vtioВестник трансплантологии и искусственных органовRussian Journal of Transplantology and Artificial Organs1995-1191Academician V.I.Shumakov National Medical Research Center of Transplantology and Artificial Organs", Ministry of Health of the Russian Federation10.15825/1995-1191-2015-1-109-120vtio-503Research ArticleКлинические наблюденияClinical CasesУСПЕШНОЕ ПРИМЕНЕНИЕ ПЕРИФЕРИЧЕСКОЙ ВЕНО-АРТЕРИАЛЬНОЙ ЭКСТРАКОРПОРАЛЬНОЙ МЕМБРАННОЙ ОКСИГЕНАЦИИ ПРИ КРИЗЕ ОСТРОГО ГУМОРАЛЬНОГО ОТТОРЖЕНИЯ СЕРДЕЧНОГО ТРАНСПЛАНТАТАSUCCESSFUL APPLICATION OF PERIPHERAL VENO-ARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION FOR CARDIAC ALLOGRAFT ANTIBODY-MEDIATED REJECTION WITH SEVERE HEMODYNAMIC COMPROMISEПопцовВ. Н.PoptsovV. N.poptsov_vit@mail.ruСпиринаЕ. А.SpirinaE. A.ФГБУ «Федеральный научный центр трансплантологии и искусственных органов имени академика В.И. Шумакова» Минздрава России, Москва, Российская ФедерацияРоссияV.I. Shumakov Federal Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation, Moscow, Russian FederationRussian Federation201503042015171109120Copyright © Попцов В.Н., Спирина Е.А., 20152015Попцов В.Н., Спирина Е.А.Poptsov V.N., Spirina E.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.transpl.ru/vtio/article/view/503

Введение. Гуморальное, или антителообусловленное, отторжение сердечного трансплантата (АООСТ), являющееся одним из грозных осложнений раннего и отдаленного периодов после трансплантации сердца (ТС), развивается у 4–15% реципиентов и характеризуется высокой летальностью (около 55%). При неэффективности медикаментозных методов коррекции дисфункции пересаженного сердца при АООСТ показано применение механической поддержки кровообращения (МПК). Целью являлось представление собственного успешного опыта применения периферической вено-артериальной ЭКМО (ВА ЭКМО) у реципиентки сердца с АООСТ, сопровождавшимся развитием кардиогенного шока. Материалы и методы. Пациентке К. 60 лет в связи с дилатационной кардиомиопатией была выполнена трансплантация сердца (ТС). Ранний период после ТС протекал без особенностей. Реципиентка сердца была переведена из ОРИТ на 4-е послеоперационные (п/о) сутки. По результатам 1-й эндомиокардиальной биопсии (4-е п/о сутки) отторжение сердечного трансплантата отсутствовало. На 11-е п/о сутки отмечено развитие ОСН, что потребовало повторного перевода в ОРИТ. Параметры инвазивного исследования центральной гемодинамики на фоне введения допамина (15 мкг/кг/мин) и адреналина (110 нг/кг/мин): АД – 78/49/38 мм рт. ст., ЧСС – 111 уд./мин, давление правого предсердия (ДПП) – 20 мм рт. ст., давление легочной артерии (ДЛА) – 45/32/22 мм рт. ст., заклинивающее давление легочной артерии (ЗДЛА) – 25 мм рт. ст., СИ – 1,5 л/мин/м2. Выявили резкое ухудшение систолической функции левого желудочка (снижение ФИ с 64 до 25%), увеличение толщины МЖП (1,7 см), задней стенки левого желудочка (1,4 см) и толщины стенки правого желудочка (0,8 см), митральную регургитацию 2–3-й ст. Повторная эндомиокардиальная биопсия выявила АООСТ. Результаты. На фоне механической поддержки кровообращение методом периферической ВА ЭКМО отмечено быстрое улучшение системной гемодинамики, регресс метаболических нарушений. На фоне ВА ЭКМО и проводимых лечебных мероприятий наступила стойкая стабилизация системной гемодинамики: АД – 133/81/54 мм рт. ст., ДПП – 5 мм рт. ст., ДЛА – 31/21/12 мм рт. ст., ЗДЛА –12 мм рт. ст., СИ – 3,4 л/мин/м2, ЧСС – 85 уд/мин в отсутствие потребности в кардиотонической поддержке. Улучшению гемодинамических показателей сопутствовало увеличение ФИ левого желудочка до 53% и уменьшение толщины МЖП и задней стенки левого желудочка до 1,3 см. Контрольная эндомиокардиальная биопсия продемонстрировала регресс гистопатологических проявлений антителоопосредованного отторжения сердечного трансплантата. Через 2 суток после окончания применения ВА ЭКМО больная была переведена из ОРИТ, а на 26-е (или 44-е после ТС) сутки выписана из стационара в стабильном состоянии. Заключение. Периферическая ВА ЭКМО обеспечивает гарантированное поддержание системного кровообращения и газообмена у реципиентов сердца с выраженными расстройствами гемодинамики, возникшими на фоне острого криза отторжения клеточной или антитело-обусловленной этиологии. 

Introduction. Acute antibody-mediated rejection (AMR) is one of the severe complications of early and late period after heart transplantation (HT). Only few case reports and studies presented of mechanical circulatory support (MCS) application for refractory acute rejection causing hemodynamic compromise. Aim. We report the case of a woman with cardiogenic shock caused by severe AMR that was successfully treatment by peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO). Material and methods. In december 2014, a 60-year-old woman with dilated cardiomyopathy was operated for HT. The patient had a good initial cardiac allograft function and no and was discharged from ICU on the 4th day after HT. 1st endomyocardial biopsy (EMB) (the 7th day after HT) showed absence of acute cellular and antibody-mediated rejection. On the 11th day after HT patient aggravated and presented clinical signs of life-threatening acute cardiac allograft dysfunction: arterial blood pressure 78/49/38 mm Hg, HR 111 in min, CVP 20 mm Hg, PAP 47/34/25 mm Hg, PCWP 25 mm Hg, CI 1.5 l/min/m2, adrenalin 110 ng/kg/min, dopamine 15 mcg/kg/min. ECG showed impairment of systolic left (LVEF 25%) and right (RVEF 15%) ventricle function, left and right ventricle diffuse hypokinesis, thickness of IVS, LV and RV wall 1.7, 1.4 and 0.8 cm, tricuspid and mitral valve regurgitation 2–3 degrees. EMB presented AMR. In conscience peripheral VA ECMO was installed. We used peripheral transcutaneous cannulation technique via femoral vessels – arterial cannula 15 F, venous cannula – 23 F, vascular catheter 14 G for anterograde leg’s perfusion. ACT 130–150 sec. AMR therapy included: methylprednisolon pulse-therapy (10 mg/kg for 5 day), IgG, plasmapheresis (No 7), rituximab. Results. Under MCS by VA ECMO we noted quick improvement of hemodynamic, metabolic homeostasis and organ functions. On the 6th day of VA ECMO (blood flow 1.8 l/min): arterial blood pressure 133/81/54 mm Hg, CVP 5 mm Hg, PAP 31/21/12 mm Hg, PCWP 12 mm Hg, CI 3,4 l/min/м2, HR 85 in min, LVEF 53%, IVS 1.3 cm, mitral valve regurgitation <1 degree, inotropic support was discontinued. Control EMB showed resolution of AMR. Duration of VA ECMO was 7 days. Patient was discharged from ICU on the 2nd and 26th day after VA ECMO in stable clinical status. Conclusion. VA ECMO should be crucial component of treatment of cardiac allogaft antibody-mediated rejection with severe hemodynamic compromise. 

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The authors declare that there are no conflicts of interest present.