Eltzschig H K, Zwissler B, Felbinger T W
Klinik für Anaesthesiologie und Intensivmedizin, Eberhard-Karls-Universität Tübingen.
Anaesthesist. 2003 Aug;52(8):678-89. doi: 10.1007/s00101-003-0556-1.
Over the past 30 years, heart transplantation has evolved into a definitive therapy for patients with end-stage cardiomyopathy. However, perioperative management of patients undergoing heart transplantation remains a challenge for anesthesiologists. The presence of biventricular failure, arrhythmias and associated multisystem organ dysfunction may contribute to significant intraoperative hemodynamic instability prior to the initiation of cardiopulmonary bypass (CPB). Even after an uneventful transplantation, weaning from CPB may be difficult. Acute right ventricular failure can develop in the recipient secondary to pre-existing pulmonary hypertension. Treatment options frequently focus on therapeutic interventions directed towards decreasing pulmonary vascular resistance and improving right ventricular contractility. Intraoperative use of transesophageal echocardiography (TEE) enables the anesthesiologist to diagnose acute right ventricular failure early on and guide therapy. Concurrent pathology including kinking of the pulmonary artery anastomosis or valvular insufficiency in the transplanted heart can also be recognized and addressed. The number of patients undergoing cardiac transplantation is continually increasing. In addition, the use of more effective immunosuppressive agents has curtailed transplant rejection and permitted longer survival. Consequently, heart transplant recipients are more frequently presenting for non-cardiac surgical procedures. Thus, an understanding of physiological and pharmacological implications associated with heart transplantation is crucial for managing these patients in the perioperative period.
在过去30年里，心脏移植已发展成为终末期心肌病患者的一种确定性治疗方法。然而，心脏移植患者的围手术期管理对麻醉医生来说仍然是一项挑战。双心室衰竭、心律失常以及相关的多系统器官功能障碍的存在，可能会导致在体外循环（CPB）开始前出现显著的术中血流动力学不稳定。即使移植过程顺利，脱离CPB也可能很困难。由于术前存在肺动脉高压，受者可能会发生急性右心室衰竭。治疗方案通常侧重于旨在降低肺血管阻力和改善右心室收缩力的治疗干预措施。术中使用经食管超声心动图（TEE）可使麻醉医生早期诊断急性右心室衰竭并指导治疗。同时存在的病理情况，包括移植心脏的肺动脉吻合口扭结或瓣膜功能不全，也能够被识别并加以处理。接受心脏移植的患者数量在持续增加。此外，使用更有效的免疫抑制剂减少了移植排斥反应，并延长了生存期。因此，心脏移植受者更频繁地接受非心脏外科手术。因此，了解与心脏移植相关的生理和药理学影响对于在围手术期管理这些患者至关重要。
