同种异体原位心脏移植40例受者疗效分析

发布时间：2018-03-03 14:37

本文选题：心脏移植　切入点：终末期心脏病　出处：《山东大学》2014年硕士论文　论文类型：学位论文

【摘要】：目的：总结分析原位心脏移植术治疗终末期心脏病的方法、疗效和经验。方法：回顾性分析同种异体原位心脏移植40例受者的临床资料。原发病包括扩张型心肌病29例、缺血性心肌病6例、肥厚型心肌病4例及限制性心肌病1例。手术方式采用标准法原位心脏移植术1例,双腔静脉吻合法原位心脏移植术39例。免疫抑制治疗为环孢素、吗替麦考酚酯、泼尼松的三联用药方案。其中5例受者未给予免疫诱导治疗,6例受者术中给予抗Tac单克隆抗体诱导治疗,29例受者于麻醉诱导及术后第4天给予巴利昔单克隆抗体的诱导治疗。预防性抗菌素采用头孢曲松钠术前30分钟及术后每日1次静滴,术后根据痰培养及尿培养结果及时调整抗菌素方案。排斥反应的监测采用症状、心脏彩超、肌钙蛋白、心肌酶谱的综合评价。根据血药谷浓度(CO)与峰浓度(C2)调整环孢素的血药浓度至理想区间(CO理想区间150-200ng/mL和C2理想区间为800-1200ng/mL)。将患者基本信息及手术相关数据建立数据库,采用SPSS18.0软件包对数据进行综合分析处理,各项数据用均数±标准差(x±s)表示,分析心脏移植术后疗效。结果：受者随访1-129个月,术后1月存活率95%(38/40)。1,3,5年生存率分别为90%,82.5%,77.5%。死亡原因包括：术后早期(术后1个月内)1例受者死于肠道出血,1例受者死于急性右心衰,术后晚期(术后1个月后)1例受者死于肺癌,1例受者死于真菌感染,4例受者死于移植物衰竭。共出现急性排斥反应7例,包括术后早期急性排斥反应2例,晚期5例,经激素冲击治疗后均逆转,各排斥相关指标恢复正常,排斥反应发生率17.5%。采用单纯监测血药谷浓度时发生排斥反应4例,发生率20%；采用环孢素血药浓度谷、峰值同时监测后发生排斥反应3例,发生率15%。结论：心脏移植术治疗各类终末期心脏病疗效确实可靠,可提高各类终末期心脏疾病患者的生存率和生活质量。术后主要并发症有：急性右心功能衰竭,急性排斥反应,感染。血药浓度谷、峰值同时监测可控制环孢素浓度在有效的范围内,并可及时发现环孢素吸收的个体差异,给予及时调整环孢素用量,避免早期急性排斥反应的发生。
[Abstract]:Objective: to summarize the methods, efficacy and experience of orthotopic heart transplantation in the treatment of end-stage heart disease. Methods: the clinical data of 40 patients with orthotopic heart transplantation were retrospectively analyzed. The primary diseases included dilated cardiomyopathy (29 cases) and ischemic cardiomyopathy (6 cases). There were 4 cases of hypertrophic cardiomyopathy and 1 case of restrictive cardiomyopathy. Standard method of orthotopic heart transplantation was used in 1 case and double vena cava anastomosis in 39 cases. Prednisone triplex regimen. Among them, 5 patients were not treated with immune induction. 6 recipients were treated with anti Tac monoclonal antibody induction during operation. 29 recipients were given baliximab monoclonal antibody during anesthesia induction and 4 days after operation. Prophylaxis of ceftriaxone sodium 30 minutes before operation and once a day after operation, The antibiotic regimen was adjusted according to the results of sputum culture and urine culture. The rejection was monitored by symptoms, color Doppler echocardiography, cardiac troponin. Comprehensive evaluation of myocardial zymogram. According to the concentration of ciclosporin (CO) and peak concentration (C2), the serum concentration of cyclosporine was adjusted to the ideal range of 150-200ng / mL CO and 800-1200ng / mL C2. The basic information of patients and the relevant data of operation were established. The data were analyzed by SPSS18.0 software package. The data were expressed as mean 卤standard deviation (x 卤s). Results: the recipients were followed up for 1-129 months, the survival rate was 95 / 38 / 40 / 1 on January, and the 5-year survival rate was 90 / 82.5 / 77.5 respectively. The causes of death included: early postoperative (1 patient died of intestinal bleeding within 1 month after operation) and 1 patient died of acute right heart failure (right heart failure). 1 case died of lung cancer and 1 case died of fungal infection 4 cases died of graft failure. Acute rejection occurred in 7 cases, including early acute rejection in 2 cases and late stage in 5 cases. After hormone shock treatment, all of them were reversed, the rejection indexes returned to normal, the incidence of rejection was 17.5%. 4 cases (20%) were treated with simple monitoring of blood drug concentration, and 20 cases with cyclosporine concentration valley. Rejection occurred in 3 cases after simultaneous monitoring of peak value, and the incidence was 15%. Conclusion: heart transplantation is effective and reliable in the treatment of various end-stage heart diseases, which can improve the survival rate and quality of life of patients with various end-stage heart diseases. The main postoperative complications are acute right heart failure and acute rejection. The peak concentration of cyclosporine can control the concentration of cyclosporine within the effective range, and the individual difference of the absorption of cyclosporine can be found in time, and the dosage of cyclosporine can be adjusted in time to avoid the occurrence of early acute rejection.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R654.2

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