急性肺栓塞的外科治疗后的生存和右心室功能。
Survival and Right Ventricular Function After Surgical Management of Acute Pulmonary Embolism.
机构信息
Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York.
出版信息
J Am Coll Cardiol. 2020 Aug 25;76(8):903-911. doi: 10.1016/j.jacc.2020.06.065.
BACKGROUND
Acute pulmonary embolism (PE) is associated with high morbidity and mortality because of right ventricular (RV) failure. There is evidence suggesting surgical therapy (surgical embolectomy or venoarterial extracorporeal membrane oxygenation [ECMO]) is safe and effective.
OBJECTIVES
The aim of this study was to assess the safety and efficacy of surgical management of acute PE.
METHODS
Surgical embolectomy and/or venoarterial ECMO were compared, between 2005 and 2019, for massive PE (MPE) versus high-risk submassive PE (SMPE). RV recovery was defined as improvements in central venous pressure, pulmonary artery systolic pressure, RV/left ventricular ratio, and RV fractional area change.
RESULTS
One hundred thirty-six patients with PE (92 with SMPE and 44 with MPE) were identified. Patients with MPE more often presented with syncope (59.1% [26 of 44] vs. 25.0% [23 of 92]; p = 0.0003), Glasgow Coma Scale score ≤4 (22.7% [10 of 44] vs. 0% [0 of 92]), and failed thrombolysis (18.2% [8 of 44] vs. 4.3% [3 of 92]; p = 0.008). Pre-operative cardiopulmonary resuscitation occurred in 43.2% of patients with MPE (19 of 44). Most patients with SMPE were treated with embolectomy (98.9% [91 of 92]), while ECMO was used more in those with MPE (ECMO in 40.9% [18 of 44], embolectomy in 59.1% [26 of 44]). RV function improved as measured by central venous pressure (from 23.4 ± 4.9 to 10.5 ± 3.1 mm Hg), pulmonary artery systolic pressure (from 60.6 ± 14.2 to 33.8 ± 10.7 mm Hg), RV/left ventricular ratio (from 1.19 ± 0.33 to 0.87 ± 0.23; p < 0.005), and fractional area change (from 26.8 to 41.0; p < 0.005). Mortality was 4.4% (6 of 136; SMPE, 1.1% [1 of 92]; MPE, 11.6% [5 of 44]). Subgroup analysis showed morbidity and mortality were highly associated with pre-operative cardiopulmonary resuscitation.
CONCLUSIONS
Surgical management of patients with MPE and high-risk SMPE is safe and highly effective at achieving RV recovery.
背景
急性肺栓塞（PE）可导致右心室（RV）衰竭，其发病率和死亡率较高。有证据表明，手术治疗（外科取栓术或静脉动脉体外膜肺氧合[ECMO]）是安全有效的。
目的
本研究旨在评估急性 PE 手术治疗的安全性和疗效。
方法
比较了 2005 年至 2019 年期间大量 PE（MPE）与高危次大量 PE（SMPE）的外科取栓术和/或静脉动脉 ECMO。RV 恢复定义为中心静脉压、肺动脉收缩压、RV/左心室比值和 RV 射血分数的改善。
结果
共确定了 136 例 PE 患者（92 例 SMPE 和 44 例 MPE）。MPE 患者更常出现晕厥（59.1%[26/44] vs. 25.0%[23/92]；p=0.0003）、格拉斯哥昏迷评分≤4（22.7%[10/44] vs. 0%[0/92]）和溶栓失败（18.2%[8/44] vs. 4.3%[3/92]；p=0.008）。43.2%的 MPE 患者（19/44）接受了术前心肺复苏。大多数 SMPE 患者接受了取栓术（98.9%[91/92]），而 MPE 患者更多地接受了 ECMO（ECMO 占 40.9%[18/44]，取栓术占 59.1%[26/44]）。RV 功能改善，通过中心静脉压（从 23.4±4.9 至 10.5±3.1mmHg）、肺动脉收缩压（从 60.6±14.2 至 33.8±10.7mmHg）、RV/左心室比值（从 1.19±0.33 至 0.87±0.23；p<0.005）和射血分数（从 26.8 至 41.0；p<0.005）测量。死亡率为 4.4%（136 例中有 6 例；SMPE 为 1.1%[92 例中有 1 例]；MPE 为 11.6%[44 例中有 5 例]）。亚组分析显示，发病率和死亡率与术前心肺复苏高度相关。
结论
外科治疗 MPE 和高危 SMPE 是安全有效的，可高度实现 RV 恢复。
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