赤澤 舞衣, 清水 祥子, 閻 国珊, 清水 盛浩, 湯浅 真由美, 小牧 史明, 北川 裕利

Mai AKAZAWA, Shoko SHIMIZU, GUOSHAN Yan, Morihiro SHIMIZU, Mayumi YUASA, Fumiaki KOMAKI, Hirotoshi KITAGAWA

滋賀医科大学麻酔学講座

Department of Anesthesiology, Shiga University of Medical Science

キーワード : left atrial myxoma, mitral regurgitation, mitral valve prolapse, preoperative ultrasonographer

心臓手術において経胸壁心臓超音波検査 （transthoracic echocardiography：TTE） は大きな影響を与える．当院では周術期専従の超音波検査士を配置し，緊急手術でも可能な限り術前TTEを施行している．今回，左房粘液腫に合併した僧帽弁逸脱症を術前に検出し，腫瘍切除術と僧帽弁輪形成術 （mitral valve annuloplasty：MVA） を同時に施行した1例を経験した．症例は68歳，女性．うっ血性心不全の診断で近医に入院し，TTEで左房内腫瘤と中等度の僧帽弁閉鎖不全症 （mitral regurgitation：MR） を指摘され手術目的に当院へ搬送された．搬送後の周術期超音波検査 （TTE） でMRの責任部位と考えられる僧帽弁前尖A3の軽度逸脱を認めた．所見は速やかに麻酔科医と心臓血管外科医に伝えられた．腫瘤は有茎性で心房中隔と付着しており，一部心房中隔ごと切除した．僧帽弁は弁輪径の拡大による接合不全を来しており，前尖A3の変性と余剰も認めていた．MVAを施行し，逆流が制御されたことを確認して手術を終了した．術後組織診検査で左房粘液腫と診断された．左房粘液腫ではしばしばMRを合併するが，その正確な検出や重症度評価は困難である．限られた時間の中で速やかにTTEを行い所見を共有できる体制を構築していたことが，適切な術前評価と術式選択に繋がった．

Echocardiography has a considerable impact on the surgical strategy employed during cardiac surgery. However, emergency surgeries generally do not permit the thorough evaluation of patients. The addition of a dedicated perioperative ultrasonographer to our surgical team has allowed for perioperative evaluations such as transthoracic echocardiography (TTE) to easily be performed on patients undergoing elective or emergency surgeries. There are no reports in the literature on the benefit of a dedicated perioperative ultrasonographer performing preoperative TTEs. We herein report a case of a left atrial myxoma and associated mitral valve (MV) prolapse that was detected by the perioperative ultrasonographer preoperatively and treated simultaneously with tumor resection and mitral valve annuloplasty (MVA). A 68-year-old female patient was diagnosed with congestive cardiac failure on admission to a nearby hospital. TTE revealed a massive mass in the left atrium and moderate mitral regurgitation (MR). She was transferred to our hospital for surgery. The perioperative ultrasonographer reviewed the TTE and found a slight deviation of the A3 anterior MV leaflet towards the apex, which had been theorized to be the site of MR. The findings were promptly reported to the anesthesiologist and cardiovascular surgeon; subsequently, tumor resection and MVA were performed. The tumor mass had a stalk attached to the atrial septum. MV degeneration and excessive leaflet tissue of the A3 anterior leaflet were found. Moreover, the diameter of the valvular ring was enlarged, resulting in a defect of the junction between the anterior and posterior leaflets. The regurgitation was stabilized. Left atrial myxoma is frequently correlated with MR, which is challenging to accurately detect and evaluate for the severity thereof. Particularly within the limited time frame, the perioperative ultrasonographer was able to promptly perform the TTE and share the findings with the surgical team. This led to selection of the appropriate preoperative evaluation and surgical procedure.