胸部外科
Volume 66, Issue 1, 2013
Volumes & issues:
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特集 【重症心不全に対する外科治療】
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重症心不全を伴う弁膜症開心術における心臓再同期療法の有用性
66巻1号(2013);View Description Hide DescriptionBackground:Cardiac resynchronization therapy (CRT)has been accepted broadly as an alternative to medical treatment in managing severe heart failure patients. Despite advance in CRT, the presence of a significant valvular heart disease was currently specific exclusion criteria and a response to this therapy remains unclear. The purpose of this study was to determine the effectiveness of CRT in heart failure patients undergoing valvular operation simultaneously. Patients and methods:Between July 2010 and May 2012, 8 heart failure patients who underwent CRT in conjunction with valvular surgery were experienced. Right and left ventricular and atrial epicardial leads were implanted after completion of valvular procedures. In patients with chronic atrial fibrillation(Af),maze procedure was performed in order to eliminate Af. To evaluate the improvement of ventricular mechanical dyssynchrony, the echocardiographic assessment was repeated on admission and 1 month after the CRT implantation. Results:There was no operative death. One patient of ischemic cardiomyopathy died of sustained ventricular tachycardia 2 months after the operation. Postoperative course of severe heart failure patients was uneventful and all patients except 1 discharged on foot with improved New York Heart Association (NYHA) class. Echocardiographic parameters of dyssynchrony did not reach to statistical significance, but several parameters, left ventricular( LV)-pre-ejectionperiod( PEP) and interventricular mechanical delay (IVMD) showing time delay of cardiac contraction, tended to be improve, suggesting contribution to satisfactory postoperative course. Conclusion:The acceptable outcome was demonstrated with our concept to recover the intraventricular and atrioventricular synchrony. Although it might be difficult to establish the patient selection criteria for concomitant CRT and valvular surgery, our strategy is considered to be a feasible procedure to improve the morbidity and mortality in patients with severe heart failure due to valvular disease. -
左室機能低下と僧帽弁閉鎖不全症を有する重症心不全に対する心拍動下手術
66巻1号(2013);View Description Hide DescriptionMitral valve surgery is usually performed under the arrested heart condition. However, cardioplegic arrest techniques will inevitably produce some degree of reperfusion injury. We expected that keeping heart beating decrease the reperfusion injury in patients with poor left ventricular function. The present study compared the results of beating heart technique and conventional mitral valve surgery to demonstrate the merit of this technique. Thirty six patients with low left ventricular function[ ejection fraction (EF)≦35%] who underwent mitral valve surgery between April 2004 and July 2012 were enrolled in this study. On-pump beating mitral valve surgery were performed in 21 patients (beating group). Fifteen patients underwent conventional mitral valve surgery with cardiac arrest using blood cardioplegia (arrest group). Postoperative cardiac events in the beating group were less than that in the arrest group. However, this difference in both groups was not statistically significant. The visual field of the beating heart was equal to that of conventional surgery, and technical accuracy was not compromised. To decrease postoperative cardiac events, beating-heart mitral valve surgery may be suitable surgical option for patients with poor left ventricular function. -
機能性僧帽弁閉鎖不全症に対する左室形成術の適応と限界
66巻1号(2013);View Description Hide DescriptionBackground:This study evaluated the effectiveness and limitations of the surgical ventricular restoration(SVR)procedure in patients with functional mitral regurgitation(FMR)due to severe leaflet tethering. Methods:From 2008 to 2012, FMR was treated in 39 patients by either mitral annuloplasty(MAP)alone( group M:n=17) or MAP combined with SVR( group S:n=22). Preoperatively, patients in group S had lower ejection fraction( EF), larger left ventricle, and more severe mitral regurgiation( MR) comparing to group M. Results:The SVR performed in group S included posterior wall exclusion(Batista)in 10, septal-anteriorventricular exclusion in 8, overlapping ventriculoplasty in 2, and others in addition to papillary muscle approximation(PMA). Coronary revascularization was more common in the group M. Hospital mortality were 18% in group S and 0 in group M. There were no significant improvement on EF in both group, but left ventricular( LV) dimensions decreased significantly in both groups. Also, MR grade decreased significantly in both groups. Leaflet tethering was improved significantly in group S. There were 5 and 1 late deaths in group S and M, respectively. Conclusion:SVR in addition to MAP yielded excellent reduction of leaflet tethering and MR in patients with severe LV dilatation. However, long-term outcomes were poor in those requiring SVR. -
左室形成術の適応と限界
66巻1号(2013);View Description Hide DescriptionIn this study, we assessed mid-term results of surgical ventricular restoration (SVR) for dilated cardiomyopathy. The study subjects were 107 patients who underwent SVR for both ischemic (ischemic cardiomyopathy:ICM, n=57) and non-ischemic (dilated cardiomyopathy:DCM, n=50) dilated cardiomyopathy. In 49(86%)patients ICM was associated with New York heart Association(NYHA) class Ⅲ or more. Preoperative left ventricular ejection fraction (LVEF) and left ventricular end-diastolic dimension(LVDd)were 22±6% and 67±9 mm, respectively. Hospital mortality was 14% and 5-year mortality was 40%. In contrast, 46( 92%) of the DCM patients presented with NYHA class Ⅲ or more. Preoperative LVEF and LVDd were 20±6% and 74±9 mm, respectively. Hospital mortality was 28% and 5-year mortality was 63%. For NYHA class Ⅲ or less, however, 5-year mortality rates were 23% and 39% in those with ICM and DCM, respectively. For those with NYHA functional class Ⅲ or less, SVR was associated with a satisfactory survival rate and is recommended. For those with severe heart failure, however, ventricular assist devices or heart transplantation may have to be indicated. -
拡張型心筋症に対する自己心温存手術―術式の変遷,遠隔期成績,予後規定因子
66巻1号(2013);View Description Hide DescriptionObjective:We report non transplant surgical procedure (preserving autologous heart operation) for the patients with dilated cardiomyopathy( DCM), clinical outcomes, and the factor of predict prognosis. Patient and method:Since May 2000, 258 patients received surgical procedure for 11 years. Surgical procedures:We performed mitral surgery (plasty or replacement) for the patients with more than mild mitral regurgitation (MR). We performed papirally muscule plication since 2005, and we performed 2nd chordal cutting since 2008, for the patients with MR due to mitral tethering. The surgical left ventricular reconstruction( SVR) was performed for the patients with dilated left ventricular. We use spackle tracking echocardiography to decide the type of SVR since 2008. Result:Hospital death was 18.2%, and late cardiac death was 27.5%.Almost the cause of death was congestive heart failure and ventricular arrhythmia. Five years survival was 58%, 10 years survival was 39%.Preoperative condition, emergent operation, inotropic support, intra aortic balloon pumping(IABP),affect the prognosis. But left ventricular size did not affect it. Conclusion:Surgical treatment for the patient with DCM should be performed with stable preoperative condition. -
ウィスコンシン大学液を用いたドナー心臓の保存法とtacrolimus 点滴静注による免疫抑制療法
66巻1号(2013);View Description Hide DescriptionClinical approach for heart transplantation in Kyushu University Hospital Heart Center about donor heart preservation and immunosuppressive therapy is reviewed. University of Wisconsin solution has been used for donor heart preservation as the 1st-line solution, because left ventricular function after both 6-hour and 24-hour preservation with University of Wisconsin solution was superior to that with Celsior solution on the cross-circulated rabbit heart preparation model. Donor hearts are arrested by the extracellular-type cardioplegia to prevent coronary vasoconstriction associated with preservation in University of Wisconsin solution. Tacrolimus has been used as immunosuppressive agent. Drip-infusion of tacrolimus (0.02 mg/kg per day) is started immediately after heart transplantation aiming at definitive blood level control. -
植込み型補助人工心臓による重症心不全治療
66巻1号(2013);View Description Hide DescriptionThe strategy for severe heart failure treatment has changed dramatically since 2011 by the initiation of clinical use of implantable continuous flow ventricular assist devices( LVADs) in Japan. The continuous flow LVADs include DeBakey ventricular assist device (VAD), HeartMateⅡ, HeartWare, Dura-Heart, and EVAHEART, although EVAHEART alone is clinically available in Japan currently. Hear-Mate Ⅱ is the most popular LVAD with more than 10,000 worldwide implants, while its clinical result is superior to implantable pulsatile LVADs. Crucial complications with implantable LVADs include infection, aortic valve insufficiency, thromboembolism, bleeding, and right heart failure during circulatory support. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) has started in the United States, while Japanese Registry for Mechanically Assisted Circulatory Support(JMACS) initiated in Japan in 2010. These registries are essential for clinical evaluation of implantable LVADs as well as research and development in this field. The circulatory support with implantable LVADs is expected to be further contribution for the treatment of for end-stage heart failure patients. -
重症心不全に対する植込み型補助人工心臓治療の中長期成績
66巻1号(2013);View Description Hide DescriptionTwo implantable left ventricular assist devices(I-LVADs)were approved in Japan in 2011. I-LVADs were used for end-stage heart failure of 20 patients in our institute until March 2012. We examine the clinical course of these 20 patients who were treated with I-LVADs. End points are transplantation, death, or weaning from I-LVADs. Mean hospital days after I-LVAD implantation were 58.1 days, and all 20 patients could discharge from hospital alive. Until September 2012, mean follow up interval was 515 days. Five patients reached heart transplantation, 2 died, weaning from an I-LVAD could be done in 1 patient, and 12 continued to wait for heart transplantation. Survival rate was 100% at 1 month, 95% at 3 months, and 89% at 1 year, respectively. Mean follow up duration after discharge were 457 days, and 16 patients(80%)needed a total of 41 times of readmission in this period. Freedom from readmission was 75% at 1 month, 60% at 3 months, and 25% at 1 year, respectively. In conclusion, prognosis of I-LVAD treatment was good, but many patients needed readmission after I-LVAD implantation and follow up system for I-LVAD treatment should be improved immediately. -
植込み型補助人工心臓および心臓移植の成績
66巻1号(2013);View Description Hide DescriptionBackground:Continuous-flow left ventricular assist device(LVAD)has undergone dramatic change into strategy of treating severe heart failure. In this report, we describe our clinical results and problems of continuous-flow LVAD and discuss the future strategy for heart failure patients. Methods and results:Twenty-nine heart failure patients (34.9±12.2 year-old, 20 male) underwent continuous-flow LVAD at Osaka University Hospital since approval of reimbursement of health insurance at 2010. The overall survival and the LVAD related complications were retrospectively evaluated in these 29 patients. The overall survival rate was 96% at 1 year and 96% at 2 years. Seven patients required right ventricular assist device (RVAD) including 3 patients converted to durable RVAD. Cerebrovascular complications was developed in 7 patients and 1 of the 7 patients died from hemorrhagic infarction. Device related infection was detected in only 1 patient with immunosuppressive therapy. Conclusions:The clinical results of continuous-flow LVAD were sufficient and the trend of recent increment of aging donor demands reconsideration of comprehensive strategy for severe heart failure. -
心臓移植および補助人工心臓の経験
66巻1号(2013);View Description Hide DescriptionSince the organ transplantation law was passed, we performed 50 heart transplantation at National Cerebral and Cardiovascular Center. Of those, 2 patients have been doing well over 13 years and 10 years survival rate was 93.4%.During those years, we performed 139 applications of left ventricular assist systems( LVAS). Initially, extracorporeal LVASs had been used. Now, 2 implantable LVAS were approved by medical insurance as bridge to transplant in 2011. Now, our 1st option as bridge to transplantation(BTT) is implantable LVAS.
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REVIEW
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食道癌の分子生物学的知見
66巻1号(2013);View Description Hide DescriptionEsophageal squamous cell carcinoma accounts for most esophageal cancers in East Asia. Esophageal adenocarcinoma arises from Barrett’s esophagus. However, patients with advanced disease remain poor prognosis. Therefore, it is needed to clarify the carcinogenic mechanism and cancer metastatic process in esophageal cancer. Here, we described the recent research approaches of microarray and next generation sequence in esophageal squamous cell carcinoma and esophageal adenocarcinoma.
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連載 胸部外科医の生活を楽にするiPad の利用 第6 回
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まい・てくにっく
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1枚のシェーマ
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画像診断Q&A
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胸部外科医の散歩道
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書評
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