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。     

Outcomes of Heart Transplantation for Cardiac Amyloidosis: Subanalysis of the Spanish Registry for Heart Transplantation

Amyloidosis (Am), a systemic disease, has poor prognosis because of organ damage produced by protein deposition in the extracellular space. Although heart transplantation (HTx) is possible, donor availability concerns and high mortality make this approach controversial. The Spanish Registry for Heart Transplantation includes 25 Am patients (54 ± 9 years): 13 with AL type, 2 with AA and 10 with TTR mutation. Fifteen patients (60%) died during follow-up (4.9 ± 1.3 years): 9 AL-Am patients, both AA-Am patients and 4 with TTR-Am. HTx survival for Am patients was similar to patients without Am at 1 month but significantly worse at 5 years: 46% versus 78% (p < 0.02). Of 10 AL-Am patients undergoing successful HTx, 4 died of systemic Am. Stem cell transplantation was performed in 3 (1 died of acute rejection). Five of 10 patients with TTR-Am underwent liver transplant; 4 remained alive at the last follow-up. Findings include poor outcome for AL-Am patients despite HTx and better survival for TTR-Am patients if HTx is associated with liver transplantation. Given the shortage of donors and poor outcome for Am patients, we would recommend that HTx be reserved for patients without or with mild systemic Am and be supplemented by additional therapies as indicated.     

同种异体原位心脏移植24例临床分析

正同种异体原位心脏移植是目前公认治疗终末期心脏病的有效手段之一[1-2],但我国心脏移植受限于诸多因素尚未普及,目前全国每年心脏移植总量不足500例,与国外相比还有一定差距。昆明市第一人民医院2014年5月至2018年3月共成功实施24例同种异体原位心脏移植,现报道如下。1资料和方法1. 1供、受者资料24例受者中,男性18例,女性6例,平均年龄(37±14)岁(16～69岁),平均体质量(56±3) kg     

一种改进的大鼠心脏异位移植模型

为移植免疫、病理和器官保存等方面的实验研究提供一种操作简便、易于观察的大鼠心脏异位移植实验动物模型。方法以Ｏｎｏ和Ｃｈｅｎ设计模型为基础，采用供心活体灌注及颈部异位移植（供心无名动脉、肺动脉分别与受体右颈总动脉和右颈外静脉作端端吻合）。结果１０例移植手术，８例移植心存活超过１月，１月存活率８０％。结论缩短手术时间、减少术中出血是手术成功的关键     

Heart Transplantation:

The gap between the number of potential recipients of a cardiac graft and the availability of donor hearts is still growing. A proper selection of heart transplant candidates is mandatory to ensure that patients in critical need, who are likely to benefit from this procedure, are identified. The work-up of a patient with terminal chronic heart failure includes a comprehensive cardiac and systemic evaluation. Critical in the decision is the exclusion of irreversible pulmonary hypertension. Furthermore, underlying diseases that could compromise short-and long-term prognosis after transplantation should be carefully assessed. The mortality on the waiting list and the growing pool of patients with chronic heart failure that is excluded from transplantation has stimulated the search for alternative treatment modalities. Besides a pharmacologic approach, the last few years have witnessed a tremendous evolution in so-called mechanical devices, designed to improve both morbidity and mortality of these patients. Although several of these devices have only just entered the clinical phase, internal cardioverter defibrillators, left ventricular assist devices and biventricular pacemakers can no longer be viewed as experimental tools.     

Kidney Transplantation in Previous Heart or Lung Recipients

Outcomes after heart and lung transplants have improved, and many recipients survive long enough to develop secondary renal failure, yet remain healthy enough to undergo kidney transplantation. We used national data reported to United Network for Organ Sharing (UNOS) to evaluate outcomes of 568 kidney after heart (KAH) and 210 kidney after lung (KAL) transplants performed between 1995 and 2008. Median time to kidney transplant was 100.3 months after heart, and 90.2 months after lung transplant. Renal failure was attributed to calcineurin inhibitor toxicity in most patients. Outcomes were compared with primary kidney recipients using matched controls (MC) to account for donor, recipient and graft characteristics. Although 5-year renal graft survival was lower than primary kidney recipients (61% KAH vs. 73.8% MC, p < 0.001; 62.6% KAL vs. 82.9% MC, p < 0.001), death-censored graft survival was comparable (84.9% KAH vs. 88.2% MC, p = 0.1; 87.6% KAL vs. 91.8% MC, p = 0.6). Furthermore, renal transplantation reduced the risk of death compared with dialysis by 43% for KAH and 54% for KAL recipients. Our findings that renal grafts function well and provide survival benefit in KAH and KAL recipients, but are limited in longevity by the general life expectancy of these recipients, might help inform clinical decision-making and allocation in this population.     

Experience with the Berlin Heart Assist Device

Abstract: Different mechanical circulatory support systems (MCSS) have been in clinical use since 1987 to keep patients alive by assisting the heart during cardiac recovery after open heart surgery, myocardial infarction, acute graft failure after heart transplantation, or as a bridge to transplantation in heart transplant candidates. Four different hospitals in Germany used the Berlin Heart Assist Device. Up until 1993, there were 22 patients in the "recovery" group; 4 patients were weaned from the system, and only 1 patient was discharged from the hospital. In 112 patients the Berlin Heart Assist Device was implanted for the purpose of a bridge to transplantation, 68 were transplanted and 46 patients left the hospital. It was concluded that patients may be kept alive with this system for weeks and months after any kind of cardiogenic shock. Complete cardiac recovery may be achieved in patients with early posttransplant graft failure. Reliable prediction of outcome in bridge–to–transplantation patients requires further experience and improvement of system components.     

Domino Heart Transplantation Involving Infants

Domino heart transplantation has been well described in adults, but has not previously been reported in infant patients. We report the successful transplantation of a 'domino' heart from a 3-month-old infant with primary pulmonary hypertension undergoing heart-lung transplantation, into a 3-month-old infant with complex congenital heart disease. Both infants have survived past 1 year post-transplant, and neither infant has experienced any clinically significant allograft-related complications. Echocardiography and cardiac catheterization of the domino heart have consistently demonstrated stable hypertrophy of the right ventricle (RV) and interventricular septum, but good right and left ventricular function. Domino heart transplant surgery may be an effective way to provide 'pre-conditioned' donor hearts to infants urgently in need of heart transplantation.     

原位心脏移植1例

１例扩张型心肌病伴严重室性心律失常的１６岁女病人，因持续心功能衰竭５年，心功能Ⅳ级（ＮＹＨＡ）。以利尿剂控制心衰、利多卡因抗心律失常、多巴胺和多巴酚酊胺维持血压，于１９９２年３月行原位心脏移植术。术后７个月病人死于急性排异反应和感染。     

Heart transplantation for radiation-associated end-stage heart failure

Radiation-induced heart disease is an increasingly recognized late sequela of mediastinal radiation therapy for malignant neoplasms. We report four cases of heart transplantation for end-stage heart failure induced by mediastinal radiation therapy. Short-term and intermediate-term results are excellent with all four patients currently surviving a mean of 48 months after transplantation. Neither a second malignancy nor recurrence of the primary malignancy has been observed to date. The early results of heart transplantation for end-stage, radiation-induced heart disease are encouraging.     

Current Strategy for Severe Heart Failure with Mechanical Circulatory Support

Abstract: In the last 10 years, 37 patients received assisted circulation or a ventricular assist device after open-heart operations at the Heart Institute of Japan. After cardiovascular surgery, 12 patients underwent venoarte-rial bypass (VAB), 13 had biventricular bypass (BVB), 8 had left ventricular bypass (LVB), and the remaining 4 received a left ventricular assist device (LVAD). Weaning and discharge rates of the patients by type of circulatory supports were 41.7 and 25.0% with VAB, 69.3 and 46.2% with BVB, 87.5 and 37.5% with LVB, 75.0 and 50.0% with LVAD, and 44.4 and 11.1% with PCPS, respectively. Concerning complications of postcardiotomy circulatory support, hemorrhage and ventricular arrhythmia postcardiotomy circulatory support, hemorrhage, and ventricular arrhythmia (immature weaning) decreased with low-heparinized isolated left ventricular supports (i.e., LVB, LVAD). However, profound biventricular failure, infection, and multiple organ failure remain as possible complications with any type of assisted circulation. These results suggest that early application of circulatory support and appropriate selection of the mode of support and devices used are important for successful circulatory support.     

Destiny of candidates for heart transplantation in the Eurotransplant heart allocation system

OBJECTIVE: We analyzed the prognosis of candidates for heart transplantation (HTx) after being listed with 'urgent status' for donor heart allocation or after ventricular assist device (VAD) implantation without application for urgent status. METHODS: Urgent status as used in this study refers to both the high urgency (HU) status awarded by Eurotransplant until August 31, 2005 and the urgent (U) status that replaced it from then on. Patients who underwent primary VAD implantation between January 2001 and December 2006 and who were listed as transplantable (T) (group VAD-prim, n=159), and patients listed primarily in urgent status before VAD implantation and/or HTx during the same period (group U-prim, n=168) were enrolled in the study. Group U-prim consists of subgroups: group U-HTx (n=123), who underwent primarily HTx in urgent status; group U-VAD (n=25), who underwent primarily VAD implantation in urgent status; patients who died in urgent status before HTx or VAD implantation (n=6); and patients in urgent status without HTx or VAD implantation (n=14). The survival rate in each group was studied. RESULTS: Survival rates after VAD implantation in group VAD-prim were comparable to those after urgent status listing in group U-prim (67.0% vs 68.5% for 1-year survival, 56.6% vs 65.8% for 2-year survival, respectively). Actuarial survival after listing for urgent status in group U-HTx was significantly better than that in group U-VAD (73.7% vs 46.0% for 1-year survival, p<0.05, log-rank test). Actuarial survival during mechanical circulatory support after the VAD implantation (censored at HTx or weaning from the device) in group VAD-prim was significantly better than that in group U-VAD (80.7% vs 56.2% for 3-month survival, p<0.001, log-rank test). CONCLUSIONS: In order to receive urgent HTx, HTx candidates may choose urgency listing without primary VAD implantation at the risk of failed donor heart allocation in urgent status. However, the prognosis of the patients in the latter situation is poor.     

In Vivo Evaluation of Zirconia Ceramic in the DexAide Right Ventricular Assist Device Journal Bearing

Zirconia is a ceramic with material properties ideal for journal bearing applications. The purpose of this study was to evaluate the use of zirconium oxide (zirconia) as a blood journal bearing material in the DexAide right ventricular assist device. Zirconia ceramic was used instead of titanium to manufacture the DexAide stator housing without changing the stator geometry or the remaining pump hardware components. Pump hydraulic performance, journal bearing reliability, biocompatibility, and motor efficiency data of the zirconia stator were evaluated in six chronic bovine experiments for 14–91 days and compared with data from chronic experiments using the titanium stator. Pump performance data including average in vivo pump flows and speeds using a zirconia stator showed no statistically significant difference to the average values for 16 prior titanium stator in vivo studies, with the exception of a 19% reduction in power consumption. Indices of hemolysis were comparable for both stator types. Results of coagulation assays and platelet aggregation tests for the zirconia stator implants showed no device‐induced increase in platelet activation. Postexplant evaluation of the zirconia journal bearing surfaces showed no biologic deposition in any of the implants. In conclusion, zirconia ceramic can be used as a hemocompatible material to improve motor efficiency while maintaining hydraulic performance in a blood journal bearing application.     

In‐Series Versus In‐Parallel Mechanical Circulatory Support for the Right Heart: A Simulation Study

Right heart failure (RHF) is a serious health issue with increasing incidence and high mortality. Right ventricular assist devices (RVADs) have been used to support the end‐stage failing right ventricle (RV). Current RVADs operate in parallel with native RV, which alter blood flow pattern and increase RV afterload, associated with high tension in cardiac muscles and long‐term valve complications. We are developing an in‐series RVAD for better RV unloading. This article presents a mathematical model to compare the effects of RV unloading and hemodynamic restoration on an overloaded or failing RV. The model was used to simulate both in‐series (sRVAD) and in‐parallel (pRVAD) (right atrium‐pulmonary artery cannulation) support for severe RHF. The results demonstrated that sRVAD more effectively unloads the RV and restores the balance between RV oxygen supply and demand in RHF patients. In comparison to simulated pRVAD and published clinical and in silico studies, the sRVAD was able to provide comparable restoration of key hemodynamic parameters and demonstrated superior afterload and volume reduction. This study concluded that in‐series support was able to produce effective afterload reduction and preserve the valve functionality and native blood flow pattern, eliminating complications associated with in‐parallel support.     

Clinical experience of left ventricular assist systems at the Heart Institute of Japan

The main indications for left ventricular assist system (LVAS) support are postcardiotomy ventricular failure as temporary circulatory support and end-stage cardiomyopathy as chronic circulatory support. To clarify the efficacy of LVAS support, we assessed the clinical outcome of a pneumatic LVAS and an electromagnetic LVAS for patients with severe ventricular failure. As of March 1998, 5 patients with postcardiotomy ventricular failure had received the pneumatic LVAS support, and 2 other patients with end-stage idiopathic cardiomyopathy had undergone implantation of the electromagnetic LVAS. The drive control of the LVAS was mainly counterpulsation in the diastole of the native heart. In the 5 postcardiotomy patients, the duration of pneumatic LVAS support ranged from 30 to 312 h (mean, 109.2). All 3 patients with more than 72 h support were successfully weaned, and 2 of them survived. The other 2 patients with cardiogenic shock and less than 36 h support could not be weaned from the LVAS. In the 2 cardiomyopathy patients, 1 patient was well maintained by the electromagnetic LVAS support and underwent successful heart transplantation 7 months later. The other patient has been chronically supported by the LVAS for 2 months and is doing well so far. These results suggest that selective application of the pneumatic LVAS as a temporary support and the electromagnetic LVAS as a chronic support might be appropriate for maximizing the effectiveness of LVAS treatment for profound cardiac failure.