心脏移植术后急性排斥反应的超声心动图监测

心脏移植目前被公认为是治疗终末期心力衰竭患者的有效治疗手段,然而,心脏移植术后的急性排斥反应仍然是移植后1年内最主要的并发症和致死原因。因此,及时、准确的诊断心脏移植术后急性排斥反应尤为重要。经颈静脉心内膜心肌活检作为诊断心脏移植术后急性排斥反应的＂金标准＂已得到广泛认可,但仍存在一些局限性。超声心动图检查凭其无创、简便、可随时监测、动态连续观察指标等优点,被一些学者用于监测心脏移植术后的排斥反应。现主要介绍了各种超声心动图技术在心脏移植病人中的应用及进展。     

Heart transplantation for cardiac light chain amyloidosis with subsequent autologous stem cell transplantation

Our report describes a case of 57-year-old man with manifest heart failure on the basis of cardiac amyloidosis, which was detected by endomyocardial biopsy. Due to the heart failure, the patient was unable to undergo myeloablative therapy. We changed our previous decision for conservative therapy of heart failure and the patient underwent heart transplantation. Autologous stem cell transplantation was performed 6 months later. After the successful stem cell transplantation, the serum free light chain lambda levels promptly decreased. One year later, their levels started again to increase. Chemotherapy was therefore initiated. The patient has now completed the seventh cycle of chemotherapy in good condition. The graft function is normal and the latest endomyocardial biopsy revealed no amyloid.     

Diagnosis of Rejection by Analyzing Ventricular Late Potentials in Heart Transplant Patients

Background

Heart transplant rejection originates slow and fragmented conduction. Signal-averaged ECG (SAECG) is a stratification method in the risk of rejection.

Objective

To develop a risk score for rejection, using SAECG variables.

Methods

We studied 28 transplant patients. First, we divided the sample into two groups based on the occurrence of acute rejection (5 with rejection and 23 without). In a second phase, we divided the sample considering the existence or not of rejection in at least one biopsy performed on the follow-up period (rejection pm1: 18 with rejection and 10 without).

Results

On conventional ECG, the presence of fibrosis was the only criterion associated with acute rejection (OR = 19; 95% CI = 1.65-218.47; p = 0.02). Considering the rejection pm1, an association was found with the SAECG variables, mainly with RMS40 (OR = 0.97; 95% CI = 0.87-0.99; p = 0.03) and LAS40 (OR = 1.06; 95% IC = 1.01-1.11; p = 0.03). We formulated a risk score including those variables, and evaluated its discriminative performance in our sample. The presence of fibrosis with increasing of LAS40 and decreasing of RMS40 showed a good ability to distinguish between patients with and without rejection (AUC = 0.82; p < 0.01), assuming a cutoff point of sensitivity = 83.3% and specificity = 60%.

Conclusion

The SAECG distinguished between patients with and without rejection. The usefulness of the proposed risk score must be demonstrated in larger follow-up studies.     

同种原位心脏移植术后的特殊心电图研究

目的观察同种原位心脏移植术后的心电图改变。方法分析资料完整的8例同种原位心脏移植术后患者的心电图。结果观察到5种特殊的心电图表现：8例（最长1例时间达12年）均出现双重窦性P波,貌似心房分离。食管导联心电图有助于显示受体P波,供体心房起搏或房性心律失常不影响受体窦性周长。受体心房颤动合并供体房室交接区性逸搏伴逆行P波,假性心房内不完全性传导阻滞,假性完全性房室传导阻滞。结论认识这些心电图改变有助于同种心脏移植术后的心电图诊断。     

同种异体原位心脏移植的临床研究（附5例报道）

目的　总结 5例心脏移植经验 ,探讨心脏移植的近远期疗效。方法　 1998年 10月至 2 0 0 3年 12月施行5例原位心脏移植 ,5例均为心肌病 ,其中 3例为扩张型 ,2例为限制型 ,手术方法采用标准法 4例、双腔静脉法 1例 ,供心平均冷缺血时间为 (16 5 .6± 2 6 3)min ,术后定期行心内膜活检 ,使用 4联免疫抑制剂。结果　第 1例存活 5d ,死于低心排及主动脉内球囊反搏 (IABP)的并发症 ,第 4例存活 18月 ,死于中———重度的急、慢性并存的排斥反应 ,余 3例至今存活 ,至今存活时间分别为 5年 8个月、4年 5个月、6月。结论　心脏移植是治疗终末期心脏病的有效手段 ,充分的术前准备 ,良好的心肌保护 ,合理使用免疫抑制剂 ,能取得良好的近远期疗效 ,长期生存病例需注意慢性排斥反应。     

8例同种异体原位心脏移植的应用体会

目的:总结8例同种异体原位心脏移植手术的处理经验,探讨心脏移植的围术期处理及预防感染等问题。方法:2004年5月至2006年2月,先后进行了8例同种异体心脏移植手术,全部采用双腔静脉法行原位心脏移植。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:8例患者均于术后6周左右康复出院。1例患者术后8个月因严重感染死亡,余7例患者心功能状况及生活质量良好,未出现明显免疫排异反应和肺部感染等并发症。结论:重视心脏移植的围术期处理及感染的预防,可使患者顺利康复,提高生存率和生活质量。     

原位心脏移植后的病理改变

本文报告１例原拉心脏移植植术后存活２１４天。按１９９０年国际心脏移植学会统一的标准，给予七次心肌活检和尸检的急性排异划定级，结果显示本例有持续性的细胞排异反应和体液排异反应。且曾因抗排异药物的减量加快，而使排异加重。讨论了心肌活检对移植排异诊断的重要性，并讨论了死亡原因。     

Adult T-Cell Leukemia in a Liver Transplant Recipient That Did Not Progress after Onset of Graft Rejection

A liver allograft recipient developed acute-type adult T-cell leukemia (ATL) during tacrolimus treatment, 2 years after undergoing transplantation for subacute fulminant hepatitis. Both donor and recipient were asymptomatic carriers of human T-cell lymphotropic virus type I (HTLV-I), but the ATL cells originated from the recipient. Tacrolimus treatment was discontinued, and combination chemotherapy was administered. The patient achieved complete remission, but the transplanted liver was acutely and chronically rejected. The patient did not respond to rescue therapy with tacrolimus, prednisolone, and mycophenolate mofetil and died of hepatic failure. Liver biopsies showed CD4+ ATL cell infiltration at the onset of ATL but not at the terminal stage. Moreover, Southern blotting revealed clonal integration of HTLV-I into the host genome of lymphoma cells at onset but not at the terminal stage. ATL after liver transplantation has not been previously described. The clinical course of the posttransplantational ATL was atypical, because it did not progress after the onset of rejection.     

Tricuspid Regurgitation after Orthotopic Heart Transplantation

Background: Tricuspid regurgitation (TR) is a relatively common abnormality in normal adults as well as after orthotopic heart transplantation (OHT). A few studies have shown reduction in the incidence of TR after OHT by total bicaval surgical anastomosis technique. Other studies reported no significant difference in the rates of TR between the standard and bicaval techniques. Objective: Evaluate and compare the degree of TR after OHT by standard and bicaval anastomosis techniques. Method: Echocardiograms from the first 56 consecutive patients that had the total bicaval surgical technique performed were retrospectively reviewed and compared with the last 57 consecutive patients who had the standard biatrial technique performed. Patients with adequate two-dimensional and Doppler echocardiograms were included. Results: No statistical difference was observed for each grade of TR at both early and late time points. No significant difference was observed between the TR velocities of both biatrial and bicaval anastomosis patients at different periods. Conclusion: There appears to be no difference between the TR severity and TR velocity at early and late time points regardless of anastomotic technique. (Echocardiography 2010;27:1-4)     

细胞凋亡与移植心脏急性排斥反应的实验研究

目的 探讨大鼠异位心脏移植的急性排斤反应与细胞凋亡之间的关系.方法采用大鼠颈部心脏移植的动物模型,在移植术后的不同时间,取下移植心脏,流式细胞术测定移植心脏组织的细胞凋亡率.结果急性排斥反应时,移植心脏的细胞凋亡率比正常心脏组织增高.结论 细胞凋亡参与大鼠心脏移植的急性排斥反应,在整个排斥反应过程中细胞凋亡率均增高.     

白细胞介素10在心脏移植免疫治疗中的研究现状

白细胞介素10是一种具有多种生物学功能的细胞因子,它能通过多种途径来抑制或减轻器官移植排斥反应的程度,从而延长移植物的存活时间。因此,白细胞介素10在心脏移植免疫治疗中有重要的应用前景。现就白细胞介素10在心脏移植体中的表达和意义、免疫抑制作用机制及其在心脏移植中应用研究的现状等作一综述。     

克山病患者心脏移植术后急性排异反应的监测

目的对３例重症克山病患者同种原位心脏移植术后进行监测,探讨心脏移植术后急性排异反应的监测指标。方法监测指标：临床症状;１２导联心电图;超声心动图;单光子计算机体层扫描;外周血Ｔ淋巴细胞检查;心内膜心肌活检;Ｘ线影像。结果行ＥＭＢ１９次,发现１ｂ级和２级各１次,３ａ级２次。３ａ级时ＵＣＧ发现心包积液有增加趋势,其余指标未见明显改变。结论心内膜心肌活检是诊断急性排异反应敏感可靠的指标,其它一些常用的指标不敏感且缺乏特异性,但可做为辅助指标。     

Prediction of Rejection in Renal Transplantation by Immune Parameters

Background: Monitoring of phenotypic characteristics of T-lymphocytes in peripheral blood is commonly performed to give the clinical parameters in the management of kidney transplant recipients.   Objective: To predict rejection in renal transplantation by immune parameters. Methods: 16 non-diabetic kidney transplant candidates (4 females and 12 males, age = 20-65 yr, first time transplant) were selected. The transplanted patients were divided into two groups based on the rejection during 3 weeks post transplant: group I (n = 9) without rejection and group II (n = 7) with a rejection episode. Immune parameters including lymphocytes subpopulations (by flowcytometry) and immunoglobulin classes (IgM, IgG, IgA and IgE by nephlometric assay) before and 45 days after transplantation were determined.   Results: The results of this investigation showed that the level of immunoglobulin IgG, IgM, IgA and IgE decreased post transplantation due to immunosuppressive drugs. CD3, CD4, CD8 T cells count, CD56 NK cells count and CD20 B cells count pre- and post-transplantation did not show any significant differences. The amount of IgE (220   vs. 462 IU/ml), CD3 (62% vs. 69.7%) and CD4 (35% vs. 41.3%) cells increased in group II during rejection episode pre-transplantation. In addition, IgA increased pretransplantation in group I those without rejection episode in comparison with group II with a rejection episode. Forty five days post transplantation IgA (209   vs. 152 mg/dl), IgG (1009 vs. 703 mg/dl) and CD20 (15%   vs. 10%) increased in group I patients. Conclusion: It is suggestive that pre-transplantation increases IgE, CD3 and CD4 are predictive of acute rejection.     

同种心脏移植急性排斥反应机制研究进展

同种原位心脏移植已成为临床治疗终末期心脏病的有效方法 ,供心保存、外科手术技术、术后感染已不再是阻碍心脏移植成功的最主要因素。影响心脏移植成败 ,术后病人的生存期以及生存质量的主要因素是术后免疫排斥反应。因此 ,对心脏移植急性排斥反应的发生机制的研究便显得尤为重要。本文就其基本理论 ,目前研究现状及进展进行探讨和综述。     

Do clinical diagnoses correlate with pathological diagnoses in cardiac transplant patients? The importance of endomyocardial biopsy

BACKGROUND:

Heart transplantation remains the last treatment option for patients with end-stage cardiac disease. Such diseases include ischemic cardiomyopathy, nonischemic cardiomyopathy and other conditions such as arrhythmogenic right ventricular dysplasia, cardiac sarcoidosis and cardiac amyloidosis.

OBJECTIVE:

To review the changes that have occurred over time in the etiology of heart disease in patients requiring heart transplantation, and to compare the clinical and histological diagnoses of explanted hearts from patients with progressive cardiac disease.

METHODS:

The pathological findings of 296 surgically excised hearts over a 20-year period (January 1987 to July 2006) at one institution were examined. Patients were separated into groups based on year of heart transplantation. The tissue was examined to determine the underlying cardiac pathology leading to congestive heart failure. Patient records were reviewed for preoperative clinical diagnoses and other relevant data, including pretransplant endomyocardial biopsy (EMB) results, information regarding left ventricular assist devices and, finally, evidence of disease recurrence in the grafted heart.

RESULTS:

A shift in the underlying etiology was found in patients who underwent heart transplantation from 1992 to 1996, and 1997 to 2001. Between 1987 and 1997, the majority of transplant cases consisted of ischemic cardiomyopathies. From 1997 to 2001, the majority of patients had nonischemic cardiomyopathies, and this trend continued to 2006. A majority of patients with ischemic and hypertrophic cardiomyopathy were diagnosed correctly (96.5% and 82%, respectively) before transplantation. Most patients diagnosed post-transplant with lymphocytic (viral, 15%), hypersensitive/eosinophilic (25%) and giant cell (100%) myocarditis, arrhythmogenic right ventricle dysplasia (100%), cardiac sarcoidosis (83%) and iron overload toxicity-associated cardiomyopathy (100%) had been misdiagnosed in pre-transplantation investigations. Investigations before transplantation did not include an EMB. Of all 296 patients, 51 patients (17%) were misdiagnosed. Excluding the patients with ischemic cardiomyopathy, 46 of 152 patients (30%) were misdiagnosed before transplantation.

CONCLUSIONS:

Although cardiac transplantation is a viable treatment option for patients with a variety of cardiac diseases, accurate diagnosis of patients before transplantation remains a priority. Accurate diagnosis of particular diseases (sarcoidosis, myocarditis, iron toxicity-associated cardiomyopathy and others) allows for proper treatment before transplantation, which may slow down disease progression and improve patient outcomes. Furthermore, it is important to accurately diagnose patients with diseases such as sarcoidosis, amyloidosis and particular types of myocarditis because these can readily recur in the grafted heart. The risk for recurrence must be known to practitioners and, most importantly, to the patient. We strongly recommend the use of EMB if a nonischemic cardiomyopathy is suspected, because the results may alter the diagnosis and modify the treatment strategy.     

心脏移植术后窦房结功能异常（附1例报道）

心脏移植术后窦房结自律性及传导功能受损的发生率很高，临床表现为以心率缓慢为主的窦房结功能紊乱。我院于１９９２年收治一例。供心缺血时间２７１分钟，采用美国Ｓｔａｎｆｏｒｄ医疗中心基本术式，术后窦性、结性心律交替，出现窦房阻滞及窦暂停，于术后第１４周安装了永久性心内膜起搏器。心脏移植术后发生窦房结功能损害的原因是多方面的，可以是各种因素的综合影响，再通过窦房结供血障碍而加剧。术后早期可采用药物治疗或临时起搏技术，心动过缓持续３～４周以上者，应尽早考虑安装心内膜永久性起搏系统。     

Heart transplantation

Heart failure remains a major global problem with approximately 6 million individuals suffering from heart failure in the United States alone. The surgical technique of heart transplantation, popularized by Dr. Norman Shumway, has led to its success and currently remains the best treatment options for patients with end-stage. However, with the continued limitation of donor organs and the rapid development of ventricular assist device technology, the number of patients bridged to transplant with mechanical circulatory support has increased significantly. This has created some new technical challenges for heart transplantation. Therefore, it is now important to be familiar with multiple new technical challenges associated with the surgical techniques of heart transplantation with an ultimate goal in reducing donor heart ischemic time, recipient cardiopulmonary bypass time and post-operative complications. In this review, we described our technique of heart transplantation including the timing of the operation, recipient cardiectomy and donor heart implantation.     

The potential clinical role of ultrasonic strain and strain rate imaging in diagnosing acute rejection after heart transplantation.

BACKGROUND: There has been a continued search for a more sensitive noninvasive technique for detecting sub-clinical acute rejection in heart transplant recipients. Ultrasonic deformation imaging (strain/strain rate) is sensitive in detecting sub-clinical abnormalities in regional systolic function and could potentially be sufficiently sensitive to detect changes in deformation induced by graft rejection. AIM: To assess the use of strain (S) and strain rate (SR) imaging as a noninvasive method for monitoring and diagnosing acute rejection in heart transplant recipients. METHODS AND RESULTS: A prospective preliminary study was carried out involving 31 consecutive heart transplant patients who underwent a total of 106 routine follow up endomyocardial biopsy with correlative cardiac ultrasound data. To assess regional longitudinal deformation, ultrasonic S and SR data were acquired from the intraventricular septum, left ventricular (LV) lateral and right ventricular free walls (RVFW). For radial deformation, data were obtained from the LV posterior wall (LVPW). According to the International Society of Heart and Lung Transplantation criteria, 88 biopsies (Group 1) had grade 0 or IA rejection, and 18 biopsies (Group 2) had > or =grade IB rejection. Longitudinal peak systolic S and SR were decreased (p<0.05) in Group 2, compared to Group 1 in the RVFW basal and apical segments and the basal and mid segments of the LV lateral wall. Radial peak systolic S and SR were significantly lower (p<0.001) in Group 2, compared to Group 1. CONCLUSIONS: S/SR imaging might be a good technique and an additional tool for detecting > or =IB grade of acute rejection. The myocardial deformation, as assessed by S/SR imaging could be of clinical value in monitoring and diagnosing acute rejection in heart transplant recipients and could improve patients' management by reducing the number of biopsies performed.     

Surface Electrocardiography and Histologic Rejection Following Orthotopic Heart Transplantation*

Background: Intraventricular conduction delay and QT interval dispersion may be related to electrical instability and the risk of ventricular arrhythmogenesis. The interlead variability of the QT interval on a surface 12‐lead electrocardiogram (ECG) has been associated with an increased likelihood of sudden death in patients with long QT syndromes, in patients recovering from myocardial infarction, and dilated cardiomyopathy. We sought to determine the incidence of increased QT_c dispersion (QT_c‐d) relative to biopsy grade of severity of rejection. Methods: Records of patients having undergone orthotopic heart transplantation (OHT) were reviewed focusing specifically on surface ECGs performed in temporal proximity to endomyocardial biopsy. Results: Seventy‐five patients were evaluated on 1573 occasions, to include 999 surface ECGs, and 847 endomyocardial biopsies. There were 269 interpretable surface ECGs and endomyocardial biopsies performed within 1.1 ± 4.6 days. There were no identifiable trends in atrioventricular or intraventricular conduction abnormalities (to include right bundle branch block) when comparing those with and without significant rejection on endomyocardial biopsy. The mean QT_c‐d of those with none (n = 34), mild (n = 194), moderate (n = 39), and severe (n = 2) rejection was 49 ± 29, 49 ± 35, 57 ± 38, 81 ± 7 ms, respectively (P = 0.28 by ANOVA of means). When comparing those with significant rejection so as to change management there was a trend toward increased dispersion (no to mild rejection, 49 ± 34 ms vs moderate to severe rejection, 59 ± 37 ms, P = 0.09). Conclusions: In this study investigating noninvasive ventricular depolarization/repolarization and correlation to histologic manifestation of rejection, there was suggestion, but no statistical significance, of QT_c‐d and severity of rejection. QT_c‐d should not be considered a sensitive marker for OHT rejection.