経カテーテル的心不全治療を経由した植込み型補助人工心臓治療

Durable Left Ventricular Assist Device Therapy for Patients with a Prior MitraClip or Impella Intervention

近年の心不全治療は大きな進歩とともに多岐に渡っている．ナトリウム・グルコース共輸送体2（sodium glucose cotransporter 2：SGLT2）阻害薬やアンジオテンシン受容体ネプリライシン阻害薬（angiotensin receptor neprilysin inhibitor：ARNI）をはじめとする新たな薬剤の登場により，薬物治療のはたす役割もこれまで以上に大きくなっている．非薬物治療も，心臓再同期療法やカテーテルアブレーションに加え，Impella（Abiomed社）やMitraClip（Abbott社）といった低侵襲性に優れた経カテーテル的心不全治療の発展も著しい．外科医も手術にいたるまでの心不全治療に精通しておかなければならない時代となっている．しかし，このような種々の心不全治療でもってしても治療抵抗性となった重症心不全においては，植込み型左室補助人工心臓（left ventricular assist device：LVAD）や心臓移植の有効性は揺るぎないものである．

Some patients have undergone implantation of a durable left ventricular assist device （LVAD） following heart failure treatment with Impella （Abiomed） or MitraClip （Abbott）. Impella may carry a potential risk of de novo aortic insufficiency （AI）, while MitraClip may pose hemodynamic issues under LVAD circulation. In this report, we present the outcomes of durable LVAD therapy in patients with these prior treatments. Seventeen patients had previously received Impella support, and five had undergone MitraClip implantation. Among the 17 post-Impella patients, seven underwent aortic valvuloplasty during LVAD implantation, and one required surgical intervention due to AI progression 10 months postoperatively. Of the nine non-interventional patients, one with moderate AI underwent heart transplantation without intervention five years after the LVAD implantation, while the remaining eight patients had mild or less AI. Four of the five post-MitraClip patients underwent mitral valve replacement with a bioprosthetic valve during LVAD implantation. The remaining non-interventional patient experienced no hemodynamic problems. The number of LVAD therapies for patients with a prior Impella or MitraClip intervention is expected to increase in the future. It is essential to establish an appropriate therapeutic strategy based on detailed and careful evaluations of individual cases.