Taka Hirosh, Miyoshi Kentaroh, Kurosaki Takeshi, Douguchi Takuma, Itoh Hideshi, Sugimoto Seiichiro, Yamane Masaomi, Kobayashi Motomu, Kasahara Shingo, Oto Takahiro
Department of Clinical Engineering, Okayama University Hospital, Okayama, Japan.
Department of Thoracic Surgery, Okayama Medical Center/Okayama University Hospital, 2-5-1, Shikata-cho, kita-ku, Okayama, 700-8558, Japan.
Gen Thorac Cardiovasc Surg. 2019 Jul;67(7):624-632. doi: 10.1007/s11748-019-01067-w. Epub 2019 Jan 18.
The role of intraoperative cardiopulmonary bypass (CPB) in lung transplant (LTx) surgery is controversial. CPB enables slow pulmonary reperfusion and initial ventilation with low oxygen concentrations, both theoretically protective of transplanted lungs. In this study, we explored clinical outcomes following extended criteria donor LTx surgery implementing a thoroughly protective allograft reperfusion strategy using CPB.
Thirty-nine consecutive adult patients who underwent bilateral LTx with elective CPB and protective allograft reperfusion were reviewed. Bilaterally implanted lungs were reperfused simultaneously, via slow CPB flow reduction and initial ventilation with 21% oxygen and nitric oxide, followed by a brief modified ultrafiltration. During weaning from CPB, mean pulmonary arterial pressure was strictly maintained at 10-15 mmHg by controlling CPB and pulmonary flow. The clinical outcomes in 23 patients who received lungs from extended criteria donors (ECD group) were elucidated and compared to 16 patients undergoing LTx from standard criteria donors (SCD group).
No life-threatening deterioration was observed to graft functionality during the first 72 h after LTx in the ECD group; however, only one patient required post-transplant extracorporeal membrane oxygenation. In three of 23 ECD LTx patients (12%), surgical revision for bleeding was required. Survival outcomes for the ECD group were favorable, with 100% survival at 6-months, 87.0% at 1-year, and 80.7% at 5-years. Outcomes in the ECD group were comparable to those in the SCD group.
Despite a certain extent of risk associated with full-dose heparinization, use of CPB does not undermine survival outcomes after ECD LTx surgery if protective allograft reperfusion is securely performed.
术中体外循环（CPB）在肺移植（LTx）手术中的作用存在争议。CPB可实现缓慢的肺再灌注和低氧浓度初始通气，从理论上讲，这两者都对移植肺具有保护作用。在本研究中，我们探讨了在实施使用CPB的全面保护性同种异体移植再灌注策略的扩大标准供体LTx手术后的临床结果。
回顾了39例接受双侧LTx并采用选择性CPB和保护性同种异体移植再灌注的成年患者。双侧植入的肺通过缓慢降低CPB流量和用21%氧气及一氧化氮进行初始通气同时进行再灌注，随后进行短暂的改良超滤。在CPB撤机过程中，通过控制CPB和肺血流量将平均肺动脉压严格维持在10 - 15 mmHg。阐明了23例接受扩大标准供体肺的患者（ECD组）的临床结果，并与16例接受标准标准供体LTx的患者（SCD组）进行比较。
ECD组在LTx术后的前72小时内未观察到移植肺功能出现危及生命的恶化；然而，只有1例患者术后需要体外膜肺氧合。23例ECD LTx患者中有3例（12%）因出血需要进行手术修正。ECD组的生存结果良好，6个月时生存率为100%，1年时为87.0%，5年时为80.7%。ECD组的结果与SCD组相当。
尽管全剂量肝素化存在一定程度的风险，但如果能安全地进行保护性同种异体移植再灌注，CPB的使用不会损害ECD LTx手术后的生存结果。
