心肺联合移植后长期存活一例报告

Heart-lung transplantation （one long-term survival case report）

目的总结心肺联合移植的体会。方法2006年3月23日对1例患有先天性室间隔缺损合并艾森曼格综合征的27岁女性患者施行了心肺联合移植术。术后对患者进行了长期密切监护，采用达利珠单抗进行免疫诱导，以他克莫司（后转换为环孢素A）、霉酚酸酯及糖皮质激素预防排斥反应，并严密监测和控制感染。结果患者术后恢复顺利，未发生严重感染和急性排斥反应，术后109d痊愈出院。术后1年7个月时，患者自行停用所有免疫抑制剂，2周后出现发热和活动后气促症状，行心脏彩色B型超声波、胸部CT、纤维支气管镜等检查，未发现排斥反应的特异性改变，肺功能检查显示第1秒最大呼气量为0．54，根据患者症状仍高度怀疑移植肺发生排斥反应，给予甲泼尼龙冲击治疗3d，然后以泼尼松持续治疗1个月，维持血环孢素A浓度为0．1664～0．3328μmol／L（0．2～0．4mg／L），霉酚酸酯用量由0．5g／d调整到1g／d，同时行抗感染治疗，2周后患者症状消失。术后2年时，行纤维支气管镜肺活检，未见闭塞性细支气管炎综合征。术后2年5个月时，冠状动脉造影检查显示冠状动脉无狭窄，检测心功能正常。至2009年5月，患者已存活3年余。结论重视供、受者的HLA配型，合理有效的预防排斥反应方案和感染的有效控制是心肺联合移植术成功的关键。

Objective To summarize the heart-lung transplantation （HLT） experience. Methods One case of ventricular septal defect of congenital heart disease with Eisenmenger syndrome, a 27-yearold female, underwent HLT on March 23,2006. Postoperatively the patient received guardianship of a long close,and induction therapy is applied with monoclonal antibodies. Rejection was prevented with Tacrolimus （converted to cyclosporine A later）, mycophenolate mofetil （MMF）, corticosteroids. Infection was monitored and controlled. Results The patient survived after the operation. No severe infection or acute rejection occurred. The postoperative hospital stay was 109 days. The patient has been alive till now for 3 years and 1 month. One year and 7 months after operation, the patient terminate immunosuppressive therapy by herself, and 2 weeks later hypoxia and low-grade fever occurred. Heart color B type ultrasound,chest CT scan,and the fiberoptic bronchoscopy did not reveal rejection-specific changes. Forced expiratory volume in 1 second was 0. 54. The symptoms still occurred on the height of suspected lung transplant rejection. Methylprednisolone was administered （500 mg× 3 days）,and the patient received oral prednisone for one month. Cyclosporine A was adjusted to maintain through blood levels of 0. 1664 0. 3328 μmol/L （0. 2-0. 4 mg/L） ,MMF dosage was adjusted from 0. 5 to 1 g/clay,and at the same time the anti-infective therapy was done. Two weeks later the symptoms disappeared. Two years after operation, lung biopsy by the fiberoptic bronchoscopy did not show bronchiolitis obliterans syndrome. Two years and 5 months after operation, coronary angiography indicated that there was no stenosis of coronary artery, and cardiac function was normal. Conclusion The success of HLT is based on human leukocyte antigen （HLA） matching, reasonable organ preservation, careful surgical procedures, strict preventive measures against infection and immunosuppressive management.