双肺移植同期冠状动脉旁路移植术治疗特发性肺纤维化合并冠心病1例临床分析  

Clinical analysis of concomitant bilateral lung transplantation and coronary artery bypass grafting in one case of idiopathic pulmonary fibrosis and coronary heart disease

作　　者：丁志丹[1] 王跃斌[1] 李丰科[1] 杨建辉[1] 赵凯 方泽民[1] 乔晨晖[2] 王勇[3] 金峰[3] 曹彬 黄明君[4] 赵俊杰[4] 冯敏[5] 常薇[5] 张新[2] 赵高峰[1] DING Zhi-dan;WANG Yue-bin;LI Feng-ke;YANG Jan-hui;ZHAO Kai;FANG Ze-min;QIAO Chen-hui;WANG Yong;JIN Feng;CAO Bin;HUANG Ming-jun;ZHAO Jun-jie;FENG Min;CHANG Wei;ZHANG Xin;ZHAO Gao-feng(Department of Thoracic Surgery and Lung Transplantation Surgery,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China;Department of Cardiac Surgery,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China;Department of Anesthesiology,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China;In vitro Support Center,the First Af filiated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China;Surgical ICU,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China)

机构地区：[1]郑州大学第一附属医院胸外科/肺移植外科,河南郑州450052 [2]郑州大学第一附属医院心脏外科,河南郑州450052 [3]郑州大学第一附属医院麻醉科,河南郑州利450052 [4]郑州大学第一附属医院体外支持中心,河南郑州450052 [5]郑州大学第一附属医院外科ICU,河南郑州450052

出　　处：《中华实用诊断与治疗杂志》2022年第11期1081-1085,共5页Journal of Chinese Practical Diagnosis and Therapy

基　　金：河南省高等学校重点科研项目计划(20A320059)。

摘　　要：目的 探讨1例特发性肺纤维化合并冠心病患者行双肺移植同期冠状动脉旁路移植术治疗的效果。方法 1例特发性肺纤维化合并冠心病患者,男,55岁,于体外膜肺氧合辅助下行双肺移植同期冠状动脉旁路移植术。建立静脉-静脉体外膜肺氧合后患者先取右侧卧位,左后外侧第5肋间切口进胸,游离左乳内动脉,与左冠状动脉前降支行端侧吻合;然后切除左侧病肺,行左肺移植术;变换体位为左侧卧位,经右后外侧第5肋间切口进胸,切除右侧病肺,行右肺移植术。肺动脉开放前予以甲泼尼龙诱导免疫。供体器官为院外脑死亡捐献,与受者血型相同。结果 手术过程顺利,术中出血量700 mL,手术时间8.7 h,冠状动脉旁路移植术时间2.7 h。供体左肺冷缺血时间7.25 h,右肺冷缺血时间10.4 h。术后3 h行X线胸片检查显示患者移植肺纹理清晰,膨胀好,与胸腔大小匹配良好。术后16 h撤除体外膜肺氧合系统,体积分数60%氧浓度下,pa(O_(2)) 127 mm Hg,较术前(76.1 mm Hg)明显增高。术后第1天患者出现低心排血量综合征,超声心动图显示左室射血分数39%,肺动脉压37 mm Hg,左心室室壁搏动减弱,给予强心药物等治疗后好转。术后第2天患者出现中度移植物失功,肺泡灌洗液微生物第二代宏基因测序提示肺炎克雷伯菌、脑膜炎败血伊丽莎白菌感染,在原抗感染方案基础上加用替加环素加强抗感染治疗;超声心动图显示左室射血分数63%,肺动脉压28 mm Hg,左心室舒张功能下降。术后第6天行气管切开以便于气道管理。术后第7天气道分泌物减少,可床上活动。术后第8天下床活动,可间断脱离呼吸机,体积分数40%氧浓度下,心率116次/min,律齐,血压126/92 mm Hg,血氧饱和度98%,pa(O_(2)) 102 mm Hg,pa(CO_(2)) 36 mm Hg。目前继续恢复中。结论 特发性肺纤维化合并冠心病患者行双肺移植同期冠状动脉旁路移植术早期效果良好,远期效果待观察Objective To analyze the effect of concomitant bilateral lung transplantation and coronary artery bypass grafting(CABG)in a patient with idiopathic pulmonary fibrosis(IPF)and coronary heart disease(CHD).Methods A 55-year-old male patient with IPF and CHD underwent concomitant bilateral lung transplantation and CABG assisted with extracorporeal membrane oxygenation (ECMO).In the right lateral position after venovenous ECMO,the left posterolateral 5th intercostal incision was made,and the left internal mammary artery was separated and anastomosed with the anterior descending branch of the left coronary artery.The left diseased lung was removed and the left donor lung transplantation was performed.The body position was changed to the left lateral position,and the right posterolateral 5th intercostal incision was made.The right diseased lung was removed and the right donor lung transplantion was performed.Methylprednisolone was used before pulmonary artery opening to induce immunity.The donor organ was from an out-of-hospital brain-dead donation with the same blood type as the recipient.Results The operation was completed smoothly in 8.7h,the intraoperative blood loss was 700mL,and the CABG lasted for 2.7h.The cold ischemia time of the left lung and right lung was 7.25h and 10.4h,respectively.Three hours after the operation,the chest X-ray was done and showed that the transplanted lung had clear texture,well expanded,and was well matched the size of the thoracic cavity.After ECMO was removed 16h after operation,the pa(O_(2))at 60% oxygen concentration was 127mm Hg,which was significantly higher than that before operation(76.1mm Hg).On the first postoperative day,the patient developed low cardiac output syndrome.Echocardiography showed left ventricular ejection fraction of 39%,pulmonary artery pressure of 37mm Hg,and left ventricular wall beat weakened,which were corrected after cardio-tonic therapy.On the second postoperative day,the patient had moderate primary graft dysfunction,and the next generation sequencing of

关 键 词：特发性肺纤维化 冠心病 双肺移植 冠状动脉旁路移植术 

分 类 号：R563[医药卫生—呼吸系统] R541.4[医药卫生—内科学]