Smith J A, Ribakove G H, Hunt S A, Miller J, Stinson E B, Oyer P E, Robbins R C, Shumway N E, Reitz B A
Department of Cardiothoracic Surgery, Stanford University School of Medicine, Calif. 94304, USA.
J Heart Lung Transplant. 1995 Sep-Oct;14(5):832-9.
The current critical shortage of cardiac allograft donors means that the decision to offer a patient repeat heart transplantation must be carefully considered. Since 1968, a total of 66 heart retransplantation procedures (63 first-time and three second-time) have been performed in 63 patients at Stanford.
There were 52 male and 11 female patients, ranging in age from 3 to 62 years with a mean age of 41 years. Indications for retransplantation were primary allograft failure in nine patients, acute rejection in 17, graft atherosclerosis in 37, and constrictive disease in three. Six of the seventeen patients (35%) who underwent retransplantation before 1981 died in the hospital, and none are currently alive. Of the 46 patients who underwent retransplantation since 1981 treated with cyclosporine-based immunosuppression, 11 (24%) died in the hospital. Actuarial survival estimates for the whole retransplantation group at 1, 5, and 10 years were 55% +/- 8%, 33% +/- 8%, and 22% +/- 7%, respectively.
This survival was significantly worse (p < 0.05) than that in patients undergoing primary heart transplantation (81% +/- 2%, 62% +/- 2%, 44% +/- 13% at 1, 5, and 10 years). Those patients who underwent retransplantation for graft atherosclerosis since 1981 had a significantly better 1-year survival (p < 0.05) than those who underwent retransplantation for allograft rejection (69% +/- 10% versus 33% +/- 16%), but the 5-year survival was similar in both groups (34% +/- 11% versus 33% +/- 16%). Since 1981, actuarial freedoms from infection and rejection were 22% +/- 8% and 41% +/- 9%, respectively, at 1 year, and 7% +/- 7% and 36% +/- 9% at 5 years. Patients with cyclosporine-induced renal dysfunction (serum creatinine level of greater than 2.0 mg/dl) had a high probability of requiring postoperative dialysis and also of death after retransplantation. Three patients with significant cyclosporine-induced renal dysfunction underwent simultaneous kidney transplantation and heart retransplantation, and all were alive and well at the time this article was written. Sixteen patients were also currently alive at a mean follow-up of 44 months, and 15 were in New York Heart Association functional class I.
We continue to list carefully selected candidates with good rehabilitation potential for heart retransplantation.
目前心脏同种异体移植供体严重短缺，这意味着对于为患者提供再次心脏移植的决定必须谨慎考虑。自1968年以来，斯坦福大学共为63例患者实施了66例心脏再次移植手术（63例首次移植和3例二次移植）。
患者中男性52例，女性11例，年龄3至62岁，平均年龄41岁。再次移植的指征包括9例原发性移植失败、17例急性排斥反应、37例移植血管粥样硬化和3例缩窄性疾病。1981年前接受再次移植的17例患者中有6例（35%）死于医院，目前无一存活。1981年以来接受基于环孢素免疫抑制治疗的46例再次移植患者中，11例（24%）死于医院。整个再次移植组1年、5年和10年的精算生存率分别为55%±8%、33%±8%和22%±7%。
该生存率显著低于初次心脏移植患者（1年、5年和10年分别为81%±2%、62%±2%、44%±13%，p<0.05）。1981年以来因移植血管粥样硬化接受再次移植的患者1年生存率显著高于因移植排斥反应接受再次移植的患者（69%±10%对33%±16%，p<0.05），但两组5年生存率相似（34%±11%对33%±16%）。1981年以来，1年时感染和排斥反应的精算无事件生存率分别为22%±8%和41%±9%，5年时分别为7%±7%和36%±9%。发生环孢素诱导的肾功能不全（血清肌酐水平大于2.0mg/dl）的患者术后需要透析以及再次移植后死亡的可能性很高。3例发生显著环孢素诱导的肾功能不全的患者同时接受了肾脏移植和心脏再次移植，在撰写本文时均存活且状况良好。16例患者目前也存活，平均随访44个月，15例纽约心脏协会心功能分级为I级。
我们继续谨慎筛选具有良好康复潜力的心脏再次移植候选人。
