植込み型左室補助人工心臓治療中の関連合併症に対する再手術を回避するには

How to Avoid Reoperation for Complications Associated with Durable Mechanical Circulatory Support Therapy

2011年4月から植込み型補助人工心臓（durable mechanical circulatory support：DMCS）によるbridge to transplant（BTT）を適応としたDMCS治療（BTT-DMCS）が始まった．BTT-DMCSの成績が良好であったことを受け，2021年から長期在宅補助人工心臓治療（destination therapy：DT）が保険収載された．本稿執筆時点において，全国20施設でDTを適応としたDMCS治療（DT-DMCS）が実施可能である．一方で，DMCS関連合併症のマネジメントは満足できるものではなく，高い再入院率が患者の生活の質（QOL）に悪影響を与え，DMCS治療実施施設の負担となっている．

Since April 2011, durable mechanical circulatory support （DMCS） has been used for bridge to transplant （BTT-DMCS） in Japan, with its success leading to insurance coverage for destination therapy （DT-DMCS） in 2021. Despite advancements, managing DMCS-related complications remains challenging, with high readmission rates impacting patients’ quality of life and healthcare facilities’ workloads. Key complications include de novo aortic insufficiency （dnAI）, driveline infections （DLI）, and external outflow graft obstruction （EOGO）. dnAI contributes significantly to chronic right heart failure, with no consensus on optimal intervention timing. Techniques such as bioprosthetic aortic valve replacement （bioAVR） and central aortic valve closure （CAVC） are employed, each with distinct benefits and limitations. DLI, often caused by mechicillin-resistant Staphylococcus aureus （MRSA）, multidrug-resistant bacteria, or Mycobacterium abscessus, necessitates advanced wound management, driveline translocation, and prolonged antibiotic therapy. Imaging modalities like 18-FDG PET/CT are crucial for accurate diagnosis and treatment planning. EOGO, frequently caused by seroma compression, can lead to circulatory failure and often requires surgical intervention or catheter-based treatments. Preventing reoperations, optimizing intervention timing, and ensuring multidisciplinary collaboration are essential strategies for improving patient outcomes and enhancing the long-term effectiveness of DMCS therapy.