リードレスペースメーカ挿入患者に開心術を施行し脱転を契機に循環管理に難渋した1症例

Intraoperative Intractable Hypotension during Coronary Artery Bypass Grafting in a Patient with a Leadless Pacemaker

要旨

　リードレスペースメーカ（leadless pacemaker：LLPM）留置後1カ月の患者に開心術を施行中，心臓脱転時に血圧低下を生じた。エコー所見より，LLPMによる右室流出路狭窄とそれによる右心不全を生じたと考えられた。LLPM留置患者ではデバイスの脱落・干渉に加えペースメーカ本体による循環不全の可能性も考え麻酔・循環管理を行う必要がある。

　A leadless pacemaker（LLPM）is placed in the heart’s right ventricle. There are few reports on the perioperative management of cardiac surgery in patients with LLPMs. We report the case details of a 79-year-old male patient who underwent coronary artery bypass grafting；due to bradycardic atrial fibrillation he had had an LLPM implanted 1 month before this surgery. Intraoperatively, the displacement of the patient’s heart in order to find the bleeding site in the left atrium resulted in severe right-heart failure. The LLPM was strongly suspected of contributing to the occlusion of the right ventricular outflow tract and to the compression by the displaced heart itself. The patient underwent extracorporeal membrane oxygenation and intra-aortic balloon pumping. Postoperatively, a pulmonary artery catheter was inserted under transesophageal echocardiography（TEE）monitoring for cardiac assessment, which was uneventful. On post operative day 16, the patient was discharged from the intensive care unit.