2. Alias of combined heart-lung transplantation; Cardiopulmonary transplantation; Cardiopulmonary transplantation; Combined heart-lung transplantation; Combined heart-lung transplantation; Combined heart-lung transplantation
3 classification cardiovascular surgery
4 ICD code 33.6 0 1
Summary 1907, Karel carried out the animal experiment of heterotopic heart-lung transplantation. From 65438 to 0940, Mihov of the former Soviet Union transplanted the heart and lungs of animals into the chest cavity, and the animals survived for 6 days after operation without cardiopulmonary bypass. In 196 1, Lower simplified the operation of heart-lung transplantation through experiments, and emphasized the importance of preserving the phrenic nerve and vagus nerve of the recipient, carefully ligating the bronchial vessels, and preserving the donor lung with low temperature saline. In the early 1980s, Stanford Laboratory used a small amount of cyclosporine in monkey heart-lung transplantation, which was the first time that cyclosporine was used for immunosuppression in animal heart-lung transplantation. Several kinds of animals have survived for more than 65,438+0 years.
1968 Cooley performed the first combined heart-lung transplantation for an infant with atrioventricular canal malformation and pulmonary hypertension, and the child survived 14h. 1969 and 197 1 year, Lillehei and Barnard also underwent heart-lung transplantation. 198 1 year, the first patient with combined heart-lung transplantation in Stanford University achieved long-term survival. By March of 1999, it was reported that there were 25 cases of heart-lung transplantation in the world, with patients ranging in age from newborns to 59.3 years old. Cardiopulmonary transplantation has become an acceptable and effective method to treat end-stage cardiopulmonary diseases.
Indications Combined heart-lung transplantation is suitable for:
1. Primary pulmonary hypertension.
2. Congenital heart disease complicated with Eisenmenger syndrome.
3. Terminal chronic obstructive pulmonary disease.
4. Interstitial pulmonary fibrosis.
5. Pulmonary cystic fibrosis.
6. Pulmonary lymphomyomatosis.
7.α 1 can resist trypsin deficiency and pneumoconiosis.
7 contraindications Patients with a history of heart or chest surgery should be classified as contraindications for cardiopulmonary transplantation.
Preoperative preparation for donor selection and treatment: In addition to completely meeting the standards of heart transplantation, the chest X-ray of the donor before heart-lung transplantation is clear, and there is no pulmonary infection, contusion, pulmonary edema and atelectasis. Mechanical assisted breathing shall not exceed 48h, and the ventilation pressure shall not exceed 30mmHg. When the inhaled oxygen concentration is less than 40%, the arterial blood gas analysis is normal. Sputum bacteria culture was negative. The chest is about the same size as the recipient. Comparing the chest radiographs of the donor and the recipient, it is more appropriate for the donor to be slightly smaller than the recipient, because the donor's lung is too large to cause postoperative atelectasis.
9 Operation step 9. 1. 1. The donor heart and lungs were removed as a whole. Preoperative preparation and most operations are basically the same as those of orthotopic heart transplantation. Thoracotomy was performed in the middle of the chest, and pericardium was widely cut to bilateral pulmonary veins, and ascending aorta, innominate artery and superior vena cava were separated respectively, and azygos vein was ligated. The free trachea is sheathed 5cm above the carina, and the front of the trachea near the carina is separated very little, so as not to damage the blood supply of the coronary collateral. Intravenous injection of heparin 3mg/kg and prostaglandin E1.20 ng/(kg min) can eliminate the reaction of pulmonary vessels to cold perfusion solution. Ligate and cut off the superior vena cava at a high position, close to the diaphragm, clamp the inferior vena cava with a vascular clamp, and cut it at the upper side of the clamp. After cardiac arrest, the aorta was blocked and cold crystalloid cardioplegia 500 ~ 1000 ml was injected into the aortic root. Then, the improved Collin lung protective solution at 4℃ was perfused into the main pulmonary artery with a French 14 suction tube (65 ml of 50% glucose solution was added to every liter of Collin solution), the perfusion volume was 60ml/kg, the perfusion pressure was 20mmHg, and the perfusion time was 20 mmhg. During lung perfusion, the lung is ventilated with low tidal volume, which makes the lung in a semi-tense state and makes the perfusion fluid distribute evenly. Cut the left atrial appendage and drain the lung perfusion fluid to prevent the left ventricle from expanding. Then cut off the ascending aorta on the plane of the innominate artery, clamp the trachea above 5 tracheal rings on the carina and cut it off. The heart and lung were separated from the lower part to the posterior mediastinum, and the ligament of the lower lung was ligated and cut off. Take out the heart and lungs from the chest and soak them in normal saline at 4℃ (Figure 6.38+0).
9.2 2. The key point of the recipient's cardiopulmonary resection is to protect the phrenic nerve, vagus nerve and recurrent laryngeal nerve and stop bleeding completely. Minimally separate the tissues around the trachea to maintain blood supply.
Make an incision in the middle of the sternum and pull the sternum to both sides. Cut both pleura, and if there is pleural adhesion, separate the adhesion before heparinization. After vertical incision of pericardium and heparinization, heart transplantation and intubation were used to establish cardiopulmonary bypass. The diseased heart can be removed in three steps, which can avoid the complexity of the whole removal operation:
(1) Only the ascending aorta, superior vena cava, inferior vena cava or vena cava and part of the right atrium are reserved when the diseased heart is removed, and four pulmonary veins are reserved, and the left atrial posterior wall between them is cut off (Figure 6.582).
(2) Lift the left pericardial incision forward and left with two vascular forceps, fully showing the direction of phrenic nerve. A longitudinal incision was made in the pericardium about 3cm behind the phrenic nerve, extending down to the diaphragm and up to the pulmonary artery, and then the pericardium about 3cm in front of the phrenic nerve was removed to form a broad heart cord (Figure 6.582). Cut the left atrial posterior wall longitudinally through the oblique sinus in the center of the left atrial posterior wall, lift the left atrial stump and the left pulmonary vein connected with it forward, and separate it from the posterior mediastinal tissue with electrotome, and stick to the pulmonary vein when separating, so as not to damage the posterior vagus nerve. Pull out the left lung to the right through the pleural incision, fully free the hilum, ligate the bronchial artery, and then cut off the left pulmonary artery. Clamp the left main trachea, cut it off at its distal end, and take out the left lung (Figure 6.583).
(3) The right posterolateral pericardium was cut, and the right phrenic nerve cord was preserved according to the treatment of the left lung. Open the left atrium behind the atrial sulcus, so that the right atrium and the right pulmonary vein can be completely separated without damaging the atrial septum (Figure 6.584). Separate the right pulmonary vein and the residual left atrial posterior wall from the posterior mediastinum, and pay attention to protect the phrenic nerve in front of it and the vagus nerve in the back (Figure 6.585). Pull the right lung forward to the left, ligate the bronchial artery, horizontally free the right pulmonary artery at the hilum of the lung, clamp the right main bronchus and cut it off, and then the right lung can be removed. Expose the trachea from the right side of the aorta, free the trachea, pay attention to the tissues around the trachea, ensure the blood supply of the trachea, cut off the recipient's trachea just above the carina, and take out all the heart and lungs of the recipient (Figure 6.586).
9.3 3. Donor cardiopulmonary resection combined transplantation: After the donor trachea carina is removed and trimmed neatly, part of the trachea secretion is taken for bacterial culture, and then the trachea secretion is sucked clean. The donor's right lung passes through the recipient's right atrium and phrenic nerve and is placed in the right chest cavity, while the left lung passes through the left phrenic nerve and is placed in the left chest cavity. The recipient trachea was further trimmed, and the tracheal membrane was continuously sutured with 40 polypropylene thread. If the sizes of the trachea ports at both ends are different, adjust the membrane suture, and the cartilage can be sutured as shown in Figure 8 or continuously (Figure 6.587). After the anastomosis, lung ventilation was started, and the donor's right atrium was arcuately cut upward from the inferior vena cava according to the standard heart transplantation method, and the donor's and recipient's right atrial openings were continuously sutured with 40 polypropylene thread (Figure 6.588), and finally the aorta was continuously anastomosed with 40 polypropylene thread (Figure 6.589). Open the superior vena cava and inferior vena cava, exhaust the gas in the heart, open the ascending aorta, suture the pacing lead or use isoproterenol to maintain the heart rate of about 1 10 beats/min, and stop cardiopulmonary bypass after complete hemostasis.
The early postoperative management of 10 heart-lung transplantation patients is basically the same as that of orthotopic heart transplantation.
The particularity is that patients have immune rejection and infection after cardiopulmonary transplantation, especially the lung infection rate is higher. Transient interstitial pulmonary edema can occur in the lungs, which is related to lymphatic rupture, ischemia, denervation and surgical trauma. The main treatment in the reaction period is active diuresis to maintain low circulating blood volume; Give proper nutrition to maintain the normal level of serum protein. Chest physical therapy is helpful to alleviate pulmonary interstitial edema. For individual patients, it may be necessary to consider the application of hemodialysis to remove excessive body fluids or positive pressure ventilation to support respiratory function.
1 1 Complications 1 1. 1. Rejection After combined heart-lung transplantation, heart-lung rejection can occur simultaneously or separately. Lung rejection is common, earlier than heart rejection, and may not be related to heart rejection. The pulmonary function of patients after heart-lung transplantation was slightly lower due to early postoperative pulmonary edema, and gradually recovered after appropriate treatment 1 ~ 3 weeks. Most rejection reactions are characterized by cough, fever, dyspnea and hypoxemia. If the forced respiratory volume (FEV 1) decreases within1s, or the tidal volume (VC) decreases by 50%, the possibility of lung rejection is high, which cannot be distinguished from lung infection. X-ray showed unclear boundary around hilum, diffuse focal lung infiltration and pleural effusion. Bronchoscope was used for alveolar lavage, and the histological examination of alveolar lavage fluid showed that the number of alveolar cells and toxic lymphocytes increased, which was meaningful for the diagnosis of rejection. Pathogen culture of alveolar lavage fluid can distinguish lung infection, cytomegalovirus and pneumocystis carinii pneumonia. Histopathological examination of fiberoptic bronchoscopy biopsy is the most important method to diagnose lung rejection. Histological changes are mainly infiltration of lymphocytes around pulmonary blood vessels, later diffusion and invasion into alveolar septum and bronchial mucosa, alveolar and bronchial fibrosis.
Anti-immune rejection treatment: cyclosporine A 4 ~ 6 mg/kg and azathioprine 2 ~ 3 mg/kg were given orally before operation. Methylprednisolone 1.0g was given before aortic opening during operation. After operation, cyclosporine A 5 ~ 6 mg/(kg d) and azathioprine 2 ~ 3 mg/(kg d) were given orally, and methylprednisolone 175mg was given daily for * * 3 days, then hormone was stopped to avoid affecting the healing of tracheal anastomosis, and 0.2 mg/(kg d) was given orally 2 ~ 3 weeks after operation. The anti-immune rejection treatment of combined heart-lung transplantation can refer to the scheme of orthotopic heart transplantation.
1 1.2 2. The infection rate of heart-lung transplant recipients is higher than that of heart transplant recipients, and almost all infections are fatal. There are many pathogens, mainly bacterial pneumonia in the early postoperative period; Cytomegalovirus infection mainly occurred in the first 2 months after operation; Pneumocystis carinii pneumonia usually occurs 4 ~ 6 months after operation. The clinical manifestations, chest X-ray changes and lung function changes of infection are similar to rejection. The differentiation between them needs to be based on the results of pathogen culture and histological examination of bronchopulmonary biopsy samples. According to bacterial culture and drug sensitivity test, effective antibiotics can be selected to treat pneumonia. The prevention and treatment of cytomegalovirus pneumonia can be given ganciclovir and cytomegalovirus immunoglobulin. Pneumocystis carinii infection can be treated with sulfamethazine and trimethoprim.
1 1.3 3. bronchiolitis obliterans