肺移植國內(nèi)外進展課件

1、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 y

2、r old 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 pr

3、oblemBackground ：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 introdu

4、ced by Starnes and colleagues in 1991Recipient (son) PPH Donor (mother) right lower lobe Background ：Lung TransplantationThe Registry of the International Society for Heart andLung Transplantation: Twenty-seventh ofcial adult lungand heart-lung transplant reportISHLT2010Background ：Lung Transplantat

5、ionNUMBER OF LUNG TRANSPLANTS 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. 2010ADUL

6、T LUNG TRANSPLANTATIONKaplan-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 (Tra

7、nsplants: January 1988 June 2008)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, pressu

8、re,ventilation, etcTransport from A to BBarriers 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 dono

9、rs betterDevelop better strategies to predict post transplant lung functionStrategies to assess lungs (ex-vivo)Strategies to “repair” donor lungsDonor LungPhysiologic AssessmentExcellentBiologic AssessmentExcellentTRANSPLANTFailsEx-vivo Assessment and TreatmentDONOR LUNGPhysiologic AssessmentExcelle

10、ntBiologic AssessmentExcellentTRANSPLANTFailsEx-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

11、 Yu-ping BLTx for PPH with CPB urvived 1978 Dr.Xing Yu-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.T

12、he LTx stoped in China from 1998-Sep.2002 because of low survival rate.Second stage Since the SLTx for COPD was performed by Wuxi Group on Sep. 2002, remarkable progress have be achieved in China. 移植器官種類首例（年）至07年累計例數(shù)至今累計例數(shù)尸體腎移植196980488105000（預計）活體腎移植197314952500（預計）尸體肝移植19771273020251活體肝移植199513915

13、69心臟移植19785341100（預計）肺移植1979128260（預計）小腸移植19941540（預計）器官移植學會登記處各種器官移植統(tǒng)計*數(shù)據(jù)主要來源于各移植數(shù)據(jù)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

14、thoracotomy incision)Antero muscle sparing thoractomyMinimally invasive technique with VATSInsision considerationInsision considerationInsision considerationOperative technique Bronchial anastomosisArterial anastomosisLeft atrium anastomosis Size discrepancies Unusual circumstance Operative techniqu

15、eOperative techniquePulmonary Artery AnastomosisOperative techniqueLeft Atrial Anastomosis術(shù)后病理 術(shù)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

16、sternal division12. Male,46y,BAC BLTx單肺移植同期心內(nèi)缺損修補治療艾森曼格綜合征男性，16歲，先天性心臟病室間隔缺損心內(nèi)直視探查術(shù)后，術(shù)前肺動脈壓力110/60mmHg（Pp/Ps 1.0），靜息紫紺4年，活動耐力明顯減低，于2004年10月22日在全麻低溫體外循環(huán)下行室缺修補、同期右側(cè)單肺移植術(shù)。術(shù)中體外循環(huán)時間244分鐘，供肺冷缺血時間6小時，術(shù)后FK506、MMF、激素三聯(lián)免疫抑制治療。術(shù)后三天內(nèi)移植肺出現(xiàn)中等度再植反應(yīng)性肺水腫，術(shù)后7天氣管切開，12天撤離呼吸機；術(shù)后14天出現(xiàn)急性排斥1次，治療后緩解。術(shù)后肺動脈壓力53/39mmHg（Pp/Ps 0

17、.57）。術(shù)后30天胸片及胸部CT顯示右移植肺清晰，肺通氣血流灌注掃描示右側(cè)移植肺血流占90%， UCG示左室內(nèi)徑較術(shù)前縮小17%，室缺修補完整無殘余分流，術(shù)后活動耐力明顯改善，62天出院。術(shù)后隨訪已有5近年，生活質(zhì)量良好。16 F，PPH, BLT with ECMO術(shù)前術(shù)后左室舒張末內(nèi)徑*23 mm47 mm右室舒張末內(nèi)徑*54.7 mm28 mm左房內(nèi)徑*21 mm34 mm主動脈根部內(nèi)徑*24 mm25 mm主肺動脈內(nèi)徑44.5 mm22 mm左肺動脈內(nèi)徑30.9 mm14 mm右肺動脈內(nèi)徑26.2 mm14 mm肺動脈收縮壓159.4 mmHg三尖瓣和肺動脈瓣無返流平均肺動脈壓92.

18、4 mmHg三尖瓣和肺動脈瓣無返流左室射血分數(shù)82%69%右室射血分數(shù)19%62%每搏輸出量19.7 ml63 ml移植前后心超結(jié)果比較（術(shù)前及術(shù)后2.5月） /versace_baby國際標準化腦死亡供肺的獲取及應(yīng)用(附3例報告)南京醫(yī)科大學附屬無錫市人民醫(yī)院肺移植中心陳靜瑜資料與方法性別年齡診斷機械通氣氧合指數(shù)其他供體一女性39歲腦腫瘤術(shù)后復發(fā)3天461纖支鏡檢查氣管、支氣管內(nèi)無明顯感染，聽診兩肺均呼吸音清，無羅音。術(shù)前胸片均未見明顯肺部浸潤和異常。術(shù)前EB、HIV、CMV、HSV 病毒及乙肝均為陰性。三位供體均同時捐獻心、肺、肝、腎和角膜等多個器官。供體二男性27歲腦外傷12天310供體三男性31歲腦外傷6天420供 體 資 料資料與方法供 體 資 料家屬與腦死亡供體告別供體肺手術(shù)方法資料與方法供體獲取團隊在術(shù)前禱告供體肺手術(shù)方法資料與方法國際標準化腦死亡供肺的獲取及應(yīng)用性別年齡診斷其他受體一男性32歲支擴伴感染、肺心病、呼衰感染已控制，無發(fā)熱、咯血，需