Hummel M, Warnecke H, Schüler S, Hempel B, Spiegelsberger S, Hetzer R
Deutsches Herzzentrum Berlin.
Klin Wochenschr. 1991 Aug 16;69(12):495-505. doi: 10.1007/BF01649285.
Heart transplantation (HTx) has now become an accepted treatment modality for end-stage heart disease. The limited supply of suitable donor organs imposes constraints upon the decision of who should be selected for transplantation. Usually patients are candidates for HTx, who remain NYHA functional class III or IV despite maximal medical therapy. Further criteria are low left ventricular ejection fraction (less than 20%) with heart rhythm disturbances class IIIA-V (LOWN), which are associated with poor prognosis. Additionally, the suffering of the patient and also the course of heart failure are essential for judging the urgency of HTx. Contraindications are absolute in patients with untreated infections, fixed pulmonary vascular resistance (PVR) above 8 WOOD-degrees, severe irreversible kidney and liver disease, active ventricular or duodenal ulcers and acute, psychiatric illness. HTx is relatively contraindicated in patients with diabetes mellitus, age over 60 years, PVR above 6 WOOD-degrees and an unstable psychosocial situation. To prevent rejection of the transplant heart, live-long immunosuppressive therapy is needed. Most immunosuppressive regimes consist of Cyclosporine A and Azathioprine (double drug therapy) or in combination (tripple drug therapy) with Prednisolone. For monitoring of this therapy, control of hole blood cyclosporine A level and white blood count is needed. Rejection episodes can be suspected if there is a greater than 20 mmHg decrease of systolic blood pressure, elevated body temperature, malaise, tachycardia or heart rhythm disturbance. The diagnosis of cardiac rejection can be established by endomyocardial biopsy. Measurement of the voltage of either the surface or intramyocardial ECG, echocardiography with special consideration to early left ventricular filling time as well as immunological methods are additionally used tools. Graft sclerosis as the main risk factor of the late transplant period remains an unsolved problem.
心脏移植（HTx）现已成为终末期心脏病的一种公认治疗方式。合适供体器官的供应有限，这对选择谁进行移植的决策施加了限制。通常，尽管接受了最大程度的药物治疗，但仍处于纽约心脏协会（NYHA）心功能Ⅲ级或Ⅳ级的患者是心脏移植的候选者。进一步的标准是左心室射血分数低（低于20%）且伴有ⅢA - V级心律失常（洛恩分级），这些与预后不良相关。此外，患者的痛苦以及心力衰竭的病程对于判断心脏移植的紧迫性至关重要。未治疗的感染、固定肺血管阻力（PVR）高于8伍德单位、严重不可逆的肾脏和肝脏疾病、活动性心室或十二指肠溃疡以及急性精神疾病患者存在绝对禁忌证。糖尿病患者、年龄超过60岁、PVR高于6伍德单位以及社会心理状况不稳定的患者相对禁忌心脏移植。为防止移植心脏发生排斥反应，需要进行终身免疫抑制治疗。大多数免疫抑制方案由环孢素A和硫唑嘌呤（双联药物治疗）组成，或与泼尼松龙联合使用（三联药物治疗）。为监测这种治疗，需要控制全血环孢素A水平和白细胞计数。如果收缩压下降超过20 mmHg、体温升高、不适、心动过速或心律失常，则可能怀疑发生排斥反应。心脏排斥反应的诊断可通过心内膜心肌活检来确定。此外，还使用体表或心肌内心电图电压测量、特别考虑早期左心室充盈时间的超声心动图以及免疫学方法等工具。移植后期的主要危险因素——移植物硬化仍然是一个未解决的问题。
