肺移植治疗慢性栓塞性肺动脉高压六例临床分析

Lung transplantation for chronic thromboembolic pulmonary hypertension： a report of 6 cases

目的 探讨肺移植治疗慢性栓塞性肺动脉高压的手术适应证、围手术期的处理及疗效.方法 回顾性分析2012年1月至2016年6月6例接受肺移植治疗的慢性栓塞性肺动脉高压受者的临床资料.6例受者中,男性4例,女性2例,年龄34～59岁,术前均诊断为慢性栓塞性肺动脉高压.移植前6例受者的胸部增强CT或CTPA检查接均显示不同程度的肺动脉栓塞,其平均肺动脉压均＞30 mmHg,心功能Ⅲ～Ⅳ级.6例受者中,4例在ECMO辅助下接受续贯式双肺移植,2例接受了单肺移植,其中1例在ECMO辅助下完成.观察手术前后受者氧合指数、肺动脉收缩压、肺动脉舒张压、肺动脉平均压以及中心静脉压等指标变化.采用配对t检验比较上述指标,P＜0.05为差异有统计学意义.结果 6例受者氧合指数由术前的（195±85）mmHg上升至术后的（440±140）mmHg,肺动脉收缩压由术前的（108±28） mmHg下降至术后的（56±16） mmHg,肺动脉舒张压由术前的（72±18） mmHg下降至术后的（25±10） mmHg,平均肺动脉压由术前的（84±27） mmHg下降至术后的（36±10） mmHg,中心静脉压由术前的（17.5±4.5） mmHg下降至术后的（8.5±1.5） mmHg,移植前后上述指标的比较,差异均有统计学意义（P＜0.05）.最终5例受者康复出院,随访至今,心肺功能良好,长期生活质量佳.1例受者术后3d出现休克、多器官功能衰竭而死亡.结论 肺移植能够有效治疗慢性栓塞性肺动脉高压,受者术后远期的存活情况还需进一步观察.

Objective To investigate the selection of recipients,operative technique,and perioperative management of lung transplantation for chronic thromboembolic pulmonary hypertension.Methods This article reviews the clinical data of 6 patients with chronic thromboembolic pulmonary hypertension receiving lung transplantation from January 2012 to June 2016.From January 2012 to June 2016,6 patients with chronic thromboembolic pulmonary hypertension underwent lung transplantation at Department of Thoracic Surgery,Affiliated Wuxi People＇s Hospital,Nanjing Medical University.There were 4 male and 2 female patients aged from 34 to 59 years.Chest enhancement of CT or CTPA in 6 patients prior to transplantation suggests a different degree of pulmonary embolism.The mean pulmonary artery pressure （mPAP） was〉30 mmHg,NYHA 11Ⅰ or Ⅳ.Four patients received bilateral sequence lung transplantation （BSLT） under extracorporeal membrane oxygenation （ECMO） support.Two patients received single lung transplantation （SLT）.We analyzed the differences of oxygenation index,pulmonary systolic pressure,pulmonary artery diastolic pressure,mean pulmonary arterial pressure,and central venous pressure before and after treatment.Using paired t test to compare these indicators,P〈0.05 was considered statistically significant.Results The oxygenation index increased from （195 ± 85） to （440 ± 140） mmHg after treatment,the difference was statistically significant （P〈0.05）.the The systolic pressure of pulmonary artery was decreased from （108 ± 28） mmHg to （56 ± 16） mmHg,and the difference was statistically significant （P〈0.05）.the The diastolic pressure of pulmonary artery was decreased from （72 ± 18） mmHg to （25 ± 10） mmHg,and the difference was statistically significant （P〈0.05）.the The mean pulmonary artery pressure was decreased from （84 ± 27） mmHg to （36 ± 10） mmHg,and the difference was statistically significant （P〈0.05）.the The central venous pressure was decreased from （17.5 ± 4.5） mmHg to （8.5 ± 1.5） mmHg,and the difference was statistically significant （P〈0.05）.Finally,5 patients were discharged from the hospital,and the pulmonary valve？ functioned？ well.1 patients died of shock and systemic failure 3 days after operation.Conclusion Lung transplantation is effective in the treatment of chronic thromboembolic pulmonary hypertension,and long-term survival requires further investigations.