肝移植术后腹腔出血的临床相关因素分析

目的 探讨肝移植术后早期腹腔出血的临床相关因素,为临床合理处理提供线索.方法 观察我院行肝移植术后早期发生腹腔出血患者的术前终末期肝病模型(MELD)评分、凝血功能和术中出血量、凝血功能变化;腹腔探查血管性出血情况.结果 肝移植术后出血组患者(12例)术前MELD评分较非出血组(82例)显著增高(P＜0.01);出血组患者术前存在凝血功能障碍,术中出血量显著增加,术后凝血功能较术前进一步恶化,与非出血组差异均有统计学意义(P＜0.01);6例腹腔探查手术患者均发现存在小动脉出血.结论 肝移植术后腹腔出血与术前高MELD分值、凝血功能障碍和术中大出血量密切相关,但术中血管处理不当仍是肝移植术后腹腔出血的重要原因.     

肝移植术后患者呼吸衰竭原因及防治措施探讨(附19例分析)

目的 探讨肝移植术后患者呼吸衰竭的原因及相应防治措施.方法 回顾本院19例因各种不同肝脏疾病而行肝移植手术的病例,分析其术后呼吸衰竭发生率、相关监测项目数据及相应处理措施.结果 术后14/19例(73.7%)发生呼吸衰竭,其中8/19例(57.1%)为急性呼吸窘迫综合征(ARDS),4/19例(28.6%)为急性肺损伤(ALI).呼吸衰竭的发生与围手术期血制品输入量、液体出入量、pH值异常、术前并发症、合并感染有密切关系.给予氧疗、抗感染、控制液体出入量及其它对症治疗后,14例呼吸衰竭均得以纠正.结论 围手术期输入过多血制品,液体出入量正平衡,PH值异常、合并其他严重并发症及感染是术后呼吸衰竭的主要原因.控制血制品的输入量及液体出入量、纠正PH值,给予氧疗,治疗感染及并发症可有效地纠正呼吸衰竭.     

神经精神系统并发症

神经精神系统并发症在肝移植术后较为常见,包括移植后脑病(也称肝移植术后谵妄样精神障碍)、癫痫、脑血管病、中枢神经系统感染(颅内感染)、周围神经病变等。发生率为8％～47％,大多发生在移植后1个月之内,可增加围手术期病死率。现就肝脏移植后神经精神系统并发症的有关问题进行分析。     

肝移植术后血管并发症的治疗探讨

目的 探讨肝移植术后血管并发症非手术及介入治疗转归。方法 总结分析1999～2001年期间29例肝移植病例，其中9例术后发生不同类型的血管并发症，采取非手术及介入治疗的临床转归。结果 血管并发症总发生率31％(9／29)，其中门静脉附壁血栓2例(7％)，门静脉血栓2例(7％)，肝动脉狭窄1例(3．4％)，肝动脉假性动脉瘤1例(3．4％)，流出道梗阻4例(4％)。8例经抗凝治疗及介入治疗均取得良好临床效果，1例需要再次肝移植。结论 肝移植术后早期发生的肝流入道血管并发症多需手术干预或终致再次肝移植。流出道梗阻则采取介入治疗多有良好结局。远期发生的肝动脉血栓或门静脉血栓，有转向良好愈后的可能。对于肝动脉吻合口处的假性动脉瘤建议早期行动脉再成型术。     

肝移植术后胆道并发症的内镜治疗

胆道并发症是影响肝移植受者和提高移植肝存活率的主要原因,目前常见的胆道并发症主要有胆管狭窄、胆漏、胆管结石、胆管炎、乳头肌功能紊乱等.现对我院肝移植术后出现胆道并发症的16例患者进行回顾性分析,总结内镜治疗肝移植术后胆道并发症的疗效,报道如下.     

先天性心脏病心导管及心血管造影检查死亡病例分析

目的:总结先天性心脏病心导管及心血管造影术死亡病例的特点,分析死亡原因及危险因素,为降低先天性心脏病(先心病)心导管心血管造影术病死率提供理论依据。方法:回顾性分析阜外心血管病医院近11年间,先心病行心导管或心血管造影检查术死亡的12例患者的临床资料、超声、胸X线片、心导管及造影检查、尸体解剖结果,分析各种先心病行心导管及心血管造影检查的病死率。结果:先心病行心导管及心血管造影术总病死率1.4‰,58.3%的患者死于缺氧发作,33.3%的患者死于恶性心律失常,8.3%的患者死于心源性休克;在各种先心病中,威廉斯综合征(Williams syndrome,WS)行心导管心血管造影术的病死率最高,达23.1%;83.3%的患者术前有严重的低氧血症,50%的患者临床NYHA心功能分级III-IV;33.3%的患者心血管造影术中经过顺利而死于术后并发症。结论:先心病行心导管心血管造影检查时缺氧发作是引起死亡最常见的并发症,严重的低氧血症及心功能不全是心导管及心血管造影术死亡的重要危险因素,威廉斯综合征行造影检查存在较高的病死率,术后24小时是并发症高发时期,应加强心血管造影术后监护。     

肝移植相关心血管并发症的发生与防治

肝移植是治疗急性肝衰竭、失代偿期肝硬化及肝细胞癌等终末期肝病的有效方法。近年,随着患者对医疗技术水平的认识和对术后生活质量要求的提高,肝移植已逐渐成为临床常见手术。从肝移植术前、术中及术后3个方面,阐述肝移植相关心血管并发症发生的原因和防治方法,旨在更好的认识和指导肝移植临床工作。     

成人间活体肝移植受体术后肺部感染分析

目的 探讨活体肝移植受体术后早期(≤30 d)肺部感染的发生率、主要病原菌,预后以及肺部感染的危险因素.方法 回顾性分析四川大学华西医院肝移植中心2005年3月至2008年9月,术前无呼吸系统疾病的108例成人活体肝移植受体的临床资料,分析术后肺部感染的发生率、主要病原菌、患者的预后以及肺部感染的危险因素.对所有相关因素先用单因素分析(t检验,秩和检验及卡方检验)逐一筛选,然后将所有P<0.05的因素进行非条件Logistic回归分析.结果 肺部感染发生率为22.2%(24例),病原体包括细菌23例,其中4例患者为细菌与真菌混合感染,细菌中革兰阴性菌18例(78.3%),巨细胞病毒l例.24例中6例术后早期死亡,病死率为25.0%,84例未发生肺部感染者,有4例术后早期死亡,病死率为4.8%,X2=6.850,P=0.009,差异有统计学意义.单因素分析提示术后肺部感染与术中输全血/红细胞悬液量、术中输血浆量、术中输液总量、术后拔管时间、术后待重症监护室时间及急性排斥有关.Logistic回归分析提示仅术后拔管时间及急性排斥与术后肺部感染相关.结论 肺部感染是活体肝移植术后常见的并发症,有较高病死率,革兰阴性细菌为主要的病原菌,其发生与术后拔管时间及急性排斥密切相关.     

供肝处理对肝移植术后早期胆道并发症的影响

胆道并发症是原位肝移植术后常见的并发症，也是目前导致肝移植失败的主要原因之一。目前，术后胆道并发症的发生率仍高达10％-30％，而且常需要二次手术处理。供肝的质量是术后胆道并发症发生与否的关键。本研究回顾性分析临床资料，观察改进供体处理方法后肝移植术后早期胆道并发症的发生情况。[第一段]     

22例肝移植术后内科危重并发症分析

为提高肝移植的存活率,本文就22例背驮式肝移植术后常见的危及生命的内科并发症加以总结分析.本组肝移植术后内科危重并发症主要为成人呼吸窘迫症(18%)、严重感染(27%),急性排斥反应(13.6%),环孢素中毒致肝功能损害(4.5%).除急性排斥反应外,肝移植术后并发症的病死率高.ARDS主要的发病原因是术中输血过多,无肝期及手术时间过长.术后感染发生的原因与术后移植肝的功能恢复不良、免疫抑制剂与抗生素的应用不够合理有关.术后肝功能不良除手术原因外,与排斥反应以及环孢素A浓度掌握不当密切相关.文中对各种并发症的防治进行了讨论.     

244例造血干细胞移植的心血管并发症

目的:探讨造血干细胞移植(HSCT)治疗恶性血液病过程中心血管并发症的发生。方法:对1990年8月至2007年8月我院244例造血干细胞移植患者并发心血管疾病的情况进行回顾性分析。结果:244例无心血管病史和心电图正常的患者中有40例(16.39%)出现心血管系统井发症,除1例移植后早期心源性猝死外,其它移植患者的心血管症状均得到控制。心律失常19例(47.5%),是其中最多的心血管并发症,以窦性心动过速、频发性房性早搏、室性早搏、房室交界性早博为多;其次为心脏缺血性改变和高血压。结论:移植相关心血管并发症是影响造血干细胞移植效果的重要因素,应在移植全过程中予以监护和处理。     

Distinct factors correlating with adverse cardiac events after major vascular surgery

INTRODUCTION: Cardiovascular complications remain the principal cause of both morbidity and mortality after major vascular surgery. The well-known coincidence between vascular disease and coronary artery disease provided the rationale for a detailed analysis of major perioperative cardiovascular complications in their relation to preoperative and intraoperative parameter METHODS AND PATIENTS: 90 patients scheduled to undergo either femoral-popliteal bypass (n = 74) or repair of an infrarenal aortic aneurysm (n = 16) were prospectively included in the study. All patients had no signs of unstable cardiac disease and required no cardiac testing. Both preoperative and intraoperative parameter were correlated to adverse cardiac events (cardiac death and myocardial infarction -MI). RESULTS: Univariate analysis identified the following parameter to be significantly related to cardiac complications: prior MI and intraoperative hypertension (systolic blood pressure above 200 mmHg). In contrast perioperative betablocker therapy was revealed to be protective. In multivariate analysis the history of MI and intraoperative hypertension correlated with poor cardiac outcome. CONCLUSIONS: Our results underline the importance of the individual history in predicting perioperative risk and corroborate the beneficial effects of long-standing beta-blocker therapy. Additionally the significance of stable intraoperative hemodynamic parameter is demonstrated.     

Evaluation of cardiovascular risk for renal transplantation in diabetic patients

Cardiovascular disease contributes in a major way to morbidity and mortality in diabetic patients with end-stage renal disease. Sixty patients with type I diabetes were evaluated prior to renal transplantation to determine the risk of cardiovascular complications. On the basis of results of thallium stress testing and/or cardiac catheterization, each patient was assigned to one of five categories. There were no cardiovascular events in the seven patients who had negative results on stress testing. Of the remaining 53 patients, all of whom underwent cardiac catheterization, 30 had normal coronary arteries. None of these 30 patients had any cardiac morbidity, and the two deaths that occurred in this group were not attributable to cardiac causes. Significant coronary artery disease was present in 38 percent of the patients. The overall mortality rate was 5.4 percent in those patients without coronary artery disease and 43.5 percent in those with the disease. In addition, the mortality rate in patients with coronary disease classified as severe was 62 percent, whereas it was 20 percent in those categorized as having moderate disease. The data indicate that patients with diabetes and end-stage renal disease who are at highest risk for cardiovascular events can be identified, and these patients probably should not undergo renal transplantation.     

Pediatric heart transplantation: 17-year Brno experience

AimTo summarize the follow-up of children who underwent orthotopic heart transplantation (HTx) in the Center of Cardiovascular and Transplantation Surgery in Brno during the past 17 years.Patients and methodsBetween May 1995 and October 2012, 42 children aged 2 months–17.5 years were listed for HTx, of these 26 underwent HTx later.ResultsOf 42 children listed for HTx, 12 died, 26 underwent HTx, 3 were excluded because of improved clinical status, and 1 is waiting for HTx. Five children died early after the transplantation, one patient died 6.5 years after HTx. The 1-year, 5-years and 10-years post-transplantation survival rates are 81%, 81%, and 76.9%, respectively. One patient underwent re-transplantation 11.5 years after HTx because of coronary artery disease affecting the graft. Long-term follow-up data are available for 21 children surviving 1.6–17.4 years (mean 8.7±5.3 years). The most common morbidities were hypertension and mild chronic kidney disease (CKD 2). Pneumonia was the most common infectious complication requiring hospitalization. EBV infection with subsequent development of post-transplant lymphoproliferative disorder (PTLD) was a severe late complication in two patients (diagnosed 8 and 15 years after transplantation). The increase in incidence of coronary artery disease during the second decade post-HTx (affecting 7.7% patients after 5 years and 42.8% patients after 10 years) leads to a significant increase in the morbidity of pediatric patients surviving more than 10 years after transplantation.ConclusionHeart transplantation currently represents an effective treatment of terminal heart failure in children. Improving outcomes of pediatric HTx mainly reflect the drop in early mortality. The main causes of late morbidity and mortality of children after HTx are the increase in incidence of coronary artery disease and malignant diseases (PTLD). Our results of long-term follow-up of children after heart transplantation are consistent with published data from other centers.     

Cardiovascular Complications and Their Association With Mortality in Patients With Thrombotic Thrombocytopenic Purpura

BackgroundDespite widespread availability of plasmapheresis, the mortality in thrombotic thrombocytopenic purpura remains high. Cardiovascular complications have been reported as an important cause of morbidity in these patients. The burden and prognostic implications of these complications have not been well studied. We analyzed the rates of cardiovascular complications in thrombotic thrombocytopenic purpura, temporal trends, and studied its impact on in-hospital mortality.MethodsWe analyzed the National Inpatient Sample (NIS) from January 2005 to September 2015 to identify adult patients with thrombotic thrombocytopenic purpura. This group was further refined by excluding patients who did not receive therapeutic plasmapheresis, and other conditions that can mimic thrombotic thrombocytopenic purpura. We identified the age- and sex-stratified rates of cardiac arrhythmias, cardiac conduction system disorders, heart failure, acute coronary syndrome, myocarditis, pericarditis, takotsubo cardiomyopathy, cardiogenic shock, cardiac arrest, and stroke. We also compared in-hospital mortality with and without cardiovascular complications.ResultsAmong 15,054 thrombotic thrombocytopenic purpura hospitalizations (mean age 46.4 years, 69% in the 18- to 54-age group, 66.2% women, and 42.9% white), a cardiovascular complication was observed in 3802 (25.3%) hospitalizations. The following cardiovascular complications were identified: stroke (10.4%), heart failure (8.3%), acute coronary syndrome (6.4%), atrial tachyarrhythmia (5.9%), ventricular tachyarrhythmia (2.0%), cardiogenic shock (0.5%), takotsubo cardiomyopathy (0.1%), atrioventricular block (0.2%), myocarditis or pericarditis (0.3), and cardiac arrest (1.9%). Rates of several cardiovascular complications were significantly higher in patients 55 years or older compared to a younger age group, whereas males had higher rates of acute coronary syndrome and tachyarrhythmias compared to females. Overall, the cardiovascular complication rate was stable during the study period. The presence of a major cardiovascular complication was associated with a significantly higher in-hospital mortality (19.7%) as compared with no major cardiovascular complication (4.1%) (adjusted odds ratio 2.09, 95% confidence interval 1.41-3.09, P <0.001). Results were generally consistent in age and sex subgroups.ConclusionCardiovascular complications were frequently observed at a rate of 1 in 4 in patients hospitalized for thrombotic thrombocytopenic purpura and were associated with substantially higher in-hospital mortality. These findings underscore the need to promptly identify and treat these complications to improve outcomes.     

Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery: the Statins for Risk Reduction in Surgery (StaRRS) study

OBJECTIVES: We sought to assess whether statins may decrease cardiac complications in patients undergoing noncardiac vascular surgery. BACKGROUND: Cardiovascular complications account for considerable morbidity in patients undergoing noncardiac surgery. Statins decrease cardiac morbidity and mortality in patients with coronary disease, and the beneficial treatment effect is seen early, before any measurable increase in coronary artery diameter. METHODS: A retrospective study recorded patient characteristics, past medical history, and admission medications on all patients undergoing carotid endarterectomy, aortic surgery, or lower extremity revascularization over a two-year period (January 1999 to December 2000) at a tertiary referral center. Recorded perioperative complication outcomes included death, myocardial infarction, ischemia, congestive heart failure, and ventricular tachyarrhythmias occurring during the index hospitalization. Univariate and multivariate logistic regressions identified predictors of perioperative cardiac complications and medications that might confer a protective effect. RESULTS: Complications occurred in 157 of 1,163 eligible hospitalizations and were significantly fewer in patients receiving statins (9.9%) than in those not receiving statins (16.5%, p = 0.001). The difference was mostly accounted by myocardial ischemia and congestive heart failure. After adjusting for other significant predictors of perioperative complications (age, gender, type of surgery, emergent surgery, left ventricular dysfunction, and diabetes mellitus), statins still conferred a highly significant protective effect (odds ratio 0.52, p = 0.001). The protective effect was similar across diverse patient subgroups and persisted after accounting for the likelihood of patients to have hypercholesterolemia by considering their propensity to use statins. CONCLUSIONS: Use of statins was highly protective against perioperative cardiac complications in patients undergoing vascular surgery in this retrospective study.     

Increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium in patients with chronic renal insufficiency

Cardiovascular morbidity and mortality is high in patients with chronic renal insufficiency. Patients with chronic renal insufficiency have an increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium than patients with normal renal function. These risk factors for cardiovascular morbidity and mortality contribute to the increased incidence of cardiovascular morbidity and mortality seen in patients with chronic renal insufficiency.     

Cardiovascular mortality in end-stage renal disease

Cardiovascular disease accounts for more than 50% of end-stage renal disease (ESRD) deaths. The reported cardiovascular death rates in patients receiving dialysis are substantially higher than in the general population. Cardiovascular mortality in ESRD is particularly high after acute myocardial infarction, but it is also elevated in ESRD patients with other forms of atherosclerotic vascular disease (eg, chronic coronary artery disease, strokes, transient ischemic attacks, and peripheral arterial disease). Left ventricular hypertrophy and dilation are associated with increased cardiovascular mortality, as is congestive heart failure. One of the major reasons for such high cardiovascular mortality in ESRD is the large burden of cardiovascular disease present in patients with chronic artery disease before renal replacement therapy. These observations mandate not only aggressive diagnosis and treatment of cardiovascular disease in patients with ESRD, but also active screening, diagnosis, and treatment in those with chronic kidney disease before renal replacement therapy.     

Kardiovaskuläre Komplikationen nach Nierentransplantation

Cardiovascular diseases are the leading cause of morbidity and mortality after renal transplantation. The highest number of hospitalizations after renal transplantation is due to congestive heart failure in addition to infections. A reduction of traditional and non-traditional risk factors and a critical cardiovascular evaluation of dialysis patients on the waiting list could help to reduce cardiovascular events after renal transplantation. Clinical symptoms and physical activity should be evaluated to differentiate between stable and active cardiac diseases and to decide on further non-invasive and invasive diagnostics and treatment. This article summarizes the prevalence and risk factors of cardiovascular complications after renal transplantation and describes possible preventive strategies.     

肾移植患者近期心血管问题的临床研究

本文对３０５例（３１１次）肾移植患者移植前及移植后近期（３个月）的主要心血管并发症进行回顾性分析。结果表明，对疑为冠心病的患者应进行严格筛选，尽可能行冠脉造影术，以确定是否能行外科纠正术，术前低血压影响移植后肾功能的恢复，值得深入探讨；术前高血压是常见并发症，应寻找病因并积极处理。充分透析对纠正术前心律失常极为重要。洋地黄是术后心律失常的重要危险因素，需根据肾功能情况小心调节其用量。术后心力衰用多由容量过多引起，超滤脱水非常重要。