原位心脏移植的初步体会

The experience of the heart transplantation

目的总结9例原位心脏移植经验,探讨该方法的近、远期疗效。方法心脏移植病人9例,均患终末期扩张型心肌病,术前射血分数(ejection fraction,EF)为0．10-0．29(0．21±0．03),均有频发室性期前收缩。用标准法处理5例,用双腔静脉法4例。供心热缺血时间2．6-6．7(4．2±1．0)min,冷缺血时间110- 175(141±16)min。抗排斥反应采用环孢素、麦考酚酸酯和甲泼尼龙三联方案,以环孢素为主。维持其血药浓度200μg／L;综合临床表现、超声心动图和心电图观察排斥反应,必要时行心内膜活检。结果手术全部成功,病人均在术后1-3月内出院,出院时心功能均恢复到0-Ⅰ级。随访4-42(27±20)个月,除1例病人在8个月时自行停服免疫抑制药因排斥反应死亡外,其余8例病人健康状况良好,6例病人已恢复工作。结论原位心脏移植是治疗终末期心脏病的有效手段。术前认真选择供体和受体,并造好血液配型及组织配型,移植过程中尽量缩短热、冷缺血时间和良好吻合是手术成功的关键。术后应用免疫抑制药和密切观察排斥反应是取得远期疗效的重点。

Objectives To review the 9 cases of heart transplantation and to find out the early and late results. Methods 9 transplantation patients all were in final stage of dilated cardiomyopathy（DCM）. Pretransplantation left ventricular ejection fraction were 10%～29%（21.2%±3.3%）. All 9 patients had frequent premature ventricular contractions. The standard anastomosis were performed in 5 cases and of double vena cava in 4 patients. The warm ischemic time of donor heart was 2.6～6.7 min（4.2±1.0）min, and cold ischemic time was 110～175 min（141±16） rain. Cyclosporine A（CsA）, mycophenolate mofetil （MMF）, and methylprednisolone（pred） were used for inhibiting cardiac rejection. The dose of CsA was adjusted to maintain blood through levels of 200 ng/ml. The rejection was diagnosed by clinical signs of heart failure, echocardiography and ECG. Endomyocardial biopsy was still the most accurate for using in this diagnosis. Results 9 patients were all survived from the operation and discharged from the hospital within 90 days. The heart function were recovered to grade 0～Ⅰ. The follow-up time was 4～42 （27±20） months. All patients were in good condition except one patient died at the eighth month because of the rejection. Conclusions The heart transplantation is effective for DCM. The keys for successful operation are choosing appropriate candidate, better matching in ABO blood types and HLA between donor and recipient, shorting the ischemic time, and quality anastomosis. Closely follow-up is still important for heart transplantation patients.