肺移植国内外进展课件.ppt

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1、肺移植国内外进展Lung Transplant HistoryFirst experimental operation:1950-54 Metras,HardinFirst human operation:1963 Hardy Recipient:58-yr-old man,emphysema Donor:MI,shock-ER left single lung TxBackground：Lung TransplantationBackground：Lung Transplantation1st Success1983-Toronto Lung Transplant Group58 yr ol

2、d male,IPFSurvived 7 yearsDied of kidney failure caused by anti-rejection medicationBackground：Lung TransplantationEn Bloc Double LungDark(1986)experimental technique(canine)1986 Patterson et al.-first successful en bloc double lung transplant(Alive today)Donor airway ischemia still a problemBackgro

3、und：Lung TransplantationSequential Double Lung Pasque et al.Wash U.Bilateral sequential lung transplantation emerged in 1989 May avoid CPB.No need for cardioplegiaReduced bronchial anastomotic problemsBackground：Lung TransplantationLiving-donor lobar lung transplantation was introduced by Starnes an

4、d colleagues in 1991Recipient(son)PPH Donor (mother)right lower lobe Background：Lung TransplantationThe Registry of the International Society for Heart andLung Transplantation:Twenty-seventh official adult lungand heart-lung transplant reportISHLT2010Background：Lung TransplantationNUMBER OF LUNG TRA

5、NSPLANTS REPORTED BY YEAR AND PROCEDURE TYPEISHLTNOTE:This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry.As such,this should not be construed as representing changes in the number of lung transplants performed worldwide.2010ADULT LUNG TRANSPLANTATIONKap

6、lan-Meier Survival (Transplants:January 1994-June 2008)ISHLT 2010ADULT LUNG TRANSPLANTATION:Indications(1/1995-6/2009)ISHLT 2010ADULT LUNG TRANSPLANTATIONProcedure Type within Indication,by Year ISHLT2010ADULT LUNG TRANSPLANTATIONKaplan-Meier survival by diagnosis(Transplants:January 1988 June 2008)

7、ISHLT 2010ADULT LUNG TRANSPLANT RECIPIENTS:Cause Of Death(Deaths:January 1992-June 2009)ISHLT 2010Donor LungFlushing to removeblood,preservationQuestions:Tm,Time,solutioninflation?TransplantationQuestion:How to do the operationReperfusionQuestions:Rate,pressure,ventilation,etcTransport from A to BBa

8、rriers to Successshortage of donors waiting list mortalityPGDacute rejection BOS.NovaLungBridge to Lung TransplantationNovaLungDeceased DonorsCurrent largest,best source of donor lungsWe have NOT maximized utilizationNeed to improve utilization:Manage donors betterDevelop better strategies to predic

9、t post transplant lung functionStrategies to assess lungs(ex-vivo)Strategies to“repair”donor lungsDonor LungPhysiologic AssessmentExcellentBiologic AssessmentExcellentTRANSPLANTFailsEx-vivo Assessment and TreatmentDONOR LUNGPhysiologic AssessmentExcellentBiologic AssessmentExcellentTRANSPLANTFailsEx

10、-vivo Assessment and TreatmentFailsGene Therapy,Other Repair StrategiesReassessFailsNo TransplantLung Transplantation in China First stage 1978 Dr.Xing Yu-ling,first SLTx for TB in China,died 1995 Dr.Chen Yu-ping SLTx for IPF survived 1998 Dr.Chen Yu-ping BLTx for PPH with CPB urvived 1978 Dr.Xing Y

11、u-ling first SLTx for TB in China,Dr.Chen Yu-ping 1995-2-23,SLTx for IPF survived 5y10m 1998-1-20,BLTx for PPH with CPB,survived 4y3mBackground：Lung TransplantationFrom 1994 to 1998,about 20 cases were performed,only 2 patients survived.The LTx stoped in China from 1998-Sep.2002 because of low survi

12、val rate.Second stage Since the SLTx for COPD was performed by Wuxi Group on Sep.2002,remarkable progress have be achieved in China.移植器官种类首例（年）至07年累计例数至今累计例数尸体肾移植196980488105000（预计）活体肾移植197314952500（预计）尸体肝移植19771273020251活体肝移植19951391569心脏移植19785341100（预计）肺移植1979128260（预计）小肠移植19941540（预计）器官移植学会登记处各种

13、器官移植统计*数据主要来源于各移植数据中心Number of lung transplants in China(1978-2010)本中心Result1，2，3,5 year survive rate is 73.3%,61.6%,53.5%,40.7%.Insision considerationBilateral anterolateral thoracotomiesClamshell incision(trans-sternal Bilateral thoracotomy incision)Antero muscle sparing thoractomyMinimally invasi

14、ve technique with VATSInsision considerationInsision considerationInsision considerationOperative technique Bronchial anastomosisArterial anastomosisLeft atrium anastomosis Size discrepancies Unusual circumstance Operative techniqueOperative techniquePulmonary Artery AnastomosisOperative techniqueLe

15、ft Atrial Anastomosis术后病理 术后病理 BSLTx 1st,March 20055.Ventilator dependent recipientPreoperative chest roentgenogram of a 49-year man with COPD.1.68cm,46kg,BMI 73%Preoperation depended on ventilator for 107 days.BLT without sternal division12.Male,46y,BAC BLTx单肺移植同期心内缺损修补治疗艾森曼格综合征男性，16岁，先天性心脏病室间隔缺损心内

16、直视探查术后，术前肺动脉压力110/60mmHg（Pp/Ps 1.0），静息紫绀4年，活动耐力明显减低，于2004年10月22日在全麻低温体外循环下行室缺修补、同期右侧单肺移植术。术中体外循环时间244分钟，供肺冷缺血时间6小时，术后FK506、MMF、激素三联免疫抑制治疗。n术后三天内移植肺出现中等度再植反应性肺水肿，术后7天气管切开，12天撤离呼吸机；术后14天出现急性排斥1次，治疗后缓解。术后肺动脉压力53/39mmHg（Pp/Ps 0.57）。术后30天胸片及胸部CT显示右移植肺清晰，肺通气血流灌注扫描示右侧移植肺血流占90%，UCG示左室内径较术前缩小17%，室缺修补完整无残余分流，

17、术后活动耐力明显改善，62天出院。术后随访已有5近年，生活质量良好。16 F，PPH,BLT with ECMO术术前前术术后后左室舒左室舒张张末内径末内径*23 mm47 mm右室舒右室舒张张末内径末内径*54.7 mm28 mm左房内径左房内径*21 mm34 mm主主动动脉根部内径脉根部内径*24 mm25 mm主肺主肺动动脉内径脉内径44.5 mm22 mm左肺左肺动动脉内径脉内径30.9 mm14 mm右肺右肺动动脉内径脉内径26.2 mm14 mm肺肺动动脉收脉收缩压缩压159.4 mmHg三尖瓣和肺三尖瓣和肺动动脉瓣无返流脉瓣无返流平均肺平均肺动动脉脉压压92.4 mmHg三尖瓣

18、和肺三尖瓣和肺动动脉瓣无返流脉瓣无返流左室射血分数左室射血分数82%69%右室射血分数右室射血分数19%62%每搏每搏输输出量出量19.7 ml63 ml移植前后心超结果比较（术前及术后2.5月）http:/ 病毒及乙肝均为阴性。三位供体均同时捐献心、肺、肝、肾和角膜等多个器官。供体二男性27岁脑外伤12天310供体三男性31岁脑外伤6天420供 体 资 料资料与方法供 体 资 料家属与脑死亡供家属与脑死亡供体告别体告别供体肺手术方法资料与方法供体获取团队在术供体获取团队在术前祷告前祷告供体肺手术方法资料与方法国际标准化脑死亡供肺的获取及应用国际标准化脑死亡供肺的获取及应用性别年龄性别年龄诊断诊断其他其他受体一男性32岁支扩伴感染、肺心病、呼衰感染已控制，无发热、咯血，需间断吸氧受体二男性34岁矽肺终末期、肺动脉高压右心功能不全、呼衰长期咳嗽、气喘，术前已卧床吸氧治疗受体三男性61岁IPF、肺动脉高压右心功能不全、呼衰活动后气喘明显，需卧床吸氧受 体 资 料Transplant for late stage of Pneumosilicosis主办国家级继续教育项目5项(2004-2010年)全国第一至第五届心肺移植会议