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移植心脏病理学诊断标准及其进展

郭晖

郭晖. 移植心脏病理学诊断标准及其进展[J]. 器官移植, 2021, 12(6): 662-675. doi: 10.3969/j.issn.1674-7445.2021.06.004
引用本文: 郭晖. 移植心脏病理学诊断标准及其进展[J]. 器官移植, 2021, 12(6): 662-675. doi: 10.3969/j.issn.1674-7445.2021.06.004
Guo Hui. Diagnostic criteria and research progress on heart allograft pathology[J]. ORGAN TRANSPLANTATION, 2021, 12(6): 662-675. doi: 10.3969/j.issn.1674-7445.2021.06.004
Citation: Guo Hui. Diagnostic criteria and research progress on heart allograft pathology[J]. ORGAN TRANSPLANTATION, 2021, 12(6): 662-675. doi: 10.3969/j.issn.1674-7445.2021.06.004

移植心脏病理学诊断标准及其进展

doi: 10.3969/j.issn.1674-7445.2021.06.004
基金项目: 

中国医学科学院中央级公益性科研院所基本科研业务费专项资金资助 2019PT320014

详细信息
    通讯作者:

    郭晖,研究方向为移植病理学基础与临床应用研究,Email:zcguo@tjh.tjmu.edu.cn

  • 中图分类号: R617, R36

Diagnostic criteria and research progress on heart allograft pathology

More Information
  • 摘要: 随着心脏移植外科技术的提高和强效免疫抑制剂的临床应用,心脏移植例数和移植心脏存活时间均显著提升。然而在心脏移植术后的不同阶段,仍然可出现移植心脏右心室衰竭、缺血- 再灌注损伤、急性排斥反应、“Quilty病变”、感染和以移植心脏冠状动脉血管病(TCAD)为特征的慢性排斥反应等一系列并发症。心内膜心肌活组织检查(EMB)技术的应用使得包括排斥反应在内的移植心脏多种并发症的病理学特征得以观察和掌握,并成为移植心脏并发症最为准确的诊断手段。本文对移植心脏病理学研究的简史、心脏移植术后主要并发症及其诊断标准以及移植心脏排斥反应诊断研究的最新进展进行阐述,旨在使更多的心脏移植受者受益。

     

  • 图  1  移植心脏缺血-再灌注损伤的病理学表现

    注:图示移植心脏EMB活检组织内局灶性心肌细胞溶解性坏死及心肌细胞缺失(HE,×400)。

    Figure  1.  Pathological findings of ischemia-reperfusion injury in heart allograft

    图  2  移植心脏“儿茶酚胺效应”的病理学表现

    注:图示移植心脏EMB活检组织内可见微小灶状心肌细胞坏死,损伤灶内可有极少的混合性炎症细胞浸润以及少许瘢痕组织(Masson,×400)。

    Figure  2.  Pathological findings of catecholamine effect of the heart allograft

    图  3  移植心脏HAR的大体解剖学观察

    注:图示血管吻合开放后移植心脏充血肿胀,外观呈暗红色。

    Figure  3.  Gross anatomical observation of hyperacute rejection of heart allograft

    图  4  移植心脏1R级aTCMR的病理学表现

    注:图示EMB活检组织内多个微小的局灶性炎症细胞浸润,绝大多数心肌细胞未见异常(HE,×200)。

    Figure  4.  Pathological findings of grade 1R aTCMR of heart allograft

    图  5  移植心脏2R级aTCMR的病理学表现

    注:图示EMB活检组织内多灶性的炎症细胞浸润,并有局灶性浸润灶相互融合的表现(HE,×200)。

    Figure  5.  Pathological findings of grade 2R aTCMR of heart allograft

    图  6  移植心脏3R级aTCMR的病理学表现

    注:A图示EMB活检组织内弥漫性炎症细胞浸润(HE,× 200);B图示EMB活检组织间的冠状动脉末梢分支的动脉内膜炎(箭头所示)(HE,× 1 000)。

    Figure  6.  Pathological findings of grade 3R aTCMR of heart allograft

    图  7  移植心脏aAMR的病理学表现

    注:A图示EMB活检心肌组织内的MI表现,可见心肌间毛细血管内巨噬细胞淤积浸润(Masson,× 400);B图示EMB活检心肌组织内心肌间毛细血管内巨噬细胞淤积浸润(星号所示),同时可见毛细血管内皮C4d阳性(箭头所示)(C4d免疫组化,× 1 000)。

    Figure  7.  Pathological findings of aAMR of heart allograft

    图  8  移植心脏CR的TCAD病理学表现

    注:图示冠状动脉分支内膜明显增生增厚致管腔明显狭窄(星号所示)近于闭塞(HE,× 200)。

    Figure  8.  Pathological findings of TCAD of CR of heart allograft

    图  9  移植心脏“Quilty病变”的病理学表现

    注:图示移植心脏EMB心肌活检组织的心内膜下的局灶性、密集的炎症细胞浸润(箭头所示)(HE,×200)。

    Figure  9.  Pathological findings of Quilty injury of heart allograft

    图  10  移植心脏活检标本中脂肪组织的病理学表现

    注:图示移植心脏EMB心肌活检标本的右心室组织内、心肌间少许的脂肪细胞(箭头所示)(HE,×200)。

    Figure  10.  Pathological findings of adipose tissue in biopsy specimen of heart allograft

    图  11  移植心脏活检组织内人为假象的病理学表现

    注:图示EMB活检心肌组织内出现的钳夹夹痕(Masson,×200)。

    Figure  11.  Pathological findings of artificial artifacts in biopsy tissue of heart allograft

    图  12  EMB活检组织取材重叠部位的病理学表现

    注:图示移植心脏心肌活检中的前次EMB取材部位,组织学可见局部肉芽组织或机化的纤维瘢痕组织及少许炎症细胞浸润(箭头所示)(HE,×400)。

    Figure  12.  Pathological findings of overlapping site of EMB biopsy tissue

    表  1  移植心脏AMR的病理学诊断分级(2013年ISHLT标准)

    Table  1.   Pathological diagnosis classification of AMR of heart allograft (2013 ISHLT working formulation)

    分级 定义 病理学特征
    pAMR0 病理学上无aAMR表现 组织病理学和免疫病理学染色均无表现
    pAMR1(H+) 仅有单纯的病理学aAMR表现 具有组织病理学的表现,但C4d和(或)CD68免疫组化染色呈阴性
    pAMR1(I+) 仅有单纯的免疫病理学aAMR表现 无组织病理学的表现,但C4d和(或)CD68免疫组化染色呈阳性
    pAMR2 中度病理学的aAMR 同时具备了组织病理学和免疫组化染色阳性的表现
    pAMR3 重度病理学的AMR 心肌间质出血及混合的炎症细胞浸润,血管内皮细胞水肿、核固缩和(或)核碎裂等损伤表现,心肌间质水肿并有免疫组化染色阳性;与重度的心脏血流动力学异常和移植心脏预后不良密切相关
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  • 收稿日期:  2021-10-08
  • 刊出日期:  2021-11-15

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