Hartz R S, Byrne J G, Levitsky S, Park J, Rich S
Department of Surgery, University of Illinois Hospital and Clinics, Chicago, USA.
Ann Thorac Surg. 1996 Nov;62(5):1255-9; discussion 1259-60. doi: 10.1016/0003-4975(96)00460-2.
The operative mortality associated with surgical thromboendarterectomy of the pulmonary arteries has decreased at the University of California in San Diego with the application of new techniques. For universal performance of the procedure, however, those factors that contribute to the high operative mortality must be identified. We analyzed our results in 34 consecutive patients undergoing pulmonary thromboendarterectomy to determine those preoperative factors that contribute to operative mortality.
Since 1983, 34 patients with severe, surgically correctable chronic thromboembolic pulmonary hypertension who were judged to be operable by pulmonary arteriography underwent pulmonary thromboendarterectomy. No patient was excluded because of right ventricular failure or hemodynamic severity of disease; the mean pulmonary artery pressure (PAP) was 54 mm Hg, the mean pulmonary vascular resistance (PVR) was 1,094 dynes.s.cm-5, and all patients were in New York Heart Association functional class III or IV.
Postoperative course was characterized either by swift recovery (mean length of stay, 13 days) or by rapid demise resulting from pulmonary or right ventricular failure, or both (overall operative mortality, 23%). In survivors, the mean PAP, PVR, cardiac output, and New York Heart Association functional class were significantly improved (p < 0.05). Patients who died had a significantly greater mean preoperative PAP than did those who survived (62.1 +/- 1.2 versus 49.5 +/- 2.3 mm Hg; p < 0.01) and significantly higher PVR (1,512 +/- 116 versus 949 +/- 85 dynes.s.cm-5; p < 0.01). In addition, both a PVR of more than 1,100 dynes.s.cm-5 and a mean PAP of more than 50 mm Hg could accurately predict operative mortality: operative mortality was six times greater in patients with a preoperative PVR of greater than 1,100 dynes.s.cm-5 (41% versus 5.85%) and almost five times greater in those with a mean PAP of greater than 50 mm Hg (37% versus 8%). No intraoperative factors, including the use or duration of circulatory arrest, affected outcome.
Patients with severe hemodynamic disease (PVR > 1,100 dynes.s.cm-5 and PAP > 50 mm Hg) have a high likelihood of operative mortality and perhaps should not undergo pulmonary thromboendarterectomy, except at institutions where the operation is performed frequently.
随着新技术的应用，加利福尼亚大学圣地亚哥分校实施的肺动脉血栓内膜剥脱术相关的手术死亡率有所下降。然而，为了该手术的广泛开展，必须明确那些导致高手术死亡率的因素。我们分析了连续34例行肺动脉血栓内膜剥脱术患者的结果，以确定那些导致手术死亡的术前因素。
自1983年以来，34例患有严重的、可通过手术纠正的慢性血栓栓塞性肺动脉高压且经肺动脉造影判断可手术的患者接受了肺动脉血栓内膜剥脱术。没有患者因右心室衰竭或疾病的血流动力学严重程度而被排除；平均肺动脉压（PAP）为54mmHg，平均肺血管阻力（PVR）为1094达因·秒·厘米⁻⁵，所有患者均为纽约心脏协会功能分级III级或IV级。
术后病程特点要么是迅速恢复（平均住院时间13天），要么是因肺或右心室衰竭或两者导致迅速死亡（总体手术死亡率23%）。在存活者中，平均PAP、PVR、心输出量和纽约心脏协会功能分级均有显著改善（p<0.05）。死亡患者术前平均PAP显著高于存活者（62.1±1.2对49.5±2.3mmHg；p<0.01），PVR也显著更高（1512±116对949±85达因·秒·厘米⁻⁵；p<0.01）。此外，PVR大于1100达因·秒·厘米⁻⁵和平均PAP大于50mmHg均可准确预测手术死亡率：术前PVR大于1100达因·秒·厘米⁻⁵的患者手术死亡率高6倍（41%对5.85%），平均PAP大于50mmHg的患者手术死亡率高近5倍（37%对8%）。没有术中因素，包括体外循环的使用或持续时间，影响结果。
血流动力学严重疾病（PVR>1100达因·秒·厘米⁻⁵且PAP>50mmHg）的患者手术死亡可能性高，可能不应接受肺动脉血栓内膜剥脱术，除非在经常开展该手术的机构。
