61例心脏移植术的供心获取

Donor Heart Procurement of Heart Transplantation on 61 Patients

目的总结61例心脏移植术中供心获取的经验,以提高对供心保护的效果。方法2002年4月至2006年10月我们共为61例终末期心脏病患者行原位心脏移植治疗,供体均为男性脑死亡者,年龄21～53岁,大于40岁的供体5例;6例供、受体体重相差>20%(均为大供体、小受体),其余≤±20%。45例供、受体A、B、O血型相同,16例供、受体A、B、O血型相符。脑死亡后有稳定的血流动力学和供心在不乏氧条件下获取者4例(Ⅰ类),脑死亡合并急性失血和低血容量条件下供心获取者44例(Ⅱ类),脑死亡合并心跳停止后供心获取者13例(Ⅲ类)。标准术式20例,全心式1例,双腔法40例;供心冷缺血时间52～347min(92±31min),冷缺血时间超过240min13例。结果术后早期死亡2例,分别于术后第7d和第9d死于低心排血量,供心冷缺血时间分别为327min和293min。其余患者痊愈出院。1例于术后18个月拒绝服免疫抑制剂而死于急性排斥反应,1例于术后23个月死于交通伤。其余57例患者已生存6～59个月(平均35个月),出院后生活质量良好,心功能均为0～Ⅰ级。结论较大年龄的供心移植后仍可获得满意的临床效果;对终末期扩张型心肌病患者的受体可使用较大体重供体的供心;心脏移植供、受体血型相符可获得满意的临床效果;对三类不同供心采用不同的获取方法方能最大限度地减少供心获取过程中的心肌损伤;长时间心肌保护液保护的供心应慎用。

Objective To summarize the experiences of donor heart procurement of heart transplantation so as to improve the efficiency of donor heart protection. Methods From April 2002 to October 2006, sixty one patients with end-stage heart disease had undergone orthotopic heart transplantation. Donors were all male brain deaths, aged from 21 to 53, and 5 of them were older than 40. There were 6 cases in which the weight difference between donor and recipient〉20%, and the rest ≤ ± 20%. Forty five cases had the same ABO blood type, and 16 had matching ABO blood type. Four donor hearts were procured under the condition of stable hemodynamics and enough oxygen after brain death（type Ⅰ ）, forty four donor hearts were procured under the condition of brain death with acute hemorrhage and hypovolemia （type Ⅱ ）, and 13 donor hearts were procured under the condition of brain death with cardiac arrest （type Ⅲ ）. Twenty cases underwent standard transplantation procedure, one underwent total heart transplantation procedure and 40 underwent bicaval transplantation procedure. The donor heart cold ischemic period ranged from 52 to 347 min（92±31 min）, and 13 cases were more than 240 rain. Results Two cases died of low cardiac output syndrome on 7th and 9th day after operation respectively, and their donor heart cold ischemic period were 327 and 293 min respectively. The rest of patients all recovered and discharged. One diecl of acute rejection on 18th month after operation because of rejecting immunosuppressive agents, and 1 died in traffic accident on 23rd month after transplantation. The rest 57 cases survived 6-59 months（mean 35 months）, and had good life quality with NYHA cardiac function classification in 0-Ⅰ grade. Conclusions Heart transplantation with donor aged over 40 may also have satisfactory results. Patients with end-stage dilated cardiomyopathy can procure donor hearts from donors with heavy weight. Using different techniques to procure donor hearts may furthest reduce myocardial injury. Donor hearts which have been protected by myocardium protecting liquid for a long time should be used with caution.