First Faculty of Medicine, Charles University, Prague, Czech Republic; 2nd Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
Pulmonary Hypertension Center, 2nd Internal Clinic, General University Hospital in Prague, First Faculty of Medicine, Charles University, Prague, Czech Republic.
J Thorac Cardiovasc Surg. 2018 Sep;156(3):1275-1287. doi: 10.1016/j.jtcvs.2018.04.110. Epub 2018 May 17.
Chronic thromboembolic pulmonary hypertension is surgically treated through pulmonary endarterectomy. Although pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension in terms of both functional outcomes and survival, many patients experience persistent pulmonary hypertension after pulmonary endarterectomy. The study objective was to calculate the pooled estimates of outcomes after pulmonary endarterectomy, including persistent pulmonary hypertension.
Meta-analyses were conducted on published studies reporting residual/persistent/recurrent pulmonary hypertension in 4868 patients with chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy. The rate of persistent pulmonary hypertension and change in mean pulmonary artery pressure, pulmonary vascular resistance, and 6-minute walk distance after pulmonary endarterectomy were outcomes of interest.
Twenty-five percent of patients with chronic thromboembolic pulmonary hypertension were diagnosed with persistent pulmonary hypertension after pulmonary endarterectomy. Pulmonary endarterectomy reduced mean pulmonary artery pressure and pulmonary vascular resistance by approximately 21 mm Hg (standardized mean difference, 1.75; 95% confidence interval, -1.62 to 1.88; P < .00001) and 561 dyn.s/cm (standardized mean difference, 1.64; 95% confidence interval, -1.58 to 1.70; P < .00001), respectively. Conversely, 6-minute walk distance increased by 96 m (standardized mean difference, -0.83; 95% confidence interval, -0.91 to -0.76; P < .00001) after pulmonary endarterectomy.
Pulmonary endarterectomy is the gold standard treatment for chronic thromboembolic pulmonary hypertension and provides immediate correction of hemodynamic parameters in most patients. However, in up to one quarter of operable cases, pulmonary hypertension persists after surgery. In those patients with persistent pulmonary hypertension, continued medical management with newer agents may be required to improve pulmonary hemodynamics and, therefore, patient outcomes.
慢性血栓栓塞性肺动脉高压通过肺动脉内膜切除术进行手术治疗。尽管在功能结果和生存率方面，肺动脉内膜切除术是慢性血栓栓塞性肺动脉高压的首选治疗方法，但许多患者在肺动脉内膜切除术后仍存在持续性肺动脉高压。本研究的目的是计算肺动脉内膜切除术后包括持续性肺动脉高压在内的结局的汇总估计值。
对报道 4868 例慢性血栓栓塞性肺动脉高压患者肺动脉内膜切除术后残留/持续性/复发性肺动脉高压的已发表研究进行荟萃分析。持续性肺动脉高压的发生率以及肺动脉内膜切除术后平均肺动脉压、肺血管阻力和 6 分钟步行距离的变化是本研究的观察结局。
25%的慢性血栓栓塞性肺动脉高压患者在肺动脉内膜切除术后被诊断为持续性肺动脉高压。肺动脉内膜切除术使平均肺动脉压和肺血管阻力分别降低了约 21mmHg（标准化均数差，1.75；95%置信区间，-1.62 至 1.88；P<0.00001）和 561dyn·s/cm（标准化均数差，1.64；95%置信区间，-1.58 至 1.70；P<0.00001）。相反，肺动脉内膜切除术后 6 分钟步行距离增加了 96m（标准化均数差，-0.83；95%置信区间，-0.91 至 -0.76；P<0.00001）。
肺动脉内膜切除术是慢性血栓栓塞性肺动脉高压的金标准治疗方法，可使大多数患者的血流动力学参数立即得到纠正。然而，在多达四分之一的可手术病例中，手术后仍存在肺动脉高压。在那些持续性肺动脉高压的患者中，可能需要使用新的药物进行持续的药物治疗，以改善肺血流动力学，从而改善患者的结局。
