臨床 肺高血圧を合併した僧帽弁狭窄症の術後管理の問題点
僧帽弁狭窄症を含む心臓弁膜症手術症例55例について,術前心臓カテーテル検査より全肺血管抵抗(TPR)を求め,術後肺循環動態の推移との関係について検討した.A群(TPR<500 dynes・sec・cm-5)34例,B群(TPR≧500 dynes・sec・cM-5)21例中,死亡例はそれぞれ2例(5.9%)および6例(29%)で,B群で有意に高い死亡率を認めた(P<O.05).また術後集中治療室での肺動脈収縮期圧が70rnmHg以上か,または血管拡張薬としてのプロスタグランディンE1を用いて肺高血圧の治療を行った症例はA群にはなく,B群で8例(38%)に認められた.55例中13例(...
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| Published in | 心臓 Vol. 21; no. 9; pp. 1082 - 1090 |
|---|---|
| Main Authors | , , , , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
公益財団法人 日本心臓財団
15.09.1989
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| Subjects | |
| Online Access | Get full text |
| ISSN | 0586-4488 2186-3016 |
| DOI | 10.11281/shinzo1969.21.9_1082 |
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| Abstract | 僧帽弁狭窄症を含む心臓弁膜症手術症例55例について,術前心臓カテーテル検査より全肺血管抵抗(TPR)を求め,術後肺循環動態の推移との関係について検討した.A群(TPR<500 dynes・sec・cm-5)34例,B群(TPR≧500 dynes・sec・cM-5)21例中,死亡例はそれぞれ2例(5.9%)および6例(29%)で,B群で有意に高い死亡率を認めた(P<O.05).また術後集中治療室での肺動脈収縮期圧が70rnmHg以上か,または血管拡張薬としてのプロスタグランディンE1を用いて肺高血圧の治療を行った症例はA群にはなく,B群で8例(38%)に認められた.55例中13例(5.5%)において,術後肺高血圧クリーゼが発症した,これらの症例はいずれも術前TPR1,500dynes・sec・cm-5以上であり,術直後よりも血行動態の改善が認められ安定期に入った2～3日目に突然発症し,低心拍出量症候群(LOS)に至った.これに対しプロスタグランディンE1 0.1～76ng/kg/minを中心静脈より投与し,3例中2例でLOSより離脱し循環動態の改善に有効であった.これら3例の肺血管病変としては,いずれも筋性動脈の高度な中膜肥厚が認められたが,内膜病変は軽度のも.のもあり,血管の攣縮によって急激な右室後負荷の上昇をきたし,右心不全に陥ったことが予想され,血管拡張薬の適切な使用が不可欠と考えられた. |
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| AbstractList | 僧帽弁狭窄症を含む心臓弁膜症手術症例55例について,術前心臓カテーテル検査より全肺血管抵抗(TPR)を求め,術後肺循環動態の推移との関係について検討した.A群(TPR<500 dynes・sec・cm-5)34例,B群(TPR≧500 dynes・sec・cM-5)21例中,死亡例はそれぞれ2例(5.9%)および6例(29%)で,B群で有意に高い死亡率を認めた(P<O.05).また術後集中治療室での肺動脈収縮期圧が70rnmHg以上か,または血管拡張薬としてのプロスタグランディンE1を用いて肺高血圧の治療を行った症例はA群にはなく,B群で8例(38%)に認められた.55例中13例(5.5%)において,術後肺高血圧クリーゼが発症した,これらの症例はいずれも術前TPR1,500dynes・sec・cm-5以上であり,術直後よりも血行動態の改善が認められ安定期に入った2～3日目に突然発症し,低心拍出量症候群(LOS)に至った.これに対しプロスタグランディンE1 0.1～76ng/kg/minを中心静脈より投与し,3例中2例でLOSより離脱し循環動態の改善に有効であった.これら3例の肺血管病変としては,いずれも筋性動脈の高度な中膜肥厚が認められたが,内膜病変は軽度のも.のもあり,血管の攣縮によって急激な右室後負荷の上昇をきたし,右心不全に陥ったことが予想され,血管拡張薬の適切な使用が不可欠と考えられた. |
| Author | 榊原, 謙 厚美, 直孝 酒井, 章 土井, 幹雄 岡村, 健二 井島, 宏 三井, 利夫 堀, 原一 小形, 岳三郎 筒井, 達夫 |
| Author_xml | – sequence: 1 fullname: 酒井, 章 organization: 聖隷浜松総合病院心臓血管外科 – sequence: 1 fullname: 三井, 利夫 organization: 筑波大学臨床医学系外科 – sequence: 1 fullname: 堀, 原一 organization: 筑波大学臨床医学系外科 – sequence: 1 fullname: 土井, 幹雄 organization: 筑波メディカルセンター病理 – sequence: 1 fullname: 筒井, 達夫 organization: 筑波大学臨床医学系外科 – sequence: 1 fullname: 榊原, 謙 organization: 筑波大学臨床医学系外科 – sequence: 1 fullname: 厚美, 直孝 organization: 筑波大学臨床医学系外科 – sequence: 1 fullname: 岡村, 健二 organization: 筑波大学臨床医学系外科 – sequence: 1 fullname: 井島, 宏 organization: 筑波大学臨床医学系外科 – sequence: 1 fullname: 小形, 岳三郎 organization: 筑波大学基礎医学系病理 |
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| References | 15)水川 豊: ProstaglandinE, 投与時の開心徳後急性期における血行動態日胸外会誌29: 1603, 1981. 3) Kashani, I. A., Swensson, R. E.: Pulmonary vasodilators in postoperative pulmonary hypertension. Am. Heart J__106: 778_ 1983 (letter 11) Hoffman, J. I. E., Heymann, M. A.: Pulmonary arterial hypertension secondary to congenital heart disease, Pulmonary hypertension, Weir EK, Reeves JT, ed., New York, 1984, Futura Publishing Company, Inc., p. 76. 21) Dalen, J. E., Matloff, J. M., Evans, G. L., Hoppin, F. G., Bhardwaj, P., Harken, D. E. and D exter, L.: Early reduction of pulmonary vascular resistance after mitral-valve replace ment. New Engl. J. Med., 277: 387, 1967. 6) Ferreira, S. H., Vane, J. R.: Prostaglandins, Their disappearance from and release into the circulation. Nature, 216: 868, 1967. 16)佐藤重仁, 近藤陽一, 渡辺徹, 渡辺誠治, 水谷太郎, 島騎修次, 山下 衛, 内藤裕史: 急性呼吸不全に対するプロスタグランディンE1療法-特にショック時の呼吸循環動態について-救急医学, 5: 1593, 1981. 26) Jordan, S. C., Hicken, P., Watson, D. A., Heath, D. and Whitaker, W.: Pathology of the lungs in mitral stenosis in relation to respiratory function and pulmonary haemodyna mics. Br. Heart J., 28: 101, 1966. 25) Harris, P., Heath, D.: The human pulmonary circulation, Edinburgh London and New York, 1977, Churchill Livingstone, Inc., p. 350. 27) Goodale, F. Jr., Sanchez, G., Friedlich, A. L., Scannell, J. G. and Myers, G. S.: Correlation of pulmonary arteriolar resistance with pulmonary vascular changes in patients with mitral stenosis before and after valvulotom y. New Engl. J. Med., 252: 979, 1955. 2) Jones, O. D. H., Shore, D. F., Rigby, M. L., Leijala, M., Scallan, J., Shinebourne, E. A. and L incoln, J. C. R.: The use of tolazoline hydrochlo ride as a pulmonary vasodilator in potentially fatalepisodes of pulmonary vasoconstriction a fter cardiac surgery in children. Circulation, 64(Suppl. II): II 134, 1981. 28) Wagenvoort, C. A., Wagenvoort, N.: Smooth muscle content of pulmonary arterial media in pulmonary venous hypertension compared with other forms of pulmonary hypertension. Chest, 81: 581, 1982. 4)西垣恭一, 広瀬 一, 松田 暉, 中埜 粛, 岸本英文, 野村文一・, 島田康弘, 川島康生: 先天性心疾患根治術後急性期の肺高血圧クリーゼの発生と治療に関する検討. 日胸外会誌, 34: 135, 1986. 1) Wheller, J., George, B. L., Mulder, D. G. and Jarmakani, J. M.: Diagnosis and management of postoperative pulmonary hyperte nsive crisis. Circulation, 60: 1640, 1979. 5) Bergström, S., Duner, H., Euler, U. S. v., Pernow, B. and Sjövall, J.: Observations on the effects of infusion of prostaglandin E in man. Acta. Physiol. Scand., 45: 145, 1959. 22) Mcllduff, J. B., Daggett, W. M., Buckley, M. J. and Lappas, D. G.: Systemic and pulmonary hemodynamic changes immediately following mitral valve replacement in man. J. Cardiovas. Surg., 21: 261, 1980. 19) Austen, W. G., Corning, H. B., Moran, J. M., Sanders, C. A. and Scannell, J. G.: Car diac hemodynamics immediately following mitral valve sugery. J. Thorac. Cardiovasc. Surg., 51: 468, 1966. 10) Heymann, M. A., Hoffman, J. I. E.: Persistent pulmonary hypertension syndromes in the newborn. Pulmonary hypertension, Weir E K, Reeves JT, ed., New York, 1984, Futura Publishing Company, Inc., p. 45. 23) Wagenvoort, C. A.: The morphology of certain vascular lesions in pulmonary hypertension. J. Path. Bact., 78: 503, 1959. 30) Wagenvoort, C. A., Wagenvoort, N.: Reversibility of plexogenic pulmonary arteriop a thy following banding of the pulmonary artery. J. Thorac. Cardiovasc. Surg., 87: 876, 1984. 20) Rastelli, G. C., Kirklin, J. W.: Hemodynamic state early after prosthetic replacement of mitral valve. Circulation, 34: 448, 1966. 33) Ramirez, A., Grimes, E. T., Abelmann, W. H.: Regression of pulmonary vascular changes following mitral valvuloplasty. An anatomic and physiologic case study. Am. J. Med., 45: 9 75, 1968. 8) Wagenvoort, C. A.: Morphologic changes in intrapulmonary veins. Human Path., 1: 205, 1970. 18) Ziskind, Z., Pohoryles, L., Mohr, R., Smolinsky, A., Quang, H. T., Ruvolo, G. and Goor, D. A.: The effect of low-dose intravenous nitroglycerin on pulmonary hypertension imm ediately after replacement of a stenotic mitral valve. Circulation, 72 (Suppl. II): II 164, 1985. 7) Heath, D., Edwards, J. E.: Histological changes in the lung in diseases associated with pulmonary venous hypertension. Br. J. Dis. Chest., 53: 8, 1959. 14) Szczeklik, J., Dubiel, J. S., Mysik, M., Pyzik, Z., Krol, R. and Horzela, T.: Effects of prostaglandin E1 on pulmonary circulation in patients with pulmonary hypertension. Br. Heart J., 40: 1397, 1978. 31) Harris, P.: Influence of acetylcholine on the pulmonary arterial pressure. Br, Heart J., 19: 979 1007 13) Hauge, A., Lunda, P. K. M. and Waaler, B. A.: Effects of prostaglandin E1 and adrenaline on the pulmonary vascular resistance (PVR) in isolated rabbit lungs. Life Sciences, 6: 673, 1967. 12) Kadowitz, P. J., Joiner, P. D., Hyman, A. L. and George, W. J.: Influence of prostaglandins E1and F2α on pulmonary vascular resistance, isolated lobar vessels and cyclicnucleotide levels. J. Pharmacol. Exp. Ther., 192: 677, 1975. 32)伊藤健二: 外科的心疾患にともなう肺動脈圧充進に関する研究. 日本循環器学誌. 23: 830. 1959. 29)酒井 敬, 堀田隆久, 加藤雅明, 中埜 粛, 河本知秀, 広瀬 一, 川島康生: 僧帽弁狭窄症における肺血管病変の評価. 日胸外会誌, 34: 1481, 1986. 9) Dexter, L., Dow, J. W., Haynes, F. W., Whittenberger, J. L., Ferris, B. G., Goodale, W. T. and Hellems, H. K.: Studies of the pulmonary circulation in man at rest. Normal variations and the interrelations between increased pulm onary blood flow, elevated pulmonary arterial pressure, and high pulmonary“capillary” pressures. J. Clin. Invest., 29: 602, 1950. 17) D'Ambra, M. N., LaRaia, P. J., Philbin, D. M., Watkins, W. D., Hilgenberg, A. D. and Buckley, M. J.: Prostaglandin E1. A new ther apy for refractory right heart failure and pulmonary hypertension after mitral valve replacement. J. Thorac. Cardiovasc. Surg., 89: 567, 1985. 24) Harris, P., Heath, D.: The human pulmonary circullation, Edinburgh London and New York, 1977, Churchill Livingstone, Inc., p. 344. |
| References_xml | – reference: 8) Wagenvoort, C. A.: Morphologic changes in intrapulmonary veins. Human Path., 1: 205, 1970. – reference: 24) Harris, P., Heath, D.: The human pulmonary circullation, Edinburgh London and New York, 1977, Churchill Livingstone, Inc., p. 344. – reference: 1) Wheller, J., George, B. L., Mulder, D. G. and Jarmakani, J. M.: Diagnosis and management of postoperative pulmonary hyperte nsive crisis. Circulation, 60: 1640, 1979. – reference: 21) Dalen, J. E., Matloff, J. M., Evans, G. L., Hoppin, F. G., Bhardwaj, P., Harken, D. E. and D exter, L.: Early reduction of pulmonary vascular resistance after mitral-valve replace ment. New Engl. J. Med., 277: 387, 1967. – reference: 33) Ramirez, A., Grimes, E. T., Abelmann, W. H.: Regression of pulmonary vascular changes following mitral valvuloplasty. An anatomic and physiologic case study. Am. J. Med., 45: 9 75, 1968. – reference: 22) Mcllduff, J. B., Daggett, W. M., Buckley, M. J. and Lappas, D. G.: Systemic and pulmonary hemodynamic changes immediately following mitral valve replacement in man. J. Cardiovas. Surg., 21: 261, 1980. – reference: 5) Bergström, S., Duner, H., Euler, U. S. v., Pernow, B. and Sjövall, J.: Observations on the effects of infusion of prostaglandin E in man. Acta. Physiol. Scand., 45: 145, 1959. – reference: 23) Wagenvoort, C. A.: The morphology of certain vascular lesions in pulmonary hypertension. J. Path. Bact., 78: 503, 1959. – reference: 11) Hoffman, J. I. E., Heymann, M. A.: Pulmonary arterial hypertension secondary to congenital heart disease, Pulmonary hypertension, Weir EK, Reeves JT, ed., New York, 1984, Futura Publishing Company, Inc., p. 76. – reference: 30) Wagenvoort, C. A., Wagenvoort, N.: Reversibility of plexogenic pulmonary arteriop a thy following banding of the pulmonary artery. J. Thorac. Cardiovasc. Surg., 87: 876, 1984. – reference: 4)西垣恭一, 広瀬 一, 松田 暉, 中埜 粛, 岸本英文, 野村文一・, 島田康弘, 川島康生: 先天性心疾患根治術後急性期の肺高血圧クリーゼの発生と治療に関する検討. 日胸外会誌, 34: 135, 1986. – reference: 6) Ferreira, S. H., Vane, J. R.: Prostaglandins, Their disappearance from and release into the circulation. Nature, 216: 868, 1967. – reference: 12) Kadowitz, P. J., Joiner, P. D., Hyman, A. L. and George, W. J.: Influence of prostaglandins E1and F2α on pulmonary vascular resistance, isolated lobar vessels and cyclicnucleotide levels. J. Pharmacol. Exp. Ther., 192: 677, 1975. – reference: 31) Harris, P.: Influence of acetylcholine on the pulmonary arterial pressure. Br, Heart J., 19: 979 1007 – reference: 9) Dexter, L., Dow, J. W., Haynes, F. W., Whittenberger, J. L., Ferris, B. G., Goodale, W. T. and Hellems, H. K.: Studies of the pulmonary circulation in man at rest. Normal variations and the interrelations between increased pulm onary blood flow, elevated pulmonary arterial pressure, and high pulmonary“capillary” pressures. J. Clin. Invest., 29: 602, 1950. – reference: 7) Heath, D., Edwards, J. E.: Histological changes in the lung in diseases associated with pulmonary venous hypertension. Br. J. Dis. Chest., 53: 8, 1959. – reference: 29)酒井 敬, 堀田隆久, 加藤雅明, 中埜 粛, 河本知秀, 広瀬 一, 川島康生: 僧帽弁狭窄症における肺血管病変の評価. 日胸外会誌, 34: 1481, 1986. – reference: 3) Kashani, I. A., Swensson, R. E.: Pulmonary vasodilators in postoperative pulmonary hypertension. Am. Heart J__106: 778_ 1983 (letter)_ – reference: 14) Szczeklik, J., Dubiel, J. S., Mysik, M., Pyzik, Z., Krol, R. and Horzela, T.: Effects of prostaglandin E1 on pulmonary circulation in patients with pulmonary hypertension. Br. Heart J., 40: 1397, 1978. – reference: 15)水川 豊: ProstaglandinE, 投与時の開心徳後急性期における血行動態日胸外会誌29: 1603, 1981. – reference: 16)佐藤重仁, 近藤陽一, 渡辺徹, 渡辺誠治, 水谷太郎, 島騎修次, 山下 衛, 内藤裕史: 急性呼吸不全に対するプロスタグランディンE1療法-特にショック時の呼吸循環動態について-救急医学, 5: 1593, 1981. – reference: 25) Harris, P., Heath, D.: The human pulmonary circulation, Edinburgh London and New York, 1977, Churchill Livingstone, Inc., p. 350. – reference: 26) Jordan, S. C., Hicken, P., Watson, D. A., Heath, D. and Whitaker, W.: Pathology of the lungs in mitral stenosis in relation to respiratory function and pulmonary haemodyna mics. Br. Heart J., 28: 101, 1966. – reference: 19) Austen, W. G., Corning, H. B., Moran, J. M., Sanders, C. A. and Scannell, J. G.: Car diac hemodynamics immediately following mitral valve sugery. J. Thorac. Cardiovasc. Surg., 51: 468, 1966. – reference: 28) Wagenvoort, C. A., Wagenvoort, N.: Smooth muscle content of pulmonary arterial media in pulmonary venous hypertension compared with other forms of pulmonary hypertension. Chest, 81: 581, 1982. – reference: 17) D'Ambra, M. N., LaRaia, P. J., Philbin, D. M., Watkins, W. D., Hilgenberg, A. D. and Buckley, M. J.: Prostaglandin E1. A new ther apy for refractory right heart failure and pulmonary hypertension after mitral valve replacement. J. Thorac. Cardiovasc. Surg., 89: 567, 1985. – reference: 2) Jones, O. D. H., Shore, D. F., Rigby, M. L., Leijala, M., Scallan, J., Shinebourne, E. A. and L incoln, J. C. R.: The use of tolazoline hydrochlo ride as a pulmonary vasodilator in potentially fatalepisodes of pulmonary vasoconstriction a fter cardiac surgery in children. Circulation, 64(Suppl. II): II 134, 1981. – reference: 13) Hauge, A., Lunda, P. K. M. and Waaler, B. A.: Effects of prostaglandin E1 and adrenaline on the pulmonary vascular resistance (PVR) in isolated rabbit lungs. Life Sciences, 6: 673, 1967. – reference: 10) Heymann, M. A., Hoffman, J. I. E.: Persistent pulmonary hypertension syndromes in the newborn. Pulmonary hypertension, Weir E K, Reeves JT, ed., New York, 1984, Futura Publishing Company, Inc., p. 45. – reference: 20) Rastelli, G. C., Kirklin, J. W.: Hemodynamic state early after prosthetic replacement of mitral valve. Circulation, 34: 448, 1966. – reference: 18) Ziskind, Z., Pohoryles, L., Mohr, R., Smolinsky, A., Quang, H. T., Ruvolo, G. and Goor, D. A.: The effect of low-dose intravenous nitroglycerin on pulmonary hypertension imm ediately after replacement of a stenotic mitral valve. Circulation, 72 (Suppl. II): II 164, 1985. – reference: 27) Goodale, F. Jr., Sanchez, G., Friedlich, A. L., Scannell, J. G. and Myers, G. S.: Correlation of pulmonary arteriolar resistance with pulmonary vascular changes in patients with mitral stenosis before and after valvulotom y. New Engl. J. Med., 252: 979, 1955. – reference: 32)伊藤健二: 外科的心疾患にともなう肺動脈圧充進に関する研究. 日本循環器学誌. 23: 830. 1959. |
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| Title | 臨床 肺高血圧を合併した僧帽弁狭窄症の術後管理の問題点 |
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| ispartofPNX | 心臓, 1989/09/15, Vol.21(9), pp.1082-1090 |
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