Management of patients with high-risk pulmonary embolism: a narrative review.
Management of patients with high-risk pulmonary embolism: a narrative review.
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DOI：
10.1186/s40560-018-0286-8
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发表时间：
2018
影响因子：
7.1
通讯作者：
Yamamoto T
中科院分区：
文献类型：
--
作者：
Yamamoto T
高危肺栓塞（PE）是一种危及生命的疾病，具有高死亡率和发病率。大多数休克患者的死亡发生在发病后的最初几个小时内，因此快速诊断和治疗对挽救患者的生命至关重要。主要PE的主要表现是急性右心室（RV）衰竭和缺氧。RV压力超负荷主要与机械性肺血管阻塞和基础心肺状态之间的相互作用有关。计算机断层扫描血管造影不仅可以充分显示肺血栓栓塞，至少可以显示肺段水平，还可以显示右心室扩大，作为右心室功能障碍的指标。在这种情况下，床旁超声心动图是一种可接受的替代方法。虽然超声心动图通常不能提供明确的诊断或排除肺栓塞，但可以确认或排除严重的RV压力超负荷和功能障碍。肺外膜氧合支持是治疗PE所致循环衰竭的有效方法。血栓溶解通常被接受在不稳定的高风险PE患者中;然而，血栓溶解剂不能完全用于高出血风险的患者。相反，导管导向治疗是有溶栓禁忌症的高危PE患者的最佳治疗策略，是外科取栓术的微创替代方案。它可以使用最小剂量的血栓溶解剂或不使用，并且可以根据肺血管造影片上的血栓程度与各种手术（包括导管破碎术或栓子切除术）相结合。混合导管导向治疗可以降低快速心率和高肺动脉压，并可以改善气体交换指数和结果。对于有溶栓禁忌症或对溶栓反应不充分的患者，也可进行外科取栓术。有重症监护室的大医院应预先建立诊断和治疗方案，并对高危PE患者进行多学科管理。与由重症监护医生、心脏病专家、心脏外科医生、放射科医生和其他专家组成的熟练团队的协调对于最大限度地取得成功至关重要。
High-risk pulmonary embolism (PE) is a life-threatening disorder associated with high mortality and morbidity. Most deaths in patients with shock occur within the first few hours after presentation, and rapid diagnosis and treatment is therefore essential to save patients’ lives. The main manifestations of major PE are acute right ventricular (RV) failure and hypoxia. RV pressure overload is predominantly related to the interaction between the mechanical pulmonary vascular obstruction and the underlying cardiopulmonary status. Computed tomography angiography allows not only adequate visualization of the pulmonary thromboemboli down to at least the segmental level but also RV enlargement as an indicator of RV dysfunction. Bedside echocardiography is an acceptable alternative under such circumstances. Although it does not usually provide a definitive diagnosis or exclude pulmonary embolism, echocardiography can confirm or exclude severe RV pressure overload and dysfunction. Extracorporeal membrane oxygenation support can be an effective procedure in patients with PE-induced circulatory collapse. Thrombolysis is generally accepted in unstable patients with high-risk PE; however, thrombolytic agents cannot be fully administered to patients with a high risk of bleeding. Conversely, catheter-directed treatment is an optimal treatment strategy for patients with high-risk PE who have contraindications for thrombolysis and is a minimally invasive alternative to surgical embolectomy. It can be performed with a minimum dose of thrombolytic agents or without, and it can be combined with various procedures including catheter fragmentation or embolectomy in accordance with the extent of the thrombus on a pulmonary angiogram. Hybrid catheter-directed treatment can reduce a rapid heart rate and high pulmonary artery pressure and can improve the gas exchange indices and outcomes. Surgical embolectomy is also performed in patients with contraindications for or an inadequate response to thrombolysis. Large hospitals having an intensive care unit should preemptively establish diagnostic and therapeutic protocols and rehearse multidisciplinary management for patients with high-risk PE. Coordination with a skilled team comprising intensivists, cardiologists, cardiac surgeons, radiologists, and other specialists is crucial to maximize success.
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影响因子：
37.8
作者：
Lavonas, Eric J.;Drennan, Ian R.;Donnino, Michael W.
通讯作者：
Donnino, Michael W.
DOI：
10.1016/s0735-1097(97)00319-7
发表时间：
1997-11-01
影响因子：
24
作者：
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影响因子：
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作者：
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39.3
作者：
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通讯作者：
Zompatori, Maurizio
影响因子：
2.6
作者：
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