心脏移植术后急性排异反应的无创性监测  

Noninvasive monitoring of acute rejection after heart transplantation

作　　者：邱志兵[1] 陈鑫[1] 蒋英硕[1] 徐明[1] 汪黎明[1] 史宏伟[2] 穆心苇[3] 章翠[3] 

机构地区：[1]南京医科大学附属南京医院心血管外科,南京210006 [2]南京医科大学附属南京医院麻醉科,南京210006 [3]南京医科大学附属南京医院重症医学科,南京210006

出　　处：《中国医师杂志》2014年第8期1035-1038,共4页Journal of Chinese Physician

基　　金：国家自然科学基金面上项目（81270192）

摘　　要：目的 寻找可靠的非侵入无创性手段监测或诊断排异反应,研究无创监测技术在心脏移植术后急性排异反应监测中的安全性和有效性.方法 2001年4月至2013年6月,31例终末期心脏病患者接受了同种异体原位心脏移植手术.术中麻醉后用甲泼尼龙琥珀酸钠500 mg抗排异治疗,主动脉开放前给予甲泼尼龙琥珀酸钠500 mg抗排异反应.术后抗排异采用新三联疗法：环孢素（CsA）或FK506＋强的松＋骁悉.2009年以来术中、术后第4天分别用一次舒莱.术后监测急性排异反应手段主要依靠临床症状与体征、心电图、超声心动图、X线影像和心肌酶谱.联合诊断急性排异反应.结果 全组共3例死亡（9.7％）（均为肺动脉高压、右心衰继发肾、肺等多脏器衰竭）.28例顺利康复出院,随访期间1例于术后1.5年死于霉菌感染.1例术后2个月、1例术后4年发生一次急性排异反应,均经甲强龙冲击治疗后,症状减轻,各项指标迅速好转,未进行心内膜活检.其余26例患者均未出现急性排异反应.1例术后12年肾功能衰竭需要血透治疗.结论 采用非侵入无创性监测技术联合诊断监测急性排异反应,敏感、安全、可靠、无创伤和可重复,可作为心脏移植患者抗排异疗效观察的依据.而围术期及术后积极、合理的抗排异治疗方案是减少急性排异反应的前提.Objective To evaluate the effect and safety of noninvasive monitoring during episodes of acute rejection after heart transplantation.Methods Since April 2001 to June 2013,totally 31 homogeneous orthotopic heart transplants were performed.During the operation,500 mg methylprednisolone sodium succinate was used for anti-rejection treatment after anaesthesia.In order to avoid the acute rejection,another 500 mg methylprednisolone sodium succinate was given before aortic-clamp opened.After the operation,we choose a new triple therapy as the standard of anti-rejection treatment after the heart transplantation.CsA or FK506,prednisone metacortandracin and the CellCept.Since 2009,Simulect was used during the operation and the forth day after the operation.Acute rejection after transplantation was monitored by noninvasive monitoring including clinical features,body surface electrocardiogram,echocardiography,thoracic radiograph,and myocardial enzymogram.Results Among all the patients,3 cases （9.7％） died of the pulmonary hypertension,and right heart failure secondary to multiple organ failure such as the kidney or pulmonary; 28 patients of the group had a quick recovery and discharge,and one of them die of fungal infection about one and a half years after the operation.Two patients had acute rejections,the first one was happened two months postoperation and another was about four years later,both of them were relieved by using a large amount of methylprednisolone,all the clinical index took a turn for the better.The acute rejection did not happen to the other 26 patients after the heart transplantation.One patient took a chronic hemodialysis because of the renal failure 12 years after the surgery.Conclusions Noninvasive monitoring was a sensitive,reliable and non-invasive approach monitoring acute rejection after heart transplantation.It was especially suitable for monitoring anti-rejection therapy.Their combination was proved to be of great value in and screening of cardiac allograft rejection.It is the premise for pe

关 键 词：心脏移植 手术后并发症 移植物排斥/诊断 移植物排斥/病因学 超声心动描记术 心电描记术 放射摄影术 心肌/酶学 

分 类 号：R654.2[医药卫生—外科学]