原位心脏移植治疗终末期心脏病25例临床分析

目的总结同种异体原位心脏移植治疗终末期心脏病的临床疗效和经验。方法山东大学附属千佛山医院心外科自2003年3月至2012年10月为25例终末期心脏病患者施行了同种异体原位心脏移植术。原发病包括扩张型心肌病18例、肥厚型心肌病4例和缺血性心肌病3例。采用标准原位心脏移植术1例,双腔静脉吻合法原位心脏移植术24例。7例受者术前合并中度及以上肺动脉高压,术后给予一氧化氮吸入、伊洛前列素持续静脉泵入等综合措施降低肺动脉压。免疫抑制治疗采用环孢素＋糖皮质激素＋吗替麦考酚酯三联方案,有6例受者术中给予抗Tac单克隆抗体诱导治疗,14例受者在麻醉诱导时及术后第4天给予巴利昔单克隆抗体诱导治疗。根据血药浓度谷、峰值调整环孢素用量。结果手术成功率为96%（24/25）,1例受者于术后25h死于肠道出血。余24例受者术后平均随访（58±37）个月（1～116个月）,受者1,3,5年生存率分别为87.0%,82.3%,72.7%。术后早期发生急性排斥反应2例,晚期发生急性排斥反应4例,均经糖皮质激素冲击治疗后逆转。术后早期发生急性肾功能衰竭2例,经血液透析治疗后肾功能恢复正常;晚期发生肾功能不全4例。肺部霉菌感染3例,2例治愈。发生移植物失功2例,受者分别于术后14个月和41个月死亡。1例受者术后17个月发现子宫内膜肿瘤行子宫切除术。结论心脏移植治疗终末期心脏病疗效肯定,需严格掌握手术适应证及加强围手术期受者管理,术后规范抗排斥反应药物治疗,同时重视急性排斥反应及感染的监测和治疗。

Analysis on 25 cases of orthotopic cardiac transplantation for end-stage heart disease

Objective To analyze and summarize the clinical effects and experiences of orthotopic cardiac transplantation for end-stage heart disease.Methods Twenty-five patients underwent orthotopic cardiac transplantation from March 2003 to October 2012 in Qianfoshan Hospital affiliated to Shandong University.The primary diseases included dialated cardiomyopathy in 18 patients,hypertrophic cardiomyopathy in 4,and ischemic heart disease in 3（one also accompanied by abdominal aorta aneurysm）.Conventional Standford orthotopic cardiac transplantation was performed in 1 patient and double cavity vein anastomosis method was performed in 24 patients.Seven patients with moderate or severe pulmonary hypertension received nitric oxide inhalation and iloprost intravenous pumping to treat pulmonary arterial hypertension.Immunosuppressive therapy included cyclosporine A,corticosteroid,and mycophenolate mofetile.Six patients received the Tac monoclonal antibody induction therapy during operation,while 14 received the basiliximab monoclonal antibody during anesthesia induction and on postoperative day 4.According to the plasma peak and vale concentration,the dose of cyclosporine A was regulated in time.Results The succesful rate of the operation was 96%（24/25）,with 1 patient died of intestinal bleeding in 25 h after operation.The rest 24 patients were followed up（58±37） months（1-116 months）.The 1-,3-,5-year survival rate was 87%,82.3%,72.7%,respectively.Acute rejection occurred in 2 cases at early stage and in 4 at late stage after operation,all recovered after cortieasteriod impulse therapy.Renal failure occurred in 2 cases at early stage（renal function recovery after hemodialysis） and in 4 at late stage after operation.Three patients had lung aspergillus infection（2 of them were cured）.Two patients died from transplant dysfunction in 14 months and 41 months after operation.One patient was diagnosed as having endometrial neoplasm after 17 months and was cured by hysterectomy.Conclusion Orthotopic cardiac transplantation is a reliable choice for end-stage heart disease.Strict indication,careful management,and regulatory immunosuppressive therapy of perioperative period are required.Moreover,we should pay attention to observation and treatment of acute injection and infection.