14例心脏移植术后早期原发性移植物衰竭的处理及预后

Treatment strategy and prognosis of primary graft dysfunction after heart transplantation

目的分析及探讨心脏移植术后早期原发性移植物衰竭的处理方法、疗效及预后。方法回顾性分析2017年3月至2019年9月海军军医大学附属长海医院74例心脏移植受者的临床资料,所有受者均采用巴利昔单抗免疫诱导,手术采用经典的双腔静脉吻合原位心脏移植。其中14例受者在术后早期出现原发性移植物衰竭,在药物治疗的基础上联合采用体外膜氧合(ECMO)、ECMO+主动脉内球囊反搏(IABP)以及单纯IABP的机械辅助循环支持。14例受者中13例为男性,女性1例;年龄为(51.1±9.5)岁(30~63岁);供者年龄为(42.7±6.5)岁(29~53岁);供受者体重比为0.91±0.12(0.73~1.27);供心缺血时间为(251.2±117.5)min(62~370 min)。所有受者均在术中行经食道超声心动图(TEE)检查发现移植物功能衰竭(5例表现为右心室功能障碍,9例双心室功能障碍),故在术中体外循环停机前给予机械辅助循环支持,其中ECMO辅助2例,ECMO+IABP辅助8例,单纯IABP辅助4例。结果心脏移植术后早期发生原发性移植物衰竭者占18.9%(14/74)。出现原发性移植物衰竭受者5例(35.7%)住院死亡。ECMO脱机率为80%(8/10),IABP脱机率为100%。余9例存活受者,机械辅助循环时间:ECMO为(154.2±46.5)h(104~216 h),IABP为(176.2±64.5)h(78~288 h)。随访24个月,9例受者健康存活,门诊定期复查心脏超声多普勒检查提示心脏收缩功能良好,无明显排斥反应及不良心血管事件发生。结论机械辅助循环(ECMO和/或IABP)支持是其治疗心脏移植后原发性移植物功能衰竭的有效手段;经机械辅助循环救治成功后,受者远期存活率及疗效满意。

Objective To explore the treatment strategy and prognosis of primary graft dysfunction(PGD)after heart transplantation.Methods A retrospective review was performed for 74 consecutive patients undergoing orthotopic heart transplantation between March 2017 and September 2019.Basiliximab was prescribed as an immune induction therapy.Over that time period,14 patients developed PGD and required extracorporeal membrane oxygenation(ECMO)and/or intra aortic balloon pump(IABP)support.They were 13 males and 1 female with a mean age of(51.1±9.5)(30~63)years.Donor age was(42.7±6.5)(29~53)years,weight ratio of donor/recipient(0.91±0.12)(0.73~1.27)and ischemic time(251.2±117.5)(62~370).Diagnosed by interoperative transesophageal echocardiography,PGD was defined as having a need for supporting of ECMO and/or IABP during immediate post-operation because of impossibility of weaning from cardiopulmonary bypass.The specific procedures included ECMO(2 cases),ECMO+IABP(8 cases)and IABP(4 cases).Results The incidence of PGD was 18.9%(14/74).And 80%patients were successfully weaned from ECMO,100%stayed off from IABP and 5 patients died in-hospital.Duration of ECMO support was(154.2±46.5)(104~216)hours and IABP support time(176.2±64.5)(78~288)hours.The survivors were followed up for 1~24 months,Ultrasound cardiogram ohowed that cardiac contractile function was satisfied.There was no instance of transplant rejection or cardiovascular adverse event.Conclusions As a life-threatening condition,PGD is a leading cause of early death after heart transplantation.ECMO and/or IABP support for PGD patients after heart transplantation may yield a satisfactory long-term prognosis.