HEART TRANSPLANTATION

From Big Medical Encyclopedia

HEART TRANSPLANTATION (synonym transplantation of heart) — operation of substitution of heart of the recipient a transplant from the donor.

History

the First attempts of P. of page in an experiment belong to the beginning of 20 century — in 1905 A. Karrel, Guthrie (S. S. of Guthrie) carried out change of the second heart on a neck of a dog recipient. In 1933. Mann (F. Page of Mann) and sotr., using this technique, achieved functioning of a transplant to 4 days. In 1948 N. P. Sinitsyn developed an original method P. of page at frogs, to-rye lived a long time with the functioning transplant. This model was the proof of a basic possibility of life of animals with the replaced heart. The big contribution to a problem P. of page was made by the Soviet scientist V. P. Demikhov. Since 1946 it began wide-ranging pilot studies, and in 1955 the basic possibility of orthotopical P. of page at a hematothermal animal and his functioning in an organism of the recipient within several hours is for the first time shown them. With development of a heart surgery, anesthesiology and artificial circulation methods of pilot studies according to P. were improved by page. Abroad the first attempts of orthotopical allotransplantation of heart in an experiment belong to 1953 — 1958. In 1961 there was Louer's work, Shamueya (R. R. Lower, N. E. Shumway) and soavt, with the description of a new method P. of page. Instead of sewing together of numerous vessels they left on site both auricles of heart of the recipient to which sewed the relevant departments of auricles of a transplant with the subsequent anastamosing of an aorta and pulmonary artery. This method soon entered practice of experimental transplantology. Further in an experiment it was proved that the transplant of heart provides normal blood circulation in an organism of an animal for a long time. Also the reinnervation of an autograft coming in 3 — 5 months is established. In an experiment William (V. L. William, 1964), H. To. Zimin, A. Ya. Kormer (1977) showed a possibility of orthotopical allotransplantation of heart at puppies using a method of a deep hypothermia (see. Hypothermia artificial ).

Also researches on development of methods of preservation of heart were conducted, admissible terms of a fence of a transplant and its storage were defined (see. Conservation of bodies and fabrics ). The results received in pilot studies allowed Shamueyu et al. (1964) approximately to define the list of states at which P. can be shown to page at patients.

The item of page cannot be standard cardiac operation since there is a number of the most serious problems limiting its use: a tissue incompatibility and lack of effective methods of the prevention of reaction of rejection (see. Immunity transplant ); unavailability of receiving in necessary quantity of funktsionalnosokhranny transplants; need to have at least in short term working artificial heart (see), a cut by analogy with artificial kidney (see) would give the chance in emergency situations to support blood circulation in an organism of the patient until identification of an adequate transplant.

Artificial heart could be used also for treatment of heavy crisis of graft rejection.

In all known cases of attempts of P. of page abroad surgeons used the functioning heart taken from donors with the diagnosis of so-called brain death.

The extensive discussion which arose on this matter not only among specialists but also with attraction of various sectors of society, created public opinion about non-compliance with moral and ethical and legal norms at P.'s performance by page in a wedge, practice. Besides, in a number of the countries, including willows of the USSR, the legislation does not recognize the diagnosis «brain death» for criterion biol, death of an organism, granting performing right of a question of a possibility of removal of organs. In these countries at the existing legislation it is really possible to carry out P. of page at patients only after development of methods of recovery of full sokratitelny function of the transplant withdrawn from an organism of the donor at which the termination of cordial reductions is registered.

This question demands further deep studying. Owing to stated in the USSR this operation it is impossible to apply in clinical practice.

At the same time in a number of the countries P. of page practices. The first attempt of clinical P. of page was made on January 23, 1964 an amer. the cardiosurgeon J. D. Hardy who replaced heart of a chimpanzee sick with heart. The transplant functioned one hour. In December 1967 Mr. Barnard (Page N. Barnard) made the first operation of orthobog-chesky transplantation of heart from the person to the person. The patient lived 18 days.

In 1974 — 1975 it executed two operations P. of page on new option — transplantation of the second additional heart working parallel to own heart of the recipient and unloading his left ventricle (fig. 1).

According to Barnard and soavt. (1979). advantage of this technique consists that right after transplantation when donor heart still is insufficiently actively reduced, the left ventricle of heart of the recipient provides an optimum blood stream. At hypertensia of a small circle of blood circulation at the recipient when ortotopiches-ky P. is contraindicated to page, the right ventricle of a transplant adequately overcomes the increased resistance in vessels of a small circle of blood circulation. If the help to a right ventricle of heart of the recipient in overcoming this resistance is necessary, then an upper vena cava of a transplant in addition anastomose the end sideways with an upper vena cava of heart of the recipient, and a pulmonary artery of a transplant — the end sideways with a pulmonary artery of the recipient. At such technique of transplantation long unloading of heart of the recipient is created. Thus, Barnard carried out V. P. Demikhov's (I960) ideas, having for the first time used in a wedge, practice the principle of heterotopic transplantation of heart.

Indications

the Question of a formulation of exact and correct indications to P. the page is represented very difficult. Apparently from history of development of surgery, views of indications to operation form for years and change depending on development of medical science over time. In the main P. the page in the countries where it is resolved, is carried out by the patient at whom any exercise stress is followed by a sensation of discomfort (on the New York functional classification of heart failure these patients treat the IV group).

Symptoms of heart failure or coronary pains at these patients are shown at rest, amplifying at the slightest loading. However and they not everything can be recognized as candidates for P. page. So, according to the Stanford center (USA), from each 100 patients inspected within a year deviates for various reasons apprx. 75%, it is hospitalized apprx. 25%, and operation is made approximately at 15% of patients. According to Flu (R. Century of Gripp, 1979), in future P. will be carried out by page more often at inborn heart diseases, and heterotopic P. is more preferable than page at reversible acute disorders of function of heart.

In these countries the following contraindications to P. are developed by page: age more than 50 — 55 years; general diseases and infections; high resistivity in pulmonary vessels (more than 8 — 10 international units); fresh nnfarkt lungs and the expressed defeat of peripheral blood vessels; insulinoustoychivy diabetes.

Thus, P. is applied by page in these countries only in an end-stage of a heart disease and has rather emergency character.

By the end of 1979 in the world 406 orthotopical P. by page to 395 patients, including some repeatedly were executed. From 395 sick 100 people were live in terms from several months to more than 10 years. Since 1974 20 operations of heterotopic transplantation of heart are executed. The operational lethality was not. From among the operated patients within a year there lived 62%, within two years — 58%, within three years — 50%. The active program for P. of page in clinic is carried out by 5 centers (the greatest experience has the center Stanford un-that, the leading Shamueem, in Krom by the end of 1978 153 operations were executed).

A technique

At P. the page use the standard methods of anesthesia applied at big cardiac operations. Operation consists of several stages: a harvesting of heart at the donor, providing are sewn up a myocardium of a transplant in before - and the intra-transplant periods, removal of heart (or speak rapidly it) the recipient, sewing of a transplant.

The harvesting of heart at the donor can be made only after ascertaining of death of a brain which is established on the basis nevrol, researches, existence of the isoelectric line on EEG, the given cerebral angiography or character and volume of damage of a brain established at an operative measure.

Capture of a transplant and protection it for transfer, i.e. in time from the moment of removal of a transplant until its inclusion in a blood stream of the recipient, are carried out as follows: after a median sternotomy (see. Mediastinotomy ) at the donor cross an aorta immediately below an otkhozhdeniye of a brachiocephalic trunk, then a pulmonary trunk proksimalny its bifurcations and, delaying stumps of these vessels, cut auricles as it is possible distalny from a coronal furrow (an atrioventricular furrow). The transplant with open cavities is placed in special cold solution (t ° 4 — 10 °). At capture of a transplant under protection coronary perfusions (see) a technique more difficult to demands preliminary catheterization of vessels. However any of these methods cannot give preference and it is probably necessary to use the most acceptable in specific conditions.

By preparation of a transplant make opening of the right auricle, directing a section from the mouth of the lower vena cava slantwise upward to the basis of the right ear that prevents damage of conduction paths of heart (fig. 1, a).

Fig. 1. Diagrammatic representation of some stages of orthotopical heart transplantation: and — the beginning of connection of heart of the recipient with heart of the donor, at the left — a part of heart and large vessels of the recipient: 1 — a part of the left auricle, 2 — a part of the right auricle, 3 — an upper vena cava, 4 — the lower vena cava (the dotted line designated the catheters entered into them), 5 — the ascending part of an aorta, 6 — a pulmonary trunk; on the right — heart of the donor: 7 — an opening in the left auricle, 8 — a ligature for an anastomosis of the left auricles, 9 — a pulmonary trunk, 10 — the ascending part of an aorta, 11 — the alloyed upper vena cava, 12 — a section of the right auricle; — the initial stage of connection of auricles of the recipient and donor: 1 — an anastomosis of the left auricles, 2 — a ligature for an anastomosis of the right auricles; in — connection of large vessels: 1 — an anastomosis of the right auricles, 2 — a ligature for an anastomosis of the ascending part of an aorta of the recipient and the donor, 3 — a pulmonary trunk of the recipient, 4 — a pulmonary trunk of the donor; — the final stage of heart transplantation: 1 — an anastomosis of the ascending part of an aorta of the recipient and the donor, 2 — an anastomosis of pulmonary trunks, 3 — an anastomosis of the right auricles, 4 — a left ventricle of heart of the donor, 5 — a right ventricle of heart of the donor.

Removal of heart of the recipient is carried out after inclusion artificial circulation (see); operation is begun with crossing of an aorta and a pulmonary trunk at the level of valves. Then open the right auricle on an atrioventricular furrow, partially cut the left auricle. The partition is cut with leaving as it is possible the bigger site of fabric. Most of surgeons considers necessary removal of an ear of both auricles of the recipient in view of a possibility of receipt of blood clots from them.

Sewing of a transplant differs at different surgeons only on the sequence and time. Louer's technique et al. is generally used (1961) at which sewing is begun with imposing of seams handles on auricles (see fig. 1, a), then consistently anastomose the left auricles, the right auricles by means of a continuous two-row blanket suture (fig. 1, b). Sewing together of a pulmonary trunk and an aorta also make by one of options vascular seam (see), more often a continuous two-row blanket suture (fig. 1, in, d). An important point of operation is prevention of an air embolism of coronary arteries of a transplant — drainage of a left ventricle with the subsequent deaerating a puncture of ventricles and aortas. Recovery of cordial activity is made by means of electric defibrillations (see) with the subsequent podshivaniye of myocardial electrodes of an electrocardiostimulator (EX-) to a transplant (see. Cardiostimulation ).

Fig. 2. Diagrammatic representation of some stages of heterotopic heart transplantation: and — the first stage: 1 — heart of the donor, 2 — heart of the recipient, 3 — an anastomosis between the left auricles of hearts of the donor and recipient, 4 — the catheters entered in top and bottom venas cava of the recipient for artificial circulation, 5 — the ascending part of an aorta of the recipient, 6 — the catheters entered into left ventricles, 7 — an aorta of the donor, 8 — a pulmonary trunk of the donor; — the second stage: 1 — heart of the donor, 2 — heart of the recipient, 3 — the pulmonary trunk of the donor anastomozirovan with a pulmonary trunk of the recipient by means of a vascular prosthesis (is shaded), 4 — an aorta of the donor of an anastomozirovan with an aorta of the recipient.

At heterotopic P. pages in the left auricles of a transplant and own heart make in the beginning openings and sew auricles with each other; then the pulmonary trunk of a transplant is anastomosed with a pulmonary trunk of the recipient, and the ascending aorta of a transplant — with an aorta of the recipient (fig. 2).

Maintaining the postoperative period

the Main thing under the authority of the next postoperative period — ensuring optimum cordial emission that it is reached by maintenance of high central venous pressure (thanks to infusion of enough liquid), maintenance of sokratitelny function of a transplant (introduction of Isoproterenolum and cardiac glycosides), normalization of a rhythm of the replaced heart with a frequency not less than 100 reductions of 1 min. managed by ventilation of the lungs (see. Artificial respiration ). The feature of the post-transplant period defining the result of operation at these patients is the possibility of development of reaction of graft rejection (see. Incompatibility immunological ) and need of prolonged use immunodepressive substances (see) and means. Monitor overseeing immunol, a condition of the patient creates a possibility of early diagnosis and timely treatment of crisis of rejection. Signs of acute graft rejection of heart are various. They are subdivided on clinical, electrocardiographic, echocardiographic, morphological and immunological. Rise in final diastolic pressure, signs of the right ventricular insufficiency which is replaced by left ventricular belong to clinical signs reduction precardiac a push; to electrocardiographic — decrease in a voltage of the QRS complex, shift of an electrical axis of heart to the right, atrial, is more rare ventricular arrhythmias, blockade of the carrying-out system of heart of various degree; to echocardiographic — increase in diameter of a right ventricle and wall thickness of a left ventricle; to morphological — dystrophic and necrobiotic changes of muscle fibers, focal limfogistiotsitarny infiltrates in a stroma; to immunological — increase in level of lymphotoxins, quantities of T lymphocytes, decrease in a caption of reaction of an ingibition of spontaneous rosetting.

At P. of page, as well as any other body, optimum immunosuppressive therapy which includes introduction of steroids, Azathioprinum, Methylprednisolonum, anti-lymphocytic serums (see is essential. Immunotherapy ). Doses and the mode of administration of drugs vary, but generally apply 200 mg of Azathioprinum, 200 mg of Methylprednisolonum entered intravenously just before operation and then Azathioprinum in a dose of 2 — 3 mg/kg a day. Introduction of Methylprednisolonum is gradually limited: in a week after operation and in the next 3 months reduce to 10 mg every the 8th hour. Anti-lymphocytic serum is entered intravenously right after operation, and further in the decreasing dosages during 6 — 8 weeks. At emergence of signs of rejection appoint Methylprednisolonum on 1 g daily within 3 — 4 days. Other medicines, including also heparin, give in maintenance doses.

Complications

Complications of the postoperative period, according to J. Rottembonrg et al. (1977), can be divided into two groups — an exudate in a cavity of a pericardium and inf. complications.

Formation of an exudate in a cavity of a pericardium most often is connected with treatment by heparin. The main way of fight against this complication is drainage of a cavity of a pericardium. As a rule, drainages delete only in several days.

At P. pages belong to the most dangerous and often found complications of the postoperative period inf. complications among which the most terrible is pneumonia. Inf. complications remain one of the main causes of death both in the next, and in the remote terms after operation. Within the first year after operation P. of page is the main reason for dysfunction of a transplant, according to Thomas (F. T. Thomas), Louera (1978), atherosclerosis of coronary arteries. The prevention of its development can be reached by administration of anticoagulants, anti-agregantov, and also the special diet poor in fats.

Social and the prof. rehabilitation of patients after P. of page happens on average in 6 months. In some cases patients can be engaged in the prof. in activity.

See also Transplantation (bodies and fabrics) .



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V. I. Shumakov.

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