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難治性うっ血性心不全の治療において,従来の強心剤,利尿剤の投与に血管拡張剤を併用する方法は成人領域ではすでに一般的となっている1〜7)。これに対して,小児科領域での血管拡張剤の臨床使用の報告8〜13)は開心術後に使用された例14〜17)を除けば極めて少ない。これは,その対象となる疾患が成人では主に逆流性弁膜疾患,心筋症,心筋梗塞後心不全など血管拡張剤の効果が十分に期待出来る疾患が多いのに対して,小児では左右短絡群による心不全が主であり,その効果については急性効果についてさえ十分に検討されていないことによると思われる。これまでに血管拡張剤が心室中隔欠損(VSD)に及ぼす血行動態の影響についての報告18〜22)はいくつか散見されるが,検討の不十分な例も多く,その結果も必ずしも一致していない。今回われわれは,心カテーテル検査時に代麦的な血管拡張剤であるソディウム・ニトロプルシッド(SNP)を負荷し,僧帽弁逆流(MR),心室中隔欠損(VSD),および動脈管開存(PDA)の血行動態的変化について検討したので報告する。
The hemodynamic effects of sodium nitroprusside (SNP) were studied in 39 infants and children with congenital heart disease. They were divided into three groups acoording to their anatomic lesions ; 8 of isolated mitral regurgitation (MR), 19 of ventricular septal defect (VSD), 12 of patent ducats arteriosus (PDA). VSD and PDA were divided into two subgroups according to the association of pulmonary hypertension (PH). Before and after 4 minutes of administration of SNP at 3μg/kg/min, aortic, pulmonary artery, left atrial and right atrial pressures and saturations were measured.
In MR, forward cardiac output increased from 23.5±7.2 ml to 31.0±8.2 ml (mean±SD, p<0.001) and cardiac index 2.56±0.34 1/min/m2 to 4.08±0.57 1/min/m2 (p<0.001) as a consequence of a marked decrease in systemic vascular resistance (31.9±2.3 U・m2 to 17.4±4.1 U・m2, p<0.001). In VSD without PH and VSD with PH, left atrial pressure decreased from 8.6±2.3 mmHg to 5.2±1.5 mmHg (p<0.05) and 11.8±1.7 mmHg to 8.1+1.3 mmHg (p<0.001), respectively. Right atrial pres-sure also decreased from 4.3±2.1 mmHg to 2.0±1.2 mmHg (p<0.01) and 6.1±1.5 mmHg to 3.3±1.4 mmHg (p<0.001), respectively. In spite of these reduction of preload, the pulmonary and systemic flow did not decrease significantly. These data show that the systemic blood flow can be maintained at the lower left atrial pressure induced by administra-tion of SNP.
Although limited to the acute setting, it is suggested that SNP may be beneficial in the management of infants and children with VSD as well as MR.
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