同种异体原位心脏移植的临床应用(附3例报告)

目的总结3例同种异体原位心脏移植手术的近期处理经验,探讨围手术期处理、抗免疫排斥治疗及预防感染等问题。方法2004年5月至2004年10月,进行了3例同种异体原位心脏移植手术。全部采用双腔静脉法原位心脏移植。术后均采用环孢素A+骁悉+强的松口服联合抗免疫治疗。结果3例患者均于术后7周左右出院,心功能状况及生活质量良好,未出现免疫排异反应和肺部感染等并发症。结论重视围手术期处理及感染的预防,选择合理的术式及抗免疫排斥治疗方案,可使患者早日康复,提高生存率和生活质量。     

心脏移植围术期处理经验

目的:总结8例心脏移植围术期处理的临床经验.方法:8例晚期心肌病患者接受同种异体原位心脏移植术,围术期免疫抑制剂采用两剂赛尼哌加环磷酰胺诱导方案,维持治疗为环孢素A 霉酚酸酯(或硫唑嘌呤) 泼尼松三联方案,术后72 h内保持低水平的中心静脉压.结果:8例受者均存活,围术期及随访期间受者均无急性排斥反应、移植物功能不全、肝肾功能不全、严重机会性感染等并发症.结论:围术期适当强度的免疫抑制治疗,合理应用强心利尿和抗生素预防治疗是防治心脏移植术后并发症的有效方法.     

原位心脏移植5例报告

目的总结5例同种异体原位心脏移植的治疗经验,探讨手术方式及术后围术期处理。方法2005年1月至2005年6月连续为5例终末期心脏病患者实施了原位心脏移植手术。术后免疫抑制剂应用环饱素A+骁悉+泼尼松"三联疗法。结合临床表现、超声心动图、化验检查及心肌内心电图,对心脏移植术后急性排斥反应的监测进行分析。结果5例手术均顺利,其中1例存活时间仅为9 d,其余均近期存活,生活质量良好。结论原位心脏移植是治疗终末期心脏病的有效方法。作为一种监测排斥反应的无创方法,心肌内心电图可以明显减少心肌活检的次数。低血管阻力受体的选择和合理的免疫抑制治疗方案的应用是心脏移植成功的关键。     

同种异体原位心脏移植(附11例报告)

目的总结同种异体原位心脏移植的手术经验。方法对11例终末期心脏病患者施行同种异体原位心脏移植术。其中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10例,心肾联合移植术1例。5例术前存在中度肺动脉高压者,术中及术后给予一氧化氮（NO）吸入等措施治疗。抗排异治疗采用环孢素A（CsA）＋甲基强的松龙（MP）＋霉酚酸酯（MMF）三联方案。结果2例术后出现急性排异反应．给予大剂量MP冲击治疗3d缓解;1例术后第3天出现肾功能衰竭．给予血液透析后缓解。1例行心肾联合移植术者术后18d死于肺动脉栓塞。随访6～45个月,晚期死亡2例,其余病例心功能正常,恢复正常工作和生活。结论严格掌握受体适应证、合适的手术方法及严格的围术期管理可提高同种异体原位心脏移植术的疗效。     

心脏移植术后肾功能衰竭的围手术期处理(附2例报告)

目的报告2例原位心脏移植术后肾功能衰竭的发生及治疗经过,探讨其围手术期处理的初步经验和要点.方法我院自2000年12月一2002年12月共对4例终末期心脏病患者施行同种异体原位心脏移植术,4例均为男性,采用标准原位心脏移植术,术后应用三联免疫治疗的方法抗排异.结果4例患者均获得手术成功,术后未发现超急性排斥反应或急性排斥反应,2例术后1周左右并发急性肾功能衰竭,应用床边连续肾脏替代(CRRT)治疗后,1例存活22d,1例完全康复,随访半年患者心功能恢复Ⅰ～Ⅱ级(NYHA),生活质量良好.结论心脏移植手术后肾功能损害较常见,围手术期的肾功能保护非常重要,如符合手术指征,及早手术治疗是抢救成功的关键.     

同种原位心脏移植（附3例报告）

目的观察3例同种原位心脏移植患者的近、远期疗效,总结心脏移植的经验。方法3例心肌病患者施行原位心脏移植,手术方法采用标准法1例、双腔静脉法2例,供心保护液为4℃的HTK液,术后免疫抑制治疗采用赛尼哌加＂三联＂方案。结果3例手术均成功,2例术后未发生明显感染及其他并发症,心功能Ⅰ级,已恢复正常工作,1例于术后13 d死于急性排斥反应。结论选择合适的供心及保护方法是同种原位心脏移植手术成功的前提,合理应用免疫抑制剂、正确处理并发症是手术成功的关键。     

原位心脏移植的围术期处理

目的总结3例原位心脏移植成功患者的围术期处理经验。方法2001年8月至2003年12月为3例终末期心脏病患者施行原位心脏移植术,术式均采用双腔静脉吻合法,术后采用环孢素A、泼尼松及吗替麦考酚酯联合免疫抑制治疗。结果3例患者均顺利出院,心功能恢复至Ⅰ-Ⅱ级(NYHA),围术期无感染或严重排异反应发生。结论正确的围术期处理是心脏移植术后早期顺利康复的关键。     

同种异体原位心脏移植术后的监测治疗

目的总结昆明市延安医院云南省心脏移植中心11例同种异体原位心脏移植术后的监测治疗。方法选择2003年3月—2008年9月进行同种异体原位心脏移植术患者11例,手术均按标准法行同种异体原位心脏移植,术后抗排斥反应治疗采用环孢素(CsA)+霉酚酸酯(MMF)+泼尼松(Pred)三联方案,并给予严密的监测治疗。结果 11例患者均一期恢复良好出院,出院后6例患者存活至今,心理状态良好,血流动力学稳定,无明显免疫排斥迹象;3例患者死亡,其中1例因患者自己暗地里不规律服用免疫抑制药物引起急性排斥反应,经我科救治好转后出院,仍然不规律服用免疫抑制药物而猝死家中,1例肺部严重感染,1例急性右心衰竭经再次入院抢救,无效死亡。结论心脏移植是目前终末期心脏病最有效的治疗手段,术后的监测治疗十分关键。     

同种原位心脏移植二例报告

目的报告2例原位心脏移植的初步体会。方法2003年8月与2004年12月进行了2例原位心脏移植,1例为瓣膜型心肌病,另1例是扩张型心肌病。采用冷晶体停跳液顺灌进行供心保护,中度低温体外循环下行双腔静脉法原位心脏移植手术。免疫抑制方案采用环孢素A、骁悉、甲基泼尼松龙三联。结果1例术后52h右心衰竭至全心衰竭死亡;另1例围术期无急性排斥反应及感染发生。心功能恢复至Ⅰ级,术后存活8个月。结论合理选择受体,良好的心肌保护、术后合理的监测与抗排异治疗是心脏移植成功的关键。     

心脏移植术后ICU的监测与护理

心脏移植是治疗终末期心脏病的一种重要手段,术后ICU期间的监测与护理质量是提高心脏移植成功率、预防术后并发症的关键.我院于2003年2月成功为1例心脏病患者实施了同种异体原位心脏移植术,术后通过严密的监护,病人恢复良好,21天后转普通病房,现将体会报告如下.     

Management of the patient after heart transplant

Cardiac transplantation is a highly effective therapy for selected patients with end-stage cardiac disease. The management of the patient after heart transplant involves three main strategies: optimization of immunosuppressive therapy, prevention of complications resulting from the transplant or the immunosuppressive agents, and treatment of those complications when they arise. For most patients, optimal current immunosuppression in the first year after transplantation consists of combination therapy with a calcineurin inhibitor (eg, cyclosporine or tacrolimus), corticosteroids, and an antimetabolite agent (eg, azathioprine or mycophenolate mofetil). Ideally, the corticosteroid is weaned and discontinued 1 to 2 years following transplantation and the patient is managed chronically with a two-drug immunosuppressive regimen. The major complications that occur following cardiac transplantation include infection, hypertension, diabetes, dyslipidemia, osteoporosis, graft coronary disease, renal insufficiency, and malignancy. Preventive efforts focused on infection, osteoporosis, renal insufficiency, and malignancy include minimization of immunosuppression. Once established, treatment of any of the above conditions generally relies on standard pharmacologic therapies; however, an understanding of potential drug interactions is critical. In addition, although standard nonpharmacologic therapies may be used to treat several of these conditions, one must be cognizant of special issues related to the post-transplant state.     

原位心脏移植长期存活原因分析（附34例报告）

目的探讨原位心脏移植长期存活的原因和价值。方法选自2004·10～2012·12在广西壮族自治区人民医院和解放军181医院进行同种异体心脏移植患者34例。男性29例,女性5例;年龄12～56岁。扩张型心肌病30例,肥厚型心肌病2例,冠心病2例。心脏功能Ⅲ一Ⅳ级。全部病例均采用双腔静脉吻合法进行原位移植。对患者的个体因素、供心保护、手术过程、围手术期情况、免疫抑制剂治疗和术后检测情况、生活质量进行分析。随访1—99个月。结果早期死亡3例,其中2例死于肺动脉高压危象一右心功能衰竭。出院的31例患者全部存活,心脏功能恢复I～Ⅱ级。存活3年以上13例,其中8年以上1例,心功能I级,已生育一小孩。免疫抑制剂血液浓度监测和B型超声检查未发现异常。64排CT检查未发现冠状动脉有狭窄表现。结论组织配型、供心保存、缺血．再灌注损伤、手术过程、免疫抑制剂合理使用是移植后长期存活的关键因素,防治免疫排斥、代谢、感染等是防治心脏移植物血管病变的重要措施。64排CT等非创伤性检查可作为常用的监测手段。     

Immunsuppression nach Herz- und Lungentransplantation

Immunosuppression after heart and lung transplantation is generally based on four groups of immunosuppressive agents: calcineurin inhibitors (cyclosporin A or tacrolimus), antimetabolites (azathioprine or mycophenolate mofetil), mammalian target of rapamycin inhibitors (rapamycin or everolimus), and corticosteroids. Most patients after heart or lung transplantation are treated with a triple immunosuppressive regimen, consisting of a calcineurin inhibitor, an antimetabolite, and corticosteroids. In addition, some centers use induction therapy, consisting of the perioperative application of intravenous mono- or polyclonal antibodies, targeting activated host lymphocytes.     

机械循环辅助装置治疗围手术期急性心肺功能衰竭

目的:观察心室辅助(VAD)、体外膜式氧合(ECMO)及主动脉内气囊反搏(IABP)等机械循环辅助装置治疗围手术期急性心肺功能衰竭的疗效。方法:回顾2005年1月至2006年12月我院心脏外科监护病房224例围手术期进行循环辅助患者临床资料,VAD4例、ECMO47例及IABP173例。结果:VAD死亡2例(50%),ECMO死亡23例(48.9%),IABP死亡49例(28.3%)。并发症为感染27例、肾功能衰竭需要透析26例、出血23例、下肢缺血15例及脑并发症7例。结论:机械辅助是救治围手术期急性心肺功能衰竭的有效方法,应根据患者病情选择适合的辅助方式并及早放置,防治并发症对提高成功率非常重要。     

High-risk pulmonary surgery in potential candidates for a heart transplant

Severe ventricular dysfunction and concomitant infection are considered absolute contraindications for major thoracic operations and immunosuppressive therapy, respectively. However, cardiac transplantation represents the first-choice treatment in advanced heart failure. We report the case of a patient with dilated cardiomyopathy and severe left ventricular dysfunction (ejection fraction = 25%), initially not considered as a potential heart transplant candidate due to the presence of a lung abscess. The patient subsequently underwent atypical pulmonary resection with intraoperative and perioperative intraaortic balloon counter-pulsation for circulatory support and was then listed for cardiac transplant. Pitfalls and intra/postoperative strategy, all of which are potentially important aspects in minimizing operative risk, are discussed.     

Hepatitis C virus and liver transplantation.

Advances in immunosuppressive therapy, operative techniques, and perioperative management have resulted in long-term patient survival rates approaching 90% following liver transplantation for chronic viral hepatitis. The increasing number of referrals for liver transplantation reflects the impact of chronic HCV infection as a cause of end-stage liver disease. Unlike hepatitis B, there is still no effective treatment in preventing recurrent hepatitis C after liver transplantation. The spectrum of allograft injury related to universal HCV infection recurrence ranges from no evidence of histologic injury to mild inflammation to severe disease with allograft failure in small proportion of patients. Various factors may explain these differing outcomes, including degree of pretransplantation viremia, HLA compatibility, presence of more pathogenic HCV genotypes, integrity of cellular immune response, and type of immunosuppression. Fortunately, patient survival does not seem to be affected short-term; the long-term outcome of liver transplantation for chronic hepatitis C is unclear but is likely to be decreased. Combination therapy with interferon plus ribavirin seems to be a promising treatment strategy for posttransplantation recurrent hepatitis C, and the use of pegylated interferon plus ribavirin may improve these results. Patients with moderate to severe allograft hepatitis are appropriate candidates for combination antiviral therapy. Histopathologically documented recurrent hepatitis C in liver transplant recipients is associated with impaired quality of life, inferior physical condition, and a higher incidence of depression compared with patients who did not have HCV and in those without HCV recurrence. In conclusion, it is possible that the continued improvements in antiviral therapy against HCV infection may ultimately decrease the number of patients needing liver transplantation. Suitable candidates with chronic HCV infection thus warrant treatment with pegylated interferon plus ribavirin combination therapy in the hope of decreasing disease progression. Recent studies, which require confirmation, suggest that nonresponders to standard antiviral therapy may benefit from maintenance therapy. The donor pool for patients with chronic hepatitis C and decompensated cirrhosis can be improved by using HCV-positive donors and by increasing utilization of newer surgical techniques, including adult-to-adult living-donor liver transplantation and split-liver transplantation.     

The Challenge of Rejection and Cardiac Allograft Vasculopathy

Since the first human heart transplantation was performed in 1967, the field of heart transplantation has advanced to the point where survival and acceptable quality of life are commonplace. Despite remarkable progress in the clinical management of rejection, rejection continues to limit survival and quality of life in the heart transplant population. This review will discuss the biologic processes involved in hyperacute rejection, acute rejection, and humoral (vascular) rejection. The development of endomyocardial biopsy techniques represented a significant advancement in the diagnosis of cardiac rejection, and endomyocardial biopsy remains the gold standard in the diagnosis of cellular rejection. To date, no noninvasive parameters will diagnose rejection with adequate sensitivity and specificity. Biopsy frequency and immunosuppressive therapies may be tailored to the risk of rejection. Immunosuppression for cardiac transplantation can be divided into three major phases: 1) perioperative immunosuppression; 2) maintenance immunosuppression, and; 3) treatment of rejection. The strategy for treating transplant rejection should be influenced by several variables: 1) Histologic grade of rejection; 2) Evidence of hemodynamic compromise by ejection fraction or right heart catheterization; 3) Severity of previous rejection episodes and types of immunosuppressives used; and 4) Risk factors for rejection, including time after transplantation. Future rejection therapy will involve more sophisticated attempts to alter host responses toward the donor organ in a more specific and selective way. Despite considerable advances in the care of the heart transplant recipient, long-term survival is limited by cardiac allograft vasculopathy. The final section of this chapter will review the pathology, immunopathology, nonimmunologic risk factors, diagnosis, prevention and treatment of allograft vasculopathy.