Doerge H C, Schoendube F A, Loeser H, Walter M, Messmer B J
Klinikum Aachen, Germany.
Eur J Cardiothorac Surg. 1996;10(11):952-7. doi: 10.1016/s1010-7940(96)80396-4.
Surgical intervention for fulminant pulmonary embolism is nowadays most commonly restricted to patients with failure of or contraindication to thrombolytic therapy. Such a second choice indication may alter operative risks or late outcome, and this was investigated in a retrospective study.
Thirty-six patients (17 male, mean age: 50.6 +/- 15.5 years) with fulminant pulmonary embolism of either the pulmonary trunk or one of the pulmonary arteries and at least one contralateral segment underwent pulmonary embolectomy on cardiopulmonary bypass during a 15-year period (1979-89: 31 patients, group I; 1990-94: 5 patients, group II). Group II included only patients who did not meet the criteria for acute thrombolysis. All patients were in strongly compromised circulatory conditions (29/36 high dose catecholamines, 20/36 mechanical ventilation, 14/36 pre-operative cardiopulmonary resuscitation).
The perioperative mortality rate was 26% in group I (8/31 patients, 7 with pre-operative cardiac arrest) and 20% in group II (1/5 patients not related to failure of previous thrombolytic therapy). Severe but non-fatal complications occurred in six patients who fully recovered following treatment. Follow-up was completed to 93% (25/27 patients) and comprised a total of 248 patient-years (mean: 119 months). Twenty-three out of 25 patients (92%) were in functional class I or II (NYHA). No recurrent pulmonary embolism or late clinical symptoms related to embolectomy were observed. One patient died 8 years postoperatively (late mortality: 0.4% patient-year). There was no difference between group I and group II regarding perioperative mortality, complications and late results.
Late results after pulmonary embolectomy are excellent in respect to functional class and late mortality. Early mortality is closely associated with preoperative cardiac arrest. Previous thrombolysis does not alter the perioperative risks, occurrence of complications or late outcome after surgical intervention.
如今，暴发性肺栓塞的外科干预大多仅限于溶栓治疗失败或有禁忌证的患者。这种次选适应证可能会改变手术风险或远期预后，本回顾性研究对此进行了调查。
36例患者（17例男性，平均年龄：50.6±15.5岁）患有肺动脉主干或其中一支肺动脉的暴发性肺栓塞且至少有一个对侧肺段，在15年期间（1979 - 1989年：31例患者，I组；1990 - 1994年：5例患者，II组）在体外循环下行肺动脉血栓切除术。II组仅包括不符合急性溶栓标准的患者。所有患者的循环状况均严重受损（29/36例使用高剂量儿茶酚胺，20/36例使用机械通气，14/36例术前进行心肺复苏）。
I组围手术期死亡率为26%（8/31例患者，7例术前心脏骤停），II组为20%（1/5例患者，与先前溶栓治疗失败无关）。6例患者出现严重但非致命的并发症，经治疗后完全康复。随访完成率为93%（25/27例患者），共248患者年（平均：119个月）。25例患者中有23例（92%）心功能分级为I级或II级（纽约心脏协会）。未观察到复发性肺栓塞或与血栓切除术相关的晚期临床症状。1例患者术后8年死亡（晚期死亡率：0.4%患者年）。I组和II组在围手术期死亡率、并发症和远期结果方面无差异。
肺动脉血栓切除术后的远期功能分级和晚期死亡率结果良好。早期死亡率与术前心脏骤停密切相关。先前的溶栓治疗不会改变手术干预后的围手术期风险、并发症发生率或远期预后。
