原位心脏移植治疗终末期心脏病141例

Orthotopic heart transplantations for end-stage heart diseases

目的 分析总结原位心脏移植治疗终末期心脏病的临床疗效及经验。方法 为141例终末期心脏病患者施行原位心脏移植术，原发病包括扩张性性心肌病118例，肥厚性心肌病2例，限制性心肌病2例，缺血性心肌病9例，原发性心脏恶性肿瘤4例，瓣膜性心肌病3例，其它病因3例。供心冷缺血时间为（191．0±28．5）min，供心卵圆孔未闭者9例，大室间隔缺损者1例，冠状动脉开口异常者1例。9例卵圆孔未闭的供心，先行卵圆孔缝闭术，然后再行移植；1例大室间隔缺损的供心，先行室间隔缺损修补术，然后再行移植；1例冠状动脉开口异常的供心，复跳后心肌收缩乏力，遂施行右冠状动脉松解术，其后复跳良好。120例行双腔静脉吻合法原位心脏移植术，19例行标准Stanford原位心脏移植术，2例行全心脏移植术。主动脉阻断时间为（53．0±4．5）min，吻合时间为（41．5±5．5）min。术后应用环孢素A（或他克莫司）、激素及霉酚酸酯预防排斥反应，28例患者同时应用达利珠单抗1～5剂。结果 手术成功率为97．9％，术后随访1～65个月，1年、3年、5年存活率分别为90．8％、84．6％、81．4％，术后1年内的主要死因是急性排斥反应、感染、移植物功能衰竭及心脏肿瘤转移，术后中远期的主要死因是急性排斥反应、感染、肾功能衰竭及移植心脏冠状动脉硬化。术后并发症以急性排斥反应、感染、肾功能异常、移植心脏功能衰竭多见。结论 终末期心脏病行原位心脏移植的临床疗效良好；远期需注意对急性排斥反应、感染及移植心脏冠状动脉硬化的监测及治疗。

Objective To summarize the outcomes and clinical experience of orthotopic heart transplantations in Shanghai Zhongshan Hospital. Methods From May 2000 through October 2005, 141 patients, 101 males and 40 females, diagnosed as having dilated cardiomyopathy in 118, hypertrophic cardiomyopathy in 2, restrictive cardiomyopathy in 2, end-stage ischemic heart disease in 9, primary malignant cardiac tumor in 4, valvular heart disease in 3 and others in 3, underwent orthotopic heart transplantations at our center. The operative procedures included 120 bicaval anastomotic cardiac transplantations, 19 conventional Stanford orthotopic cardiac transplantations and 2 total heart transplantations. The immunosuppressive therapy strategies included Cyclosporine A or tacrolimus, corticosteroids and mycophenolate mofetil. For the latest 28 patients, induction therapy with Daclizumah was applied. Results There were 3 operative deaths with an operative survival of 97.9 %. During the follow-up from 1 month to 65 months, the actuarial survival rate was 90.8% after 1 year, 84. 6 % after 3 year and 81.4 % after 5 year. Acute rejection, infections, graft failure and metastasis of primary cardiac tumor were the main causes of death in the 1st postoperative year, while acute rejection and graft coronary vasculopathy were the leading causes of death thereafter. Postoperative complications included acute rejection, infections, renal dysfunction and graft failure. Conclusions Orthotopic heart transplantation was proved to he a reliable choice for end - stage heart disease with excellent outcomes. More attention should he paid to surveillance and management of acute rejection, infections and graft coronary vasculopathy in the long-term follow-up.