症例は茨城県在住の 63 歳の男性.2008 年 6 月 5 日大分県別府に旅行中,AMI にて近医救急搬送された. LMT 閉塞を認め,PCI を施行した.再開通するも LOS にて IABP,PCP S 離脱できず,6 月 19 日大分大 学付属病院へ転院し東洋紡社製 LVAD を装着した.12 月 7 日縦隔洞炎を契機に敗血症となる.創部より MRSA が検出され,創部開放し連日縦隔洗浄を行った.患者および家族の強い希望にて,東京大学付属病 院を経由し,4 月 1 日当院へ転院となる.医師,リハビリ士,臨床工学士,看護師と綿密な打ち合わせの元, 全身状態の悪化の可能性も考え,外出に要すると考えられる必要最小限の外出プログラムを計画した.起 立,立位,歩行器による室内歩行,段差昇降リハビリを行い,4 月 25 日モバート NCVC にて一時外出した. 片道 40 km,自宅滞在時間 2 時間 30 分,外出時間 5 時間であった.移動中トラブルは無かった.今回の一 時帰宅は,患者および家族に対する精神的効果は絶大であった.治療の目標や到達点を見出せない中,心臓 移植や離脱困難な LVAD 装着患者にとって外出プログラムは,患者および家族の QOL 向上になり得る.日 心外会誌 39 巻 2 号:65-68(2010) キーワード:destination therapy,LVAD,外出プログラム The left ventricle assist device(LVAD)has become an important therapeutic option in the treatment of acute or chronic heart failure. It is usually used as bridge to transplantation or recovery. At present, destination therapy with LVAD has been a therapeutic option in patients with heart failure in whom transplantation is not indicated. We describe a patient, who received destination therapy with LVAD, and was able to go home temporarily. The patient was a 63-year-old man with low output syndrome after acute myocardial infarction. An LVAD(TOYOBO)was implanted at Oita University Hospital, however the patient suffered from MRSA mediastinitis 6 months later. He and his family wished for him to temporarily go home to Ibaraki. The patient, supported by LVAD, was transferred from Oita to Ibaraki by a regular commercial flight and ambulance. Rehabilitation training involved stretching, in-bed muscle strength training, maintaining a standing position, walking on flat ground with a walker and going up and down ramps. All training was measured at the patient's home. The patient was out of hospital for 5 hours, and this period was uneventful upon leaving hospital. The patient also took an active part in rehabilitation after discharge. This program can help to improve the quality of life(QOL)of patients with implanted LVADs for destination therapy. Jpn. J. Cardiovasc. Surg. 39 : 65-68(2010) Keywords:destination therapy, LVAD, leaving hospital program 補助心臓(LVAD)の治療成績の向上に伴い,在宅療法 を目的とした長期補助が,今後の重症心不全治療の選択肢 の一つとなりつつある.それに伴い,心移植を目的とした LVAD 患者とは違った外出プログラムが必要とされる.今 回我々は,重症感染症を伴う destination therapy を目的と した LVAD 患者の外出例を経験したので報告する. 症 例 症例:茨城県在住の 63 歳,男性. 主訴:胸痛. 既往歴:高血圧. 現病歴:2008 年 6 月 5 日大分県別府市に旅行中,急性 心筋梗塞にて近医救急搬送された.緊急カテーテル検査施 65 2009 年 6 月 22 日受付,2009 年 10 月 27 日採用 筑波記念病院心臓血管外科 〒 300-2622 つくば市要 1187-299 * 東京大学心臓外科 ** 東京大学大学院重症心不全治療開発講座
We report a rare case of concomitant coronary artery disease, abdominal aortic aneurysm, and bile duct cancer. A 65-year-old man, who had been recognized to have jaundice in late November 2005, was found to have bile duct cancer, an abdominal aortic aneurysm with a diameter of 70 mm, and coronary artery disease (with two severely diseased branches).To avoid extended operation, a two-stage operation was performed; at the first operation, off-pump coronary artery bypass surgery (LITA to LAD and Ao-SVG to 4 PD) and replacement of the abdominal aortic aneurysm by an artificial blood vessel with minimal incision were implemented. In 21 days after the cardiovascular surgery, the patient underwent pylorus-preserving pancreatoduodenectomy (modified Child method) in the second operation. After the two-stage operation, the patient showed a favorable outcome without any major complications.On the basis of the outcome of two-stage operation we successfully applied, we discuss the strategy for treatment of patients having both cardiovascular and abdominal malignant diseases, with reference to the literature.
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