抢救性球囊肺动脉成形术治疗体外膜氧合支持的慢性血栓栓塞性肺动脉高压1例

Rescue balloon pulmonary angioplasty for a patient with acute exacerbation of chronic thromboembolic pulmonary hypertension supported by extracorporeal membrane oxygenation:a case report

本文报道1例33岁男性患者,因“活动后呼吸困难3年,加重15 d”入院,既往存在膜性肾病,未规范抗凝治疗,CTEPH急性加重出现急性呼吸衰竭。给予气管插管机械通气,阿替普酶溶栓和肝素充分抗凝治疗,病情仍进行性加重,血流动力学恶化,行VA-ECMO抢救治疗,患者无法脱离ECMO,并出现了肺部感染、右肺出血、高胆红素血症、凝血功能障碍等合并症,经多学科讨论认为患者病情危重,合并多器官功能衰竭,无法耐受肺动脉血栓内膜剥脱(PEA)手术,入院第2天行抢救性球囊肺动脉成形术(BPA)治疗,术中测量肺动脉压力98/40(59)mmHg(1 mmHg=0.133 kPa),肺动脉造影示主肺动脉扩张,右肺下叶肺动脉完全闭塞,右肺上叶、中叶肺动脉和左肺动脉分支可见多发狭窄,对右肺中叶、右肺上叶和左肺下叶各段肺动脉共9支血管进行了BPA治疗。入院第6天撤离VA-ECMO,入院第41天撤离呼吸机,入院第72天出院。提示抢救性BPA是不能行PEA的重症CTEPH患者的有效治疗策略。

A 33-year-old male patient was admitted to hospital because of"dyspnea after activity for 3 years and aggravation for 15 days".With a history of membranous nephropathy,irregular anticoagulation led to acute exacerbation of Chronic thromboembolic pulmonary hypertension(CTEPH)and acute respiratory failure,and endotracheal intubation and mechanical ventilation was given.Although treated with thrombolysis and adequate anticoagulation,the condition worsened and hemodynamics deteriorated,and then VA-ECMO was performed.Due to severe pulmonary hypertension and right heart failure,ECMO could not be weaned off,and the patient subsequently developed pulmonary infection,right lung hemorrhage,hyperbilirubinemia,coagulation dysfunction and other complications.Then the patient was transferred to our hospital by airplane,and multidisciplinary discussions were quickly arranged after admission.Considering that the patient was critically ill and complicated with multiple organ failure,pulmonary endarterectomy(PEA)could not be tolerated,rescue balloon pulmonary angioplasty(BPA)was recommended and performed on the second day after admission.The mean pulmonary artery pressure was 59 mmHg(1 mmHg=0.133 kPa)measured by right heart catheterization,and pulmonary angiography showed that the main pulmonary artery was dilated,while the right lower pulmonary artery was completely occluded,and there were multiple stenoses in the branches of the right upper lobe,middle lobe pulmonary artery and the left pulmonary artery.BPA was performed on a total of 9 pulmonary arteries.VA-ECMO was weaned off on day 6 after admission,and the mechanical ventilation was weaned off on day 41 after admission.The patient was successfully discharged on day 72 after admission.Rescue BPA was an effective treatment for severe CTEPH patients who could not be treated with PEA.