Jeevanandam V, Mather P, Furukawa S, Todd B, Regillo T, Bove A A, McClurken J, Addonizio V P
Section of Cardiothoracic Surgery, Temple University Health Sciences Center, Philadelphia, Pa.
Circulation. 1994 Nov;90(5 Pt 2):II74-7.
Because of the critical shortage of adult donor hearts, many recipients die awaiting transplantation of an organ of appropriate size. Undersized hearts (donor/recipient weight ratio < 0.7) have been used for heterotopic heart transplantation. We report on 6 moribund adult heart transplant candidates who were rescued with orthotopic heart transplantation of undersized pediatric hearts.
Recipients were hypotensive (mean blood pressure, 62.3 +/- 13.4 mm Hg), had high pulmonary artery pressures (mean pulmonary artery pressure, 42.4 +/- 6.3 mm Hg), and had mean cardiac indexes of 1.7 +/- 0.6 L.min-1.m-2. Four had pretransplant intra-aortic balloon pumps, and one was on a Thoratec left ventricular assist device complicated by fungemia. Since conventionally sized donors were unavailable (+/- 30% recipient weight), the patients were listed in a wider weight range (+/- 60%). Donor characteristics were age, 8.7 +/- 1.5 years; weight, 32.8 +/- 7.0 kg; and donor/recipient weight ratio, 0.44 +/- 0.2, with average ischemic time of 236.0 +/- 59.3 minutes. Technical considerations during transplantation included (1) opening the donor right atrium from the inferior vena cava to superior vena cava to facilitate size matching, (2) performing size-mismatched pulmonary artery and aortic anastomoses end to end, (3) infusing prostaglandin E1 12 ng.kg-1.min-1 to decrease pulmonary and systemic vascular resistance, (4) pacing donor and recipient atria synchronously to improve ventricular filling, (5) maintaining high heart rates up to 140 beats per minute (initially with isoproterenol or pacing, chronically with theophylline), (6) hyperventilating with sedation and paralysis as necessary, (7) reperfusing with triiodothyronine, and (8) minimizing afterload. All patients were discharged from the hospital. At 1 week, hemodynamics were normal and echocardiograms demonstrated left ventricular growth.
Hence, undersized pediatric hearts can be used successfully to salvage moribund patients and expand the potential donor pool for adult orthotopic heart transplantation.
由于成人供体心脏严重短缺，许多受者在等待合适大小器官移植的过程中死亡。过小的心脏（供体/受体体重比<0.7）已被用于异位心脏移植。我们报告了6例濒临死亡的成人心脏移植候选者，他们通过原位移植过小的小儿心脏而获救。
受者血压偏低（平均血压，62.3±13.4mmHg），肺动脉压力较高（平均肺动脉压，42.4±6.3mmHg），心脏指数平均为1.7±0.6L·min⁻¹·m⁻²。4例在移植前使用了主动脉内球囊泵，1例使用Thoratec左心室辅助装置并并发真菌血症。由于无法获得常规大小的供体（±30%受体体重），这些患者被列入更宽的体重范围（±60%）。供体特征为年龄8.7±1.5岁；体重32.8±7.0kg；供体/受体体重比0.44±0.2，平均缺血时间为236.0±59.3分钟。移植过程中的技术考虑包括：（1）从下腔静脉至上腔静脉打开供体右心房以促进大小匹配；（2）进行大小不匹配的肺动脉和主动脉端端吻合；（3）输注前列腺素E1 12ng·kg⁻¹·min⁻¹以降低肺血管和体循环血管阻力；（4）同步起搏供体和受体心房以改善心室充盈；（5）将心率维持在高达每分钟140次（最初用异丙肾上腺素或起搏，长期用茶碱）；（6）必要时通过镇静和麻痹进行过度通气；（7）用三碘甲状腺原氨酸进行再灌注；（8）尽量减少后负荷。所有患者均出院。1周时，血流动力学正常，超声心动图显示左心室生长。
因此，过小的小儿心脏可成功用于挽救濒临死亡的患者，并扩大成人原位心脏移植的潜在供体库。
