原位心脏移植术的研究进展

自开展原位心脏移植以来,手术术式虽不断改进,但可归纳为全心原位心脏移植术（ＴＯＨＴ）、双腔原位心脏移植术（ＢＯＨＴ）及标准原位心脏移植术（ＳＯＨＴ）［１３］。本文拟对这３种手术的应用和研究进展进行综述。一、标准原位心脏移植术（ＳＯＨＴ）１．手术方法...     

一例原位心脏移植术后一年随访报告

１例终末期扩张型心产现患者施行原位心脏移植手术，至今存活已逾１年，其生活质量十分良好。本文详细介绍与讨论患者术后一年期间的免疫抑制治疗及排以应的监测。术后第２、１６周增出现过２次急性排斥反应，均用甲基泼尼松龙冲击治疗告愈。     

右位心原位心脏移植患者的术后护理

目的 总结6例右位心原位心脏移植患者的术后护理经验。方法 6例右位心原位心脏移植患者术后护理要点包括术后出血的观察及护理、呼吸道的管理、抗凝的护理、大供心/小受体的护理、抗排斥反应的观察及护理等。结果 6例右位心原位心脏移植患者术后心功能达到I级,5例康复出院,出院后持续随访48个月,均恢复良好;1例术后因顽固性低氧血症伴肺部感染在术后59 d死亡。结论 右位心合并复杂心脏畸形是先天性心脏病的极端情况,病情复杂、手术难度大、心脏移植术后病死率较高,护理时应引起足够重视,全方位关注患者术后的病情变化尤为重要。     

可供选择的心脏移植术式——全心脏原位移植术

可供选择的心脏移植术式——全心脏原位移植术臧旺福原位心脏移植术用于临床已近三十年。手术方法中应用最广、被公认为有效、已规范化的是原位心脏移植的标准术式。但随着近代一些新技术的出现，它已面临着许多挑战。本文就标准原位心脏移植术存在的问题和全心脏原位移植...     

右房血管瘤破裂形成巨大血肿致急性右心功能衰竭1例

病人　女 ,2 6岁。突然晕厥 0 5ｈ ,后胸闷、气促、全身发绀 ,逐渐加重 9ｄ。查体 :体温 38℃、脉搏 12 0次 /ｍｉｎ、呼吸 32次 /ｍｉｎ、血压 90 /6 0ｍｍＨｇ(12 /8ｋＰａ)。全身发绀、瘀斑 ,颈静脉怒张 ,极度呼吸困难 ,两肺可闻及喘鸣音及湿性罗音。三尖瓣区闻及轻度隆隆样舒张期杂音 ,腹稍膨隆 ,四肢稍肿胀、湿冷。超声心动图可见右房内增强回声团、充满全腔 ,并延至三尖瓣口 ,右房、室内血流疏少。诊断“右房巨大粘液瘤、急性右心衰。”2 0 0 1年 2月入院后急诊在全麻低温体外循环下手术。术中见 :右房巨大 ,表面饱满、质韧 ,压力大 …     

原位心脏移植术后早期肾功能损伤的防治

目的分析原位心脏移植术后受者早期肾功能损伤情况,探讨其发生原因及防治措施。方法浙江省人民医院心胸外科于1997年6月至2011年12月期间对16例受者行原位心脏移植手术。供、受者ABO血型相合15例,不相合1例。淋巴细胞毒性试验阳性（〈10%）。受者术前肝肾功能均有一定程度损伤,需服用较大剂量利尿剂控制。6例受者采用环孢素（或他克莫司）＋硫唑嘌呤（或吗替麦考酚酯）＋糖皮质激素三联免疫抑制方案。10例受者在三联免疫抑制方案基础上加用单克隆抗体。结果 16例受者均顺利完成手术,术后均有不同程度的肾功能损伤。4例受者术后出现急性肾功能衰竭,其中1例血型不相合受者术后第7天移植心脏发生超急性排斥反应合并急性肾功能衰竭,血液透析后第10天死亡;1例受者移植术后第21天因急性肾功能衰竭合并肺部感染死亡。截至2013年3月31日,术后随访15~201个月（中位随访时间96个月）,受者1,3,5年生存率分别为87.5%,81.3%,75.0%。结论心脏移植受者术前心功能状态、手术操作以及使用肾毒性药物、感染都会引起术后肾功能损伤,只要积极预防、及时诊断、有效处理,可避免或减轻肾功能损伤,提高心脏移植围术期成功率。     

61例心脏移植术的供心获取

目的总结61例心脏移植术中供心获取的经验，以提高对供心保护的效果。方法2002年4月至2006年10月我们共为61例终末期心脏病患者行原位心脏移植治疗，供体均为男性脑死亡者，年龄21～53岁，大于40岁的供体5例；6例供、受体体重相差〉20％（均为大供体、小受体），其余≤±20％。45例供、受体A、B、O血型相同，16例供、受体A、B、O血型相符。脑死亡后有稳定的血流动力学和供心在不乏氧条件下获取者4例（Ⅰ类），脑死亡合并急性失血和低血容量条件下供心获取者44例（1／类），脑死亡合并心跳停止后供心获取者13例（Ⅲ类）。标准术式20例，全心式1例，双腔法40例；供心冷缺血时间52～347min（92±31min），冷缺血时间超过240min 13例。结果术后早期死亡2例，分别于术后第7d和第9d死于低心排血量，供心冷缺血时间分别为327min和293min。其余患者痊愈出院。1例于术后18个月拒绝服免疫抑制剂而死于急性排斥反应，1例于术后23个月死于交通伤。其余57例患者已生存6-59个月（平均35个月），出院后生活质量良好，心功能均为0～Ⅰ级。结论较大年龄的供心移植后仍可获得满意的临床效果；对终末期扩张型心肌病患者的受体可使用较大体重供体的供心；心脏移植供、受体血型相符可获得满意的临床效果；对三类不同供心采用不同的获取方法方能最大限度地减少供心获取过程中的心肌损伤；长时间心肌保护液保护的供心应慎用。     

The Influence of Chronic Heart Failure on Pulmonary Function Tests in Patients Undergoing Orthotopic Heart Transplantation

Background

Chronic heart failure and airway obstruction produce overlapping syndromes. Existent criteria for the diagnosis and grading of airway obstruction based on spirometry results may be inadequate in the presence of coexistent cardiac failure. The cardiac component of pulmonary function tests (PFT) can be measured in patients undergoing orthotopic heart transplantation (OHT).

Materials and Methods

Before and 1 year after OHT between 2006 and 2008 PFT were performed in 29 patients according to existent guideline. Willcoxon matched pair tests were used for analysis in Statistica 7.1. The general group characteristic included age, gender, New York Heart Association class, CCS class, body mass index, present medications, blood and chemistry tests, as well as exercise tolerance tests, right heart catheterization, and echocardiography results.

Results

One year after OHT we observed significant improvements in forced expiratory volume in the first second (FEV₁) and its percent of normal value (FEV₁%) as well as forced vital capacity (FVC), FVC%, vital capacity (VC) and VC%: namely, 2.56 L versus 2.96 L; 82% versus 93%; 3.30 L versus 3.81 L; 85% versus 97%; 3.38 L versus 4.04 L and 85% versus 100% (all P < .01). FEV₁ and FVC increments of: 0.39 and 0.471 respectively, exceeded the cutoff point of 12% of predicted value established as the spirometry criterion for reversibility of obstruction. Elimination of heart failure by OHT did not significantly change the FEV₁ to FVC ratio (FEV₁%FVC).

Conclusion

Chronic heart failure contributed to significant FEV₁ reduction, which limits the usefulness of PFT for diagnosis and grading of airway obstruction. FEV₁%FVC, the main diagnostic criterion of chronic obstructive lung disease, seems to be an index independent of concomittant heart function impairment.     

Recurrent Aortic Dissection After Orthotopic Heart Transplantation

A patient with Marfan's syndrome and previous Bentall repair for aortic dissection required orthotopic cardiac transplantation for end-stage cardiomyopathy. Postoperatively he suffered recurrent aortic dissection involving the transverse and descending aorta leading to tracheal and esophageal compression. He underwent successful surgical replacement of his ascending aorta, transverse arch, and descending aorta.     

原位心脏移植1例

１例扩张型心肌病伴严重室性心律失常的１６岁女病人，因持续心功能衰竭５年，心功能Ⅳ级（ＮＹＨＡ）。以利尿剂控制心衰、利多卡因抗心律失常、多巴胺和多巴酚酊胺维持血压，于１９９２年３月行原位心脏移植术。术后７个月病人死于急性排异反应和感染。     

Predictive Factors for Chronic Renal Failure One Year after Orthotopic Liver Transplantation

Chronic renal failure (CRF) is increasingly prevalent in solid-organ-transplant patients. This is in part related to the long-term use of calcineurin inhibitor (CNI) agents. However, in orthotopic liver-transplant (OLT) patients, the effects of superimposed hepatitis C virus (HCV)-related renal lesions could also be a factor. The aim of this cohort study (February 2000 to September, 2003) was to identify the predictive factors at one year post-transplantation for CRF in OLT patients associated with induction therapies. CRF was defined as having a creatinine clearance (CC) lower than 60 mL/min. Of the 97 transplants performed during that period, 72 were still functioning after one year. Of these, 33 patients (45.8%) had CRF. In univariate analysis, the predicting factors for CRF were recipient sex (female), initial liver disease (HCV-related cirrhosis), pre-transplant CC (<80 mL/mn), and post-transplant serum creatinine >130 μmol/L at day 3 and months (M) 1, 3, and 6. In multivariate analysis, the independent predictive factors for CRF included female sex [OR: 11.5 (2.3–58.3); p = 0.003], HCV infection [OR: 5.01 (1.1–22.7); p = 0.03], pre-OLT CC <80 mL/mn [OR: 5.4 (1.2–23.7); p = 0.025], and serum creatinine at M6 greater than 130 μmol/L [OR: 19.6 (3.7–102.5); p = 0.0004]. Among all of the predictive factors for post-OLT CRF, only one is modifiable: post-transplant serum creatinine, which could be, to some extent, related to the long-term use of CNIs.     

Reversal of Cardiac Cirrhosis Following Orthotopic Heart Transplantation

Irreversible hepatic cirrhosis greatly increases the risks attending heart transplantation (HT), and is accordingly considered to be an absolute contraindication for HT unless combined heart and liver transplantation can be performed. It is now recognized that hepatic cirrhosis can undergo regression if the source of insult is removed, but no cases of post-HT regression of cirrhosis of cardiac origin have hitherto been reported. Here we report a case of cardiac cirrhosis that underwent complete regression following orthotopic HT, and we discuss the implications of this case.     

原位心脏移植术特殊情况的处理经验

原位同种异体心脏移植作为终末期心衰最为有效的治疗手段之一，已在我国逐渐得到推广。常规的手术技术及围术期处理方法已为多数医师所熟悉，但临床上一些特殊病例或情况若处理不当必将影响手术效果。作者结合近五年来所施行的103例原位心脏移植的手术经验，探讨临床上可能遇到的特殊情况的处理。     

Predictors of Systolic Heart Failure and Mortality Following Orthotopic Liver Transplantation: a Single-Center Cohort

ObjectivesThe purpose of this study was to identify risk factors that may predict heart failure with reduced ejection fraction (HFrEF) following orthotopic liver transplantation (OLT) and associated mortality.BackgroundHFrEF following OLT is a poorly understood phenomenon, reported in 3% to 7% of transplanted patients.MethodsThis is a retrospective analysis of 176 consecutive patients who underwent OLT from 2010 to 2017. Multivariate logistic regression was used to identify associations between cardiovascular risk factors and perioperative variables with post-OLT HFrEF, defined as reduction in left ventricular ejection fraction of at least 10% and left ventricular ejection fraction less than or equal to 40% with acute heart failure symptoms. Multivariate cox proportional hazards regression (with inverse probability weighting by propensity scores) was used to evaluate effects of HFrEF on 1-year mortality.ResultsOf the176 patients, 14% developed HFrEF with a median of 5 days. History of heart failure (OR 10.99, 2.15–56.09; P = .04) and intraoperative transfusion of greater than 11 units of packed red blood cells (OR 3.377, 1.025–11.13; P = .045) were associated with increased incidence of HFrEF. Pre-transplant hemoglobin greater than 8.5 g/dL (OR 0.252, CI 0.0954- 0.665; P = .05) was protective against HFrEF. Thirty-three percent of HFrEF group died within 1 year (HR 7.36, 2.57–21.12; P < .001).ConclusionsThe incidence of acute HFrEF post-OLT is 14% and is associated with a 7-fold increase in 1-year mortality. Cirrhotic cardiomyopathy and stress-induced cardiomyopathy maybe the underlying mechanisms. Our study identified risk factors associated with post-OLT HFrEF and should provide additional guidance for risk stratification of patients undergoing OLT.