心肺联合移植的体外循环管理经验

Preliminary study of extracorporeal circulation management in heart-lung transplantation

目的总结心肺联合移植体外循环管理的初步经验。方法回顾性分析2014年7月至2022年12月行原位心肺联合移植术病例资料。男4例,女1例,年龄22~37岁,体重46~60 kg。诊断均为重度肺动脉高压合并心肺功能衰竭,其中3例为艾森曼格综合征。结果供体心肺冷缺血时间225~420 min。转流总时间188~323 min,主动脉阻断时间108~219 min,体外循环辅助时间71~134 min,体外循环流量2.4~3.2 L/(m2·min),平均动脉压50~80 mmHg,术中均采用改良超滤,超滤液1500~2000 ml。4例顺利撤离体外循环,1例出现停机术后止血困难及常规药物治疗不佳的循环不稳,行床边联合应用体外膜氧合(ECMO)、主动脉内球囊反搏(IABP)和连续性肾脏替代疗法辅助治疗,ECMO辅助153 h后成功撤机。最终5例患者均存活出院。结论心肺联合移植的体外循环管理具有其特殊性。患者术后出现常规药物治疗无效的呼吸循环衰竭时,应积极尽早使用IABP或ECMO等机械循环辅助联合治疗。

Objective To summarize the preliminary experience of cardiopulmonary bypass management in heartlung transplantation.Methods The cases with orthotopic heart-lung transplantation from July 2014 to December 2022 were analyzed.They were 4 male patients and 1 female patient,aged 22 to 37 years with a weight of 46 to 60 kg.They were diagnosed with severe pulmonary hypertension combined with cardiopulmonary failure,and three of them were Eisenmenger syndrome.Results Donor cardiopulmonary cold ischemia time was 225 to 420 min.The cardiopulmonary time was 188 to 323 min,the aortic blocking time was 108 to 219 min,and cardiopulmonary bypass assistance time was 71 to 134 min,the extracorporeal flow was 2.4-3.2 L/(m2∙min),and the mean arterial pressure was 50-80 mmHg.Modified ultrafiltration was used during the operation,and the dosage of ultrafiltrate was 1500-2000 ml.Four patients were successfully evacuated from cardiopulmonary bypass,one patient experienced difficulty in postoperative hemostasis and circulatory instability with poor conventional drug treatment,and he was treated with extracorporeal membrane oxygenation(ECMO),intra-aortic balloon pump(IABP)and continuous renal replacement therapy.ECMO was successfully evacuated after 153 hours.All five patients were finally left alive and discharged.Conclusion The cardiopulmonary bypass management of heart-lung transplantation has a certain particularity.Once postoperative respiratory and circulatory failure is refractory to conventional drug treatment,mechanical circulatory adjuvant combination therapy,such as IABP or ECMO,should be actively used as early as possible.