心、肺联合移植治疗艾森门格综合征四例

Heart-lung transplantation for 4 patients with Eisenmenger’s syndrome

目的 总结心、肺联合移植的经验。方法 为4例艾森门格综合征患者施行同种异体心、肺联合移植，所有患者均合并严重的肺动脉高压，心功能Ⅳ级。受者主动脉、上腔静脉及下腔静脉远端插管，建立体外循环。供心置入心包内，于两侧膈神经前将左、右肺置入胸腔。于供肺隆突上1～2软骨环处切断气管，4-0 prolene线连续缝合气管膜部，4-0 ethibond线“8”字间断缝合软骨部，证实无漏气后，机械通气（〈2．94kPa，或〈30cmH2O）。再依次吻合主动脉、上腔静脉及下腔静脉，开放阻断钳，恢复心脏血液供应，心脏自动复跳。分别在右心房和右心室缝置双腔起搏导线。术中患者主动脉阻断时间平均为174．5min。结果 4例手术均顺利完成，无患者死亡。术后患者无严重出血和感染发生，气管插管拔出时间平均为17．75h。术后3例发生排斥反应，其中2例为轻度排斥反应，经甲泼尼龙治疗逆转；1例术后第20d发生严重血管性排斥反应，经甲泼尼龙、抗CD3单克隆抗体及抗胸腺细胞球蛋白治疗无效，于术后35d死亡。出院的3例患者目前存活3～24个月。结论 周密的术前准备是手术成功的保证；供心、肺的保存质量，以及术后排斥反应和感染是影响临床效果的重要因素。

Objective To summarize the experience of heart-lung transplantation. Methods Four patients with Eisenmenger＇s syndrome underwent heart-lung homoplastic transplantation. All patients were complicated with severe pulmonary hypertension in New York Heart Association （NYHA） functional class IV. Cannulation for cardiopulmonary bypass consisted of a cannula in the high ascending aorta and separate vena caval cannulas. The heart-lung graft was moved into the chest, beginning with passage of the lung before the phrenic nerve pedicle. The bronchus was trimmed, leaving two cartilaginous rings proximal to the orifice of the upper lobe. The tracheal anastomosis was performed with a continuous 4-0 polypropylene suture, with the posterior portion continuously and anterior interrupted. The lungs were then ventilated （〈30 cmH20）. The caval and aortic anastomoses were performed with a continuous 4-0 polypropylene suture. The aortic cross-clamp and caval tapes were removed. The heart beats were restored automatically. Results The operation was successful. There were no operative deaths. Hemadynamics was stable after operation. The endotracheal intubation was eradicated 17. 75 h （mean） after operation. There were no hemorrhage and severe infectious complications. There was light graft rejection in 2 patients. One patient died of episode of severe rejection 35 days after operation. Three patients were discharged, remained alive and well, 3 to 24 months postoperatively. Conclusion The success of heart-lung transplantation is based on preoperational management and fine organ preservation; Rejection and infections have large impact on survival rate; Heart-lung transplantation will play more and more important role in the treatment of end-stage heart lung disease.