同种原位心脏移植的免疫抑制治疗

对２例同种原位以及移植受者采用环孢素Ａ（ＣｓＡ）、硫唑嘌呤（Ａｚａ）及皮质类固醇三联疗法进行免疫抑制治疗，治疗分为围手术期及长期维持两个阶段。围手术期的免疫抑制剂用量较大，１周后逐渐减量，ＣｓＡ１２个月后达维持量（２－３ｍｇ，ｋｇ＾－１／ｄ），Ａｚａ术后４０周达维持量（１．２－１．５ｍｇ．ｋｇ＾－１／ｄ），皮质粝固醇１年后停用。例１、例２分别发生３次，１急性排斥反应，经冲击治疗逆转。２例患者用药后     

八例心脏移植和一例心肺联合移植术后近期并发症的防治

目的探讨8例心脏移植和1例心肺联合移植术后近期并发症的预防和治疗。方法2004年5月至2006年2月，对8例患者进行了同种原位心脏移植术，1例患者进行了同种原位心肺联合移植术。术后密切观察并及时处理患者的近期并发症。结果9例患者中，1例术后近期出现高血压；1例发生心功能不全；2例发生巨细胞病毒感染；心肺联合移植的患者出现。肾功能不全、气管吻合口狭窄和霉菌感染。经调整免疫抑制剂及对症、支持等处理后，所有患者症状均缓解。结论重视围手术期的处理和选择合理的抗排斥反应治疗方案，正确处理术后并发症，可降低患者移植术后死亡率，获得满意的早期疗效。     

肝移植术后免疫抑制剂的应用

１９９５年９月至１９９８年７月，我们施行了１３例１４次同种异体原位肝移植，其中１１例术后接受免疫抑制治疗。本文报告肝移植术后应用免疫抑制剂的初步体会。一、临床资料１．一般情况：本组１１例均为男性，平均年龄３３．４岁（９～６１岁），原发疾病为Ｗｉｌｓｏｎ氏病３例，肝硬变并原发性肝癌６例，亚急性重症肝炎、肾移植术后肝功能衰竭各１例。供受者血型不相配１例（供者为Ａ型血，受者为Ｏ型血），其余１０例供受者血型均相同。手术方式为经典式原位肝移植４例，背驮式原位肝移植７例。２．术后免疫抑制剂应用情况：预防排斥…     

6例心脏移植围手术期的处理

目的总结6例心脏移植围手术期处理经验。方法6例晚期心肌病患者接受同种体原位心脏移植术。围术期免疫抑制剂采用赛尼哌诱导方案。维持治疗为环孢素A＋吗替麦考酚酯（或硫唑嘌呤）＋泼尼松三联方案,术后保持低水平的中心静脉压。随访23～30个月,平均（25．6＋4．2）个月。结果6例受者均存活。1例因牙髓感染并发败血症致胸部伤口延期愈合．1例出现硬膜外血肿、脑疝形成行开颅手术。所有患者围术期及随访期间受者均无急性排斥反应、移植物功能不全、肝肾功能不全等并发症。结论围术期适当强度的免疫抑制治疗,合理应用强心利尿,密切监测血流动力学和重视受者的个体化治疗是防治心脏移植术后并发症的有效方法。     

肾移植术后并发淋巴结Kaposi肉瘤一例

肾移植术后并发淋巴结Ｋａｐｏｓｉ肉瘤一例胡仲荣，孔照如患者，男，２２岁。因慢性肾衰尿毒症经３４次血液透析后，于１９９２年６月１３日行尸体肾移植术。术后４２小时肾功能恢复正常。术后免疫抑制剂的应用：术前分２次给唑嘌呤（Ａｚａ）３００ｍｓ，术中及术后２天...     

5例心脏移植后外科疾病的手术治疗

目的总结原位心脏移植受者再行外科手术的围术期处理经验，了解心脏移植术后外科疾病的特点。方法对5例原位心脏移植受者施行手术治疗，其中急性胆囊炎2例，急性阑尾炎、双侧巨乳及肺部肿瘤各1例。再次手术时患者平均年龄44．6岁（14～60岁），距心脏移植手术时间平均为16．4个月（4～37个月）。急性胆囊炎和阑尾炎患者均在急诊情况下切除病灶；双侧巨乳患者施行双侧巨乳缩小术；肺部肿瘤患者先于胸腔镜下切除肿块，经快速冰冻病理证实肿瘤为恶性后再行小切口肺癌根治性切除术。术后连续监测环孢素A（CsA）或他克莫司（FK506）血药浓度，动态调整免疫抑制剂用量；加强围手术期抗感染治疗力度。结果4例患者术后2周内康复，顺利出院；1例急性胆囊炎患者因术后发生胃潴留经内科治疗66d后康复出院。所有患者围手术期均无严重感染、出血等手术并发症，无急性排斥反应及心脏移植物功能不全发生。平均住院时间为21．3d（8～66d）。术后随访1～13个月，无手术疾病复发，亦未出现移植心脏功能不全，生活质量良好。结论心脏移植术后虽因长期服用免疫抑制剂导致抵抗力低下，但如患外科疾病仍需积极手术治疗。经充分的术前准备，患者能够耐受再次手术治疗并获良好的疗效。     

尸体肾移植术后137例急性排斥反应的治疗体会

自１９８５年２月至１９９３年３月施行尸体肾移植４７５例，术后均应用环抱素Ａ（ＣｓＡ）、硫唑嘌呤（Ａｚａ）及强的松（Ｐｒｅｄ）治疗，其中发生急性排斥反应（ＡＲ）１３７例（２８．８％），经正确的使用免疫抑制剂，并分别应用甲基强的松龙（ＭＰ），ＯＫＴ３及ＡＬＧ冲击治疗，９６例逆转（７０．０％），２９例摘除移植肾（２１．２％），１２例死亡（８．８％）。就发生ＡＲ的原因，诊断与鉴别诊断及处理进行讨论。     

重症心脏瓣膜病的外科治疗

自１９８５年６月～１９９５年１月共收治重症心脏瓣膜病３０８例。重症病例判断标准为：（１）心功能Ⅳ级；（２）急诊手术；（３）心胸比率≥０．８０；（４）合并冠心病需行搭桥术；（５）ＬＶＥＤＤ≥８０ｍｍ或ＬＶＥＳＤ≥６０ｍｍ；（６）心导管检查ＣＩ≤２．０Ｌ／ｍｉｎ·ｍ２并ｍＰＡＰ≥９．５ｋＰａ或ＰＶＲ≥２０００ｄｙｎｅ·ｓ·ｃｍ－５；（７）三瓣膜置换术；（８）瓣膜再次置换术。结果：手术死亡３１例，死亡率１０．１％；远期随访２～９４月（平均３４月），远期死亡率３％／人·年。远期心功能Ⅰ、Ⅱ级２１５例，Ⅲ级１７例，Ⅳ级４例。讨论了手术指征，手术方法和围术期处理。     

肝移植术后停用免疫抑制剂59天一例报道

肝移植术后一般常规应用免疫抑制剂抗排斥反应。但是随着肝移植术后治疗的不断成熟．免疫抑制剂的应用方案也越来越趋向个体化。我院2007年8月对一例术前乙型肝炎肝硬化（失代偿期）并发自发性腹膜炎患者施行了经典原位肝移植术．术后一直未用免疫抑制剂长达2个月，患者未出现排斥反应且肝功能恢复良好出院，总结报告如下。     

肾移植术后恶性肿瘤五例报告

本院１９８９年１０月至１９９６年７月接受同种异体肾移植术患者１９８例，５例并发恶性肿瘤，其中男３例，女２例，年龄５０～６７岁，平均６１．２岁。移植肾功能良好。使用环孢素Ａ（ＣｓＡ）、硫唑嘌呤（Ａｚａ）和泼尼松（Ｐｒｅｄ）免疫抑制治疗。术后１个月免疫抑...     

10例同种异体原位心脏移植的术后近期处理经验

目的 总结10例同种异体原位心脏移植的术后近期处理经验,着重探讨术后近期的抗排拆治疗、常见并发症的处理等问题。方法 2000年5月至4月共施行了10例同种异体原位心脏移植手术,术后分别采用了两种免疫抑制治疗方案。6例用环孢素A 霉酚酸酯 强的松;4例用他克莫司（FK506） 霉酚酸酯 强的松。结果 10例病人均于术后1个月左右康复出院,心功能状况及生活质量良好。其中2例术后1周出现一过性糖尿病,1例出院1个月恢复工作出现肺部感染,经治疗后均痊愈。结论 同种异体原位心脏移植手术后,合理应用免疫抑制剂,积极、正确处理并发症,能使病人早日康复,提高生存率和生存质量。     

Symptomatic abdominal aortic aneurysms in long-term survivors of cardiac transplantation

Herein we report the only two long-term survivors of cardiac transplantation who underwent successful repair of symptomatic abdominal aortic aneurysms since the advent of cyclosporine therapy in 1983. Review of the world's literature indicates that the only two recorded cases of repair of symptomatic abdominal aortic aneurysms after cardiac transplantation occurred before the use of cyclosporine. The presentation and clinical course of our patients recently treated are presented, and perioperative care and immunosuppressive management are outlined. As the number of long-term survivors after cardiac transplantation increases, the incidence of other atherosclerotic complications including abdominal aortic aneurysm is likely to become more common, requiring extended cardiovascular follow-up.     

Intraoperative management of heart transplantation in Japan--report of two cases

We experienced intraoperative anesthetic management of two cases of heart transplantation in Japan. Both patients were in the end stage of cardiac failure due to dilated cardiomyopathy. One patient had had implantation of left ventricular assist system, and another patient had had implantation of automated cardioveter defibrillator. Transesophageal echocardiography was useful for the monitoring of cardiac function during the operation. Anti-arrythmic therapy including heart pacing and protection of right heart failure are important for the circulatory management of heart transplantation. The anesthesiologist is needed not only for the management of respiration and circulation but also for the prevention of infection and control of the time schedule.     

Sirolimus in de novo heart transplant recipients with severe renal impairment

Two patients with end-stage heart failure and advanced renal dysfunction (under chronic dialysis therapy) underwent heart transplantation. In order to avoid further renal impairment, a calcineurine inhibitor-free immunosuppression regimen based on the sirolimus was used. Although temporary perioperative support with hemofiltration and dialysis was needed, both patients eventually regained a reasonable renal function with no episodes of clinical rejection and normal cardiac function at 13 and 11 months, respectively, after transplantation. Sirolimus-based immunosuppression might be an interesting alternative to calcineurine inhibitors in the management of patients with significant renal impairment.     

原位心脏移植治疗终末期心脏病25例临床分析

目的总结同种异体原位心脏移植治疗终末期心脏病的临床疗效和经验。方法山东大学附属千佛山医院心外科自2003年3月至2012年10月为25例终末期心脏病患者施行了同种异体原位心脏移植术。原发病包括扩张型心肌病18例、肥厚型心肌病4例和缺血性心肌病3例。采用标准原位心脏移植术1例,双腔静脉吻合法原位心脏移植术24例。7例受者术前合并中度及以上肺动脉高压,术后给予一氧化氮吸入、伊洛前列素持续静脉泵入等综合措施降低肺动脉压。免疫抑制治疗采用环孢素＋糖皮质激素＋吗替麦考酚酯三联方案,有6例受者术中给予抗Tac单克隆抗体诱导治疗,14例受者在麻醉诱导时及术后第4天给予巴利昔单克隆抗体诱导治疗。根据血药浓度谷、峰值调整环孢素用量。结果手术成功率为96%（24/25）,1例受者于术后25h死于肠道出血。余24例受者术后平均随访（58±37）个月（1～116个月）,受者1,3,5年生存率分别为87.0%,82.3%,72.7%。术后早期发生急性排斥反应2例,晚期发生急性排斥反应4例,均经糖皮质激素冲击治疗后逆转。术后早期发生急性肾功能衰竭2例,经血液透析治疗后肾功能恢复正常;晚期发生肾功能不全4例。肺部霉菌感染3例,2例治愈。发生移植物失功2例,受者分别于术后14个月和41个月死亡。1例受者术后17个月发现子宫内膜肿瘤行子宫切除术。结论心脏移植治疗终末期心脏病疗效肯定,需严格掌握手术适应证及加强围手术期受者管理,术后规范抗排斥反应药物治疗,同时重视急性排斥反应及感染的监测和治疗。     

Applications of statins in cardiothoracic surgery: more than just lipid-lowering.

Statins exert several actions in cardiothoracic surgical procedures besides lipid-lowering. In patients undergoing coronary artery bypass grafting (CABG), statins improve bypass graft patency, perioperative as well as long-term mortality rates. In addition, statins reduce the number of postoperative complications and clinical events, revascularization rates and postoperative hospital stay (as well as associated costs). Furthermore, they are protective against de novo atrial fibrillation and renal dysfunction following CABG. In cardiac transplantation, statins decrease cardiac allograft vasculopathy and cardiac rejection rates. They are also associated with a significant reduction in mortality rates in cardiac transplant patients. According to the results of a meta-analysis, statins are associated with one life saved for every 8.5 heart transplant recipients treated for 1 year. Alternatively, routine statin treatment in cardiac transplant patients might have the potential to save 471 lives each year among the 4000 heart transplantation operations performed worldwide. The results from several studies suggest that statins may also play a role in heart valve surgery, lung transplantation, pulmonary resection and thoracic aortic aneurysm repair. Statin use is safe and cost-effective. Despite the multiple beneficial effects of statin therapy, there is evidence suggesting that a large percentage of cardiothoracic surgical patients are suboptimally treated with respect to statins. Risk management in these patients should be improved to reduce cardiovascular morbidity and mortality rates.     

心脏移植的发展现状和新挑战

心脏移植是终末期心力衰竭患者的首选治疗。供者不足一直以来都是限制心脏移植数量增长的主要问题,随着新技术的不断更新和引入,供者池被不断扩大,比如使用年龄较大的供者、丙型肝炎病毒感染的供者、毒品过量致死的供者或心脏死亡器官捐献（DCD）供者的心脏等。与此同时,高龄、多器官功能不全、机械循环支持及人类白细胞抗原抗体致敏受者的比例近几年明显增加。供者数量的不足、受者状况的复杂化、免疫抑制治疗的个体化管理和远期移植物血管病的防治等都是心脏移植领域面临的挑战。本文通过概述现今全球在扩大供者库、提高受者质量、加强排斥反应的诊治和心脏移植物血管病变的预防等方面的新进展,以期有助于改善在等待或已经接受心脏移植的终末期心力衰竭患者的生存时间和生活质量。     

The first clinical experience with heart transplantation

The article analyses the first clinical experience in orthotopic allotransplantation of the heart at the Scientific Research Institute of Transplantology and Artificial Organs, USSR Ministry of Health, in the period from October, 1986 to July, 1989 (26 transplantations of the heart and one two-stage transplantation of the heart with the use of "Poisk-10M" artificial heart for 3.5 days in the first stage). Eleven patients are alive. Follow-up periods: maximum over 2.5 years, minimum 3 months. Sixteen patients died in different periods (up to 12 months). Three-component therapy (cyclosporine A, methylprednisolone, azathioprine) was applied for immunosuppression. The authors analyse the problems of the selection of potential recipients (indications and contraindications) and donor, the optimum surgical techniques, complications of immunosuppressive therapy, and infectious complications. The first clinical experience in two-stage transplantation of the heart is analysed. The first experience in transplantation of the heart in patients allows the conclusion that the use of this method for the management of the terminal stage of congestive cardiac insufficiency is a reality.     

肝移植受者术前心脏疾病风险评估的现状及展望

随着肝移植疾病谱和器官分配体系等因素的改变,越来越多伴有心血管合并症的患者进入移植等待名单。手术应激、严重感染、免疫抑制药物不良反应等亦会导致术后心脏并发症发生风险显著增加,影响受者短期及长期生存。因此,术前对受者心脏结构及功能进行全面评估,对改善肝移植预后尤其重要。本文就肝移植围手术期心脏疾病风险增加的主要原因、肝移植受者心脏疾病风险评估的时机和方法进行综述,介绍当前肝移植术前常见心脏疾病的评估手段,以期为进一步降低肝移植术后心脏并发症发生率、提高移植物和受者存活率、改善临床预后结果提供参考。