9．急性弁膜症（僧帽弁・大動脈弁）の管理および治療—早期手術のための評価・検査・診断

Management and treatment of acute valvular heart disease（mitral regurgitation/aortic regurgitation）

急速に病状が悪化する急性弁膜症には急性の僧帽弁逆流や急性の大動脈弁逆流，人工弁の機能不全がある。多くの症例では心臓の代償が間に合わず，血行動態は不安定になる。緊急の心臓手術しか救命の方法はなく，そこまでのbridgeとして機械的循環補助の導入が急務になる。急性弁膜症の多くは血行動態が不安定なため，診断は時に難しい。条件が許せば経食道心エコー検査は有効である。心エコー検査では，心機能，壁運動評価，弁形態や逆流の重症度，大血管の評価を行うが，逆流評価は慢性期評価とは異なるアプローチが必要である。可及的早期の手術とそれまでの集中管理がkeyであり，循環器科医，集中治療医，麻酔科医，心臓外科医の連携が何より重要である。

Acute valvular heart disease, including acute mitral regurgitation, acute aortic regurgitation and prosthetic valve insufficiency, can rapidly exacerbate systemic hemodynamic derangements. It is too late for the heart to compensate in that situation, so that it would be most important to set up mechanical support systems and to perform emergent cardiac surgery as soon as possible. It is sometimes difficult to diagnose accurately due to unstable hemodynamics in patients with acute valvular disease. Transesophageal echocardiography can be useful for diagnosis if the condition permits. Cardiac function, left ventricular wall motion abnormalities, valve abnormalities, severity of valve regurgitation, and vascular findings are subject to evaluation using echocardiography；however, the approach for these evaluations are different from patients with chronic valvular heart disease. It would be absolutely necessary to perform emergent operation and provide intensive cardiac care as soon as possible. For successful patient management, cooperation among cardiologists, intensivists, anesthesiologists, and cardiovascular surgeons is essential.