Patent ductus arteriosus ligation and simultaneous double-lung transplantation in the treatment of patent ductus arteriosus and Eisenmenger syndrome
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摘要:
目的 探讨动脉导管结扎同期双肺移植治疗动脉导管未闭合并艾森曼格综合征的可行性和围手术期的处理方案。 方法 2014年6月27日无锡市人民医院为1例先天性心脏病动脉导管未闭合并艾森曼格综合征患者在体外膜肺氧合(ECMO)辅助下同期行动脉导管结扎术及序贯式双肺移植。严格按照流程行供肺切取，并采用本院配制的改良的低钾右旋糖酐液(LPD液)灌注保存供肺。手术过程要求操作精细到位。术中左肺冷缺血时间3.3 h，右肺冷缺血时间6.0 h。采用他克莫司(FK506)+吗替麦考酚酯(MMF)+肾上腺皮质激素(激素)三联免疫抑制方案。 结果 患者术后36 h循环稳定、氧合良好后撤除ECMO，术后3 d成功拔除气管插管。术后7 d发生1次急性排斥反应，经治疗后缓解。术后14～22 d痰细菌培养阳性，予敏感抗生素后治愈。术后1年患者存活，血气分析指标和肺功能均明显改善，胸部CT显示双侧移植肺清晰、肺动脉总干直径缩小明显，心脏超声检查显示动脉导管闭合良好，无残余分流。 结论 对终末期右向左分流的艾森曼格综合征实施心脏畸形修补同期行同种异体双肺移植是可行的。良好的供肺切取和保护、精细的手术操作和正确的术后处理是成功的关键。 Abstract:Objective To investigate the feasibility of patent ductus arteriosus(PDA) ligation and simultaneous double-lung transplantation in the treatment of PDA and Eisenmenger syndrome and its perioperative treatment scheme. Methods On June 27, 2014, one patient with PDA complicated with Eisenmenger syndrome underwent ligation of PDA and simultaneous bilateral sequential lung transplantation assisted under extracorporeal membrane oxygenation (ECMO) in Wuxi People's Hospital. The lung sample was excised strictly according to the standard procedures and perfused in modified low potassium dextran (LPD) solution, which was prepared by our hospital. Surgical procedures were performed precisely and properly. Intraoperative cold ischemia time of the left lung was 3.3 h and 6.0 h for the right lung. Immunosuppressive regimen of tacrolimus (FK506), mycophenolate mofetil (MMF) and adrenal cortical hormone was adopted. Results ECMO support was discontinued when the patient had stable circulation and favorable oxygenation at postoperative 36 h. The tracheal intubation was successfully removed at 3 d after surgery. The patient suffered from acute rejection at postoperative 7 d and relieved after treatment. At postoperative 14-22 d, sputum bacterial culture yielded positive outcomes and recovered after sensitive antibiotics therapy. The patient survived at 1 year after surgery. The parameters of blood gas analysis and lung function were significantly improved. Chest CT scan displayed bilateral transplant lung explicitly and the diameter of pulmonary arterial trunk was dramatically shortened. Cardiac ultrasound examination revealed complete closure of ductus arteriosus with no residual shunt. Conclusions PDA ligation combined with simultaneous allogeneic double-lung transplantation is a feasible approach in the treatment of Eisenmenger syndrome with right-to-left shunt. Favorable lung excision and protection, precise surgical operation and appropriate postoperative management determine the surgical success. -
图 1 本例患者先天性心脏病动脉导管结扎同期双肺移植术前和术后1年的胸部CT比较
注： A图和C图为术前胸部CT；B图和D图为术后1年胸部CT。移植后1年双肺清晰，肺动脉主干直径较移植前明显缩小(通过胸部CT纵隔窗肺动脉主干的直径宽度直观比较，临床体现为移植术后肺动脉压下降)
Figure 1. CT images of the patient with ductus ligation and simultaneous double lung transplantation for congenital heart disease before and 1 year after operation
表 1 本例先天性心脏病动脉导管结扎同期双肺移植患者术前和术后1年的血气分析及肺功能变化
Table 1. Blood gas analysis and lung function of the patient with ductus ligation and double lung transplantation for congenital heart disease before and 1 year after operation
时间 血气分析 肺功能 PaO2(mmHg) PaCO2(mmHg) VC(L) FVC(L) FEV1(L) MVV(L) 术前 50.0 35.5 3.52 3.95(94.63%) 1.04(30.50%) 66.5(58.44%) 术后1年 91.0 38.3 3.00 2.87(73.60%) 1.93(56.52%) 81.9(69.52%) 注：表中数值后面百分比为实测值占预计值的比值；PaO2为动脉血氧分压；PaCO2为动脉血二氧化碳分压；VC为肺活量；FVC为用力呼吸肺活量；FEV1为第1秒用力呼出量；MVV为最大通气量 
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