Unique aspects of heart and lung transplantation exhibited in the 'domino-donor' operation

During the past 2 decades various refinements in heart and lung transplantation procedures have taken place. Improved preservation methods, new immunosuppressive medications, and advances in technical capabilities have allowed innovative procedures to be performed. In May 1987 the first "domino-donor" operation was performed in the United States. A 28-year-old man with cystic fibrosis and end-stage lung disease received the heart and lungs of an anonymous donor after he donated his heart to a 38-year-old man with end-stage ischemic cardiomyopathy. The technical and logistical aspects of this transplantation procedure are described herein. Other unusual features of this case that are discussed include heart-lung transplantation for a patient with cystic fibrosis, the use of cardiopulmonary bypass to allow lung procurement and transplantation across long distances, and the current role of heterotopic cardiac transplantation.     

肾移植2 200例次临床分析

目的 总结1908例（2200例次）肾移植手术的临床经验,提高肾移植术后人、肾存活率。方法 总结1985年以后人、肾1年、3年、5年的存活率;肾移植主要并发症及其处理原则;影响患者再移植存活率的因素;HLA－抗原／基因配型及群体反应抗体（PRA）检测。结果 （1）自1985年临床使用环孢素A（CSA）后,其1年人、肾存活率为87.3％,3年人、肾存活率为80.2%,5年人、肾存活率为67.0%.(2)50岁以上肾移植患者302例,术后1年移植肾存活率8.4%(252/302),1年人存活率8534%(258/302).(3)肾移植术后患者死亡原因主要是心血管系统疾病及感染。心血管系统疾病占死亡原因的50.7%,感染占死亡率的13.5％（4）。肾移植术后恶性肿瘤 的发病率为1.5％（23／1580）。（5）肝损害患者有独特的药代动力学特点。（6）良好的HLA供－受者配型可以减少肾移植术后急性排斥反应的发生率,有利于移植肾的长期存活。在HLA抗原不配合的情况下,受者应尽量选择不具有免疫原性抗原／基因的供肾移植。（8）对于慢性排斥应应采取综合方法进行治疗。结论 良好的组织配型、肾移植术后免疫抑制药物的合理应用、对移植术后并发症的预防及及时治疗是提高肾移植术后人、肾存活率的重要因素。     

Double lung transplant in primate

Experimental en-bloc double lung transplantation was first reported by Dark et al. to broaden the indications for heart-lung and single lung transplantations. They used puppies as an acute model: however primates are optimal in expecting improving survival. In this study we used Taiwan cynomolgus monkeys for 20 enbloc double lung transplants. The animals weighing 2.4-8.0 kgs. were divided into two groups: one with surface cooling and profound hypothermia and the other one with bypass using heart lung machine. For surface cooling group the average ischemic time was 58.5 minutes, and the result was disappointing: The best survivor sustained only 8 hours after transplant, and 5 died on table. In the group with bypass, the perioperative course was rather smooth. The animals could restore their respiratory function after transplant. Postoperative bleeding was the major course of complication. All the animals died within one day. During operation, evidence of tuberculosis and filariasis were observed. While some problems have to be solved before a clinical trial starts, clinical en-bloc double lung transplant is technically feasible.     

大鼠心脏移植急性排斥反应动物模型的建立

目的为探索器官移植后急性排斥反应的一种快速可靠的诊断方法。方法先暴露和游离受体的吻合段血管,再获取供心以缩短移植心脏冷缺血时间;保留供者的心脏及右上肺,将其胸主动脉与受者的腹主动脉间断端侧吻合;开放血流时,先开放远心端再间断开放近心端,同时按摩心脏至心脏搏动规律、有力,其色泽恢复红润,右上肺亦充盈良好。结果A组(n=20)成功16只,动脉吻合口出血2只、心脏复跳失败1只、吻合口狭窄1只;B组(n=20)成功17只,2只死于吻合口出血,1只死于吻合口狭窄。A组手术成功率为80%,B组为85%(P>0.05)。结论(1)先暴露并游离好受体血管吻合段,再获取供心,可以缩短移植心冷缺血时间。(2)边灌注边获取的方法利于快速而又完整的获取供心。(3)在切取和植入的过程中一定要注意低温保护。(4)利用腹主动脉段进行移植,使手术方便易行。左心做功的大鼠腹部心脏移植模型简单、安全、实用,因其左心参与循环而使血流动力学更接近生理状态,是进行心脏移植及血流动力学研究的较理想模型。     

Cardiac transplantation: University of South Florida--Tampa General Hospital experience

Cardiac transplantation has evolved from an experimental procedure to an accepted mode of therapy that prolongs life in patients with severe heart failure. The University of South Florida-Tampa General Hospital began performing cardiac transplantation for the treatment of end-stage cardiac disease in June 1985. Since then 42 heart transplantations have been performed and 30 patients are alive and well. The one-year actuarial survival is 78.73% and the two-year actuarial survival is 72.15%. Multiple complications have been encountered most notably rejection and infection. The recent approval of the USF/TGH program as a Medicare funded cardiac transplantation center is expected to greatly expand the number of potential recipients and will provide the residents of Florida, and the Southeastern United States, with an additional health care resource.     

The Queensland Liver Transplant Programme: the first two years

Orthotopic liver transplantation began in Brisbane in January 1985. During the first two years of the programme an assessment committee evaluated 55 patients (38 adults, 17 children). Patients were either accepted for transplantation, rejected as unsuitable or deferred for elective reassessment. All of the 10 adults who were rejected for transplantation because they had "too advanced" disease died within four months of assessment. Six children who were accepted for transplantation died before a suitable donor liver could be found. In the first two years, 21 orthotopic liver transplantations were performed on 18 patients (adults, 13 patients; children, five patients). Fifteen of 21 grafts were procured from within Queensland. Twelve (67%) patients are alive at three to 23 months and all have been discharged from hospital. Deaths in adults were due to sepsis (three patients), aspiration pneumonitis (one patient), rejection and hepatic artery thrombosis (one patient) and the recurrence of a hepatocellular carcinoma five months after discharge from hospital (one patient). Two patients underwent a second transplantation procedure because of chronic rejection at four months and at 11 months, respectively, after the initial operation. One patient received a second transplant for primary graft failure at four days after the operation. A scoring system which considered the presence of pre-operative patient factors, such as coma, ascites, malnutrition and previous abdominal surgery, partly predicted the operative blood loss and patient survival. In conclusion, orthotopic liver transplantation is being performed in Australia with survival rates that are comparable with those of established overseas units.     

连续缝合间断打结吻合动脉在小鼠心脏移植中的应用

 目的  应用连续缝合间断打结法吻合动脉建立小鼠心脏移植模型。方法  近交系C57BL／6j (H-2b)、BALB／c (H-2d)小鼠各30只,建立小鼠腹部心脏移植模型 (C57BL／6j→BALB/c),连续缝合间断打结法端侧吻合供体升主动脉和受体腹主动脉;一针后壁先缝法连续吻合供体肺动脉和受体下腔静脉。观察移植心脏搏动持续时间及受体生存时间。结果  手术成功率90%(27/30),总手术时间 (91.77±6.70)min,动脉吻合时间 (24.63±1.67)min,静脉吻合时间 (15.17±1.80)min。供心中位存活时间8 天,病理组织学示典型排斥反应。结论  应用连续缝合间断打结法吻合动脉降低了小鼠心脏移植的手术难度,效果可靠,值得推广。     

Organ transplant improvements, demands draw increasing attention

Gunby reviews current policy initiatives in organ donation and recent clinical advances in organ transplantation. Increasing demand for organs has led to the creation of the American Council on Transplantation, a private sector organization charged with coordinating policy on organ procurement and transplantation, and has resulted in the introduction of a national organ transplantation act in Congress. Developments in transplantation surgery include an increase in the number of heart transplants spurred by improvements in combatting rejection, federal funding for research into heart and heart-lung transplantation, the world's first heart-liver transplant, and preparations for the implantation of another artificial heart.     

Center-Specific Graft and Patient Survival Rates: 1997 United Network for Organ Sharing (UNOS) Report

Context.— Multiple comprehensive, risk-adjusted studies evaluating short-term surgical mortality have been reported previously. This report analyzes short-term and long-term outcomes, both nationally and at each individual transplant program, for all solid organ transplantations performed in the United States. Objectives.— To report graft and patient survival rates for all solid organ transplantations, both nationally and at each specific transplant program in the United States, and to compare the expected survival rate with the actual survival rate of each individual program. Design and Setting.— Multivariate regression analysis of donor and recipient factors affecting graft and patient survival of all kidney, liver, pancreas, heart, lung, and heart-lung transplants reported to the United Network for Organ Sharing from 742 separate transplant programs. Patients.— A cohort of 97587 solid organ transplantations performed on 92966 recipients in the United States from January 1988 through April 1994. Main Outcome Measures.— Short-term and conditional 3-year national and individual transplant program graft and patient survival rates overall and from 2 separate eras (era 1, January 1988-April 1992; era 2, May 1992-April 1994); comparison of actual center-specific performance with risk-adjusted expected performance and identification of centers with better-than-expected or worse-than-expected survival rates. Results.— One-year graft follow-up exceeded 98% and conditional 3-year follow-up exceeded 91% for all organs. Graft and patient survival improved significantly in era 2 compared with era 1 for all cadaver organs except heart, which remained the same. One-year cadaveric graft survival ranged from 81.5% for heart to 61.9% for heart-lung and 3-year conditional graft survival ranged from 91.3% for pancreas to 74.7% for lung. The percentage of programs whose actual 1-year graft survival was not different from or was better than their risk-adjusted expected survival ranged from 98.3% for heart-lung to 75.7% for liver. Most kidney, liver, and heart programs whose actual survival was significantly less than expected performed small numbers (less than the national average) of transplantations per year. Conclusions.— Graft and patient survival for solid organ transplantations showed improvement over time. Conditional 3-year graft and patient survival rates were approximately 90% for all organs except for lung and heart-lung. The conditional 3-year survival rates were better than 1-year survival rates, indicating the major risk after transplantation occurs in the first year. The majority of transplant programs achieved actual survival rates not significantly different from their expected survival rates. Center effects were most significant within the first year after transplantation and had much less influence on long-term survival outcomes.      

改良LPD液在心肺联合移植术中的肺保护作用

目的：探讨改良低钾右旋糖酐（LPD）溶液在心肺移植术中的肺保护作用。方法：在我省首例心肺联合移植术中,采用低温改良LPD溶液对供体肺行肺动脉灌注。结果：术后患者未出现严重肺部并发症、感染及重度排斥反应,已健康存活555 d。结论：在心肺联合移植术中采用改良LPD液对供体肺行肺动脉灌注具有良好的肺保护效果。     

The importance of PRA detection and PRA clearance in cadaveric renal transplantation

Though complement-dependent cytototicity (CDC)asSay is widely adopted as a standald histocompatibilitytest before haplantalon in most of the transplantationcenters in our countw, it yields unacceptably high ~ ofhypemeute rejechon (HR) Of the allograft because of itslow sensihvity[']. In some cases, even the new powerful~nosuPPressants fail to suPPress the disastIDus edejection (GR). In this stUdy, we examined the validity.Of Panel reactive antibodies (PRA) measmnt as a pretranSPlant h…     

改良大鼠腹部心移植模型的制作

目的:总结制作大鼠腹部心脏移植模型的技巧并改良此模型的制作方法.方法:对传统Ono术式的受体准备、供心切取、供心移植等环节进行改良,建立Wistar和SD大鼠的腹部异位心脏移植模型.结果:共完成100例大鼠腹部心脏移植术,90例成功,手术成功率90%.结论:与传统0n0术式相比,此改良术式缩短供心冷缺血时问和腹主动脉阻断时间,降低吻合难度,提高手术成功率,是一种稳定、可靠的大鼠腹部心脏移植模型.     

乙肝/丙肝阳性供肾移植临床观察

目的：探讨乙肝/丙肝阳性供肾移植的安全性。 方法：回顾性分析中南大学湘雅二医院2002年1月至2006年6月间283例乙肝/丙肝阳性供肾移植受者的临床资料。其中乙肝阳性供肾的肾移植共31例,阳性供肾均移植给乙肝表面抗原阳性的受者（DB+/RB+）,同期有26例乙肝表面抗原阳性的受者接受了乙肝表面抗原阴性的供肾(DB-/RB+)。丙肝阳性供肾的肾移植6例（DC+/RC+）,同期有13例丙肝阳性的受者接受了丙肝阴性的供肾(DC-/RC+)。平均随访14个月。结果：接受乙肝/丙肝阳性供肾的受者在肝损害、急性排斥的发生率、移植肾和人的存活率方面与对照组相比无统计学差异。结论：将乙肝/丙肝阳性供肾移植给相应的血清学阳性受者短期内是安全的,远期效果有待进一步观察。     

6例再次尸体肾移植的初步体会

<正> 不论什么原因引起移植肾功能丧失而再次转入血液透析者,是再次移植的适应症。据报道,再移植例数约占肾移植数的10％左右。我院自1978年7月至1983年12月共行同种尸体肾移植44例,50次。其中6例由于排斥反应导致移植肾功能丧失再次行同种尸体肾移植,再移植率为13.6％。现就6例再次移植病人的临床经过,结合有关文献对再移植的手术时机、无功能肾的处理以及手术前后的有关问题作初步探讨。     

猪原位心脏移植的实验研究

①目的　通过建立猪原位心脏移植模型 ,为临床心脏移植提供依据。②方法　家猪 6 0头 ,分为供、受体两组 ,模拟临床心脏移植程序 ,进行供心切取、心脏保存和原位心脏移植。总结猪心脏血管解剖结构特点。测定移植前后血流动力学指标变化。③结果　共完成心脏移植 2 8例 ,因麻醉和受体心血管畸形原因各死亡 1例。猪心解剖结构与人类心脏相似。移植后猪平均动脉压与移植前比较差异有显著性 (t=2 .2 9,P <0 .0 5 ) ;移植后猪心排血指数与移植前比较差异有显著性 (t=2 .71,P <0 .0 1) ;其他指标比较差异无显著性 (t =1.36～ 1.70 ,P >0 .0 5 )。④结论　以猪作为动物模型模拟临床人心脏移植过程 ,用于基础和临床研究是可行的。     

原位心脏移植的临床分析(附2例报告)

目的：总结２例终末期扩张必心肌病原位心脏移植的诊断。方法：２例病人围手术期处理各有特点。手术在全麻、中低温体外循环下施行,供体系２例严重创伤的脑死亡病人。结果：２例存活１例,死亡原因为肺动脉高压所致的右心衰竭及急性排斥反应。结论：采用右心转流可改善右心功能,克服肺动脉高压危象。将成人心脏移植于儿童心包腔内,术前应认真研究,细心准备,术后加强监护与处理,仍可获得良好效果。     

心肌内心电图监测大鼠心脏移植术后急性排斥反应的实验研究

目的探讨心肌内心电图（IMEG）监测大鼠心脏移植术后急性排斥反应的可行性。方法穿刺法建立大鼠异位心脏移植模型,定期描记IMEG,观察QRS波振幅的变化,分别于术后第3、5、8、10天 4个时点处死3～4只动物,切取心脏行心肌组织病理学检查,心肌组织经HE染色和免疫荧光染色判断有无急性排斥反应发生。IMEG QRS波振幅下降10％认为发生排斥反应,并与心肌组织病理学检查结果对照,分析IMEG监测急性排斥反应的敏感性和特异性。对IMEG监测诊断为急性排斥反应的大鼠应用甲基强地松龙冲击治疗。结果共有22只大鼠在术后第5～7天出现QRS波振幅明显下降,下降幅度为（21±7）％。其中有21只经HE染色和免疫荧光染色检查证实发生排斥反应。采用IMEG的QRS波振幅监测心脏移植术后急性排斥反应的敏感性为95％,特异性为78％。经治疗后,IMEG的QRS波振幅和心肌阻抗监测大多迅速恢复至原来水平。结论IMEG是一种实时有效监测急性排斥反应的方法,尤其适合抗排斥疗效的监测。     

Using intramyocardial electrograms combined with other noninvasive methods for monitoring acute rejection following human heart transplantation

Background Acute allograft rejection in heart transplantation remains as one of the major complications. Obligatory graft surveillance is still achieved with the invasive and expensive endomyocardial biopsy （EMB）. Our study aimed to study the use of intramyocardial electrograms combined with other noninvasive methods for the monitoring of acute rejection after human heart transplantation. Methods Permanent pacemakers were implanted in 58 patients undergoing heart transplantations. Intramyocardial electrograms （IMEG） were recorded periodically and the results were compared with those from EMBs. The R wave amplitude of the IMEG was used as the index value, the average R wave amplitude at the third week following transplantation was considered as the baseline, and a reduction of 〉20% compared with the baseline was regarded as a positive result. EMB was performed in cases of positive IMEG results and also at other times. Other noninvasive methods were used to help the diagnosis. Acute rejection （AR） was defined as International Society of Heart-Lung Transplantation grade IliA or higher. Results We obtained 1231 IMEG records and 127 EMBs. Of the total 127 EMBs, 53 were positive, in which there were 42 IMEG positive results and 11 negative, while in the rest 74 negative EMBs, there were 9 IMEG positive results and 65 negative. The sensitivity of IMEG for the diagnosis of AR was 79.2%, and the specificity was 87.8%. The positive predictive value was 82.4% and the negative predictive value was 85.5%. Of the total of 1231 IMEG records, 51 were positive and 1180 were negative. Excluding 11 proved by EMB to be false negative, if the other 1169 were considered as no evidence of rejection, through the other noninvasive methods, AR diagnosed by this noninvasive monitoring strategy, the sensitivity was 79.2%, and the specificity was 99.2%. The positive predictive value was 82.4% and the negative predictive value was 99.1%. Conclusions IMEG can be used as a noninvasive method for monitoring AR following heart transplantation. It is a continuous, safe and inexpensive method, and could reduce the need for EMB combined with other noninvasive methods without reducing the detection of rejection. Chin Med J 2009; 122（2）： 136-139     

The technique of heterotopic heart-lung transplantation in the rat

Summary A simple technique of heterotopic heart-lung transplantation in the rat has been established. The preparation of donor heart-lung and surgical procedures used on the recipient are those originally described by Lee, with minor modifications. The donor’s ascending aorta is anastomosed to the recipient’s abdominal aorta and all the other vessels are permanently ligated. Except the right inferior lobe of the lung which is left attached to the heart all the rest of the pulmonary lobes is removed. The direction of blood flow through the transplanted heart and lung is as follows: aorta, coronary arteries, coronary sinus, pulmonary lobe, left atrium and left ventricle and then to the aorta (with blood exiting from donor aorta to host aorta during contraction of the donor heart). In inbred Wistar rats, the one month survival rate was 90 %. The model is used for experimental selection of immunosuppressive drugs to prolong the survival time of allografts in the rat.     

心肺联合移植1例术后8.5年随访报告

对1例健康生存8.5年心肺移植患者进行总结分析。2003年9月20日湘雅二医院为1例室间隔缺损并重度肺动脉高压的患者施行心肺联合移植术。分别采用1500 mL改良St.Thomas心脏停搏液和3000 mL改良LPD液保护供体心肺。术后抗排斥反应,在诱导期使用甲泼尼龙+抗人淋巴细胞球蛋白治疗,稳定期采用环孢素A+骁悉+泼尼松龙三联免疫治疗。至2007年改为骁悉500 mg+FK506 4 mg,均每天2次。定期复查超声心动图、FK506血药浓度。随访时患者存活已超过8.5年。心功能恢复为(NYH A)I～II级,左心室射血分数61%～74%;提示心肺联合移植是治疗心肺功能衰竭的有效方法,良好心肺保护、正确术后处理是心肺联合移植患者长期存活的关键。