14例原位心脏移植体外循环管理及供心保护措施

目的:总结14例同种异体原位心脏移植的体外循环管理经验。方法:体外循环采用中度低温、轻度血液稀释和高流量灌注法,有效的保护了心、肺及肾等重要脏器。供心保护:经主动脉根部灌注4℃改良St.Thomas液500 mL使供心快速停搏,取下后用4℃UW液1000 mL灌注,并置于UW液中低温保存。结果:热缺血时间(5.7±1.6)min,冷缺血时间(183.2±57.2)min,体外循环时间(148.4±80.1)min,其中12例患者主动脉开放后自动复跳,2例电除颤后复跳。术后14例患者顺利脱离体外循环机,围手术期病死率为零。康复出院11例,后期死亡3例。结论:有效的心肌保护措施,完善体外循环管理,良好重要脏器保护是成功脱离体外循环的关键。     

犬温血持续灌注不停跳供心长时间保存效果观察

目的：观察犬温血持续灌注不停跳供心长时间保存的效果。方法成年犬7只,其中5只作为实验犬（供心1～5）,2只作为对照犬（供心6、7）。供心1～5采用温血持续灌注不停跳保存,供心6、7采用冷停跳灌注保存;计算供心保护6 h时的质量增长率,化学发光法检测供心血肌钙蛋白I（TnI）,检查供心左心室收缩舒张功能。结果供心1跳动2h后出现室颤终止实验,供心2～5跳动直至8h至实验结束。保护6h时,供心2～7质量增长率分别为10．00％、17．59％、7．94％、14．08％、22．00％、21．10％;供心6、7血TnI自2 h后较供心2～5显著升高（P均＜0．05）,供心2～5之间比较,差异没有统计学意义（P均＞0．05）;供心2～5左心室收缩及舒张功能随时间延长而下降,供心间比较,差异没有统计学意义（P均＞0．05）。结论犬温血持续灌注不停跳供心可较长时间保存。     

3例供心保护时间较长的原位心脏移植

心脏移植是目前治疗终末期心脏疾病患者的合理而又有效的方法。我们2005年3月至8月，完成了3例供心离体保护时间较长的原位心脏移植，心肌缺血时间均在6h以上，现报告如下。     

褪黑激素对大鼠体外供心延时保存效果的作用研究

目的:探讨褪黑激素对大鼠供心延时保存效果的作用。方法:将 64 只 Wistar大鼠随机分为对照组和实验组。对照组:供心单用St Thomas液4℃保存;实验组:用含褪黑激素(0.1 mmol/L)的St Thomas液4℃保存。分别于保存前及保存6,12,24 h后,取出供心,在改良的非循环式Langendorff Neely灌注模型上测定血流动力学指标。高效液相色谱法测心肌细胞线粒体ATP水平。原位末端标记法(TUNEL)检测细胞凋亡,计算心肌细胞凋亡指数(AI)。电镜观察心肌超微结构。结果:实验组左心功能恢复、心肌超微结构、线粒体 ATP水平等均明显优于对照组(P<0.01)。实验组各时间点心肌细胞 AI明显小于相应对照组(均 P<0.01)。结论:褪黑激素增补于供心保存液中可明显改善体外供心延时保存效果,机制可能与其减少心肌细胞凋亡有关。     

蛇床子素注射液在犬原位心脏移植中对供心的保护作用

目的探讨蛇床子素注射液在犬原位心脏移植中对供心的保护作用。方法取健康杂种犬24条,随机分为对照组和试验组;建立犬原位心脏移植模型,先于试验开始前1h经供体犬股静脉内滴注蛇床子素注射液(25mg/kg),再用含有蛇床子素注射液(25mg/kg)的4℃改良ST.Thomas液对供体心脏进行灌注和保存,心脏移植成功后5min从右房采集血液标本,检测实验组及对照组血清超氧化物歧化酶(SOD)、丙二醛(MDA)含量及心肌肌钙蛋白(cTnI)、乳酸脱氢酶(LDH)、心肌肌酸激酶(CK)及其同工酶(CK-MB)漏出率;并于移植成功后10min取移植心脏左室心尖部心肌组织用电镜对心肌超微结构进行形态学观察。结果实验组中MDA含量较对照组明显升高,而SOD含量及cTnI、LDH、CK、CK-MB漏出率较对照组明显降低。试验组心肌超微结构损伤程度较对照组轻。结论在心脏移植过程中应用蛇床子素注射液,可减轻移植心脏的缺血/再灌注损伤,对移植心脏功能具有保护作用,能增加心脏移植的成功率。     

心脏移植体外循环一例

男性患者,54岁,诊断终末期心脏病。在静脉复合麻醉低温体外循环下行同种异体原位心脏移植。笔者对体外循环的体会:①适当的血液稀释及维持一定的胶体渗透压;②良好的心脏保护;③防止脏器组织水肿和减轻炎性介质反应。     

37例心脏移植的体外循环管理经验

目的:总结37例原位心脏移植体外循环管理经验。方法:37名患者进行了同种异体心脏移植手术,术前心脏超声检查EF值平均(24.52±4.79)%;采用中度低温、轻中度血液稀释、中高流量体外循环灌注。术中监测血气和电解质,常规使用超滤技术和白蛋白。供心保护采用HTK心肌保护液,经主动脉根部灌注冷HTK心脏停搏液,快速取下心脏,并放置于冷HTK液中低温保存。结果:供心热缺血时间(7.7±1.7)min,冷缺血时间(194.52±121.57)min,体外循环时间(110.87±29.83)min。主动脉阻断时间为(47.83±8.91)min,平均动脉压55～85mmHg。37例患者均顺利脱离体外循环机。结论:良好的供心保护,体外循环过程中保持平均动脉压在60～80mmHg及晶胶比在0.45～0.60,血气和电解质的动态监测以及超滤和白蛋白的应用是心脏移植体外循环管理的关键。     

热缺血后低温保存对供心心肌细胞凋亡的影响

原位心脏移植是治疗终末期心脏疾患的有效方法.供心质量的好坏是决定手术效果的重要因素.本研究采用猪原位心脏移植模型,观察短暂常温热缺血后低温保存对供心心肌细胞凋亡的影响,为进一步改进供心保护提供理论依据.     

同种原位心脏移植二例

本院于１９９２年７月５日和１１日在６天内连续为２例晚期扩张型心肌病患者施行同种原位心脏移植术。２例患者术后已度过１年３个月，现健康状况良好。     

缬草单萜氧化物预处理对供心保存的实验研究

目的观察缬草单萜氧化物（VMO）预处理对供心保存效果的影响,并探讨其机制。方法随机将兔分为5组:对照组（Con组）;缺血预处理组（IP组）;VMO预处理组（VMO组）;格列苯脲加VMO预处理组（G li+VMO组）;格列苯脲组（G li组）。各预处理组均在Langendorff灌注模型下行预处理,随后停搏,4℃保存180 m in,最后行再灌注。观察低温保存后的左室压力变化最大速率（±dp/dtm ax）、心肌磷酸肌酸激酶（CK-MB）释放量、心肌ATP含量和能荷（EC）。结果①与Con组比较,IP组+dp/dtm ax增加29.9%、-dp/dtm ax增加29.9%,CK-MB降低25.1%,ATP提高76.1%、EC提高27.9%;VMO组+dp/dtm ax增加25.1%、-dp/dtm ax增加25.3%,CK-MB降低20.7%,ATP提高72.8%、EC提高20.9%;②G li+VMO组和G li组分别与Con组比较,±dp/dtm ax,CK-MB,ATP和EC均无显著差异（P>0.05）;③G li+VMO组与VMO组比较,±dp/dtm ax,CK-MB,ATP和EC差异显著（P<0.05或P<0.01）。结论VMO预处理供心可以发挥和缺血预处理类似的心脏保护作用。开放KATP通道可能是VMO发挥药物预处理作用的重要机制之一。     

Congestive heart failure induced by recipient atrial tachycardia conducted to the donor atrium after orthotopic heart transplantation: complete regression after successful radiofrequency ablation

We describe the case of a 30-year-old female patient who developed an interatrial tachycardia from the recipient to the donor atrium associated with signs of congestive heart failure 5 years after orthotopic heart transplantation. The patient underwent catheter mapping followed by successful radiofrequency (RF) ablation at the site of the presumed electrical connection between the recipient and the donor atria, through the interatrial surgical suture line, with stable recovery of sinus rhythm and disappearance of signs of left ventricular dysfunction. RF catheter ablation is confirmed to be feasible and safe in the treatment of heart transplant patients even in the presence of rare forms of arrhythmias, thus offering a cure for tachycardia to these patients.     

Reversible pulmonary hypertension in heart transplant candidates--pretransplant evaluation and outcome after orthotopic heart transplantation

BACKGROUND: Heart transplantation is the most effective treatment for well-selected patients with endstage heart failure. Unfortunately, transplant candidates with pulmonary hypertension (PHT) are often not considered for heart transplantation. This study was performed to assess the value of prostaglandin E(1) (PG-E(1)) for reduction of PHT and to predict the postoperative outcome, compared to patients without PHT. PATIENTS AND METHODS: We studied a group of 151 consecutive heart transplant candidates using right heart catheterization. In patients with PHT (pulmonary vascular resistance, PVR> or =2.5 Wood-Units (WU) and/or transpulmonary gradient (TPG)> or =12 mmHg) a short-term treatment protocol with PG-E(1) was performed, to achieve PVR<2.5 WU and TPG<12 mmHg. RESULTS: 61 patients (40%) had PHT according to our criteria. Reduction of PHT was successful in 71% of patients (n=43), of these, 18 patients underwent cardiac transplantation and the 1-year mortality rate was 22% (n=4). The 1-year mortality rate in transplanted patients without PHT was 14% (n=3). There was no statistical difference in survival between the PHT and the non-PHT group. Outcome in patients without heart transplantation was similar in both groups, except for patients with non-reducible PHT (1-year mortality 50%). CONCLUSIONS: Our study demonstrates the efficacy and safety of PG-E(1) in lowering PHT in heart transplant candidates, as well as the need for aggressive evaluation and treatment in these patients. Patients with reversible PHT have comparable post-transplant outcomes and no tendency to higher acute right ventricular failure.     

Prevalence of pleural effusions post orthotopic heart transplantation

BACKGROUND AND OBJECTIVE: The prevalence and natural history of pleural effusions occurring after orthotopic heart transplantations (OHT) are essentially unknown. The objective of this study was to determine the prevalence, laterality, size and prognosis of pleural effusions occurring after OHT. METHODS: Eighty-three patients who underwent OHT between August 1997 and January 2003 were screened retrospectively. CXR and chest CT scans of all patients were reviewed. Chart review was performed for patients with large effusions (occupying 25% or more of a hemithorax) with specific attention to thoracentesis results. RESULTS: Seventy-two patients were included in the study. Sixty-one (85%) developed an effusion at some time during the first 365 postoperative days. The majority of post-OHT effusions were bilateral and small, occupying less than 25% of the hemithorax. Pleural effusions occupying 25% or more of a hemithorax occurred in 17% (12/72) of the patients within 12 months of OHT. Overall, the majority of effusions resolved within the first year after transplantation. CONCLUSIONS: The prevalence of pleural effusions within 12 months following OHT is high (85%). Most effusions are small, bilateral and resolve within 1 year.     

Coronary compliance in patients following orthotopic heart transplantation: An intravascular ultrasound study

BACKGROUND: The aim of this study was to investigate coronary compliancein patients early and 71.8 weeks after orthotopic heart transplantation. METHODS: Thirty patients (mean age 51.4 years, women n=6) underwent coronaryangiography early after orthotopic heart transplantation (meaninterval 11.6 ± 5.5 weeks), by which time 12 recipientshad already been treated for episodes of rejection. A totalof 153 different coronary segments were investigated using amechanical 30 MHz intravascular ultrasound system. In all segments,the intimal index and the circumferential extension of the vesselwall, which had a three-layered appearance, were assessed. Systolic-diastolicchanges in area, and pressure with respect to vessel wall area,were used to study normalized compliance. All measurements wererepeated in a subgroup of 13 patients 71.8 ± 10.7 weeksafter transplantation. RESULTS: At the first investigation, the mean intimal index of all estimatedcross-sectional areas was 0.07 ± 0.10. The mean circumferentialextension of the ‘three-layered’ coronary vesselwall was 74° ± 101°. No correlation could befound between normalized compliance and the intimal index (r=– 0.322, P<0.001) or between normalized complianceand the circumferential extension of the three-layered vesselwall (r= – 0.362, P<0.001). Donor age did not correlatewith normalized compliance either (r= –0.515, P=0.004).In 12 patients with proven rejection periods before the firstinvestigation, normalized compliance was significantly lower(1.76 ± 0.81 mmHg^–1) than in those without rejection(2.95 ± 1.22 mmHg^–1, P=0.005). Both the intimalindex and the circumferential extension of the three-layeredarchitecture of the vessel wall were significantly higher inrecipients with rejection periods. A comparison of the subgroupof 13 recipients between first and second investigation showedthat the intimal index increased slightly from 0.03 ±0.03 to 0.09 ± 0.13 (ns) 71.8 weeks after transplantation,but that normalized compliance did not differ significantlybetween the first and the follow-up investigation. CONCLUSIONS: Early after orthotopic heart transplantation, normalized compliancedoes not correlate with donor age or the extent of atheroscleroticvessel alterations identifiable by intravascular ultrasound.Early rejection periods are associated with reduced coronaryarterial compliance. Using intravascular ultrasound, this adversefunctional effect on arterial compliance can be observed togetherwith an increase in the intimal index.     

体外循环心脏停跳和不停跳心内直视手术对机体免疫功能的影响

目的观察体外循环心脏停跳和不停跳心内直视手术对机体免疫功能的影响。方法60例风湿性二尖瓣膜病变患者,随机分为实验组（不停跳组,40例）和对照组（停跳组,20例）,分别于10个时点抽取静脉血,测定T细胞亚群、NK细胞以及IgA、IgG、IgM。结果两组CD3＋、CD4＋、NK细胞以及IgA、IgG、IgM在转机后下降,CD8＋上升,两组比较P≤0.05,实验组CD3＋、CD4＋、CD8＋、NK细胞以及IgA、IgG、IgM恢复较对照组快（P均〈0.05）。结论体外循环不停跳心内直视手术对机体免疫功能影响较心脏停跳者轻。     

急诊体外循环在抢救胸心危重患者的应用

目的 :评价应用急诊体外循环 （ECPB）抢救危重患者的效果 ,并探讨其开展的条件和临床应用指征。方法 :1988-0 2～ 2 0 0 2 -0 2年紧急应用 ECPB抢救危重患者 11例。结果 :11例中 10例成活 （成活率 91% ） ,1例心肺复苏成功 ,但由于 ECPB前缺氧时间长达 3 5m in,术后多脏器功能衰竭而死亡。结论 :急诊体外循环是抢救胸心外科危重患者的一种非常有效的辅助治疗措施     

Do the lungs contribute to propofol elimination in patients during orthotopic liver transplantation without veno-venous bypass?

Introduction Propofol (2, 6 diisopropyl phenol), a rapidly acting intravenous anesthetic agent, is commonly used for induction and maintenance of generalanesthesia and sedation of human patients.[1-4] The pharmacokinetics of propofol can be described by a three-compartment open mammalian model with a rapid distribution phase(T1/2α about 3 minutes), rapid elimination(T1/2β 45 minutes) and a slower final phase (T1/2γ about 300 minutes).[5] The elimination kinetics of propofol is characterize…