Lehnert Per, Møller Christian H, Mortensen Jann, Kjaergaard Jesper, Olsen Peter Skov, Carlsen Jørn
Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Eur J Cardiothorac Surg. 2017 Feb 1;51(2):354-361. doi: 10.1093/ejcts/ezw297.
The aim of this study was to investigate the long-term outcome after acute high- and intermediate-risk pulmonary embolism (PE) treated with surgical embolectomy or thrombolysis.
Prospective follow-up including assessment of 30-day and 5-year mortality. Clinical evaluation including ventilation/perfusion scintigraphy by single-photon emission computed tomography in combination with X-ray computed tomography, measurement of pulmonary diffusion impairment, spirometry and echocardiography.
A total of 136 patients (64 with high-risk and 72 with intermediate-risk PE) were included, 80 participated in the clinical follow-up, 16 were alive but declined follow-up and 40 were deceased. For high-risk PE patients the median time to clinical follow-up was 31 months [8–133]. No significant difference was observed in 30-day (Plog-rank = 0.16) or 5-year (Plog-rank = 0.53) mortality between patients treated with surgical embolectomy or thrombolysis. Ventilation/perfusion mismatch identified residual emboli in 4 patients (31%) treated with surgical embolectomy compared to 16 (76%) treated with thrombolysis (P = 0.009). Pulmonary diffusion impairment was identified in 4 patients (31%) treated with surgical embolectomy in comparison to 15 (71%) treated with thrombolysis (P = 0.02). In intermediate-risk PE patients, no significant difference in mortality (Plog-rank = 0.51 and 0.86), diffusion impairment or ventilation/perfusion mismatch was found between patients treated with surgical embolectomy or thrombolysis.
Surgical embolectomy for acute high-risk PE has similar mortality, but better outcome on pulmonary end-points when compared to thrombolysis. Patients with high-risk PE could benefit from being referred to a centre with both specialized cardiology and cardiothoracic surgery for interdisciplinary evaluation of optimal treatment strategy.
本研究旨在调查接受手术取栓或溶栓治疗的急性高危和中危肺栓塞（PE）后的长期结局。
前瞻性随访包括评估30天和5年死亡率。临床评估包括单光子发射计算机断层扫描联合X线计算机断层扫描进行通气/灌注闪烁扫描、测量肺弥散功能障碍、肺量计检查和超声心动图检查。
共纳入136例患者（64例高危PE和72例中危PE），80例参与临床随访，16例存活但拒绝随访，40例死亡。高危PE患者临床随访的中位时间为31个月[8 - 133]。接受手术取栓或溶栓治疗的患者在30天（对数秩检验P = 0.16）或5年（对数秩检验P = 0.53）死亡率方面未观察到显著差异。与16例（76%）接受溶栓治疗的患者相比，4例（31%）接受手术取栓治疗的患者通气/灌注不匹配提示存在残余栓子（P = 0.009）。4例（31%）接受手术取栓治疗的患者存在肺弥散功能障碍，相比之下，15例（71%）接受溶栓治疗的患者存在该情况（P = 0.02）。在中危PE患者中，接受手术取栓或溶栓治疗的患者在死亡率（对数秩检验P = 0.51和0.86）、弥散功能障碍或通气/灌注不匹配方面未发现显著差异。
与溶栓治疗相比，急性高危PE的手术取栓死亡率相似，但在肺部终点方面结局更好。高危PE患者可受益于转诊至具备专业心脏病学和心胸外科的中心，以进行最佳治疗策略的多学科评估。
