Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK.
Crit Care Resusc. 2010 Dec;12(4):242-7.
Massive pulmonary embolism (PE) (PE associated with hypotension or shock) is a condition with a mortality rate in excess of 50%. Although expert opinion favouring thrombolysis exists, this is based predominantly on studies demonstrating physiological benefits rather than a mortality benefit. The optimal treatment for massive PE remains unclear. The majority of studies to date have studied medical therapy, and case series of surgical pulmonary embolectomy have also been reported. No studies directly comparing mortality between medical and surgical therapies have been published. In our institution, both medical and surgical therapies are used in the treatment of massive PE.
To identify the characteristics and outcomes of patients who received thrombolysis, surgical embolectomy or heparin anticoagulation for management of massive PE.
Retrospective cohort study of patients with massive PE at the Royal North Shore Hospital, Sydney, Australia. The hospital medical records database was searched from 1 January 1996 to 31 December 2006. In addition, both the intensive care and cardiothoracic surgery databases were searched for the diagnosis of PE. Patients were included in our study if there was an ICD-9 diagnosis of PE and a review of notes indicated that the criteria for massive PE were met.
Fifty-one patients with massive PE were identified. Nine received embolectomy, 10 thrombolysis and 14 heparin anticoagulation. There were no statistically significant differences in mortality between these three groups, although resource utilisation was higher in the embolectomy group. Eighteen patients received no definitive treatment because of the poor prognosis of their underlying disease. All patients who received no definitive therapy died.
Massive PE has a high mortality. No significant mortality benefit was associated with any particular therapy. Patients for whom thrombolysis and/or embolectomy are contraindicated may benefit from simple anticoagulation.
大面积肺栓塞（PE）（与低血压或休克相关的 PE）的死亡率超过 50%。尽管存在支持溶栓治疗的专家意见，但这主要基于显示生理益处而非死亡率益处的研究。对于大面积 PE 的最佳治疗方法仍不清楚。迄今为止，大多数研究都研究了药物治疗，也有外科肺血栓切除术的病例系列报道。没有研究直接比较过药物治疗和手术治疗之间的死亡率。在我们的机构中，对于大面积 PE，既采用药物治疗，也采用手术治疗。
确定接受溶栓、外科取栓或肝素抗凝治疗的大面积 PE 患者的特征和结局。
在澳大利亚悉尼皇家北岸医院对大面积 PE 患者进行回顾性队列研究。从 1996 年 1 月 1 日至 2006 年 12 月 31 日，对医院的病历数据库进行了检索。此外，还对重症监护和心胸外科数据库进行了搜索，以确定 PE 的诊断。如果患者的 ICD-9 诊断为 PE，并且病历记录表明符合大面积 PE 的标准，则将其纳入本研究。
共确定了 51 例大面积 PE 患者。9 例接受取栓术，10 例接受溶栓治疗，14 例接受肝素抗凝治疗。这三组患者的死亡率无统计学差异，尽管取栓组的资源利用率更高。由于基础疾病的预后较差，18 例患者未接受确定性治疗。所有未接受确定性治疗的患者均死亡。
大面积 PE 死亡率高。任何特定治疗方法均未显著提高生存率。对于溶栓和/或取栓治疗禁忌的患者，单纯抗凝治疗可能有益。
