接受肺动脉内膜剥脱术的慢性血栓栓塞性肺动脉高压患者血栓组织病理学与血流动力学结果之间的关联

Association Between Thrombus Histopathology and Hemodynamic Outcomes Among Patients With Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy.

作者信息

Mounsey Louisa A, Alape Moya Daniel, Wright Cameron, Langer Nathaniel, Stone James R, Channick Richard, Wong Alexandra K, Rodriguez-Lopez Josanna, Witkin Alison S

机构信息

Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, MA.

Department of Medicine, Cape Cod Hospital, Hyannis, MA.

出版信息

Chest. 2025 Apr;167(4):1182-1190. doi: 10.1016/j.chest.2024.10.018. Epub 2024 Oct 23.

DOI:10.1016/j.chest.2024.10.018

PMID:39454997

Abstract

BACKGROUND

Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). Although most have normalization of pulmonary artery (PA) pressures, development of residual pulmonary hypertension (RPH) is challenging to predict.

RESEARCH QUESTION

Among patients with CTEPH undergoing PEA, is there a relationship between specimen histopathology and postoperative hemodynamics?

STUDY DESIGN AND METHODS

In this single-center retrospective cohort study, patients with CTEPH who underwent PEA were classified by thrombus chronicity: organized (chronic), organizing (subacute), or mixed (combined organizing and organized). Change in mean PA pressure, pulmonary vascular resistance (PVR), and transpulmonary gradient (TPG) were examined by thrombus organization. Associations with RPH were assessed with multivariable logistic regression.

RESULTS

A total of 163 patients were identified: 34% had organized thrombi, 17% had organizing thrombi, and 49% had mixed thrombi. Pre-PEA mean TPG and PVR were highest in the mixed group (TPG: 37 mm Hg [29-42 mm Hg]; PVR: 8.7 Wood units [WU] [interquartile range (IQR), 5.6-11.2 WU]) compared with the organized (TPG: 30 mm Hg [24-38 mm Hg]; PVR: 6.2 WU [IQR, 4.2-8.8 WU]) and organizing (TPG: 24 mm Hg [19-37 mm Hg]; PVR: 4.2 WU [IQR, 3.5-9.2 WU]) groups (TPG: P = .05; PVR: P = .01). The adjusted change in mean PA pressure among the mixed group was -19.8 mm Hg (-21.7 to -17.8 mm Hg), significantly greater than -16.2 mm Hg (-18.4 to -14.1 mm Hg) in the organized group and -14.1 mm Hg (-17.3 to -10.9 mm Hg) in the organizing group (P = .004). Fifty-two patients (32%) had RPH. Mixed thrombus organization was associated with lower odds of RPH (OR, 0.35; 95% CI, 0.14-0.85; P = .02), whereas preoperative mean PA pressure (OR, 1.10; 95% CI, 1.06-1.16; P < .001) and age (OR, 1.04; 95% CI, 1.01-1.07; P = .02) were associated with higher odds of RPH.

INTERPRETATION

Patients with mixed thrombi were less likely to have RPH, suggesting there may be an optimum time to perform PEA after the clot has mostly organized, but prior to development of irreversible small vessel disease.

摘要

背景

肺动脉内膜剥脱术（PEA）是慢性血栓栓塞性肺动脉高压（CTEPH）的首选治疗方法。尽管大多数患者的肺动脉（PA）压力可恢复正常，但残余肺动脉高压（RPH）的发生难以预测。

研究问题

在接受PEA的CTEPH患者中，标本组织病理学与术后血流动力学之间是否存在关联？

研究设计与方法

在这项单中心回顾性队列研究中，将接受PEA的CTEPH患者按血栓慢性程度分类：机化（慢性）、正在机化（亚急性）或混合性（正在机化与机化并存）。通过血栓机化程度检查平均PA压力、肺血管阻力（PVR）和跨肺压差（TPG）的变化。采用多变量逻辑回归评估与RPH的相关性。

结果

共纳入163例患者：34%为机化血栓，17%为正在机化血栓，49%为混合性血栓。与机化组（TPG：30 mmHg [24 - 38 mmHg]；PVR：6.2 Wood单位 [WU] [四分位间距（IQR），4.2 - 8.8 WU]）和正在机化组（TPG：24 mmHg [19 - 37 mmHg]；PVR：4.2 WU [IQR，3.5 - 9.2 WU]）相比，混合组术前平均TPG和PVR最高（TPG：37 mmHg [29 - 42 mmHg]；PVR：8.7 Wood单位 [WU] [IQR，5.6 - 11.2 WU]）（TPG：P = 0.05；PVR：P = 0.01）。混合组平均PA压力的调整变化为 -19.8 mmHg（-21.7至 -17.8 mmHg），显著大于机化组的 -16.2 mmHg（-18.4至 -14.1 mmHg）和正在机化组的 -14.1 mmHg（-17.3至 -10.9 mmHg）（P = 0.004）。52例患者（32%）发生RPH。混合性血栓机化与RPH的发生几率较低相关（OR，0.35；95% CI，0.14 - 0.85；P = 0.02），而术前平均PA压力（OR，1.10；95% CI，1.06 - 1.16；P < 0.001）和年龄（OR，1.04；95% CI，1.01 - 1.07；P = 0.02）与RPH的发生几率较高相关。