祝贺陈良万等利用脑死亡捐献的供体进行心脏移植成功

近年来，我国的临床心脏移植有了长足的进展，移植术后近、中期效果达到国际先进水平，使许多危重心脏病患者因此而重获新生。但随着心脏移植的广泛开展，供体心脏的来源必将成为影响心脏移植发展的主要因素。虽然供体来源有多种方式，如有心跳死亡（脑死亡）器官捐献、无心跳死亡器官捐献、活体器官捐献等，但对心脏移植来说，只有脑死亡器官捐献才能达到要求。目前我国官方已公开承认从死刑者身上获取移植器官这一事实，这种落后的器官来源模式与目前大规模的移植医疗活动极不相称，这种状态必须尽快改变，以实现我国器官移植公开化、正规化、合法化的目标。我们很高兴看到陈良万等同志在国内率先利用脑死亡无器官捐献的供体心脏进行心脏移植，尝试我国心脏移植史上新的供体心脏来源，     

心脏移植的受体和供体体重差异之临床意义

多年来心脏移植采用供体心脏的重要标准是受体和供体的体重相差<20％。然而需要心脏移植的病人越来越多,常常采用低于标准体重供体的心脏。1985年4月到1991年5月间美国亚利桑那大学为200例病人植入心脏。回顾分析如下。 A组27例接受低于体重标准供体的心脏,供体体重比受体体重轻30％—46％,分别     

心脏移植脑死亡供体的选择标准与管理

据估计美国每年有1．2万名潜在的器官供体，美国每年等待心脏移植的患者有6000～8000人，但每年只有2000～3000的供体用来做心脏移植。这种供需之间的巨大差距使得等待心脏移植的患者每年死亡率为17％，而在迫切需要心脏移植的患者死亡率为45％。美国联合器官共享网络（UNOS）统计显示1998年有5798例潜在的心脏移植供体，但只有2450例被用于心脏移植，使用率仅为42％。造成各个地区使用率差异的原因包括供体的年龄、死亡原因和供体的选择和管理标准等，但即使在成功率高的地区。仍然有很多的供体心脏被放弃使用。供体和受体数目巨大差异的原因主要在于供体的管理和选择问题，以及死者家属器官捐献同意率不到50％。这些问题的根本解决还需要很长时间。     

13例原位心脏移植围术期的处理

目的总结原位心脏移植围手术期的治疗方法。方法13例扩张性心肌患者进行了同种原位心脏移植,围手术期间加强受体的维护、供心离体时间的保护、血流动力学的支持、抗排异反应及感染方面的处理。结果11例患者存活,2例死亡。结论选择合适的供体和受体、良好的供心保护技术、有效的血流动力学支持、抗排异反应方疗案得当、防止感染是围手术期处理的重要组成部分,是手术成功的关键。     

心脏移植供体的选择

心脏移植供体的选择ＤａｌｅＧ．Ｒｅｎｌｕｎｄ不像肾移植者，在选择供体时要求人类白细胞抗原（ＨＬＡ）要一致，而心脏移植者，在选择供体时，要符合以下三个条件：１．ＡＢＯ血型一致或相容２．供受体心脏重量匹配，一般要求供体体重不低于受体体重的８０％，如受体有...     

肝移植术后自发性肝破裂出血1例报告

<正>1 病例资料患者男性，55岁，因乙型肝炎肝硬化失代偿期于2020年8月14日在兰州大学第一医院普外科行同种异体背驮式原位肝移植术。供体来自23岁女性，重度颅脑损伤达到脑死亡状态，捐献前无既往病史，按照中国一类(C-1)器官捐献获取流程实施。采用肝肾联合获取法，获取过程顺利。供肝体外修整术中，仔细结扎和缝扎了下腔静脉上的小静脉分支，注气法检查无渗漏。缝扎了供肝各韧带中可疑的血管断端，查肝动脉未见变异，仔细检查供肝各部位，     

如何确定扩展的供肝标准？

1．引言 在肝移植供体器官的供应和接受移植受体数量的需求之间全球性的巨大不平衡不断地促进人们去最大程度的利用现有供体资源．增加供体的数量和发现新的供体资源。直到最近，尸体供肝移植仍然很大程度上受到供体需要是诊断脑死亡但仍有持续心脏活性标准的限制。在脑死亡（DBD）之后捐赠的供体仍然占到全美肝移植肝源的人约95％。摄近几年．已经有关于活体右半肝捐赠的报道。这种成人对成人的活体供体移植将一个健康供体置丁严重的并发症和死亡的风险中，并且这种肝移植的数量对全部可获得的肝脏供体数量并没有大的影响。     

改进套管法建立大鼠颈部心脏移植模型

目的改进套管连接血管技术制作大鼠颈部异位心脏移植模型,建立更合理、符合实验需要的心脏移植模型。方法心脏移植供体为雄性Wistar大鼠80只,清洁级,体重250-300g;受体为雄性F344大鼠80只,清洁级,体重300-350g。用自制套管将供心肺动脉套接于受体右颈外静脉,将供心升主动脉套接于受体右颈总动脉。结果正式实验80次,移植成功77次,成功率96％。总手术时间50-70min,吻合时间2-4min,供心冷缺血时间10-15min。结论改进套管法建立大鼠颈部同种异体心脏移植模型无需显微外科操作,是一种经济实用、操作简单、稳定可靠、易于复制的动物模型,便于推广。     

无心跳供体心脏移植热缺血时限的实验研究

目的探讨未经药物预处理的无心跳供体心脏移植成功的热缺血时限。方法实验犬30只，供体和受体组各5只，对照组：心脏以0℃组氨酸-色氨酸-酮戊二酸溶液（histidine—tryptophan—ketogluarate solution，HTK）500ml主动脉根部灌注，心脏停跳后切取供心，置于0℃HTK液中保存2h；热缺血16min组：心脏缺氧停跳后热缺血16min．用0℃ HTK液500ml灌注冲洗冠状动脉，切取供心．置于0ccHTK液中保存2h；热缺血18min组：心脏缺氧停跳后热缺血18min，灌注及保存方法同热缺血16min组。以标准心脏移植方法行原位移植，监测供体心脏移植前后的血流动力学指标、心脏质量，测定心肌酶等指标，电镜观察心肌组织超微结构改变。结果心脏移植实验中对照组及热缺血16min组均可成功复跳、脱离体外循环辅助，血流动力学指标差异无统计学意义（P〉0．05）。热缺血18min组仅有2例可以脱机，与对照组及热缺血16min组相比，左心室舒张末期压升高、-dp／dtmax下降较明显．与对照组差异有统计学意义（P〈0．05），但与16min组比较，差异无统计学意义（P〉0．05），心脏质量及心肌酶明显升高（P〈O．05），电镜观察超微结构破坏明显。结论常温热缺血16min的供心有可能被成功用于心脏移植。     

大鼠腹部心脏移植模型的改进

目的:建立一种操作简单、成功率高的大鼠异位心脏移植模型。方法:以雄性SD大鼠为供体,Wistar大鼠为受体,切除受体鼠左肾,使供心升主动脉与受体腹主动脉端侧吻合,供心右肺动脉套接于受体左肾静脉。结果:50例实验成功46例,成功率92％,供心平均缺血时间为(38.9±1.8)min。失败原因:吻合口出血2只,血栓形成和套管扭转各1只。结论:该改良术式是建立大鼠心脏移植模型简单实用的方法之一。     

Heterotopic abdominal heart transplantation: a pilot study

The increasingly severe shortage of donor hearts has prompted a liberalization of what is considered an acceptable donor heart. The use of marginally acceptable organs has increased in recent years. Although these marginal donors have proved effective, there still remains a tremendous shortage of donors to treat the large number of patients who are candidates for cardiac transplantation. Further use of marginal donors is limited by the requirement to assume immediate and full support of the circulation. New strategies are required to increase donor organ use even further. The authors developed a model of heterotopic abdominal heart transplant (HAHT) to investigate the possibility of using marginal donor hearts to expand the donor pool for cardiac transplantation. The authors' goal was to show that HAHT was technically feasible and could potentially function as auxiliary circulatory support in the setting of low cardiac output. The hemodynamic and metabolic consequences of a HAHT were investigated in a pilot study that provides proof of concept and lays the groundwork for future investigations.     

Brain death-induced impairment of cardiac contractile performance can be reversed by explantation and may not preclude the use of hearts for transplantation.

The shortage of suitable donor hearts for cardiac transplantation is exacerbated by the exclusion of those that exhibit contractile malfunction during the period after brain death but before excision. We have replicated the phenomenon of brain death-induced hemodynamic deterioration in the rat in vivo. After 60 minutes of brain death (defined as the absence of electrical activity in the brain), a variety of indicators of cardiac contractile function fell by approximately 50% (thus cardiac index fell from 21 +/- 2 to 11 +/- 1 ml/min per 100 g body weight). However, once excised and perfused ex vivo, the hearts recovered a level of cardiac function that was identical to that from control animals that had not been subjected to brain death. Similarly, when hearts were excised, stored (6 hours at 4 degrees C), and reperfused ex vivo with blood, they also recovered a functional capability identical to that of normal hearts from animals that had not been subjected to brain death. Our results question whether hemodynamic instability in brain-dead individuals is necessarily an irreversible detrimental cardiac phenomenon and whether these hearts should be excluded from transplantation.     

Beta adrenoceptor density in the donor heart: a guide to prognosis?

BACKGROUND--Failure of the donor (graft) heart is the main cause of mortality in the first month after orthotopic cardiac transplantation. In a preliminary study marked downregulation of cardiac beta adrenoceptor density was found in apparently normal donor hearts of recipients who developed severe cardiac failure soon after implantation. Cardiac beta adrenoceptors are an important factor in the development of cardiac failure in the human heart. The aim of this study therefore was to determine whether fatal graft failure in the first month after transplantation is associated with downregulation of beta adrenoceptor density in the donor heart. PATIENTS AND METHODS--Right ventricular endomyocardial biopsy specimens were taken from consecutive adult donor patients immediately before implantation. A previously described radioligand binding method was used to determine beta adrenoceptor density in consecutive patients who developed fatal graft failure and died within 1 month of transplantation and in a group of control donors transplanted during the same period. RESULTS--Perioperative fatal graft failure developed in 13 patients. Forty one specimens from donor hearts that were transplanted into recipients who did not develop fatal graft heart failure formed the control group. There were no systematic differences in donor or recipient characteristics between the graft heart failure and control groups. In particular donor catecholamine requirement and recipient pulmonary vascular resistance did not differ between groups. Total beta adrenoceptor density was reduced in the fatal graft heart failure group compared with that in the controls (13.4 (7) fmol/mg v 21 (7) fmol/mg; P < 0.01). There was a positive correlation between beta adrenoceptor density in the donor heart and time to death in the graft heart failure group (r2 = 0.3, P < 0.05). The beta adrenoceptor binding affinity (Kd) did not differ between the graft failure group and the controls (47 (6) pM v 44 (7) pM). CONCLUSION--The development of perioperative fatal cardiac failure after orthotopic cardiac transplantation is associated with downregulation of beta adrenoceptors in the donor heart before implantation.     

Induction of left ventricular remodeling and dysfunction in the recipient heart after donor heart myocardial infarction: new insights into the pathologic role of tumor necrosis factor-alpha from a novel heterotopic transplant-coronary ligation rat model

OBJECTIVES: The present study investigated the effects of tumor necrosis factor (TNF)-alpha and angiotensin II (ANG II) on cardiac remodeling and dysfunction at the early stage of acute myocardial infarction (MI) by using a novel heterotopic cardiac transplantation-coronary ligation model. BACKGROUND: A recent clinical study has demonstrated a possible role of monocytosis in the development of left ventricular (LV) remodeling in patients with acute MI reperfusion. METHODS: We performed isogenic heterotopic cardiac transplantation and simultaneous coronary ligation to produce MI in the donor heart and to evaluate the hearts of both donors and recipients in Lewis rats. RESULTS: A significant decrease in LV fractional shortening and positive rate of rise in LV pressure and a significant increase in LV end-diastolic dimension/body weight and LV end-diastolic pressure were observed in the recipient hearts in the ligation group on day 7. TNF-alpha was significantly elevated not only in the plasma but also in the recipient hearts in the ligation group. In contrast, ANG II was significantly increased only in the infarct region of the donor hearts, but not in the plasma. Furthermore, the recipients' transient LV remodeling and dysfunction were completely abolished by the intravenous administration of a TNF-alpha antagonist. CONCLUSIONS; We developed a novel cardiac transplantation-coronary ligation model capable of inducing MI in the absence of downstream hemodynamic effects and allowing differential quantification of indexes of cardiac remodeling in vivo, including the local and remote effects of ANG II and TNF-alpha on cardiac remodeling.     

Dopamine treatment of locally procured donor hearts: relevance on postoperative cardiac histology and function

Administration of catecholamines can lead to myocyte damage. Dopamine treatment is often used in potential cardiac donors to attain hemodynamic stability. Donor hearts exposed to dopamine are rejected or selected for transplantation without clearly defined criteria. A prospective study was undertaken to analyze the clinical relevance of dopamine-induced myocardial lesions in 25 hearts (21 male, 4 female; 15-40 years, mean: 26 +/- 7) that were later used for transplantation. Donors were divided into those who had received dopamine and those who had not. Dopamine doses ranged from 2-12.5 micrograms/kg/min (mean: 6.3 +/- 3). Time of administration was 3-26 hours (mean: 16 +/- 8). Use of dopamine was unrelated to donor electrocardiographic findings, intra- or postoperative death, or difficulty coming off by-pass. Postoperatively, filling pressures were similar in both groups of patients at 2 and 10 days postoperatively. Left ventricular ejection fraction was similar in the two groups. Dopamine requirements were significantly higher in the dopamine-treated hearts (P = 0.05). Histologic findings at first biopsy revealed infiltration and cell damage in a similar proportion of patients in both groups. In conclusion: donor hearts exposed to dopamine can be accepted for transplantation if doses ranging from 2-12.5 micrograms/kg/min have been administered up to 24 hours.     

Postoperative hemodynamic improvement with paced linkage of the donor and recipient hearts following heterotopic cardiac transplantation

It has been shown that following heterotopic heart transplantation the recipient left ventricle ejects more effectively when it contracts out of phase with the donor left ventricle. However, this is rarely the situation, as the two hearts beat independently of one another and the denervated donor heart tends to beat faster than the recipient. In this study the hemodynamic effects of connecting the two hearts by an external temporary dual-chamber pacemaker were evaluated. The donor right ventricle was sensed and the recipient right atrium paced after a timed delay. The delay was adjusted so that recipient systole coincided with donor diastole. Eleven patients were studied in the first postoperative day. Pacing resulted in an improvement in cardiac output from 5.0 to 5.61/min (p = 0.003) and a reduction in pulmonary capillary wedge pressure from 16 to 12 mmHg (p = 0.0035). This was associated with a 35% reduction in inotrope requirements. It is concluded that sequential pacing of the two hearts is a useful adjunct to inotropic support in the postoperative period.     

全心脏原位移植(附4例报告)

目的总结4例全心脏原位移植的经验。方法我院于2005年4月至2006年12月对4例扩张型心肌病患者施行了全心脏原位移植手术,其中男性2例,女性2例,年龄32～57岁。供体均为急性脑死亡者。供心心肌保护3例为UW,1例为HTK液。全心脏移植吻合次序依次左肺静脉、右肺静脉、下腔静脉、上腔静脉、肺动脉及主动脉,其中2例由于受体全心脏扩大,按常规保留的受体上、下腔静脉长度无法与供体腔静脉吻合,为此,截取一段长4cm的供体肺动脉,一端与受体下腔静脉吻合,另一端与供体下腔静脉吻合。吻合时间78～104min,主动脉阻断时间136～197min,体外循环时间202～261min。主动脉开放后,1例电击复跳,3例自动复跳,均为窦性心律,未安置心脏临时起搏器。结果患者术后3～6h神志清楚,14～19h拔除气管插管,6d拔除所有侵入性监测管道,两周后从ICU迁至普通病房,1例术后52d出现急性排异反应,经处理得到控制,均痊愈出院。术后随访心功能均为I级,窦性心律,2例有轻度三尖瓣反流,2例已经恢复工作。结论全心脏原位移植法不仅保存左右心房解剖上完整性,有利于心功能恢复,减少移植后血栓的发生率,而且使房、室间隔传导系统的完整性免遭破坏,降低了心律失常的发生率,这是一种值得推荐的心脏移植方法。     

Heart transplantation: approaching a new century

Although cardiac surgeons have gained considerable experience with heart transplantation during the past 30 years, this operation still presents many challenges. The number of transplant candidates continues to exceed the number of available donor hearts, and the shortage is not expected to improve. For patients fortunate enough to receive a donor heart, perioperative mortality is a serious concern. After the 1st postoperative year, the most frequent cause of death is transplant vasculopathy. Other potential complications include renal dysfunction, bleeding, infection, and allograft rejection. Despite these problems, heart transplantation remains the best hope for patients with end-stage heart failure that is unresponsive to conventional therapy. In the future, mechanical cardiac assistance and new medical treatments for end-stage heart disease may offer alternatives to heart transplantation, reducing the competition for scarce donor hearts.     

Heterotopic heart transplantation: current indications for the procedure, with results in 10 patients

From January 1986 to September 1987, we performed 27 orthotopic and 10 heterotopic cardiac transplantations at our institution. Of the 10 heterotopic transplantation recipients, 9 were men; ages ranged from 36 to 65 years; and indications for transplantation were ischemic cardiomyopathy in 8 patients and dilatative cardiomyopathy in 2 patients. Five of the 10 heterotopic transplantation recipients received donor hearts under emergency conditions, when no hearts of suitable size for orthotopic transplantation were available. In 3 of the 10 heterotopic procedures, we performed pure left ventricular (rather than biventricular) bypass in patients with chronic conditions requiring only aneurysmectomy, or aneurysmectomy in combination with an aortocoronary graft. During postoperative hospitalization, the following complications occurred in the 10 heterotopic-transplantation recipients: 10 infectious episodes in 6 patients; 1 episode of severe graft rejection; and 1 episode of severe gastrointestinal bleeding. All these complications were overcome, and no patient in the heterotopic-transplantation group died. Fifteen months postoperatively, one male in the group lost his graft, but his own heart had by then recovered function, despite dilatative cardiomyopathy. More commonly, late investigation (6 months or longer after transplantation) has yielded ambiguous overall evaluations of pump performance of the recipients' native hearts, showing slight improvement in some instances and further deterioration in others. We conclude that heterotopic heart transplantation is a life-saving procedure in urgent cases when only small donor hearts are available, and that it offers a good chance of hemodynamic and functional improvement not only in emergency cases, but also in cases of chronic cardiomyopathy when there is salvageable myocardium.     

Influence of beta blockade on exercise capacity and heart rate response after human orthotopic and heterotopic cardiac transplantation

It has been reported that use of beta blockers may not be safe after cardiac transplantation because the denervated hearts may be largely dependent on circulating catecholamines to increase cardiac output. Therefore, the effects of intravenous propranolol were studied during maximal treadmill exercise in 7 patients with heterotopic and 6 with orthotopic cardiac transplantations. An average decrease of about 15% in exercise duration (p less than 0.001), a 34% reduction in systolic blood pressure increase (p less than 0.05) and a 40% attenuation in heart rate increase (p less than 0.001) were observed after beta blockade. In patients with heterotopic transplantation, beta blockade produced similar effects on heart rate in the denervated donor hearts and the innervated recipient hearts during and after mild exercise. During peak exercise, beta blockade attenuated the rate to a greater extent in the donor hearts. Although the denervated donor heart is more sensitive to beta blockade than the innervated recipient heart during exercise, no adverse effects were observed. Beta-blocker therapy should be considered for cardiac transplant patients if longer-term studies confirm their safe use in these patients.