不同受者同期分别接受同一供者的心、肺移植六例

目的为提高供者器官的利用率，探讨将同一供者的心、肺同期移植给不同受者的可行性及手术方法。方法采用原位灌洗、整块切取的方法获得3例供者的心脏和双肺，分别同期移植给3例终末期心脏疾病患者和3例终末期肺脏疾病患者。供者先行机械通气，然后开胸，主动脉及肺动脉分别插入灌注管，经主动脉插管灌注HTK液，经肺动脉插管灌注改良棉子糖低钾右旋糖酐液，对心、肺进行灌洗，然后整块切取心、肺。受者手术前进行供心、肺的分离，然后再次进行心、肺的逆行灌洗（通过上、下肺静脉插管和主动脉根部或者经腔静脉冠状窦逆行插管）。施行单侧肺移植者，再将左、右供肺分离。3例肺移植受者中，1例行左单肺移植，其他2例为非体外循环下序贯式双肺移植；3例心脏移植者均采用双腔静脉吻合法施行原位心脏移植。结果1例左单肺移植受者术后恢复良好；1例双肺移植受者术后出现右肺上叶静脉栓塞，于术后第9天再次手术，切除右肺上叶，后痊愈出院；另1例双肺移植受者，术后出现支气管吻合口狭窄，并发肺部感染，经对症治疗后好转出院，术后7个月死于重症感染。1例心脏移植受者术后早期出现肾功能衰竭，经血液透析治疗后痊愈出院，3例心脏移植受者术后生活质量良好，心功能恢复到0-I级。结论将同一供者的心、肺分别移植给不同受者，能充分利用供者器官，方法可行，效果良好。     

心肺联合移植11例单中心经验

目的总结心肺联合移植经验。 方法回顾性分析2015年9月至2018年11月广州医科大学附属第一医院完成的11例心肺联合移植受者临床资料。男性7例,女性4例,平均年龄(32±11)岁。原发病为艾森曼格综合征3例,特发性肺动脉高压4例,复杂先天性心脏合并肺血管病变、肺动脉栓塞、双肺移植术后心肺功能衰竭及扩张型心肌病合并慢性阻塞性肺疾病各1例。供者选择参照肺移植及心脏移植标准。11例受者均采用胸骨正中切口,经主动脉和上、下腔静脉远端插管建立体外循环,切除受者心肺后,植入供肺和供心,依次吻合气管、主动脉、上腔静脉及下腔静脉。 结果11例受者中,4例术后30 d内死亡,其中2例死于胸腔及纵隔出血,2例死于脑血管并发症;术后30 d至1年死亡3例,死因为排斥反应引起的移植物功能障碍及感染、移植物功能障碍导致的多器官功能衰竭。术后1年有4例受者存活。 结论严格选择供、受者以及术中后纵隔彻底止血可显著降低心肺联合移植手术死亡率,提高受者术后生存率及生存时间。     

套管法与缝合法行大鼠异位心脏移植术的比较

目的：分别采用缝合法和套管法制作大鼠异位心脏移植模型，以便为器官移植的研究提供理想的手术方式。方法：SD大鼠为受者，Wistar大鼠为供者。套管法是将供者的无名动脉和肺动脉分别与受者的颈总动脉和颈外静脉行套管连接。缝合法是将供者的升主动脉和肺动脉分别与受者的腹主动脉和下腔静脉吻合。结果：套管法手术180次，手术成功率高于96％；缝合法手术20次，手术成功率小于40％。结论：套管法心脏移植术操作简单，热缺血时间短，并发症少，手术成功率明显提高。     

双腔法原位心脏移植术后心脏功能和形态学观察

目的:探讨双腔原位心脏移植术对移植后远期心脏形态和功能的影响。方法:1997年8月10日为一例终末期慢性克山病患者实施了双腔原位心脏移植。供心的上、下腔静脉分别与受体的上、下腔静脉吻合,左房的吻合同标准术式。手术吻合时间为61分钟,体外循环时间为182分钟。结果:主动脉开放后心脏自动复跳,生命体征平稳,心电图示单一房性P波。至今已存活1年余,生活质量良好,心功能Ⅰ级。经食道超声心动图示心房和心室大小正常,无房室瓣返流。结论:此方法在技术上是可行的,能够保留供心右心房解剖和功能的完整性,特别是能保持传导系统的完整性。     

大鼠的工作型与非工作型同种异体心脏移植模型比较

目的比较大鼠的工作型与非工作型同种异体心脏移植模型的优缺点。方法供者为Wistar大鼠（20只），受者为SD大鼠（20只），随机平均分为2组，建立工作型与非工作型腹部同种异体心脏移植模型。工作型移植模型为：供心肺动脉与受者左心房吻合，左心室血液经供心主动脉吻合口进入受者腹主动脉。非工作型移植模型为：供心肺动脉与受者下腔静脉端侧吻合，供心主动脉与受者腹主动脉端侧吻合。结果工作型与非工作型心脏移植模型手术成功率均为90％；总手术时间分别为（75．1±4．9）min和（85．8±7．4）mira术后恢复时间分别为（261．1±45．4）min和（387．8±39．6）min。工作型心脏移植模型总手术时间比非工作型约少10min，术后恢复时间明显缩短，差异有统计学意义。术后超声心动图显示工作型移植心有射血功能。结论大鼠的工作型腹部心脏移植模型总手术时间短、受者存活率高，更接近心脏的生理要求。     

大鼠原位肝、肾一期联合移植模型的建立

目的　建立一种简易可靠的大鼠肝、肾联合移植模型。方法　以SD大鼠作供、受者,以4 ℃乳酸林格液经门静脉和腹主动脉对供者的肝脏和左肾进行原位灌洗,肝下下腔静脉在右肾静脉以下切断。供肝肝上下腔静脉用显微外科技术缝合,双袖套法吻合肝下下腔静脉及门静脉;带瓣左肾动脉与受者的腹主动脉吻合,袖套管法吻合肾静脉;用支架管重建胆道和输尿管。结果　共完成54次大鼠肝、肾一期联合移植手术,其中预实验24 次,正式实验30 次,正式实验的手术成功率为76.7 %,移植肝及肾功能良好。结论　此模型可以用于移植相关研究。     

大鼠胰十二指肠移植动物模型的制作

目的　建立大鼠腔静脉内分泌引流、肠道外分泌引流的动物模型。方法　雄性SD大鼠为供受者,供体鼠门静脉与受体鼠左肾静脉行袖套吻合,形成腔静脉内分泌引流;供者腹主动脉与受者腹主动脉行端侧吻合;供者十二指肠与受者近端空肠行侧侧吻合。结果　5 0只药物诱导的糖尿病大鼠移植术后超过2 4h者46只,手术时间为(93±7)min。移植前大鼠血糖为(2 8.3±1.7)mmol/L ,移植后43只大鼠血糖降至正常水平。结论　该模型方法简单易行,可作为胰腺移植的理想模型     

大鼠原位肝移植模型不同灌注方式和吻合方法的效果比较

目的 分析不同灌注方式和不同肝上下腔静脉吻合方法对建立大鼠原位肝移植模型的影响。方法 将80只SD大鼠随机分为供肝获取组和受体肝移植组，每组40只。供肝获取组10只大鼠采用腹主动脉输液器滴灌法（1滴/s）,10只大鼠采用腹主动脉微量泵灌注法（6 mL/min），之后分别进行受体肝移植（每组对应10只大鼠肝移植），收集2组大鼠的供肝灌注时间和供肝获取时间，并于灌注后、肝移植24 h取肝脏组织行HE染色。受体肝移植组10只大鼠肝移植时采用连续吻合法，10只采用减张力半针吻合法（2组均在成功完成10只肝移植后截止），收集2组大鼠的肝上下腔静脉吻合时间、无肝期时间和术后发生并发症发生情况。结果 与腹主动脉输液器滴灌组比较，腹主动脉微量泵灌注组的供肝灌注时间和供肝获取时间较短（P<0.05）;HE染色结果显示，腹主动脉微量泵灌注组的肝细胞、门静脉及胆管形态学无明显改变，仅个别淋巴细胞浸润。与连续吻合组比较，减张力半针吻合组大鼠的肝上下腔静脉吻合时间和无肝期时间较短（P<0.05），术后吻合口出血和供肝灌注不全发生率较低（P<0.05）。结论 相对于腹主动脉输液器滴灌法，腹主动脉...     

改进的套袖法吻合肾动脉建立大鼠原位肾移植模型

目的 观察改进的套袖法吻合肾动脉用于大鼠肾移植的可行性.方法 选择F344大鼠和Lewis大鼠分别作为肾移植的供、受者.切取供者左侧肾脏时,先剪断输尿管,然后阻断肾动、静脉水平上下的腹主动脉和下腔静脉,靠近下腔静脉剪断左肾静脉根部,经腹主动脉注入含肝素的4℃生理盐水对供肾进行原位灌洗后,靠近腹主动脉剪断肾动脉根部,取出供肾,放入4℃生理盐水中保存.切除受者左侧肾脏时,尽可能长的保留肾动、静脉以利于吻合.供肾植入时,采用改进的套袖法:用显微镊轻轻扩张供肾动脉后,协助显微持针器将针从供肾动脉血管外向血管内穿入,并从血管断端穿出第1针;接着穿入受者肾动脉断端,从受者肾动脉腔内向腔外穿出第2针;然后再从供肾动脉腔内、靠近第1针进针点处向腔外穿出,并与第1针的另外一端打结,此时受者的肾动脉已套入供肾动脉内;将供肾动脉边缘与受者肾动脉外膜固定2针,2针呈180度对角.供、受者的肾静脉及输尿管均行端端吻合.术后5 d内.若受者死亡,则认为手术失败.结泉共行肾移植20次,整个手术耗时70～90 min,供肾热缺血时间为4～9 s,冷缺血时间为30～40 min,肾动脉吻合用时(4.6±0.6)min,肾静脉吻合用时(11.8±1.2)min,输尿管吻合用时(12.2±1.4)min.术后5 d内,受者不明原因死亡1只,存活19只,手术成功率为95%.结论 采用改进的套袖法吻合肾动脉具有便捷、易于掌握、可靠及实用等优点,大鼠肾移植的成功率较高.     

二例原位心脏移植的术后处理

我院于 1992年 7月连续为 2例晚期扩张型心肌病患者施行了原位心脏移植术 ,结果 1例术后存活 17个月 ,另 1例术后存活 31个月。报告如下。一、临床资料例 1　男 ,5 5岁。临床确诊为晚期扩张型心肌病 ,频发多源性室性早搏 ,心功能Ⅳ级。 1992年 7月 5日在全身麻醉、体外循环下切除病变心脏 ,同时行原位心脏移植术。主动脉阻断时间 45ｍｉｎ ,体外循环时间 78ｍｉｎ。尸体供心 ,供者为男性 ,18岁 ,供、受者ＡＢＯ血型相同 ,体重比为 1∶1.0 5 ,供心总缺血时间 85ｍｉｎ。受者术后在严格消毒隔离的单间监护室治疗和护理 1个月 ,其后转入普通单…     

Late failure of double-inlet left ventricle septation: treatment by orthotopic heart transplantation

We report a patient in whom orthotopic heart transplantation was performed after late failure of ventricular septation for double-inlet left ventricle. This case shows that orthotopic heart transplantation represents a valid therapeutic alternative in children with previous correction of complex congenital heart defects not amenable to further intracardiac repair.     

肝、肾联合移植治疗肾移植术后移植肾功能衰竭并肝硬化一例报告

目的 报告1例移植肾功能丧失并肝炎后肝硬化者再次接受肝，肾联合移植。方法 给1例肾移植术后移植肾功能丧失并肝炎皇肝硬化患者先行失功能移植肾的切除。针对患者群体反应抗体（PRA）较高（66%），切除术后第5d开始每天给予环磷酰胺50mg。连服3个半月，并行血浆置换2次。PRA降至23%。3个半月后施行一期肝，肾联合移植，肝移植采用原位背驮式肝移植术式。供肾移植于左髂窝，肝血流开放后每间隔30min检测PRA1次，术后免疫抑制治疗采用他克莫司（FK506）。霉酚酸酯（MMF）和激素。结果 术后移植肝，肾立即发挥功能。肝动，静脉血流开放后，，PRA由23%降至5%。并维持在8%左右。术后乙型肝炎病毒表面抗原转阴，丙型肝炎病毒抗体阴性，随访3个月，移植肝，肾功能正常。结论 对于移植肾功能丧失，且合并有肝硬化，肝功能不良者，再次施行肝，肾联合移植是可行的。     

A pooled analysis of posttransplant survival following combined heart-liver transplantation

Because no single center has accumulated a large experience with this complex operation, the effectiveness of combined orthotopic heart transplantation (OHT) and orthotopic liver transplantation (OLT) in achieving long-term survival has been unknown. Cases of OHT-OLT were pooled from a U.S. transplant recipient registry and from previously published literature. Aggregate data from these sources was used for survival analysis. Thirty-six patients having undergone OHT-OLT were listed in the national registry; the one- and five-year patient survival rates of these patients were 88% and 78%, respectively. Many patients remain alive at 8+ years after transplantation. An analysis of the pooled results of previously-published cases estimated a one-year patient survival rate of 84%. In selected disease processes, OHT-OLT can correct underlying metabolic deficiencies. While rarely indicated, OHT-OLT is a successful treatment for patients with end-stage heart and liver disease, with survival comparable to that seen after isolated orthotopic heart or orthotopic liver transplantation.     

Repeated paracentesis for treatment renal failure after heart transplantation in patient with ascites

We report a case of orthotopic heart transplantation in a 42-year-old man who had cardiomyopathy with severe biventricular heart failure, ascites, and large umbilical hernia. He successfully received an orthotopic heart transplantation. After heart transplantation, renal failure was noted. Ascites and renal failure were successfully managed with repeated paracentesis. His cardiac and abdominal symptoms subsided gradually following transplantation. His umbilical hernia was repaired 55 days after the heart transplantation because of strangulation. In this case study, we report a patient with ascites who was treated for postoperative renal failure with repeated paracentesis.     

Successful orthotopic heart transplantation in a patient with Marfan syndrome

Cardiovascular diseases represent the leading cause of mortality in patients with Marfan syndrome. Many treatments have been developed for patients with end‐stage heart failure, among which orthotopic heart transplantation remains the gold standard. We report a successful orthotopic heart transplantation for a Marfan syndrome patient in end‐stage heart failure.     

原位心脏移植21例近期疗效分析

目的总结21例原位心脏移植的近期疗效。方法2002年4月至2005年6月连续对21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3.0~5.9wood单位,平均(4.3±1.4)wood单位;应用4℃Stanford大学心肌保护液或HTK液保护供心,供心冷缺血时间为52~310min,平均(81±23)min;3例受体有既往体外循环心脏手术史,除1例采用全心脏原位移植术外,其余20例为标准式原位心脏移植手术;术前使用抗Tac单抗诱导治疗1次,术后采用环孢素A、霉酚酸酯和泼尼松预防急性排异反应;术后应用药物控制血压、血糖、血清胆固醇和尿酸水平在合理范围。结果术后早期并发急性右心衰3例,心包大量积液4例。未出现感染、急性排异反应和急性肾功能衰竭等并发症。均痊愈出院。21例患者已生存2~37个月(平均23个月),出院后生活质量良好。结论原位心脏移植可获得满意的近期疗效。低肺血管阻力受体的选择、良好的供心心肌保护、熟练的移植技术、免疫抑制剂的合理选择和围手术期的正确处理是提高心脏移植近期疗效的主要措施。     

心脏移植治疗终末期冠心病五例

目的总结心脏移植治疗终末期冠心病的体会。方法共有5例患者,1例为2次急性心肌梗死后行左心辅助泵植入术后25个月的患者,3例为急性心肌梗死后大面积无存活心肌、出现心力衰竭的患者,1例为经皮冠状动脉支架置入术和冠状动脉旁路移植术后仍反复发生心力衰竭的患者。均施行标准式原位心脏移植术。术前使用达利珠单抗诱导治疗1次,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5例患者均痊愈出院,恢复正常的生活和工作,心功能均恢复至Ⅰ级;术后未发生严重的感染和急性排斥反应。结论心脏移植可作为治疗不适宜施行冠状动脉旁路移植术,或冠状动脉旁路移植术后效果较差的终末期冠心病患者的有效手段;选择合适的供心、良好的心肌保护、合理的抗排斥治疗方案,以及围手术期血压、血糖、血清胆固醇、尿酸的有效控制,是手术成功的关键。     

Successful treatment of acute dissection of the donor aorta after orthotopic heart transplantation.

Acute aortic dissection is one of the rare aortic complications that occur after orthotopic heart transplantation. We report the second case of successful surgical treatment of aortic dissection confined to the donor aorta in a recipient of an orthotopic cardiac allograft. A 68-year-old patient was admitted with chest pain and shortness of breath 7 years after orthotopic heart transplantation. He previously had undergone twice coronary artery bypass grafting. Echocardiography revealed acute dissection of the donor aorta. The patient underwent urgent Bentall procedure with a prosthetic conduit. The post-operative course was uneventful. The heart donor was a 40-year-old man with known arterial hypertension and who had received long-term ergotamine tartrate therapy for migraine. This case demonstrates that heart-transplant recipients with arterial hypertension and donor-related risk factors are prone to aortic complications and require careful follow-up.     

Resting hemodynamics after total versus standard orthotopic heart transplantation in patients with high preoperative pulmonary vascular resistance

Objective: Pretransplant pulmonary vascular resistance ≥4 Wood-units predisposes to right ventricular failure after heart transplantation. Total orthotopic heart transplantation with bicaval and pulmonary venous anastomoses offers synchronous contractions of the atria and a normal ventricular filling pattern, but requires longer ischemic time than standard orthotopic heart transplantation. To test if total orthotopic heart transplantation improves resting hemodynamics in pts with high preoperative pulmonary vascular resistance, we analyzed 65 pts with standard and 65 with total orthotopic heart transplantation transplanted between 12/88 and 7/94. Of these, 18 with total and 15 with standard orthotopic heart transplantation had a preoperative pulmonary vascular resistance ≥4 Wood-units. Methods: Right heart catheterization data were obtained at each endomyocardial biopsy. All data from biopsies at both 2 weeks and 1 year posttransplant that were free from humoral or greater than 1A cellular rejection (9 versus 13 pts) were included in a two way ANOVA. Pts with postop pacemakers, atrial fib or β-blocker therapy at the time of biopsy were excluded. Results: Ischemic time was different (172±44 versus 142±28 min, P=0.03). Demographics, NYHA class, pre-TX hemodynamics, donor age and inotropes were similar. Cardiac output and index were higher in the total orthotopic group at 2 weeks (6.5±1.7 versus 5.1±1.0 l/min; 3.4±0.9 versus 2.8±0.6 l/min per m²) and 1 year (7.1±2.0 versus 4.9±1.1 l/min, P=0.002; 3.6±1.1 versus 2.6±0.5 l/min per m², P=0.009). Right atrial and pulmonary arterial mean pressure (mmHg) were lower with total orthotopic heart transplantation at 2 weeks (6±4 versus 9±5, P=0.04; 22±3 versus 25±7, P=0.1) and 1 year (5±2 versus 7±3, P=0.02; 19±4 versus 25±7, P=0.03). Pulmonary capillary wedge pressure (mmHg) was borderline nonsignificant (11±4 versus 13±7 at 2 weeks, 8±3 versus 14±5 at 1 year, P=0.055), as well as pulmonary vascular resistance (1.9±1 versus 2.5±1 at 2 weeks, 1.5±0.6 versus 2.7±1.7 WU at 1 year, P=0.051). Conclusions: Total orthotopic heart transplantation improves cardiac output and index in pts with high preoperative pulmonary vacular resistance. There is a lower mean RA and PA pressure perhaps due to less tricuspid and mitral regurgitation. In view of the frequently observed restrictive filling pattern after cardiac transplantation, total orthotopic heart transplantation can be beneficial until this pattern has subsided by preserving atrioventricular synchrony and offering better atrial transport.