Perioperativeballoon pulmonary angioplasty enabled noncardiac surgery of a patient with chronic thromboembolic pulmonary hypertension (CTEPH)
Perioperativeballoon pulmonary angioplasty enabled noncardiac surgery of a patient with chronic thromboembolic pulmonary hypertension (CTEPH)
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围术期球囊肺血管成形术使慢性血栓栓塞性肺动脉高压 (CTEPH) 患者能够进行非心脏手术
DOI：
10.1097/md.0000000000014807
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发表时间：
2018
期刊：
影响因子：
1.6
通讯作者：
Yamada Y
中科院分区：
文献类型：
--
作者：
Watanabe K;Ito N;Ohata T;Kariya T;Inui H;Yamada Y
干预：对双侧肺动脉的8个分支进行4次BPA治疗，直到平均PAP（mPAP）低于30 mm Hg。对于TKA，我们选择脊髓麻醉，以尽量减少术中血流动力学变化。心脏外科医生随时待命，以防需要启动体外膜肺氧合（ECMO）。结局：通过适当的疼痛管理和静脉血管加压药的使用，术中生命体征稳定。术后未观察到血流动力学衰竭症状。患者康复后于术后第46天出院。两年后，计划进行左侧单髁膝关节置换术（UKA）。右心导管检查显示mPAP为30 mm Hg，与上次检查的值几乎相同。手术在腰麻下进行，连续动脉压监测，术中不需要血管加压药。结论：BPA是一种有效的术前干预措施，可用于CTEPH患者的非心脏手术。1引言慢性血栓栓塞性肺动脉高压（CTEPH）是一种罕见的肺动脉高压，其特征为肺动脉分支的慢性血栓栓塞性阻塞，世界卫生组织（WHO）将其归类为第4组肺动脉高压（PH）。[1，2] CTEPH预后不良，因为它与肺动脉压（PAP）升高和随后的进行性右侧心力衰竭有关; 1年和3年生存率分别为82%和70%。[3]肺动脉内膜切除术（PEA）是晚期CTEPH的唯一既定治疗方法，[4]但必须在深低温停循环下进行，并且仅在有限数量的机构中可用。球囊肺血管成形术（BPA）是CTEPH的一种新的紧急治疗方法，可持续且微创地进行。BPA与PEA一样成功地改善了肺血流动力学状态，并且比单独药物治疗对死亡率和生活质量的影响更大。[5，6]之前没有报告证明BPA作为肺动脉高压患者术前干预的有效性。
Interventions:Four BPA sessions for 8 branches of the bilateral pulmonary arteries were done, until the mean PAP (mPAP) went under 30 mm Hg. For the TKA, we selected spinal anesthesia in order to minimize intraoperative hemodynamic changes. Cardiac surgeons were standby in case extracorporeal membrane oxygenation (ECMO) initiation was required.Outcomes:With appropriate pain management and use of intravenous vasopressors, intraoperative vital signs were stable. No symptoms of hemodynamic collapse were observed postoperatively. The patient was discharged on the 46th postoperative day following rehabilitation. Two years later, left-side unicompartment knee arthroplasty (UKA) was scheduled. Right heart catheterization study revealed the mPAP was 30 mm Hg, nearly the same value as the last study. The operation was performed under spinal anesthesia with continuous arterial pressure monitoring without need for intraoperative vasopressor. He was discharged without complications on the 24th postoperative day.Lessons:BPA can be an effective preoperative intervention for CTEPH patients undergoing noncardiac surgery.1 IntroductionChronic thromboembolic pulmonary hypertension (CTEPH) is a rare type of pulmonary hypertension characterized by chronic thromboembolic obstruction of pulmonary arterial branches, and is categorized into group 4 pulmonary hypertension (PH) by the World Health Organization (WHO) Classification of PH.[1, 2] CTEPH has a poor prognosis because it is associated with elevated pulmonary arterial pressure (PAP) and consequent progressive right-sided heart failure; the 1-year and 3-year survival rates have been reported as 82% and 70%, respectively.[3] Pulmonary endarterectomy (PEA) is the only established treatment for advanced CTEPH,[4] but it must be performed under deep hypothermic circulatory arrest and is only available at a limited number of institutions. Balloon pulmonary angioplasty (BPA) is a newly emergent treatment for CTEPH that is performed percutaneously and less invasively. BPA improves the pulmonary hemodynamic state as successfully as PEA, and has a much greater effect on mortality and quality of life than medication therapy alone.[5, 6] No previous reports have demonstrated the efficacy of BPA as a preoperative intervention for pulmonary hypertensive patients.