. 1minutes and the mean circulation arrest time was 47. 7 minutes. The mean extubation time was 85. 1 hours. Compared with preoperation, postoperative arterial pressure of oxygen （ Pao2 ） was significantly improved （88. 9± 6. 0 mmHg vs. 56. 2 ± 8.6 mmHg,P 〈 0. 01 ）, so was arterial oxygen saturation （SaO2 ） （0. 97 ± 0. 01 vs. 0. 90 ± 0. 05, P 〈 0. 05） and systolic pulmonary artery pressure （ 91.4 ± 22.4 mmHg vs. 48.3 ±10. 7 mmHg, P 〈 0. 05 ）. Twenty-six patients were followed up for an average time of 36. 8 months. Twenty-two had NYHA class Ⅰ ,three had class Ⅱ and one had class Ⅲ. Conclusion： PTE is an effective method for CTEPH. The keys to successful PTE are selection of eligible patients, complete stripping of thrombus, and prevention and treatment of complications.