婴儿原位心脏移植术后早期的免疫抑制治疗一例

目的：总结婴儿原位心脏移植术后早期免疫抑制剂应用的临床经验。方法：为1例患难治性先天性心脏病的8个月龄婴儿施行原位心脏移植术，术后1个月内应用环孢素A（CsA），霉酚酸酯（MMF）及泼尼松预防急性排斥反应，1个月后停用泼尼松，仅用CsA和MMF，原则为小剂量用药。术后监测血CsA浓度、白细胞数及T淋巴细胞亚群，定期行超声心动图、心电图及X线胸片检查，结合临床症状与体征综合判断是否发生排斥反应，同时观察药物的不良反应。结果：受者顺利渡过围手术期，现已存活260d，未发生急性排斥反应及感染。术后1个月内血CsA浓度谷值（G0）维持在0．1664～0．2080μmol／L，2～3个月G，维持在0．1248～0．1664μmol／L，4～6个月G，维持在0．（1832～0．1248μmol／L，7～10个月G0维持在0．0666～0．0998μmol／L。未见药物不良反应。结论：婴儿原位心脏移植术后早期免疫抑制剂应根据婴儿免疫反应的特点，以1：3服给药为主，小剂量、不过多干预为原则。     

Twenty-four hours postoperative results after orthotopic cardiac transplantation in swine

BACKGROUND: In-vivo explants in pigs are well-established to investigate myocardial function directly after transplantation. However, there is no functional data available for a longer time period after transplantation. We have established a pig model to investigate myocardial function 24 hours after orthotopic transplantation. MATERIALS AND METHODS: Orthotopic cardiac transplantations (HTx) in pigs were performed with a postoperative observation period of 24 hours (n = 6). To analyze myocardial function after transplantation, hemodynamical parameters (Swan-Ganz- and impedance-catheter data) as well as tissue and blood samples were obtained. Regional myocardial blood flow (RMBF) was assessed using fluorescent microspheres. RESULTS: The impedance-catheter parameters demonstrated a preserved contractility in both ventricles 24 hours post-transplantation. In contrast, cardiac output 24 hours after HTx was diminished by 50% as compared to the preoperative value. Conversely, pulmonary vascular resistance increased significantly. The RMBF was increased in both ventricles. Metabolic and histological analyses indicate myocardial recovery 24 hours after HTx with no irreversible damage. CONCLUSIONS: For the first time, we were able to establish a porcine model to investigate myocardial function 24 hours after heart transplantation. While the contractility of the transplanted hearts was well-preserved, impaired cardiac output was going along with an increase in pulmonary vascular resistance. Using this clinical relevant model, improvements of human cardiac transplantation and post-transplant contractile dysfunction, especially, could be investigated.     

大鼠两种不同供肝对原位肝移植术中和术后影响的比较

目的　比较正常 (HB)和心跳停搏 (NHB)供肝对大鼠原位肝移植术中和术后的影响。方法　雄性SD大鼠随机分成HB和NHB两组 ;NHB组又分别设心跳停搏 30min(HNB - 30 )和 4 5min(NHB - 4 5 )两组。每组各行原位肝移植 5 0、30和 30次。结果　HB和NHB组冷缺血、无肝期、肝下下腔静脉 (IVC)阻断、受体手术时间分别为 (6 9.76± 1.5 2 )min和 (70 .32± 1.5 3)min、(16 .4 6± 0 .96 )min和(16 .4 0± 0 .73)min、(2 2 .5 6± 1.73)min和 (2 2 .75± 1.16 )min、(89.38± 3.75 )min和 (90 .5 8± 3.76 )min ;术后受体苏醒和主动饮水时间分别为 (5 .4 3± 3.88)min和 (5 4 .0 6± 5 .99)min、(43.0 4± 10 .19)min和(12 6 .79± 15 .0 2 )min ;受体术后鼻粘膜出血率分别为 4 .17%和 92 .6 8% ;受体第 1周体重下降幅度分别为 (6 .15± 1.92 ) %和 (9.6 2± 1.80 ) % ;第 2周体重增加幅度分别为 (7.4 4± 2 .5 9) %和 (3.16± 1.0 4 ) %。HB组近期死因分别为原发性移植肝无功能 (PGF)、麻醉过深、肺部感染和肝上下腔静脉 (SVC)吻合口漏 ;而NHB组分别为PNF、麻醉过深、无肝期较长 (>17min)和再灌注后供肝渗血 ;HB和NHB - 30、NHB - 4 5组术后 1周存活率分别为 90 %、5 0 %和 30 %。结论　NHB较HB术中操作更复杂 ,更需     

Infant orthotopic cardiac transplantation

Infant orthotopic cardiac transplantation has been recently applied to various forms of congenital heart disease with encouraging short-term results. Between June 1986 and September 1987 we evaluated 16 infants for orthotopic cardiac transplantation. Fourteen had hypoplastic left heart syndrome, one had endocardial fibroelastosis with aortic atresia, and one had anomalous pulmonary arterial origin of the left main coronary. Eight families accepted the treatment program and eight families refused (two because of associated anomalies and six on philosophical grounds). Of the eight patients who were candidates for orthotopic cardiac transplantation, one died 6 hours after diagnosis, one was allowed to die after 60 days because of acquired neurologic complications, and another had congenital cytomegalic virus infection. The remaining five patients (four with hypoplastic left heart syndrome, one with anomalous pulmonary arterial origin of the left main coronary) had orthotopic cardiac transplantation. The operation was performed with absorbable polydioxanone suture with deep hypothermia and circulatory arrest in four neonates for hypoplastic left heart syndrome (average time 47 minutes) and bicaval cannulation and continuous bypass in one 11-month-old infant for anomalous origin of the left main coronary. In-house retrieval was used in all. One neonate died of complications as a result of pretransplant donor heart dysfunction and size discrepancy, whereas the remaining three neonates and one infant survived and are home 23 months, 12 months, and 8 months (the patients with hypoplastic left heart syndrome) and 17 months (the patient with anomalous origin of the left main coronary) postoperatively. Triple-drug immunosuppression included cyclosporine, azathioprine, and prednisone. Rejection was diagnosed by clinical evaluation of child activity and monocyte cell cycle analysis from peripheral blood samples without myocardial biopsies. Routine echocardiograms, electrocardiograms, and chest x-ray films were not helpful. Six episodes of rejection were successfully treated in four patients. Twelve-month postoperative catherization in one patient (hypoplastic left heart syndrome) showed appropriate graft growth, no aortic or pulmonary anastomotic strictures, normal right and left ventricular function, and no coronary artery disease. We conclude that infant orthotopic cardiac transplantation is an acceptable procedure for severe forms of untreatable congenital heart disease. The excellent short-term results warrant continued application of orthotopic cardiac transplantation.     

Clinical orthotopic cardiac transplantation

The results of orthotopic cardiac transplantation have improved dramatically since the early experiences in the late 1960s. After almost 20 years of research and experience and the introduction of cyclosporine, 1 and 5 year survival rates are now 80 percent and 60 percent, respectively. The number of potential recipients far exceeds that of available donors, which is the limiting factor in cardiac transplantation. Complications related to immunosuppressive therapy remain significant, and despite decreased length of hospitalization, costs remain high. The majority of patients have good functional rehabilitation and are free of cardiac symptoms. Moreover, orthotopic cardiac transplantation has finally become a therapeutic treatment of end-stage heart disease.     

原位心脏移植28例报道

目的 总结28例心脏移植的临床资料，探讨手术效果以及免疫诱导方法。方法 2000年1月至2005年5月共完成28例同种原位心脏移植术。2003年前进行心脏移植的14例受者围手术期采用环孢素A＋霉酚酸酯免疫诱导方案，2003年后的14例受者采用达利珠单抗＋霉酚酸酯免疫诱导方案。结果 28例受者均顺利完成手术，术后无出血、扭曲、右心功能不全等手术并发症。2003年前移植的受者中，有6例出现不同程度的肝、肾功能不全，3例并发不同程度的感染。2003年后移植的受者无1例术后发生肝、肾功能不全和感染。结论 心脏移植是治疗终末期心肌病变的有效手段。达利珠单抗＋霉酚酸酯诱导方法效果较好。     

Early and late results of orthotopic liver transplantation

Between 4/1986 to 1/1989, 74 orthotopic liver transplantation were performed in 62 patients (62 first liver transplants, 10 as second graft and two as a third graft); 57 in adults and 17 in children. The main indication for the operation was liver cirrhosis (61.4%) (the most frequent etiology was alcoholic cirrhosis, 28.5%). Six cirrhotic patients had a hepatocarcinoma (9.6%). Two received a liver and kidney transplant due to terminal renal insufficiency and hemodialysis. The most frequent indication in children was biliary atresia (33.3%). Six patients had a fulminal liver failure (9.6%). AB0 blood group compatibility was identical in 87.5%, compatible in six and incompatible in three patients. Total orthotopic liver transplantation was performed in 67 patients, and size-reduced liver was indicated in 7 patients. Extracorporeal veno-venous bypass was used in adults but never in children. In 93.1% of the transplants a single hepatic artery was anastomosed to the recipient and in 6.9% a double anastomosis was performed. In 62.5% of the patients a end-to-end choledocho-choledochostomy was performed and in 34.8% hepatico-jejunostomy was indicated. Three months postoperative mortality rate was 12.9%. Arterial stenosis and thrombosis were the most frequent complication.     

Long-term results of cardiac transplantation

Heart transplantation is a successful therapeutic option for patients with end-stage heart cardiomyopathy. From April 1991 to December 2000, 345 patients underwent heart transplantation at the Juan Canalejo Hospital. The mean age of recipients was 54.5 +/- 11.4 years; 286 (83%) were male patients. Idiopathic (52.2%) and ischemic (34.9%) end-stage cardiomyopathy were the main causes leading to transplantation. Ninety-four patients had undergone a previous heart operation. The mean left ventricular ejection fraction was 22.8 +/- 11.4. Forty patients (11.5%) were transplanted in urgent (status I) condition. The mean time spent on the waiting list was 35.9 days. In-hospital mortality was 10.6% and 24% for transplantations performed on an elective and urgent basis, respectively. Operative (30-day), one-year and six-year survival was 87.2%, 81.3% and 64%, respectively. In terms of actuarial survival, there were no significant differences with regard to the recipient's age, sex, previous cardiac surgery, and the etiology of the end-stage cardiomyopathy. The six-year actuarial survival for recipients receiving hearts from female donors was 59% compared with 72% for male donors (p = 0.05). There has been a low incidence of rejection, as well as cardiac graft vasculopathy. Actuarial survival at six years was 66% for patients transplantated on an elective basis compared with 57% for patients transplanted on an urgent basis (p = 0.04). The aim of the study was to evaluate long-term results for patients who underwent orthotopic heart transplantation. In our experience, status I is associated with a higher mortality.     

二例原位心脏移植失败的经验总结

分别于１９９６年１１月１４日与１９９７年３月２０日为２例终末期扩张型心肌病的危重患者施行了原位心脏移植术。其中１例患者术前肝肾功能衰竭，术中全身器官功能继续恶化，无法脱离体外循环而死亡；另一例患者术前有重度肺动脉高压，术后因右心衰竭，肺动脉高压危象而死亡。     

Intermediate term results of total lymphoid irradiation for the treatment of non-specific graft dysfunction after heart transplantation.

BACKGROUND: A proportion of heart transplant recipients develop poor graft function in the absence of cellular infiltrate in endomyocardial biopsies or transplant associated coronary artery disease. The condition has a poor prognosis and its aetiology is poorly understood. We report encouraging intermediate term results with total lymphoid irradiation (TLI) in the management of this condition. METHODS: Eleven adult cardiac transplant recipients who developed severe allograft dysfunction (NYHA class-4) at a median period of 4 months after orthotopic heart transplantation were successfully treated with TLI. Endomyocardial biopsies and coronary angiography were normal in each patient and biventricular failure developed in spite of immunosuppression with Cyclosporin-A, Azathioprine, oral Prednisolone, Cyclophosphamide and intravenous Methylprednisolone therapy. Total lymphoid irradiation was given with standard Mantle and inverted Y-fields over ten treatments to achieve a cumulative dose of 8 Gy. RESULTS: Each patient had a significant improvement in clinical response and in ventricular performance within 2 months of commencing TLI. Nine patients are currently well (four NHYA class-1, five NHYA class-2) at 4-48 (median 26) months following TLI. Two patients died; one from bacterial septicaemia and one as a consequence of chronic renal failure. Three patients developed opportunistic infection which was successfully treated with appropriate antimicrobial agents. An Ebstein-Barr virus associated lymphoproliferative disorder occurred in one patient and was successfully treated by reduction in immunosuppression and high dose Acyclovir. Two patients developed transient bone marrow suppression. CONCLUSION: The intermediate term results of TLI in the management of poor graft function in cardiac transplant recipients with normal endomyocardial biopsies and coronary angiography are encouraging. Although complications of opportunistic infection, bone marrow suppression and lymphoproliferative disorder occurred, treatment was successful in each case.     

AML非骨水泥型股骨假体全髋置换术的中期疗效

[目的]观察髓腔解剖交锁假体(anatomic medullary locking,AML)非骨水泥型股骨假体全髋置换术的中期疗效。[方法]1997年11月～2003年1月,采用AML非骨水泥型股骨假体行全髋置换24例26髋,平均年龄53.7(32～69)岁,术后进行7年3个月～12年5个月随访,平均9.7年。通过临床(Harris评分)和X线进行观察。假体的生存率采用Kaplan-Meier分析,以股骨假体的无菌性松动和任何原因所致的翻修为终点。[结果]临床随访:Harris评分从术前平均51.1分改善至末次随访时平均91.3分,优良率达88%,95%的患者对手术疗效满意。X线随访:25髋(96.2%)股骨假体位于中立位,1髋(3.8%)内翻位,末次随访股骨假体位置无改变,24髋(92.3%)髓腔填充良好,24髋(92.3%)骨长入。股骨假体周围区域性透亮带10髋(38.5%),无1髋全周透亮带;骨溶解1区11髋(42.3%)、7区11髋(42.3%);假体远端骨皮质增厚8髋(30.8%),骨性底座5髋(19.2%)。Kaplan-Meier分析假体生存率为1.0(95%可信区间,0.98～1.00)。异位骨化I度2例,Ⅱ度2例,Ⅲ度1例。[结论]AML非骨水泥型股骨假体全髋置换术中期疗效满意,良好的髓腔填充是获得假体最佳固定的最重要因素,是其获得满意疗效的关键。但在X线随访中,假体周围出现的异常骨反应较高,远期有假体松动可能,需进一步观察。     

Ex-vivo mitral valve repair prior to orthotopic cardiac transplantation

Mitral valve annuloplasty was performed prior to orthotopic cardiac transplantation in two donor hearts which were diagnosed with moderate to severe mitral regurgitation. The technical aspects are reviewed of ex-vivo mitral valve repair with concomitant heart transplantation. The recipients were classified as United Network for Organ Sharing (UNOS) I and both patients have had an excellent postoperative recovery. Over 2-year follow-up demonstrates normal mitral valve function without regurgitation.     

同种异体原位心脏移植的手术护理配合

目的探讨同种异体原位心脏移植术的手术配合以提高手术成功率、缩短手术时间的相关因素。方法通过对10例患者实行同种异体原位心脏移植手术,分析总结心脏移植术中手术护理配合经验,逐步完善手术护理配合,以达到最快捷准确的手术配合效果,保证移植手术顺利完成。结果所有心脏移植手术术中完成顺利。术后1例患者因消化道出血死亡,其中1例患者术中吻合口渗血不止经填塞纱条止血,24小时后拔出引流物。9例患者术后住院时间14~30天,ICU监护时间为7~12天。结论充分的术前准备,术中有效的保暖措施,娴熟的护理配合,人员的调配,良好的心肌保护是心脏移植术顺利完成的有力保障。