原位心脏移植术的围术期临床经验及效果

目的总结心脏移植围术期的心肌保护方法和经验。方法2003年3月至2005年11月为11例终末期心脏病患者实施了原位心脏移植,其中心-肺联合移植、心-肾联合移植各1例。采取标准法1例,双腔静脉法10例。结果全组热缺血时间8￣12min,冷缺血时间90￣292min,术中心肌自动复跳10例,1例电除颤复跳。术后1周超声心动图示各心腔大小、EF值均在正常范围。死亡3例:心-肺联合移植术后气管吻合口瘘合并重度感染1例,心-肾联合移植、单纯心脏移植术后急性肾功能衰竭各1例。随访1￣29个月,8例存活患者心功能均恢复至Ⅰ￣Ⅱ级。结论心脏移植术中除在供心的正确切取过程中注意供心的心肌保护外,还应在术中吻合、术后管理过程的整个围手术期都要重点加强心肌保护,这些均是手术成功的重要基础。     

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。     

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。     

心脏移植受者供心临床心律变化意义的探讨

结合３例原位心脏移植受者探讨供心临床心律变化的特点。经动态观察发现：２例供心在术中血运再通后出现心室颤动，电除颤后转为窦性自律，１例自行出现窦性心律；１例供心在术后出现一过性Ⅲ度房室阻滞；２例心电图显示双心房心律，１例为单心房心律；３例供心的特殊传导系统能够维持正常功能．     

心脏移植专栏讲座·（下）

心脏移植专栏讲座·（下）心脏移植的并发症ＤａｌｅＧ．Ｒｅｎｌｕｎｄ心脏移植术后的并发症主要包括（１）原位移植的排异反应；（２）感染；（３）移植后的冠脉疾病；（４）高血压；（５）高脂血症；（６）骨质疏松症一、原位移植后的排异反应：１．排异反应的监测：包...     

原位心脏移植一例报告

报告晚期扩张型心肌病人行原位心脏移植1例,手术经过顺利,术后心功能恢复良好,病人存活28d,死于第二次急性排斥反应.就供心的提取、手术方法、抗排异治疗等进行讨论.     

29例原位心脏移植近期疗效报告

目的:总结29例原位心脏移植的近期疗效。方法:2006年10月至2012年12月,对29例终末期心脏病患者行原位心脏移植治疗。受体肺血管阻力为3.6~5.2 wood单位,平均(4.2±1.8)wood单位;应用4℃的HTK液保护供心,供心冷缺血时间为63~360 min,平均(95.5±26.7)min;29例均采用双腔静脉吻合法原位心脏移植手术;术前使用免疫诱导治疗,术后采用环孢素A、霉酚酸酯和泼尼松预防急性排斥反应。结果:术后死亡2例,1例死于术后低心排出量综合征(低心排),1例死于急性右心衰竭。术后早期并发症有急性右心衰竭3例,急性肾衰竭2例,心包大量积液4例。结论:心脏移植近期疗效满意。选择肺血管阻力较低的患者、妥善的供心心肌保护、熟练的手术操作、合理应用免疫抑制剂和正确处理术后肾功能不全是提高心脏移植近期疗效的重要措施。     

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。     

心脏移植受者供心临床心律变化意义的探讨（附三例报告）

结合３例原位心脏移植受者探讨供心临床心律变化的特点。经动态观察发现：２例供心在术中血运再通后出现心室颤动，电除颤后转为窦性心律，１例自行出现窦性心律；１例供心在术后出现一过性ＩＩ度房室阻滞；２例心电图显示双心房心律，１例为单心房心律；３例供心的特殊传导系统能够维持正常功能；发生中、重度急性排斥反应时未出现心律失常。提示单凭体液调控能使供心维持正常心律，心律失常并非急性排斥反应的敏感指标。     

克山病的心肌损伤与细胞凋亡

为探讨克山病的心肌损伤与细胞凋亡的关系，采用Ｏｎｃｏｒ公司的细胞凋亡原位检测试剂盒（ＴＵＮＥＬ）对３０例克山病尸检心肌组织进行了检测，其中急型、亚急型、慢型克山病心肌组织各１０例，以因交通事故死亡的５例正常人尸检心肌组织作为对照，结果显示，急型、亚急型、慢型克山病心肌组织中凋亡细胞阳性检出率分别为２／１０、８／１０与７／１０。５例正常心肌组织中，未检出凋亡细胞，以上结果提示：在克山病的发生发展中有凋亡机制参与。     

A Patient with Giant Left Atrium Undergoes Orthotopic Heart Transplantation

We present a novel technique for resolving the problem of radical size mismatch at the time of orthotopic transplantation. A 48-year-old man presented with chronic rheumatic heart disease and a giant left atrium. Twenty-three years before, he had undergone mitral valve replacement with a mechanical prosthesis. At the time of the repeated intervention, the volume of his left atrium was 350 mL.Surgical features of the transplantation included approximation of the pulmonary vein ostia by gathering sutures intentionally, in order to decrease the area of the left atrial posterior wall and thereby enable appropriate coaptation with the donor left atrium. After the operation, left atrial volume had been reduced to 60 mL.Key words: Cardiomyopathy, dilatation, pathologic/complications/surgery, heart atria/pathology, heart disease, rheumatic, heart transplantation/methods, mitral valve, organ size, pulmonary veins/surgeryOrthotopic heart transplantation (OHT) remains the operation of choice in patients with end-stage chronic heart failure. Nowadays, up to 3,800 such operations are performed annually. Only 2.7% of patients undergo transplantation as a consequence of valvular cardiomyopathy.¹ In patients with rheumatic heart disease, the presence of giant left atrium (GLA) makes the technical aspects of transplantation more difficult because of substantial size mismatch between donor and recipient at the point of anastomosis. We present a rare case of OHT in a recipient with GLA.     

扩张型心肌病并发痛风患者的心脏移植

目的 :报告 1例并发痛风的扩张型心肌病的心脏移植手术和进行痛风患者心脏移植的文献回顾。方法 :受体是扩张型心肌病并发痛风患者 ,供体是 5 0岁急性脑死亡患者。手术采用中度低温全麻体外循环 ,采用标准原位心脏移植手术方法。免疫抑制方案手术后早期采用骁悉 ,普乐可复和强的松 ,2周后改为硫唑嘌呤 ,环胞素 A和强的松。结果 :供体心脏热缺血时间为 2 min,冷缺血时间为 130 m in,升主动脉阻闭时间为 75 min,开放升主动脉后心脏自动复跳 ,循环平稳。应用呼吸机时间为 18h。患者在手术后 10 d出现一次急性痛风性关节炎发作 ,用万络治疗好转。患者于手术后 18d由隔离病房回到普通病房 ,病情稳定 ,血尿酸浓度正常 ,无关节症状。结论 :尽管痛风患者进行心脏移植有许多风险 ,手术后还涉及痛风控制药物和免疫抑制剂的相互作用 ,但是如果处理得当 ,还是能够取得良好的手术效果     

Orthotopic heart transplantation in patients with univentricular physiology

Parallel advancements in surgical technique, preoperative and postoperative care, as well as a better understanding of physiology in patients with duct-dependent pulmonary or systemic circulation and a functional single ventricle, have led to superb results in staged palliation of most complex congenital heart disease (CHD) [1]. The Fontan procedure and its technical modifications have resulted in markedly improved outcomes of patients with single ventricle anatomy [2,3,4]. The improved early survival has led to an exponential increase of the proportion of Fontan patients surviving long into adolescence and young adulthood [5]. Improved early and late survival has not yet abolished late mortality secondary to myocardial failure, therefore increasing the referrals for cardiac transplantation [6]. Interstage attrition [7] is moreover expected in staged palliation towards completion of a Fontan-type circulation, while Fontan failure represents a growing indication for heart transplantation [8]. Heart transplantation has therefore become the potential "fourth stage" [9] or a possible alternative to a high-risk Fontan operation [10] in a strategy of staged palliation for single ventricle physiology. Heart transplant barely accounts for 16% of pediatric solid organ transplants [11]. The thirteenth official pediatric heart transplantation report- 2010 [11] indicates that pediatric recipients received only 12.5% of the total reported heart transplants worldwide. Congenital heart disease is not only the most common recipient diagnosis, but also the most powerful predictor of 1-year mortality after OHT. Results of orthotopic heart transplantations (OHT) for failing single ventricle physiology are mixed. Some authors advocate excellent early and mid-term survival after OHT for failing Fontan [9], while others suggest that rescue-OHT after failing Fontan seems unwarranted [10]. Moreover, OHT outcome appears to be different according to the surgical staging towards the Fontan operation and surgical technique of Fontan completion [12].The focus of this report is a complete review of the recent literature on OHT for failing single ventricles, outlining the clinical issues affecting Fontan failure, OHT listing and OHT outcome. These data are endorsed reporting our experience with OHT for failing single ventricle physiology in recent years.     

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.     

Heterotopic heart transplantation: current indications for the procedure, with results in 10 patients

From January 1986 to September 1987, we performed 27 orthotopic and 10 heterotopic cardiac transplantations at our institution. Of the 10 heterotopic transplantation recipients, 9 were men; ages ranged from 36 to 65 years; and indications for transplantation were ischemic cardiomyopathy in 8 patients and dilatative cardiomyopathy in 2 patients. Five of the 10 heterotopic transplantation recipients received donor hearts under emergency conditions, when no hearts of suitable size for orthotopic transplantation were available. In 3 of the 10 heterotopic procedures, we performed pure left ventricular (rather than biventricular) bypass in patients with chronic conditions requiring only aneurysmectomy, or aneurysmectomy in combination with an aortocoronary graft. During postoperative hospitalization, the following complications occurred in the 10 heterotopic-transplantation recipients: 10 infectious episodes in 6 patients; 1 episode of severe graft rejection; and 1 episode of severe gastrointestinal bleeding. All these complications were overcome, and no patient in the heterotopic-transplantation group died. Fifteen months postoperatively, one male in the group lost his graft, but his own heart had by then recovered function, despite dilatative cardiomyopathy. More commonly, late investigation (6 months or longer after transplantation) has yielded ambiguous overall evaluations of pump performance of the recipients' native hearts, showing slight improvement in some instances and further deterioration in others. We conclude that heterotopic heart transplantation is a life-saving procedure in urgent cases when only small donor hearts are available, and that it offers a good chance of hemodynamic and functional improvement not only in emergency cases, but also in cases of chronic cardiomyopathy when there is salvageable myocardium.     

Increased incidence of atrial flutter associated with the rejection of heart transplantation

Atrial fibrillation (AF) and atrial flutter (Afl) are common dysrhythmias that occur after orthotopic heart transplantation (OHT); however, their etiology and clinical significance have not been defined. To determine the precise incidence of sustained AF and Afl and their association with cardiac rejection, 892 consecutive patients who underwent OHT were studied. A total of 104 patients had 113 episodes of Afl; 102 patients had 117 episodes of AF. The incidence of Afl (12.7%) was the same as AF (13.1%). Sixty-nine AF episodes occurred in first 2 weeks after transplantation, and 22 of which were associated with rejection. In contrast, only 20 Afl episodes occurred the first 2 weeks after OHT, 10 of which were associated with rejection. Fifty-two episodes of Afl occurred during from the third week to 6 months after transplantation, 34 of which were associated with moderate to severe cellular or humoral rejection and/or transplant coronary artery disease (TCAD). All 41 Afl episodes that occurred 6 months after transplantation were associated with cellular and humoral rejection, and/or TCAD. The prevalence of Afl was significantly higher in biatrial than bicaval anastomosis. Atrial conduction defect, manifested by the increase of terminal force of the P wave in lead V(1) of the surface electrocardiogram, predicted the occurrence of Afl and AF associated with rejection in OHT with a sensitivity of 89% and specificity of 92%. These results demonstrate that the incidence of Afl increased after OHT, which might be a consequence of cellular and humoral rejection, and coronary vasculopathy of the transplanted hearts.     

Influence of pre-existing donor atherosclerosis on the development of cardiac allograft vasculopathy and outcomes in heart transplant recipients.

OBJECTIVES: This study sought to evaluate the influence of donor lesions on the development of cardiac allograft vasculopathy and outcomes in heart transplant recipients. BACKGROUND: After orthotopic heart transplantation (OHT), coronary artery narrowing occurs as a combination of pre-existing donor lesions and new lesions that develop as a result of cardiac allograft vasculopathy. METHODS: Intravascular ultrasound (IVUS) studies were performed in 301 recipients at 1.3 +/- 0.6 months and again at 12.2 +/- 0.8 months after OHT. Additional IVUS studies were performed in 90 patients at two and three years of follow-up. Sites at baseline with maximum intimal thickness > or =0.5 mm were defined as pre-existing donor lesions. The angiographic diagnosis of transplant coronary artery disease (TCAD) was defined as a new > or =50% diameter narrowing of a major epicardial vessel. RESULTS: Donor lesions were present in 30% of the hearts. By IVUS, sites with donor lesions did not have a greater increase in intimal area compared with sites without donor lesions. Angiographically, the incidence of TCAD up to three years after transplantation was higher in recipients with donor lesions than in recipients without donor lesions (25% vs. 4%, p < 0.001). However, the three-year mortality rate was similar between recipients with or without donor lesions (4.5% vs. 5.2%, p = 1.0). CONCLUSIONS: Pre-existing donor lesions do not act as a nidus for accelerating the progression of intimal hyperplasia. However, patients with donor lesions have a higher incidence of angiographic TCAD. Donor lesions do not affect the long-term survival of patients with OHT up to three years.     

全心脏原位移植(附4例报告)

目的总结4例全心脏原位移植的经验。方法我院于2005年4月至2006年12月对4例扩张型心肌病患者施行了全心脏原位移植手术,其中男性2例,女性2例,年龄32～57岁。供体均为急性脑死亡者。供心心肌保护3例为UW,1例为HTK液。全心脏移植吻合次序依次左肺静脉、右肺静脉、下腔静脉、上腔静脉、肺动脉及主动脉,其中2例由于受体全心脏扩大,按常规保留的受体上、下腔静脉长度无法与供体腔静脉吻合,为此,截取一段长4cm的供体肺动脉,一端与受体下腔静脉吻合,另一端与供体下腔静脉吻合。吻合时间78～104min,主动脉阻断时间136～197min,体外循环时间202～261min。主动脉开放后,1例电击复跳,3例自动复跳,均为窦性心律,未安置心脏临时起搏器。结果患者术后3～6h神志清楚,14～19h拔除气管插管,6d拔除所有侵入性监测管道,两周后从ICU迁至普通病房,1例术后52d出现急性排异反应,经处理得到控制,均痊愈出院。术后随访心功能均为I级,窦性心律,2例有轻度三尖瓣反流,2例已经恢复工作。结论全心脏原位移植法不仅保存左右心房解剖上完整性,有利于心功能恢复,减少移植后血栓的发生率,而且使房、室间隔传导系统的完整性免遭破坏,降低了心律失常的发生率,这是一种值得推荐的心脏移植方法。     

Recurrent Protein‐losing Enteropathy and Tricuspid Valve Insufficiency in a Transplanted Heart: A Causal Relationship?

This case report describes a toddler who developed a protein‐losing enteropathy (PLE) 4 years after orthotopic heart transplantation (OHT). He was born with a hypoplastic left heart syndrome for which he underwent a successful Norwood procedure, a Hemi–Fontan palliation, and a Fontan palliation at 18 months of age. Fifteen months following the Fontan operation, he developed a PLE and Fontan failure requiring OHT. Four years after OHT, he developed a severe tricuspid regurgitation and a PLE. His PLE improved after tricuspid valve replacement. It is now 2 years since his tricuspid valve replacement and he remains clinically free of ascites and peripheral edema with a normal serum albumin level. His prosthetic tricuspid valve is functioning normally.     

Incidence of atrial fibrillation in heart transplant patients: long-term follow-up

BACKGROUND: The incidence of atrial fibrillation (AF) in heart transplant patients has not been well documented. METHODS: To determine the incidence of AF in a cohort of patients undergoing cardiac transplantation, clinical data were obtained from a prospectively collected database for all consecutive orthotopic heart transplantation (OHT) patients and for all consecutive coronary artery bypass graft (CABG) surgery patients between January 1984 and March 2004 at our institution. A cohort of 1,714 OHT patients and low-risk CABG (normal ejection fraction [EF] and no left ventricular hypertrophy [LVH]) patients were age- and sex-matched. RESULTS: The average age in the two groups was 56 +/- 7 years with 87% male and 81% white race and body mass index (BMI) of 26 +/- 4. There were 3 cases of AF (0.3%) in the OHT group and 757 cases of AF (21%) in the low-risk CABG group. The strongest independent predictor of freedom from postoperative AF was having had a transplant (odds ratio [OR] 96, 95% confidence interval [CI] 13-720). The incidence of AF, atrial flutter (AFL), and supraventricular tachycardia (SVT) in OHT was 0.33, 2.8%, and 1.3%, respectively. Given that incidence of AF, AFL, and SVT in historical post-CABG population is 25%, 17%, and 4.3%, transplanted patients appear to have lower incidence of AF, AFL, and SVT than the reference population. Consistent with this, transplanted patients underwent few ablation procedures for atrial arrhythmias. Additionally, the three patients with AF had bicaval anastomoses suggesting the possibility of PACs originating in the donor superior vena cava (SVC) or IVC (inferior vena cava) initiating AF in these patients. CONCLUSIONS: In a cohort study of transplant and low-risk CABG patients, the strongest independent predictor of freedom from AF is having undergone transplant surgery. One potential explanation for the markedly lower incidence of AF may be effective isolation of thoracic veins with documented cases retaining the native SVC.