Wheeldon D R, Potter C D, Jonas M, Wallwork J, Large S R
Transplant Unit, Papworth Hospital Trust, Cambridge, UK.
Eur J Cardiothorac Surg. 1994;8(1):7-9; discussion 10-1. doi: 10.1016/1010-7940(94)90125-2.
Donor availability is the single most limiting factor in heart transplantation. From a consecutive series of 100 heart donors, there were 21 which fell well outside our minimum criteria on initial inspection: mean arterial pressure (MAP) more than 60 mm Hg, central venous pressure (CVP) less than 12 mm Hg, pulmonary capillary wedge pressure (PCWP) less than 12 mm Hg, left ventricular stroke work index (LVSWI) more than 15 g.m. on inotropes less than 5 mcg/kg per min. Of these 13 out of 21 had a MAP less than 55 mm Hg, 6 out of 21 a CVP more than 15 mm Hg and 2 out of 21 were on inotropes at more than 20 mcg/kg per min. Following full invasive monitoring another 14 donors fell outside our criteria; 5 had a mean LVSWI of 12.4 g.m. and 9 had a mean PCWP of 19.6 mm Hg. Following the institution of our hormone-based pharmacological resuscitation regime 30 of these donors yielded 19 transplantable hearts and 11 transplantable heart-lung blocks. The other five were not used due to left ventricular hypertrophy (2), inotrope dependency (2) and persistent poor function (1). Twenty-five of the 30 recipients of these organs (83.3%) are alive and well, 4-25 months post transplant. Four early deaths occurred; one arrhythmia (heart), one acute respiratory distress syndrome (heart), one cerebrovascular accident (heart lung) and one infection (heart, lung and liver). One death occurred at 90 days from tamponade (heart). Aggressive and focussed donor management has helped us to maintain our levels of transplant activity, without compromising the outcome--a 30-day mortality of 16.2% in 1989, 11.8% in 1990 and 6.8% in 1991.
供体的可获得性是心脏移植中最为关键的限制因素。在连续的100例心脏供体中，有21例在初次检查时就明显不符合我们的最低标准：平均动脉压（MAP）超过60 mmHg，中心静脉压（CVP）低于12 mmHg，肺毛细血管楔压（PCWP）低于12 mmHg，左心室每搏功指数（LVSWI）在使用剂量小于5 mcg/kg每分钟的血管活性药物时超过15 g.m。在这21例中，13例MAP低于55 mmHg，6例CVP超过15 mmHg，2例使用血管活性药物的剂量超过20 mcg/kg每分钟。在进行全面的有创监测后，又有14例供体不符合我们的标准；5例左心室每搏功指数平均为12.4 g.m，9例肺毛细血管楔压平均为19.6 mmHg。在实施我们基于激素的药物复苏方案后，这些供体中有30例获得了19个可用于移植的心脏和11个可用于移植的心肺联合器官。另外5例因左心室肥厚（2例）、依赖血管活性药物（2例）和功能持续不佳（1例）而未被使用。这些器官的30例接受者中有25例（83.3%）在移植后4至25个月存活且状况良好。发生了4例早期死亡；1例死于心律失常（心脏移植），1例死于急性呼吸窘迫综合征（心脏移植），1例死于脑血管意外（心肺联合移植），1例死于感染（心脏、肺和肝脏联合移植）。1例在术后90天因心包填塞（心脏移植）死亡。积极且有针对性的供体管理帮助我们维持了移植手术的开展水平，同时并未影响手术效果——1989年30天死亡率为16.2%，1990年为11.8%，1991年为6.8%。
