Anaesthetic Management of 41 Patients with Orthotopic Cardiac Transplantation<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

姜 桢 金翔华 柳 冰* 李颖川
复旦大学附属中山医院麻醉科 200032
Jiang Zhen, Jin Xianghua, Li Yingchuan.
Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
*中国人民解放军455医院麻醉科

Objectives: To review the experience of the anaesthetic management of cardiac transplant patients.
Background: Appropriate perioperative management will reduce the mortality of cardiac allograft recipients. However, there is no consensus on the anesthetic management regimen of these high-risk patients. This article describes our experiences.
Methods: 41 patients with end-stage myocardial failure underwent heart transplantation. Induction of anesthesia was carried on after the injection of ketamine, fentanyl, midazolam and succinylcholine or Esmeron. Besides the routine monitoring of EKG, SpO₂, invasive BP, etc., Swan-Ganz CCO catheter was inserted from internal jugular vein to measure CVP, CO, PCWP and SvO₂. Pacing wires were attached to the epicardium in all patients for possible future use. Continuous infusion of PGE1(10-30ng/kg/min) was administered during perioperative period if the patients suffering from pulmonary hypertension.
Results: Dopamine and/or doputamine (60% patients), Milrinone(50% patients)even epinephrine(10% patients)were given after weaning from CPB. After CPB, 16 patients who developed acute pulmonary hypertension were treated with central venous L-arginine, milrinone and theophylline and pulmonary arterial phenolamine infusion, and it was necessary to inhale NO in 14 patients. All patients succeeded in weaning from cardiopulmonary bypass and shifting to ICU safely. All patients recovered consciousness after 2～4 hours and mechanical ventilation was stopped after 5～37 hours (averaging 15±9 hours). On the average they were hospitalized for 4±14 (27～66)days.
Conclusions: Heart transplantation is a challenge to anesthesiologists during the period of anesthetic induction as well as during the weaning from CPB and early postoperative periods. More attention should be paid to monitoring the circulation and respiratory system, performing active inotropic support and taking precautions against the crisis of serious pulmonary hypertension.
Key words: Heart Transplantation; Anesthesia; Hypertension Pulmonary

　　心脏移植是目前治疗多种原因所致终末期心脏病的最有效方法^[1]。我院自2000年5月到2003年7月连续进行了41例原位心脏移植全部获得成功。移植手术的成功与否不仅赖于供心的获取、手术技巧、受体围麻醉期的处理至关重要。本文从麻醉角度对41例病员的围麻醉期处理进行总结。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

临床资料

　　41例心脏移植病员，包括：男性30例，女性11例。年龄12-20岁6例，21-49岁33例，51-60岁6例，61岁以上2例。术前诊断除16例为扩张性心肌病外，1例为先天性二尖瓣闭锁行姑息术后，1例是主动脉瓣替换术后重度心衰、左心持续扩张、2例缺血性心肌病病员和2例心脏肿瘤。41例病员术前心功能Ⅲ级5例，其余均Ⅳ级，经内科保守治疗效果差，需口服地高辛、速尿、消心痛、β-洛克，静滴硝酸甘油、多巴胺、多巴酚丁胺、米力农甚至肾上腺素维持生命。术前超声心动图：左室舒张末期内径(LVEDD)75.19±9.00，左室末收缩末期内径(LVESD)64.42±9.81，缩短分数(TS)14.76±6.63(2.63-28.21)，左房面积48.89±11.51，EF24.89±7.43(11～45)%。肺动脉收缩压56.43±13.11(30～88)mmHg。
　　全部移植手术在全身麻醉、体外循环下进行。本组病员术前持续应用血管活性药到手术室。麻醉前晚和术前2小时口服安定5mg，雷尼替定150mg。2例心脏肿瘤病人，进手术室前半小时再肌注吗啡5mg和东莨菪硷0.3mg。入室后先面罩吸氧，监测心电图、无创血压、SpO₂，再行左桡动脉穿刺、置管；左颈外静脉穿刺，置入Allow 14号导管；经右颈内静脉穿刺，置入Baxter Swan-Gans(CCOmbo CCO-SVO₂ 744HF75)导管。术中持续监测：CM5心电图、有创动脉压，CVP、PWCP、鼻咽温度、SpO₂、血气、电解质、尿量。
　　凡SPAP达50mmHg以上的病人，围术期全程用前列腺素E110-30ng/kg／min。除两例心脏肿瘤病人，与常规心内手术一样用芬太尼、咪唑安定、罗库溴铵诱导外，其余39例病人均用氯胺酮0.2～0.3mg/kg，咪唑安定30～40μg/kg，芬太尼0.05mg，琥珀酰胆硷2mg/kg或罗库溴铵0.9mg/kg诱导，经口明视插管，维持机械通气。FiO₂ 1.0，潮气量6～7ml/kg，呼吸频率16～18/min，PEEP 4cm H₂O。麻醉维持用芬太尼、异丙酚、咪唑安定、哌库溴铵。开始体外循环后停止机械通气，用MallinckRODT的CPAP Valve在5L/min的氧供下，保持气道压力在5cm H₂O。

　　中度低温(28℃)体外循环采用Sarns离心泵、Dideco膜式氧合器、30ml/kg晶胶体（乳酸林格及血浆）预充液，维持Het在25%。灌注流量为50-100ml/kg/min，维持均压在50-80mmHg、静脉氧饱和度70%以上。在进入体外循环前和主动脉开放前的即刻给予乌司它丁各1万单位/kg、左旋精氨酸5mg。体外循环时间11.97±29.2(69-269)分，移植手术完成，开放主动脉前即刻注入甲基强的松龙500mg。除16例病员需电击1次外，其余病员心脏自动复跳。全部病例均安置心室起搏器备用，35%病例需给予0.03～0.2μg/kg／min异丙肾上腺素提高心率和增强心肌收缩力，使心率维持在90-110次/分。其中有16例病例在主动脉开放后，肺动脉压较高，并伴气道内压力急剧上升，立即给予氨茶硷0.25～0.5mg，米力农：负荷量50～60μg/kg，维持量0.375μg/kg/min改善心肌张力、顺应性和控制肺动脉压。并经肺动脉导管（退到肺动脉根部）泵入酚妥拉明、增加PEEP的呼出末压到7cm H₂O，甚至利用体外循环超滤，使气道内压力恢复。60%病例曾用多巴胺、多巴酚丁胺、50%病例需用米力农、甚至10%病例需用肾上腺素增加心肌收缩力后，才能脱离体外循环。其中有14例需经气管导管吸入NO 14～20 ppm，才能脱离体外循环。
　　全部病例经中心静脉或主动脉根部推注鱼精蛋白对抗肝素(1.5:1)，逐层闭合手术切口，手术结束。在3M Hp监测仪监测有创血压、心电图、SpO₂；Teama呼吸机维持机械通气；静脉泵维持中心静脉和肺动脉用药下，安全转运到ICU。病员于术后2～4小时清醒，15±9(5～37)小时拔除气管导管。住院41±14(27～66)天后返家。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

讨　论

　　尽管移植手术存在伦理问题^[2]，器官供体十分短缺，由于手术的高成功率和受体长期存活率，近几年心脏移植的数量在我国也见增长，已成为扩张性心肌病和某些终末期心衰治疗的常规手术^[1]。鉴于受体反复发作的循环危象和伴复杂的并发症，在围术期，麻醉师将面临严峻挑战，麻醉的风险除了终末期心脏本身因素以外，还得面对难逆的肺、肝、肾等脏器的继发性损害，要求麻醉师具备对晚期心衰病理生理、终末期心脏对各种药物的异常反应及去神经心脏病理生理的知识。围麻醉期的处理归纳为以下几个阶段：

　　综上所述，心脏移植的成败，从麻醉的角度，最具挑战性的在“麻醉诱导”“体外脱机”“术后早期”三个时期，因此我们需把工作的重点放在加强对循环和呼吸内环境的监测；移植前后心脏活性药物的支持和伴肺高压危象右心低心排的防治上。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

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