肺移植术后早期原发性移植物失功的危险因素与防治  

Clinical analysis of risk factors for early primary graft dysfunction after lung transplantation

作　　者：纪勇[1] 陈静瑜[1] 郑明峰[1] 刘峰[1] 吴波[1] 周敏[1] 叶书高[1] 陈若[1] 何毅军[1] 

机构地区：[1]江苏省器官移植重点实验室南京医科大学附属无锡市人民医院,214023

出　　处：《中华胸心血管外科杂志》2017年第12期738-742,共5页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：国家科技支撑计划（2008BAl60805）,国家自然科学基金（面上项目81070074-H0116）

摘　　要：目的 探讨肺移植患者术后早期（〈7天）发生原发性移植物失功（primary graft dysfunc-tion,PGD）的危险因素与预后分析.方法 回顾性分析2002年9月至2013年12月接受肺移植治疗的286例终末期肺病患者临床资料,术后均在重症监护病房连续有创监测生命体征、机械通气及免疫抑制治疗.根据早期PGD发生情况,将286例患者分为PGD组和非PGD组.对两组患者的年龄、术式（单肺或双肺移植）、肺动脉压力、供肺缺血再灌注时间、是否应用体外循环（CPB）等进行多因素logistic回归分析比较.结果 术后早期发生3级PGD 22例,死亡10例,病死率45.4％.单肺移植7例,其中体外膜式氧合（ECMO）辅助下3例;双肺移植15例,其中CPB辅助下2例,ECMO辅助下6例.PGD患者术后30天、1年、5年生存率分别为55％、40％、25％,显著低于非PGD组84.9％、78.6％和49.2％.统计学分析显示,术前合并肺动脉高压、供体缺血再灌注时间、术中失血量是肺移植患者术后早期发生PGD的危险因素,术中ECMO支持则是PGD发生保护因素.而年龄、性别、手术方式、手术时间、术前呼吸机依赖并非影响移植术后早期PGD发生的危险因素.结论 3级PGD是肺移植术后常见的严重并发症,病死率极高,对于合并危险因素较多患者,应在围手术期加强管理,进行积极预防;早期诊断,及时治疗能有效提高肺移植手术的成功率.Objective To investigate the institution of extracorporeal membrane oxygenation（ECMO） for primary graft dysfunction（ PGD） after lung transplantation and analysis its clinical outcome. Methods From September 2002 to December 2013, 286 patients with end-stage lung disease underwent lung transplantation（LTx） in Wuxi People＇s Hospital. Among them, there were 22 patients occured grade 3 PGD in early stage after LTx. In which there were 2 cases with chronic obstructive pulmonary disease, 12 with idiopathic pulmonary fibrosis, 4 case with primary pulmonary hypertension, 1 case with lung tuber-culosis, 1 case with silicosis, 2 cases with bronchiectasis. There were 7 patients with single LTx（3 cases with ECMO support） and 15 patients with bilateral LTx（2 cases with CPB support and 6 cases with ECMO support）. According to the severity levels of PGD, different treatment measures were used, such as reinforce ventilatory support, negative fluid balance, extending the treatment time of the ventilator, the use of pulmonary vasodilators, such as prostaglandin E1 and ECMO. Results Six patients were treated by adjusting low volume, high frequency and high positive end expiratory pressure ventilation（ PEEP） mode, and 2 cases reversed, 4 cases died of respiratory failure. 16 cases accepted ECMO support, among them 10 cases apply venous-ve-nous mode, 6 cases venous-artery mode, the average flow time was 5. 5 days. 10 cases dismantled from ECMO successly and 6 cases died of multiple organ failure, infection and cardiac arrest. 30-day, 1-year and 5-year survival of PGD recipients post-op-eratively were 55％, 40％, 25％, respectively. Conclusion The high incidence of PGD causes high mortality peri-operative-ly after LTx. Preventing PGD can improve the survival rate of the lung transplant patients. Once PGD happens, appropriate treatment should be given as soon as possible. ECMO can effectively promote the transplanted lung function recovery, reduce the perioperative mortality. If the indications of ECMO use

关 键 词：肺移植 原发性移植物失功 体外膜肺氧合 预防 治疗 

分 类 号：R655.3[医药卫生—外科学]