Chae M S, Kim Y, Oh S A, Jeon Y, Choi H J, Kim Y H, Hong S H, Park C S, Huh J
Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Transplant Proc. 2018 Dec;50(10):3988-3994. doi: 10.1016/j.transproceed.2018.08.017. Epub 2018 Sep 7.
Combined liver and kidney transplant is a very complex surgery. To date, there has been no report on the intraoperative management of patients with impaired cardiac function undergoing simultaneous ABO-compatible liver and ABO-incompatible kidney transplant from 2 living donors.
A 60-year-old man underwent simultaneous ABO-compatible liver and ABO-incompatible kidney transplant from 2 living donors because of IgA nephropathy and alcoholic liver cirrhosis. The preoperative cardiac findings revealed continuous aggravation, shown by large left atrial enlargement, severe left ventricular hypertrophy, a very prolonged QT interval, and a calcified left anterior descending coronary artery. Severe hypotension with very weak pulsation and severe bradycardia developed, with an irregular junctional rhythm noted immediately after the liver graft was reperfused. Although epinephrine was administered as a rescue drug, hemodynamics did not improve, and central venous pressure and mean pulmonary arterial pressure increased to potentially fatal levels. Emergency phlebotomy via the central line was performed. Thereafter, hypotension and bradycardia recovered gradually as the central venous pressure and mean pulmonary arterial pressure decreased. The irregular junctional rhythm returned to a sinus rhythm, but the QTc interval was slightly more prolonged. Because of poor cardiac capacity, the volume and rate of fluid infusion were increased aggressively to maintain appropriate kidney graft perfusion after confirming vigorous urine production of the graft.
A heart with impaired function due to both end-stage liver and kidney diseases may be less able to withstand surgical stress. Further study on cardiac dysfunction will be helpful for the management of patients undergoing complex transplant surgery.
肝肾联合移植是一项非常复杂的手术。迄今为止，尚无关于接受来自2名活体供体的ABO血型相合肝脏和ABO血型不相合肾脏同期移植的心脏功能受损患者术中管理的报道。
一名60岁男性因IgA肾病和酒精性肝硬化接受了来自2名活体供体的ABO血型相合肝脏和ABO血型不相合肾脏同期移植。术前心脏检查结果显示病情持续加重，表现为左心房显著增大、严重左心室肥厚、QT间期极延长以及左前降支冠状动脉钙化。肝脏移植再灌注后立即出现严重低血压，搏动极弱，伴有严重心动过缓，出现不规则交界性心律。尽管使用肾上腺素作为抢救药物，但血流动力学并未改善，中心静脉压和平均肺动脉压升至可能致命的水平。通过中心静脉导管进行了紧急放血。此后，随着中心静脉压和平均肺动脉压降低，低血压和心动过缓逐渐恢复。不规则交界性心律恢复为窦性心律，但QTc间期略有延长。由于心脏功能较差，在确认移植肾有大量尿液生成后，积极增加输液量和输液速度以维持移植肾的适当灌注。
终末期肝脏和肾脏疾病导致功能受损的心脏可能更难以承受手术应激。对心脏功能障碍的进一步研究将有助于复杂移植手术患者的管理。
