Diagnosis and treatment of Takotsubo syndrome after liver transplantation and literature review
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摘要:
目的 总结肝移植术后Takotsubo综合征(TTS)的诊疗经验。 方法 回顾性分析1例肝移植术后TTS患者的临床资料,总结其临床特点、诊断方法及治疗策略,并进行文献复习。 结果 1例43岁女性患者,因原发性胆汁性肝硬化8年行劈离式肝移植,手术过程顺利。术后3 d患者出现焦虑、烦躁、呼吸困难以及定向力障碍,低血压,氨基末端脑钠肽前体(NT-proBNP) > 35 000 pg/mL,肌酸激酶同工酶(CK-MB)5.9 U/L,肌钙蛋白I(TnI)1.78 μg/L。心电图提示窦性心律,超声心动图提示左心室壁运动弥漫减弱及心尖部球形扩张,并伴有二尖瓣、三尖瓣中~重度反流,左心室射血分数(LVEF)下降至23%,但未见心室壁节段性运动异常或对应的心电图改变,不考虑急性冠状动脉综合征。InterTAK诊断评分为73分,考虑肝移植术后TTS,给予美托洛尔、辅酶Q10、重组人脑利钠肽、去乙酰毛花苷及劳拉西泮等治疗。术后10 d复查超声心动图,左心功能明显改善,LVEF恢复至50%。术后40 d患者出院,移植肝功能恢复良好,随访期间继续服用美托洛尔至投稿日,未再复发。 结论 肝移植术后TTS的发生较罕见,诊断上存在困难,但病情严重及预后较差,需要早期识别和及早干预。 Abstract:Objective To summarize the experience of diagnosis and treatment of Takotsubo syndrome (TTS) after liver transplantation. Methods Clinical data of one TTS patient after liver transplantation was retrospectively analyzed. Clinical features, diagnosis and treatment strategies were summarized, and literature review was conducted. Results A 43-year-old female patient successfully underwent split liver transplantation due to primary biliary cirrhosis for 8 years. At postoperative 3 d, the patient developed anxiety, irritation, dyspnea, disorientation, hypotension, N-terminal pro-brain natriuretic peptide (NT-proBNP) of > 35 000 pg/mL, creatine kinase isoenzyme (CK-MB) of 5.9 U/L and troponin I (TnI) of 1.78 μg/L. Electrocardiogram indicated the signs of sinus rhythm. Echocardiography indicated diffuse weakening of the left ventricular wall motion and spherical dilatation of the apex, accompanied with moderate and severe regurgitation of the mitral valve and tricuspid valve. The left ventricular ejection fraction (LVEF) declined to 23%, whereas no abnormal segmental motion of ventricular wall or corresponding electrocardiogram changes were observed. The possibility of acute coronary syndrome was excluded. The InterTAK diagnostic score was 73. The diagnosis of TTS after liver transplantation was considered. Metoprolol, coenzyme Q10, recombinant human brain natriuretic peptide, deacetyl lanatoside and lorazepam were given. Echocardiography at postoperative 10 d showed that the left ventricular function was significantly improved and the LVEF recovered to 50%. The patient was discharged 40 d after liver transplantation. The liver function was recovered well. During postoperative follow-up, she was given with metoprolol till the submission date, and no recurrence was reported. Conclusions TTS after liver transplantation is rare in clinical practice. It is difficult to make the diagnosis. The condition of TTS is severe and clinical prognosis is poor. Prompt diagnosis and interventions should be implemented. -
表 1 文献报道的肝移植术后TTS
Table 1. TTS after liver transplantation in literature
作者 年份 国家 例数(n) 原发病 发生时间 最低LVEF(%) 机械辅助 分型 结局 Lee HR, et al[2] 2007 美国 1 NASH合并肝癌 术后1 d -① 无 心尖型 - Phillips MS, et al[4] 2008 美国 1 原发性硬化性胆管炎 术后10 d 20 无 心尖型 好转出院 Saner FH, et al[5] 2010 德国 2 乙肝②肝硬化、丙肝肝硬化 术后5 d 20 无 心尖型 1例术后2 d死亡,1例好转 Anders MM, et al[6] 2011 巴西 1 ALC 术后2 d 9 IABP 心尖型 好转出院 Tachotti Pires LJ, et al[7] 2012 巴西 1 PBC 术后4 d 25 无 局灶型 好转出院 Bedanova H, et al[8] 2013 捷克 1 自身免疫性肝炎 术后2 d 20 IABP 心尖型 心功能未完全恢复,术后30 d出院 Vachiat A, et al[9] 2016 南非 1 丙肝肝硬化及ALC - 23 LVAD 心尖型 好转出院 Aniskevich S, et al[3] 2017 美国 24 ALC 8例、丙肝肝硬化5例、NASH 5例、隐源性肝硬化3例、PBC 1例、自身免疫性肝炎1例、多囊肝1例,4例合并肝癌 术后3(0~27)d 27(15~35) - 均存在弥漫性运动减弱或无运动 2例分别在术后63 d和145 d死亡,其余好转出院 Biondi RS, et al[10] 2017 巴西 1 隐源性肝硬化 术后2 d 12 ECMO 心尖型 好转出院 Reddy RV, et al[11] 2018 印度 1 乙肝肝硬化 术后1 d 25 IABP 局灶型 好转出院 Galván NT, et al[12] 2018 美国 6 ALC,2例合并丙肝及肝癌 5例在术后2 d内,1例在术后7 d 10~35 IABP 3例,VAD 2例 仅1例为典型心尖型 3例心功能未恢复,1例术后2 d死亡 Maestas C, et al[13] 2019 美国 7 丙肝肝硬化4例、ALC 1例、PBC合并自身免疫性肝炎1例、NASH 1例 术后7 d 10~25 1例行ECMO+IABP 仅1例为典型心尖型 1例术后14 d死亡,其余好转出院 Tanaka A, et al[14] 2019 日本 1 丙肝肝硬化合并肝癌 术后4 d 40 无 心尖型 好转出院 Luu LA, et al[15] 2020 美国 1 NASH 术后3 d 15 无 弥漫型 好转出院 Bedanova H, et al[16] 2021 捷克 1 ALC 术后1 d 25 无 中间型 好转出院 Shamaa O, et al[17] 2021 美国 2 ALC 术后201 d,术后9 d 19~37 无 双心室型 1例术后1 d后死亡,1例术后20 d出院 Yang J, et al[18] 2021 美国 38 ALC 17例、丙肝肝硬化7例、肝癌6例、NASH 5例、乙肝肝硬化1例、其他2例 术后1个月内,其中31例在术后5 d内 26±8 IABP 5例,ECMO 2例 - 均好转恢复 注:①-为无数据。
②乙肝为乙型病毒性肝炎。 -
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