非体外循环下序贯式双肺移植的麻醉处理

目的探讨终末期肺病患者在非体外循环下进行序贯式双肺移植中的麻醉处理方式和注意事项。方法2例重度肺功能减退合并呼吸机依赖的终末期肺气肿患者和1例支气管扩张患者,手术均为非体外循环下序贯式双肺移植。麻醉诱导常规采用咪唑安定0.05~0.1mg/kg、芬太尼4μg/kg、依托咪酯0.2~0.4mg/kg及维库溴胺0.1mg/kg等药物;术中麻醉维持以静脉持续泵注异丙酚0.03~0.05mg.kg-1.min-1和维库溴胺1~2μg.kg-1.min-1。术中严密监测各项生命体征,根据血气指标及生命体征调节机械通气参数,必要时行手控通气。结果3例患者手术过程较为顺利,分别于术后6、11、10d脱离呼吸机。术后肺功能明显改善,分别于术后第41、67、30d出院。结论充分的术前准备,合适的麻醉诱导和维持,术中全面的监测和术中对移植肺的保护等措施,是肺移植成功的关键因素之一。序贯式双肺移植术中应尽可能不使用体外循环。     

Successful surgical management of bronchial dehiscence after single-lung transplantation

A case of bronchial dehiscence despite bronchial omentopexy is described in a patient nine days after single-lung transplantation. Rethoracotomy was undertaken as soon as the diagnosis was established before superinfection occurred. Necrotic bronchus was excised, with the anastomosis sited distally on the donor bronchus. The omentum was necrotic, and the new anastomosis was wrapped with a vascularized pedicle of pericardium. Six months after this procedure, the patient remains well.     

Lung transplantation for lymphangioleiomyomatosis.

BACKGROUND: Lymphangioleiomyomatosis is a rare disease in women leading to respiratory failure. We describe a single-institution experience with lung transplantation for end-stage lymphangioleiomyomatosis. METHODS: We retrospectively reviewed records of patients transplanted for lymphangioleiomyomatosis between 1989 and 2001. Follow-up was complete on all patients (median 3.5 years). RESULTS: Seven single and 7 bilateral transplants were performed on 14 recipients (mean age 41.8 years). Eleven patients suffered the following intra-operative complications: dysrhythmia (1); blood loss > 1,000 ml (7); extensive pleural adhesions (10); hypothermia (1); phrenic nerve injury (1); and graft dysfunction (2). The following post-operative complications occurred in 11 recipients: dysrhythmia (7); respiratory failure (5); sepsis (3); airway dehiscence (2); vocal cord dysfunction (1); cholecystitis (1); deep vein thrombosis (1); acute renal failure (1); and pericarditis (1). Post-operative chylous fistulas necessitated thoracic duct ligation (1); sclerosis (6); and drainage of ascites (1). There were no peri-operative deaths. Late deaths occurred due to sepsis in 2 patients and obliterative bronchiolitis in 1 patient. Survival rates were 100%, 90% and 69% at (1, 2 and 5 years, respectively.) Mean FEV1 (1.77 +/- 1.06 vs 0.60 +/- 0.91) and 6-minute walk (1,519 +/- 379 vs 826 +/- 293 feet) improved at 1 year as compared with pre-transplant evaluation. Five patients reached criteria for bronchiolitis obliterans syndrome. One recipient has had a documented recurrence of lymphangioleiomyomatosis in the transplanted lung. CONCLUSIONS: Early and late survival after lung transplant are comparable in lymphangioleiomyomatosis patients versus patients with other diseases. Morbidity is common after transplant for lymphangioleiomyomatosis and is usually due to lymphangioleiomyomatosis-related complications. Lymphangioleiomyomatosis recurrence in the allograft does not pose a substantial clinical problem.     

Living-donor lobar lung transplantation for lymphangioleiomyomatosis

Living-donor lobar lung transplantation seems to be best suited for children and small adults because only two lobes are transplanted. However, the amount of tolerable size discrepancy between donors and recipients is currently unknown. We report two cases of lymphangioleiomyomatosis with hyperinflation successfully treated with living-donor lobar lung transplantation in spite of large size disparity.     

Contralateral pneumonectomy after single-lung transplantation for emphysema.

An intractable contralateral air leak developed in a 46-year-old woman after right single-lung transplantation for emphysema. A left pneumonectomy was performed on postoperative day 17, leaving the patient with only one transplanted lung. Fifteen months postoperatively the patient is well and has satisfactory pulmonary function. Survival with a good quality of life is possible after single-lung transplantation and bilateral sequential pneumonectomies.     

Differential lung ventilation after single-lung transplantation for emphysema

OBJECTIVE: To review outcome and cardiovascular and respiratory function after initiation of differential lung ventilation for acute severe native lung hyperinflation in patients who have had a single-lung transplant for end-stage emphysema. DESIGN: Retrospective review. SETTING: Cardiothoracic tertiary referral center. PARTICIPANTS: Thirteen patients who had differential lung ventilation for acute severe native lung hyperinflation, of a total of 132 patients who had a single-lung transplant for end-stage emphysema between 1988 and the end of 2000. INTERVENTIONS: None. measurements and main results: Thirteen patients had differential lung ventilation for acute severe native lung hyperinflation; 7 survived to 1 year after transplant. There was a highly significant (p = 0.0006) improvement in mean PaO(2) from 8.23 (95% confidence interval [CI], 6.15 to 10.3) to 16.6 (95% CI, 12.84 to 20.45) 1 hour after start of differential lung ventilation. The average ratio of estimated dynamic compliance in the native lung compared with the transplanted (donor) lung was 2.69 (95% CI, 1.75 to 3.62). CONCLUSION: In addition to previous case reports, this series shows that differential lung ventilation is an appropriate treatment for acute severe native lung hyperinflation. A difference in estimated effective dynamic compliance of > or = 2.69 between native and transplanted lung may require differential lung ventilation.     

犬单肺移植后的血液动力学变化

目的 研究犬单肺移植术后的血液动力学变化以及低温的影响。方法 健康犬14条随机分为供肺犬和受肺犬各7条。受肺犬行单肺移植30分钟后，采用物理方法（腹腔大网膜及颈部、四肢大血管处用冰袋冷敷）降温至35℃，观察30分钟，然后复温，测定受肺犬的血液动力学指标：心输出量（CO）、心率（HR）、平均动脉压（MAP）、平均肺动脉压（MPAP）、肺毛细血管楔压（PCWP）、中心静脉压（CVP）、肺血管阻力（PVR）、体循环血管阻力（SVR）、左室每搏功（LVSW）和右室每搏功（RVSW）。结果 与术前基础值比较，单肺移植后30分钟的MPAP、PVR、SVR和RVSW显著升高，CO和LVSW显著降低（P＜0.05）。降温后，PVR和SVR比肺移植后30分钟进一步升高，HR、MAP、CO、LVSW进一步降低（P＜0.05），MPAP和RVSW降温前后保持不变。复温后上述各指标均恢复至基础值。结论 单肺移植可引起犬肺动脉压升高和体循环功能紊乱，低温进一步加剧肺移植术后的血液动力学改变。     

Combined heart-lung transplantation for terminal pulmonary lymphangioleiomyomatosis

Combined heart-lung transplantation with cyclosporine is reported in a 26-year-old patient who presented with end-stage pulmonary lymphangioleiomyomatosis. The operation was successful and the patient's rehabilitation excellent over the first 7 postoperative months. She then developed obliterative bronchiolitis of unknown origin. To our knowledge, this is the first published report of an out-hospital survival after heart-lung transplantation for terminal nonvascular lung disease.     

Intraoperative contralateral pneumothorax during single-lung transplantation

Contralateral intraoperative tension pneumothorax is a rare complication of thoracic surgical procedures. Here we present three cases of tension pneumothorax that developed during single-lung transplantation for emphysema and pulmonary fibrosis. To the best of our knowledge, this is only the second report of contralateral intraoperative tension pneumothorax during single-lung transplantation. A high index of clinical suspicion is required for the detection of this potentially catastrophic complication.     

Postoperative management following heart transplantation.

Advances in surgical techniques, postoperative care, and experience have led to improved outcome in heart transplant patients. Specifically, the use of corticosteroid-free immunosuppression has reduced the risk of infection. The use of pravastatin early after transplantation has led to a decrease in clinically severe rejection episodes, improvement in survival, and reduction in transplant coronary artery disease. Reduction in natural-killer-cell cytotoxicity in the pravastatin-treated patients suggests an adjunct immunosuppressive effect of pravastatin in those patients on CyA-based immunosuppression. Quality of life has also improved in the heart transplant recipient with cardiac rehabilitation demonstrating a beneficial role in the improvement of exercise capacity. Newer immunosuppressive agents and strategies continue to demonstrate benefit in improving survival and the quality of life of the heart transplant recipient.