植込み型補助人工心臓治療の現状と長期使用に向けての展望

Outcomes of Implantable Left Ventricular Assist Device for Treating Advanced Heart Faire in Our Institute and Outlook for Long-term Use

植込み型補助人工心臓（ventricular assist device：VAD）は心臓移植への橋渡し治療（bridge to transplantation：BTT）として2011年春から保険償還され，これまでに1,500例を超える症例に治療が行われている．本邦における成績はJapanese registry for Mechanically Assisted Circulatory Support（J-MACS）により報告されているが，Interagency registry for Mechanically Assisted Circulatory Support（INTERMACS）試験による成績よりも優れている．ただし，植込み後の移植までの待機期間も延長され，平均5年を超えている．また移植を前提としない永久使用目的としたdestination therapy（DT）は2021年から始まっている．米国ではすでに全体の3/4程度がDT使用となっており，本邦でも今後大きな柱となることが予想される．

From 2011, 13 patients with implantable ventricular assist device （VAD） have followed in our institute, 11 as a bridge to transplant （BTT）, and two as destination therapy （DT）. All patients were implanted left VAD （LVAD） in INTERMACS profile level 2 to 4, except two as a bridge to bridge （BTB） cases. The EVAHEART LVAD was selected in four, Jarvic2000 was in four, and HeartMate3 was in five patients. There were no major complications in perioperative period. Outpatient cares were provided by VAD team members every week. Of the 13 patients, six underwent transplant, two died during support and five are ongoing. Support averaged 38 months （three cases over 60 months）. Eight patients required rehospitalization for more than one time. First three patients had cerebral hemorrhages in four, 10 and 25 months. One patient suffered severe right heart faire, and was repeatedly hospitalized （22 times）. There was no driveline infection, and no aortic regurgitation over moderate level. Several patients have continued cardiac rehabilitation, and improved physical strength and ventilatory power. Complications caused implantable VAD have been decreasing due to progressions of the device and appropriate managements for outpatient care. The current implantable LVAD can be used safely in advanced heart failure patients not only as BTT but also as DT. We can look forward to improve the technology of implantable VAD system in the future too. However, aging changes will be considered for long term follow-up of the DT patients.