298例原位心脏移植受者远期疗效分析

目的分析原位心脏移植受者远期疗效。方法 2000年5月至2011年4月,复旦大学附属中山医院298例终末期心脏病患者施行原位心脏移植术。男性235例,女性63例;病因构成：扩张性心肌病占73.2%、缺血性心肌病占8.7%、瓣膜性心脏病占6.4%、原发性心脏恶性肿瘤占2.3%、移植物冠状动脉硬化占0.7%。供心不停搏获取238例、停搏获取60例。采用改良圣托马斯液或结合UW液或单用UW液保存技术,供心冷缺血时间69～600min,平均（191.0±28.5）min。移植方法采用双腔静脉法272例、标准法19例、全心法7例。术后采用环孢素或他克莫司＋激素＋吗替麦考酚酯三联免疫抑制方案;85%受者采用单克隆抗体免疫诱导治疗。术后定期随访。结果所有存活病例均获完整随访,随访时间1～121个月,平均（42.5±9.8）个月。移植后1、3、5、8年受者存活率分别为90.3%、82.8%、73.4%、65.2%。移植物衰竭、急性排斥反应、感染、心脏肿瘤转移、猝死为术后1年内主要死亡原因。远期受者主要死亡原因包括移植物冠状动脉硬化、移植物衰竭、急性排斥反应、感染、肾衰竭等。移植后并发症以感染、急性排斥反应、肾功能不全多见。243例存活受者90%心功能恢复至NYHAⅠ～Ⅱ级,20%恢复全日工作。结论 298例原位心脏移植受者长期疗效良好且稳定。严格规律随访并注意监测和防治感染、急性排斥反应、移植物冠状动脉硬化对提高远期疗效具有重要意义。

Long-term results of 298 cases of orthotopic heart transplantations: a single center experience

Objective To summarize the 11 years＇ heart transplantation results at single center and analyze the risk factors of long term survival. Methods From May 2000 to April 2011, 298 patients, including 235 males and 63 females, underwent orthotopic heart transplantation in Zhongshan Hospital of Fudan University. Etiology comprised 73.2% dilated cardiomyopathy, 8.7% ischemic heart disease, 6.4% valvular heart disease, 2.6% primary malignant cardiac tumor, and 0.7% cardiac allograft arteri- osclerosis. Donor heart grafts were harvested with beating hearts in 238 cases and with fibrillated hearts in 60 cases. Heart grafts were preserved with St. Thomas solution and UW solution, with cold ischemic time ranging from 69 to 600 min, （ 191.0 ± 28.5） min on average. The operative procedures included 272 bicaval anastomotic cardiac transplantations, 19 conventional Stanford orthotopic cardiac transplantations, and 7 total heart transplantations. Postoperatively, immunosuppressive therapy strategies included cyclos- porine or tacrolimus, corticosteroids, and mycophenolate mofetil. Induction therapy with daclizumab was applied in the latest 85% patients. Regular follow-up was arranged postoperatively. Results All recipients were followed up with duration from 1 to 121 months, （42.5 ± 9.8） months on average. The actuarial survival rate was 90.8% after 1 year, 82.8% after 3 year, 73.4% after 5 year, and 65.2% after 8 year. Graft failure, acute rejection, infections, metastasis of primary cardiac tumor, and sudden death contributed to the main causes of death in the 1 st postoperative year, while graft coronary vasculopathy,graft failure, acute rejection, infections, and renal failure contributed to most of long-term mortality. Ninety percent of survivors （243 cases） enjoyed heart function of class I-1I （NYHA） and 20% of them resumed full-time job. Conclusion Long-term results of heart transplantation in the 298 patients proved to be promising and stable. Regular follow-up with more attention on surveillance and management of acute rejection, graft coronary vasculopathy and infections should result in a better long-term survival.