Sarris G E, Smith J A, Shumway N E, Stinson E B, Oyer P E, Robbins R C, Billingham M E, Theodore J, Moore K A, Reitz B A
Department of Cardiothoracic Surgery, Stanford University School of Medicine, Calif.
J Heart Lung Transplant. 1994 Nov-Dec;13(6):940-9.
We assessed the long-term results of our experience with 109 patients with end-stage cardiopulmonary disease who underwent primary combined heart-lung transplantation at Stanford University Medical Center between March 1981 and January 1994. Average recipient age was 31 +/- 10 years (mean +/- standard deviation) median, 31 years; range, 1 month to 52 years. Recipient diagnoses included primary pulmonary hypertension (31%), Eisenmenger's syndrome (39%), complex congenital heart disease (8%), cystic fibrosis (14%), bronchiectasis (2%), and emphysema (3%). Immunosuppression was with cyclosporine and a tapering regimen of corticosteroids. In 1986 azathioprine was added, and since 1987 induction therapy with OKT3 has been employed. Actuarial survival rates at 1, 5, and 10 years were 68% +/- 4.6%, 43% +/- 5.4%, and 23% +/- 8.1%, respectively (mean +/- 1 standard error of the mean). Fourteen deaths occurred in the hospital for an operative mortality rate of 12.8% +/- 3.3%, and 61 deaths occurred overall. Causes of death included hemorrhage (five patients), infection (21), rejection (one), nonspecific pulmonary failure (four), graft coronary artery disease (six), and obliterative bronchiolitis (eight). Infection, rejection, and obliterative bronchiolitis were the major complications. Only 20% +/- 3.9% of patients were free from any infection 3 months after transplantation. Heart and lung rejection commonly occurred asynchronously; actuarial estimates of freedom from isolated lung rejection at 1 and 5 years were 47% +/- 5.2% and 40% +/- 5.6%, respectively. For simultaneous heart and lung rejection these estimates were 87% +/- 3.5% and 86% +/- 3.8%, and for isolated heart rejection 63% +/- 5.1% and 51% +/- 6.4%, respectively. Although graft coronary artery disease developed less frequently than in patients after isolated heart transplantation (90% +/- 4.6% of patients were free of graft coronary artery disease at 5 years), obliterative bronchiolitis remains a major long-term complication and cause of morbidity and mortality. Actuarial estimates of freedom from obliterative bronchiolitis at 1, 5, and 10 years were 71% +/- 5.1%, 51% +/- 6.1%, and 42% +/- 7.8%, respectively. These results show satisfactory early and medium-term outcome after combined heart-lung transplantation but also underscore that much progress is needed in controlling infection, rejection, and obliterative bronchiolitis, all of which remain as major impediments to long-term survival.
我们评估了1981年3月至1994年1月期间在斯坦福大学医学中心接受初次心肺联合移植的109例终末期心肺疾病患者的长期治疗结果。受者平均年龄为31±10岁（均值±标准差），中位数为31岁；范围为1个月至52岁。受者诊断包括原发性肺动脉高压（31%）、艾森曼格综合征（39%）、复杂先天性心脏病（8%）、囊性纤维化（14%）、支气管扩张症（2%）和肺气肿（3%）。免疫抑制采用环孢素和逐渐减量的皮质类固醇方案。1986年加用硫唑嘌呤，自1987年起采用OKT3诱导治疗。1年、5年和10年的精算生存率分别为68%±4.6%、43%±5.4%和23%±8.1%（均值±均值的1个标准误）。14例患者在医院死亡，手术死亡率为12.8%±3.3%，总体死亡61例。死亡原因包括出血（5例患者）、感染（21例）、排斥反应（1例）、非特异性肺功能衰竭（4例）、移植冠状动脉疾病（6例）和闭塞性细支气管炎（8例）。感染、排斥反应和闭塞性细支气管炎是主要并发症。移植后3个月仅有20%±3.9%的患者未发生任何感染。心脏和肺排斥反应通常不同时发生；1年和5年无孤立性肺排斥反应的精算估计分别为47%±5.2%和40%±5.6%。对于同时发生的心脏和肺排斥反应，这些估计分别为87%±3.5%和86%±3.8%，对于孤立性心脏排斥反应分别为63%±5.1%和51%±6.4%。尽管移植冠状动脉疾病的发生率低于单纯心脏移植患者（5年时90%±4.6%的患者无移植冠状动脉疾病），但闭塞性细支气管炎仍然是主要的长期并发症以及发病和死亡的原因。1年、5年和10年无闭塞性细支气管炎的精算估计分别为71%±5.1%、51%±6.1%和42%±7.8%。这些结果显示心肺联合移植术后早期和中期结果令人满意，但也强调在控制感染、排斥反应和闭塞性细支气管炎方面仍需取得很大进展，所有这些仍是长期生存的主要障碍。
