301.4 📋 章末速記 Summary

301.4.1 🔑 一句話總結

心臟移植 = advanced HF 的 definitive 治療；1 年存活 ~ 90%, 5 年 ~ 75%, 10 年 ~ 50-60%；indications: refractory NYHA III-IV + EF < 25% + optimal therapy；contraindications: active malignancy, severe fixed PH (PVR > 4-5), substance abuse, severe comorbidities, advanced age；MCS hierarchy: IABP → Impella → Tandem Heart → VA-ECMO → durable LVAD；HeartMate 3 (magnetically levitated centrifugal, MOMENTUM 3) 改寫 LVAD 治療；immunosuppression: induction (ATG / basiliximab) + maintenance (tacrolimus + MMF + steroid)；Cardiac Allograft Vasculopathy (CAV) 是 top late mortality cause；xenotransplantation 2022-2024 (David Bennett, Lawrence Faucette) + iPS-derived cardiomyocytes + DCD donor hearts 為前沿。

301.4.2 💊 治療精要

  • MCS：IABP (counterpulsation) / Impella (DanGER-SHOCK 2024) / Tandem Heart / VA-ECMO / HeartMate 3 LVAD (MOMENTUM 3) / TAH / ECPELLA
  • transplant：bicaval anastomosis + ex-vivo perfusion (OCS Heart) + DCD donors
  • immunosuppression：tacrolimus (CNI) + MMF + prednisone；mTOR inhibitor (sirolimus / everolimus) for CAV
  • rejection surveillance：EMB + AlloMap (gene expression) + donor-derived cfDNA
  • CAV management：annual coronary angiography + aggressive CV risk control + statin + ASA + mTOR inhibitor + re-transplantation in severe
  • CMV prophylaxis：valganciclovir；PJP：TMP-SMX

301.4.3 🎯 盧醫師的考前提醒

  1. transplant indications: refractory HF NYHA III-IV + EF < 25% + optimal medical therapy + reversible PH（fixed PH > 4-5 WU 是禁忌）
  2. MOMENTUM 3 (2017, 2022, 2024)：HM3 比 HM2 thrombosis 大幅減少、stroke 較少；5-yr survival ~ 75%（接近 transplant）
  3. DanGER-SHOCK 2024：Impella 在 STEMI cardiogenic shock 改善 survival — 改寫 IABP-SHOCK II 留下的問題
  4. immunosuppression 三大核心：calcineurin inhibitor (tacrolimus preferred) + antiproliferative (MMF) + steroid；mTOR inhibitor for CAV / malignancy reduction
  5. CAV 是 long-term killer：diffuse intimal hyperplasia + 加速 atherosclerosis；denervated heart 無 angina 警訊；annual angiography + IVUS
  6. rejection surveillance：EMB is gold standard；AlloMap (gene expression in peripheral blood) for low-risk patients；donor-derived cfDNA emerging
  7. acute rejection 種類：acute cellular (T-cell, ↑ IS)；antibody-mediated (anti-HLA, plasmapheresis + IVIG + rituximab)；hyperacute (pre-formed Ab, 罕見 with crossmatch)
  8. post-transplant complications：CAV、HTN、DM、hyperlipidemia、CMV、PJP、PTLD (EBV-driven lymphoma)、skin cancer、CNI nephrotoxicity (25-30% ESRD)
  9. xenotransplantation 2022-2024：David Bennett (60 d)、Lawrence Faucette (40 d)；10+ gene-edited pig hearts；hyperacute rejection 仍是挑戰
  10. DCD donor hearts + Organ Care System (OCS Heart) ex-vivo perfusion → 延長 ischemic time → 擴大 donor pool；台灣 transplant 量持續成長