千葉県循環器病センター心臓血管外科Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center ◇ Chiba, Japan
背景：ファロー四徴（TOF）術後遠隔期における肺動脈弁逆流（PR）は右心機能低下，不整脈発生の危険因子となる．TOF術後遠隔期におけるPRに対して肺動脈弁置換術（PVR）を施行した症例の中期成績を検討した．
方法：2003年4月から2017年3月までの期間，PVRを施行した32例を対象とした．PVR後の平均follow up期間は5.4±4.2年であった．臨床症状，心電図，胸部レントゲン，心エコー，MRI，心臓カテーテル検査などの精査を行って手術適応を決定した．
結果：周術期死亡例はなく，観察期間中に再手術例（re-PVR）はなかった．1例に大動脈弁逆流，大動脈弁輪拡張を認めたため，PVR後3年でBentall手術を施行した．RVEDVIは術前176.3±57.2 mL/m2に対して，術後108.1±19.4 mL/m2と有意な低下を認めた（p＜0.05).RVEFは術前42.7±8.49％に対して術後42.4±7.94％と有意差はなかった．RVEDVI＜160 mL/m2の早期手術群のLVEFは，術前53.9±6.14％に対して術後58.8±5.05％と有意差はなかった（p＝0.11）．術後のLVEDPは早期群より進行群のほうが有意に高い結果となり拡張障害を認めた（p＜0.05）．
結語：TOF術後遠隔期におけるPRに対するPVRは安全かつ有効であった．両心機能維持の観点から，RVEDVI 160 mL/m2を指標に手術適応を検討することが妥当と考えられた．
Background: Pulmonary regurgitation (PR) after repair of tetralogy of Fallot (TOF) is a risk factor of right ventricular (RV) dysfunction and arrhythmia. The aim of this study was to evaluate the mid-term outcome of pulmonary valve replacement (PVR) using bioprosthetic valves in adult patients with PR after a TOF repair.
Method: A total of 32 patients with repaired TOF, who underwent PVR in our hospital between April 2003 and March 2017, were retrospectively examined. The mean follow-up duration after the PVR was 5.4±4.2 years. Decision regarding the surgery was made on the basis of clinical symptoms, electrocardiography results, chest radiography, echocardiography findings, magnetic resonance imaging results, and cardiac catheter examination findings.
Results: There was no perioperative mortality or the need for re-intervention after PVR. A patient underwent Bentall operation 3 years after PVR. RV end-diastolic volume index (RVEDVI) was significantly reduced (176.3±57.2 mL/m2 before to 108.1±19.4 mL/m2 after PVR, p＜0.05). There was no difference in the RV ejection fraction (42.7％±8.49％ before and 42.4％±7.94％ after PVR, p＞0.05). The left ventricular (LV) ejection fraction of RVEDVI group was ＜160 mL/m2, which showed an improvement; however, there was no significant statistical difference (55.3％±8.03％ before and 58.5％±4.95％ after PVR, p＝0.12). It was significantly higher in postoperative left ventricular end-diastolic pressure (LVEDP) (15.2±2.78 mmHg) of RVEDVI ≥160 mL/m2 group than postoperative LVEDP (11.2±2.81 mmHg) of RVEDVI ＜160 mL/m2 group (p＜0.05).
Conclusion: PVR after TOF repair in adult patients with PR is effective and involves a low risk of mortality. It is suggested that 160 mL/m2 of RVEDVI would be valid for determining whether surgery is indicated for the maintenance of RV and LV functions.
Key words: pulmonary valve replacement; tetralogy of Fallot; pulmonary valve regurgitation; mid-term outcome; surgical indication
© 2018 特定非営利活動法人日本小児循環器学会© 2018 Japanese Society of Pediatric Cardiology and Cardiac Surgery
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