肺移植术后肺动脉狭窄2例临床分析

Clinical analysis of 2 cases of pulmonary stenosis after lung transplantation

目的观察2例肺移植术后肺动脉狭窄患者的临床表现,总结治疗经验。方法回顾性分析2021年1月-2022年12月郑州大学第一附属医院肺移植术后发生肺动脉狭窄2例患者的临床资料。例1在体外膜肺氧合下行左单肺移植术,例2在体外膜肺氧合下先行右肺移植术再行左肺移植术,2例术后均常规给予免疫抑制、抗感染、抗凝及营养支持等治疗。结果例1左肺移植术后第7天大便后出现胸闷,指脉氧饱和度迅速降至84%,平卧位吸氧后胸闷缓解,指脉氧饱和度升至99%;之后患者静息状态一般情况可,下床稍剧烈活动即出现胸闷气喘,考虑右心衰竭及肺部感染,经加强抗感染、强心、利尿等对症治疗,症状稍缓解;术后第36天行肺动脉CT血管造影,示左肺动脉干狭窄,于肺移植术后第64天行肺动脉球囊扩张术,症状缓解,但次日再次出现胸闷气喘;于肺移植术后第84天行左肺动脉干支架植入术后胸闷症状缓解;肺移植术后第119天出院,恢复基本正常生活;随访1年以上无胸闷表现。例2双肺移植术后第6天床旁站立突发呼吸、心脏骤停,予以气管插管并于右侧股动静脉建立体外膜肺氧合;术后第10天患者血流动力学稍稳定情况下行肺动脉CT血管造影,示双侧肺动脉狭窄并多发动脉栓塞形成,给予抗凝、溶栓等支持治疗;术后第25天发生感染性休克,术后第31天自动出院。结论肺移植术后出现活动后胸闷气喘,排除心力衰竭、肺部感染、气道病变等后应考虑肺动脉狭窄可能,行肺动脉血管造影检查明确肺动脉狭窄后根据患者情况行药物或肺动脉球囊扩张术、肺动脉支架植入术手术治疗。

Objective To observe the clinical manifestations of 2 patients with pulmonary stenosis after lung transplantation,and to summarize the treatment experience.Methods The clinical data of 2 patients with pulmonary stenosis after lung transplantation in the First Affiliated Hospital of Zhengzhou University from January 2021 to December2022 were retrospectively analyzed.Patient 1 received left single lung transplantation under extracorporeal membrane oxygen(ECMO),and patient 2 received right lung transplantation followed by left lung transplantation under ECMO.Both two patients were routinely given immunosuppression,anti-infection,anti-coagulation,nutrition support and other treatments after transplantation.Results By day 7 after transplantation,patient 1 developed chest tightness,with finger pulse oxygen saturation rapidly decreasing to 84%.After receiving oxygen inhalation and rest,chest tightness was relieved,with finger pulse oxygen saturation reaching to 99%.His resting state was generally fair,and chest tightness and asthma appeared after slight strenuous out-of-bed activity.The symptoms of suspected right heart failure and pulmonary infection were slightly relieved after anti-infection,cardiotonic,diuresis and other symptomatic treatment.Pulmonary artery CT angiography was performed by day 36 after transplantation.For stenosis of the left pulmonary trunk,pulmonary balloon dilatation was performed by day 64 after lung transplantation,and the symptoms were relieved,but chest tightness and asthma appeared again the next day.Left pulmonary trunk stenting was performed by day 84 after transplantation,and the symptoms of chest tightness were relieved.The patient was discharged by day 119 after transplantation and returned to normal life.No chest tightness was observed during follow-up for more than 1 year.Patient 2 developed sudden respiratory and cardiac arrest during bedside activity by day 6 after double lung transplantation,and were intubated,and right femoral arteriovenous ECMO was established.Pulmonary artery CT angiography was done by day 10 after transplantation when the hemodynamic indexes were slightly stable,suggesting bilateral pulmonary artery stenosis and bilateral pulmonary embolism.He received anticoagulation and thrombolytic therapy.Septic shock developed by day 25 after transplantation and was discharged by day 31 after transplantation.Conclusions Pulmonary stenosis should be considered when the patients develop chest tightness and asthma after lung transplantation,excluding heart failure,lung infection,and airway disease.Pulmonary artery CT angiography should be performed.If the diagnosis of pulmonary artery stenosis is confirmed,medicinal administration or surgery is chosen according to the patients'condition.