原位心脏移植治疗终末期心脏病141例

目的分析总结原位心脏移植治疗终末期心脏病的临床疗效及经验。方法为141例终末期心脏病患者施行原位心脏移植术,原发病包括扩张性性心肌病118例,肥厚性心肌病2例,限制性心肌病2例,缺血性心肌病9例,原发性心脏恶性肿瘤4例,瓣膜性心肌病3例,其它病因3例。供心冷缺血时间为(191.0±28.5)m in,供心卵圆孔未闭者9例,大室间隔缺损者1例,冠状动脉开口异常者1例。9例卵圆孔未闭的供心,先行卵圆孔缝闭术,然后再行移植;1例大室间隔缺损的供心,先行室间隔缺损修补术,然后再行移植;1例冠状动脉开口异常的供心,复跳后心肌收缩乏力,遂施行右冠状动脉松解术,其后复跳良好。120例行双腔静脉吻合法原位心脏移植术,19例行标准Stanford原位心脏移植术,2例行全心脏移植术。主动脉阻断时间为(53.0±4.5)m in,吻合时间为(41.5±5.5)m in。术后应用环孢素A(或他克莫司)、激素及霉酚酸酯预防排斥反应,28例患者同时应用达利珠单抗1~5剂。结果手术成功率为97.9%,术后随访1~65个月,1年、3年、5年存活率分别为90.8%、84.6%、81.4%,术后1年内的主要死因是急性排斥反应、感染、移植物功能衰竭及心脏肿瘤转移,术后中远期的主要死因是急性排斥反应、感染、肾功能衰竭及移植心脏冠状动脉硬化。术后并发症以急性排斥反应、感染、肾功能异常、移植心脏功能衰竭多见。结论终末期心脏病行原位心脏移植的临床疗效良好;远期需注意对急性排斥反应、感染及移植心脏冠状动脉硬化的监测及治疗。     

原位心脏移植17例报告

目的探讨影响心脏移植手术效果的主要因素。方法2003年3月至2009年7月连续为17例患者施行了原位心脏移植术,其中扩张型心肌病13例,肥厚型心肌病3例,缺血性心肌病1例。采用标准原位心脏移植手术1例,双腔静脉吻合法原位心脏移植手术16例,其中1例联合肾脏移植。5例术前存在中度肺动脉高压,NO吸入等措施降肺动脉压力,2例重度肺动脉高压者增加前列环素治疗。抗排异治疗采用环孢素A（CsA）＋皮质激素（Pred）＋骁悉（MMF）三联方案。结果2例分别于术后早期出现急性排斥反应,给予大剂量甲基强的松龙冲击治疗3天缓解,1例术后第3天出现。肾衰竭,给予血液透析治疗,1例术后25h死于肠道出血,1例心肾联合移植者于术后18天死于肺动脉栓塞。随访1～76个月,晚期死亡1例,1例于术后35天死于肾衰竭及抗排斥药物神经毒性反应,存活病例心功能恢复至0～I级,恢复正常工作和生活,晚期发生急性排斥反应1例,经激素冲击治疗恢复正常。结论心脏移植是治疗终末期心脏病的有效方法,严格掌握受体适应证、良好的供心保护、合适的手术方法及严格围术期患者管理可提高心脏移植手术效果。可逆性重度肺动脉高压患者,经过药物治疗肺阻力降至6wood单位以下者可取得良好效果。     

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。     

原位同种心脏移植—1例报告

我们报告１例久治无效的扩张型心肌病病人接受同种原位心脏移植，至今仍存活，生活质量良好，已恢复劳动。术中采用温血停跳保护心肌，效果满意，避免或缩短热缺血时间至关重要。对于供受心正确对位、防止吻合口出血和血管外翻式吻合等提出要点和对策。联合应用多种抗排异反应药物，均有效，但药量不宜过大。心肌活检仍为诊断排异反应的唯一手段，应减少心肌活检次数。在我国供心来源仍是阻碍心脏移植的关键问题。     

同种异体原位心脏移植(附6例报道)

目的　探讨心脏移植术过程中术式 ,心肌保护 ,术后并发症等相关问题。方法　对 6例实施原位心脏移植患者的临床资料进行分析、总结 ,得出相关数据 ,经统计学处理。结果　 6例患者中 ,移植方法采用标准法 4例 ,双腔法 1例 ,全心脏法 1例。供心平均热缺血时间为 (10 .5± 1.8)min,冷缺血时间为 (4 9± 14.7)min。存活时间分别为 8年、7年、5年、3 .5年、2年、0 .5年。结论　充分的术前准备 ,适当的术式选择 ,良好的心肌保护 ,术后右心衰竭的预防与治疗是心脏移植成功的关键     

总结69例心脏移植中供心的心肌保护技术

目的总结心脏移植中供心的心肌保护技术，分析供心的灌注、保存以及缺血时间对心脏移植效果的影响。方法回顾性分析2004年6月至2006年9月间的69例晚期心脏病患者行心脏移植术的临床资料。供心的心肌保护采用低温St．Thomas液和HTK液顺序灌注方法，术中供心保持持续低温状态。根据供心缺血时间长短将受者分为两组，A组36例，供心缺血时间小于240min；B组33例，供心缺血时间大于240min。术后对受者进行定期随访。结果在心脏移植术中，B组受者较A组的体外循环时间延长。术后两组受者的死亡率、移植心功能、排斥反应以及并发症等资料的比较，差异无统计学意义（P〈0．05）。所有受者在心脏移植后，无近期死亡，但随访期间死亡6例。结论采用St．Thomas液和HTK液顺序冷灌注的改良方法，能够有效的保护供心心肌组织；供心缺血时间的缩短会使心肌泵血功能恢复较快。这些对移植心功能的恢复和受者的预后具有良好的近期和中期效果。     

三例原位心脏移植的疗效分析

自１９９２年４月以来我们成功地实施了３例原位心脏移植。术中供心保护采用经冠状静脉连续灌注信上微温血。２例采用原位心脏移植的标准式，１例采用全心脏原位移植术。采用连续血管内膜外翻缝合。术后患者恢复佳。无并发症，心功能Ⅰ级，已分别存活５年、３年和１年半。正确的手术方法，早期发现急性排以应和正确的自理等是提高移植后近，远期疗效的重要因素。     

心脏移植中供心保护新策略

心脏移植是现代医学对临床治疗无效的晚期或进展期心脏病惟一可行的治疗方法.供心保护是在常规心脏手术心肌保护的基础上发展起来的,贯穿于供心采集和移植吻合的各个环节之中,包括能量状态保护、能量资源保护以及结构保护,以期为受体提供一个具有活力和最大潜能的心脏.良好的供心保护,不仅直接提高移植的成功率,改善移植后的远期疗效,而且可以延长保存时间,扩大供心来源.此文结合当前心肌保护领域的研究热点阐述了各阶段供心保护的策略.     

原位心脏移植术后右心衰竭四例

目的为降低原位心脏移植患者术后右心衰竭的发生率,分析其术后发生右心衰竭的原因,并总结治疗经验。方法4例晚期心脏病患者行原位心脏移植,术后均发生右心衰竭。根据心导管资料及尸体检查结果,分析原位心脏移植受者的选择,并提出右心衰竭的处理方法。结果4例原位心脏移植术后发生右心衰竭患者中2例死亡;2例存活患者恢复顺利。结论右心衰竭是原位心脏移植术后近期死亡的主要原因,必须严格掌握对受者的选择。     

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。     

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。     

Infant orthotopic cardiac transplantation

Infant orthotopic cardiac transplantation has been recently applied to various forms of congenital heart disease with encouraging short-term results. Between June 1986 and September 1987 we evaluated 16 infants for orthotopic cardiac transplantation. Fourteen had hypoplastic left heart syndrome, one had endocardial fibroelastosis with aortic atresia, and one had anomalous pulmonary arterial origin of the left main coronary. Eight families accepted the treatment program and eight families refused (two because of associated anomalies and six on philosophical grounds). Of the eight patients who were candidates for orthotopic cardiac transplantation, one died 6 hours after diagnosis, one was allowed to die after 60 days because of acquired neurologic complications, and another had congenital cytomegalic virus infection. The remaining five patients (four with hypoplastic left heart syndrome, one with anomalous pulmonary arterial origin of the left main coronary) had orthotopic cardiac transplantation. The operation was performed with absorbable polydioxanone suture with deep hypothermia and circulatory arrest in four neonates for hypoplastic left heart syndrome (average time 47 minutes) and bicaval cannulation and continuous bypass in one 11-month-old infant for anomalous origin of the left main coronary. In-house retrieval was used in all. One neonate died of complications as a result of pretransplant donor heart dysfunction and size discrepancy, whereas the remaining three neonates and one infant survived and are home 23 months, 12 months, and 8 months (the patients with hypoplastic left heart syndrome) and 17 months (the patient with anomalous origin of the left main coronary) postoperatively. Triple-drug immunosuppression included cyclosporine, azathioprine, and prednisone. Rejection was diagnosed by clinical evaluation of child activity and monocyte cell cycle analysis from peripheral blood samples without myocardial biopsies. Routine echocardiograms, electrocardiograms, and chest x-ray films were not helpful. Six episodes of rejection were successfully treated in four patients. Twelve-month postoperative catherization in one patient (hypoplastic left heart syndrome) showed appropriate graft growth, no aortic or pulmonary anastomotic strictures, normal right and left ventricular function, and no coronary artery disease. We conclude that infant orthotopic cardiac transplantation is an acceptable procedure for severe forms of untreatable congenital heart disease. The excellent short-term results warrant continued application of orthotopic cardiac transplantation.     

二例原位心脏移植成功的围术期处理

目的总结２例原位心脏移植成功的围术期处理经验，探讨供心保护、免疫抑制剂应用、早期诊治急性排斥反应、预防右心功能不全、抗感染和营养支持等问题。方法１９９５年８月和１９９７年４月先后为２例终末期扩张型心肌病患者施行了原位心脏移植术。术后免疫抑制剂应用环孢素Ａ（ＣｙｃｌｏｓｐｏｒｉｎＡ）、硫唑嘌呤（Ａｚａｔｈｉｏｐｒｉｎｅ）、强的松（Ｐｒｅｄｎｉｓｏｎｅ）三联疗法。结果２例患者目前已分别存活３年和１年半，心功能正常、生活质量良好。结论围术期的处理是否得当是术后早期顺利康复的关键，亦直接影响着手术患者的存活率     

Nitric oxide inhalation in the treatment of primary graft failure following heart transplantation.

BACKGROUND: Primary graft failure from right or left ventricular insufficiency remains a serious cause of early death following heart transplantation. Inhaled nitric oxide (NO) is a potent pulmonary vasodilator that could decrease pulmonary pressure and improve right ventricular function. METHODS: Two cases of early graft failure following orthotopic heart transplantation were treated with NO inhalation. The treatment consisted of inhalation of 20 ppm of NO, introduced 4 to 6 hours following transplantation, in 2 patients supported with high doses of inotropic agents and vasopressors in addition to the intra-aortic balloon pump. RESULTS: In the first and second cases, NO inhalation resulted in a decrease in pulmonary artery pressure, in a decrease in pulmonary vascular resistance and in an increase in cardiac index. In the second patient, systemic oxygenation improved markedly 30 minutes after initiation of NO. In the 2 patients, NO inhalation, mechanical ventilation and the intra-aortic balloon pump were weaned 4 days following transplantation. CONCLUSION: Primary graft failure from donor ischemic damage, reperfusion injury or pulmonary hypertension remains a serious complication. The use of an intra-aortic balloon pump, inotropic agents and of inhaled NO appears to offer the best support for recovery of donor heart function. Primary graft failure from right or left ventricular insufficiency remains a serious cause of early mortality following heart transplantation. Ischemic damage of donor heart, reperfusion injury or pulmonary hypertension are the main causes of early graft failure. Although the cause is multifactorial, treatment of primary organ failure remains difficult with dismal results. The objective of the present study was to review the result of 2 patients with donor right heart failure following heart transplantation treated with inhaled nitric oxide (NO).     

Distant heart procurement for transplantation.

Between January 1, 1977, and September 15, 1978, 39 cardiac transplants were performed on 38 patients. Twenty donor hearts were removed at Stanford University Hospital, and 19 donor hearts were removed at distant hospitals. The characteristics of recipients and donors in both groups were similar. The only significant difference between donor hearts was the mean ischemia time (154 +/- 30 minutes in distant hearts and 52 +/- 12 minutes in local hearts, P less than 0.001). As of February 1, 1979, the total mortality rate was 32% for the distant heart donors and 40% for the local heart donors. No difference between the two groups was present in immediate myocardial function, the need for postoperative inotropic support, the mortality rate within the first 90 days after operation, the mean maximum serum enzyme levels, the occurrence of rejection or infection, and the histological appearance of the hearts, both early and late. The results of cardiac transplantation when hearts are removed at distant hospitals are entirely comparable to the results with hearts removed on site with a minimum ishchemic time. Distant heart procurement provides an expanded donor pool for potential cardiac recipients.     

Relationship of cardiac allograft size and pulmonary vascular resistance to long-term cardiopulmonary function.

The purpose of this study was to evaluate the long-term cardiopulmonary function of heart transplant patients who received disproportionately sized allografts for varying levels of pulmonary vascular resistance. Resting hemodynamics and oxygen uptake during exercise were recorded at 1 year after transplantation in 52 patients. No differences in resting heart rate, cardiac output, stroke volume, peak oxygen uptake during exercise, and exercise duration were found in recipients of undersized hearts (donor:recipient weight ratio [D:R] < 0.75), sized-matched hearts (D:R = 0.75 to 1.25), and oversized (D:R > 1.25) hearts. In a further analysis according to preoperative pulmonary vascular resistance, resting cardiac output (5.8 +/- 1.3 L/min) was normal, and peak exercise oxygen uptake (22.7 +/- 8.0 ml/kg/min) was mildly decreased in recipients of size-matched allografts with a pulmonary vascular resistance of less than 3 Wood units (size-matched hearts, with mild or no pulmonary vascular resistance). Of patients with moderate pulmonary hypertension (pulmonary vascular resistance > or = 3 Wood units), resting cardiac output was normal (5.1 +/- 0.6 L/min) in recipients of oversized hearts and was reduced (4.7 +/- 1.0 L/min) in recipients of sized-matched hearts (p < 0.05 versus recipients of size-matched hearts with pulmonary vascular resistance less than 3 Wood units).(ABSTRACT TRUNCATED AT 250 WORDS)     

Heterotopic heart transplantation--a means to increase donor availability

From November 1985 to August 1989, 105 patients underwent heart transplantation at our institution of whom 8 (7%) underwent heterotopic heart transplantation (HHTx). There were 7 males and 1 female with a mean age of 49 +/- 6 years (range, 41-58 years), 7 of whom had ischaemic cardiomyopathy and 1 had dilated cardiomyopathy. The indications for HHTx were gross donor/recipient size mismatch, unreliable donor heart, elevated pulmonary vascular resistance and the need for urgent transplantation or their combination. HHTx was performed as a left ventricular bypass in 6 patients and as biventricular bypass in 2 combined with various surgical procedures on the native heart in 5. There was one perioperative death with a mean follow-up of the survivors of 17 +/- 10 months (range, 6-30 months). Comparison of preoperative and postoperative (1 year) 2-D echocardiographic studies of the native heart showed haemodynamic stability of the latter with no substantial changes in left ventricular ejection fraction and cardiac index, while left ventricular end-diastolic volume tended to increase in 2 patients. In conclusion, preservation of the native heart allows recovery or growth of a graft considered unsuitable for orthotopic transplantation. Our experience confirms that HHTx may still be considered a valuable alternative to orthotopic transplantation in selected patients, thus expanding donor utilization.     

Heterotopic heart transplantation: A valid alternative to orthotopic transplantation: Results,advantages, and disadvantages

Thirty-eight heterotopic heart transplantations (HHT) were performed in Cape Town from November 1975 to April 1981. Indications were ischemic heart disease (61%), cardiomyopathy (31%), and rheumatic heart disease (8%). No operative death occurred; 1 year survival is 60% and 4 year 50%. These results compare favorably with the best orthotopic heart transplant results at Stanford (63% 1 year and 44% 4 year survival). The longest HHT alive is now $\text{6}\text{1}\text{2}$ year posttransplant, back to normal activity. Infections caused over 50% of deaths, rejection over 34%. A major advantage of HHT is to be suitable in cases with severe pulmonary hypertension (PHT): four patients had PHT > 6 Wood units, and two had PHT > 8 Wood units. None had post-HHT right-sided failure. A significant advantage is that assisted ventilation and intravenous catecholamines can be stopped shortly after surgery ($\text{±5}\text{1}\text{2}$ hr), the recipient heart assisting the donor heart through its postischemic recovery. Should acute donor heart failure occur the patient survival is assured by his own heart. Similarly, during acute rejection the recipient heart assists, and was life-saving in one case when the graft arrested for hours. Two patients survived irreversible acute rejection requiring removal of the donor heart 1 and 3 months after HHT. Retransplantation after HHT is easy, not urgent as it is after orthotopic heart transplantation and was successful in both cases when performed. The disadvantages have been one case of endocarditis in the recipient heart, successfully managed by partial recipient's heart resection, and two nonfatal cerebral emboli probably originating from the recipient's left heart, or progress of the disease in the recipient heart. A specific disadvantage of HHT is the greater difficulty in diagnosing acute rejection early, the recipient's heart limited work masking minor donor heart alterations. HHT appears thus a valid alternative to orthotopic heart transplantation, with significant intrinsic advantages.     

Heart transplantation in Norway. One-year experience

Eight patients underwent orthotopic heart transplantation in Norway during 1984, with retransplantation in one case. The age range of the 5 men and 3 women was 19-53 years. The preoperative diagnosis was cardiomyopathy in 6 patients, ischaemic heart disease in one, and a combination of the two disorders in one patient. The immunosuppressive regimen, with cyclosporin A and low-dose prednisolone, and the treatment of graft rejection, followed the Stanford University protocol. There was no operative mortality. Three patients died shortly after the transplantation, 2 of them after about a week from acute rejection; in one of these 2 cases a second transplant was made, but was followed by pulmonary and renal complications. The third death occurred about 10 weeks postoperatively, from donor heart failure due to Toxoplasma myocarditis. The 5 survivors are clinically in good condition.     

Current trends in lung transplantation. Lobar transplantation and expanded use of single lungs.

Heart-lung transplantation remains the only therapeutic option for patients with combined end-stage cardiopulmonary disease. Because of the scarcity of heart-lung donors, we have been investigating other surgical alternatives for patients with end-stage vascular and parenchymal lung disease. From June 1989 through June 1991, 48 patients underwent pulmonary transplantation. Seventeen of the 48 patients underwent single lung transplantation. Of the 17 patients in the single lung group, eight patients had pulmonary hypertension and nine had parenchymal lung disease. Four of the 17 patients underwent repair of a cardiac defect with single lung transplantation. One-year actuarial survival was 68%. Pulmonary function has been excellent. The forced expiratory volume in 1 second was 79.6 +/- 13.6 (percent predicted), forced expiratory flow 25%-75% was 72.6 +/- 14.5 (percent predicted), and arterial oxygen tension was 82.8 +/- 10.06 mm Hg when measured at annual follow-up in a group of eight patients without obliterative bronchiolitis. Pulmonary artery pressures of systemic level or greater in the group with pulmonary vascular disease were normal at annual catheterization. Most patients had at least one episode of allograft rejection. Actuarial freedom from rejection at the end of 3 months was 30%. Three of the 17 single lung patients receiving lung lobes were children. Two children received living-related lobe transplants and one neonate received a lobe from a 2-year-old cadaver donor. Single lung transplantation is an effective therapeutic option for selected patients with vascular or parenchymal lung disease. Expanding indications will permit more individuals to receive transplants from the existing donor pool. Living-related and cadaver lobe transplantation will also increase the options available to children in need of lung transplantation.