肺切除术围手术期右心功能变化的研究
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摘要
背景:肺切除术是治疗肺癌、肺结核、肺良性肿瘤等肺部疾病有效的治疗方法。尽管肺切除手术技巧的进步及术后监护水有了明显的提高,但随着肺切除适应症放宽及手术范围的进一步扩大,肺切除术后心血管方面的并发症仍然高达30%左右,且与病死率密切相关,所以对肺切除术围手术期右心功能变化的研究为心胸外科临床所关注。目前,对不同手术方式对右心功能影响的研究还比较少。目的:运用多普勒肺血流频谱,观察不同术式的肺切除后右心后负荷及泵功能的变化情况。并通过对右室心肌运动指数(MPI)的测定,了解肺切除术后右室心肌收缩功能的变化。同时研究肺切除术后血浆心钠素(ANP)改变情况及其与右心功能变化的相关关系。方法:①把50例肺切除患者分为全肺切除组(12)、肺叶切除组(28)及肺楔形切除组(10),通过多普勒肺血流频谱测定出患者术前、术后3-5天、术后8-10天的右室射血前期(PEP)、射血加速时间(AT)、血流速积分(VI)、心率(HR)及肺动脉瓣环面积(PVAA)等指标,从而计算出肺动脉平均压(PAMP)、肺血管阻力(PVR)、右室每搏输出量(RVSV)及右心输出量(RVCO)等右心功能指标,了解不同手术方式在肺切除术后右心负荷及泵功能的变化情况。②用三尖瓣舒张期脉冲多普勒血流频谱及右室流出道收缩期多普勒血流频谱测出右室射血时间(RVET)、等容舒张期时间(IRT)及等容收缩期时间(ICT),计算出MPI,用以反映肺切除后右室心肌收缩功能状况。③通过放射免疫分析法检测肺切除术前后相应时点患者血浆ANP水平,了解右心功能的变化与心钠素水平变化的相关关系。④按术前肺功能状况把患者分为COPD组及非COPD组,了解两组之间右心功能改变的程度是否相同。此外看术后有心律失常组和无心律失常组之间右心功能改变情况。结果:①肺楔形切除术对右心后负荷及泵功能无明显影响;而肺叶及全肺切除术后3-5天,右心后负荷(PAMP、PVR)增加,右心室泵功能(RVSV)下降,全肺切除较肺叶切除改变更为明显;术后8-10天,肺叶切除术患者右心后负荷及泵功能恢复到术前水平,但全肺切除患者右心后负荷及泵功能与术前相比仍然异常。②肺楔形切除术前后MPI无明显改变;而肺叶及全肺切除术后3-5天,MPI均升高;术后8-10天,肺叶切除术患者的MPI恢复到术前水平,但全肺切除术患者MPI较术前明显升高。MPI与PAMP及PVR呈正相关(r=0.84,r=0.87),与RVSV呈负相关(r=-0.88)。③肺楔形切除术前后
血浆ANP水平无明显变化;肺叶及全肺切除术后3-5天,血浆ANP均升高,全肺切除组明显高于肺叶切除组;术后8-10天,肺叶切除患者血浆ANP恢复到术前水平,但全肺切除患者血浆ANP仍然异常。相关分析表明ANP与PAMP、PVR、MPI呈显著正相关(r=0.81,r=0.89,r=0.91),与RVSV呈负相关(r=-0.86)。④COPD患者术前存在右心后负荷(PAMP、PVR)升高,右室心肌收缩力(MPI)下降,右心泵功能(RVSV)降低,血浆ANP升高。肺切除术后加重这些改变,容易导致术后心律失常等并发症的发生。结论:①肺楔形切除对右心功能无明显影响;肺叶及全肺切除术后3-5天右心功能较术前明显下降,表现为右心后负荷升高,右室心肌收缩力下降,右心泵功能降低。术后8-10天,肺叶切除组的右心功能恢复到术前水平,而全肺切除组右心功能与术前相比仍然异常。②对COPD患者术前除了要正确评估肺功能外,还要准确评价患者右心功能。③脉冲多普勒血流技术具有无创、安全、方便、重复性高、相对准确等特点,可以比较准确地反映肺切除患者右心血液动力学的变化,为肺切除患者围手术期的监测及处理提供了客观依据。④术前MPI可以作为评估肺切除术危险性的一个有效指标。⑤血浆ANP可以在一定程度上反映肺切除术后右心功能的变化状况。
Background: Pulmonary resection is an effective therapy method for patients with lung cancer, pulmonary tuberculosis, pulmonary benign tumor. At present, Pulmonary resection technique and postoperative care have improved. However cardiovascular complication have approximately reached to 30% after pulmonary resection with increasement of operation indication and enlargement of operation range. So more and more cardiothoracic surgeons focus on the changes of right cardiac function in perioperation for pulmonary resection. Currently, little is known about different operation ways influnce on right cardiac function. Objective: To study on the changes of right cardiac afterload and right ventricle pumping function according to different operation ways after pulmonary resection by Doppler pulmonary flow spectrum. To explore the change of right ventricular contraction function after pulmonary resction by estimation of MPI. To explore the change of ANP and the correlation between ANP and right cardiac function after pulmonary resection. Methods: ① 50 cases of pulmonary resection were divided into three groups. Group Ⅰ(12 cases) were treated by pneumonectomy, group Ⅱ(28 cases) by lobectomy and group Ⅲ(10 cases) by wedge resection. The changes of right cardiac afterload and right ventricular pumping function were evaluated by PEP, AT, VI, PAMP,PVR,RVSV at pre-operation, post-operation 3rd-5th day and post-operation 8th-10th day by Doppler pulmonary flow spectrum. ② To explore to change of right ventricle contraction function, RVET, IRT ,ICT and MPI were measured by tricuip relaxation pulsed Doppler flow spectrum and right ventricle outflow contraction spectrum. ③ The change of plasma ANP level was investigated by radioimmonoassay at corresponding time point and the correlation between ANP and right cardiac function was explored. ④ Right cardiac function was compared according to whether or not COPD before operation and whether or not arrhythmia at postoperation. Results: ① Wedge resection didn’t obviously influence on right cardiac afterload(PAMP and PVR) and right ventricular pumping function(RVSV). However PAMP and PVR evidently increased and
RVSV decreased at post-pneumonectomy or lobectomy 3rd-5th day. Group Ⅰ changed more odviously than group Ⅱ. The right cardiac afterload and right ventricular pumping function restored to the level of preoperation at post-lobectomy 8th-10th day. However the right cardiac afterload and right ventricular pumping function were still abnormal compared with preoperation at post-pneumonectomy 8th-10th day. ② MPI didn’t change for wedge resection in perioperation. MPI evidently increased at post-pneumonectomy or lobectomy 3rd-5th day. MPI restored to the level of preoperation at post-lobectomy 8th-10th day and was still abnormal at post-pneumonectomy 8th-10th day. MPI was evidently positive correlation to PAMP, PVR(r=0.84,r=0.87)and was negative correlation to RVSV(r=-0.88). ③ Plasma ANP of wedge resection didn’t change. Plasma ANP level increased at post-pneumonectomy or lobectomy 3rd-5th day. It restored to the level of preoperation at post-lobectomy 8th-10th day. But it was higher than that of preoperation at post-pneumonectomy 8th-10th day. Plasma ANP was evidently positive correlation to PAMP, PVR, MPI (r=0.81,r=0.89,r=0.91)and was negative correlation to RVSV(r=-0.86). ④ PAMP, PVR,ANP and plasma ANP with COPD increased and RVSV decreased before operation. Conclusions: ①Wedge resection don’t evidently influence on right cardiac function. However right cardiac function evidently decrease at post-pneumonectomy or lobectomy 3rd-5th day compared with preoperation.Group Ⅰchange more obviously than group Ⅱ. Right cardiac function of group Ⅱ restore the level of preoperation and that of group Ⅰ is still abnormal at 8th-10th day. ② We should properly evaluate right cardiac function except for evalution of lung function for patients with COPD before pulmonary resection. ③Pulsed Doppler flow spectrum have some characteristics, such as noninvasion, safty, convenience,b
血浆ANP水平无明显变化;肺叶及全肺切除术后3-5天,血浆ANP均升高,全肺切除组明显高于肺叶切除组;术后8-10天,肺叶切除患者血浆ANP恢复到术前水平,但全肺切除患者血浆ANP仍然异常。相关分析表明ANP与PAMP、PVR、MPI呈显著正相关(r=0.81,r=0.89,r=0.91),与RVSV呈负相关(r=-0.86)。④COPD患者术前存在右心后负荷(PAMP、PVR)升高,右室心肌收缩力(MPI)下降,右心泵功能(RVSV)降低,血浆ANP升高。肺切除术后加重这些改变,容易导致术后心律失常等并发症的发生。结论:①肺楔形切除对右心功能无明显影响;肺叶及全肺切除术后3-5天右心功能较术前明显下降,表现为右心后负荷升高,右室心肌收缩力下降,右心泵功能降低。术后8-10天,肺叶切除组的右心功能恢复到术前水平,而全肺切除组右心功能与术前相比仍然异常。②对COPD患者术前除了要正确评估肺功能外,还要准确评价患者右心功能。③脉冲多普勒血流技术具有无创、安全、方便、重复性高、相对准确等特点,可以比较准确地反映肺切除患者右心血液动力学的变化,为肺切除患者围手术期的监测及处理提供了客观依据。④术前MPI可以作为评估肺切除术危险性的一个有效指标。⑤血浆ANP可以在一定程度上反映肺切除术后右心功能的变化状况。
Background: Pulmonary resection is an effective therapy method for patients with lung cancer, pulmonary tuberculosis, pulmonary benign tumor. At present, Pulmonary resection technique and postoperative care have improved. However cardiovascular complication have approximately reached to 30% after pulmonary resection with increasement of operation indication and enlargement of operation range. So more and more cardiothoracic surgeons focus on the changes of right cardiac function in perioperation for pulmonary resection. Currently, little is known about different operation ways influnce on right cardiac function. Objective: To study on the changes of right cardiac afterload and right ventricle pumping function according to different operation ways after pulmonary resection by Doppler pulmonary flow spectrum. To explore the change of right ventricular contraction function after pulmonary resction by estimation of MPI. To explore the change of ANP and the correlation between ANP and right cardiac function after pulmonary resection. Methods: ① 50 cases of pulmonary resection were divided into three groups. Group Ⅰ(12 cases) were treated by pneumonectomy, group Ⅱ(28 cases) by lobectomy and group Ⅲ(10 cases) by wedge resection. The changes of right cardiac afterload and right ventricular pumping function were evaluated by PEP, AT, VI, PAMP,PVR,RVSV at pre-operation, post-operation 3rd-5th day and post-operation 8th-10th day by Doppler pulmonary flow spectrum. ② To explore to change of right ventricle contraction function, RVET, IRT ,ICT and MPI were measured by tricuip relaxation pulsed Doppler flow spectrum and right ventricle outflow contraction spectrum. ③ The change of plasma ANP level was investigated by radioimmonoassay at corresponding time point and the correlation between ANP and right cardiac function was explored. ④ Right cardiac function was compared according to whether or not COPD before operation and whether or not arrhythmia at postoperation. Results: ① Wedge resection didn’t obviously influence on right cardiac afterload(PAMP and PVR) and right ventricular pumping function(RVSV). However PAMP and PVR evidently increased and
RVSV decreased at post-pneumonectomy or lobectomy 3rd-5th day. Group Ⅰ changed more odviously than group Ⅱ. The right cardiac afterload and right ventricular pumping function restored to the level of preoperation at post-lobectomy 8th-10th day. However the right cardiac afterload and right ventricular pumping function were still abnormal compared with preoperation at post-pneumonectomy 8th-10th day. ② MPI didn’t change for wedge resection in perioperation. MPI evidently increased at post-pneumonectomy or lobectomy 3rd-5th day. MPI restored to the level of preoperation at post-lobectomy 8th-10th day and was still abnormal at post-pneumonectomy 8th-10th day. MPI was evidently positive correlation to PAMP, PVR(r=0.84,r=0.87)and was negative correlation to RVSV(r=-0.88). ③ Plasma ANP of wedge resection didn’t change. Plasma ANP level increased at post-pneumonectomy or lobectomy 3rd-5th day. It restored to the level of preoperation at post-lobectomy 8th-10th day. But it was higher than that of preoperation at post-pneumonectomy 8th-10th day. Plasma ANP was evidently positive correlation to PAMP, PVR, MPI (r=0.81,r=0.89,r=0.91)and was negative correlation to RVSV(r=-0.86). ④ PAMP, PVR,ANP and plasma ANP with COPD increased and RVSV decreased before operation. Conclusions: ①Wedge resection don’t evidently influence on right cardiac function. However right cardiac function evidently decrease at post-pneumonectomy or lobectomy 3rd-5th day compared with preoperation.Group Ⅰchange more obviously than group Ⅱ. Right cardiac function of group Ⅱ restore the level of preoperation and that of group Ⅰ is still abnormal at 8th-10th day. ② We should properly evaluate right cardiac function except for evalution of lung function for patients with COPD before pulmonary resection. ③Pulsed Doppler flow spectrum have some characteristics, such as noninvasion, safty, convenience,b
引文
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Erirsson LT,Roscher R, Ingemansson R, et al .Vascular effects of induced hypothermia after lung transplantation. Ann Thorac Surg,1999 ,67(5):804-809.
Rhodes J,Udelson JE,Marx GR, et al. A new noninvasive method for the estimation of peak dp/dt. Circulation,1993,88(10):2693-2697.
Busch E,Uerazin G, Antkowlak JG, et al. Pulmonary complication in patients undergoing thoracotomy for lung carcinoma. Chest,1994,105(3):760-765.
Larsen KR, Svendsen UG, Milman N, et al. Cardiopulmonary function at rest and during exercise after resection for bronchial carcinoma. Ann Thorac Surg, 1997,64(4):960-964.
Patel RL, Townsend ER, Fountain SW, et al. Elective pneumonectomy:factors associated with morbidity and operative mortality. Ann Thorac Surg, 1992,54(1): 84-88.
Ferguson MK, Reeder LB, Mick R, et al. Optimizing selection of patients for major lung resection. J Thorac Cardiovasc Surg, 1995,109(2):275-281.
Kearney DJ, Lee TH, Reilly JJ, DeCamp MM, Sugarbaker DJ. Assessment of preoperative risk in patients undergoing lung resection. Importance of predicted pulmonary function. Chest, 1994,105(2):753-793.
Karunanithi MK, Michniewicz J, Copeland SE, et al. Right ventricular preload recruitable stroke work, end-systolic pressure volume, and dP/dTmax-end-diastolic volume relations compared as indexes of right ventricular contractile performance in conscious dogs. Circ Reserch, 1992,70(7):1169-1179.
Melendez JA, Barrera R. Predictive respiratory complication quotient predicts pulmonary complications in thoracic surgical patients. Ann Thorac Surg, 1998,66(2): 220-224.
Ferguson MK, Durkin AE. A comparison of three scoring systems for predicting complications after major lung resection. European Journal of Cardio-thoracic Surgery,2003, 23(1): 35-42.
Jemal A, Thomas A, Murray T, et al. Cancer statistics, 2002. CA Cancer J Clin, 2002,52(1):23-27.
Takamori S, Mifune H, Tayama K. An experimental study of atrial natriuretic peptide levels and the effect of inhaled nitric oxide after pneumonectomy. Suryery Today 2000,30(2):360-363.
Poulsen SH, Nielsen JC, Andersen HR, et al. The influence of heart rate on the Doppler-derived myocardial performance index. J Am Echocardiol, 2000,13(5): 379-384.
Abd El Rahman, Abdul-Khaliq, Vogel, et al. Relation between right ventricular enlargement, QRS duration, and right ventricular function in patients with tetralogy of Fallot and pulmonary regurgiation after surgical repair. Heart, 2000,84(5): 416-420.
Mattioli AV, Vandelli R, MattioliG,et al. Doppler echocardiographyic evaluation of right ventricular function in patients with right ventricular infarction. J Ultrasound Med, 2000,19(8): 831-6.
Eidem BW, O'Leary PW, Tei C, et al. Usefulness of the myocardial performance index for assessing right ventricular function in congenital heart disease. Am J Cardiol, 2000,86(9):654-651.
Poulsen SH, Nielsen JC, Andersen HR, et al. The influence of hearton Doppler-derived myocardial performance index. J Am Soc Echocardiogr, 2000,13(4):379-394.
Tei C, Dujardin KS, Hodge DO, et al. Doppler index combining systolic and diastolic myocardial performance: clinical value in cardiac amyloidosis. J Am Coll Cardiol, 1996,28(6):658-664.
Yeo TC, Dujardin KS, Tei C, et al. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol,1998,81(11):1157-1161.
Tei C, Nishimura RA, Seward JB, et al. Noninvasive Doppler-derived myocardial performance index: correlation with simultaneous measurements of cardiac catheterization measurements. J Am Soc Echocardiogr, 1997,10(1):169-178.
Tarkan T, Alper O, Ceyhun C, et al. Value of measuring myocardial performance index by tissue Doppler echocardiography in normal and diseased heart. Japanese Heart Journal,2003,44(3):403-416.
Kurulu O, Bulent BA, Hasan G, et al. Does the myocardial performance index affect pulmonary artery pressure in patients with mitral stenosis? A tissue Doppler imaging study. Echocardiography,2003, 20(3): 249-256.
Rahman AE, Abdul-Khaliq H, Vogel M, et al. Value of the new Doppler-derived myocardial performance index for the evaluation of right and left ventricular function following repair of tetralogy of fallot. Pediatric Cardiology, 2002, 23(5): 502-507.
Ocal B, Oguz D, Karademir S, et al. Myocardial performance index combining systolic and diastolic myocardial performance in doxorubicin-treated patients and its correlation to conventional echo/Doppler indices. Pediatric Cardiology, 2002, 23(5): 522-527.
Frogoudaki AA, Davlouros PA, Li W, et al. Right ventricular doppler myocardial performance index in adults with repaired tetralogy of fallot: correlations with ventricular volume indices assessed by cardiac magnetic resonance. J Am Coll Cardiol, 2002, 39(2): 398.
Takten T, Onbasili AO, Ceyhun C, et al. Value of measuring myocardial performance index by tissue Doppler echocardiography in normal and diseased heart. Japanese Heart Journal, 2003,44(2):403-416.
Ishii M, Eto G, Tei C, et al. Quantitation of the global right ventricular function in children with normal heart and congenital heart disease: a right ventricular myocardial performance index. Pediatric Cardiology, 2000,21(5):416-421.
Dujardin KS, Tei C, Yeo TC, et al. Prognostic value of a Doppler index combining systolic and diastolic performance in idiopathic-dilated cardiomyopathy. Am J Cardiol, 1998,82(10):1071-1076.
Herrington CS, Shumway SJ. Myocardial ischemia and infection postthoracotomy. Chest Surg Clin N Am,1998 ,8(3): 495-502.
张丽,赵玉生,汪德清,等.肺叶切除对犬围手术期心肌缺血的影响.解放军医学杂志,1998, 23(4): 290-291.
Stephen J, Chen YM and Peggy AW, et al. Atrial natriuretic peptide degradation by CPA47 cells: evidence for a divalent cation-independent cell-surface proteolytic activity. Biochimica et Biophysica Acta (BBA) - Biomembranes, 1992,1112( 1):45-51.
Tamura K, Takamori S, Mifune H, et al.Changes in atrial natriuretic peptide concentration and expression of its receptors after pneumonectomy in the rat. Clin Sci, 2000, 99(4):343-348.
黄彦生,魏经汉,魏太星,等. 脑钠素和N-心钠素对无症状心力衰竭的诊断价值.中华心血管病杂志,1998, 26(3): 231.
Tsutamoto T, Wada A, Maeda K, et al. Plasma brain natriuretic peptide level as a biochemical marker of morbidity and mortality in patients with asymptomatic or minimally symptomatic left ventricular dysfunction-comparison with plasma angiotensin II and endothelin-1.Eur Heart J, 1999,20(8):1799-1807.
Wang J, Olak J, Ultmann RE, Ferguson MK. Assessment of pulmonary complications after lung resection. Ann Thorac Surg, 1999,67(12):1444-1447.
侯宇虹,潘金兵王,书钧. 慢性阻塞性肺疾病患者血浆心钠素、C型利尿利钠因子的变化及意义. 中华老年医学杂志,2002, 21(2):375-376.
罗百灵,尹本义,海镇环,等.肺癌患者血浆内皮素及心钠素的初步研究.当代医师杂志,1997,2(7):8.
徐建芳,周彩存,秦萍. 肺癌患者血浆内皮素和心钠素水平及化疗对其的影响. 中国肿瘤临床与康复,2001,8(6):43-45.