关节镜下同种异体半月板移植的护理配合

目的 探讨全关节镜下同种异体半月板移植的手术护理配合.方法 对5例半月板损伤患者行关节镜下同种异体半月板移植术;术前访视,做好仪器、物品及同种异体半月板供体的准备;术中巡回、器械护士与术者密切配合;术后协助术者妥善包扎伤口,并送患者返回病房等.结果 5例患者平均手术时间3.7 h,术程顺利;术后均未出现排斥反应和其他并发症;随访1～5个月,均已完全负重,无疼痛、肿胀等临床症状.结论 关节镜下行同种异体半月板移植术,安全、患者恢复快;积极有效的护理配合是手术成功的重要保障.     

同种异体关节移植的手术配合

对13例患者行同种异体关节移植手术.结果 均顺利完成手术,未发生术中、术后并发症.提出重视患者的心理护理,充分的术前准备,正确熟练的手术配合及术中护理是顺利手术的重要环节.     

同种异体关节移植的手术配合

对13例患者行同种异体关节移植手术。结果均顺利完成手术，未发生术中、术后并发症。提出重视患者的心理护理。充分的术前准备，正确熟练的手术配合及术中护理是顺利手术的重要环节。     

心脏移植术后早期ICU监测与治疗

目的总结同种异体原位心脏移植术后在ICU的监测与治疗经验.方法对我院自2001年8月至2005年5月开展的9例原位心脏移植手术的临床资料进行回顾性分析.结果全组存活8例,8例病人于术后8～14 h脱离呼吸机,术后2～5 d下床活动,住ICU时间5～10 d,死亡1例,因右心功能衰竭直至死亡未能脱机.术后并发症有急性右心功能不全4例,肾衰2例,高血糖2例,大量胸腔积液1例,室性心律失常1例.结论心脏移植术后早期加强监测,有效的抗排异治疗,积极防治并发症,维护重要脏器功能是心脏移植成功的关键.     

同种异体原位心脏移植和心肺联合移植的麻醉处理

目的 总结8例同种异体原位心脏移植手术和2例心肺联合移植手术的麻醉处理经验.方法 术前依据患者心肺功能及全身状况,给予强心、利尿、营养心肌等治疗.采用静吸复合麻醉,气管插管控制呼吸,在心肺转流下行同种异体原位心脏移植手术或心肺联合移植手术.根据血流动力学监测选用合适剂量的多巴胺、肾上腺素、异丙肾上腺素等血管活性药物.结果 10例患者术中血流动力学均平稳,术后17～25 h拔除气管导管,无早期死亡.结论 术前重视对心肺功能的调整,术中维护血流动力学的稳定,术后正确处理右心功能不全和低心排是心脏移植手术和心肺联合移植手术的麻醉关键.     

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。     

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。     

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。     

心脏移植术后并发症13例分析报告

目的：探讨心脏移植术后并发症的危险因素及处理方法。方法：对13例终末期扩张型心肌病患者施行了同种原位心脏移植术,12例为改良经典式,1例为全心脏原位移植,结果：13例手术均顺利,其中4例存活时间短于10d,1例存活17周,其余均长期存活,且生活质量良好,心功能0－1级;本组病例术后并发症以感染为主,其次为心律失常及各种原因所致的肝,肾功能损害,结论：心脏移植术后的并发症可发生在各个系统,术前各脏器的一般情况,手术打击,术后监护的程度及用药情况等均可影响并发症的发生。     

同种异体原位肝脏移植手术的围手术期护理

报告了11例同种异体原位肝脏移植手术患者的围手术期护理。主要包括在做好心理疏导、健康教育、术后监护、体位护理、疼痛护理、T管观察护理及营养支持的同时,密切观察有无排斥反应、肝动脉栓塞,胆道狭窄、腹泻等并发症,并做好康复锻练及出院指导。本组未发生护理并发症,除1例死于其他并发症外,余10例均健康存活。     

Rescue cardiac transplantation for early failure of the Fontan-type circulation in children

OBJECTIVE: Early failure of the Fontan-type circulation is a potentially fatal complication. We review our experience with cardiac transplantation in children presenting with end-stage heart failure in this scenario. METHODS: We performed a retrospective review. Between 1985 and 2003, 6 children aged less than 16 years were referred for cardiac transplantation. The indication for cardiac transplantation was end-stage cardiac failure early after the completion of the Fontan-type operation. RESULTS: All 6 patients listed for transplantation underwent cardiac transplantation; the median interval to transplantation from the operation was 36 days (range, 6-180 days). Four patients had undergone the Fontan procedure, and 2 had one-and-a-half-ventricle repair. All 6 patients were ventilated and inotrope dependent, with varying degrees of multiorgan dysfunction. One patient was bridged to transplantation with extracorporeal membrane oxygenation. The median age at transplantation was 7.1 years (range, 3-12.5 years), and weight was 18.9 kg (range, 11-35 kg). One patient died on the operating table (graft failure and hemorrhage). In 5 survivors the median intensive care unit stay was 10 days (range, 8-61 days). On follow-up of 6 to 81 months, there have been no subsequent deaths, and the quality of life in survivors is good. CONCLUSION: Rescue cardiac transplantation in the setting of an early failure of the Fontan-type circulation and end-stage cardiac failure is an effective treatment option and can be performed with acceptable early mortality and encouraging short-term to medium-term results.     

缺血对移植心脏冠状血管的影响

目的 探讨缺血对移植心脏远期冠状血管的形态学影响。方法 雄性Wistar大鼠为供者和受者，建立大鼠腹部异位心脏移植模型。实验分为4组，即假手术对照组、立即移植组、供心缺血3h移植组和缺血6h移植组。每组术后均用环孢素A(CsA)灌胃20d，抗排斥反应。20d时，取出供心，观察心脏冠状血管病理改变及超微结构变化。结果 假手术对照组心脏和立即移植组的供心冠状血管内皮超微结构均无明显损害；随着供心缺血时间的延长，移植后冠脉小血管内皮细胞肿胀，冠状动脉的内皮细胞增生，内膜增厚；缺血6h移植组供心冠状血管内膜超微结构改变非常明显。结论 供心缺血可导致移植后冠状血管内皮损伤，是心脏移植术后冠状血管病理改变的重要因素。     

原位心脏移植16例报告

总结16例心脏移植经验,探讨心脏移植的近期与远期疗效.方法 对1998年10月至2009年9月施行的16例次(15例患者)原位心脏移植的临床资料进行总结分析.结果 16例次心脏移植中,经典式原位心脏移植术4例次、双腔静脉吻合法心脏移植术12例次,全部病例采用术后早期免疫诱导+三联免疫抑制剂的抗排斥反应方案.6例死亡,存活时间5 d~103个月,中位数3.5个月.1例存活5 d,死于低心排血量及主动脉内球囊反搏(IABP)的并发症;1例存活13 d,死于金黄色葡萄球菌感染及多器官功能衰竭;1例存活3个月,死于肺部细菌、真菌感染;1例存活4个月,死于肺结核;1例存活18个月,死于中、重度急、慢性排斥反应;1例存活103个月,死于肺部真菌感染合并肝功能衰竭,尸体解剖检查未发现排斥反应.余9例(10例次)至今存活,存活时间3~119个月,中位数49个月.结论 心脏移植是治疗终末期心脏病的有效手段,近、远期疗效良好.术后近期须密切监测和处理感染、急性排斥反应等术后并发症,长期生存病例须特别注意慢性排斥反应的发生.     

体外膜肺氧合技术在心脏移植不同时期的应用

目的 探讨体外膜肺氧合技术(ECMO)在心脏移植术前辅助、术中替代体外循环及术后辅助治疗的临床应用效果.方法 对心脏移植术前过渡、术中代替常规体外循环以及术后心功能衰竭辅助治疗中使用ECMO技术患者的临床资料进行回顾分析.结果 3例等待心脏移植的患者术前应用ECMO 5～8 d,其中2例患者在等待供心的过程中发生多器官功能衰竭而死亡;1例患者成功接受心脏移植,术后顺利撤除了ECMO.12例在心脏移植术中应用了ECMO代替常规体外循环技术,均顺利完成手术,术后持续应用ECMO辅助的时间平均为(38±14)h,1例患者因发生多器官功能衰竭死亡,其余11例患者均痊愈,顺利出院,无患者发生右心功能衰竭和三尖瓣返流等心脏移植术后常见的并发症.心脏移植术后由于严重右心功能衰竭接受ECMO辅助治疗的患者有10例,起始时间为返回监护室后2 h至2 d,持续时间为43～176 h,其中7例患者痊愈,顺利出院,1例因发生严重感染而死亡,2例因发生多器官功能衰竭而死亡.以上死亡患者的死亡原因均与ECMO的出血或血栓形成等并发症无关.结论 尽早应用ECMO可以使等待心脏移植的心功能衰竭患者有效地过渡到心脏移植;术中应用ECMO替代常规体外循环技术可以更好地保护供心,有利于缺血时间较长供心的功能恢复,提高心脏移植手术成功率;术后患者出现右心功能衰竭时,应用ECMO有良好的辅助治疗效果.

Abstract：

Objective To investigate the clinical results of extracorporeal membrane oxygenation (ECMO) technique during the peri-operative heart transplantation. Methods The clinical data of heart transplantations supported by the ECMO were retrospectively analyzed, including during the bridge to transplant, working as routine bypass in the operation room, and supporting the heart failure after surgery. Results Three 3 cases were supported with ECMO to extend the waiting time: 2cases died of multi organ failure during the waiting, and the third one received the heart transplant and the ECMO was successfully removed. Totally 12 cases of heart transplantation received the modified open style ECMO techniques replacing the routine bypass. The ECMO was removed after assistance for (38 ± 14) h. All the recipients except one death recovered well without right ventricular failure or obvious tricuspid regurgitation which was common after heart transplantation. Ten cases received ECMO support for the heart failure after the transplant. The initial application time ranged from 2 h to 2 days and lasted 43～176 h. One died of infection and two died of multi organ failure nothing to do with ECMO application and other 7 discharged with NYHA Ⅰ/Ⅱ cardiac function. Conclusion Early use of ECMO could safely bridge the heart failure patients to the transplant. Replacing the routine with ECMO techniques in the heart transplantation could get good myocardial protection results even with long cold ischemic time and improve the cardiac function recovery. For the heart failure patients after the surgery the ECMO could afford good support effect.     

Clinical experience with the Novacor ventricular assist system. Bridge to transplantation and the transition to permanent application

At Stanford University, a Novacor left ventricular assist system (Baxter Healthcare Corporation, Novacor Division, Oakland, Calif.) was placed as a bridge to heart transplantation in 13 patients. During the hospitalization preceding device implantation, all patients were receiving inotropic support for biventricular failure, 11 had pulmonary edema, 6 had life-threatening ventricular arrhythmias, 5 had liver dysfunction with coagulopathy, and 2 had renal failure necessitating artificial support. The mean cardiac index before implantation of the Novacor system was 1.5. All survivors with the Novacor device had a dramatic increase in cardiac output (mean cardiac index = 3.1). One patient with cardiac allograft rejection died during implantation of the left ventricular assist system. Two patients died of pulmonary sepsis and multiorgan failure after the device was implanted. All patients who had the Novacor device implanted for more than 7 days were able to walk and ride stationary bicycles while awaiting transplantation. Ten patients (77%) underwent successful heart transplantation after a mean of 18 days' support with the Novacor device. One patient died of presumed sepsis 2 days after transplantation. Nine patients (90%) are alive 4 months to 6 years after transplantation. In the overall United States experience, 68 patients (as of May 1990) have had a Novacor left ventricular assist device implanted. Five were still being supported, 39 had received a transplant (62%), and 35 patients (90%) survived the transplant hospitalization (1 died later). No instances of device failure have occurred. Overall, the Novacor assist system provided effective bridging to transplantation, with posttransplant survival similar to results after routine transplantation. Modifications and improvements based on this clinical experience have been made in the areas of patient selection, techniques of operative placement, postoperative management, and design of the assist system. Isolated left heart support with a fully implantable left ventricular assist system will be offered as an alternative to heart transplantation for selected patients by 1992.     

猪到猕猴异种心脏异位移植术的手术配合

目的：介绍猪到猕猴异位心脏移植的手术配合方法。方法：选用猪到猕猴为移植模型，配合完成异位心脏移植术21例。结果：异种移植手术受体猕猴平均存活11d，手术成功率70％。结论：要确保猕猴异种移植手术成功，除了常规方法外，充分的术前准备、术中配合是异种移植手术成功的重要环节。     

原位心脏移植18例

目的 总结1995年8月至2000年6月18例同种原位心脏移植的临床治疗经验和教训。方法 18例终末期扩张性心肌病病人接受标准式或全心脏式移植术,其中1例为心肾联合移植。供心保护液为4℃Stanford大学溶液、福协VI号溶液或冷血液。免疫抑制治疗采用三联方案。结果 全组无手术后早期死亡。4例早中期死亡。其余14例长期生存,生活质量良好。 结论 心脏移植是治疗终末期扩张性心肌病的有效方法。提高心脏移植后生存率的基本经验是：正确选择病例、合适的手术方法、良好的供心保护以及合理应用免疫抑制剂和慎密的随访。     

Primary cardiac tumours — is there a place for cardiac transplantation?

Between 1979 and 1985, seven patients (five children and two adults) were treated for primary cardiac tumours other than benign atrial myxomas. There were five malignant neoplasms (two non-classifiable sarcomas, one haemangiosarcoma, one histiocytoma and one neurofibrosarcoma) and two benign tumours (fibromas). Echocardiography, cardiac catheterisation, computed tomography and magnetic resonance imaging provided diagnostic confirmation. The two patients with fibroma are alive and well 4 and 5 years after radical resection of the tumours from the interventricular septum. The patient with a neurofibrosarcoma underwent orthotopic cardiac transplantation and is well 5.5 years postoperatively with no evidence of residual disease or recurrence. One patient died awaiting a donor heart for transplantation. Another patient who was a candidate for heart and lung transplantation was found to have an unresectable tumour at the time of operation. One patient with sarcoma who underwent a successful emergency partial resection for relief of cardiac tamponade died 18 months later from wide-spread metastases. The seventh patient was inoperable due to multiple secondaries. It is concluded that radical resection of large, benign, cardiac tumours can give good results and that early cardiac transplantation probably offers the only hope for patients with malignant tumours of the heart.     

Tricuspid annuloplasty significantly reduces early tricuspid regurgitation after biatrial heart transplantation.

BACKGROUND: The incidence of tricuspid annuloplasty (TR) observed early after cardiac biatrial implantation is unpredictable and in our experience not infrequently problematic. Although the bicaval method of implant may reduce the incidence of TR, its benefit has not been conclusively documented. METHODS: In an attempt to reduce the incidence of TR observed early after cardiac transplantation, 25 consecutive patients undergoing cardiac transplantation received donor heart tricuspid annuloplasty (TA) with either a DeVega or Ring technique. Early transthoracic echocardiograms were analyzed and compared with an immediately prior and consecutive cohort of 25 patients undergoing transplantation without TA. The biatrial technique of cardiac transplantation with a Cabrol modification was used for donor heart implant in both groups. Echocardiograms obtained 5 days after cardiac transplantation were reviewed in blinded fashion. TR was scored 0 = none, 1 = mild, 2 = moderate, and 3 = severe. RESULTS: Donor and recipient characteristics were not different between groups. No hospital deaths occurred in either group. Patients undergoing transplantation without TA had a higher TR score, 1.3 (range 0-3), than did patients with TA, 0.7 (range 0-1.5, p = 0.002). Moderate or severe TR was present in 8 of 25 patients without TA compared with 0 of 25 patients with TA (p = 0.004). No patients required permanent pacemaker. CONCLUSIONS: TA can significantly reduce the incidence of early postoperative TR after biatrial cardiac transplant without adding to the complexity of operation.     

Assessment of cardiac rejection following heart and lung transplantation (I)

To diagnose the cardiac rejection after the heart and lung transplantation, the histopathological assessment is the most reliable method at the present time. In this study, the heterotopic heart and lung transplantation was performed using rat model and the rejection process of heart allograft was sequentially examined at 1 day, 4 days, 7 days, and 12 days after the transplantation. The gross finding of both ventricles were observed to investigate the development process of the rejection. Then, the most typical findings in each period were analysed using a microscope with our criteria including three components, which are 1. Perivascular findings 2. Interstitial findings, 3. Myocyte degeneration. This study demonstrates that allograft rejection after heart and lung transplantation initiates from right ventricular free wall and spreads into outer layer of left ventricle as same fashion as orthotopic cardiac transplantation. The assessment of these 3 components using the indicators shown in this study might be very useful method to objectively determine the grades of rejection after the heart and lung transplantation.