伴有心功能不全的分化型甲状腺癌患者围术期临床治疗分析

摘要

Objective To summarize the clinical experience of perioperative treatment of differentiated thyroid cancer complicated with cardiac insufficiency.Methods Clinical records of 55 differentiated thyroid cancer patients with cardiac insufficiency in Beijing Anzhen Hospital,Capital Medical University from April 2012 to January 2016 were retrospectively analyzed.Coronary CT showed no coronary artery stenosis ＞ 75％.Echocardiography showed 25 cases of left ventricular ejection fraction(LVEF) 50％-60％,20 cases of LVEF 40％-＜ 50％ and 10 cases of LVEF ＜40％.Cardiac specific assay showed B-type natriuretic peptide(BNP) ＞400 ng/L in 5 cases,BNP 200-400 ng/L in 10 cases and BNP ＜ 200 ng/L in 40 cases;troponin level was normal in all patients.Partial thyroidectomy was performed in 21 patients and total thyroidectomy was performed in 34 patients.Heart function,blood pressure and fluid intake were observed during perioperative period;anticoagulant and anti-heart failure therapies were performed as needed.Results All patients had successful operation.One patient had acute heart failure after partial thyroidectomy;1 patient had total thyroidectomy 3 months after cardiac valve replacement;both of them were cured.No acute myocardial ischemia occurred during perioperative period.LVEF showed no significant difference before and 3 months after surgery in partial thyroidectomy patients[(46 ± 7)％ vs (45 ± 6) ％] and total thyroidectomy patients[(49 ± 8) ％ vs (48 ± 8) ％] (P ＞ 0.05).Conclusion Differentiated thyroid cancer with cardiac insufficiency patients can have thyroidectomy on the basis of adequate cardiac function assessment and proper anesthesia and postoperative management.%目的 总结伴有心功能不全的分化型甲状腺癌的围术期临床治疗经验.方法 回顾性分析2012年4月至2016年1月在首都医科大学附属北京安贞医院诊治的伴有心功能不全的分化型甲状腺癌患者55例.术前冠状动脉CT示3支冠状动脉分支无＞75％狭窄.心脏超声示左心室射血分数(LVEF)50％～60％者25例,40％～＜50％者20例,＜40％者10例.心脏特异化验示B型脑钠肽(BNP) ＞400 ng/L者5例,200～400 ng/L者10例,＜200 ng/L者40例.肌钙蛋白水平均在正常范围.术前充分评估心脏功能,行抗凝治疗,调控血压,处理心律失常.术中控制血压和进液量,围术期密切监测患者的生命体征,治疗心力衰竭.根据2012年美国国立综合癌症网络分化型甲状腺癌诊治指南,甲状腺部分切除21例,全甲状腺切除34例.结果 所有患者都顺利完成手术,治愈出院.1例部分甲状腺切除患者术后出现急性心力衰竭,强心利尿治疗后好转出院.1例患者先行心脏换瓣术后3个月再行全甲状腺切除治疗,好转出院.围术期依据化验指标和症状处理得当,无急性心肌缺血发生.部分甲状腺切除和全甲状腺切除患者手术前后LVEF差异均无统计学意义[部分切除:(46±7)％比(45±6)％,全部切除:(49±8)％比(48±8)％](均P＞0.05).结论 对于伴有心功能不全的分化型甲状腺癌,术前充分评估心脏功能,麻醉及术后处理得当,可根据国际规范切除部分甲状腺或全甲状腺.