21例心脏移植经验报告

发布时间：2018-10-24 06:33

【摘要】：目的总结21例心脏移植的临床疗效和经验。方法回顾性纳入2012年1月至2017年03月,在浙江大学医学院附属第一医院连续做的21例心脏移植患者,均采用双腔静脉吻合法原位心脏移植术。通过查阅历史病例收集患者的一般情况,及围术期相关资料。肺动脉高压患者予曲前列尼尔治疗,4例术前重度肺动脉高压患者予凡瑞克治疗。围术期加强抗生素预防感染,右心功能不全患者及早予ECMO辅助治疗,肾功能不全患者及早予CRRT辅助治疗。术后为他克莫司+吗替麦考酚酯+糖皮质激素的三联免疫抑制治疗方案抗排异治疗。通过随访得到患者生存率。通过统计分析,评估患者术后转归情况。结果21例患者均成功完成手术,体外循环时间(115.6±19.8)min(67-223min)、主动脉阻断时间(33.9±4.6)min(19-56min)。术后1周心脏射血分数(Ejection Fraction,EF)值(71±2.8)%。术后气管插管机械通气时间(73.9±30.8)h,ICU时间(8.00±1.7)d,住院时间(29.0±4.0)d。术后早期发生二次气管插管1例(4.8%),急性肾功能衰竭需行CRRT 11例(52.4%),行ECMO 3例(14.3%),发生肺部感染7例(33.3%),大出血开胸止血4例(19.0%)(其中1例应用ECMO),肝功能异常3例(14.3%),脑梗1例(4.8%),心源性休克3例(14.3%)。死亡患者共6例,其中Ⅱ2例因心源性休克后并发多器官功能衰竭在围术期自动出院,其余4例分别于术后1月、4月、6月、7月死亡。术后1月、3月、6月、1年、3年生存率分别为91%,86%,81%,71%,71%。结论心脏移植是治疗终末期心脏病的有效手段,严格掌握手术指征,合理优化手术吻合口顺序,围术期加强抗生素预防感染,右心功能不全患者及早予ECMO辅助治疗,肾功能不全患者及早予CRRT辅助治疗,能有效提高心脏移植的疗效。
[Abstract]:Objective to summarize the clinical effect and experience of 21 cases of heart transplantation. Methods from January 2012 to March 2017, 21 consecutive cases of heart transplantation were performed in the first affiliated Hospital of Zhejiang University Medical College. All the patients underwent orthotopic heart transplantation with double vena cava anastomosis. The general information of patients and related data during perioperative period were collected by consulting historical cases. Patients with pulmonary hypertension were treated with troxonil, and 4 patients with severe pulmonary hypertension before operation were treated with Varek. The patients with right heart failure were treated with ECMO as early as possible, and patients with renal insufficiency with CRRT as early as possible. After operation, tacrolimus-metocophenolate glucocorticoid triple immunosuppressive regimen anti-rejection therapy. The survival rate was obtained by follow-up. By statistical analysis, the outcome of the patients after operation was evaluated. Results all the 21 patients completed the operation successfully, the CPB time was (115.6 卤19. 8) min (67-223min) and the aortic occlusion time was (33. 9 卤4. 6) min (19-56min). The cardiac ejection fraction (Ejection Fraction,EF) was (71 卤2.8)% 1 week after operation. The mechanical ventilation time after tracheal intubation was (73.9 卤30.8) h and the ICU time was (8.00 卤1.7) days, and the hospitalization time was (29.0 卤4.0) days. Early secondary tracheal intubation occurred in 1 case (4.8%), acute renal failure required CRRT in 11 cases (52.4%), ECMO in 3 cases (14.3%), pulmonary infection in 7 cases (33.3%), massive bleeding in 4 cases (19.0%) (1 case with ECMO), liver dysfunction in 3 cases, cerebral infarction 1 case). There were 4. 8% (4. 8%) and 3 (14. 3%) with cardiogenic shock. Six patients died, 2 of them were discharged from hospital during perioperative period due to cardiogenic shock and the other 4 died in January, April, June and July after operation. The survival rate of 1 month, 3 month, 6 month, 1 year, 3 year after operation was 91 / 861 and 71 / 71, respectively. Conclusion Cardiac transplantation is an effective method for the treatment of end-stage heart disease. The indication of operation should be strictly grasped, the order of anastomotic site should be optimized rationally, antibiotics should be strengthened to prevent infection in perioperative period, and the patients with right cardiac insufficiency should be treated with ECMO as soon as possible. Early CRRT adjuvant therapy in patients with renal insufficiency can effectively improve the effect of cardiac transplantation.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.2

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