九州大学学術情報リポジトリ
Kyushu University Institutional Repository
薬物治療，血行再建，リズムコントロールを含む集 学的治療を行った心不全症例；治療の至適時期と順 序は？
Kawai, Shunsuke
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
Mukai, Yasushi
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
Uwatoku, Toyokazu
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
Yakabe, Daisuke
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
他
https://doi.org/10.15017/2236354
出版情報：福岡醫學雜誌. 110 (1), pp.39-44, 2019-03-25. Fukuoka Medical Association バージョン：
権利関係：
Case Report
Multidisciplinary Therapeutic Interventions in Heart Failure Including Medication, Revascularization and Rhythm Control ;
What is the Optimal Timing andOrder?
Shunsuke K
AWAI1), Yasushi M
UKAI1), Toyokazu U
WATOKU1), Daisuke Y
AKABE1), Kazuhiro N
AGAOKA1), Ken-ichi H
IASA1), Akiko C
HISHAKI2)and Hiroyuki T
SUTSUI1)1)Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
2)Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan Abstract
A 71-year-old man complained of dyspnea on exertion and fatigue. He had persistent atrial fibrillation with enlarged left atrium, severe left ventricular dysfunction, systemic congestion and multivessel coronary disease. An electrical cardioversion restored to sinus rhythm, maintained with amiodarone. Staged percutaneous coronary interventions were performed. Pulmonary vein isolation was performed 6 months after the last PCI. Consequently, the left ventricular systolic function and left atrial volume were well maintained, and symptoms improved from NYHA class Ⅲ to Ⅰ. The strategic order of therapeutic interventions is a key issue of decision making for successful outcome in performing contemporary, multidisciplinary therapies.
Key words: atrial fibrillation, heart failure, catheter ablation, percutaneous coronary intervention
Introduction
The prevalence of coronary artery disease (CAD) in atrial fibrillation (AF) patients has been reported to be 15-17％1)2). In Japan, where population aging is advancing, the prevalence of CAD companying with AF patients will increase in the future. AF patients with CAD are more likely to develop heart failure and cardiogenic shock, and hence, such conditions often make the treatment difficult3).
Case report
A 71-year-old man who complained of dyspnea on exertion and fatigue persisting for 1 month visited a local doctor. He was diagnosed as persistent AF of unknown onset and heart failure
with reduced EF (HFrEF). A Holter ECG detected AF persisting all day and the average heart rate was 113 beats per minute (bpm). He was referred to our hospital because oral medica- tions did not improve his symptoms nor left ventricular dysfunction. He was obese (body mass index 31.1 kg/m2) and had AF tachycardia (107 bpm) on admission.
Laboratory tests revealed renal dysfunction (serum creatinine level of 1.57 mg/dL) and elevation of plasma brain natriuretic peptide (BNP) (190 pg/mL). A chest x-ray showed cardiomegaly (cardiothoracic ratio (CTR) 53％) and pulmonary edema. A transthoracic echocar- diography detected an enlarged left atrium (left atrial diameter (LAD) 65 mm, LAVI 81.3 ml/m2) and severe left ventricular systolic dysfunction
Corresponding author : Yasushi MUKAI
Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
Tel : + 81-92-642-5360 Fax : + 81-92-642-5374 E-mail : [email protected]
(EF 34％). Pressure values showed elevated right atrial pressure (RAP) (mean RAP=9 mmHg), pulmonary artery pressure (PAP) (mean PAP=24 mmHg), pulmonary capillary wedge pressure (PCWP) (mean PCWP=21 mmHg) and left ven- tricular end-diastolic pressure (19 mmHg). Ther- modilution method showed low cardiac output (cardiac index=2.0 L/min/m2, SvO2=61.3％). Left ventriculography showed diffuse severe hypo- kinesis. Coronary angiography (CAG) revealed two-vessel disease (90％ stenosis at seg. 1, seg. 6, seg. 7, and chronic total occlusion at seg. 3).
Rentrop Grade 1 collateral from the left circumf- lex artery to the right coronary artery could be detected. At this point, coronary revasculariza- tion, rhythm control and optimal medical therapy (OMT) for HFrEF were the conceivable therapeu- tic approaches (Fig. 1a). First of all, SR was
restored with an electrical cardioversion (Biphasic 100 J). Subsequently, an ACE inhibitor (lisinopril 10 mg/day), a beta blocker (bisoprolol 2.5 mg/
day) and a mineral corticoid receptor antagonist (eplerenone 50 mg/day) were introduced as OMT for HFrEF. Amiodarone (200 mg/day) was also introduced to maintain SR. After the initial treatment, SR was maintained for 3 months. An improvement of cardiomegaly (CTR : 53 to 48％) and an improvement of left ventricular systolic dysfunction (EF : 34 to 56％) were achieved (Fig.
1b). At this point, PCI to the left anterior descending artery was performed, PCI to the right coronary artery was followed 2 months after the index PCI (Fig. 2).
A follow-up CAG was performed 6 months after the last PCI, and it did not reveal intra-stent restenosis nor de-novo lesion. On this occasion, S. Kawai et al.
40
MulƟdisciplinary Therapies of Heart Failure
Medical Therapy RevascularizaƟon Rhythm Control Fig. 1 (a)
Fig. 1 Therapeutic strategy.
(a) Multidisciplinary therapies of heart failure.
(b) Therapeutic course and clinical variables.
ACEI : angiotensin converting enzyme inhibitor, ARB : angiotensin receptor blocker, AAD : antiarrhythmic drug, MRA : mineral corticoid receptor antagonist, LAD : left anterior descending artery, RCA : right coronary artery
Cibenzoline 200mg ACEI/ARB
First Visit 3 M 5 M 11 M 20 M
LVEF (%) 34.0 56.0 57.0 54.0 56.5
LVDd/s (mm) 56/48 59/42 54/36 56/41 54/36
LAD (mm) 65 54 47 46 45
LAVI (mL/㎡) 81.3 71.0 46.9 45.2 46.7
BNP (pg/ml) 190.1 71.3 43.2 58.9 53.9
NYHA Ⅲ Ⅰ Ⅰ Ⅰ Ⅰ
Rhythm AF SR SR SR SR
PCI to LAD PCI to RCA PVI DC to SR
OMT
AAD
Telmisartan 40mg Lisinopril 10mg
Amiodarone 200mg
Beta blocker Bisoprolol 2.5mg
MRA Eplerenone 50mg
Fig. 1 (b)
LVA=2.1%
Fig. 3 Pulmonary vein antrum isolation.
Voltage values ＜ 0.5 mV was defined as low voltage. LVA was quantified and calculated in the ratio to the whole left atrial surface area except for the pulmonary vein and pulmonary vein antrum area.
LVA : low voltage area PCI to LAD
(3M)
PCI to RCA (5M) (a)
(b)
Fig. 2 Coronary revascularization.
(a) PCI to LAD was performed 3 months after the initial treatment. A zotarolimus-eluting stent (3.0 mm in diameter and 34 mm in length) was implanted to seg. 6 and a sirolimus-eluting stent (3. 0 mm in diameter and 28 mm in length) was implanted to seg. 7.
(b) PCI to RCA was performed 5 months after the initial treatment. A biolimus A9-eluting stent (3.5 mm in diameter and 8 mm in length) was implanted to seg. 1, a sirolimus-eluting stent (3.0 mm in diameter and 15 mm in length) was implanted to seg. 2 and a sirolimus-eluting stent (2.5 mm in diameter and 28 mm in length) was implanted to seg. 3.
LAD : left anterior descending artery, RCA : right coronary artery
catheter ablation for AF was performed. Left atrial voltage map during SR showed that only a few low voltage areas (2.1％) existed in the left atrial body. Thus, pulmonary vein antrum isola- tion alone was performed (Fig. 3). Amiodarone was discontinued a month before the catheter ablation, and it was not restarted after the procedure. To date, AF did not recur during 9 months of follow-up. The left ventricular systolic function (EF 56％), left atrial volume (LAVI 46.7 ml/m2) and BNP (53.9 pg/mL) were well main- tained, and subjective symptoms improved from NYHA class Ⅲ to Ⅰ (Fig. 1b).
Discussion
When multiple therapeutic approaches coexist as treatment options in a patient, a misjudgment of therapeutic order may lead to a fatal outcome.
As shown in previous reports4), low EF, mul- ti-vessel disease and symptoms of heart failure were the main risk factors for invasive proce- dures on admission in the present case. The preceding rhythm control and OMT for HFrEF improved the low EF and symptoms of heart failure, and these risk reductions led to the safer interventional therapies. It was assumed that a tachycardia-induced cardiomyopathy (TIC) coex- isted with ischemic heart disease since the restoration of SR improved EF before PCI was performed. The characterization of a mild left ventricular dilatation on admission also implicated TIC5). It was also assumed that the maintenance of SR as well as the control of heart failure prior to the catheter ablation for AF led to the left atrial reverse remodeling6)7). If maintenance of SR had been difficult to achieve, AF would have been managed with the rate control strategy. In that case, it may be considered that extensive left atrial remodeling progressed and the catheter ablation could no longer suppressed AF persist- ence. It was also considered that left ventricular systolic function was improved insufficiently despite the adequate rate control8). Recently, several studies indicated that catheter ablation for
AF in patients with HFrEF improved long-term prognosis9)10).
In the AATAC multicenter randomized trial, some patients who received amiodarone failed to maintain SR partly because amiodarone had to be discontinued due to severe adverse side effects9). In the present case, it was considered that discontinuation of amiodarone after catheter ablation avoided the potential side effects in the future. Following these studies, the catheter ablation in AF patients with heart failure is recently more considered11).
In conclusion, when multidisciplinary therapy which consists of coronary revascularization, rhythm control and OMT for HFrEF are per- formed, it is important that each therapy is performed at a proper time, and in a proper order.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1) Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen JGP, Alings AM, Hillege HL, Bergsma-Kadijk JA, Cornel JH, Kamp O, Tukkie R, Bosker HA, Van Veldhuisen DJ, Van den Berg MP, RACE Ⅱ Investigators : Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 362 : 1363-1373, 2010.
2) Akao M, Chun Y, Wada Y, Esato M, Hashimoto T, Abe M, Hasegawa K, Tsuji H and Furuke K : Current status of clinical background of patients with atrial fibrillation in a community-based survey : the Fushimi AF Registry. J Cardiol. 61 : 260-266, 2013.
3) Kundu A, OʼDay K, Shaikh AY, Lessard DM, Saczynski JS, Yarzebski J, Darling CE, Thabet R, Akhter MW, Floyd KC, Goldberg RJ and McManus DD : Relation of atrial fibrillation in acute myocardial infarction to in-hospital com- plications and early hospital readmission. Am J Cardiol. 15 : 1213-1218, 2016.
4) Ammirati E, Guida V, Latib A, Moroni F, Arioli F, Scotti I, Rimoldi OE, Colombo A and Gamici PG : Determinants of outcome in patients with chronic ischemic left ventricular dysfunction undergone percutaneous coronary interven- S. Kawai et al.
42
tions. BMC Cardiovascular Disorders. 15 : 1-8, 2015.
5) Fujino T, Yamashita T, Suzuki S, Sugiyama H, Sagara K, Sawada H, Aizawa T, Igarashi M and Yamazaki J : Characteristics of congestive heart failure accompanied by atrial fibrillation with special reference to tachycardia-induced car- diomyopathy. Circ J. 71 : 936-940, 2007.
6) Raitt HM, Kusumoto W, Giraud G and Mcanulty HJ : Reversal of electrical remodeling after cardioversion of persistent atrial fibrillation. J Cardiovasc Electrophysiol. 15 : 507-512, 2004.
7) John B, Stiles KM, Kuklik P, Brooks GA, Chandy TS, Kalman MJ and Sanders P : Reverse remodeling of the atria after treatment of chronic stretch in humans. J Am Coll Cardiol.
55 : 1217-1226, 2010.
8) Khan MN, Jaïs P, Cummings J, Biase LD, Sanders P, Martin DO, Kautzner J, Hao S, Thermistoclakis S, Fanelli R, Potenza D, Mas- saro R, Wazni O, Schweikert R, Saliba W, Wang P, Al-Ahmad A, Beheiry S, Santarelli P, Starling RC, Russo AD, Pelargonio G, Brachmann J, Schibgilla V, Bonso A, Casella M, Raviele A, Haïssaguerre M and Natale A : Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med. 359 : 1778-1785, 2008.
9) Biase LD, Mohanty P, Mohanty S, Santangeli P, Trivedi C, Lakkireddy D, Reddy M, Jaïs P, Thermistoclakis S, Russo DA, Casella M, Pelargonio G, Narducci LM, Schweikert R, Neuzil P, Sanchez J, Horton R, Beheiry S, Hongo R, Hao S, Rossillo A, Forieo G, Tondo C,
Burkhardt JD, Haïssaguerre M and Natale A : Ablation versus amiodarone for treatment of persistent atrial fibrillation in patients with congestive heart failure and implanted device.
Results from the AATAC multicenter rando- mized trial. Circulation. 133 : 1637-1644, 2016.
10) Marrouche FN, Brackmann J, Andresen D, Siebels J, Boersma L, Jordaens L, Merkely B, Pokushalov E, Sanders P, Proff J, Schunkert H, Christ H, Vogt J and Bänsch D : Catheter ablation for atrial fibrillation with heart failure.
N Engl J Med. 378 : 417-427, 2018.
11) Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, Avila AD, Groot NMS, Biase LD, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schill- ing R, Tondo C, Tsao HM, Verma A, Wilber DJ and Yamane T : 2017 HRS/EHRA/ ECAS/
APHRS/ SOLAECE expert consensus state- ment on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 14 : e275-e444, 2017.
(Received for publication December 26, 2018)
（和文抄録）
薬物治療，血行再建，リズムコントロールを含む 集学的治療を行った心不全症例；
治療の至適時期と順序は？
1)九州大学大学院医学研究院 循環器内科学分野
2)九州大学大学院医学研究院 保健学部門
河 合 俊 輔
1)，向 井 靖
1)，上 徳 豊 和
1)，矢加部大輔
1)， 長 岡 和 宏
1)，日 浅 謙 一
1)，樗 木 晶 子
2)，筒 井 裕 之
1)症例は 71 歳男性．労作時息切れ，倦怠感を主訴とし精査目的に紹介となった．左房拡大（left atrial volume index（LAVI）81.3 ml/m2）を伴う持続性心房細動，重度左室機能障害（ejection fraction（EF）34％），体うっ血所見，冠動脈 2 枝病変（seg6：90％，seg7：90％，seg1：90％，seg3：
慢性完全閉塞）を認め，虚血性心疾患に加えて頻脈誘発性心筋症を合併したため心不全が顕在化し たと判断した．電気的除細動で洞調律復帰させ心不全に対する内服治療を行った．アミオダロン にて洞調律維持し，staged PCI にて冠血行再建（左冠動脈前下行枝，右冠動脈）を行った．最終 PCI 後 6 か月時点で確認冠動脈造影及び肺静脈隔離術を行った．左房拡大改善（LAVI 46.7 ml/m2），左心機能改善（EF 56％），NYHA Ⅲ度からⅠ度への自覚症状改善が得られた．リズムコ ントロール，冠血行再建，抗心不全治療の集学的治療を行う上で，治療介入のタイミングを熟慮す ることが重要であった示唆に富む症例と考え報告する．
キーワード：心房細動，心不全，カテーテルアブレーション，経皮的冠動脈形成術
S. Kawai et al.
44
