原位心脏移植63例临床经验  

Clinical experience of 63 cases orthotopic heart transplantation

作　　者：刘天起[1] 王东[1] 厉泉[1] 李培杰[1] 毕严斌[1] 李敏[1] 许莉[1] 于建民[1] 陈善良[1] 王勇[1] 

机构地区：[1]山东大学附属千佛山医院心外科山东省心脏移植中心,济南250014

出　　处：《中华移植杂志（电子版）》2017年第1期19-23,共5页Chinese Journal of Transplantation(Electronic Edition)

基　　金：山东省自然科学基金面上项目(Z2006C10;ZR2013HM028)

摘　　要：目的总结分析原位心脏移植的临床疗效。方法回顾性分析2003年3月至2016年6月山东大学附属千佛山医院心外科完成的63例同种异体原位心脏移植供、受者临床资料。受者原发病包括扩张型心肌病47例、缺血性心肌病10例、肥厚型心肌病4例、限制性心肌病及瓣膜性心脏病各1例。心脏移植手术采用Stanford标准法1例,双腔静脉吻合法62例。术后采用CNI+吗替麦考酚酯+泼尼松三联免疫抑制方案,其中92.1%受者(58/63)采用抗Tac单抗或巴利昔单抗进行免疫诱导治疗,根据血药浓度谷、峰值调整环孢素剂量。术后早期重度移植物功能不全采用主动脉内球囊反搏(IABP)、体外膜肺氧合(ECMO)及连续性肾脏替代治疗(CRRT)等支持。结果 4例受者围手术期死亡,1例受者术后第2天再次接受心脏移植,移植手术成功率92.2%(59/64)。截至2016年6月,受者术后中位随访时间43个月,1、3、5年生存率分别为92.2%、82.1%、71.4%,其中8例存活10年以上。主要死亡原因包括:移植物功能衰竭、急性排斥反应和严重感染。存活受者术后心功能均恢复至Ⅰ~Ⅱ级(NYHA分级),恢复正常生活。术后发生右心衰竭8例,其中2例为术前存在重度肺动脉高压的受者,经IABP和ECMO支持治疗后顺利出院。发生多器官功能衰竭2例,肾功能损害11例,急性排斥反应9例。结论心脏移植是治疗终末期心脏疾病的有效方法,需根据综合因素考虑供、受者体质量匹配;同时监测环孢素血药浓度谷、峰值有助于合理用药,减少急性排斥反应的发生;合理应用IABP、ECMO等辅助治疗可提高心脏移植手术成功率,获得良好的早期疗效。Objective To summarize the clinical experience on 63 patients undergoing orthotopic heart transplantation. Methods Clinical data of 63 cases getting heart transplantation in our centre during the past 13 years was retrospectively reviewed. The protopathy included dilated cardiomyopathy, ischemic heart disease, cardiomyopathy, valvular heart disease and restrictive cardiomyopathy. Stanford standard orthotopic heart transplantation was used in 1 case and bicaval orthotopic heart transpalantation was used in 62 cases. Immunosuppressive therapy with calcineurin inhibitor, mycophenolate mofetile and corticosteroid was adopted. Immunity induction therapy with Tac monoclonal antibody or basiliximab monoclonal antibody was used in 92.1% （58/63） of recipients. Results Four recipients died during the perioperation, one recipients received the second heart transplantation 2 days after operation. The success rate of operation was 92.2% （59/64）. The median follow-up time was 43 months up to June 2016. The survival rate was 92.1% after 1 year, 82.1% after 3 years, 71.4% after 5 years. Cardiac function of surviving recipients all recovered to NYHA I - 1I. Heart failure occured in 8 cases, two recipients suffering severe pulmonary arterial hypertension pre- operation were successfully discharged from hospital after being applied with intra-aortic balloon bump （IABP） and extraeorporeal membrane oxygenation （ECMO）. Muhiple organ failure oecured in 2 cases, kidney function harm oecured in 11 cases, acute rejection accured in 9 cases. Conclusions Heart transplantation was an effective treatment method for end stage heart disease, and quality matching between donor and recipient should be based on multi factors. Scientific application of adjuvant therapy like IABP and ECM0 could increase success rate of heart transplantation.

关 键 词：心脏移植 免疫抑制治疗 血药浓度 体外膜肺氧合 

分 类 号：R654.2[医药卫生—外科学]