心脏移植.ppt

Heart Transplant （HT）,Definition It is the act or process of moving a whole or partial organ from one body to another by surgery for the purpose of replacing the recipients damaged or failing organ.,Organ transplant,Organ transplant,History Indication of heart transplant Selection of donors and recipients Patient management Outcome,Content,Story from ancient China In the 5th century BC, Bian Que switched two adult mens hearts, their mind were swapped after the surgery.,History,Bian Que,1964, Hardy performed the first heterogeneity HT (chimpanzee human),History,Norman E. Shumway and Richard R. Lower did revolutionary experimental work on developing and establishing the technique of orthotopic cardiac transplantation in dogs.,1905, Alexis Carrel performed the first heterotopic HT in dogs,Organ transplantation developed from experimental stage to clinical stage followed with the development of immunity, pathology and medicine.,History,The immunity theory was built up and developed from 1908 to 1961.,The worlds rst successful human-to-human heart transplant was performed on 3 December 1967 in South Africa by Christian Barnard.,The patient dead for lung infection after 18 days. Over the next several years, poor early clinical results led to few heart transplantation attempts.,History,A new beginning After the application of cyclosporine A in the 1980s, the number of transplants dramatically increased from only 106 in 1980 to over 4000 cases in 2002 worldwide.,History,The first baby heart transplant in 1984.,History,The first baby heart transplant in 1984.,Indication of HT,The end-stage heart failure with or without ventricular arrhythmia can not be cured by systematic and complete internal medical treatment or conventional surgery: Advanced primary cardiomyopathy: Dilated, hypertrophic and limited cardiomyopathy The severe coronary heart disease which can not be treated with bypass surgery or laser myocardial perforation.,The complex congenital heart disease which cant be treated End-stage multi-valvular disease who cannot be treated with a replacement valve Difficult surgical treatment of heart trauma, cardiac tumors Graft failure after heart transplantation,Indication of HT,The life expectancy is 1 year. Other organs (liver, kidney, lung, etc.) are all reversible.,Indication of HT,Contraindications,The ABO blood group of the recipient is not consistent. Active infection Recent cardiac malignant tumors Lung, liver and kidney have irreversible function failure Severe systemic disease limited survival time,Contraindications,The average pressure of the pulmonary artery was 8.0Kpa (60mmHg), and pulmonary vascular resistance (PVR)8Wood unit, after complete internal medicine treatment Serum HIV positive Not subject to treatment Mentally ill or abuse of drugs or alcohol Recent history of severe pulmonary infarction,Patients and their families can understand and actively cooperate with the transplant operation. Patients is able to resume a relatively normal active life after HT Patients is able to be compliant with the rigorous medical regimen postoperatively,Selection of recipients,Selection of donors,Sibling or parent - survival rate of kidney is greater; preferred for transplantation. Cadaver - greater rate of rejection following transplantation, although majority of transplantations are with cadaver organs.,Brain dead Age, gender, ABO blood type, weight Infectious disease (Hepatitis B and C viruses, HIV, etc) Heart disease Ischemic time,Selection of heart donors,Although heart transplantation is difficult and dangerous, most people are waiting for heart, and fewer than half can be expected to proceed to heart transplantation.,medical urgency proximity of the potential donor to the patient (age, size, ABO, HLA*) duration on the transplant list,Who has priority of HT,You are members of the heart transplant surgery team at a hospital. You have seven patients who desperately need a transplantation. All patients are classified as “critically ill,” and could die at any time.,Discussion,You have just received news that the heart of a 16-year-old boy who was killed in an auto accident has become available for transplantation.,Discussion,Speed is extremely important as you decide which of the following patients is to receive the heart: not only might one of the patients die, but the donors heart will soon begin to deteriorate.,Discussion,Patient 1,Amegneza Edorh, female, age 58. a renowned poet and novelist from Nigeria, received the 1987 Nobel Prize for literature Mrs. Edorh has been confide to bed for the past five months with steadily deteriorating health.,Patient 2,Soohan Kim, male, age 12. Soohan, a junior high school student from South Korea, was born with a congenital heart defect. Doctors wanted to wait until he was a teenager to replace his heart, but his condition has worsened dramatically. He is being kept alive on a heart-lung machine*.,Patient 3,Peter Sun, male, age 43. Mr. Suns family has a history of heart. Mr. Sun has already had one heart transplant operation. Since his body rejected that heart (three weeks ago), Mr. Sun has been kept alive by an artificial heart*.,Patient 4,Ma Li, female, age 25. Unemployed and on welfare, Mrs. Ma raised money for operation through the contributions of those in her neighborhood. Divorced, she has one son (age 4).,Patient 5,Liu Dazhi, male, age 34. Mr. Liu works for Shanghai Municipal government. Mr. Liu is being kept alive on a heart-lung machine. Unmarried (his wife died in an automobile accident), he has twin daughters.,Get into groups of four Compare your decisions Explain and defend your opinions,Discussion,1. Do you think that only doctors should decide who receives transplant? Are there any other people who should help make such decisions?,Discussion,2. How do you think you would feel if you received the heart of another person? How would it feel to have another persons heart in your chest?,Discussion,3. When you die would you be willing to donate your organs to a person who needs them?,Discussion,Patient 1: A famous world-wide famous poet and novelist, 58 years old Patient 2: 12 years old boy, who is keeping alive by heart-lung machine. Patient 3: A man aged 43, who was got graft heart failure and was kept alive by artificial heart Patient 4: 25 years old woman, unemployed, and has one son aged 4. Patient 5: Male, age 34, he is being kept alive on a heart-lung machine. he has twin daughters.,Patient list,Surgeons Heart failure cardiologists Nurses Social workers,Who could decide the recipients?,Discussion,Preoperative treatment Surgery Procedure Perioperative care,Patient management,Preoperative treatment,Reverse heart failure Improve living quality Prolong living time Sustain the recipients life until the transplantation,Preoperative,Medicine treatment Diuresis （Furosemide） Reduction of myocardial oxygen consumption (-blocker) Reconstructing cardiac muscular structure （ACEI or ARB）,Preoperative,Life assistant,Artificial heart Ventricular assistant device, VAD ECMO,Surgery procedure,Donor heart harvest,Surgery procedure,Donor heart preservation,Cardioplegia: HTK solution, UW solution, Hypothermic preservation Continuous perfusion,limit of cold ischemia Pancreas 20h Kidney 25h Liver 12h Heart 6h,Surgery procedure,Surgery procedure,Recipient cardiectomy,Biatrial procedure,Bicaval procedure,Surgery procedure,Cardiac implantation (Bi-atrial),Surgery procedure,Cardiac implantation (Bi-caval),Surgery procedure,Cardiac implantation (Bi-caval),Postoperative care,Inotropic support inotropic support and pacing, if needed, is weaned over 23 days to allow the RV to slowly adapt to high afterload Echocardiography is used extensively to guide the therapy. Isoproterenol is weaned off over the course of 2448 hours, starting on postoperative day 2, while maintaining a heart rate of greater than 100 beats/minute.,Postoperative care,Special consideration is given to facilitate early extubation and removal of intravenous lines, tubes, and catheters. Further management continues in a telemetry ward, where aggressive physical therapy and ambulation is instituted. If the patient has an uncomplicated postoperative course, he or she is routinely discharged home within 14 days.,Surgery procedure,Complications Low cardiac output (R-HF, L-HF) Bleeding Infection Arrythmia (tachycardia) Graft rejection,Graft rejection,Definition The recipients body fails to accept a transplanted tissue or organ as the result of immunological incompatability, i.e. immunological resistance to foreign tissue.,Graft rejection,Rejection process Cellular immunity mechanisms (T. B cell lymphocytes) Humoral immunity mechanisms (circulating antibody) Important compatibility system ABO blood group HLA class & systems,Graft rejection,Categories Hyperacute rejection Accelerated rejection Acute rejection Chronic rejection,Graft rejection,Hyperacute rejection CAUSE: Which is due to preformed cytotoxic antibodies against donor lymphocytes or cardiac cells. This reaction begins soon after completion of the anastomosis, and complete graft destruction occurs in 2448hours. THERAPY: There is no effective method of treating this reaction, and patients who have preformed antibodies against donor cells should not be from that donor. Pretransplant crossmatch testing can eliminate this type of rejection.,Graft rejection,Accelerated rejection It usually appears within 5 days after a period of good function. It is believed to be related to subliminal preformed cytotoxic antibodies against donor cells not detected by the usual cytotoxicity techniques. It has also been suggested that sensitized cells could bring about this reaction.,Graft rejection,Acute rejection CAUSE: Which is the most common type of rejection episode during the first 3 months after transplantation. It is primarily an immune cellular reaction against foreign antigens. THERAPY: This type of rejection process may be reversed by increasing the dosage of corticosteroids. If this is unsuccessful, an ALG or ATG preparation or muromonab-CD3 can be used.,Graft rejection,Chronic rejection CAUSE: Which is a late cause of cardiac deterioration mediated by humoral factors. PRESENTATION: Coronary artery stenosis caused by graft vessels disease (GVD) THERAPY: Chronic rejection is resistant to corticosteroid therapy and graft loss will eventually occur, it could last for several years. Re-transplant is necessary.,Graft rejection,Immunosuppressive therapy,Goal: override any response of the immune system to tissue histoincompatibility while at the same time to preserve the remaining functions of the recipients immune system to protect against infection.,Graft rejection,Immunosuppressive therapy 1st stage (1910), radiation or chemical drugs, indiscriminate destruction of all Cells 2nd stage (1960), the inhibition of the lymphocyte 3rd stage (1978), cyclosporine A (CsA) Clinical 4th stage, studies the more ideal immunosuppressive agents and the induction of clinical application.,Azathioprine Mechanism: Inhibit nucleic acid synthesis. Dose: 1mg/kg/d, adjusted by white cell count. Side effect: Depression of the bone marrow elements (leukocytes and platelets); jaundice.,Immunosuppressive therapy,Corticosteroids (Prednisone) Mechanism: believed to affect lymphocyte production : anti-inflammatory action helps prevent tissue damage if rejection occurs. Dose: 0.5mg/kg/d to 10mg/d (Adult). Side effect: (a) Stress ulcer with bleeding (give with food). (b) Decreased glucose tolerance (hyperglycemia). (c) Muscle weakness. (d) Osteoporosis. (e) Moon faces. (f) Acne and striae (g) Depression and hallucinations.,Immunosuppressive therapy,Cyclosporine A, (Neoral, sandimmune) CsA was the first of the new generation of important immunosuppressants Mechanism: It inhibits the production and release of interleukin-2 by T help cells. It also interferes with the release of interleukin-1 by macrophages as well as with proliferation of B lymphocytes. Dose: Adjusted by blood levels.,Immunosuppressive