Jamieson S W, Auger W R, Fedullo P F, Channick R N, Kriett J M, Tarazi R Y, Moser K M
Division of Cardiothoracic Surgery, University of California, School of Medicine, San Diego 92103-8892.
J Thorac Cardiovasc Surg. 1993 Jul;106(1):116-26; discussion 126-7.
A program to alleviate chronic, major vessel thromboembolic pulmonary hypertension by pulmonary thromboendarterectomy was initiated at this institution in 1970. Multiple evolutionary changes in the diagnostic evaluation, surgical approach, and postoperative management have been implemented over the series of 323 thromboendarterectomies performed through March 1992. A sequence of five surgeons at the University of California at San Diego have performed these procedures, with the last 150 having been performed by one surgeon. We report here the changes in surgical approach developed over the last 150 cases and the results obtained. The operation involves a median sternotomy incision, the institution of cardiopulmonary bypass, and deep hypothermia with circulatory arrest periods. Incisions are made in both pulmonary arteries into the lower lobe branches. Pulmonary thromboendarterectomy is always bilateral, with removal of both organized thrombus and an endarterectomy plane from all involved vessels. The right atrium is routinely explored for atrial septal defects. Current techniques appear to allow more thorough revascularization and shorter circulatory arrest times. The surgical mortality of 8.7% over this span is below that previously reported from this and other institutions. Among survivors, the hemodynamic and functional results have been excellent. Surgically correctable chronic thromboembolic pulmonary hypertension likely remains underdiagnosed. The diagnostic, surgical, and postoperative management evolution provided by the coordinated team involved at this institution has established that pulmonary thromboendarterectomy can be performed with an acceptable risk and good hemodynamic and symptomatic results.
1970年，该机构启动了一项通过肺动脉血栓内膜剥脱术缓解慢性、大血管血栓栓塞性肺动脉高压的项目。在截至1992年3月所施行的323例肺动脉血栓内膜剥脱术中，诊断评估、手术方法和术后管理发生了多次渐进性变化。加利福尼亚大学圣地亚哥分校的五位外科医生先后开展了这些手术，其中最后150例由一位外科医生完成。我们在此报告过去150例手术中手术方法的变化及所取得的结果。该手术包括正中胸骨切开切口、建立体外循环以及采用深低温并伴有循环停止期。在双侧肺动脉中下叶分支处做切口。肺动脉血栓内膜剥脱术均为双侧手术，要从所有受累血管中清除机化血栓和内膜剥脱层面。常规探查右心房以寻找房间隔缺损。目前的技术似乎能实现更彻底的血管再通并缩短循环停止时间。在此期间8.7%的手术死亡率低于本机构及其他机构先前报告的死亡率。在存活者中，血流动力学和功能结果都非常好。外科手术可矫正的慢性血栓栓塞性肺动脉高压可能仍未得到充分诊断。本机构相关协作团队所提供的诊断、手术及术后管理的演变表明，肺动脉血栓内膜剥脱术可以在可接受的风险下施行，并能取得良好的血流动力学和症状改善效果。
