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変性性僧帽弁閉鎖不全症に対する僧帽弁形成術の遠隔期成績の改善に関する研究

川本 尚紀 東北大学

2020.03.25

概要

【背景】
僧帽弁閉鎖不全症に対する僧帽弁形成術は弁形成が可能と判断される場合は第一選択の手術治療として急激に普及しつつある。しかしながら、遠隔期成績の観点からどのような形成術をすべきかは一概に定められていない。また、僧帽弁形成術を施行される患者群は、比較的若年であり、遠隔期の再発や再手術、心血管イベントの発生が臨床的に問題となってきている。そこで今回、遠隔期成績を改善する変性性僧帽弁閉鎖不全症に対する僧帽弁形成術の研究を以前誌上報告した研究と併せて、国立循環器病研究センターの経験例を用いて後方視的に検討した。

【方法と結果】
研究Ⅰの方法:2015年までの変性性僧帽弁閉鎖不全症に対して僧帽弁形成術を施行した、318例を用いて、術前背景、手術背景、術後心エコー所見から、術後に新規心房細動の発症に関与する因子を抽出した。また、術後の新規心房細動の発症が、遠隔期成績に及ぼす影響を検討した。

研究Ⅰの結果:フォローアップ期間に29例の新規心房細動発症患者を検出した。多変量解析による新規心房細動発症のリスク因子としては、圧半減期時間の上昇や、左房径の拡大、小さい人工弁輪サイズが独立した危険因子となった。生存率に関しては、新規心房細動発症患者とその他の患者では有意差はなかった(p=0.99)。しかしながら、一過性脳虚血発作や脳梗塞の頻度は、新規心房細動発症患者で相対的に高い傾向となった。(p=0.05)研究Ⅱの方法:2017年までの変性性僧帽弁閉鎖不全症に対して僧帽弁形成術を施行した、602例を対象に、術後機能的僧帽弁狭窄症を発症するリスク因子を術前背景と手術背景から抽出し、機能的僧帽弁狭窄症が術後の心機能や、遠隔期成績に与える影響を混合効果モデルを用いて検討した。

研究Ⅱの結果:術後経僧帽弁圧格差が5mmHG以上の機能的僧帽弁狭窄症を示した患者は51例となった。術後機能的僧帽弁狭窄症を引き起こすリスク因子としては、edge to edge repair、術前左房径、3度以上の三尖弁逆流、そして小さい人工弁輪のサイズのみが危険因子であることが判明した。また、混合効果モデルを用いた心機能の経時的な比較では、機能的僧帽弁狭窄症患者では、左房径拡大、右房右室圧格差上昇、三尖弁逆流の進行が有意に早いことが明らかとなった。しかしながら、生存率やMACCE回避率には明らかな有意差はなかった。

研究Ⅲの方法:2017年までの変性性僧帽弁閉鎖不全症に対して、僧帽弁形成術を施行した602例に対して、低侵襲アプローチで施行した群139例と正中切開群463例に対してpropensity score matchingを用いて、23因子の背景を均一化し、術後心機能、術後経過、遠隔期成績を比較検討した。

研究Ⅲの結果:matching後、両群ともに93例となった。手術時間の短縮、輸血率の減少、早期抜管、入院期間の短縮が低侵襲アプローチ群で認められた。しかしながら、左室駆出率の低下、左室収縮末期径の上昇が認めれ、不十分な心筋保護の灌流によるものと考えられた。遠隔期生存率、再手術回避率などには両群で有意差は認めなかった。

【結論】
上記3研究において、種々の弁形成の手法は手術成績、遠隔期成績には影響を及ぼさず、遠隔期成績を改善するためには、小さな人工弁輪を用いた弁輪形成をできるだけ避ける必要があると考えられた。また、低侵襲僧帽弁形成術は既存の形成術と同等以上の成績を出すことができるが、心筋保護を改善することでさらに良好な結果を残せる可能性が示唆された。

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