目的:肺动脉内膜切除术(PEA)是慢性血栓栓塞性肺动脉高压(CTEPH)患者的潜在治疗方法。这项研究报告了葡萄牙PH中心在国际外科参考中心接受PEA的患者的初步经验。
方法:在国家PH中心随访的连续CTEPH患者的前瞻性观察性研究,2015年10月至2019年3月在国际外科参考中心接受PEA治疗。临床,功能,实验室,在手术前12个月内获得影像学和血流动力学参数,并在PEA后4-6个月内重复。
结果:有27例患者(59%为女性)中位年龄为60岁(49-71岁)接受PEA治疗。在34(21-48)个月的中位随访中,所有患者的功能等级都有改善,只有一个心脏死亡。从血液动力学的角度来看,平均肺动脉压从48(42-59)mmHg降至26(22-38)mmHg,心输出量从3.3(2.9-4.0)L/min增加到4.9(4.2-5.5)L/min,肺血管阻力从12.1(7.2-15.5)uW减少到3.5(2.6-5,2)uW。在后续行动中,44%(n=12)的患者没有PH标准,44%(n=12)有残余PH,11%(n=3)有PH复发。N-末端前B型钠肽从868(212-1730)pg/mL减少到171(98-382)pg/mL。右心室收缩功能参数显示,三尖瓣环平面的纵向收缩偏移和峰值速度从14(13-14)mm和9(8-10)cm/s提高到17(16-18)mm和13(11-15)cm/s,分别。26例术前右心功能不全,85%(n=22)恢复。接受特定血管扩张剂治疗的患者比例从93%降至44%(p<0.001),需要氧气治疗的患者比例从52%降至26%(p=0.003)。与基线相比,六分钟步行测试距离增加了约25%,并且在测试期间仅有8名患者发生显著的去饱和。
结论:在有经验的高容量中心进行肺内膜切除术是一种安全的手术,对功能,患有可手术疾病的CTEPH患者的血流动力学和右心室功能参数。没有PEA分化的PH中心可以安全有效地将患者转诊到需要空运的国际外科中心。
OBJECTIVE: Pulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center.
METHODS: Prospective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA.
RESULTS: 27 consecutive patients (59% female) with a median age of 60 (49-71) years underwent PEA. During a median follow-up of 34 (21-48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42-59) mmHg to 26 (22-38) mmHg, an increase in cardiac output from 3.3 (2.9-4.0) L/min to 4.9 (4.2-5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2-15.5) uW to 3.5 (2.6-5, 2) uW. During the follow-up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n = 3) had PH recurrence. There was a reduction of N-terminal pro-B-type natriureticpeptide from 868 (212-1730) pg/mL to 171 (98-382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13-14) mm and 9 (8-10) cm/s to 17 (16-18) mm and 13 (11-15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six-minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test.
CONCLUSIONS: Pulmonary endarterectomy performed at an experienced high-volume center is a safe procedure with a very favorable medium-term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.