Dynamic Risk Stratification of Patient Long-Term Outcome After Pulmonary Endarterectomy: Results From the United Kingdom National Cohort.
Dynamic Risk Stratification of Patient Long-Term Outcome After Pulmonary Endarterectomy: Results From the United Kingdom National Cohort.
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DOI：
10.1161/circulationaha.115.019470
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发表时间：
2016-05-03
期刊：
影响因子：
37.8
通讯作者：
Pepke-Zaba J
中科院分区：
文献类型：
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作者：
Cannon JE;Su L;Kiely DG;Page K;Toshner M;Swietlik E;Treacy C;Ponnaberanam A;Condliffe R;Sheares K;Taboada D;Dunning J;Tsui S;Ng C;Gopalan D;Screaton N;Elliot C;Gibbs S;Howard L;Corris P;Lordan J;Johnson M;Peacock A;MacKenzie-Ross R;Schreiber B;Coghlan G;Dimopoulos K;Wort SJ;Gaine S;Moledina S;Jenkins DP;Pepke-Zaba J
慢性血栓栓塞性肺动脉高压是由于肺血栓未完全溶解所致。肺内膜剥脱术(PEA)具有潜在的治愈作用，但手术后残留的肺动脉高压很常见，其对长期预后的影响尚不清楚。我们希望找出与术后远期预后差相关的因素，并明确PEA术后临床上相关的残存肺动脉高压。连续880例患者(平均年龄57岁)接受了PEA治疗慢性血栓栓塞性肺动脉高压。如果患者在3至5年内临床稳定且不需要肺血管扩张剂治疗，则在3至6个月时常规进行详细的右心插管和无创检查，此后每年出院。生存(事件发生时间)分析采用Cox回归分析。整个队列1、3、5和10年的总生存率分别为86%、84%、79%和72%，最近一半队列的1和3年生存率分别为91%和90%。大多数患者在围手术期后的死亡不是由于右心衰竭(慢性血栓栓塞性肺动脉高压)。在重新评估时，≥的平均肺动脉压为30毫米汞柱与术后肺血管扩张剂治疗的开始相关。复查时平均肺动脉压≥38 mm Hg和肺血管阻力≥425dynes·S-1·cm-5与较差的长期生存相关。我们的数据证实了PEA术后良好的长期生存和维持良好的功能状态。PEA术后3-6个月和12个月的血流动力学评估可以对死于慢性血栓栓塞性肺动脉高压的高风险患者进行分层，并确定可能指导患者术后长期管理的残余肺动脉高压水平。
Chronic thromboembolic pulmonary hypertension results from incomplete resolution of pulmonary emboli. Pulmonary endarterectomy (PEA) is potentially curative, but residual pulmonary hypertension following surgery is common and its impact on long-term outcome is poorly understood. We wanted to identify factors correlated with poor long-term outcome after surgery and specifically define clinically relevant residual pulmonary hypertension post-PEA. Eight hundred eighty consecutive patients (mean age, 57 years) underwent PEA for chronic thromboembolic pulmonary hypertension. Patients routinely underwent detailed reassessment with right heart catheterization and noninvasive testing at 3 to 6 months and annually thereafter with discharge if they were clinically stable at 3 to 5 years and did not require pulmonary vasodilator therapy. Cox regressions were used for survival (time-to-event) analyses. Overall survival was 86%, 84%, 79%, and 72% at 1, 3, 5, and 10 years for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the perioperative period were not attributable to right ventricular failure (chronic thromboembolic pulmonary hypertension). At reassessment, a mean pulmonary artery pressure of ≥30 mm Hg correlated with the initiation of pulmonary vasodilator therapy post-PEA. A mean pulmonary artery pressure of ≥38 mm Hg and pulmonary vascular resistance ≥425 dynes·s–1·cm–5 at reassessment correlated with worse long-term survival. Our data confirm excellent long-term survival and maintenance of good functional status post-PEA. Hemodynamic assessment 3 to 6 months and 12 months post-PEA allows stratification of patients at higher risk of dying of chronic thromboembolic pulmonary hypertension and identifies a level of residual pulmonary hypertension that may guide the long-term management of patients postsurgery.