心肺联合移植受者随访10年一例与国内心肺联合移植现况分析

Evaluation of current combined heart-lung transplantation status in China and 10 years follow-up experience of a patient

目的总结分析1例心肺联合移植受者术后10年随访情况及国内心肺联合移植现况。方法回顾性分析复旦大学附属中山医院2003年12月完成的1例心肺联合移植受者临床资料。受者女性，43岁，原发病为先天性心脏病房间隔缺损合并艾森曼格综合征。供者男性，28岁。供、受者ABO血型相合，人类白细胞抗原配型5个位点错配。供者心、肺分别以uw液、HTK液灌洗保存。心脏移植采用双腔静脉吻合法，肺移植气管吻合采用3-0聚丙烯缝合线连续缝合外加自体组织包裹。采用达利珠单抗＋环孢素＋吗替麦考酚酯＋糖皮质激素四联免疫抑制方案，术后9个月将环孢素替换为他克莫司，术后8年撤除糖皮质激素。门诊随访定期复查超声心动图、肺功能及胸部CT。同时，检索1992年1月1日至2013年12月31日中国期刊全文数据库、中国生物医学文献数据库、维普中文科技期刊数据库以及万方数据资源系统心肺联合移植相关文献，对数据进行归类分析，采用Kaplan-Meier法计算受者生存率。结果截至2014年5月，该受者已存活10年3个月，生活质量良好。心功能恢复至美国纽约心脏病协会心功能分级I～Ⅱ级，术后9年超声心动图示左室射血分数65％。氧合指标稳定，血气分析指标良好。无急性排斥反应发生，术后5周及3．5年发生肺部感染治愈。1992年至2013年，国内26家医疗单位共完成心肺联合移植44例，病因以先天性心脏病伴艾森曼格综合征为主。44例受者1，3，5年生存率分别为39．4％，36．7％，30．6％。主要死亡原因为感染和移植物功能衰竭。结论心肺联合移植的远期疗效与供者心肺组织块的妥善保存、良好的手术技术，以及术后平衡抗排斥反应与抗感染治疗之间的矛盾密切相关。

Objective To evaluate the cardiopulmonary allografts function on a heart-lung transplantation patient survived more than 10 years at Zhongshan Hospital and to summarize the status and results of current heart-lung transplantation in China. Methods A homologous heart-lung transplantation was performed on a female, diagnosed as Eisenmenger＇s syndrome secondary to congenital atrial septal defect on December 2003. Heart-lung allograft was preserved with 1000 mL UW solution and 3000 mL HTK solution. Postoperative immunosuppressive therapies were managed with daclizumab ＋ cyclosporine A ＋ mycophenolate mofetil ＋ corticosteroids. Cyclosporine A was transferred to tacrolimus at the 9th month and corticosteroids was withdrew at the 8th years postoperative. Prophylaxis against virus was managed with oral Valacicloviri for 3 months. Echocardiogram, pulmonaryfunction and thoracic CT were followed-up periodically. Literatures on clinical heart-lung transplantation between January 1992 and December 2013 in China were retrieved and analyzed attentively. Results The patient survived operation and experienced normal daily life during the follow-up of 10 years and 3 months. Echocardiogram showed left ventricular ejection fraction of 65%. Pulmonary function examinatiorr exhibited with signs of small airway obstruction. However, no severe acute allograft rejection episode was experienced. The patient was complicated with two episodes of pneumonia at the 5th week and 3.5 years and both were cured. A total of 44 heart-lung transplantations were completed at 26 transplant centers in China mainland. Eisenmenger＇s syndrome secondary to congenital heart diseases constituted most of the etiologies. The actuarial 1-yr, 3-yr, 5-yr survival rate was 39.3%, 36.7%, 30.6%, respectively. Infections and graft failure contributed to the main cause of death. Conclusion Excellent cardiopulmonary grafts preservation, skilled operation technique, carefully tailor immunosuppressive strategy and keep the balance of rejection and infection were key factors of long-term survival for heart-lung transplantation.