Esmore D S, Spratt P M, Branch J M, Keogh A M, Lee R P, Farnsworth A E, Shanahan M X, Chang V P
Department of Cardiothoracic Surgery, St. Vincent's Hospital, Darlinghust, Sydney, Australia.
J Heart Transplant. 1990 Mar-Apr;9(2):136-41.
The presence of high pulmonary vascular resistance (PVR) greater than 4 Wood units contributes to significant early posttransplant mortality, and remains a negative predictor of long-term survival. Current trends have been toward exclusion of the recipient with high PVR from the orthotopic procedure; elective heterotopic allograft placement is increasingly advocated. A patient with a PVR of 6 Wood units underwent orthotopic transplantation; the cardiac allograft from a 12 kg heavier donor was implanted after an ischemic time of 115 minutes. Early graft failure at 4 hours and subsequent cardiac arrest were followed by reinstitution of cardiopulmonary bypass, during which time optimal pharmacologic manipulation of the pulmonary vasculature was undertaken, including the use of high-dose prostacyclin. Refractory right heart failure indicated the requirement for right ventricular assistance (RVA) for patient survival. RVA with a Bio-Medicus pump was instituted in association with high-dose prostacyclin; an intraaortic balloon pump was inserted 12 hours later. Maintenance immunosuppression consisted of cyclosporine and azathioprine alone. RVA was maintained for 3 days; during this time the patient was totally pump dependent. Over an 18-hour period the patient was weaned and successfully withdrawn from RVA. Intraaortic balloon pump counterpulsation and the prostacyclin infusion were continued for 6 and 10 days, respectively. The clinical implications of the various interventions that resulted in the patient's survival are discussed.
肺血管阻力（PVR）大于4伍德单位会导致移植后早期显著的死亡率，并仍然是长期生存的负面预测指标。目前的趋势是将PVR高的受者排除在原位移植手术之外；越来越多地提倡选择性异位同种异体移植。一名PVR为6伍德单位的患者接受了原位移植；来自体重重12千克的供者的心脏同种异体移植物在缺血115分钟后植入。4小时时早期移植物功能衰竭及随后的心脏骤停后，重新建立了体外循环，在此期间对肺血管系统进行了最佳的药物处理，包括使用高剂量前列环素。难治性右心衰竭表明需要右心室辅助（RVA）以维持患者生存。使用Bio-Medicus泵进行RVA并联合高剂量前列环素；12小时后插入主动脉内球囊泵。维持性免疫抑制仅包括环孢素和硫唑嘌呤。RVA维持了3天；在此期间患者完全依赖泵。在18小时内患者脱机并成功停用RVA。主动脉内球囊泵反搏和前列环素输注分别持续了6天和10天。讨论了导致患者存活的各种干预措施的临床意义。
