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心臓移植(HTx)や植込み型補助人工心臓(LVAD)はいずれも適応条件があり,すべての心不全患者に適用できない.非虚血性心筋症(NIDCM)に対する僧帽弁手術は限定的な症例に施行されているが,5年生存率は70%程度であり,内科的治療に対する優位性は依然明らかでない1).われわれは非移植適応患者を中心にこれまで左室形成や僧帽弁手術を施行してきたが,術後に十分な心拍出量の増加を得られない症例が多いことから,2015年以降は左室切開を施行しない新術式であるpapillary muscle tugging approximation(PMTA)法を施行している.本検討では急性期の成績を従来の左室形成を中心とした術式と比較し,われわれが左室形成術の予後判定因子として有用としているMw(slope in the preload recruitable stroke work relationship)の観点から,今後の重症心不全患者の治療選択を考察する2).
Surgical strategy for non-ischemic dilated cardiomyopathy (NIDCM) is currently controversial. Subjects were 20 patients who underwent left ventriculoplasty (LVP) from 2006 to 2013 and 6 patients who underwent papillary muscle tugging approximation (PMTA) after 2015. PMTA is a new trans-mitral approach combined with valve replacement without left ventriculotomy. Another group of patients (n=14)who were registered for heart transplantation (HTx) after 2013 was also analyzed for left ventricular assist device (LVAD) free survival. Mw (slope in the preload recruitable stroke work relationship) calculated by single beat technique using echocardiography was employed as a load-independent cardiac functional parameter. The baseline characteristics and Mw were not different between the LVP and PMTA groups. One-year survival was significantly lower in the LVP group(53%)than in the PMTA group(100%)[log-rank:p=0.024]. In the HTx group, early LVAD implantation was necessary in the patients who had low Mw(<20)at the time of registration. In conclusion, PMTA would be one option for NIDCM patients (non-HTx candidates) with severe mitral regurgitation. Early LVAD implantation might be predicted in HTx candidates with low Mw(<20).
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