僧帽弁閉鎖不全症モデル犬における左室圧容量曲線解析法を応用した麻酔時心血管機能解明に関する研究

Title 僧帽弁閉鎖不全症モデル犬における左室圧容量曲線解析法を応用した麻酔時心血管機能解明に関する研究( 本文 (Fulltext) ) Author(s) 合屋, 征二郎 Report No.(Doctoral Degree) 博士(獣医学) 甲第505号 Issue Date 2018-03-13 Type 博士論文 Version ETD URL http://hdl.handle.net/20.500.12099/75228 ※この資料の著作権は、各資料の著者・学協会・出版社等に帰属します。

ൔ ൔᖗᘚ㛢㙐୙඲⑕ࣔࢹࣝ≟࡟࠾ࡅࡿᕥᐊᅽᐜ㔞᭤⥺ゎᯒἲࢆᛂ⏝ࡋࡓ 㯞㓉᫬ᚰ⾑⟶ᶵ⬟ゎ᫂࡟㛵ࡍࡿ◊✲ 2017 ᖺ ᒱ㜧኱Ꮫ኱Ꮫ㝔㐃ྜ⋇་Ꮫ◊✲⛉ 㸦ᮾி㎰ᕤ኱Ꮫ㸧 ྜᒇᚁ஧㑻

┠ḟ ␎ ␎ྕ୍ぴ……….1 ⥴ゝ……….3 ➨1 ❶ య఩ኚ໬ࡀ⤒㣗㐨ᚰ࢚ࢥ࣮࡟ࡼࡗ࡚ồࡵࡽࢀࡓ๓᪉୍ᅇᢿฟ㔞࡟ཬࡰࡍᙳ     㡪 ᗎᩥ……….9 ᮦᩱ࠾ࡼࡧ᪉ἲ………...10 ⤖ᯝ………...16 ⪃ᐹ………...24 ᑠᣓ………...26 ➨2 ❶ ⤒㣗㐨ᚰ࢚ࢥ࣮࠾ࡼࡧᅽᐜ㔞᭤⥺ゎᯒ࠿ࡽᚓࡽࢀࡓ๓᪉୍ᅇᢿฟ㔞ࡢẚ㍑ ᗎᩥ………...27 ᮦᩱ࠾ࡼࡧ᪉ἲ………...29 ⤖ᯝ………...33 ⪃ᐹ………...40 ᑠᣓ………...42 ➨3 ❶ ⭝⣴㞳᩿ㄏⓎᛶჾ㉁ⓗൔᖗᘚ㛢㙐୙඲⑕≟࡟࠾ࡅࡿ࢖ࢯࣇࣝࣛࣥ࡜ࢻࣈࢱ ࣑ࣥࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿ⏝㔞౫Ꮡᛶຠᯝ ᗎᩥ………...43 ᮦᩱ࠾ࡼࡧ᪉ἲ………...45 ⤖ᯝ………...50 ⪃ᐹ………...59 ᑠᣓ………...64 ➨4 ❶ ᣑᙇᆺᚰ➽⑕⥆Ⓨᛶᶵ⬟ⓗൔᖗᘚ㛢㙐୙඲⑕≟࡟࠾ࡅࡿ࢖ࢯࣇࣝࣛࣥ࡜ࢻ

ࣈ ࣈࢱ࣑ࣥࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿ⏝㔞౫Ꮡᛶຠᯝ ᗎᩥ………...65 ᮦᩱ࠾ࡼࡧ᪉ἲ………...67 ⤖ᯝ………...70 ⪃ᐹ………...79 ᑠᣓ………...82 ⥲ᣓ………...83 ㅰ㎡………...85 ᘬ⏝ᩥ⊩………...86

1 ␎ ␎ྕ୍ぴ A Ἴ: ᕥᐊὶධ⾑ὶᚰᡣ཰⦰ᮇ㏿ᗘ Am: ൔᖗᘚ㍯㒊㏿ᗘᚰᡣ཰⦰ᮇἼ CO: ᚰᢿฟ㔞 CTR: ᚰ⬚㒌ẚ DAP: ᣑᙇᮇ⾑ᅽ DCM: ᣑᙇᆺᚰ➽⑕ E Ἴ: ᕥᐊὶධ⾑ὶ᪩ᮇᣑᙇᮇ⾑ὶ㏿ᗘ Ea: ᐇຠື⬦࢚ࣛࢫࢱࣥࢫ Ees: ᕥᐊ཰⦰ᮎᮇ࢚ࣛࢫࢱࣥࢫ Em: ൔᖗᘚ㍯㒊㏿ᗘᣑᙇ᪩ᮇἼ FSV: ๓᪉ 1 ᅇᢿฟ㔞 HR: ᚰᢿᩘ IV: 㟼⬦ෆ࣮࣎ࣛࢫᢞ୚ LAP: ᕥᡣᅽ MAP: ᖹᆒ⾑ᅽ MI: ൔᖗᘚ㛢㙐୙඲⑕ MR: ൔᖗᘚ㏫ὶ MRV: ൔᖗᘚ㏫ὶ㔞 SAP: ཰⦰ᮇ⾑ᅽ SC: ⓶ୗᢞ୚ Sm: ൔᖗᘚ㍯㒊཰⦰ᮇ㏿ᗘἼ SV: 1 ᅇᢿฟ㔞 SVR: ⥲ᮎᲈ⾑⟶᢬ᢠ

2 TEE: ⤒㣗㐨ᚰ࢚ࢥ࣮

3 ⥴ ⥴ゝ

ൔᖗᘚ㛢㙐୙඲⑕㸦Mitral valve insufficiency; MI㸧ࡣ≟࡟࠾࠸࡚㢖⦾࡟ㄆࡵࡽࢀࡿ ᚋኳᛶᚰ⑌ᝈ࡛࠶ࡿࠋCarpentier ࡣ MI ࢆჾ㉁ⓗ࡞ࢱ࢖ࣉ࡜ᶵ⬟ⓗ࡞ࢱ࢖ࣉ࡟ศ㢮ࡍ ࡿࡇ࡜࡛⑓ែࡢ⌮ゎࡸ἞⒪࡟㈉⊩࡛ࡁࡿࡇ࡜ࢆ᫂ࡽ࠿࡟ࡋࡓ㸦11㸧ࠋ≟࡟࠾࠸࡚ࡇࡢ ศ㢮ࢆእᤄࡋࡓ࡜ࡁ, ᑠᆺ≟࡛ㄆࡵࡽࢀࡿ MI ࡣ⢓ᾮ⭘ᵝኚᛶ࡟ࡼࡿൔᖗᘚ⿦⨨ࡢᔂ ቯࢆ⏕ࡌ࡚࠸ࡿࡇ࡜࠿ࡽ, ჾ㉁ⓗ࡞ࢱ࢖ࣉ࡟ศ㢮ࡉࢀࡿࠋ୍᪉, ኱ᆺ≟࡛ㄆࡵࡽࢀࡿ MI ࡣᣑᙇᆺᚰ➽⑕㸦Dilated cardiomyopathy; DCM㸧࡟ࡼࡿᘚ㍯ᣑ኱࠾ࡼࡧ཰⦰⬟ప ୗ࡟ࡼࡗ࡚ࡶࡓࡽࡉࢀࡿࡇ࡜࠿ࡽ, ᶵ⬟ⓗ࡞ࢱ࢖ࣉ࡟ศ㢮ࡉࢀࡿࠋ࠸ࡎࢀࡢ MI ࡶࡑ ࡢ୺ࡓࡿ⑓ែࡣൔᖗᘚ㏫ὶ㸦Mitral valve regurgitation; MR㸧࡟㉳ᅉࡍࡿࡶࡢ࡛࠶ࡾ, MR ࡢᏑᅾ࡟ࡼࡗ࡚๓㈇Ⲵࡢቑ኱࡜๓᪉ᢿฟ㔞㸦Forward stroke volume; FSV㸧ࡢపୗ ࡀᘬࡁ㉳ࡇࡉࢀ㸦26㸧, ࡑࢀࡣ⫵Ỉ⭘ࡸ⮚ჾ㞀ᐖࡢཎᅉ࡜࡞ࡾ, Ṛ࡟⮳ࡿࠋ ㏆ᖺ, ࣌ࢵࢺࡢ㧗㱋໬࡟క࠸, MI ࡢ⑕౛࡟᳨ᰝࡸᡭ⾡ࡢࡓࡵࡢ඲㌟㯞㓉ࢆ࠿ࡅࡿᶵ ఍ࡀቑຍࡋ࡚࠸ࡿࠋ඲㌟㯞㓉࡟ࡼࡃ⏝࠸ࡽࢀࡿ࢖ࢯࣇࣝࣛࣥࡣᚰ➽ᢚไຠᯝࢆ᭷ࡍ ࡿࡇ࡜࠿ࡽ, ࠺ࡗ⾑ࡢቑᝏࡸ FSV ࡢపୗࢆᘬࡁ㉳ࡇࡍᜍࢀࡀ࠶ࡿ㸦38, 66, 81㸧ࠋࡑࡢ ࡓࡵMI ≟ࡢ㯞㓉୰ࡣྍ⬟࡞㝈ࡾప࠸⃰ᗘ࡛࢖ࢯࣇࣝࣛࣥࢆ⥔ᣢࡍ࡭ࡁ࡛࠶ࡿࡀ, MI ≟ࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿ࢖ࢯࣇࣝࣛࣥࡢ⃰ᗘ౫Ꮡᛶຠᯝ࡟ࡘ࠸࡚ࡣ᫂ࡽ࠿࡟ࡉࢀ࡚ ࠸࡞࠸࡜࠸࠺ၥ㢟Ⅼࡶ࠶ࡾ, ṇࡋ࠸ᚰ⾑⟶ᶵ⬟ࢥࣥࢺ࣮ࣟࣝἲࡢ⌮ゎࢆ῝ࡵࡿࡇ࡜ࡀ ᚲせ࡛࠶ࡿࠋ࢖ࢯࣇࣝࣛࣥ㯞㓉୰ࡢప⾑ᅽ࡟ᑐࡋ, ᪼ᅽ๣㸦ࢻࣃ࣑ࣥ, ࢻࣈࢱ࣑ࣥ, ࢚ࣆࢿࣇࣜࣥ࡞࡝㸧࡛ᑐᛂࡍࡿࡇ࡜ࡣࡼࡃ⏝࠸ࡽࢀࡿ᪉ἲ࡛࠶ࡿࡀ, ࢻࣃ࣑ࣥࡸ࢚ࣆ ࢿࣇࣜࣥࡢࡼ࠺࡞⾑⟶཰⦰స⏝ࢆࡶࡘ᪼ᅽ๣ࡣ࠺ࡗ⾑ࡢቑᝏࢆᘬࡁ㉳ࡇࡋ࠺ࡿ༴㝤 ᛶࡀ࠶ࡿ㸦67㸧ࠋ୍᪉, ࢻࣈࢱ࣑ࣥࡣ⏝㔞౫Ꮡᛶ࡟ᙉᚰస⏝ࡔࡅ࡛࡞ࡃ⾑⟶ᣑᙇస⏝ ࡶ᭷ࡍࡿࡓࡵ, ๓㈇Ⲵࡢቑᝏ࡞ࡋ࡟⾑ᅽࢆୖ᪼ࡉࡏࡿࡇ࡜ࡀᮇᚅࡉࢀ࡚࠸ࡿ㸦67㸧ࠋ ࡋ࠿ࡋ࡞ࡀࡽMI ≟ࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿࢻࣈࢱ࣑ࣥࡢຠᯝࡶ༑ศ࡟ࡣࢃ࠿ࡗ࡚࠾ࡽ ࡎ, ṇࡋ࠸౑⏝ἲࡢᣦ㔪ࡣ࡞࠸ࠋࡉࡽ࡟ࢻࣈࢱ࣑ࣥࡢᙉᚰస⏝࡜࢖ࢯࣇࣝࣛࣥࡢᚰ➽

4 ᢚไస⏝ࡣ஫࠸࡟ᣕᢠࡍࡿྍ⬟ᛶࡀ࠶ࡾ, ୧⸆๣㔞ࡢࣂࣛࣥࢫ࡟ࡼࡗ࡚ࡣᮇᚅ㏻ࡾࡢ ᪼ᅽຠᯝࡀᚓࡽࢀ࡞࠸ࡇ࡜ࡀ⪃࠼ࡽࢀࡿࠋMI ≟ࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡋ࡚࢖ࢯࣇࣝࣛࣥ ࡜ࢻࣈࢱ࣑ࣥࡀ⏝㔞౫Ꮡᛶ࡟࡝ࡢࡼ࠺࡞ຠᯝࢆ♧ࡍ࠿ゎ᫂ࡍࡿࡇ࡜ࡣ, Ᏻ඲࡞㯞㓉⟶ ⌮࡟࠾࠸࡚୙ྍḞ࡛࠶ࡿࠋ ᅽᐜ㔞᭤⥺ゎᯒࡣᚰᶵ⬟ホ౯ࡢࢦ࣮ࣝࢻࢫࢱࣥࢲ࣮ࢻ࡛࠶ࡾ㸦15㸧, ᚰᶵ⬟ࡢ࡯ࡰ ࡍ࡭࡚ࢆ᫂ࡽ࠿࡟ࡍࡿࡇ࡜ࡀྍ⬟࡛࠶ࡿ࡜ࡉࢀ࡚࠸ࡿࠋᅽᐜ㔞᭤⥺ࡣ, ᅽࢺࣛࣥࢫࢹ ࣮ࣗࢧ࡜ᐜ✚ࢭࢢ࣓ࣥࢺࡀྜࢃࡉࡗࡓPV ࢥࣥࢲࢡࢱࣥࢫ࢝ࢸ࣮ࢸࣝࢆᕥᐊෆ࡟␃⨨ ࡍࡿࡇ࡜࡟ࡼࡗ࡚ࢥࣥࣆ࣮ࣗࢱୖ࡛ᚓࡿࡇ࡜ࡀ࡛ࡁࡿࠋᚓࡽࢀࡓᅽᐜ㔞᭤⥺ࡣᑓ⏝ ࡢࢯࣇࢺ࢙࢘࢔࡛ゎᯒࡋ, 1 ᚰ࿘ᮇ࡟࠾ࡅࡿᅽ࣭ᐜ✚ࢆồࡵࡿࡇ࡜࡛ྛ✀ᚰᶵ⬟ࢆᚓ ࡿࡇ࡜ࡀྍ⬟࡜࡞ࡿ(ࡓ࡜࠼ࡤ FSV ࡣᣑᙇᮎᮇᐜ✚࡜཰⦰ᮎᮇᐜ✚ࡢᕪ࠿ࡽồࡵࡽࢀ ࡿ)ࠋࡲࡓ, Ⳣࡽࡣ๓ᚋ㈇Ⲵࡢᙳ㡪ࢆཷࡅ࡞࠸ᚰ➽ᅛ᭷ࡢ཰⦰⬟ᣦᶆ࡜ࡋ࡚ᕥᐊ཰⦰ ᮎᮇ࢚ࣛࢫࢱࣥࢫ㸦End-systolic elastance; Ees㸧ࢆ㸦75㸧, ◁ᕝࡽࡣᚋ㈇Ⲵࡢᣦᶆ࡜ࡋ ࡚ᐇ⾜ື⬦࢚ࣛࢫࢱࣥࢫ㸦Effective arterial elastance; Ea㸧ࡢᴫᛕࢆᥦၐࡋ㸦77㸧, ᚰ ⾑⟶ᶵ⬟࡟ᑐࡍࡿ⪃࠼ࢆ኱ࡁࡃ๓㐍ࡉࡏ࡚ࡁࡓ㸦ᅗ1㸧ࠋEes ࡣ๓ᚋ㈇Ⲵࢆኚ໬ࡉࡏ ࡚ࡶ୍ᐃࡢ཰⦰᮲௳ୗ࡛ࡣ୙ኚࡢ್ࢆ♧ࡍᙎᛶ᫬ኚ≉ᛶ࡛࠶ࡾ, Ea ࡜ࡢ㛵ಀᛶ࡟ࡼ ࡾᚰ⾑⟶ᶵ⬟ࢆ⾲ࡋ, ⾑ᅽࢆỴᐃࡍࡿࠋ⾑ᅽࡣ㏻ᖖᚰᢿฟ㔞࡜⥲ᮎᲈ⾑⟶᢬ᢠ

㸦Systemic vascular resistance; SVR㸧ࡢ✚࡛⾲ࡉࢀࡿࡀ, ࡑࢀࡔࡅ࡛ࡣᚰ⾑⟶ᶵ⬟ࢆ༑ ศ࡟⾲ࡍࡇ࡜ࡣ࡛ࡁ࡞࠸ࠋᚰᢿฟ㔞ࡣ๓㈇Ⲵ, ᚋ㈇Ⲵ, ᚰ➽཰⦰⬟, ᚰᢿᩘ࡜࠸ࡗࡓ ከࡃࡢᅉᏊ࡟ᙳ㡪ࢆཷࡅ, ⏕యෆ୍࡛ᐃ࡟ಖࡓࢀࡿഴྥ࡟࠶ࡿࡓࡵ࡛࠶ࡿࠋࡲࡓ, SVR ࡣཝᐦ࡟ࡣື⬦⣔ࡍ࡭࡚ࡢ᢬ᢠࡢ⥲࿴ࢆព࿡ࡋ࡚࠸࡞࠸ࡇ࡜ࡶၥ㢟ࡢ 1 ࡘ࡛࠶ ࡿࠋSVR ࡣᐃᖖὶ࡟ᑐࡍࡿ᢬ᢠ࡛࠶ࡾ, ᢿືᛶࡢ⾑ὶ࡟ᑐࡍࡿ᢬ᢠࢆព࿡ࡋ࡚࠸࡞ ࠸ࡓࡵ࡛࠶ࡿ㸦57㸧ࠋᢿືᛶࡢᅽ࡜⾑ὶ࡟ᑐࡍࡿ᢬ᢠࢆホ౯ࡍࡿ㝿ࡢࢦ࣮ࣝࢻࢫࢱࣥ ࢲ࣮ࢻࡣື⬦࢖ࣥࣆ࣮ࢲࣥࢫࢆ ᐃࡍࡿࡇ࡜࡛࠶ࡿࡀ㸦57㸧, ື⬦࢖ࣥࣆ࣮ࢲࣥࢫࡢ ィ ࡣ㠀ᖖ࡟↹㞧࡛࠶ࡾ, ᅔ㞴࡛࠶ࡿࠋࡇࢀ࡟ᑐࡋ࡚ Ea ࡣᐃᖖὶ࡟ᑐࡍࡿ᢬ᢠ࡜ᢿ

5 ືὶ࡟ᑐࡍࡿ᢬ᢠࢆ⤫ྜࡋࡓᣦᶆ࡛࠶ࡾ, ື⬦࢖ࣥࣆ࣮ࢲࣥࢫࡢホ౯ᣦᶆ࡜ࡋ࡚༑ศ ࡞ಙ㢗ᛶࢆ᭷ࡋ࡚࠸ࡿࡇ࡜ࡀࢃ࠿ࡗ࡚࠸ࡿ㸦45, 78㸧ࠋࡇࡢࡼ࠺࡟, ᅽᐜ㔞᭤⥺ゎᯒ࠿ ࡽᚓࡽࢀࡓEes ࡜ Ea ࢆ⏝࠸ࡿࡇ࡜࡛, ࢖ࢯࣇࣝࣛࣥ㸦38, 81㸧ࡸࢻࣈࢱ࣑ࣥ㸦50, 60, 70㸧ࡀṇᖖື≀ࡢᚰ⾑⟶ᶵ⬟࡟୚࠼ࡿຠᯝࡣゎ᫂ࡉࢀ࡚ࡁࡓࠋࡋ࠿ࡋ࡞ࡀࡽ, MR ࢆ ᭷ࡍࡿື≀ࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿ࢖ࢯࣇࣝࣛࣥࡸࢻࣈࢱ࣑ࣥࡢຠᯝ࡟ࡘ࠸࡚ㄪ࡭ࡓ ሗ࿌ࡣ࡞࠸ࠋ ᡃࠎࡣ㐣ཤ࡟ᐇ㦂ⓗ࡟⭝⣴ࢆ᩿⿣ࡋൔᖗᘚ⿦⨨ࢆᔂቯࡉࡏࡓჾ㉁ⓗMI ࣔࢹࣝ≟ 㸦42, 43, 79, 80㸧ࡸ㧗㢖ᗘྑᐊ࣮࣌ࢩࣥࢢ࡟ࡼࡿ DCM ⥆Ⓨᛶᶵ⬟ⓗ MI ࣔࢹࣝ≟ 㸦35㸧ࢆసᡂࡋ࡚ࡁࡓᐇ⦼ࡀ࠶ࡿࠋࡇࢀࡽࣔࢹࣝ≟࡟ᅽᐜ㔞᭤⥺ゎᯒࢆ⾜࠺ࡇ࡜࡛ ჾ㉁ⓗ࡞ࡶࡋࡃࡣᶵ⬟ⓗ࡞MI ࡟ᑐࡍࡿ࢖ࢯࣇࣝࣛࣥ࡜ࢻࣈࢱ࣑ࣥࡢᚰ⾑⟶ᶵ⬟࡟ᑐ ࡍࡿຠᯝ࡜୧⸆๣ࡢే⏝ຠᯝ࡟ࡘ࠸࡚ゎ᫂ࢆヨࡳࡓࠋ ࡋ࠿ࡋ, MI ࣔࢹࣝ≟࡟ᅽᐜ㔞᭤⥺ゎᯒࢆ⾜࠺ୖ࡛ 1 ࡘࡢ㔜኱࡞ၥ㢟ࡀᏑᅾࡋࡓࠋ MR Ꮡᅾୗ࡛ࡣᅽᐜ㔞᭤⥺ゎᯒ࠿ࡽᚓࡽࢀࡿ 1 ᅇᢿฟ㔞㸦Stroke volume; SV㸧ࡣ FSV ࡜ൔᖗᘚ㏫ὶ㔞㸦Mitral valve regurgitation volume; MRV㸧ࡢ࿴ࢆ⾲ࡋ࡚࠸ࡿࡓࡵ, FSV ࡀṇ☜࡟ホ౯࡛ࡁ࡞࠸ࡇ࡜࡛࠶ࡿ㸦ᅗ2㸧ࠋࡇࡢၥ㢟ࢆゎỴࡍࡿࡓࡵ, ᡃࠎࡣ⤒㣗㐨 ᚰ࢚ࢥ࣮㸦Transesophageal echocardiography; TEE㸧࡛ィ ࡋࡓ FSV ࢆᅽᐜ㔞᭤⥺ゎᯒ ࡟ᑟධࡍࡿ᪉ἲࢆ⪃᱌ࡋࡓࠋ ࿘⾡ᮇ୰ࡢᚰᢿฟ㔞ィ ࡟ࡣࡇࢀࡲ࡛⫵ື⬦࢝ࢸ࣮ࢸࣝ࡟ࡼࡿ⇕ᕼ㔘ἲࡀ⏝࠸ࡽ ࢀ࡚ࡁࡓࠋࡋ࠿ࡋ, ࡇࡢ᪉ἲ࡛ࡣྑᚰ⣔ࡢᚰᢿฟ㔞ࡋ࠿ィ ࡛ࡁࡎ, ୍ᚰᢿ࡟࠾ࡅࡿ FSV ࡣཝᐦ࡟ホ౯࡛ࡁ࡞࠸ࠋ୍᪉, TEE ࡣ ᐃࡋࡓ࠸㒊఩ࡢᢿฟ㔞ࢆ┤᥋ ᐃ࡛ࡁ ࡿࠋࡑࡢࡓࡵࣄࢺ་Ꮫ࡟࠾࠸࡚, TEE ࡣඛኳᛶᚰ⑌ᝈࡢデ᩿ࡸ࢝ࢸ࣮ࢸࣝ࢖ࣥࢱ࣮࣋ ࣥࢩࣙࣥ἞⒪ࡢ⿵ຓࢶ࣮ࣝ࡜ࡋ࡚᭷⏝࡛࠶ࡿࡔࡅ࡛࡞ࡃ㸦39, 55, 61㸧, ᚰ୙඲࡞࡝ࡢ 㔜⠜࡞ᝈ⪅࡟࠾ࡅࡿ㠀౵くⓗ࡞ᚰᶵ⬟ࣔࢽࢱࣜࣥࢢἲ࡜ࡋ࡚ࡶ౑⏝ࡉࢀ࡚࠸ࡿ㸦29, 64, 68㸧ࠋTEE ࡢࣃࣝࢫࢻࢵࣉࣛἲࢆ⏝࠸࡚ᚓࡽࢀࡓ⾑ὶἼᙧ࠿ࡽ FSV ࢆ ᐃࡍࡿሗ

6 ࿌ࡣࡇࢀࡲ࡛ࣄࢺࡸື≀࡟࠾࠸࡚ከࡃ࡞ࡉࢀ࡚࠸ࡿ㸦18, 29, 34, 68㸧ࠋࡋ࠿ࡋ࡞ࡀࡽ 㐣ཤࡢ≟ࡢሗ࿌࡛ࡣ, ୗ⾜኱ື⬦ࢆࡶ࡜࡟ FSV ࢆồࡵ࡚࠸ࡿࡓࡵ, ᕥ㙐㦵ୗື⬦ࡸ ⭎㢌ື⬦ࡢ⾑ὶࡀ↓どࡉࢀ࡚ࡋࡲ࠸, ᐇ㝿ࡢ FSV ࡜஋㞳ࡋ࡚࠸ࡿ㸦18, 34㸧ࠋࡇࢀ࡟ ᑐࡋ, ୗ⾜኱ື⬦࡛ࡣ࡞ࡃୖ⾜኱ື⬦ࢆ⏝࠸ࡿࡇ࡜࡛ࡇࡢၥ㢟ࡀゎỴ࡛ࡁࡿྍ⬟ᛶࡀ ࠶ࡿࡀ, ࡇࢀࡲ࡛≟ࡢୖ⾜኱ື⬦ࢆᇶ࡟ FSV ࢆồࡵࡓሗ࿌ࡣ࡞࠸ࠋ TEE ࡣ㣗㐨ෆ࠿ࡽᚰ⮚ࢆᥥฟࡍࡿࡓࡵ, ᥥฟྍ⬟࡞࢚ࢥ࣮᩿㠃ࡣᚰ⮚࡜㣗㐨ࡢ఩ ⨨㛵ಀ࡟౫Ꮡࡍࡿࠋࡑࡢࡓࡵయ఩ኚ᥮࡟ࡼࡗ࡚㣗㐨࡜ᚰ⮚ࡢ఩⨨㛵ಀࡀኚ໬ࡋ, య఩ ࡟ࡼࡗ࡚ࡣୖ⾜኱ື⬦ࡀᥥฟ࡛ࡁ࡞࠸ྍ⬟ᛶࡀ⪃࠼ࡽࢀࡓࠋࡋ࠿ࡋ࡞ࡀࡽ, ࡇࢀࡲ࡛ ࡟≟ࡢయ఩ࡀTEE ࡢᥥฟ᩿㠃࡟ཬࡰࡍᙳ㡪ࢆ᳨ウࡋࡓሗ࿌ࡣ࡞࠸ࠋࡲࡓ, య఩ࡢ㐪 ࠸ࡀ⇕ᕼ㔘ἲ࡟ࡼࡗ࡚ィ ࡉࢀࡓᚰᢿฟ㔞ࡸ㟁☢ὶ㔞ィ࡟ࡼࡗ࡚ィ ࡉࢀࡓFSV ࡟ ᙳ㡪ࡍࡿ࡜࠸࠺ሗ࿌ࡣ࠶ࡿࡀ(9, 40), TEE ࡟ࡼࡗ࡚ィ ࡉࢀࡓ FSV ࡟ᙳ㡪ࡍࡿ࡜࠸࠺ ሗ࿌ࡣ࡞࠸ࠋࡋࡓࡀࡗ࡚, య఩ࡢ㐪࠸ࡀ TEE ࡟ࡼࡗ࡚ィ ࡉࢀࡓ FSV ࡟ཬࡰࡍᙳ㡪 ࢆ᫂ࡽ࠿࡟ࡍࡿᚲせࡀ࠶ࡗࡓࠋ ࡑࡇ࡛➨1 ❶࡛ࡣ TEE ࠿ࡽᚓࡽࢀࡿୖ⾜኱ື⬦᩿㠃ࡢᥥฟ࠾ࡼࡧ FSV ࡬ࡢయ఩ኚ ᥮ࡢ୚࠼ࡿᙳ㡪ࢆ᳨ウࡋࡓࠋ ࡉࡽ࡟➨2 ❶࡛ࡣ TEE ࡜ PV ࡢ 2 ࡘࡢ᪉ἲ࡟ࡼࡗ࡚ィ ࡉࢀࡓ FSV ࡢ୍⮴ᛶࢆ᳨ ドࡍࡿࡓࡵ, ṇᖖ≟࡟࠾࠸࡚࢖ࢯࣇࣝࣛࣥ⃰ᗘ࠾ࡼࡧࢻࣈࢱ࣑ࣥᢞ୚㔞ࢆࡑࢀࡒࢀኚ ໬ࡉࡏࡓ≧ែ࡛, 2 ࡘࡢィ ᪉ἲ࠿ࡽᚓࡽࢀࡓ 2 ࡘࡢ FSV ࢆẚ㍑᳨ウࡋࡓࠋ ➨3 ❶࡛ࡣ⭝⣴᩿⿣࡟ࡼࡾసᡂࡋࡓჾ㉁ⓗ MI ࣔࢹࣝ≟ࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿ࢖ ࢯࣇࣝࣛࣥ࡜ࢻࣈࢱ࣑ࣥຠᯝࢆTEE ࡟ࡼࡗ࡚ồࡵࡓ FSV ࢆᑟධࡋࡓᅽᐜ㔞᭤⥺ゎᯒ ࢆ⏝࠸࡚ホ౯ࡋࡓࠋ ➨4 ❶࡛ࡣ DCM ࡟⥆Ⓨࡋࡓᶵ⬟ⓗ MI ࣔࢹࣝ≟ࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿ࢖ࢯࣇࣝࣛ ࣥ࡜ࢻࣈࢱ࣑ࣥຠᯝࢆTEE ࡟ࡼࡗ࡚ồࡵࡓ FSV ࢆᑟධࡋࡓᅽᐜ㔞᭤⥺ゎᯒࢆ⏝࠸ ࡚ホ౯ࡋࡓࠋ

7 ᅗ1 ᅽᐜ㔞᭤⥺ゎᯒ࡟ࡼࡿ Ees ࡜ Ea ࡢ㛵ಀᛶࠋᚋ኱㟼⬦ࡢ⾑ὶࢆ୍᫬ⓗ࡟㐽᩿ࡋ, ๓㈇Ⲵࢆ㍍ῶࡍࡿ࡜ᕥᐊᅽ࡜ᕥᐊᐜ✚ࡣᚎࠎ࡟ῶᑡࡍࡿࡓࡵᅽᐜ㔞᭤⥺ࡣᕥୗ࡟⦰ ᑠࡋ࡚࠸ࡃࠋྛᅽᐜ㔞᭤⥺ࡢ཰⦰ᮎᮇⅬࡢ㏆ఝ┤⥺ࡀEes ࡛࠶ࡾ, ๓ᚋ㈇Ⲵ࡟౫Ꮡࡋ ࡞࠸ᚰ➽ᅛ᭷ࡢ཰⦰⬟ࢆ⾲ࡍࠋEa ࡣື⬦᢬ᢠࢆ⾲ࡋ, ᚋ኱㟼⬦⾑ὶ㐽᩿๓ࡢᅽᐜ㔞 ᭤⥺ࡢ཰⦰ᮎᮇⅬ࡜x ㍈ୖࡢᣑᙇᮎᮇᐜ✚Ⅼࢆ⤖ࢇࡔ┤⥺ࡢഴࡁ࡛࠶ࡿࠋEa ࡣ⌮ㄽ ⓗ࡟཰⦰ᮎᮇᅽࢆFSV㸦ᣑᙇᮎᮇᐜ✚ - ཰⦰ᮎᮇᐜ✚㸧࡛๭ࡗࡓ್࡛⾲ࡉࢀࡿࠋᅗ ࡣṇᖖ≟ࡢᅽᐜ㔞᭤⥺࡛࠶ࡾ, ྑᅗࡢᅽᐜ㔞᭤⥺ୖࡢ㉥୸ࡀᣑᙇᮎᮇⅬ, ⥳୸ࡀ཰⦰ ᮎᮇⅬ࡛࠶ࡿࠋ

8 ᅗ2 MR Ꮡᅾୗ࡛ࡣ PV ࢥࣥࢲࢡࢱࣥࢫ࢝ࢸ࣮ࢸࣝࢆ⏝࠸ࡓᅽᐜ㔞᭤⥺ゎᯒ࡟ࡼࡾồ ࡵࡽࢀࡓSV ࡣᕥᐊ࠿ࡽ㥑ฟࡉࢀࡓᐜ✚㸦㟷▮༳+⥳▮༳㸧ࢆ⾲ࡋ࡚࠸ࡿࠋࡑࡢࡓࡵ FSV㸦㟷▮༳㸧ࢆ᫂ࡽ࠿࡟࡛ࡁ࡞࠸ࠋTEE ࢆ⏝࠸࡚ィ ࡉࢀࡓ FSV ࢆᅽᐜ㔞᭤⥺ゎ ᯒ࡟⤌ࡳ㎸ࡴࡇ࡜࡟ࡼࡾ, MR Ꮡᅾୗ࡟࠾࠸࡚ࡶṇ☜࡞ᚰᶵ⬟ホ౯ࡀ⾜࠼ࡿࡼ࠺࡟ヨ ࡳࡓࠋFSV ࡀᚓࡽࢀࢀࡤ, MRV㸦⥳▮༳㸧ࡣ SV ࡜ FSV ࡢᕪ࡜ࡋ࡚ồࡵࡿࡇ࡜ࡀ࡛ ࡁࡿࠋ

9 ➨ ➨1 ❶ య఩ኚ໬ࡀ⤒㣗㐨ᚰ࢚ࢥ࣮࡟ࡼࡗ࡚ồࡵࡽࢀࡓ๓᪉୍ᅇᢿฟ㔞࡟ཬࡰࡍᙳ 㡪 ᗎᩥ MR ࡀᏑᅾࡍࡿ≟࡟࠾࠸࡚ᅽᐜ㔞᭤⥺ゎᯒࢆ⾜࠺ࡓࡵ, TEE ࢆ⏝࠸࡚ FSV ࢆィ  ࡍࡿ᪉ἲࢆ⪃᱌ࡋࡓࡀ, ➨ 2 ❶࡜➨ 4 ❶࡛ࡣィ ᫬ࡢయ఩ࡀ␗࡞ࡿࠋ➨ 2 ❶࡛౑⏝ࡋ ࡓṇᖖ≟ࢆ⏝࠸࡚DCM ⥆Ⓨᛶᶵ⬟ⓗ MI ࣔࢹࣝ≟ࢆసᡂࡍࡿ㝿, ࣮࣌ࢩࣥࢢ࣮ࣜࢻ ࡣᕥ㢁㟼⬦࠿ࡽタ⨨ࡍࡿࡓࡵᕥഃࡢ㢁ື㟼⬦ࡀ౑⏝࡛ࡁ࡞ࡃ࡞ࡿᜍࢀࡀ࠶ࡗࡓࠋࡋ ࡓࡀࡗ࡚, ➨ 4 ❶ࡢ DCM ⥆Ⓨᛶᶵ⬟ⓗ MI ࣔࢹࣝ≟࡟࠾࠸࡚ࡣ PV ࢝ࢸ࣮ࢸࣝࢆྑ 㢁ື⬦࠿ࡽᤄධࡋ࡞ࡅࢀࡤ࡞ࡽ࡞࠿ࡗࡓࠋ௬࡟➨2 ❶࡟࠾࠸࡚ࡶྑ㢕ື⬦࠿ࡽ PV ࢝ ࢸ࣮ࢸࣝࢆᤄධࡋࡓሙྜ, ⾑⟶ࡀ⅖⑕࡞࡝࡛ᐇ㦂ᚋ࡟㛢ሰࡋ࡚ࡋࡲ࠺ᜍࢀࡀ࠶ࡗࡓࡓ ࡵ, ➨ 2 ❶ࡢṇᖖ≟࡛ࡣᕥ㢁ື⬦ࢆ౑⏝ࡋ࡞ࡅࢀࡤ࡞ࡽ࡞࠿ࡗࡓࠋୖグࡢ⌮⏤࡟ࡼ ࡾ, ➨ 2 ❶ࡢṇᖖ≟࡛ࡣྑᶓ⮩఩࡛➨ 4 ❶ࡢ DCM ⥆Ⓨᛶᶵ⬟ⓗ MI ࣔࢹࣝ≟࡛ࡣᕥ ᶓ⮩఩࡛ᐇ㦂ࢆ⾜ࡗࡓࠋୖ⾜኱ື⬦ࢆᥥฟྍ⬟࡞⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃ࡸ ࡑࡢ᩿㠃࠿ࡽồࡵࡓFSV ࡢ್ࡣ, య఩࡟ࡼࡗ࡚ࡣᥥฟ࡛ࡁ࡞࠸ྍ⬟ᛶࡸ FSV ࡢ್ࡀ ኚ໬ࡍࡿྍ⬟ᛶࡀ࠶ࡿࠋࡋࡓࡀࡗ࡚➨3 ࠾ࡼࡧ 4 ❶࡛ MI ࣔࢹࣝື≀࡟࠾ࡅࡿᚰ⾑⾜ ືែࡢィ ࡟TEE ࢆ౑⏝ࡍࡿࡢ࡟ඛ㥑ࡅ࡚, య఩ࡢ㐪࠸ࡀ⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗 ㍈᩿㠃ീࡸFSV ࡢ್࡟୚࠼ࡿᙳ㡪ࢆゎ᫂ࡍࡿᚲせࡀ࠶ࡗࡓࠋ  ᮏ❶࡛ࡣయ఩ኚ໬ࡀTEE ࡢ᩿㠃ീ࡜ FSV ࡟ཬࡰࡍᙳ㡪ࢆゎ᫂ࡍࡿࡓࡵ, ≟ࢆྑᶓ ⮩఩, ᕥᶓ⮩఩, ௮⮩఩, అ⮩఩ࡢయໃ࡟⨨ࡁ, ࡲࡎࡣྛయ఩࡛ୖ⾜኱ື⬦ࡀᥥฟྍ ⬟࠿࡝࠺࠿᳨ウࡋࡓࠋࡉࡽ࡟ୖ⾜኱ື⬦ࡀᥥฟ࡛ࡁࡓሙྜ, ྛయ఩࡟࠾࠸࡚ FSV ࢆ ィ ࡋࡓࠋࡲࡓయ఩ኚ᥮࡟క࠺⾑⾜ືែࡢኚ໬ࡢཎᅉࢆ᫂ࡽ࠿࡟ࡍࡿࡓࡵ, FSV ࡜ྠ ᫬࡟ᚰᢿฟ㔞㸦Cardiac output; CO㸧࡜ᕥᐊ཰⦰᫬㛫ࢆホ౯ࡍࡿࡇ࡜࡟ຍ࠼, ᶓ᩿ⓗ୰ 㒊㣗㐨ൔᖗᘚ㛗㍈᩿㠃ࡢᥥฟࢆ⾜࠸, ࣮࢝ࣛࢻࢵࣉࣛἲ࡜⤌⧊ࢻࢵࣉࣛἲࢆ⏝࠸࡚ᕥ ᐊὶධ⾑ὶ࡜ᚰ➽⛣ື㏿ᗘࢆホ౯ࡋࡓࠋ

10 ᮦᩱ࠾ࡼࡧ᪉ἲ 1)౪ヨື≀ ୍⯡㌟య᳨ᰝ, ⬚㒊 X ⥺᳨ᰝ, ᚰ㟁ᅗ᳨ᰝ࠾ࡼࡧᚰ࢚ࢥ᳨࣮ᰝ࡟ࡼࡾ␗ᖖࡀㄆࡵࡽ ࢀ࡞࠿ࡗࡓ1~2 ṓࡢࣅ࣮ࢢࣝ≟ 12 㢌㸦య㔜 10.0 ± 1.0 kg, 㞝 8 㢌, 㞤 4 㢌㸧ࢆ౪ヨࡋ ࡓࠋᮏᐇ㦂ࡣᮾி㎰ᕤ኱Ꮫ◊✲೔⌮ጤဨ఍ື≀ᐇ㦂ᑠጤဨ఍ࡢᢎㄆᚋ㸦ཷㅙ␒ྕ 26-87㸧, ᮾி㎰ᕤ኱ᏛⓎ⾜ࡢᐇ㦂ື≀ࡢᡭᘬࡁ࡟ᚑࡗ࡚㐙⾜ࡋࡓࠋ 2)㯞㓉࠾ࡼࡧᐇ㦂‽ഛ ࡑࢀࡒࢀࡢ౪ヨ≟࡟ࡣ࣓ࣟ࢟ࢩ࣒࢝0.2 mg/kg ⓶ୗᢞ୚㸦SC㸧㸦࣮࣮࣋ࣜࣥ࢞࢖ࣥ ࢤࣝࣁ࢖࣒ ࣋ࢺ࣓ࢹ࢕࢝ࢪࣕࣃࣥᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧, ࣈࢺࣝࣇ࢓ࣀ࣮ࣝ㓇▼ 㓟ሷ 0.2 mg/kg 㟼⬦ෆ࣮࣎ࣛࢫᢞ୚㸦IV㸧㸦᫂἞〇Ⳬᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧, ࣑ࢲ ࢰ࣒ࣛ 0.2 mg/kg IV㸦࢔ࢫࢸࣛࢫ〇⸆ᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧࡟ࡼࡿ๓ᢞ୚ࢆ⾜࠸, ࣉ࣏ࣟࣇ࢛࣮ࣝ 4 mg/kg IV㸦ࣇࣞࢮࢽ࢘ࢫ ࣮࢝ࣅ ࢪࣕࣃࣥᰴᘧ఍♫, ᮾி, ᪥ ᮏ㸧࡟ࡼࡾ㯞㓉ᑟධᚋ, Ẽ⟶ᤄ⟶ࡋ࡚ 100%㓟⣲࡜ΰྜࡋࡓ 1.5~2.0%ࡢ࢖ࢯࣇࣝࣛࣥ 㸦DS ࣇ࢓࣮࣐࢔ࢽ࣐ࣝ࣊ࣝࢫᰴᘧ఍♫, ኱㜰, ᪥ᮏ㸧྾ධ㯞㓉࡟࡚㯞㓉ࢆ⥔ᣢࡋ ࡓࠋ࿧྾ᩘ࠾ࡼࡧẼ㐨ෆᅽࡣᶵᲔⓗேᕤ࿧྾ჾ㸦Aestiva/5; Datex-Ohmeda, GE Healthcare, ᮾி, ᪥ᮏ㸧࡛⥔ᣢࡋࡓࠋࣔࢽࢱ࣮⿦⨨㸦Life Scope BSM-5192; ᪥ᮏග 㟁, ᮾி, ᪥ᮏ㸧ࢆ⏝࠸࡚࿧Ẽ⤊ᮎ஧㓟໬Ⅳ⣲ศᅽࢆィ ࡋ, 35ࠥ45mmHg ࡢ⠊ᅖ࡛ ⥔ᣢࡋࡓࠋ㐣ཤࡢᩥ⊩࡟ᚑ࠸㸦22, 51㸧, ㉸㡢Ἴ⿦⨨㸦Prosoundα10, ᪥❧࢔࣓ࣟ࢝ࢹ ࢕࢝ࣝᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧࡟᥋⥆ࡉࢀࡓ 5MHz ࣮ࣟࢱ࣮ࣜࣉ࣮ࣞࣥ TEE ࣉ࣮ࣟ ࣈ㸦Aloka UST 52119S, ᪥❧࢔࣓ࣟ࢝ࢹ࢕࢝ࣝᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧ࢆ㣗㐨ෆ࡟ᤄ ධࡋࡓࠋ≟ࡣྑᶓ⮩, ᕥᶓ⮩, ௮⮩఩࠾ࡼࡧఅ⮩఩ࡢ 4 ࡘࡢయ఩ࡢ࠺ࡕࡢ 1 ࡘࡢయ఩ ࡟ࣛࣥࢲ࣒࡟㓄⨨ࡋࡓࠋ1 ࡘࡢయ఩࡟࠾ࡅࡿ᳨ᰝࡀ⤊ࢃࡗࡓᚋ, ࣛࣥࢲ࣒࡟ูࡢయ఩ ࢆ㑅ࡧ, ≟ࡢయ఩ࢆ㟼࠿࡟ኚ࠼ࡓࠋయ఩ࡢ↓సⅭ㑅ᢥࡣ, ࡑࢀࡒࢀࡢయ఩ࢆ᭩࠸ࡓ⣬

11 ∦ࢆ⿄ࡢ୰࡟ධࢀ, ࡑࡇ࠿ࡽྲྀࡾฟࡋࡓ 1 ᯛ࡟᭩࠿ࢀ࡚࠸ࡿయ఩ࢆ㑅ࡪࡇ࡜࡛ࣛࣥࢲ ࣒໬ࡋࡓࠋࡇࡢࣉࣟࢭࢫࡣࡍ࡭࡚ࡢయ఩࡛ヨ㦂ࡀ⤊஢ࡍࡿࡲ࡛㐃⥆ࡋ࡚⧞ࡾ㏉ࡋ ࡓࠋྛయ఩࡟࠾࠸࡚⾑⾜ືែࡢᏳᐃ໬ࡀ㐩ᡂࡉࢀࡓᚋ, ᑡ࡞ࡃ࡜ࡶ 10 ศ⤒㐣ࡋ᳨࡚ ᰝࢆ⾜ࡗࡓࠋ 3)TEE ィ  㐣ཤࡢᩥ⊩࡟ᚑࡗ࡚㸦22, 51㸧, ⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃࠾ࡼࡧᶓ᩿ⓗ୰㒊 㣗㐨ൔᖗᘚ㛗㍈᩿㠃ࡢ2 ࡘࡢ᩿㠃ࢆྛయ఩࡛ᥥฟࡋࡓࠋᚰ࢚ࢥ᳨࣮ᰝࡢ ᐃࡣ࿧Ẽ ⤊ᮎ࡟⾜ࡗࡓࠋ5 ࡘࡢ㐃⥆ࡍࡿᚰᢿࡢ࠺ࡕ᭱኱್࠾ࡼࡧ᭱ᑠ್ࢆ㝖࠸ࡓ 3 ࡘࡢᚰᢿࡢ ᖹᆒ್ࢆ⟬ฟࡋࡓࠋ ⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃㸸ࣉ࣮ࣟࣈࢆᒅ᭤ࡉࡏࡎ࡟㣗㐨࡟ᤄධࡋࡓࠋḟ࡟ ࢺࣛࣥࢫࢹ࣮ࣗࢧࡢඛ➃ࢆᚋ᪉࡟᭤ࡆ, ᚰᇶ㒊ࡢ⏬ീࡀ⏕ᡂࡉࢀࡿࡲ࡛ᑿ㒊᪉ྥ࡟๓ 㐍ࡉࡏࡓ㸦22㸧ࠋࣉ࣮ࣟࣈゅᗘࢆ 75ࠥ85°࡟タᐃࡍࡿࡇ࡜࡛⦪᩿ⓗど㔝ࢆᚓ࡚, ㉸㡢 Ἴࣅ࣮࣒ࢆ୰ᚰ࡟ྥࡅࡿࡇ࡜࡟ࡼࡾ኱ື⬦ᘪࢆᥥฟࡋࡓࠋࢧࣥࣉ࣮࣒ࣝ࣎ࣜࣗࡣ⫵ ື⬦࡜ྑᚰ⪥ࣞ࣋ࣝࡢ㧗ࡉ࡛ୖ⾜኱ື⬦ࡢ୰ᚰ࡟⨨࠸ࡓ㸦ᅗ3㸧ࠋ࣮࢝ࣛࢻࢵࣉࣛἲ ࢆ⏝࠸, FSV ࡣ㏿ᗘ᫬㛫✚ศ࡜኱ື⬦᩿㠃✚ࡢ✚࡜ࡋ࡚ィ⟬ࡉࢀࡓࠋ኱ື⬦᩿㠃✚ࡣ QRS ࡢ㛤ጞ᫬࡟ෆ⦕ἲࢆ⏝࠸࡚ ᐃࡋࡓ኱ື⬦┤ᚄ࠿ࡽᚓࡓࠋCO ࡣ FSV ࡜ᚰᢿᩘ 㸦Heart rate; HR㸧ࡢ✚࡜ࡋ࡚ィ⟬ࡉࢀࡓࠋᕥᐊ཰⦰᫬㛫ࢆホ౯ࡍࡿࡓࡵ, ๓㥑ฟᮇ㛫 ࠾ࡼࡧ㥑ฟ᫬㛫ࢆ ᐃࡋ, ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫ࢆ⟬ฟࡋࡓࠋࡉࡽ࡟ HR ࡟ࡼࡗ࡚⿵ ṇࡉࢀࡓ⿵ṇ㥑ฟ᫬㛫࡜⿵ṇ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫ࢆ⟬ฟࡋࡓ㸦62㸧ࠋHR ࡣ ᐃ⏬ീ ࢆྲྀᚓࡋࡓ┤๓ࡢᢿືࡢR-R 㛫㝸࠿ࡽỴᐃࡋࡓࠋ

12

ᅗ3 ⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃ࡣࣉ࣮ࣟࣈゅᗘࢆ75ࠥ85°࡟タᐃࡋ࡚ᚓࡓࠋ ࢧ ࣥࣉ࣮࣒ࣝ࣎ࣜࣗࡣ⫵ື⬦㸦PA㸧࡜ྑᚰ⪥㸦Rau㸧ࡢ㛫ࡢୖ⾜኱ື⬦ࡢ୰ᚰ࡟఩⨨ ࡉࡏࡓࠋ๓㥑ฟᮇ㛫㸦LVPEP㸧ࡣᚰ㟁ᅗࡢQ࠿ࡽᕥᐊ㥑ฟ㛤ጞࡲ࡛ࡢᮇ㛫࡜ࡋࡓࠋ㥑 ฟ᫬㛫㸦LVET㸧ࡣᕥᐊ࠿ࡽ㥑ฟࡉࢀࡓ⾑ὶࡢᣢ⥆᫬㛫࡜ࡋࡓࠋ

13

ᶓ᩿ⓗ୰㒊㣗㐨ൔᖗᘚ㛗㍈᩿㠃: 㢌㒊㣗㐨ࡢ఩⨨࠿ࡽࣉ࣮ࣟࣈࢆࡉࡽ࡟Ẽ⟶࡟ࡼࡿ ᖸ΅ࡀ࡞ࡃ࡞ࡿࡲ࡛๓㐍ࡉࡏ࡚୰㒊㣗㐨᩿㠃ࢆᚓࡓࠋࡇࡢ఩⨨࡟࠾࠸࡚ࣉ࣮ࣟࣈゅ ᗘࢆ0°࡟ࡍࡿࡇ࡜࡛4⭍㛗㍈ീࢆᚓࡓ㸦22, 51㸧ࠋൔᖗᘚࢆᶓษࡿࢻࢵࣉࣛὶධࢆࡇࡢ ᩿㠃ࢆ⏝࠸࡚ ᐃࡋ, ࢧࣥࣉ࣮࣒ࣝ࣎ࣜࣗࢆൔᖗᘚࡢඛ➃࡟㓄⨨ࡋࡓ㸦ᅗ4㸧ࠋൔᖗᘚ ὶධ⾑ὶࢆ ᐃࡋ࡚᪩ᮇᣑᙇᮇ⾑ὶ㏿ᗘ㸦Peak early diastolic velocity; E wave㸧࠾ࡼ ࡧᚰᡣ཰⦰ᮇ㏿ᗘ㸦Peak atrial systolic velocity; A wave㸧ࢆỴᐃࡋ, E/Aࢆィ⟬ࡋࡓࠋࡑ ࡢᚋ, ྠࡌど㔝࡛⤌⧊ࢻࢵࣉࣛᚰ࢚ࢥ᳨࣮ᰝࢆ⾜ࡗࡓࠋൔᖗᘚ㍯ࡢ᭱኱཰⦰ᮇ㏿ᗘ 㸦Peak systolic velocity of mitral annulus; Sm㸧, ൔᖗᘚ㍯ࡢ᭱኱ᣑᙇ᪩ᮇ㏿ᗘ㸦Peak diastolic velocity of mitral annulus; Em㸧, ൔᖗᘚ㍯ࡢ᭱኱ᚰᡣ཰⦰ᮇ㏿ᗘ㸦Peak atrial systolic velocity of mitral annulus; Am㸧࠾ࡼࡧE wave࡜Emࡢẚ࡜ࡋ࡚E/Emࢆィ⟬ࡋ ࡓࠋ

14

ᅗ4 ᶓ᩿ⓗ୰㒊㣗㐨ൔᖗᘚ㛗㍈᩿㠃ࡣࣉ࣮ࣟࣈゅᗘࢆ 0°࡟タᐃࡋ࡚ᚓࡓࠋࢧࣥࣉࣝ ࣮࣒࣎ࣜࣗࢆ2 mm ࡟タᐃࡋ࡚ൔᖗᘚࡢඛ➃࡟⨨ࡁ, ᣑᙇ᪩ᮇἼ㸦E wave㸧࡜ᚰᡣ཰ ⦰ᮇἼ㸦A wave㸧ࢆᚓࡓࠋ

15 4)ື⬦ᅽィ 

ࡍ࡭࡚ࡢ≟࡟࠾࠸࡚24 ࢤ࣮ࢪࡢ࢝ࢸ࣮ࢸࣝࢆ㊊⫼ື⬦࡟ᤄධࡋ࡚┤᥋ⓗື⬦ᅽࣔ ࢽࢱࣜࣥࢢࢆ⾜ࡗࡓ㸦90㸧ࠋ౵くⓗື⬦⾑ᅽࡣ࢝ࢸ࣮ࢸࣝ࡟᥋⥆ࡉࢀࡓᅽຊኚ᥮ჾ 㸦DX-300, Nihon Kohden, Tokyo, Japan㸧ࢆ⏝࠸࡚┤᥋グ㘓ࡋࡓࠋື⬦ᅽἼᙧ࠿ࡽ཰⦰ ᮇື⬦ᅽ㸦Systolic arterial pressure; SAP㸧, ᖹᆒື⬦ᅽ㸦Mean arterial pressure;

MAP㸧, ᣑᙇᮇ⾑ᅽ㸦Diastolic arterial pressure; DAP㸧࠾ࡼࡧ HR ࢆỴᐃࡋ, ࣔࢽࢱࣜ ࣥࢢ⿦⨨ࢆ⏝࠸࡚グ㘓ࡋࡓࠋSVR ࡣ TEE ࠿ࡽᚓࡽࢀࡓ CO ࡜⤌ࡳྜࢃࡏ࡚, SVR = 㸦MAP - ୰ᚰ㟼⬦ᅽ㸧/CO ࠿ࡽィ⟬ࡋࡓࠋ୰ᚰ㟼⬦ᅽࡣྑᚰᡣࡢᣑᙇࡲࡓࡣ㢕㟼⬦ ᛣᙇࡀ࡞࠸ࡇ࡜࠿ࡽ, 5 mmHg ࡜ᐃ⩏ࡋࡓࠋ

5)⤫ィฎ⌮

ࡍ࡭࡚ࡢࢹ࣮ࢱࡣᖹᆒ ± ᶆ‽೫ᕪ㸦Standard deviation; SD㸧࡛♧ࡋࡓࠋṇつศᕸ ࢹ࣮ࢱ㸦FSV, CO, ⿵ṇ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫, E wave, A wave, Sm, Em, HR, SAP, MAP, DAP㸧࡟࠾ࡅࡿయ఩㛫ࡢᕪ␗ࡣ, 1-way repeated measurements ANOVA ࠾ࡼࡧ Tukey ࡢከ㔜ẚ㍑᳨ᐃࢆ౑⏝ࡋ࡚ศᯒࡋࡓࠋ㠀ṇつศᕸࢹ࣮ࢱ㸦๓㥑ฟᮇ㛫, 㥑ฟ᫬㛫, ๓ 㥑ฟᮇ㛫/㥑ฟ᫬㛫, ⿵ṇ㥑ฟ᫬㛫, ⿵ṇ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫, E/A, Am, E/Em, SVR㸧 ࡣKruskal-Wallis ᳨ᐃ࡜ Dunn ࡢከ㔜ẚ㍑᳨ᐃࢆ౑⏝ࡋ࡚ศᯒࡋࡓࠋࡲࡓ FSV ࡜ᚰ ᢿᩘ, 㥑ฟ᫬㛫࡜ᚰᢿᩘࡢ┦㛵㛵ಀࢆㄪ࡭ࡿࡓࡵ⥺ᙧᅇᖐศᯒࢆ⾜࠺ࡇ࡜࡛ᅇᖐᘧ࡜ ࣆ࢔ࢯࣥ┦㛵ಀᩘࢆỴᐃࡋࡓࠋp < 0.05 ࢆ⤫ィᏛⓗ࡟᭷ព࡜ࡋࡓࠋࡇࢀࡽࡢ⤫ィศᯒ

ࢆ⾜࠺ࡓࡵ࡟, GraphPad Prism 5.0a㸦GraphPad Prism version5.0a, GraphPad, CA, U.S.A㸧ࢆ౑⏝ࡋࡓࠋ

16 ⤖ᯝ 1)⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃 ௒ᅇᐇ᪋ࡋࡓ4 ࡘࡢయ఩࡟࠾࠸࡚ࡍ࡭࡚ࡢ≟࡛⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃ࡀ ᚓࡽࢀ, ୖ⾜኱ື⬦ࡀᥥฟ࡛ࡁࡓࠋయ఩ኚ໬ࡀᚰ࢚ࢥ࣮ᣦᶆ࡟ཬࡰࡍᙳ㡪࡟㛵ࡋ࡚, ௮⮩఩࡟࠾ࡅࡿFSV ࠾ࡼࡧ㥑ฟ᫬㛫ࡣᕥྑᶓ⮩఩࡟ẚ࡭࡚పୗࡋࡓࠋ๓㥑ฟᮇ㛫ࡣ ᕥྑᶓ⮩఩࡟ẚ࡭࡚௮⮩఩࡛ᘏ㛗ࡋࡓࠋ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫࠾ࡼࡧ⿵ṇ๓㥑ฟᮇ㛫/ 㥑ฟ᫬㛫ࡣᕥྑഃ⮩఩࡟ẚ࡭࡚௮⮩఩࡛ቑຍࡋࡓ㸦⾲1㸧ࠋ

17 ⾲1 ྛయ఩࡟࠾ࡅࡿ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃࠿ࡽᚓࡽࢀࡓ኱ື⬦ὶ㏿Ἴᙧᣦᶆ n = 12, *: p < 0.05 vs ᕥᶓ⮩఩, †: p < 0.05 vs ྑᶓ⮩఩  య఩ ᣦᶆ ᕥᶓ⮩఩ ྑᶓ⮩఩ ௮⮩఩ అ⮩఩ FSV (mL) 14 ± 3 14 ± 2 10 ± 3*† 13 ± 3 CO (L/min) 1.3 ± 0.3 1.3 ± 0.3 1.0 ± 0.3 1.2 ± 0.2 ๓㥑ฟᮇ㛫 (ms) 61 ± 5 59 ± 5 72 ± 11*† 66 ± 9 㥑ฟ᫬㛫 (ms) 210 ± 9 212 ± 15 185 ± 11*† 201 ± 20 ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫 0.29 ± 0.03 0.28 ± 0.03 0.40 ± 0.08*† 0.33 ± 0.06 ⿵ṇ㥑ฟ᫬㛫 (ms) 338 ± 21 337 ± 17 338 ± 29 335 ± 25 ⿵ṇ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫 0.29 ± 0.02 0.28 ± 0.02 0.35 ± 0.04*† 0.31 ± 0.03 HR (bpm) 88 ± 14 88 ± 12 108 ± 21*† 104 ± 15 ᕥྑᶓ⮩఩࡜ẚ࡭࡚௮⮩఩࡟࠾࠸࡚ FSV ࡢపୗ࡜๓㥑ฟᮇ㛫ࡢᘏ㛗࡜㥑ฟ᫬㛫ࡢ▷ ⦰, ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫࠾ࡼࡧ⿵ṇ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫ࡢୖ᪼ࡀㄆࡵࡽࢀࡓࠋ

18 2)ᶓ᩿ⓗ୰㒊㣗㐨ൔᖗᘚ㛗㍈᩿㠃

௒ᅇᐇ᪋ࡋࡓ4 ࡘࡢయ఩࡟࠾࠸࡚ࡍ࡭࡚ࡢ≟࡛ᶓ᩿ⓗ୰㒊㣗㐨ൔᖗᘚ㛗㍈᩿㠃ࡀ ᚓࡽࢀࡓࠋE wave ࡣᕥྑᶓ⮩᫬࡟ẚ࡭࡚௮⮩఩࡛పୗࡋࡓࠋEm ࡣᕥྑࡢᶓ⮩఩࡟ ẚ࡭࡚௮⮩఩࡛పࡃ, ྑᶓ⮩఩࡜ẚ㍑ࡋ࡚అ⮩఩࡛ప࠿ࡗࡓ㸦⾲ 2㸧ࠋ

19 ⾲2 ྛయ఩࡟࠾ࡅࡿ୰㒊㣗㐨ൔᖗᘚ㛗㍈᩿㠃࠿ࡽᚓࡽࢀࡓᕥᐊὶධ⾑ὶἼᙧ࠾ࡼ ࡧൔᖗᘚ㍯㒊ᣦᶆn = 12, *: p < 0.05 vs ᕥᶓ⮩఩, †: p < 0.05 vs ྑᶓ⮩఩  య఩ ᣦᶆ ᕥᶓ⮩఩ ྑᶓ⮩఩ ௮⮩఩ అ⮩఩ E wave (cm/sec) 57 ± 8 59 ± 9 46 ± 8*† 51 ± 8 A wave(cm/sec) 26 ± 6 26 ± 7 24 ± 5 26 ± 7 E/A 2.3 ± 0.8 2.4 ± 0.9 2.0 ± 0.4 2.1 ± 0.6 Sm (cm/sec) 6.0 ± 1.2 6.2 ± 1.4 6.5 ± 1.6 6.5 ± 1.3 Em (cm/sec) 7.1 ± 1.0 8.0 ± 1.5 5.7 ± 1.2*† 6.3 ± 0.9† Am (cm/sec) 3.9 ± 0.7 4.1 ± 1.5 3.1 ± 0.5 4.3 ± 1.5 E/Em 8.4 ± 1.6 7.5 ± 1.0 8.5 ± 2.4 8.2 ± 1.5 ᕥྑᶓ⮩఩࡜ẚ࡭࡚௮⮩఩࡟࠾࠸࡚E wave ࠾ࡼࡧ Em ࡢపୗࡀㄆࡵࡽࢀࡓࠋ

20 3)ື⬦ᅽィ 

௮⮩఩࡛ࡢHR ࠾ࡼࡧ SVR ࡣᕥྑᶓ⮩఩࡟ቑຍࡋࡓࡀ, SAP, MAP ࠾ࡼࡧ DAP ࡣ య఩㛫࡛᭷ពᕪࢆ♧ࡉ࡞࠿ࡗࡓ㸦⾲3㸧ࠋ

21 ⾲3 ྛయ఩࡟࠾ࡅࡿ HR, ⾑ᅽ, SVR ᣦᶆ n = 12, *: p < 0.05 vs ᕥᶓ⮩఩, †: p < 0.05 vs ྑᶓ⮩఩  య఩ ᣦᶆ ᕥᶓ⮩఩ ྑᶓ⮩఩ ௮⮩఩ అ⮩఩ HR (bpm) 88 ± 14 88 ± 12 108 ± 21*† 104 ± 15 SAP (mmHg) 89 ± 14 91 ± 16 100 ± 15 101 ± 19 MAP (mmHg) 63 ± 11 64 ± 11 72 ± 12 71 ± 14 DAP (mmHg) 49 ± 11 50 ± 10 59 ± 12 57 ± 13 SVR (Wood) 49 ± 18 48 ± 12 71 ± 23*† 59 ± 15 ᕥྑᶓ⮩఩࡜ẚ࡭࡚௮⮩఩࡟࠾࠸࡚HR ࡢୖ᪼࡜ SVR ࡢቑຍࡀㄆࡵࡽࢀࡓࠋ

22 4)HR ࡜ FSV ࠾ࡼࡧ㥑ฟ᫬㛫ࡢ㛵ಀᛶ

ᅗ4 ࠾ࡼࡧ 5 ࡣࡑࢀࡒࢀ HR ࡜ FSV, HR ࡜㥑ฟ᫬㛫࡜ࡢ㛫ࡢ┦㛵ࢆ♧ࡍࠋHR ࡣ FSV㸦p < 0.0001, r = -0.55㸧࠾ࡼࡧ㥑ฟ᫬㛫㸦p = 0.0005, r = -0.48㸧࡜ᙅࡃ┦㛵ࡋ࡚࠸ ࡓ㸦33㸧ࠋ

23

ᅗ5 FSV ࡜ HR ࡢ㛵ಀᛶ㸦ᕥ㸧࡜㥑ฟ᫬㛫㸦LVET㸧࡜ HR ࡢ㛵ಀᛶ㸦ྑ㸧ࠋࡑࢀࡒ ࢀHR ࡢ㛫࡟㈇ࡢ┦㛵ᛶࡀㄆࡵࡽࢀࡓࠋ

24 ⪃ᐹ ᮏ◊✲ࡣ≟࡟࠾࠸࡚⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃࠾ࡼࡧᶓ᩿ⓗ୰㒊㣗㐨ൔᖗᘚ 㛗㍈᩿㠃ࡀᮏᐇ㦂࡛⾜ࢃࢀࡓ4 ࡘࡢయ఩࡛ᥥฟྍ⬟࡛࠶ࡿࡇ࡜ࢆ᫂ࡽ࠿࡟ࡋࡓࠋୖ ⾜኱ື⬦ࡣ⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃࠿ࡽᥥฟྍ⬟࡛࠶ࡗࡓࠋᮏ◊✲࠿ࡽᚓࡽ ࢀࡓ⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃ࡣFSV ࠾ࡼࡧ CO ࢆᥦ౪ࡋ, 㯞㓉୰ࡢᢿฟ㔞ホ ౯࡟㛵㐃ࡍࡿ㔜せ࡞᝟ሗࢆᥦ౪ࡍࡿࡇ࡜ࡀ࡛ࡁࡓࠋᮏ◊✲࡛ࡣ௮⮩఩࡛ࡢFSV ࡢῶ ᑡ࡜๓㥑ฟᮇ㛫/㥑ฟ᫬㛫࠾ࡼࡧ⿵ṇ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫ࡢቑຍࡀᕥྑᶓ⮩఩࡜ẚ࡭ ࡚ㄆࡵࡽࢀࡓࠋ࠸ࡃࡘ࠿ࡢ◊✲࡛ࡣ⿵ṇ๓㥑ฟᮇ㛫/㥑ฟ᫬㛫ࡣ㥑ฟ⋡, dP/dt ࠾ࡼࡧ SV ࡜ࡼࡾⰋዲ࡟┦㛵ࡍࡿࡇ࡜ࡀሗ࿌ࡉࢀ࡚࠸ࡿ㸦16, 30, 31, 54㸧ࠋࡋࡓࡀࡗ࡚ࡇࢀࡽ ࡢ⤖ᯝࡣ௮⮩఩࡟࠾ࡅࡿ࣏ࣥࣉᶵ⬟ࡢపୗࢆ♧၀ࡋ࡚࠸ࡿࠋࡇࡢ⾑⾜ຊᏛⓗኚ໬ࡣ, ᚋ㈇Ⲵࡢቑຍ, ๓㈇Ⲵࡢῶᑡ࠾ࡼࡧ཰⦰⬟ࡢపୗ࡜࠸࠺࠸ࡃࡘ࠿ࡢせᅉ࡟ࡼࡗ࡚ᘬࡁ ㉳ࡇࡉࢀࡿ࡜⪃࠼ࡽࢀࡿࠋᕥᐊࡢ཰⦰⬟ࢆ⾲ࡍSm ࡛ࡣ᭷ពᕪࡀㄆࡵࡽࢀ࡞࠿ࡗࡓ ࡓࡵ,཰⦰⬟పୗࡢᙳ㡪ࡣ↓ど࡛ࡁࡿࡶࡢ࡜ᛮࢃࢀࡿࠋ௮⮩఩࡟࠾ࡅࡿ SVR ࡢቑຍࡣ ᚋ㈇Ⲵࡀᕥྑᶓ⮩఩ࡼࡾࡶቑຍࡍࡿࡇ࡜ࢆ♧ࡋ࡚࠸ࡿࠋࡉࡽ࡟E wave ࠾ࡼࡧ Em ࡢ ῶᑡ࡟ࡼࡗ࡚♧ࡉࢀ࡚࠸ࡿࡼ࠺࡟௮⮩఩࡛ࡣ๓㈇Ⲵࡢῶᑡࡶ␲ࢃࢀࡓ㸦58㸧ࠋ⿵ṇ㥑 ฟ᫬㛫ࡶ๓㈇Ⲵᣦᶆ࡛࠶ࡿࡀ㸦47, 52㸧, ⿵ṇ㥑ฟ᫬㛫ࡣᚋ㈇Ⲵ㸦73㸧࠾ࡼࡧᚰ཰⦰ ⬟㸦4, 49㸧࡟ࡼࡗ࡚ࡶᙳ㡪ࢆཷࡅࡿࠋኚ໬ࡋ࡞࠸⿵ṇ㥑ฟ᫬㛫ࡣ๓㈇Ⲵࡢῶᑡ࡜ᚋ ㈇Ⲵࡢቑຍࡀྠ᫬࡟㉳ࡇࡗࡓࡓࡵ࡜ᛮࢃࢀࡿࠋ௨ୖࢆࡲ࡜ࡵࡿ࡜, ௮⮩఩࡟࠾ࡅࡿ࣏ ࣥࣉᶵ⬟ࡢపୗࡣᚋ㈇Ⲵࡢቑຍ࠾ࡼࡧ๓㈇Ⲵࡢῶᑡ࡟ࡼࡗ࡚ᘬࡁ㉳ࡇࡉࢀࡓ࡜⪃࠼ ࡓࠋ య఩ࡢኚ໬ࡣࣄࢺ㸦21, 48, 83, 87, 89㸧࠾ࡼࡧື≀㸦9, 40, 59㸧࡟࠾ࡅࡿ⾑⾜ືែ࡟ ኱ࡁ࡞ᙳ㡪ࢆཬࡰࡍࡇ࡜ࡀ▱ࡽࢀ࡚࠸ࡿࠋṇᖖ࡞ዷ፬࡟࠾࠸࡚, ௮⮩఩࠿ࡽᶓ⮩఩࡟ ࡍࡿࡇ࡜࡛CO ࡣቑຍࡍࡿࡀ㸦48, 87, 89㸧, ࡇࢀࡣዷፎ୰ࡢᏊᐑ࡟ࡼࡿୗ኱㟼⬦ࡢᅽ ㏕࡜ゎᨺࡀࡇࡢ⏕⌮Ꮫⓗ⌧㇟ࢆᘬࡁ㉳ࡇࡋࡓ࡜⪃࠼ࡽࢀ࡚࠸ࡿࠋࡉࡽ࡟య఩ኚ໬࡟

25 ࡼࡿCO ࡢῶᑡࡣዷ፬ࡢࡳ࡞ࡽࡎ㯞㓉ࢆ࠿ࡅࡓ≟࡛ࡶㄆࡵࡽࢀࡓ㸦59㸧ࠋNakao ࡽࡣ ⭡⭍⮚ჾ࡟ࡼࡿᚋ኱㟼⬦ࡢᅽ㏕࡟ࡼࡾ௮⮩఩ࡢ๓㈇Ⲵࡀῶᑡࡍࡿࡇ࡜ࢆ♧၀ࡋࡓ 㸦59㸧ࠋHoffman ࡽࡶࡲࡓయ఩ኚ໬࡟ࡼࡗ࡚ᘬࡁ㉳ࡇࡉࢀࡓ FSV ࡢኚ໬ࡀ Frank-Starling ᶵᵓ࡟㛵㐃ࡍࡿࡇ࡜ࢆሗ࿌ࡋ࡚࠸ࡿ㸦40㸧ࠋ⭡⭍⮚ჾ࡟ࡼࡿᚋ኱㟼⬦ࡢᅽ㏕ ࡀ๓㈇Ⲵῶᑡࢆᘬࡁ㉳ࡇࡍ࡞ࡽࡤ, ᡃࠎࡢ◊✲࡟࠾ࡅࡿᚋ㈇Ⲵࡢቑຍࡣྠᵝ࡟⭡㒊኱ ື⬦ࡢᅽ㏕࡟ࡼࡗ࡚⏕ࡌࡓྍ⬟ᛶࡀ⪃࠼ࡽࢀࡿࠋࡲࡓ, ᚋ኱㟼⬦ࡢᅽ㏕࡟ࡼࡗ࡚⤌⧊ ℺ὶᅽࡀୖ᪼ࡋࠊᮎᲈ⾑⟶᢬ᢠࡀୖ᪼ࡋࡓྍ⬟ᛶࡶྰᐃ࡛ࡁ࡞࠸ࠋ࠸ࡎࢀ࡟ࡋ࡚ࡶ, య఩ኚ໬࡟క࠺FSV ࡢኚ໬ࡣ⏕⌮Ꮫⓗ࡞ࡶࡢ࡛࠶ࡿ࡜⪃࠼ࡓࠋ ࡉࡽ࡟య఩ࡢኚ໬ࡣᚰ⮚ࡢ⮬ᚊ⚄⤒⣔ࡢኚㄪ࡟ᙳ㡪ࢆ୚࠼ࡿࡇ࡜ࡀ▱ࡽࢀ࡚࠸ࡿ 㸦14, 56㸧ࠋᚰ⮚ࡢ㏞㉮⚄⤒⥭ᙇࡣྑᶓ⮩఩࡟࠾࠸࡚᭱኱࡛࠶ࡾ, ஺ឤ⚄⤒⥭ᙇࡣṇᖖ ࡞ࣄࢺ⿕㦂⪅㸦14㸧࠾ࡼࡧ࠺ࡗ⾑ᛶᚰ୙඲ᝈ⪅㸦56㸧࡟࠾࠸࡚௮⮩఩࡛ቑຍࡍࡿࠋ Bornscheuer ࡽ㸦9㸧ࡀ⾜ࡗࡓ≟ࡢ◊✲࡛ࡣࠊHR ࡀ௮⮩఩࡛㧗࠿ࡗࡓ࡜ሗ࿌ࡋ࡚࠸ ࡿࠋࡋࡓࡀࡗ࡚௮⮩఩࡟࠾࠸࡚ࡣFSV ࡢῶᑡࢆ௦ൾࡍࡿ HR ୖ᪼࡟ࡼࡾ CO ࡣኚ໬ ࡋ࡞࠿ࡗࡓ࡜⪃࠼ࡓࠋ ௨ୖࡢࡇ࡜࠿ࡽ⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃ࡣᮏᐇ㦂࡛⾜ࢃࢀࡓ࡝ࡢయ఩࡟࠾ ࠸࡚ࡶྠࡌ᩿㠃ࢆᥦ౪ࡍࡿࡀ, FSV ࡣ௮⮩఩࡟࠾࠸࡚⏕⌮Ꮫⓗኚ໬ࡢᙳ㡪ࢆཷࡅࡿࡇ ࡜ࡀ᫂ࡽ࠿࡜࡞ࡗࡓࠋ

26 ᑠᣓ

⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃࠿ࡽᚓࡽࢀࡓFSV ࡣᮏᐇ㦂࡛⾜ࢃࢀࡓ࡝ࡢయ఩࡟ ࠾࠸࡚ࡶᥥฟྍ⬟࡛࠶ࡗࡓࠋࡋ࠿ࡋ࡞ࡀࡽ௮⮩఩࡟࠾࠸࡚⏕⌮Ꮫⓗኚ໬ࡢᙳ㡪ࢆ࠺ ࡅࡿࡓࡵ, FSV ࢆᅽᐜ㔞᭤⥺ゎᯒ࡟⤌ࡳ㎸ࡴ㝿ࡣ௮⮩఩௨እࡢయ఩ࡀᮃࡲࡋ࠸ࠋ

27 ➨ ➨2 ❶ ⤒㣗㐨ᚰ࢚ࢥ࣮࠾ࡼࡧᅽᐜ㔞᭤⥺ゎᯒ࠿ࡽᚓࡽࢀࡓ๓᪉୍ᅇᢿฟ㔞ࡢẚ㍑ ᗎᩥ ➨1 ❶࡛ᡃࠎࡣ TEE ࢆ⏝࠸ࡓୖ⾜኱ື⬦ࡢᥥฟࡀྑᶓ⮩఩, ᕥᶓ⮩఩, ௮⮩఩, అ ⮩఩ࡢ࡝ࡢయ఩࡟࠾࠸࡚ࡶྍ⬟࡛࠶ࡾ, ୖ⾜኱ື⬦࡛ィ ࡉࢀࡓ FSV ࡣᕥྑᶓ⮩఩ ࡛࠶ࢀࡤ⏕⌮Ꮫⓗ࡞ᙳ㡪ࢆ㝈ࡾ࡞ࡃ↓ど࡛ࡁࡿࡇ࡜ࡀ♧ࡉࢀࡓࠋࡑࡇ࡛, ṇᖖ≟࡛ࡣ ᕥᶓ⮩఩, ჾ㉁ⓗ MI ࣔࢹࣝ≟࡜ DCM ⥆Ⓨᛶᶵ⬟ⓗ MI ࣔࢹࣝ≟࡛ࡣྑᶓ⮩఩ࢆ㑅 ᢥࡋ࡚ᐇ㦂ࢆ⾜࠺ࡇ࡜࡜ࡋࡓࠋ ḟ࡟TEE ࡛ィ ࡋࡓ FSV ࢆᅽᐜ㔞᭤⥺ゎᯒ࡟ᑟධࡍࡿ࡟࠶ࡓࡾ, TEE ࠿ࡽᚓࡽࢀ ࡓFSV ࡜ᅽᐜ㔞᭤⥺ゎᯒ࠿ࡽᚓࡽࢀࡓ FSV ࡢ୍⮴ᛶࢆṇᖖ≟࡟࠾࠸࡚❧ドࡍࡿࡇ࡜ ᚲせࡀ࠶ࡗࡓࠋ  2 ࡘࡢ ᐃἲࡢ୍⮴ᛶࢆホ౯ࡍࡿࡓࡵᮏ❶࡛ࡣ Bland-Altman ᳨ᐃࢆ⏝࠸ࡓࠋBland-Altman ᳨ᐃࡣ⌧ᅾ, ᪉ἲẚ㍑◊✲୍࡛⯡ⓗ࡟⏝࠸ࡽࢀ࡚࠸ࡿ᪉ἲ࡛࠶ࡾ, ྠ᫬࡟ 2 ࡘ ࡢ᪉ἲ࡛ ᐃࢆ⾜ࡗ࡚࣌࢔࡜࡞ࡗ࡚ᚓࡽࢀࡿ ᐃ್ࡢᕪࢆ᳨ウࡍࡿ᪉ἲ࡛࠶ࡿ㸦6, 7㸧ࠋ࣌࢔࡜࡞ࡿ ᐃ್ࡢᕪࢆࣂ࢖࢔ࢫ࡜࿧ࡧ, ࣂ࢖࢔ࢫࡢ SD ࢆ⢭ᐦᗘ࡜࿧ࡪࠋࡲࡓ, ᪉ἲ㛫ࡢᕪࡣṇつศᕸࡍࡿࡓࡵ, ᖹᆒ್ ± 2SD ࡢ⠊ᅖࡍ࡞ࢃࡕࣂ࢖࢔ࢫ ± 2 × ⢭ᐦ ᗘࡢ⠊ᅖ࡟95%ࡢ ᐃ್ࡀ཰ࡲࡿࡣࡎ࡛࠶ࡾ, ࡇࡢ⠊ᅖࢆ 95%୍⮴㝈⏺㸦95%limits of agreement; LOA㸧࡜࿧ࡪࠋ2 ࡘࡢ᪉ἲ࡛ࡢ୍⮴ᗘࡀⰋዲ࡞ሙྜࡣ⤖ᯝ࡟஫᥮ᛶࡀ࠶ ࡿ࡜࠸࠺⤖ㄽࡀ࡞ࡉࢀࡿࡀ, ୍⮴ᗘࡢチᐜ⠊ᅖࡣᐃ⩏ࡉࢀ࡚࠾ࡽࡎ, ሗ࿌⪅ࡢ⿢㔞࡟ ௵ࡉࢀ࡚࠸ࡿ㸦63㸧ࠋࡇࡢᐃ⩏࡟㛵ࡋ࡚ࡣࣂ࢖࢔ࢫ࡜ LOA ࡢ୧᪉ࢆ⪃៖ࡍࡿᚲせࡀ ࠶ࡿࠋCO ホ౯ἲࡢ୍⮴ᛶࢆホ౯ࡋࡓ㐣ཤࡢሗ࿌࡛ࡣ, ᪂つ CO ホ౯ἲࡢ∦ഃ LOA ᖜࡀࢦ࣮ࣝࢻࢫࢱࣥࢲ࣮ࢻἲࡢCO ࡢࡤࡽࡘࡁ࡜ྠ⛬ᗘ࡛࠶ࢀࡤチᐜࡋ࠺ࡿ࡜ࡍࡿ ⪃࠼ࡸ㸦17㸧, ┦ᑐࣂ࢖࢔ࢫ㸦2 ࡘࡢ ᐃἲࡢᖹᆒ್࡟ᑐࡍࡿࣂ࢖࢔ࢫࡢ๭ྜ㸧ࡀ ± 20%௨ෆ࡛࠶ࢀࡤ஫᥮ᛶ࠶ࡾ࡜ࡍࡿ࡜࠸ࡗࡓሗ࿌ࡀࡉࢀ࡚࠸ࡿ㸦72㸧ࠋᮏ❶࡛ࡣ FSV ࡢ୍⮴ᛶ࡟ࡘ࠸࡚ࡇࡢ2 ࡘࡢᇶ‽ࢆ‶ࡓࡍࡇ࡜࡛஫᥮ᛶ࠶ࡾ࡜ุ᩿ࡋࡓࠋࡲࡓ FSV

28

ࡢ୍⮴ᛶࢆホ౯ࡍࡿ࡟࠶ࡓࡾ, 2 ࡘࡢ ᐃἲࡢᖹᆒ್ࡀ኱ࡁࡃ࡞ࡿ࡟క࠸ࣂ࢖࢔ࢫࡀ ቑ኱ࡍࡿẚ౛ㄗᕪࡢᏑᅾࢆྰᐃࡍࡿࡓࡵ, ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡜ࢻࣈࢱ࣑ࣥᢞ୚㔞ࢆኚ ໬ࡉࡏࡿࡇ࡜࡛FSV ࢆ኱ࡁࡃኚ໬ࡉࡏࡓࠋࡉࡽ࡟➨ 3 ❶࠾ࡼࡧ➨ 4 ❶࡛ࡢ MI ≟ࣔ ࢹࣝ≟࡜ࡢ㐪࠸ࡢཧ⪃࡜ࡍࡿࡓࡵ⾑ᅽ᝟ሗࡶFSV ィ ࡜ྠ᫬࡟グ㘓ࡋࡓࠋ

29 ᮦᩱ࠾ࡼࡧ᪉ἲ 1)౪ヨື≀ ୍⯡㌟య᳨ᰝ, ⬚㒊 X ⥺᳨ᰝ, ᚰ㟁ᅗ᳨ᰝ࠾ࡼࡧᚰ࢚ࢥ᳨࣮ᰝ࡟ࡼࡾ␗ᖖࡀㄆࡵࡽ ࢀ࡞࠿ࡗࡓ1~2 ṓࡢࣅ࣮ࢢࣝ≟㞤 6 㢌㸦య㔜 11.0 ± 2.3 kg㸧ࢆ౪ヨࡋࡓࠋᮏᐇ㦂ࡣᮾ ி㎰ᕤ኱Ꮫ◊✲೔⌮ጤဨ఍ື≀ᐇ㦂ᑠጤဨ఍ࡢᢎㄆᚋ㸦ཷㅙ␒ྕ28-56㸧, ᮾி㎰ᕤ ኱ᏛⓎ⾜ࡢᐇ㦂ື≀ࡢᡭᘬࡁ࡟ᚑࡗ࡚㐙⾜ࡋࡓࠋ 2)㯞㓉࠾ࡼࡧᐇ㦂‽ഛ ≟ࡣ➨1 ❶࡜ྠᵝ࡟๓ᢞ୚࡜㯞㓉ࢆ⾜ࡗࡓࠋࢹ࣮ࢱ᥇ྲྀࡲ࡛ࡢ‽ഛ࡟᫬㛫ࡀ࠿࠿ ࡿࡇ࡜ࡀண ࡉࢀࡓࡓࡵ, ࢔ࢺࣟࣆࣥ 0.05 mg/kg SC㸦⏣㎶〇⸆㈍኎ᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧ࢆ㏣ຍࡋ, 㓇▼㓟ࣈࢺࣝࣇ࢓ࣀ࣮ࣝࡢ௦ࢃࡾ࡟ሷ㓟ࣈࣉࣞࣀࣝࣇ࢕ࣥ 0.01 mg/kg IV㸦኱ሯ〇⸆ᰴᘧ఍♫,ᮾி, ᪥ᮏ㸧ࢆᢞ୚ࡋࡓࠋ㯞㓉ᑟධᚋ, Ẽ⟶ᤄ⟶ࡋ࡚ 100%㓟⣲࡜ΰྜࡋࡓ 1.5~2.0%ࡢ࢖ࢯࣇࣝࣛࣥ㸦DS ࣇ࢓࣮࣐࢔ࢽ࣐ࣝ࣊ࣝࢫᰴᘧ఍ ♫, ኱㜰, ᪥ᮏ㸧྾ධ㯞㓉࡟࡚㯞㓉ࢆ⥔ᣢࡋࡓࠋ࿧྾ᩘ࠾ࡼࡧẼ㐨ෆᅽࡣᶵᲔⓗேᕤ ࿧྾ჾ㸦Aestiva/5; Datex-Ohmeda, GE Healthcare, ᮾி, ᪥ᮏ㸧࡛⥔ᣢࡋࡓࠋ≟ࡣྑᶓ ⮩఩࡟ಖᐃࡉࢀ, ࣔࢽࢱ࣮⿦⨨㸦Life Scope BSM-5192; ᪥ᮏග㟁, ᮾி, ᪥ᮏ㸧ࢆ⏝ ࠸࡚࿧Ẽ⤊ᮎ஧㓟໬Ⅳ⣲ศᅽࢆィ ࡋ, 35ࠥ45 mmHg ࡢ⠊ᅖ࡛⥔ᣢࡋࡓࠋ┤⭠ , ⤒ ⓶ⓗື⬦⾑㓟⣲㣬࿴ᗘ, ࿧Ẽ୰࢖ࢯࣇࣝࣛࣥ⃰ᗘࡶྠᵝ࡟ࣔࢽࢱࣜࣥࢢࡉࢀࡓࠋ㯞㓉 ୰, ங㓟ࣜࣥࢤࣝᾮࢆ 5 mL/kg/hr ࡛ᣢ⥆㟼⬦Ⅼ⁲ࡋࡓࠋྑ኱⭣ື⬦࡟ࡣ HR, SAP, MAP, DAP ࢆィ ࡍࡿࡓࡵ࡟࢝ࢸ࣮ࢸࣝࢆタ⨨ࡋࡓࠋPV ࢥࣥࢲࢡࢱࣥࢫ࢝ࢸ࣮ࢸࣝ

㸦Ventri-Cath-507; Millar Instruments Inc, TX, U.S.A㸧ࡣ 37 °C ࡟࡚ᅽࡢࢮࣟᰯṇࢆ⾜ ࠸, X ⥺㏱どୗ࡛ᕥ㢕ື⬦ࢆ௓ࡋ࡚ᕥᚰᐊෆ࡟␃⨨ࡋࡓࠋPV ࢥࣥࢲࢡࢱࣥࢫ࢝ࢸ࣮ ࢸࣝࡣMicro-Tip Pressure Volume System-Ultra Foundation System㸦MPVS-Ultra-S; ADInstruments, Colorado Springs, CO㸧, PowerLab hardware㸦ML880 PowerLab 16/30;

30

ADInstruments, Colorado Springs, CO㸧, ࠾ࡼࡧ LabChart Pro software㸦LabChart Pro Upgrade v7; ADInstruments, Colorado Springs, CO㸧࡟᥋⥆ࡉࢀࡓࠋ

3)⾑ᅽ ᐃ

ື⬦⾑ᅽࡣ኱⭣ື⬦࡟ᤄධࡉࢀࡓ࢝ࢸ࣮ࢸࣝ࡟᥋⥆ࡉࢀࡓᅽຊࢺࣛࣥࢫࢹ࣮ࣗࢧ 㸦DX-300, Nihon Kohden, Tokyo, Japan㸧ࢆ⏝࠸࡚┤᥋グ㘓ࡉࢀࡓࠋᅽࢺࣛࣥࢫࢹ࣮ࣗ ࢧࢆ኱ື⬦ᘚ࡛ࣞ࣋ࣝࢮࣟ࡟ᰯṇࡋ, ࢝ࢸ࣮ࢸࣝࢆ࣊ࣃࣜࣥฎ⌮ࡋࡓ⏕⌮㣗ሷỈ࡛ᐃ ᮇⓗ࡟Ὑ࠸ὶࡋࡓࠋື⬦Ἴᙧ࠿ࡽSAP, MAP, DAP ࠾ࡼࡧ HR ࢆỴᐃࡋ, ࣔࢽࢱࣜࣥ ࢢ⿦⨨㸦LifeScope, BSM-5192; Nihon Kohden, Tokyo, Japan㸧ࢆ⏝࠸࡚グ㘓ࡋࡓࠋ

4)ᅽᐜ㔞᭤⥺ゎᯒ PV ࢥࣥࢲࢡࢱࣥࢫ࢝ࢸ࣮ࢸࣝࡣඛ➃࡟➼ࡋ࠸㊥㞳࡟ᇙタࡉࢀࡓ 8 ࡘࡢᴟ㟁ᴟࢆ᭷ ࡋ, 㟁ᴟ 1 ࡜ 8 ࡜ࡢ㛫࡟㟁ὶࢆ༳ຍࡍࡿࠋࡇࡢ࢝ࢸ࣮ࢸࣝࡣྛ㟁ᴟᑐ㛫ࡢࢥࣥࢲࢡࢱ ࣥࢫࡢ࿴࡛࠶ࡿ᫬㛫ኚ໬ࢥࣥࢲࢡࢱࣥࢫࢆ ᐃࡍࡿࡇ࡜࡟ࡼࡗ࡚ᚰᐊᐜ✚ࢆᚓࡿࡇ ࡜ࡀ࡛ࡁࡿ㸦3, 74㸧ࠋᅽᐜ㔞᭤⥺ࡣ PV ࢥࣥࢲࢡࢱࣥࢫ࢝ࢸ࣮ࢸࣝ࠿ࡽᚓࡽࢀࡓᅽຊ ࠾ࡼࡧᐜ✚᝟ሗ࡟ᇶ࡙࠸࡚ᙧᡂࡉࢀࡿࠋ⮬ືⓗ࡟LabChart Pro ࡟ࡼࡗ࡚グ㘓ࡉࢀࡓ 10 ಶࡢ㐃⥆ࡍࡿᅽᐜ㔞᭤⥺࠿ࡽ FSVPVࢆ ᐃࡋࡓࠋFSVPVࡣᣑᙇᮎᮇᐜ✚࠾ࡼࡧ཰ ⦰ᮎᮇᐜ✚ࡢᕪ࡜ࡋ࡚ィ⟬ࡉࢀࡓ㸦ᅗ1㸧ࠋᐇ㦂ࡢ᭱ᚋ࡟㧗ᙇ㣗ሷỈࡢ࣮࣎ࣛࢫὀධ ࢆ⾜࠸, ᚰ➽⤌⧊ࡢᖹ⾜ࢥࣥࢲࢡࢱࣥࢫࢆ ᐃࡋࡓࠋࡇࡢᡭ㡰ࡣ⏕⌮㣗ሷỈᰯṇ࠾ࡼ ࡧ⤯ᑐᐜ✚࡬ࡢኚ᥮࡟౑⏝ࡋࡓ㸦3, 74㸧ࠋᕥᐊᐜ✚ࡣ௨ୗࡢᘧ࡛⟬ฟࡋࡓࠋ ܩሺݐሻ ൌ ߙ ܮଶߪܸሺݐሻ ൅ ܩ௉ G(t): ࠶ࡿ᫬㛫(t)࡟࠾ࡅࡿ⥲ࢥࣥࢲࢡࢱࣥࢫ, L: ྛ㟁ᴟ㛫ࡢ㛗ࡉ, α: ⾑ᾮࡢᅛ᭷ఏ ᑟ್, V(t): ᕥᐊᐜ✚, GP_{: ᚰ➽⤌⧊ࡢᖹ⾜ࢥࣥࢲࢡࢱࣥࢫ}

31 5)TEE ィ  ➨1 ❶ࡢ⤖ᯝ࡟ᚑ࠸, ࡍ࡭࡚ࡢ≟ࢆྑᶓ⮩఩࡟ᅛᐃࡋ࡚ィ ࡋ, ➨ 1 ❶࡜ྠᵝࡢ᪉ ἲ࡛㣗㐨ෆ࡟TEE ࣉ࣮ࣟࣈࢆᤄධࡋࡓࠋ⦪᩿ⓗ㢌㒊㣗㐨኱ື⬦㛗㍈᩿㠃࡟࠾ࡅࡿࣃ ࣝࢫࢻࢵࣉࣛἲࢆ⏝࠸࡚, FSVTEEࢆ➨1 ❶࡜ྠᵝ࡟⟬ฟࡋࡓ㸦32㸧ࠋFSVTEEࡣᅽᐜ㔞 ᭤⥺ゎᯒ࠿ࡽᚓࡽࢀࡓFSVPV࡜ྠࡌࢱ࢖࣑ࣥࢢ࡛ ᐃࡋࡓࠋFSVTEEࡣ5 ࡘࡢᚰᢿࡢ ࠺ࡕ᭱኱್࡜᭱ᑠ್ࢆ㝖ࡃ3 ࡘࡢᚰᢿ࠿ࡽᖹᆒ್ࢆồࡵࡓࠋ 6)࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡜ࢻࣈࢱ࣑ࣥᢞ୚㔞ࡢኚ໬ ࿧Ẽ୰࢖ࢯࣇࣝࣛࣥ⃰ᗘ1.0 ± 0.1%㸦ISO1.0㸧࡛ 20 ศ㛫⥔ᣢࡉࢀࡓᚋࡢᐃᖖ≧ែ 㸦Baseline; BL㸧࡟࠾࠸࡚⾑ᅽ, FSVPV࠾ࡼࡧFSVTEEࢆ ᐃࡋࡓࠋBL  ᐃ⤊஢ᚋ, ࢻ ࣈࢱ࣑ࣥࢆ2 μg/kg/min ࡛ 10 ศ㛫㟼⬦ෆ࡟ὀධࡋ, ⾑ᅽ, FSVPV࠾ࡼࡧFSVTEEࢆ ᐃ ࡋࡓ㸦DOB2㸧ࠋ⥆࠸࡚ࢻࣈࢱ࣑ࣥࢆ 4㸦DOB4㸧, 8㸦DOB8㸧࠾ࡼࡧ 12㸦DOB12㸧 μg/kg/min ࡛㐃⥆ᢞ୚ࡋ, ࡍ࡭࡚ࡢ ᐃ್ࢆྛࢻࣈࢱ࣑ࣥὀධ㏿ᗘ࡛ ᐃࡋࡓࠋḟ࡟ ࢻࣈࢱ࣑ࣥࡢᢞ୚ࢆ୰Ṇࡋ, ࿧Ẽ୰࢖ࢯࣇࣝࣛࣥ⃰ᗘࢆ 1.5%࡟㐩ࡍࡿࡲ࡛ୖ᪼ࡉࡏ ࡓࠋ20 ศᚋ, ISO1.0 ࡜ྠᵝ࡟ FE’ISO 1.5 ± 0.1%㸦ISO1.5㸧ࡢ BL, DOB2, DOB4, DOB8 ࠾ࡼࡧDOB12 ࡢྛ ᐃ್ࢆ཰㞟ࡋࡓࠋ᭱ᚋ࡟ ISO1.0 ࠾ࡼࡧ ISO1.5 ࡜ྠᵝ࡟, ࿧Ẽ ୰࢖ࢯࣇࣝࣛࣥ⃰ᗘ 2.0 ± 0.1%㸦ISO2.0㸧࡟࠾ࡅࡿ BL, DOB2, DOB4, DOB8 ࠾ࡼࡧ DOB12 ࡢྛ ᐃ್ࢆ཰㞟ࡋࡓࠋ㯞㓉ࢆ㏻ࡋ࡚, ឤᰁண㜵ࡢࡓࡵ࢔ࣥࣆࢩࣜࣥࢼࢺࣜ ࣒࢘30 mg/kg IV ࢆ 2 ᫬㛫ẖ࠾ࡼࡧ࢝ࢸ࣮ࢸࣝ㛵㐃⾑ᰦ⑕ࡢண㜵ࡢࡓࡵ࣊ࣃࣜࣥࢼࢺ ࣒ࣜ࢘ 100 U/kg IV ࢆ 3 ᫬㛫ẖ࡟ᢞ୚ࡋࡓࠋ

7)⤫ィฎ⌮

඲࡚ࡢࢹ࣮ࢱࡣᖹᆒ ± SD ࡛♧ࡋࡓࠋྛ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿ␗࡞ࡿࢻࣈࢱ ࣑ࣥὀධ㏿ᗘ㛫ࡢẚ㍑ࡣ1-way repeated measurements ANOVA ࢆ౑⏝ࡋࡓࠋ␗࡞ࡿ࢖

32

ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿẚ㍑ࡣ2-way repeated measurements ANOVA ࢆ౑⏝ࡋࡓࠋ࣏ ࢫࢺ࣍ࢵࢡࢸࢫࢺ࡜ࡋ࡚࣎ࣥࣇ࢙࣮ࣟࢽከ㔜ẚ㍑ࢆ⏝࠸ࡓࠋFSVPV࡜FSVTEEࡣ⥺ᙧ ᅇᖐ࠾ࡼࡧࣆ࢔ࢯࣥࡢ┦㛵ಀᩘࢆ⏝࠸࡚ẚ㍑ࡉࢀࡓࠋࡉࡽ࡟Bland-Altman ศᯒࢆ⏝ ࠸࡚FSVPV࡜FSVTEEࢆẚ㍑ࡋࡓࠋ┦ᑐࣂ࢖࢔ࢫࡣ㸦FSVPV -FSVTEE㸧/㸦[FSVPV + FSVTEE]/2㸧×100 ࡜ࡋ࡚ィ⟬ࡋࡓࠋ⤫ィⓗ᭷ពᛶࡣ p < 0.05 ࡜ࡋ࡚ᐃ⩏ࡋࡓࠋࢹ࣮ࢱ ࡢ⤫ィゎᯒࡣGraphPad Prism 5.0a㸦GraphPad Prism version5.0a, GraphPad, CA, U.S.A㸧 ࢆ⏝࠸࡚⾜ࡗࡓࠋ

33 ⤖ᯝ 1)⾑ᅽ ᐃ

SAP, MAP ࠾ࡼࡧ DAP ࡣ ISO2.0 ࡛ࡣ ISO1.0 ࡼࡾࡶప࠿ࡗࡓ㸦ᅗ 5㸧ࠋࢻࣈࢱ࣑ࣥ ᢞ୚ࡣISO1.5 ࡢ DOB8 ௨ୖ࡟࠾࠸࡚ BL ࡼࡾࡶ SAP ࢆቑຍࡉࡏࡓࠋࡲࡓࢻࣈࢱ࣑ࣥ ᢞ୚ࡣISO1.5 ࠾ࡼࡧ ISO2.0 ࡢ DOB12 ࡛ HR ࢆቑຍࡉࡏࡓࠋ

34

ᅗ5 ྛ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿྛࢻࣈࢱ࣑ࣥᢞ୚㔞࡛ࡢ⾑ᅽ࡜ HR ࡢኚ໬ࠋ࢖ࢯ ࣇࣝࣛࣥ⃰ᗘࡢୖ᪼࡟కࡗ࡚⾑ᅽࡣపୗࡋࡓࠋISO1.5 ࡟࠾࠸࡚ DOB8 ௨ୖ࡛ SAP ࡣ ୖ᪼ࡋࡓࠋHR ࡣ ISO1.5 ࠾ࡼࡧ ISO2.0 ࡟࠾࠸࡚ DOB12 ࡛ୖ᪼ࡋࡓࠋ

n = 6, *: p < 0.05 vs BL, †: p < 0.05 vs DOB2, ‡: p < 0.05 vs DOB4, §: p < 0.05 vs DOB8, ll:

35 2)ᅽᐜ㔞᭤⥺ゎᯒ࠾ࡼࡧ TEE ィ ࡢኚ໬

ISO1.0 ࠾ࡼࡧ ISO2.0 ࡢ DOB12 ࡛ࡣ BL ࡜ẚ࡭࡚ FSVPV࠾ࡼࡧFSVTEEࡀୖ᪼ࡋࡓ 㸦⾲4㸧ࠋ

36

⾲4 ྛ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿྛࢻࣈࢱ࣑ࣥᢞ୚㔞࡛ࡢ FSVPV࡜FSVTEEࡢኚ໬ࠋ n = 6, *: p < 0.05 vs BL, †: p < 0.05 vs DOB2, ‡: p < 0.05 vs DOB4, §: p < 0.05 vs DOB8, ll:

p < 0.05 vs ISO1.5, ¶: p < 0.05 vs ISO2.0.

FSVPV࠾ࡼࡧFSVTEEࡣISO1.0 ࠾ࡼࡧ ISO2.0 ࡢ DOB12 ࡟࠾࠸࡚ BL ࡼࡾࡶୖ᪼ࡋ ࡓࠋDOB12 ࡢ FSVPV࠾ࡼࡧFSVTEE࡟㛵ࡋ࡚, ISO1.0 ࡣ ISO1.5 ࡼࡾࡶ㧗࠿ࡗࡓࠋ

࢖ࢯࣇࣝࣛ ࣥ⃰ᗘ

ࢻࣈࢱ࣑ࣥᢞ୚㔞

ᣦᶆ BL DOB2 DOB4 DOB8 DOB12 FSVPV (mL) ISO1.0 11 ± 3 13 ± 2 14 ± 2 15 ± 3 17 ± 4*|| ISO1.5 10 ± 2 11 ± 3 13 ± 4 12 ± 3 12 ± 3 ISO2.0 11 ± 2 13 ± 3 15 ± 4 16 ± 3 16 ± 3* FSVTEE (mL) ISO1.0 11 ± 3 12 ± 2 15 ± 3 16 ± 3 17 ± 3*|| ISO1.5 10 ± 2 11 ± 3 13 ± 4 12 ± 4 12 ± 4 ISO2.0 11 ± 2 13 ± 3 15 ± 4 16 ± 4 16 ± 3*

37 3)ᅽᐜ㔞᭤⥺ゎᯒ࠾ࡼࡧ TEE ィ ࠿ࡽᚓࡽࢀࡓ FSV ࡢẚ㍑ FSVPV࡜FSVTEEࡢ㛫࡟㠀ᖖ࡟㧗࠸┦㛵ᛶࡀㄆࡵࡽࢀࡓ㸦r = 0.9742㸧ࠋ⥺ᙧᅇᖐ᪉ ⛬ᘧࡣFSVTEE = 1.003×㸦FSVPV㸧- 0.01248 ࡛࠶ࡗࡓࠋBland-Altman ศᯒ࡟ࡼࡗ࡚, FSVPV࡜FSVTEEࡢࣂ࢖࢔ࢫࡣ-0.19 ± 1.11 mL, LOA ࡣ-2.4 - 2.0 mL ࡛࠶ࡗࡓ㸦ᅗ 6 ࠾ ࡼࡧ⾲5㸧ࠋFSVPV࡜FSVTEEࡢ┦ᑐࣂ࢖࢔ࢫࡣ-1.9 ± 10.6%࡛࠶ࡗࡓࠋ95%ಙ㢗༊㛫ࡣ -0.42 - 0.04 ࡛࠶ࡾ, ຍ⟬ㄗᕪࡣㄆࡵࡽࢀ࡞࠿ࡗࡓࠋࡲࡓࣂ࢖࢔ࢫ࡜ 2 ࡘࡢ ᐃ್ࡢᖹ ᆒࡢࣆ࢔ࢯࣥ┦㛵ࡢ᭷ព☜⋡ࡣp = 0.2279 ࡛࠶ࡾ, ẚ౛ㄗᕪࡣㄆࡵࡽࢀ࡞࠿ࡗࡓࠋ6 㢌ࡢ≟࡟࠾࠸࡚㞟ࡵࡽࢀࡓ90 ᑐࡢẚ㍑ࢹ࣮ࢱᑐࡢ࠺ࡕ 6 ࡘࡣ FSVPV࡜FSVTEEࡢ LOA ࠿ࡽ㐓⬺ࡋࡓࠋࡋ࠿ࡋ LOA ࠿ࡽࡢእࢀᗘࡣ㠀ᖖ࡟ᑠࡉ࠸ࡓࡵ, ⥺ᙧᅇᖐ᪉⛬ᘧ ࠾ࡼࡧᖹᆒ┦ᑐࣂ࢖࢔ࢫࡢィ⟬࡟ࡇࢀࡽLOA ࠿ࡽ㐓⬺ࡋࡓ 6 ᑐࡶྵࡵࡓࠋ

38 ᅗ6 ࡍ࡭࡚ࡢ᮲௳ୗ࡟࠾ࡅࡿ FSVPV࡜FSVTEEࡢ┦㛵ᅗ㸦ᕥ㸧࡜Bland-Altman ᩓᕸ ᅗ㸦ྑ㸧 FSVPV࡜FSVTEEࡢ㛵ಀࡣ, ┦㛵ಀᩘ r = 0.9742 ࡛࠶ࡾ㠀ᖖ࡟㧗࠿ࡗࡓࠋᐇ⥺ࡣᅇᖐ ᘧ, Ⅼ⥺ࡣ 95%ಙ㢗༊㛫ࢆ♧ࡍࠋ Bland-Altman ᩓᕸᅗ࡟࠾࠸࡚᫂ࡽ࠿࡞ຍ⟬ㄗᕪࡸẚ౛ㄗᕪࡣㄆࡵࡽࢀ࡞࠿ࡗࡓࠋᐇ ⥺ࡣLOA, Ⅼ⥺ࡣᖹᆒࣂ࢖࢔ࢫࢆ♧ࡍࠋ

39 ⾲5 FSVPV࡜FSVTEE㛫ࡢBland-Altman ᳨ᐃ 95%ಙ㢗༊㛫ࡣ 0 ࢆ㊬࠸࡛࠾ࡾ, ຍ⟬ㄗᕪࡣㄆࡵࡽࢀ࡞࠿ࡗࡓࠋ┦ᑐࣂ࢖࢔ࢫࡣ-1.9 ± 10.6%࡛࠶ࡾ± 20%௨ෆ࡛࠶ࡗࡓࠋ ᣦᶆ ᖹᆒࣂ࢖࢔ࢫ ± SD 95%ಙ㢗༊㛫 LOA ┦ᑐࣂ࢖࢔ࢫ (%) FSVPV-FSVTEE (mL) -0.19 ± 1.11 -0.42 – 0.04 -2.4 – 2.0 -1.9 ± 10.6

40 ⪃ᐹ ᮏ◊✲࡟࠾࠸࡚ᅽᐜ㔞᭤⥺ゎᯒ࡜TEE ࢆ⏝࠸࡚ᚓࡽࢀࡓ FSV  ᐃࡢ㛫࡟ࡣ㧗࠸୍ ⮴ᛶࡀㄆࡵࡽࢀࡓࠋ0.9742 ࡜࠸࠺ r ್ࡣ FSVPV࡜FSVTEE࡜ࡢ㛫ࡢⰋዲ࡞┦㛵ࢆ♧ࡋ ࡚࠸ࡿࠋࡋ࠿ࡋ࡞ࡀࡽ㧗࠸r ್ࡣᚲࡎࡋࡶⰋዲ࡞୍⮴ࡀ࠶ࡿࡇ࡜ࢆព࿡ࡋ࡞࠸ࠋࡇ ࡢ2  ᐃ㛫ࡢྜពࢆㄪ࡭ࡿࡓࡵ࡟ᡃࠎࡣ Bland-Altman ศᯒࢆ⏝࠸ࡓࠋᡃࠎࡢ◊✲࡟ ࠾ࡅࡿ-1.9 ± 10.6%ࡢ┦ᑐࣂ࢖࢔ࢫࡣ 2 ࡘࡢ᪉ἲ㛫ࡢⰋዲ࡞୍⮴ࢆ♧၀ࡋࡓ㸦72㸧ࠋᖹ ᆒ┦ᑐࣂ࢖࢔ࢫࡣ0%࡟㏆ࡃ, SD ࡣ᪉ἲ㛫ࡢࣛࣥࢲ࣒ㄗᕪࢆ༢⣧࡟཯ᫎࡋ࡚࠸ࡿࡓ ࡵ, య⣔ⓗ࡞እࢀ್ࡣྵࡲࢀ࡚࠸࡞࠸࡜⪃࠼ࡽࢀࡓࠋࡉࡽ࡟ FSV ࡢ LOA ࡣࡍ࡭࡚ࡢ ᮲௳ୗ㸦ྛ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿྛࢻࣈࢱ࣑ࣥὀධ㏿ᗘ㸧ࡢ್ࡢSD ࡜࡯ࡰྠࡌ ࡛࠶ࡿࡢ࡛チᐜྍ⬟࡛࠶ࡿ࡜⪃࠼ࡽࢀࡿ㸦17㸧ࠋࡉࡽ࡟ FSVPV࡜FSVTEEࡢ㛫࡟ࡣຍ ⟬ㄗᕪࡸẚ౛ㄗᕪࡶほᐹࡉࢀ࡞࠿ࡗࡓࠋ௨ୖࡢ⌮⏤࠿ࡽFSVTEEࡣᅽᐜ㔞᭤⥺ゎᯒ࡛ ᚓࡽࢀࡓFSVPV࡜஫᥮ᛶࡀ㧗࠸࡜࠸࠼ࡿࠋ2 ࡘࡢ ᐃ㛫࡛㧗࠸୍⮴ᛶࡀㄆࡵࡽࢀࡓ ௚ࡢ⌮⏤࡜ࡋ࡚, ྍ⬟࡞㝈ࡾࣛࣥࢲ࣒ㄗᕪࢆ᭱ᑠ࡟ࡍࡿࡼ࠺࡟ᐇ㦂ࢆ⾜ࡗࡓࡇ࡜ࡀ⪃ ࠼ࡽࢀࡿࠋᮏ◊✲࡛ࡣ90 ᑐ࡜࠸࠺ከࡃࡢẚ㍑࣌࢔ࢆ⏝࠸࡚ ᐃᅇᩘࢆቑຍࡉࡏࡓࡓ ࡵṇ☜ᛶࡀቑࡋࡓࡶࡢ࡜⪃࠼ࡓࠋࡲࡓ, TEE ィ ࡜ PV ィ ࡢࢱ࢖࣑ࣥࢢࢆࡑࢁ࠼, ࢹ࣮ࢱࡢ᥇ྲྀ᮲௳ࢆྠ୍࡟ࡋࡓࡇ࡜ࡶ୧ ᐃἲ㛫ࡢ㧗࠸୍⮴ᛶ࡟㈉⊩ࡋࡓࡶࡢ࡜⪃ ࠼ࡽࢀࡿࠋ ୗ⾜኱ື⬦ࢆᇶ࡟ồࡵࡽࢀࡓ᥎ᐃFSV ࡛ࡣᐇ㝿ࡢ FSV ࢆ㐣ᑠホ౯ࡋ࡚ࡋࡲ࠺ྍ⬟ ᛶࡀ࠶ࡗࡓࡓࡵ, ᡃࠎࡢ◊✲࡛ࡣ FSV ࡢỴᐃ࡟ୖ⾜኱ື⬦ࢆ⏝࠸ࡓࠋࡑࡢ⤖ᯝ, ṇ ᖖ≟࡟࠾࠸࡚ᅽᐜ㔞᭤⥺ゎᯒ࠿ࡽồࡵࡽࢀࡓFSV ࡜ TEE ࠿ࡽồࡵࡽࢀࡓ FSV ࡣ㧗 ࠸୍⮴ᛶࢆ♧ࡋ, ஫᥮ᛶࡀ࠶ࡿࡇ࡜ࡀ᫂ࡽ࠿࡜࡞ࡗࡓࠋᮏ❶ࡢ⤖ᯝ࠿ࡽ, MR ࡀᏑᅾ ࡍࡿᚰ⮚࡟࠾࠸࡚TEE ࠿ࡽồࡵࡓ FSV ࢆᅽᐜ㔞᭤⥺ゎᯒ࡟ᑟධࡍࡿጇᙜᛶࡀド᫂ࡉ ࢀࡓࠋ ᮏ◊✲࡟ࡣ࠸ࡃࡘ࠿ࡢไ㝈ࡀ࠶ࡿࠋᡃࠎࡀ◊✲ࡋࡓ≟ࡣ࡯ࡰྠࡌయ᱁, ྠࡌရ✀ࡢ

41 ≟㸦ࣅ࣮ࢢࣝ㸧࡛࠶ࡾ, ṇᖖ࡞ᚰ⮚ - 㣗㐨ࡢ఩⨨㛵ಀࢆ᭷ࡋ࡚࠸ࡓࠋࡇࡢ◊✲࡟࠾ ࡅࡿᡃࠎࡢ⤖ᯝࡣ␗࡞ࡿయ᱁, ␗࡞ࡿရ✀, ࠾ࡼࡧᚰ⮚⑓࡟ࡼࡗ࡚ᘬࡁ㉳ࡇࡉࢀࡿ␗ ᖖ࡞ᚰ⮚ - 㣗㐨఩⨨㛵ಀࢆ᭷ࡍࡿ≟࡟ࡣᙜ࡚ࡣࡲࡽ࡞࠸࠿ࡶࡋࢀ࡞࠸ࠋḟ࡟ᮏ◊✲ ࡛ࡣ㧗ᙇ㣗ሷỈ࡛▹ṇࡋ࡚⤯ᑐᕥᚰᐊᐜ✚ࢆᚓࡓࡀ, ᚲࡎࡋࡶᐇ㝿ࡢᕥᚰᐊᐜ✚࡜ྠ ࡌ࡛ࡣ࡞࠸ྍ⬟ᛶࡀ࠶ࡿ㸦8㸧ࠋࡋ࠿ࡋࢥࣥࢲࢡࢱࣥࢫ࢝ࢸ࣮ࢸࣝࡢࡶࡘࡇࡢ㝈⏺ ࡣࠊ┦ᑐⓗ࡞ኚ໬ࡍ࡞ࢃࡕᕥᚰᐊᐜ✚ࡢኚ໬ࡸFSV ࡢ⤯ᑐ್㸦ᣑᙇᮎᮇᐜ✚࡜཰⦰ ᮎᮇᐜ✚ࡢᕪ㸧࡟ᙳ㡪ࢆ୚࠼࡞࠸ࡇ࡜࠿ࡽ, ᡃࠎࡢ⤖ᯝ࡟࡯࡜ࢇ࡝ᙳ㡪ࢆཬࡰࡉ࡞࠸ ࡜⪃࠼ࡓࠋ

42 ᑠᣓ

FSVTEEࡣ࢖ࢯࣇࣝࣛࣥ㯞㓉ୗ࡛ࢻࣈࢱ࣑ࣥᢞ୚ࢆ⾜ࡗࡓ࢖ࢾࡢFSVPV࡜୍⮴ࡋ ࡓࠋFSVTEEࡣFSVPVࡢ௦᭰ἲ࡜ࡋ࡚᭷⏝࡛࠶ࡿࡇ࡜ࡀ᫂ࡽ࠿࡜࡞ࡗࡓࠋ

43 ➨ ➨3 ❶ ⭝⣴㞳᩿ㄏⓎᛶჾ㉁ⓗൔᖗᘚ㛢㙐୙඲⑕≟࡟࠾ࡅࡿ࢖ࢯࣇࣝࣛࣥ࡜ࢻࣈࢱ ࣑ࣥࡢ⏝㔞౫Ꮡᛶຠᯝ ᗎᩥ ➨2 ❶࡟࠾࠸࡚ TEE ࠿ࡽồࡵࡽࢀࡓ FSV ࡜ᅽᐜ㔞᭤⥺ゎᯒ࠿ࡽᚓࡽࢀࡓ FSV ࡟ ஫᥮ᛶࡀㄆࡵࡽࢀࡓࡓࡵ, MR ࢆࡶࡘ≟࡟࠾࠸࡚ࡶᅽᐜ㔞᭤⥺ゎᯒ࡟ࡼࡿᚰ⾑⟶ᶵ⬟ ࡢホ౯ࡀྍ⬟࡜࡞ࡗࡓࠋTEE ࠿ࡽᚓࡽࢀࡓ FSV ࡜ᅽᐜ㔞᭤⥺ゎᯒ࠿ࡽᚓࡽࢀࡓᕥᐊ ཰⦰ᮎᮇᅽࡸSV ࢆ⤌ࡳྜࢃࡏࡿࡇ࡜࡛ Ea ࡸ MRV ࢆᚓࡿࡇ࡜ࡀ࡛ࡁࡿࠋᮏ❶࡛ࡣ ⭝⣴㞳᩿ㄏⓎᛶჾ㉁ⓗMI ࣔࢹࣝ≟࡟ TEE ࡟ࡼࡗ࡚ィ ࡋࡓ FSV ࢆ⤌ࡳྜࢃࡏࡓᅽ ᐜ㔞᭤⥺ゎᯒࢆ⏝࠸ࡿࡇ࡜࡛࢖ࢯࣇࣝࣛࣥ࡜ࢻࣈࢱ࣑ࣥࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿᙳ㡪 ࢆホ౯ࡍࡿࡇ࡜ࢆ┠ⓗ࡜ࡋࡓࠋ ≟࡟࠾ࡅࡿჾ㉁ⓗ࡞MI ࡣᑠᆺ≟࡟ከࡃ, ࡑࡢ࡯࡜ࢇ࡝ࡀ⢓ᾮ⭘ᵝኚᛶࢆཎᅉ࡜ࡍ ࡿ㸦1, 46㸧ࠋ⢓ᾮ⭘ᵝኚᛶ࡟ࡼࡿ MI ࡛ࡣ཰⦰⬟ࡣಖࡓࢀ࡚࠸ࡿࡇ࡜ࡀከࡃ, ୰➼ᗘ ௨ୖࡢ㔜⑕ᗘ࡛ࡣMR ࡟ࡼࡗ࡚ቑ኱ࡋࡓ๓㈇Ⲵ࡟ࡼࡾ LAP ࡢୖ᪼࡜ᚰᣑ኱ࢆ࿊ࡋ࡚ ࠸ࡿ㸦26㸧ࠋቑ኱ࡋࡓ๓㈇Ⲵ࡟ᑐᛂࡍࡿࡓࡵ, ៏ᛶᮇࡢჾ㉁ⓗ MI ≟࡛ࡣ FSV ࡣṇᖖ ᫬࡜ྠࡌ࠿ࡑࢀ௨ୖࢆ♧ࡍ࡜ࡉࢀ࡚࠸ࡿ㸦26㸧ࠋ௨ୖࡢࡼ࠺࡟ჾ㉁ⓗ MI ≟ࡣṇᖖ≟ ࡜ࡣ኱ࡁࡃ␗࡞ࡿ⾑⾜ືែࢆ࿊ࡋ࡚࠸ࡿࡓࡵ, ࢖ࢯࣇࣝࣛࣥ࡜ࢻࣈࢱ࣑ࣥࡢᚰ⾑⟶ᶵ ⬟࡟ᑐࡍࡿຠᯝࡶṇᖖ≟࡜ࡣ␗࡞ࡿྍ⬟ᛶࡀ⪃࠼ࡽࢀࡿࠋᮏ❶࡟ࡼࡾ, ჾ㉁ⓗ MI ≟ ࡢᚰ⾑⟶ᶵ⬟࡟ᑐࡍࡿ࢖ࢯࣇࣝࣛࣥ࡜ࢻࣈࢱ࣑ࣥࡢྛᚰᶵ⬟࡟ᑐࡍࡿస⏝ࡀゎ᫂ࡉ ࢀ, ჾ㉁ⓗ MI ≟ࡢ㯞㓉࡟࠾ࡅࡿ▱ぢࡀ῝ࡲࡿࡇ࡜ࡀᮇᚅࡉࢀࡿࠋ ჾ㉁ⓗMI ≟ࡣ㔜⑕ᗘ࡟ࡼࡗ࡚⾑⾜ືែࡀኚ໬ࡍࡿࠋᐇ㝿ࡢ⮫ᗋࡢ㯞㓉᫬࡟ၥ㢟࡜ ࡞ࡿࡢࡣᚰᣑ኱ࡀ⏕ࡌጞࡵࡓ⑕౛ࡀከ࠸ࡓࡵ, ᮏ❶࡛⏝࠸ࡿჾ㉁ⓗ MI ࣔࢹࣝ≟ࡣᚰ ᣑ኱ࡀㄆࡵࡽࢀࡿACVIM ศ㢮ࢫࢸ࣮ࢪ B2 ௨ୖ࡜タᐃࡋࡓ㸦2㸧ࠋࡲࡓ, LAP ࡢ๻ⓗ ࡞ୖ᪼ࡣჾ㉁ⓗMI ࡢ≉ᚩࡢ 1 ࡘ࡛࠶ࡿࡓࡵ, ࡑࡢホ౯ࡣ㠀ᖖ࡟㔜せ࡛࠶ࡿࠋࣛࢪ࢜ ࢸ࣓ࣞࢺ࣮ࣜࢩࢫࢸ࣒ࡣ⏕యෆࡢᅽࢆ㛫Ḟⓗ࡟グ㘓࡛ࡁࡿ᪉ἲ࡛࠶ࡾ, ᅽᐜ㔞᭤⥺ィ

44

 ᫬࡟㛤⬚࡞࡝ࡢవィ࡞౵く࡞ࡋ࡟LAP ࢆホ౯ྍ⬟࡛࠶ࡿࠋࡋࡓࡀࡗ࡚ᮏ❶࡛ࡣࣛ ࢪ࢜ࢸ࣓ࣞࢺ࣮ࣜࢩࢫࢸ࣒ࢆే⏝ࡍࡿࡇ࡜࡟ࡼࡾ, LAP ࡜኱ື⬦ᅽࡶྠ᫬࡟ィ ࡋ࡚ ホ౯ࡋࡓࠋ

45 ᮦᩱ࠾ࡼࡧ᪉ἲ 1)౪ヨື≀ ୍⯡㌟య᳨ᰝ, ⬚㒊 X ⥺᳨ᰝ, ᚰ㟁ᅗ᳨ᰝ࠾ࡼࡧᚰ࢚ࢥ᳨࣮ᰝ࡟ࡼࡾ␗ᖖࡀㄆࡵࡽ ࢀ࡞࠿ࡗࡓ1~2 ṓࡢࣅ࣮ࢢࣝ≟ 6 㢌㸦య㔜 10.3 ± 1.4 kg, 㞝 3 㢌, 㞤 3 㢌㸧ࢆ౪ヨࡋ ࡓࠋᮏᐇ㦂ࡣᮾி㎰ᕤ኱Ꮫ◊✲೔⌮ጤဨ఍ື≀ᐇ㦂ᑠጤဨ఍ࡢᢎㄆᚋ㸦ཷㅙ␒ྕ 28-86㸧, ᮾி㎰ᕤ኱ᏛⓎ⾜ࡢᐇ㦂ື≀ࡢᡭᘬࡁ࡟ᚑࡗ࡚㐙⾜ࡋࡓࠋ 2)⭝⣴᩿⿣࡟ࡼࡿ MI ࡢసᡂ࠾ࡼࡧࢸ࣓ࣞࢺ࣮ࣜ㏦ಙᶵ௜ࡁ࢝ࢸ࣮ࢸࣝࡢᇙࡵ㎸ࡳ ࡍ࡭࡚ࡢ≟ࡣ๓ᢞ୚࡜ࡋ࡚࣓ࣟ࢟ࢩ࣒࢝0.2mg/kg SC㸦࣮࣮࣋ࣜࣥ࢞࢖ࣥࢤࣝࣁ࢖ ࣒ ࣋ࢺ࣓ࢹ࢕࢝ࢪࣕࣃࣥ, ᮾி, ᪥ᮏ㸧, ◲㓟࢔ࢺࣟࣆࣥ 0.05 mg/kg SC㸦⏣㎶〇⸆ ㈍኎ᰴᘧ఍♫, ኱㜰, ᪥ᮏ㸧, ሷ㓟࣑ࢲࢰ࣒ࣛ 0.2 mg/kg IV㸦࢔ࢫࢸࣛࢫ〇⸆ᰴᘧ఍ ♫, ᮾி, ᪥ᮏ㸧, ሷ㓟ࣈࣉࣞࣀࣝࣇ࢕ࣥ 0.01 mg/kg IV㸦኱ሯ〇⸆ᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧ࢆᢞ୚ࡋࡓࠋࣉ࣏ࣟࣇ࢛࣮ࣝ 4 mg/kg IV㸦ࢩ࢙ࣜࣥࢢࣉࣛ࢘ᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧࡟ࡼࡗ࡚㯞㓉ᑟධᚋ, Ẽ⟶ᤄ⟶ࡋ࡚ 100%㓟⣲࡜ΰྜࡋࡓ 1.5~2.0%ࡢ࢖ࢯࣇࣝ ࣛࣥ㸦DS ࣇ࢓࣮࣐࢔ࢽ࣐ࣝ࣊ࣝࢫᰴᘧ఍♫, ኱㜰, ᪥ᮏ㸧྾ධ㯞㓉࡟࡚㯞㓉ࢆ⥔ᣢ ࡋࡓࠋ࿧྾⟶⌮ࡣሷ㓟ࢧࢡࢩࢽࣝࢥࣜࣥ0.2 mg/kg IV 㛫Ḟᢞ୚㸦࢔ࢫࢸࣛࢫ〇⸆ᰴ ᘧ఍♫, ᮾி, ᪥ᮏ㸧ࢆ⏝࠸࡚ㄪ⠇࿧྾ࢆ⾜ࡗࡓࠋษ⓶ᚋ, ࣈࣆࣂ࢝࢖ࣥ㸦࢔ࢫࢺࣛ ࢮࢿ࢝ᰴᘧ఍♫, ኱㜰, ᪥ᮏ㸧࡟ࡼࡾ⫘㛫⚄⤒ࣈࣟࢵࢡࢆ⾜ࡗࡓᚋ࡟ᐃἲ࡟ᚑࡗ࡚ᕥ ➨5 ⫘㛫࡟ࡼࡾ㛤⬚ࡋ, ᚰ⭷ࢸࣥࢺࡢసᡂࢆ⾜ࡗ࡚, ᕥᚰᡣቨ࡟ࡓࡤࡇ⦭ྜࢆ⾜ࡗ ࡓࠋ⥆࠸࡚ࡑࡢ୰ᚰ࡟ᑠษ㛤ࢆຍ࠼, ࢔ࣜࢤ࣮ࢱ࣮㖀Ꮚࢆᤄධࡋ, ⭝⣴ࢆࡘ࠿ࢇ࡛᩿ ⿣ࡉࡏ࡚MR ࢆసᡂࡋࡓࠋMR ࡢ⛬ᗘࡣ TEE ┘どୗ࡛☜ㄆࡋ࡞ࡀࡽㄪ⠇ࡋࡓࠋLAP ࢆ ᐃࡍࡿࡓࡵ࡟ࣛࢪ࢜ࢸ࣓ࣞࢺ࣮ࣜ㏦ಙᶵ௜ࡁ࢝ࢸ࣮ࢸࣝ㸦TL11M3-D70-PCTP Implant; Data Sciences International, St Paul, MN㸧ࡢ 1 ࡘࢆᕥᚰᡣቨࡢᑠษ㛤㒊ࢆ௓ࡋ ࡚ᕥᚰᡣෆ࡟ᤄධࡋࡓࠋ࢝ࢸ࣮ࢸࣝࡢඛ➃ࡀᚰ⮚ෆቨ࡟ゐࢀ࡚࠸࡞࠸ࡇ࡜ࢆ☜ㄆࡋ

46 ࡓᚋ, ࢝ࢸ࣮ࢸࣝࢆ 3-0 ࢼ࢖ࣟࣥ⦭ྜ࡛ᕥᚰᡣ࡟ྲྀࡾ௜ࡅࡓࠋḟ࡟⬚㒊኱ື⬦࡟ 3-0 ࢼ࢖ࣟࣥࢆ⏝࠸࡚⾜ࡗࡓᕵ╔⣣ࡢ୰ᚰ࡟㗦฼࡞࣓ࢫ࡛ᑠษ㛤㒊ࢆᙧᡂࡋࡓࠋ኱ື⬦ ᅽࢆ ᐃࡍࡿࡓࡵࡢࣛࢪ࢜ࢸ࣓ࣞࢺ࣮ࣜ㏦ಙᶵࡢࡶ࠺㸯ࡘࡢ࢝ࢸ࣮ࢸࣝࢆ, ᑠษ㛤㒊 ࢆ௓ࡋ࡚኱ື⬦࡟ᤄධࡋ, ࢝ࢸ࣮ࢸࣝࡢඛ➃ࡀື⬦ቨ࡟ゐࢀ࡞࠸ࡼ࠺࡟ 3-0 ࢼ࢖ࣟࣥ ࡛኱ື⬦࡟ྲྀࡾ௜ࡅࡓࠋࢸ࣓ࣞࢺ࣮ࣜ㏦ಙᶵࡢ㌟య࡬ࡢ⛣᳜࠾ࡼࡧ⬚㒊㛢㙐᪉ἲࡣ ௨๓ࡢᡭ㡰࡟ᚑࡗࡓ, ࡍ࡞ࢃࡕ㏦ಙᶵᮏయࡣᕥୖ⭎୕㢌➽እഃ㢌┤ୗࡢయഃ➽࡬࡜ᅛ ᐃࡋ, ๰㠃ࡢ➽⫗࠾ࡼࡧ⓶⭵ࢆ 3-0 ࢼ࢖ࣟࣥ⣒࡛⦭ྜࡋࡓ㸦42, 43, 79, 80㸧ࠋ⾡ᚋࡣᢠ ⏕≀㉁࡜ࡋ࡚࢔ࣥࣆࢩࣜࣥࢼࢺ࣒ࣜ࢘ 30 mg/kg IV or SC ࡢᢞ୚ࢆ BID ࡟࡚ 7 ᪥㛫, 㙠③ࢆ┠ⓗ࡜ࡋ࡚࣓ࣟ࢟ࢩ࣒࢝0.2 mg/kg SC ࡢᢞ୚ࢆ SID ࡟࡚ 3 ᪥㛫⾜ࡗࡓࠋ 3) ჾ㉁ⓗ MI ≟ࡢ㔜⑕ᗘホ౯ ⫵Ỉ⭘࠾ࡼࡧᚰᣑ኱ࢆホ౯ࡋ࡚ᐇ㦂ࣔࢹࣝ࡜ࡋ࡚ᡂ❧ࡋ࡚࠸ࡿࡇ࡜ࢆ☜ㄆࡍࡿࡓ ࡵ࡟, ≟ࡢ⬚㒊 X ⥺᳨ᰝ࠾ࡼࡧᚰ࢚ࢥ᳨࣮ᰝࢆ 1 㐌㛫ࡈ࡜࡟↓㯞㓉ୗ࡛⾜ࡗࡓࠋ⛣ ᳜ᚋ, ≟ࢆᑡ࡞ࡃ࡜ࡶ 6 ࣨ᭶ఇᜥࡉࡏࡿࡇ࡜࡛⭝⣴㞳᩿࡟ࡼࡿჾ㉁ⓗ MI ࣔࢹࣝ≟࡜ ࡋ࡚స〇ࡋ, ᫂ࡽ࠿࡞ᚰᣑ኱ࢆ☜ㄆᚋ࡟ᐇ㦂࡟⏝࠸ࡓࠋᮏ◊✲࡟⏝࠸ࡓჾ㉁ⓗ MI ࣔ ࢹࣝ≟ࡢ⾑⾜ືែࢆ☜ㄆࡍࡿࡓࡵ࡟, ࢖ࢯࣇࣝࣛࣥ࠾ࡼࡧࢻࣈࢱ࣑ࣥࡢ◊✲ࡢ๓᪥࡟ ࣛࢪ࢜ࢸ࣓ࣞࢺ࣮ࣜࢩࢫࢸ࣒ࢆ⏝࠸࡚1 ᪥ࡢᖹᆒ SAP, MAP, DAP ࠾ࡼࡧ LAP ࢆ ᐃ ࡋࡓࠋࡲࡓ, ⭝⣴㞳᩿๓࡜࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡜ࢻࣈࢱ࣑ࣥᢞ୚㔞ࡢኚ໬ᐇ㦂ࡢ㯞㓉๓ ࡟⬚㒊X ⥺᳨ᰝ࡜㉸㡢Ἴデ᩿⿦⨨㸦ProsoundF75, ᪥❧࢔࣓ࣟ࢝ࢹ࢕࢝ࣝᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧࡟᥋⥆ࡉࢀࡓ 5MHz ࡢࢭࢡࢱᆺࣉ࣮ࣟࣈ㸦UST-52124, ᪥❧࢔࣓ࣟ࢝ࢹ ࢕࢝ࣝᰴᘧ఍♫, ᮾி, ᪥ᮏ㸧ࢆ⏝࠸࡚⤒⬚ቨᚰ࢚ࢥ᳨࣮ᰝࢆ⾜ࡗࡓࠋ⬚㒊 X ⥺᳨ᰝ ࡛ࡣ⬨᳝ᚰ⮚ࢧ࢖ࢬ㸦Vertebral heart size; VHS㸧࠾ࡼࡧᚰ⬚㒌ẚ㸦Cardio-thoracic ratio; CTR㸧ࢆ ᐃࡋࡓࠋࡉࡽ࡟, ᚰ࢚ࢥ᳨࣮ᰝ࡟࠾ࡅࡿྑഐ⬚㦵᩿㠃ࡣᚰ⮚ࡢࢧ࢖ ࢬࢆ ᐃࡍࡿࡓࡵ࡟⏝࠸ࡓࠋᕥᚰᡣࡢᣑ኱ࢆホ౯ࡍࡿࡓࡵ࡟ᕥᡣ኱ື⬦ᚄẚࡣྑഐ

47

⬚㦵ᚰᇶ㒊▷㍈ീࡼࡾ⟬ฟࡋࡓࠋᚰᐊ୰㒊▷㍈ീங㢌➽ࣞ࣋ࣝࡢM ࣮ࣔࢻ࡟࡚ᕥᐊ ᣑᙇᮎᮇᚄ, ᕥᐊෆᚄ▷⦰⋡ࢆ ᐃࡋࡓࠋᕥഃᚰᑤ㒊㛗㍈᩿㠃ࡼࡾࣃࣝࢫࢻࢵࣉࣛἲ ࢆ⏝࠸࡚ᕥᐊὶධ⾑ὶ࠿ࡽE wave, A wave, E/A ࢆ ᐃࡋࡓࠋྠ᩿㠃࡟࠾࠸࡚ TDI ἲ ࢆ⏝࠸࡚ᚰᐊ୰㝸ഃࡢൔᖗᘚ㍯㒊⛣ື㏿ᗘ࠿ࡽSm, Em, E/Em ࢆィ ࡋࡓࠋᕥഃᚰᑤ 㒊5 ⭍᩿㠃࡟࠾࠸࡚ࣃࣝࢫࢻࢵࣉࣛἲࢆ⏝࠸࡚኱ື⬦⾑ὶ࠿ࡽ FSV ࡜ CO ࢆィ ࡋ ࡓࠋᚰᣑ኱ࡢᇶ‽ࡣ௨ୗࡢࡍ࡭࡚ࢆ‶ࡓࡍࡶࡢ࡜ࡋࡓ㸦10㸧ࠋᕥᐊᣑᙇᮎᮇᚄ Ӎ 35 mm, ᕥᡣ኱ື⬦ᚄẚ Ӎ 1.6, VHS Ӎ 10.5ࠋ 4)㯞㓉࠾ࡼࡧᐇ㦂‽ഛ ➨2 ❶࡜ྠᵝࡢ᪉ἲ࡛㯞㓉ࡢᑟධ⥔ᣢࢆ⾜࠸, ≟ࢆᕥᶓ⮩఩࡟㓄⨨ࡋࡓࠋ㯞㓉୰ࡢ ࣔࢽࢱࣜࣥࢢࡣ➨2 ❶࡜ྠᵝ࡟⾜ࡗࡓࠋ4Fr ࡢᚋ኱㟼⬦㛢ሰ⏝ࣂ࣮ࣝࣥ࢝ࢸ࣮ࢸࣝ 㸦ࢽࣉࣟᰴᘧ఍♫, ኱㜰, ᪥ᮏ㸧ࢆ X ⥺㏱どㄏᑟୗ࡛ᕥ኱⭣㟼⬦࠿ࡽᚋ኱㟼⬦ࡲ࡛๓ 㐍ࡉࡏࡓࠋPV ࢥࣥࢲࢡࢱࣥࢫ࢝ࢸ࣮ࢸࣝ㸦Ventri-Cath-507; Millar Instruments Inc, TX, U.S.A㸧ࢆ 37°C࡛ࢮࣟᰯṇࡋ, X ⥺㏱どୗ࡛ྑ㢕ື⬦ࢆ௓ࡋ࡚ᕥᚰᐊෆ࡟␃⨨ࡋࡓࠋ ࡑࡢᚋ࢝ࢸ࣮ࢸࣝࢆMicro-Tip Pressure Volume System-Ultra Foundation System

㸦MPVS-Ultra-S; ADInstruments, Colorado Springs, CO㸧, PowerLab ࣁ࣮ࢻ࢙࢘࢔ 㸦ML880 PowerLab 16/30; ADInstruments, Colorado Springs, CO㸧࠾ࡼࡧ LabChart Pro ࢯࣇࢺ࢙࢘࢔㸦LabChart Pro Upgrade v7; ADInstruments, Colorado Springs, CO㸧࡟᥋⥆ ࡋࡓࠋ

5)࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡜ࢻࣈࢱ࣑ࣥᢞ୚㔞ࡢኚ໬

ᕥᶓ⮩఩࡟࠾࠸࡚, ➨ 2 ❶࡜ྠᵝ࡟ィ ࢆ⾜ࡗࡓࠋィ 㡯┠࡜ࡋ࡚ࣛࢪ࢜ࢸ࣓ࣞ ࢺ࣮ࣜ ᐃ, TEE  ᐃ, ᅽᐜ㔞᭤⥺ ᐃࢆ⾜ࡗࡓࠋ

48 6)ࣛࢪ࢜ࢸ࣓ࣞࢺ࣮ࣜ ᐃ

㏦ಙᶵ࠿ࡽࡢᅽ᝟ሗࡣࢹࢪࢱࣝಙྕ࡜ࡋ࡚ࣞࢩ࣮ࣂ࣮RLA2000㸦Data Sciences International, St. Paul, MN, USA㸧࡟ࡼࡾ᳨▱ࡋ, ࢹ࣮ࢱ⤫ྜ⿦⨨ BCM100㸦Data Sciences International, St. Paul, MN, USA㸧࡟㏦ಙࡋࡓࠋࢹ࣮ࢱኚ᥮⿦⨨࡟ࡣ኱Ẽᅽᰯ ṇ⿦⨨APR-1㸦Data Sciences International, St. Paul, MN, USA㸧ࢆྲྀࡾ௜ࡅ, ṇࡋ࠸኱ Ẽᅽࢆ᳨▱ࡋ, వィ࡞ᅽኚືࢆ㝖እࡋࡓࠋࢹࢪࢱࣝಙྕࡢࢹ࣮ࢱࡣࢹ࣮ࢱ⤫ྜ⿦⨨࡟ ࡼࡗ࡚࢔ࢼࣟࢢಙྕ໬ࡋ, ゎᯒࢆ⾜࠺ࢥࣥࣆ࣮ࣗࢱ࡬࡜㌿㏦ࡋࡓࠋࢥࣥࣆ࣮ࣗࢱ࡛ࡣ 㐃⥆ࡋࡓᅽ᝟ሗ࠿ࡽ10 ⛊㛫㝸࡛ྛィ ᮇ㛫࡟࠾ࡅࡿᖹᆒ್ࢆ SAP, MAP, DAP, ᖹᆒ LAP ࡢᐇ ್࡜ࡋ࡚グ㘓ࡍࡿࡼ࠺࡟タᐃࡋࡓࠋゎᯒ࡟ࡣ DSI Dataquest A.R.TTM_4.1 㸦Data Sciences International, St. Paul, MN, USA㸧ࢆ⏝࠸ࡓࠋSAP, MAP, DAP ࠾ࡼࡧ LAP ࢆྛィ ᮇ㛫ࡢᚋ኱㟼⬦㛢ሰ๓ࡢ 5 ศ㛫࡟࠾࠸࡚ ᐃࡋࡓࠋ 7)TEE  ᐃ TEE ࢆ⏝࠸ࡓ FSV ࡢィ ࡣᕥᶓ⮩఩࡟࠾࠸࡚➨ 2 ❶࡜ྠᵝࡢ᪉ἲ࡛⾜ࢃࢀࡓࠋ 8)ᅽᐜ㔞᭤⥺ゎᯒ HR, ᕥᐊᣑᙇᮎᮇᅽ࠾ࡼࡧᐜ✚, ᕥᐊ཰⦰ᮎᮇᅽ࠾ࡼࡧᐜ✚, SV ࠾ࡼࡧ᭱኱ᕥᚰ ᐊᅽୖ᪼㏿ᗘࡣLabChart Pro ࡟ࡼࡗ࡚グ㘓ࡉࢀࡓ 10 ಶࡢ㐃⥆ࡋࡓᅽᐜ㔞᭤⥺ࢆศᯒ ࡍࡿࡇ࡜࡛ᚓࡽࢀࡓࠋMI ࣔࢹࣝ≟࡛ࡣᅽᐜ㔞᭤⥺ゎᯒ࠿ࡽᚓࡽࢀࡓ SV ࡣ FSV ࡜ MRV ࡢྜィࢆ⾲ࡍࡓࡵ, MRV ࡣ SV ࡜ TEE ィ ࡛ᚓࡽࢀࡓ FSV ࡢᕪ࡜ࡋ࡚ィ⟬ࡋ ࡓࠋࡲࡓFSV ࡜ HR ࡢ✚࠿ࡽ CO ࢆồࡵ, ᕥᐊ཰⦰ᮎᮇᅽࢆ FSV ࡛๭ࡗ࡚ Ea ࢆồࡵ ࡓࠋSVR ࡣ SVR = 79.9 ×㸦MAP - ୰ᚰ㟼⬦ᅽ㸧/CO ࡜ࡋ࡚ィ⟬ࡋࡓࠋ୰ᚰ㟼⬦ᅽࡣ ࠸ࡎࢀࡢ≟࡟࠾࠸࡚ࡶྑᚰᡣࡢᣑᙇࡶ㢕㟼⬦ࡢᣑᙇࡶࡳࡽࢀ࡞࠿ࡗࡓࡓࡵ5 mmHg ࡜ᐃ⩏ࡋࡓࠋ඲࡚ࡢኚᩘࡣ㐃⥆ࡍࡿ10 ࡢᅽᐜ㔞᭤⥺࠿ࡽᖹᆒ໬ࡉࢀࡓࠋࣂ࣮ࣝࣥ࢝

49 ࢸ࣮ࢸࣝࢆ⭾ࡽࡲࡏ୍࡚᫬ⓗ࡞ᚋ኱㟼⬦㛢ሰࢆ⾜࠸, 8 ࡘࡢ㐃⥆ࡍࡿᅽᐜ㔞᭤⥺࠿ࡽ ࡢᕥᐊ཰⦰ᮎᮇᅽᐜ✚Ⅼࡢ⥺ᙧᅇᖐࢆ⏝࠸࡚Ees ࢆỴᐃࡋࡓࠋHR ࠾ࡼࡧ SAP ࡀᐃ ᖖ≧ែ࡟ᡠࡗࡓᚋ, ᚋ኱㟼⬦㛢ሰࢆᑡ࡞ࡃ࡜ࡶ 3 ᅇ⾜ࡗࡓࠋEes ࡣ 3 ᅇࡢᚋ኱㟼⬦㛢 ሰ࠿ࡽᖹᆒ໬ࡋ, Ea/Ees ࢆィ⟬ࡋࡓࠋᐇ㦂ࡢ᭱ᚋ࡟, 㧗ᙇ㣗ሷỈࢆ࣮࣎ࣛࢫὀධࡋ࡚, ⏕⌮㣗ሷỈ㍑ṇ࠾ࡼࡧ⤯ᑐᐜ✚ኚ᥮ࢆ࠾ࡇ࡞ࡗࡓ㸦3, 74㸧ࠋ 9)⤫ィฎ⌮ ඲࡚ࡢࢹ࣮ࢱࡣᖹᆒ ± SD ࡛♧ࡋࡓࠋ⭝⣴㞳᩿๓ᚋࡢ⾑⾜ືែᣦᶆࡢẚ㍑ࡣᑐᛂ ࡢ࠶ࡿt ᳨ᐃࢆ⏝࠸ࡓࠋྛ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿ␗࡞ࡿࢻࣈࢱ࣑ࣥὀධ㏿ᗘ㛫ࡢ ẚ㍑ࡣ1-way repeated measurements ANOVA ࢆ౑⏝ࡋࡓࠋ␗࡞ࡿ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟ ࠾ࡅࡿẚ㍑ࡣ2-way repeated measurements ANOVA ࢆ౑⏝ࡋࡓࠋ࣏ࢫࢺ࣍ࢵࢡࢸࢫࢺ ࡜ࡋ࡚࣎ࣥࣇ࢙࣮ࣟࢽከ㔜ẚ㍑ࢆ⏝࠸ࡓࠋ⤫ィⓗ᭷ពᛶࡣp < 0.05 ࡜ࡋ࡚ᐃ⩏ࡉࢀ

ࡓࠋࢹ࣮ࢱࡢ⤫ィゎᯒࡣGraphPad Prism 5.0a㸦GraphPad Prism version5.0a, GraphPad, CA, U.S.A㸧ࢆ⏝࠸࡚⾜ࡗࡓࠋ

50 ⤖ᯝ 1)ჾ㉁ⓗ MI ࣔࢹࣝ≟ࡢ㔜⑕ᗘ

MI ࢆㄏⓎࡋ࡚ࣛࢪ࢜ࢸ࣓ࣞࢺ࣮ࣜ㏦ಙჾࢆᇙࡵ㎸ࡴ᧯సࡣࡍ࡭࡚ࡢ≟࡟࠾࠸࡚ᡂ ຌࡋࡓࠋSAP ࡣ 111 ± 8 mmHg, MAP ࡣ 92 ± 5 mmHg, DAP ࡣ 75 ± 3 mmHg, LAP ࡣ 10.1 ± 1.8 mmHg ࡛࠶ࡗࡓࠋ⬚㒊 X ⥺᳨ᰝ࡛ࡣ VHS ࡣ 13.0 ± 0.4, CTR ࡣ 60.4 ± 3.1% ࡛࠶ࡗࡓ㸦⾲6㸧ࠋᚰ࢚ࢥ᳨࣮ᰝ࡛ࡣᕥᐊᣑᙇᮎᮇᚄࡣ 41 ± 4mm, ᕥᡣ኱ື⬦ᚄẚࡣ 1.8 ± 0.2 ࡛࠶ࡾ, ᚰᣑ኱ࡀㄆࡵࡽࢀࡓࠋ⭝⣴㞳᩿๓ᚋ࡛ FSV ࡟᭷ព࡞ኚ໬ࡣㄆࡵࡽ ࢀ࡞࠿ࡗࡓࠋᐇ㦂ᮇ㛫୰࡟⫵Ỉ⭘, တ, 㐠ື୙⪏ᛶ࡞࡝ࡢ⮫ᗋ⑕≧ࡣㄆࡵࡽࢀ࡞࠿ࡗ ࡓࠋ࢞࢖ࢻࣛ࢖ࣥ࡟ᚑ࠸㸦2㸧, ࡍ࡭࡚ࡢ≟ࡣ, ᚰᣑ኱ࡣㄆࡵࡽࢀࡿࡀᚰ୙඲ࢆ࿊ࡋ ࡚࠸࡞࠸ࡓࡵACVIM ࢫࢸ࣮ࢪ B2 ࡜デ᩿ࡉࢀ, ჾ㉁ⓗ MI ࣔࢹࣝ≟ࡢタᐃ᮲௳ࢆ‶ ࡓࡋࡓࠋ

51

⾲6 ჾ㉁ⓗ MI సᡂ๓ᚋࡢ⾑⾜ືែᣦᶆࡢኚ໬ n = 6, *: p < 0.05 vs ⭝⣴㞳᩿๓

ჾ㉁ⓗMI ࣔࢹࣝ≟࡛ࡣ⭝⣴㞳᩿๓࡜ẚ࡭࡚ HR ࡣపୗࡋ, VHS ࡜ CTR ࡣୖ᪼ࡋ ࡓࠋᚰ࢚ࢥ࣮ᣦᶆ࡛ࡣᕥᐊᣑᙇᮎᮇᚄ, ᕥᡣ኱ື⬦ᚄẚ, E wave, E/A, Em, E/Em ࡢቑ ኱ࡀჾ㉁ⓗMI ࣔࢹࣝ≟࡛ㄆࡵࡽࢀࡓࠋ ⭝⣴㞳᩿๓ ჾ㉁ⓗMI ࣔࢹࣝᚋ HR (bpm) 124 ± 18 104 ± 11* X ⥺ᣦᶆ VHS 10.7 ± 0.5 13.0 ± 0.4* CTR (%) 52.0 ± 1.6 60.4 ± 3.1* ᚰ࢚ࢥ࣮ᣦᶆ ᕥᐊᣑᙇᮎᮇᚄ (mm) 32 ± 2 41 ± 4* ᕥᐊෆᚄ▷⦰⋡ (%) 40 ± 5 44 ± 3 ᕥᡣ኱ື⬦ᚄẚ 1.1 ± 0.1 1.8 ± 0.2* FSV (mL) 19 ± 3 21 ± 3 CO (L/min) 2.4 ± 0.3 2.5 ± 0.8 E wave (cm/s) 75 ± 5 127 ± 10* A wave (cm/s) 58 ± 10 61 ± 12 E/A 1.3 ± 0.2 2.0 ± 0.2* Sm (cm/s) 8.6 ± 1.1 9.4 ± 1.2 Em (cm/s) 8.5 ± 1.0 10.4 ± 1.1* E/Em 8.8 ± 1.1 11.8 ± 1.0*

52 2)ࣛࢪ࢜ࢸ࣓ࣞࢺ࣮ࣜ ᐃ

࢖ࢯࣇࣝࣛࣥ⃰ᗘࡢୖ᪼ࡣSAP, MAP ࠾ࡼࡧ DAP ࢆῶᑡࡉࡏࡓ㸦ᅗ 7㸧ࠋࡋ࠿ࡋ LAP ࡛ࡣ᭷ព࡞ኚ໬ࡣㄆࡵࡽࢀ࡞࠿ࡗࡓࠋISO1.0 ࡛ࡣ DOB8 ௨ୖ, ISO1.5 ࡜ ISO2.0 ࡛ࡣDOB4 ௨ୖ࡛ SAP ࡣ BL ࡜ẚ㍑ࡋ࡚ቑຍࡋࡓࠋISO1.5 ࠾ࡼࡧ ISO2.0 ࡛ࡣ DOB8 ௨ୖ࡛MAP ࡣ BL ࡜ẚ㍑ࡋ࡚ቑຍࡋࡓࠋࢻࣈࢱ࣑ࣥ㈇Ⲵ࡟ࡼࡿ DAP ࠾ࡼࡧ LAP ࡢ ᭷ព࡞ኚ໬ࡣㄆࡵࡽࢀ࡞࠿ࡗࡓࠋ

53

ᅗ7 ࣛࢪ࢜ࢸ࣓ࣞࢺ࣮ࣜࢩࢫࢸ࣒࡟ࡼࡗ࡚ᚓࡽࢀࡓྛ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿྛ ࢻࣈࢱ࣑ࣥᢞ୚㔞࡛ࡢMI ≟ࡢ⾑ᅽ್࠾ࡼࡧ LAP

n = 6, *: p < 0.05 vs BL, †: p < 0.05 vs DOB2, ‡: p < 0.05 vs DOB4, §: p < 0.05 vs DOB8, ll:

54 3)TEE  ᐃ

BL ࡟࠾࠸࡚, ࢖ࢯࣇࣝࣛࣥ⃰ᗘࡢ㐪࠸࡟ࡼࡿ᭷ព࡞ FSV, HR, CO ࡢኚ໬ࡣࡳࡽࢀ ࡞࠿ࡗࡓ㸦ᅗ8㸧ࠋࡍ࡭࡚ࡢ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾࠸࡚ FSV ࡣ BL ࡜ẚ㍑ࡋ࡚ DOB4 ௨ୖ࡛ቑຍࡋࡓࠋISO1.5 ࡜ ISO2.0 ࡛ࡣ HR ࡣ BL ࡜ẚ㍑ࡋ࡚ DOB4 ࡛ῶᑡࡋࡓࠋࡉ ࡽ࡟ISO2.0 ࡟࠾࠸࡚ DOB12 ࡢ HR ࡣ DOB4 ࡢ HR ࡼࡾࡶቑຍࡋࡓࠋISO1.5 ࠾ࡼࡧ ISO2.0 ࡛ࡣ CO ࡣ BL ࡜ẚ㍑ࡋ࡚ DOB12 ࡛ቑຍࡋࡓࠋ

55

ᅗ8 TEE ࡟ࡼࡗ࡚ᚓࡽࢀࡓྛ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿྛࢻࣈࢱ࣑ࣥᢞ୚㔞࡛ࡢ MI ≟ࡢFSV, HR ࠾ࡼࡧ CO

n = 6, *: p < 0.05 vs BL, †: p < 0.05 vs DOB2, ‡: p < 0.05 vs DOB4, §: p < 0.05 vs DOB8, ll:

56 4)ᅽᐜ㔞᭤⥺ゎᯒ

BL ࡟࠾࠸࡚, ISO1.0 ࡢ Ees ࡣ ISO2.0 ࡢ Ees ࡼࡾࡶ㧗࠿ࡗࡓࠋ୍᪉, BL ࡟࠾࠸࡚ Ea ࡟࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟ࡼࡿ᭷ព࡞ኚ໬ࡣࡳࡽࢀ࡞࠿ࡗࡓ㸦ᅗ9㸧ࠋࡍ࡭࡚ࡢ࢖ࢯࣇࣝ ࣛࣥ⃰ᗘ࡟࠾࠸࡚Ees ࡣ DOB8 ௨ୖ࡛ BL ࡼࡾቑຍࡋࡓࠋISO 2.0 ࡛ࡣ Ea ࡣ DOB2 ௨ୖ࡛BL ࡜ẚ㍑ࡋ࡚ῶᑡࡋࡓࠋISO1.0 ࡜ ISO1.5 ࡛ࡣ Ea ࡣ DOB4 ௨ୖ࡛ BL ࡜ẚ㍑ ࡋ࡚ῶᑡࡋࡓࠋBL ࡟࠾࠸࡚, ISO1.5 ࠾ࡼࡧ ISO2.0 ࡢ Ea/Ees ࡣ ISO1.0 ࡢ Ea/Ees ࡼࡾ ࡶ㧗࠿ࡗࡓࠋࡍ࡭࡚ࡢ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾࠸࡚, Ea/Ees ࡣࢻࣈࢱ࣑ࣥᢞ୚࡟ࡼࡗ࡚ BL ࡼࡾࡶపୗࡋࡓࠋࡲࡓ, ࡍ࡭࡚ࡢ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾࠸࡚ࢻࣈࢱ࣑ࣥᢞ୚ࡣᕥ ᐊ཰⦰ᮎᮇᐜ✚࠾ࡼࡧᕥᐊᣑᙇᮎᮇᐜ✚ࢆపୗࡉࡏࡓ㸦⾲7㸧ࠋBL ࡟࠾࠸࡚, ᕥᐊ཰ ⦰ᮎᮇᅽ࠾ࡼࡧ᭱኱ᕥᚰᐊᅽୖ᪼㏿ᗘࡣ࢖ࢯࣇࣝࣛࣥ⃰ᗘୖ᪼࡟క࠸పୗࡋࡓࠋ ISO1.5 ࠾ࡼࡧ ISO2.0 ࡛ࡣ DOB4 ௨ୖ࡛ᕥᐊ཰⦰ᮎᮇᅽࡣ BL ࡜ẚ㍑ࡋ࡚ቑຍࡋࡓࠋ ࡍ࡭࡚ࡢ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾࠸࡚ࢻࣈࢱ࣑ࣥᢞ୚࡟ࡼࡾ᭱኱ᕥᚰᐊᅽୖ᪼㏿ᗘࡣ ቑຍࡋࡓࠋISO2.0 ࡛ࡣ SVR ࡣ DOB8 ௨ୖ࡛ BL ࡼࡾపୗࡋࡓࠋ

57

ᅗ9 ᅽᐜ㔞᭤⥺ゎᯒ࡟ࡼࡗ࡚ᚓࡽࢀࡓྛ࢖ࢯࣇࣝࣛࣥ⃰ᗘ࡟࠾ࡅࡿྛࢻࣈࢱ࣑ࣥᢞ ୚㔞࡛ࡢMI ≟ࡢ Ees, Ea ࠾ࡼࡧ Ea/Ees

n = 6, *: p < 0.05 vs BL, †: p < 0.05 vs DOB2, ‡: p < 0.05 vs DOB4, §: p < 0.05 vs DOB8, ll:

58

⾲7 ⭝⣴㞳᩿ MI ≟࡟࠾ࡅࡿ࢖ࢯࣇࣝࣛࣥ࡜ࢻࣈࢱ࣑ࣥࡢᚰ⾑⟶ᣦᶆࡢኚ໬

n = 6, *: p < 0.05 vs BL, †: p < 0.05 vs DOB2, ‡: p < 0.05 vs DOB4, §: p < 0.05 vs DOB8, ll:

p < 0.05 vs ISO1.5, ¶: p < 0.05 vs ISO2.0.

EDP, ᕥᐊᣑᙇᮎᮇᅽ; EDV, ᕥᐊᣑᙇᮎᮇᐜ✚; ESP, ᕥᐊ཰⦰ᮎᮇᅽ; ESV, ᕥᐊ཰ ⦰ᮎᮇᐜ✚; SV, 1 ᅇᢿฟ㔞; MRV, ൔᖗᘚ㏫ὶ㔞; dP/dt max, ᭱኱ᕥᚰᐊᅽୖ᪼㏿ᗘ; SVR, ⥲ᮎᲈ⾑⟶᢬ᢠ. ࢖ࢯࣇ ࣝࣛࣥ ⃰ᗘ ࢻࣈࢱ࣑ࣥᢞ୚㔞 ᣦᶆ

BL DOB2 DOB4 DOB8 DOB12

EDP (mmHg) ISO1.0 16 ± 7 15 ± 7 15 ± 6 13 ± 6 14 ± 5 ISO1.5 13 ± 5 13 ± 5 13 ± 4 14 ± 6 14 ± 5 ISO2.0 13 ± 5 12 ± 5 12 ± 5 13 ± 6 11 ± 4 EDV (mL) ISO1.0 50 ± 4 51 ± 8 49 ± 12 43 ± 12 40 ± 6† ISO1.5 57 ± 7 59 ± 7 55 ± 6 44 ± 4*†‡ 44 ± 4*†‡ ISO2.0 60 ± 5 59 ± 4 56 ± 6 48 ± 5*†‡ 44 ± 5*†‡ ESP (mmHg) ISO1.0 120 ± 11||¶ 113 ± 12||¶ 122 ± 7||¶ 125 ± 14¶ 131 ± 10¶ ISO1.5 92 ± 7 97 ± 3 104 ± 5* 114 ± 8*†‡ 119 ± 9*†‡ ISO2.0 82 ± 6 88 ± 6 94 ± 8* 104 ± 9*†‡ 106 ± 17*†‡ ESV (mL) ISO1.0 30 ± 6¶ 28 ± 11 22 ± 16 11 ± 14*† 10 ± 8*† ISO1.5 40 ± 8 38 ± 8 32 ± 7 18 ± 4*†‡ 16 ± 8*†‡ ISO2.0 45 ± 7 38 ± 5* 32 ± 7*† 18 ± 5*†‡ 15 ± 6*†‡ SV (mL) ISO1.0 25.1 ± 6.1 28.4 ± 8.1 31.6 ± 8.7 38.6 ± 5.4*† 34.4 ± 4.1* ISO1.5 22.3 ± 5.8 27.7 ± 4.9 29.5 ± 3.1* 30.7 ± 3.7* 33.1 ± 6.5* ISO2.0 21.6 ± 6.2 27.8 ± 3.1* 30.3 ± 2.8* 36.8 ± 2.8*†‡ 35.1 ± 3.8*†‡ MRV (mL) ISO1.0 5.4 ± 1.8 5.4 ± 2.2 5.0 ± 2.2 6.6 ± 2.5 4.5 ± 1.0 ISO1.5 5.8 ± 2.2 6.3 ± 1.8 6.1 ± 3.0 4.5 ± 1.8 4.8 ± 1.6 ISO2.0 6.8 ± 2.1 6.8 ± 2.3 6.3 ± 1.2 6.4 ± 2.3 5.8 ± 1.9 dP/dt max (mmHg/ sec) ISO1.0 2900 ± 823¶ 2741 ± 475 3600 ± 324 4603 ± 990*† 6004 ± 713*†‡ ISO1.5 1806 ± 168 2417 ± 427 3361 ± 349*† 4603 ± 544*†‡ 5232 ± 811*†‡ ISO2.0 1498 ± 254 2154 ± 482 3088 ± 356*† 4330 ± 646*†‡ 5018 ± 1798*†‡§ SVR (mmHg/ mL/_min) ISO1.0 3803 ± 1137 3664 ± 3607 3607 ± 1269 2777 ± 653 2784 ± 398 ISO1.5 4077 ± 1272 3413 ± 878 3451 ± 455 2925 ± 675 2709 ± 751 ISO2.0 3619 ± 1027 2864 ± 637 2962 ± 897 1963 ± 457*‡ 1914 ± 425*‡

59 ⪃ᐹ ᮏ◊✲࡟⏝࠸ࡓ⭝⣴㞳᩿ㄏⓎᛶჾ㉁ⓗ MI ࣔࢹࣝ≟ࡣ⮫ᗋ⑕≧ࢆ♧ࡉ࡞࠿ࡗࡓࡀ, MR ࡟ࡼࡿ๓㈇Ⲵࡢቑຍ࡟ࡼࡗ࡚ᚰᐊ࠾ࡼࡧᚰᡣࡢᣑ኱ࡀほᐹࡉࢀࡓࠋLAP ࡣ೺ᖖ≟ ࡼࡾࡶ㧗ࡃ㸦10.1 ± 1.8 mmHg㸧, ௨๓࡟グ㍕ࡉࢀ࡚࠸ࡿჾ㉁ⓗ MI ࣔࢹࣝ≟࡜࡯ࡰྠ ࡌ࡛࠶ࡿࡓࡵ㸦42, 43, 79, 80㸧, ᮏ◊✲࡟⏝࠸ࡽࢀࡓჾ㉁ⓗ MI ࣔࢹࣝ≟ࡣࣔࢹࣝ࡜ࡋ ࡚༑ศ࡞ࡶࡢ࡛࠶ࡗࡓ࡜⪃࠼ࡽࢀࡿࠋFSV ࡣ㐣ཤࡢሗ࿌࡜ྠᵝ࡟, ⭝⣴㞳᩿๓࡜ẚ࡭ ࡚ⴭ᫂࡞ኚ໬ࡣㄆࡵࡽࢀ࡞࠿ࡗࡓ㸦26㸧ࠋFSV ࡣ௨ୗࡢᘧ࡛⾲ࡉࢀࡿ㸦36㸧ࠋ  ൌ ܧ݁ݏ ܧ݁ݏ ൅ ܧܽሺܧܦܸ െ ܸ଴ሻ EDV; ᕥᐊᣑᙇᮎᮇᐜ✚, V0; ᕥᐊෆᅽ 0 mmHg ࡢ᫬ࡢᕥᐊෆᐜ✚ ぬ㓰ୗ࡛ࡣEes ࠾ࡼࡧ Ea ࡢ᥎ᐃࡣᅔ㞴࡛࠶ࡿࡀ, Ees ࡣᕥᐊࢧ࢖ࢬ࡟཯ẚ౛ࡍࡿࡓ ࡵ, ჾ㉁ⓗ MI ࣔࢹࣝ≟ࡢ Ees ࡣ೺ᖖ≟ࡼࡾࡶపୗࡍࡿࡇ࡜ࡀ▱ࡽࢀ࡚࠸ࡿ㸦5㸧ࠋ EDV ࡀୖ᪼ࡋ࡚ࡶ V0࡟ࡣኚ໬ࡀㄆࡵࡽࢀ࡞࠸ࡓࡵ㸦5㸧, FSV ࡀኚ໬ࡋ࡞࠿ࡗࡓ⌮ ⏤ࡣEa ࡢపୗ࡟࠶ࡿࠋࡋࡓࡀࡗ࡚, ჾ㉁ⓗ MI ࣔࢹࣝ≟࡛ࡣቑຍࡋࡓ๓㈇Ⲵ࡟ᑐฎ ࡍࡿࡓࡵᚋ㈇Ⲵࢆపୗࡉࡏࡿࡇ࡜࡛FSV ࢆ୍ᐃ࡟ಖࡗ࡚࠸ࡿ࡜ᛮࢃࢀࡿࠋ ჾ㉁ⓗMI ࣔࢹࣝ≟࡟࠾ࡅࡿ࢖ࢯࣇࣝࣛࣥࡢ㝆ᅽຠᯝࡣ࢖ࢯࣇࣝࣛࣥ⃰ᗘࡢቑຍ࡟ కࡗ࡚Ees ࡢῶᑡ࠾ࡼࡧ Ea/Ees ࡢቑຍࡀほᐹࡉࢀࡓࡇ࡜࠿ࡽ, ⾑⟶ᣑᙇస⏝ࡼࡾࡶ ୺࡟ᚰ➽ᢚไస⏝࡟⏤᮶ࡍࡿࡇ࡜ࡀᮏ◊✲࡟ࡼࡗ࡚᫂ࡽ࠿࡟࡞ࡗࡓࠋື⬦⾑ᅽࡢᇶ ♏࡛࠶ࡿᕥᐊ཰⦰ᮎᮇᅽࡣEes ࡜ Ea ࡢ஺Ⅼ࡟ࡼࡗ࡚Ỵᐃࡉࢀࡿ㸦12, 19, 25, 38, 44, 69, 77㸧ࠋᚰᐊື⬦࢝ࢵࣉࣜࣥࢢࡣ Ea ࡜ Ees ࡢẚ࡜ࡋ࡚ᣦᶆ໬ࡉࢀ, ࡇࢀࡣᚰ⮚⾑⟶ ࡢᛶ⬟࠾ࡼࡧຠ⋡࡟ᙉࡃ㛵ಀࡍࡿࠋ㏻ᖖEa/Ees ࡣ⣙ 1.0 ࡛࠶ࡿࡀ㸦12, 19㸧, ཰⦰ᛶ ࡀపୗࡋࡓᚰ୙඲࡛ࡣᕥᐊ཰⦰ᮎᮇᅽࢆ⥔ᣢࡍࡿࡓࡵ࡟ື⬦᢬ᢠࡀቑຍࡋ, ⤖ᯝⓗ࡟ Ea/Ees ࡀቑຍࡍࡿ㸦25, 44㸧ࠋᚰᐊ཰⦰ᛶ࡜ື⬦᢬ᢠ࡜ࡢ㛫ࡢ୙୍⮴ࢆ⾲ࡍ Ea/Ees ࡢ