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Prognostické faktory chirurgické léčby chronické tromboembolické plicní hypertenze
Název práce v češtině: Prognostické faktory chirurgické léčby chronické tromboembolické plicní hypertenze
Název v anglickém jazyce: Prognostic factors of surgical treatment of chronic thromboembolic pulmonary hypertension
Klíčová slova: chronická tromboembolická plicní hypertenze, endarterektomie plicnice, CT angiografie, reziduální plicní hypertenze, aortopulmonální index, endarterium, Jamiesonova klasifikace, UCSD klasifikace
Klíčová slova anglicky: chronic thromboembolic pulmonary hypertension, pulmonary endarterectomy, computed tomography angiography, residual pulmonary hypertension, aortopulmonary index, endarterium, Jamieson classification, UCSD classification
Akademický rok vypsání: 2013/2014
Typ práce: disertační práce
Jazyk práce: čeština
Ústav: II. chirurgická klinika – kardiovaskulární chirurgie 1. LF UK a VFN (11-00690)
Vedoucí / školitel: prof. MUDr. Jaroslav Lindner, CSc.
Řešitel: skrytý - zadáno a potvrzeno stud. odd.
Datum přihlášení: 12.02.2014
Datum zadání: 12.02.2014
Datum potvrzení stud. oddělením: 12.02.2014
Datum a čas obhajoby: 19.05.2022 11:00
Místo konání obhajoby: I. chirurgická klinika 1. LF UK a VFN
Datum odevzdání elektronické podoby:01.03.2022
Datum proběhlé obhajoby: 19.05.2022
Předmět: Obhajoba dizertační práce (B90002)
Oponenti: doc. MUDr. Vilém Rohn, CSc.
  prof. MUDr. Radek Pudil, Ph.D.
 
 
Konzultanti: prof. MUDr. Pavel Jansa, Ph.D.
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Předběžná náplň práce
Chronická tromboembolická plicní hypertenze (CTEPH) je onemocnění charakterizované vzestupem tlaku v plicním řečišti na podkladě intraluminálně organizovaných trombů, stenóz a uzávěrů jednotlivých větví plicnice a periferní cévní remodelace. Jedná se o chronickou komplikaci akutní plicní embolie. Důsledkem obstrukce plicnice je vzestup plicní cévní rezistence (PVR) vedoucí k zatížení pravé komory srdeční a k pravostrannému srdečnímu selhání. Metodou volby v léčbě pacientů s CTEPH je chirurgická endarterektomie plicnice (PEA), výkon prováděný v hluboké hypotermii, v cirkulační zástavě. Pacienti s periferním typem postižení, u nichž nález není operabilní, a zároveň pacienti po PEA s reziduální plicní hypertenzí, jsou indikováni k balónkové plicní angioplastice (BPA) a ke specifické vasodilatační terapii. V indikovaných případech lze uvažovat o transplantaci plic.
I přes vysokou efektivitu PEA je nemalá část pacientů, u kterých i po chirurgické terapii přetrvává zvýšený tlak v plicním řečišti, který hraje klíčovou roli v pooperační mortalitě a morbiditě. Incidence reziduální plicní hypertenze se v literatuře uvádí v rozmezí 16-51 %. Tato skutečnost vede ke snaze o nalezení nástrojů k predikci vzniku reziduální plicní hypertenze po PEA. Cílem této práce bylo ověřit možnost predikce klinického a hemodynamického vývoje u pacientů po PEA na základě analýzy předoperační CT angiografie plicních tepen (CTPA) a také na základě peroperační klasifikace odstraněného plicního endarteria (dle Jamiesona a dle UCSD).
V naší práci jsme prokázali, že parametry z měření plicních tepen v předoperačních obrazech z CTPA je možné použít v klinické praxi u pacientů s CTEPH k predikci reziduální plicní hypertenze po PEA. Zjistili jsme, že nejlepším prediktorem ze sledovaných parametrů je aortopulmonální index (poměr velikosti průměru kmene plicnice měřený v axiálních řezech v úrovni bifurkace kmene plicnice, kolmo na dlouhou osu tepny, a velikosti průměru ascendentní, případně descendentní, aorty), pomocí kterého je možné predikovat jak přítomnost reziduální plicní hypertenze po PEA, tak efekt této chirurgické léčby charakterizovaný poklesem systolického tlaku v plicnici. Dále jsme zjistili, že nižší hodnota aortopulmonálního indexu (≤ 0,88 v případě poměru k velikosti ascendentní a ≤ 0,64 v případě poměru k velikosti descendentní aorty) predikuje lepší výsledek chirurgické léčby CTEPH. Tato zjištění je možné aplikovat v klinické praxi v indikační rozvaze u hraničních pacientů (jak z pohledu splnění indikačních kritérií, tak z pohledu únosnosti rizika operace) a také může vést k přesnějšímu pooperačnímu sledování rizikových pacientů s cílem časného odhalení přítomnosti reziduální plicní hypertenze a její terapie.
Dále jsme prokázali že obě v klinické praxi běžně používané chirurgické klasifikace endarteria odstraněného z plicních tepen při PEA (Jamiesonova klasifikace a UCSD klasifikace) mají prediktivní hodnotu ve vztahu k hemodynamickým a klinickým pooperačním parametrům. Při snaze o porovnání prediktivní hodnoty obou klasifikací jsme zjistili, že každá z uvedených klasifikací je lepším prediktorem pro určité sledované parametry (Jamiesonova klasifikace pro predikci systolického a středního tlaku v plicnici, UCSD klasifikace pro predikci plicní vaskulární rezistence, pooperačního krvácení do dýchacích cest, časné nemocniční mortality a dlouhodobého přežití pacientů). Při analýze kumulativní prediktivní hodnoty obou klasifikací se nicméně nepotvrdila superiorita ani jedné z klasifikací. Klinická aplikace prediktivní hodnoty těchto klasifikací je předmětem dalšího výzkumu.
Zjištění, která tato práce přinesla, by se měly stát příspěvkem do komplexní mozaiky obrazu pacientů s CTEPH a pomoci tak k lepším výsledkům jejich léčby.
Předběžná náplň práce v anglickém jazyce
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease characterized by increased pulmonary artery pressure. It is caused by intraluminal thrombi organisation, stenoses and occlusions of pulmonary artery and its branches and peripheral vascular remodeling. It is a chronic complication of acute pulmonary embolism. The obstruction of pulmonary artery branches increases pulmonary vascular resistance (PVR) and this leads to the right ventricular overload and right-sided heart failure. The treatment of choice is surgical pulmonary endarterectomy (PEA), a procedure that is performed in deep hypothermic cardiac arrest. Patients with peripheral type of CTEPH, who are not indicated for operation and also patients with residual pulmonary hypertension after PEA can be indicated for specific vasodilatation therapy. In indicated cases the treatment may involve the balloon angioplasty or lung transplantation.
Despite the high effectivity of PEA, there is a number of patients, whose pulmonary arterial pressure remains high and this plays a key role in postoperative mortality and morbidity. Incidence of residual pulmonary hypertension is according to literature between 16 and 51%. This leads to a pursuit of finding possible tools to predict residual pulmonary hypertension after PEA. The aim of this work was to evaluate the possibility of prediction of clinical and hemodynamic outcome of patients after PEA by using preoperative analysis of CT pulmonary angiography (CTPA) and also by using peroperative classification (according to Jamieson and UCSD) of pulmonary endarterium removed during PEA.
We have proven that diameter of pulmonary artery and its indices measured in preoperative CTPA images can be used for prediction of residual pulmonary hypertension after PEA. We have found out that the best predictor out of all analysed parameters is the aortopulmonary index (the ratio between the diameter of the main pulmonary artery measured at the level of its bifurcation, perpendicular to its long axis, on an axial slices and the diameter of ascending or descending aorta). The aortopulmonary index can be used for prediction of residual pulmonary hypertension after PEA and also for the prediction of the effect of PEA characterised by the pulmonary artery systolic pressure decrease.
We have also found out that the lower value of aortopulmonary index (≤ 0,88 when indexed to the diameter of ascending aorta and ≤ 0,64 when indexed to the diameter of descending aorta) is associated with a better result of surgical treatment of CTEPH. These findings can be used in clinical practice in the indication process of borderline patients (regarding both meeting the indication criteria and surgical risk stratification) and can also lead to a better follow up with aim for early identification of the presence of residual pulmonary hypertension and for early initiation of its treatment.
We have also proven that both classifications of pulmonary endarterium removed during PEA that are currently used (Jamieson classification and UCSD classification) have predictive value regarding postoperative hemodynamic and clinical parameters. When comparing the predictive value of both classifications, we found out that each of them is a better predictor for some parameters (Jamieson′s in prediction of pulmonary artery systolic and mean pressure, UCSD classification in prediction of pulmonary vascular resistance, postoperative endobronchial bleeding, early hospital mortality and long-term survival). The analysis of cumulative predictive value of both classifications, however, did not prove superiority of any of them. The clinical application of predictive values of these classifications is a matter of further research.
The findings presented in this work should become one of the pieces in the complex mosaic image of patients with CTEPH and thus help to improve the results of their treatment.
 
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