Impact of the pulmonary vein orifice area assessed using　intracardiac echocardiography on the outcome of radiofrequency catheter ablation for atrial fibrillation

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Title

Impact of the pulmonary vein orifice area assessed using

intracardiac echocardiography on the outcome of radiofrequency

catheter ablation for atrial fibrillation( 内容と審査の要旨

(Summary) )

Author(s)

中島, 孝

Report No.(Doctoral

Degree)

博士(医学) 甲第1079号

Issue Date

2018-05-16

Type

博士論文

Version

none

URL

http://hdl.handle.net/20.500.12099/75294

※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。

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Ặྡ㸦ᮏ⡠㸧 Ꮫ ఩ ࡢ ✀ 㢮 Ꮫ఩ᤵ୚␒ྕ Ꮫ఩ᤵ୚᪥௜ Ꮫ఩ᤵ୚せ௳ Ꮫ఩ㄽᩥ㢟┠ ᑂ ᰝ ጤ ဨ ୰ ᓥ Ꮥ 㸦ᒱ㜧┴㸧 ༤ ኈ㸦་Ꮫ㸧 ⏥➨1079 ྕ ᖹᡂ30 ᖺ 5 ᭶ 16 ᪥ Ꮫ఩つ๎➨㸲᮲➨㸯㡯ヱᙜ

Impact of the pulmonary vein orifice area assessed using intracardiac echocardiography on the outcome of radiofrequency catheter ablation for atrial fibrillation 㸦୺ᰝ㸧ᩍᤵ ᳃⏣ ᾈஅ 㸦๪ᰝ㸧ᩍᤵ ᅵ஭ ₩ ᩍᤵ ᳃⏣ ၨஅ ㄽ ᩥ ෆ ᐜ ࡢ せ ᪨ ᚰᡣ⣽ືࡣ⫵㟼⬦࠿ࡽࡢᚰᡣᛶᮇእ཰⦰ࡀᕥᡣ࡟⯆ዧఏ᧛ࡍࡿࡇ࡜࡛Ⓨ⑕ࡍࡿࠋᚰᡣᛶᮇእ཰⦰ࡢ 㟁Ẽⓗ⯆ዧࡢᕥᡣ࡬ࡢఏ᧛ࢆ㜼Ṇࡍࡿ⫵㟼⬦㝸㞳⾡ࡣᚰᡣ⣽ື࡟ᑐࡍࡿ᭷ຠ࡞㠀⸆≀⒪ἲ࡛࠶ࡿࡀ㸪⾡ᚋࡢ෌Ⓨࡶ⛥࡛ࡣ࡞ࡃ㸪㐺ᛂᝈ⪅ࡢ㑅ᢥ࡟࠾ࡅࡿ෌Ⓨண ᅉᏊࡢ☜❧ࡣ୙ᩚ⬦἞⒪ศ㔝ࡢ㔜せ࡞ㄢ㢟࡛࠶ࡿࠋࡇࢀࡲ࡛ᕥᡣᐜ✚ࡸ⫵㟼⬦ࡢᣑ኱ࡀ෌Ⓨண ᅉᏊ࡜ࡋ࡚ሗ࿌ࡉࢀ࡚࠸ࡿࡀឤᗘ࣭≉␗ᗘࡣ 㧗ࡃ࡞࠸ࠋᕥᡣཬࡧ⫵㟼⬦ࡢゎ๗Ꮫⓗᙧែࡢホ౯᪉ἲ࡟ࡣ㸪FRPSXWHG WRPRJUDSK\ &7㸪PDJQHWLF UHVRQDQFHLPDJLQJ05,㸪⤒㣗㐨࢚ࢥ࣮㸪ᚰ⭍ෆ㉸㡢ἼLQWUDFDUGLDFHFKRFDUGLRJUDSK\,&(ࡀ ࠶ࡿࡀ㸪,&( ࢆ⏝࠸࡚ ᮏࡢྛ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࢆ ᐃࡋࡓሗ࿌ࡣ࡞࠸ࠋᡃࠎࡣ⫵㟼⬦ධཱྀ㒊ࡀ኱ ࡁ࠸ࡇ࡜ࡣᚰᡣ⣽ື෌Ⓨࡢண ᅉᏊ࡟࡞ࡿ࡜࠸࠺௬ㄝࢆ❧࡚㸪,&( ࢆ⏝࠸࡚⫵㟼⬦ධཱྀ㒊᩿㠃✚ࢆ ᐃࡋ㸪⫵㟼⬦ධཱྀ㒊᩿㠃✚ࡀ⫵㟼⬦㝸㞳⾡ᚋࡢ෌Ⓨண ᅉᏊ࡜࡞ࡿ࠿ࢆホ౯ࡋࡓࠋ ࠙ᑐ㇟࡜᪉ἲࠚ ᚰᡣ⣽ື࡟ᑐࡍࡿ⫵㟼⬦㝸㞳⾡ࡢ⾡๓࡟㸪◊✲ෆᐜ࣭ព⩏࣭༴㝤ᛶ࣭ಶே᝟ሗࡢಖㆤ࡟㛵ࡋ࡚༑ศ ࡟࢖ࣥࣇ࢛࣮࣒ࢻࢥࣥࢭࣥࢺࢆ⾜࠸ᩥ᭩࡛ྠពࢆᚓࡓ㐃⥆ ⑕౛ࢆᑐ㇟࡜ࡋࡓࠋ⾡୰࡟᪉ྥྍኚᘧ ࢩ࣮ࢫࢆ⏝࠸࡚ ,&( ࢆ ᮏࡢ⫵㟼⬦ࡢධཱྀ㒊࡟␃⨨ࡋ࡚㸪ྛ⫵㟼⬦ࡢධཱྀ㒊᩿㠃✚ࢆ ᐃࡋࡓࠋⓎస ᛶᚰᡣ⣽ື࡟ᑐࡋ࡚ࡣ୧ഃ⫵㟼⬦㝸㞳⾡ཬࡧ୕ᑤᘚୗ኱㟼⬦⊃㛫⥺≧↝ⅎࢆ᪋⾜ࡋ㸪ᣢ⥆ᛶᚰᡣ⣽ື ࡟ᑐࡋ࡚ࡣᕥᡣኳ⵹㒊⥺≧↝ⅎࢆ㏣ຍࡋࡓࠋ⫵㟼⬦㝸㞳⾡ᚋࡢᚰᡣ⣽ື෌Ⓨࡢホ౯ࡣ㸪እ᮶⤒㐣ほᐹ ࡛ࡢ ㄏᑟᚰ㟁ᅗཬࡧ ᫬㛫 +ROWHU ᚰ㟁ᅗ࡛⾜ࡗࡓࠋ෌Ⓨࡢᐃ⩏ࡣ ㄏᑟᚰ㟁ᅗཬࡧ ᫬㛫 +ROWHU ᚰ㟁ᅗࡢ࠸ࡎࢀ࠿࡛ ⛊௨ୖࡢᚰᡣᛶ୙ᩚ⬦㸦ᚰᡣ⣽ື㸪ᚰᡣ㢖ᢿ㸪ᚰᡣ⢒ື㸧ࡀグ㘓ࡉࢀ ࡓሙྜ࡜ࡋ㸪ࣟࢪࢫࢸ࢕ࢵࢡከኚ㔞ゎᯒ࡛ᚰᡣ⣽ື෌Ⓨࡢ⊂❧ࡋࡓண ᅉᏊࢆゎᯒࡋࡓࠋ ࠙⤖ᯝࠚ ⑕౛ࡢ࠺ࡕᕥ⫵㟼⬦ࡀඹ㏻⟶࡛࠶ࡗࡓ ౛࡜㸪እ᮶⤒㐣ほᐹ୰ࡢ㠀ᚰ⮚Ṛ┤⭠⒴⑕౛ ౛ࢆ 㝖እࡋ ⑕౛s ṓ㸪⏨ᛶ ேࢆゎᯒᑐ㇟࡜ࡋࡓࠋⓎసᛶᚰᡣ⣽ືࡀ ⑕౛㸪ᣢ⥆ᛶᚰᡣ⣽ ືࡀ ⑕౛࡛࠶ࡗࡓࠋᖹᆒ㏣㊧ᮇ㛫 s ࠿᭶࡛㸪 ౛࡟෌Ⓨࢆㄆࡵࡓࠋ෌Ⓨ⩌࡜㠀෌Ⓨ⩌ ࡛㸪ᖺ㱋㸪ᕥᡣᚄࡸᕥᐊ㥑ฟ⋡࡞࡝ࡢᝈ⪅⫼ᬒ࡟᭷ពᕪࢆㄆࡵ࡞࠿ࡗࡓࠋ ,&( ࡟ࡼࡿྜే⑕ࡣㄆࡵ࡞࠿ࡗࡓࠋ,&( ࡛ ᐃࡋࡓ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࢆయ⾲㠃✚࡛⿵ṇࡋࡓ࢖ࣥ ࢹࢵࢡࢫ್ࡣ㸪ᕥୖ⫵㟼⬦sPP_P_{㸪ᕥୗ⫵㟼⬦ sPP}_P_{㸪ྑୖ⫵㟼⬦ s} PP_P_{㸪ྑୗ⫵㟼⬦ s PP}_P_{࡛࠶ࡗࡓࠋࡲࡓ෌Ⓨ⩌࡜㠀෌Ⓨ⩌࡜ࡢẚ㍑࡛ࡣ㸪ᕥୖ⫵㟼⬦} s PP_P_{ᑐ s PP}_P_{S ᕥୗ⫵㟼⬦ s PP}_P_{ᑐ s}

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PP_P_{S ྑୖ⫵㟼⬦sPP}_P_ᑐsPP_P_{S ྑୗ⫵㟼⬦} sPP_P_ᑐsPP_P_{S ࡛࠶ࡾ㸪ᕥୖ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࡢࡳࡀ෌Ⓨ⩌࡛᭷} ព࡟኱ࡁ࠿ࡗࡓࠋ ᖺ㱋㸪ᕥᡣᚄ㸪ᚰᡣ⣽ືࡢᮇ㛫㸪ᚰᡣ⣽ືࡢ✀㢮㸪⾡ᘧ㸪ᕥୖ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࢆゎᯒᅉᏊ࡜ࡋ ࡓከኚ㔞ゎᯒ࡛ࡣ㸪ᕥୖ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࡀ၏୍ࡢ⊂❧ࡋࡓᚰᡣ⣽ື෌Ⓨண ᅉᏊ࡛࠶ࡗࡓ࢜ࢵ ࢬẚ㸪ಙ㢗༊㛫㸪S ࠋࡲࡓ UHFHLYHURSHUDWLQJFKDUDFWHULVWLF ᭤⥺࡛ ゎᯒࡋࡓ࡜ࡇࢁᕥୖ⫵㟼⬦ධཱྀ㒊᩿㠃✚ PP_P_{ࡀ᭱㐺࡞࢝ࢵࢺ࢜ࣇ್࡛࠶ࡾ㸪ឤᗘ 㸪≉␗ᗘ} 㸪㝧ᛶⓗ୰⋡ 㸪㝜ᛶⓗ୰⋡ ࡛⫵㟼⬦㝸㞳⾡ᚋࡢᚰᡣ⣽ື෌Ⓨࢆண ࡛ࡁࡓࠋ ࠙⪃ᐹࠚ ⫵㟼⬦㝸㞳⾡ᚋࡢᚰᡣ⣽ື෌Ⓨࡢཎᅉ࡜ࡋ࡚㸪㝸㞳⫵㟼⬦̿ᕥᡣ㛫ࡢ෌ఏᑟࡸ⫵㟼⬦௨እࡢᚰᡣᛶ ᮇእ཰⦰ࡸᚰᡣ⣽ືࢆᣢ⥆ࡉࡏࡿ୙ᩚ⬦ᇶ㉁ࡢᏑᅾࡀሗ࿌ࡉࢀ࡚࠸ࡿࠋ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࡀ኱ࡁࡅ ࢀࡤ≀⌮ⓗ࡟㝸㞳ࡍ࡭ࡁ㠃✚࣭㊥㞳ࡀᣑ኱ࡍࡿࡓࡵᢏ⾡ⓗ࡟㞴ᗘࡀቑࡋ㸪㝸㞳୙༑ศ࡞㒊఩ࡀ⏕ࡌࡿࠋ ࡲࡓ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࡀ኱ࡁࡅࢀࡤᚰᡣ⣽ືⓎ⑕ࡢཎᅉ࡜࡞ࡾ࠺ࡿᚰᡣᛶᮇእ཰⦰ࡀ⏕ࡌᚰᡣ⣽ ືࢆᣢ⥆ࡉࡏࡿ୙ᩚ⬦ᇶ㉁ࡶቑ࠼㸪⫵㟼⬦ධཱྀ㒊᩿㠃✚ࡀ෌Ⓨ࡟㛵㐃ࡍࡿ࡜⪃ᐹࡉࢀࡓࠋຍ࠼࡚ᮏ◊ ✲ࡣ㸪⫵㟼⬦ࡢ୰࡛ࡶᕥୖ⫵㟼⬦ࡢධཱྀ㒊᩿㠃✚ࡀ⊂❧ࡋࡓண ᅉᏊ࡛࠶ࡿࡇ࡜ࢆୡ⏺࡟ඛ㥑ࡅ࡚᫂ ࡽ࠿࡟ࡋࡓࠋ&7 ࡸ 05, ࢆ౑⏝ࡋࡓ⫵㟼⬦ධཱྀ㒊ࢆ ᐃࡋࡓሗ࿌ࡣ㐣ཤ࡟ࡶ࠶ࡿࡀ㸪&7 ࡣ㐀ᙳ๣ࢆ౑ ⏝ࡍࡿࡓࡵ⭈ᶵ⬟పୗ⑕౛࡛ࡣ᪋⾜࡛ࡁࡎ㸪05, ࡣ⚗ᚷ⑕౛࡛᪋⾜࡛ࡁ࡞࠸➼ࡢ㝈⏺ࡀ࠶ࡿࠋᮏ◊✲ ࡣ㉸㡢Ἴ࡟ࡼࡿ ᐃࡢࡓࡵ㐀ᙳ๣౑⏝㔞ࡣᑡ࡞࠿ࡗࡓࠋࡲࡓ㸪&7 ࡸ 05, ࢆ౑⏝ࡋࡓ㐣ཤࡢሗ࿌ࡣධ ཱྀ㒊㛗ᚄࡸ▷ᚄࡢ ᐃ್ࡢࡳ࡛࠶ࡾ㸪⫵㟼⬦ධཱྀ㒊᩿㠃✚ࢆ ,&( ࡛ ᐃࡋࡓሗ࿌ࡣࡇࢀࡲ࡛࡞࠿ࡗ ࡓࠋᮏ◊✲࡛ࡣධཱྀ㒊᩿㠃✚ࢆ ,&( ࡛┤᥋ ᐃࡍࡿࡇ࡜࡟ࡼࡾ㸪⫵㟼⬦ࡢゎ๗Ꮫⓗ≉ᚩ࡜ᛶ㉁ࢆࡼࡾ ṇ☜࡟ホ౯࡛ࡁࡓ࡜⪃࠼ࡽࢀࡓࠋ ࠙⤖ㄽࠚ ᚰᡣ⣽ື࡟ᑐࡍࡿ⫵㟼⬦㝸㞳⾡ࡢ⾡୰࡟⫵㟼⬦ධཱྀ㒊᩿㠃✚ࢆ ,&( ࡛ ᐃࡍࡿࡇ࡜ࡣ᭷⏝࡛࠶ࡾ㸪 ,&( ࡛ ᐃࡋࡓᕥୖ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࡣ⾡ᚋࡢᚰᡣ⣽ື෌Ⓨࡢ⊂❧ࡋࡓண ᅉᏊ࡛࠶ࡿࠋ ㄽ ᩥ ᑂ ᰝ ࡢ ⤖ ᯝ ࡢ せ ᪨ ⏦ㄳ⪅ ୰ᓥ Ꮥࡣ㸪ᚰᡣ⣽ື࡟ᑐࡍࡿ㠀⸆≀⒪ἲ࡛࠶ࡿ⫵㟼⬦㝸㞳⾡ࡢ⾡ᚋ෌Ⓨ࡜ᚰ⭍ෆ㉸㡢Ἴ ࡛┤᥋ ᐃࡋࡓ⫵㟼⬦ධཱྀ㒊᩿㠃✚➼࡜ࡢ㛵㐃ࢆ᳨ウࡋ㸪ᕥୖ⫵㟼⬦ධཱྀ㒊᩿㠃✚ࡢࡳࡀ෌Ⓨ⩌࡛᭷ ព࡟኱ࡁࡃ㸪ࡇࢀࡀᚰᡣ⣽ືࡢ⾡ᚋ෌Ⓨࡢண ᅉᏊ࡜࡞ࡾᚓࡿࡇ࡜ࢆぢฟࡋࡓࠋࡇࡢࡇ࡜ࡣ㸪⫵㟼⬦ 㝸㞳⾡ࡢ㐺ᛂᝈ⪅ࡢ㑅ᢥࡸ⾡ᚋࡢணᚋண ࡟᭷⏝࡛࠶ࡿ࡜⪃࠼ࡽࢀ㸪ᚠ⎔ჾ⑓ᏛࡢⓎᒎ࡟ᑡ࡞࠿ࡽࡎ ᐤ୚ࡍࡿࡶࡢ࡛࠶ࡿࡇ࡜ࢆㄆࡵࡿࠋ 㹙୺ㄽᩥබ⾲ㄅ㹛 7DNDVKL1DNDVKLPD0DVDQRUL.DZDVDNL+LUR\XNL7R\RVKL1REXKLUR7DNDVXJL7RPRNL.XERWD +LURPLWVX.DQDPRUL+LURDNL8VKLNRVKL7DNXPD$R\DPD.D]XKLNR1LVKLJDNL6KLQ\D 0LQDWRJXFKL,PSDFWRIWKHSXOPRQDU\YHLQRULILFHDUHDDVVHVVHGXVLQJLQWUDFDUGLDF HFKRFDUGLRJUDSK\RQWKHRXWFRPHRIUDGLRIUHTXHQF\FDWKHWHUDEODWLRQIRUDWULDO ILEULOODWLRQ -RXUQDORI,QWHUYHQWLRQDO&DUGLDF(OHFWURSK\VLRORJ\GRLRUJV