[III-S10-03] 良好な房室弁機能を維持する外科治療戦略
Keywords:フォンタン循環, 房室弁, 外科治療
ここ２０年の進歩で、機能的単心室循環を持って出生した患者の７−８割が機能的修復であるフォンタン循環に到達するようになった。そして、それは同時に“正常より高い中心静脈圧のうえに成立する機能的修復の根源的ボデイブロー合併症”の検証蓄積にもなった。
良好なフォンタン循環の鍵としては、 “正常なガス交換を維持し、流れやすい肺循環”と“適切な心拍出量と低い体循環心房圧を維持できる機能的単心室機能”が重要と考えられており、房室弁機能維持もそこに大きく関与する重要因子である。機能的単心室循環における房室弁機能維持を目指した外科治療戦略のゴールデンスタンダードは確立されていないので、本日は私共の“右心系機能的単心室の房室弁に対する外科治療戦略”を提示し、任を果たさせていただく。
[Our strategy]1) Evaluation & primary planning mainly using echo: Not only the grade of the regurgitation but also the 4-D condition of the valve are checked and a primary plan to repair is considered in the heart team. 2) Reproduction of the preoperative valve condition during surgical interventionand final planning: Common AV valves are so easily deformed during cardiac arrest that the evaluation seems to be misled. This step of reproduction gives us appropriate information to make the right valve repairwithout discrepancy between preoperative findings.3) Repairbased onthe concept of leaflet apposition: After confirming potential of each leaflet, acceptably-functioning leaflets are preserved and apposed apposition to make better coaptation, mainly using localized annuloplasty on commissures and bridging anuuloplasty using fibrous annulus. 4) Staged annuloplasty: The annular diameter or opening of the AV valve is controlled by following limitation; more than 100% of normal TV diameter at palliative stage, more than 100% of MV at Glenn stage and more than 80% of MV at Fontan stage.
良好なフォンタン循環の鍵としては、 “正常なガス交換を維持し、流れやすい肺循環”と“適切な心拍出量と低い体循環心房圧を維持できる機能的単心室機能”が重要と考えられており、房室弁機能維持もそこに大きく関与する重要因子である。機能的単心室循環における房室弁機能維持を目指した外科治療戦略のゴールデンスタンダードは確立されていないので、本日は私共の“右心系機能的単心室の房室弁に対する外科治療戦略”を提示し、任を果たさせていただく。
[Our strategy]1) Evaluation & primary planning mainly using echo: Not only the grade of the regurgitation but also the 4-D condition of the valve are checked and a primary plan to repair is considered in the heart team. 2) Reproduction of the preoperative valve condition during surgical interventionand final planning: Common AV valves are so easily deformed during cardiac arrest that the evaluation seems to be misled. This step of reproduction gives us appropriate information to make the right valve repairwithout discrepancy between preoperative findings.3) Repairbased onthe concept of leaflet apposition: After confirming potential of each leaflet, acceptably-functioning leaflets are preserved and apposed apposition to make better coaptation, mainly using localized annuloplasty on commissures and bridging anuuloplasty using fibrous annulus. 4) Staged annuloplasty: The annular diameter or opening of the AV valve is controlled by following limitation; more than 100% of normal TV diameter at palliative stage, more than 100% of MV at Glenn stage and more than 80% of MV at Fontan stage.