心肺联合移植的麻醉经验

我院于 1999年 9月 2 7日为 1例先天性心脏病、室缺、艾森曼格氏综合征的患者施行了同种异体心肺联合移植术 ,手术获得成功。现报道如下。1.临床资料 :患者女性 ,2 3岁 ,体重5 0ｋｇ。活动性心慌、气喘 2 0余年 ,发绀10余年。心导管检查为右向左分流 ,重度肺动脉高压 (阻力性 ) ,压力为 10 5 / 6 7ｍｍＨｇ。供者为男性 ,2 4岁 ,脑死亡者 ,心肺正常。供、受者ＡＢＯ血型相同 ,检验细胞免疫、体液免疫均正常。2 .麻醉方法 :术前 1ｄ了解患者思想 ,做心理护理。术前 30ｍｉｎ清洁口腔、鼻腔 ,肌注吗啡 8ｍｇ、东莨菪碱0 .15ｍｇ。入室后建立 2…     

中国心肺联合移植操作规范(2019版)

目前,心肺联合移植已成为公认治疗终末期心肺疾病的有效方法。中华医学会器官移植学分会组织心脏和肺移植专家,结合当前国内外心肺联合移植形势,总结国际指南和相关研究最新进展,并结合国内临床实践经验,从心肺联合移植的适应证和禁忌证、手术时机选择、供者选择、供器官获取和保护以及手术要点和术后管理等方面制订《中国心肺联合移植操作规范(2019版)》。     

心肺联合移植的进展

心肺联合移植（ｃｏｍｂｉｎｅｄｈｅａｒｔｌｕｎｇｔｒａｎｓｐｌａｎｔａｔｉｏｎ，ＣＨＬＴ）现已被公认是治疗终末期心肺衰竭的一种有效方法。一、发展概况从１９４６年Ｄｅｍｉｋｈｏｖ应用同种异体犬在交叉循环下施行ＣＨＬＴ的实验开始至今已５０年〔１〕。１９...     

心肺联合移植受者随访10年一例与国内心肺联合移植现况分析

目的总结分析1例心肺联合移植受者术后10年随访情况及国内心肺联合移植现况。方法回顾性分析复旦大学附属中山医院2003年12月完成的1例心肺联合移植受者临床资料。受者女性,43岁,原发病为先天性心脏病房间隔缺损合并艾森曼格综合征。供者男性,28岁。供、受者ABO血型相合,人类白细胞抗原配型5个位点错配。供者心、肺分别以uw液、HTK液灌洗保存。心脏移植采用双腔静脉吻合法,肺移植气管吻合采用3-0聚丙烯缝合线连续缝合外加自体组织包裹。采用达利珠单抗＋环孢素＋吗替麦考酚酯＋糖皮质激素四联免疫抑制方案,术后9个月将环孢素替换为他克莫司,术后8年撤除糖皮质激素。门诊随访定期复查超声心动图、肺功能及胸部CT。同时,检索1992年1月1日至2013年12月31日中国期刊全文数据库、中国生物医学文献数据库、维普中文科技期刊数据库以及万方数据资源系统心肺联合移植相关文献,对数据进行归类分析,采用Kaplan-Meier法计算受者生存率。结果截至2014年5月,该受者已存活10年3个月,生活质量良好。心功能恢复至美国纽约心脏病协会心功能分级I～Ⅱ级,术后9年超声心动图示左室射血分数65％。氧合指标稳定,血气分析指标良好。无急性排斥反应发生,术后5周及3．5年发生肺部感染治愈。1992年至2013年,国内26家医疗单位共完成心肺联合移植44例,病因以先天性心脏病伴艾森曼格综合征为主。44例受者1,3,5年生存率分别为39．4％,36．7％,30．6％。主要死亡原因为感染和移植物功能衰竭。结论心肺联合移植的远期疗效与供者心肺组织块的妥善保存、良好的手术技术,以及术后平衡抗排斥反应与抗感染治疗之间的矛盾密切相关。     

心肺联合移植的手术适应证及结果

自1981年世界首例心肺联合移植手术（heartlung transplant,HLT）在美国Stanford大学医学院附属医院实施并得以长期存活以来,第2例HLT手术是在1例艾森曼格综合征无法行心脏手术的先天性心脏病患者身上实施。     

同种异体心肺联合移植1例

目的报告1例同种异体心肺联合移植术病例。方法2003年7月1例先天性心脏病、房间隔缺损合并Eisenmenger综合征女病人在全麻、中低温、全心肺转流下进行同种异体心肺联合移植术。结果手术顺利，心脏自动复跳，血流动力学平稳。无出血、感染和急性排异反应，术后1h清醒，36h拔除气管插管。第3d下床活动。术后30d病人一般情况良好，各项生命指征正常，可在隔离病房内自由活动，术后50d转普通病房。现已健康生存半年余，病人状况良好。结论选择合适的供、受体，加强心肺保存，以及重视围术期处理，同种异体心肺联合移植可以挽救终末期心肺疾患病人的生命。     

心肺联合移植术麻醉处理一例

心肺联合移植术麻醉处理一例卿恩明刘进赵砚丽焦才容俊芳陈伯銮作者单位：１０００２９北京市，中国医学科学院中国协和医科大学阜外医院〔卿恩明（现调北京安贞医院）、刘进〕；河北省人民医院（赵砚丽、焦才、容俊芳、陈伯銮）１９９４年９月１日我们成功地对１例心肺联...     

同种异体心肺联合移植术一例

于１９９２年２月９日为１例原发性肺动脉高压并进行性心力衰竭垂危患者作了心肺联合移植术。方法全麻、中低温、全心肺转流下进行同种异体全心肺联合移植术。结果术中顺利，心脏自动复跳，血流动力学稳定，血液分析正常。患者术后１３０分钟后神志清醒，第３天拔去胸腔引流管，第４天出现血氧饱和度急速下降，第１７天多器官功能衰竭死亡。结论缺乏监测手段和心肺联合移植经验，将严重全身性霉菌感染误诊为排斥反应。病理解剖诊断为全身严重霉菌感染     

同种异体原位心脏移植和心肺联合移植的麻醉处理

目的 总结8例同种异体原位心脏移植手术和2例心肺联合移植手术的麻醉处理经验.方法 术前依据患者心肺功能及全身状况,给予强心、利尿、营养心肌等治疗.采用静吸复合麻醉,气管插管控制呼吸,在心肺转流下行同种异体原位心脏移植手术或心肺联合移植手术.根据血流动力学监测选用合适剂量的多巴胺、肾上腺素、异丙肾上腺素等血管活性药物.结果 10例患者术中血流动力学均平稳,术后17～25 h拔除气管导管,无早期死亡.结论 术前重视对心肺功能的调整,术中维护血流动力学的稳定,术后正确处理右心功能不全和低心排是心脏移植手术和心肺联合移植手术的麻醉关键.     

心肺移植3例

目的 总结3例心肺移植的经验.方法 2003年7月至2012年8月,3例终末期心肺疾病患者施行心肺移植手术.1例先天性房间隔缺损伴艾森曼格综合征,心功能Ⅳ级;1例扩张性心肌病伴中重度肺动脉高压,心功能Ⅲ～Ⅳ级;1例左心室双出口合并室间隔缺损伴肺动脉主干及左、右分支狭窄,心功能Ⅲ～Ⅳ级.心肌保护液均为UW液;肺保护液均加入前列腺素E1,Euro-Collin液1例,低钾右旋糖酐液2例.术前给予赛尼派或巴利昔单抗、术中甲基泼尼松龙、术后环孢素/他克莫司+泼尼松+骁悉抗排斥治疗.术中严密止血.移植术后严格消毒、隔离,加强呼吸道护理.例2患者术毕至术后31天胸液量14 640ml,术后40天内应用纤维支气管镜吸痰13次,同时使用广谱抗生素及抗真菌药物控制感染.结果 3例患者全部痊愈出院.1例术后4年10个月因慢性排异反应引起的阻塞性支气管炎、肺功能衰竭死亡;1例术后68天因突发脑血管意外死亡;1例目前健在,已生存1年余.结论 妥善保护心肺功能,术中认真止血,手术操作精细,术后加强防治感染,重视应用纤维支气管镜和合理的抗排斥治疗是心肺移植成功的重要因素.     

L-精氨酸对心肺移植缺血再灌注损伤的保护作用

目的探讨一氧化氮(NO)前体L-精氨酸(L-Arg)在心肺移植中对心肺缺血再灌注损伤的保护作用。方法将30条成年犬随机分为对照组、实验A(L-Arg 100 mg／kg体重)、B(L-Arg 500 mg／kg体重)3组,每组10条,采用标准法行心肺移植,A、B组心肺保护液中加入不同剂量L-Arg,供心肺放入4℃EC液保存4-5 h。监测心率、平均动脉压(MAP)、肺动脉平均压(MPAP),股静脉血一氧化氮(NO)、超氧化物歧化酶(SOD)、丙二醛(MDA)、心肌肌钙蛋白I(cTnI)、乳酸脱氢酶同工酶 (LDH)含量、股动脉血氧分压(PaO2),测定肺干湿重比(W／DR)及观察心肺超微结构以评价心肺保护的效果。结果主动脉开放60 min,B组NO(82．76±12．34)μmol／L、A、B组SOD(60．19±12．42)、 (100．38±16．55)NU／ml较对照组(29．43±12．42)μmol/L、(26．65±5．68)NU／ml高(P<0．05),B组 cTnI(11．07±2．62)mg／L、MDA(2．48±0．51)nmol／ml、LDH(592．8±51．92)U／L较对照组(23．16± 2．76)mg／L、(4．48±0．54)nmol／ml、(719．80±292．16)U／L低(P<0．05),B组PaO2(207．60± 32．72)mmHg(1 mm Hg=0．133 kPa)高于对照组(130．20±13．36)mm Hg(P<0．05),A、B组W／DR (84．82±1．14)％、83．84±1．63)％小于对照组(88．44±1．42)％(P<0．05),电镜检查A、B组心肺损伤轻于对照组。结论供心肺可安全保存4-5 h,在心肺移植实验中加入L-Arg可使NO含量增加, 减轻心肺缺血再灌注损伤,B组(500 mg／kg体重)效果更好。     

外源性肺表面活性物质对心肺联合移植供肺的保护作用

目的　通过在心肺联合移植过程中导入外源性肺表面活性物质 (PS) ,探索改善移植肺的肺功能 ,增加心肺联合移植的成功率。方法　应用改良的Kaneko兔异位心肺联合移植模型 ,分别在移植物切取后和供体再灌注后导入外源性PS ,观察实验组及对照组在 3 0、60、90、12 0min的动脉血气氧分压 (PaO2 )、二氧化碳分压 (PaCO2 )的变化 ,及移植后两组兔血浆内皮素 (ET 1)和髓过氧化物酶 (MPO)的变化 ,并观察移植肺组织的超微结构。结果　实验组中PaO2 值在各时间段分别 ( 12 .64± 4.47)、( 12 .5 8± 4.13 )、( 12 .46± 3 .85 )、( 12 .5 0± 3 .93 )kPa较对照组 ( 11.71± 5 .0 0 )、( 11.69± 4.2 2 )、( 11.5 9± 4.2 6)、( 11.5 6± 3 .93 )kPa明显升高 ,PaCO2 值在 60、90、12 0min( 4 .5 5±0 .5 3 )、( 4 .93± 0 .40 )、( 5 .65± 0 .65 )kPa较对照组 ( 5 .0 7± 0 .3 9)、( 5 .47± 0 .5 5 )、( 6.3 9± 0 .65 )kPa下降 ,ET 1( 4 .3 0± 0 .45 )ng/L和MPO( 3 .2 9± 0 .5 4)U/(mg·ml)均较对照组 [分别 ( 6.0 7± 0 .79)ng/L、( 7.70± 1.18)U/(mg·ml) ]显著下降 ,差异有显著性 (P <0 .0 5 ) ,移植肺的肺泡Ⅱ型细胞 ,Ⅰ型细胞损伤减小。结论　在心肺联合移植过程中导入外源性PS ,可改善移植肺的肺功能 ,     

Paediatric kidney transplantation in small children – a single centre experience

Kidney transplantation (KTx) remains a challenging procedure in small children. This study presents our centre results. From 1983 to 2004, 40 of 442 paediatric KTx were performed in children with a body weight <11 kg. Median body weight was 9.2 kg (range: 7.2-10.9), median age was 2.7 years (range: 0.9-5.9). Preoperative dialysis was performed in 87.5%. In 24 cases (60%) grafts came from cadaveric (CAD) and in 16 cases (40%) from living related donors (LRD). Median donor age of CAD was 8 years (range: 1-40). The overall 1-, 5-, 10-, 15-year patient survival was 93%, 90%, 90% and 87% respectively. The overall 1-, 5-, 10-, 15-year graft survival was 90%, 80%, 66% and 56% respectively. There was no significant difference in survival of CAD or LRD grafts. Median follow-up was 13.7 years. Initial graft function rate was 100% for LRD and 79% for CAD. The relative glomerular filtration rate (GFR) showed no statistical difference between CAD and LRD. Main reasons for graft loss were chronic transplant nephropathy. Paediatric KTx is the treatment of choice even in very small children. Living donor KTx is the preferable donor source in terms of primary graft function and timing to transplantation.     

Polyomavirus nephropathy after renal transplantation: a single centre experience

BACKGROUND: Polyomavirus associated nephropathy (PVN) in renal transplant recipients has been observed with increasing frequency recently and has emerged as a cause of allograft failure linked to highly potent new immunosuppressive regimens containing tacrolimus or mycophenolate mofetil (MMF). METHODS: Polyomavirus associated nephropathy was identified in nine out of 182 patients who received renal transplantation between October 1998 and July 2003. PVN was confirmed by allograft biopsy. The clinical records of these nine patients were reviewed, as were all of the allograft biopsies. Electron microscopy was performed in all nine cases. After the diagnosis of PVN, maintenance immunosuppression was reduced. The clinical course and outcome of the PVN patients were reviewed in relation to manipulation of immunosuppressive agents. RESULTS: There were nine cases of PVN in renal transplant recipients and the incidence of PVN was 4.9%. All patients with PVN were under triple immunosuppression comprising tacrolimus and MMF. The mean time to a diagnosis of PVN was 7.8 months after transplantation. Three of the nine patients received antirejection therapy prior to PVN. Seven out of nine PVN patients presenting acute allograft dysfunction were initially treated with high-dose intravenous steroid pulse or OKT3 before reduction of the immunosuppression. After reduction of the immunosuppression, seven patients stabilized their renal function. Two (22%) lost their grafts due to persistent PVN and chronic rejection. Two (22%) patients later developed acute rejection after reduction of the immunosuppression. CONCLUSION: PVN can cause allograft dysfunction and graft loss. Renal allograft recipients who are at risk of PVN should be routinely screened with urine cytology and quantitative measurements of viral load in the blood, particularly patients who had graft dysfunction. Early diagnosis and judicious alteration of immunosuppressive agents might permit a superior prognosis and reduce the graft loss from PVN in renal transplant recipients.     

心肺联合移植中供者心、肺的保护及术后排斥反应的诊断和治疗二例

目的 探讨心肺联合移植中供者心、肺的保护措施,以及术后免疫抑制方案、排斥反应的临床诊断及其处理.方法 回顾分析2例心肺联合移植的临床资料.2例供肺的灌洗分别使用Perfadx保护液(每1000 ml加入氨基丁三醇0.3 ml,伊洛前列素25 μg)和Euro Collins(EC)保护液(每1000 ml加入氨基丁三醇0.3 ml,前列地尔100 μg).供心的灌洗使用UW液.心肺联合移植采用经典原位技术.免疫抑制方案采用巴利昔单抗诱导,术后采用环孢素A+吗替麦考酚酯+皮质激素.术后早期观察受者的血象变化,各器官功能,各心腔大小及室间隔、左室后壁厚度等,必要时行胸部CT、纤维支气管镜及组织病理检查,及时发现排斥反应征象.受者发生排斥反应后给予皮质激素冲击治疗,并及时调整免疫抑制剂用量.结果 2例受者分别于术后第80天和第141天康复出院,分别随访4年6个月与4年2个月,现生活质量良好.1例受者于术后第10天和第26天发生急性排斥反应,另1例受者于术后第29天和第87天发生急性排斥反应,均经皮质激素冲击治疗,并调整免疫抑制剂用量后逆转.当受者发生急性排斥反应时,往往伴有血象的变化及室间隔和左心室后壁厚度的增加,给予相应治疗后渐恢复至正常范围.结论 Perfadx保护液和EC保护液对供肺均有较好的保护作用,UW液对供心有较好的保护作用;术后及时发现排斥反应与感染,并采取恰当的处理措施有利于受者顺利康复.

Abstract：

Objective To summarize the preservation measures of the donor's heart and lung, and the postoperative immunotherapy, as well as the clinical experience of discrimination and management for graft rejection.Methods The clinical data of 2 cases of heart-lung transplantation in our department were retrospectively analyzed. Two different protective liquids were used for donor's lung lavage of 2 cases: Perfadx solution (1000 mL containing tris 0.3 mL and ilomedin 25 μg); Euro Collins solution (1000 mL containing tris 0.3 mL and PGE1 100 μg). UW solution was used for donor's heart lavage. Surgical procedure for heart-lung transplantation was classic technique in situ. The schedule of immunosuppression was induced by Basiliximab, and combined with cyclosporine+ mycophemolate mofeil+corcal hommone after operation. recipient's blood count, organ's functions, the sizes of every cavity of heart, IVSPW and LVPW were observed during early post-operation. The recipients were subjected to chest CT scan, fiberoptic bronchoscope and tissue pathological study when necessary to find the signs of rejection promptly. When the rejection occurred in the recipient, cortical hormone's impulse therapy was given and the dose of immunosuppression was adjusted in time.Results Two patients discharged in 80 days and 141 days after operation. The patients were followed up for 54 months and 50 months respectively, and their life qualities were very well. Acute rejections occurred on the 10th and 26th day in one case, and in another case, acute rejections occurred on the 29th and 87th day after operation. All were conversed by cortical hormone's impulse therapy and adjusting the dose of immunosuppressants. When acute rejection occurred, the blood count had significant change, and IVSPW and LVPW were increases. They were returned the normal range after corresponding therapy.Conclusion Perfidx solution and Euro-Collin solution may play good protective roles for donor's lungs. UW solution may play good a protective role for donor's heart. To discriminate the clinical graft rejection and infection in time and administrate correct management will have large benefits for the patients' rehabilitation.     

Bronchial fistula to the mediastinum in a heart-lung transplant patient

We present a case of heart-lung transplantation complicated by bronchial perforation as the cause or consequence of prolonged lung infection. Periodic bronchoscopic and radiological follow-up showed resolution of the condition following adequate antibiotic and physiotherapeutic treatment.