【摘要】：目的總結(jié)21例心臟移植的臨床療效和經(jīng)驗(yàn)。方法回顧性納入2012年1月至2017年03月,在浙江大學(xué)醫(yī)學(xué)院附屬第一醫(yī)院連續(xù)做的21例心臟移植患者,均采用雙腔靜脈吻合法原位心臟移植術(shù)。通過(guò)查閱歷史病例收集患者的一般情況,及圍術(shù)期相關(guān)資料。肺動(dòng)脈高壓患者予曲前列尼爾治療,4例術(shù)前重度肺動(dòng)脈高壓患者予凡瑞克治療。圍術(shù)期加強(qiáng)抗生素預(yù)防感染,右心功能不全患者及早予ECMO輔助治療,腎功能不全患者及早予CRRT輔助治療。術(shù)后為他克莫司+嗎替麥考酚酯+糖皮質(zhì)激素的三聯(lián)免疫抑制治療方案抗排異治療。通過(guò)隨訪得到患者生存率。通過(guò)統(tǒng)計(jì)分析,評(píng)估患者術(shù)后轉(zhuǎn)歸情況。結(jié)果21例患者均成功完成手術(shù),體外循環(huán)時(shí)間(115.6±19.8)min(67-223min)、主動(dòng)脈阻斷時(shí)間(33.9±4.6)min(19-56min)。術(shù)后1周心臟射血分?jǐn)?shù)(Ejection Fraction,EF)值(71±2.8)%。術(shù)后氣管插管機(jī)械通氣時(shí)間(73.9±30.8)h,ICU時(shí)間(8.00±1.7)d,住院時(shí)間(29.0±4.0)d。術(shù)后早期發(fā)生二次氣管插管1例(4.8%),急性腎功能衰竭需行CRRT 11例(52.4%),行ECMO 3例(14.3%),發(fā)生肺部感染7例(33.3%),大出血開胸止血4例(19.0%)(其中1例應(yīng)用ECMO),肝功能異常3例(14.3%),腦梗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發(fā)多器官功能衰竭在圍術(shù)期自動(dòng)出院,其余4例分別于術(shù)后1月、4月、6月、7月死亡。術(shù)后1月、3月、6月、1年、3年生存率分別為91%,86%,81%,71%,71%。結(jié)論心臟移植是治療終末期心臟病的有效手段,嚴(yán)格掌握手術(shù)指征,合理優(yōu)化手術(shù)吻合口順序,圍術(shù)期加強(qiáng)抗生素預(yù)防感染,右心功能不全患者及早予ECMO輔助治療,腎功能不全患者及早予CRRT輔助治療,能有效提高心臟移植的療效。
[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 鹵19. 8) min (67-223min) and the aortic occlusion time was (33. 9 鹵4. 6) min (19-56min). The cardiac ejection fraction (Ejection Fraction,EF) was (71 鹵2.8)% 1 week after operation. The mechanical ventilation time after tracheal intubation was (73.9 鹵30.8) h and the ICU time was (8.00 鹵1.7) days, and the hospitalization time was (29.0 鹵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.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R654.2

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