【摘要】 目的　探讨移植心冠状动脉血管病与急性排斥反应的早期诊断。方法　对 1例扩张型心肌病患者施行同种原位心脏移植术。术后定期随访 ,观察项目有 :临床表现 ,血液生化 ,标准十二导联心电图 ,超声心动图 ,心内膜心肌活检 ,冠状动脉造影术。结果　术后 5～ 6个月 ,患者出现乏力、活动后胸闷、心悸、发热等全身或心脏非特异性症状 ,并有持续存在的窦性心动过速 ,左心室射血分数(EF)降低 ,右心房内径增大 ,室间隔增厚 ,持续三尖瓣返流 ,外周血白细胞持续升高 ,增加免疫抑制剂用量后症状好转或消失。术后 9个月 ,冠状动脉造影显示典型的冠状动脉血管病改变 ,以左前降支及其中、远段分支血管弥漫性狭窄病变为甚。心内膜心肌活检显示典型的急性排斥反应改变 (I A型 )。结论　心脏移植术后系列超声心动图和心电图检查可作为早期移植心冠状动脉血管病和急性排斥反应的无创性检测方法 ,心内膜心肌活检和冠状动脉造影为确诊手段。更多还原

【Abstract】 Objective To study clinically the feasibility of early diagnosis of cardiac allograft vascularopathy (CAV) and chronic rejection. Methods A 13 year old female patient with dilated cardiomyopathy received orthotopic heart transplantation for advanced heart failure, and subsequent immunosuppressive therapy including cyclosporine, prednisone and mofetil, and a monthly close follow up. Coronary angiography and left ventricular endomyocardial biopsy (EMB) was performed 9 months after the operation. Results The clinical and follow up data of the case showed that cardiac or systemic nonspecific symptoms such as exertional chest discomfort, palpitation, fatigue or fever of unknown reasons were the first and ignorable clinical symptoms, and found disappeared after dosage addition of cyclinsporine, which indicated a early clinical manifestations of rejection or vasculopathy. While persistent sinus tachycardia on electrocardiogram, decreased left ventricular ejection fraction (from 64?% ～68?% down to 47?%～50?%), enlarged right atrial (from 32～ 41?mm up to 44?mm in diameter), thickened intraventricular septal ( 13?mm ), repetitive tricuspid regurgitation on echocardiography, increased white blood cells without infection were observed respectively. Coronary angiography showed a typical (type B) vasculopathy with diffuse concentric stenosis of mid and distal left anterior descending artery and its small braches, the distal diagonal, circumflex, and right coronary artery were also involved to some extent. Furthermore, early mild chronic rejection of grade I A was proved by pathologic study. Conclusion Close clinical observation and follow up, serial echocardiography and electrocardiogram, reaction to enhanced anti rejection, and other related laboratory methods could be analyzed and colligated for early noninvasive diagnosis of cardiac allograft vasculopathy and chronic rejection, while EMB and coronary angiography are still the precise diagnostic ways.更多还原