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ヘパリン起因性血小板減少症(HIT)は,免疫機序で発生するヘパリンの重篤な合併症である.抗PF4・ヘパリン複合体抗体(HIT抗体)はHITの病因となるが,心臓外科領域において,その詳細は明らかではない.今回,カテーテル検査後3ヵ月以内に心臓手術を施行された計28例を対象とし,HIT・HIT抗体の発生率,HIT抗体のseroconversion・危険因子について検討した.HIT抗体は術前と術後にELISAを用いて測定した.全症例において臨床上明らかなHITは認めなかった.術前HIT抗体は28例中1例(4%)にみられ,28例中6例(21%)で術前HIT抗体陰性から術後陽性となった(seroconversion).術後HIT抗体陽性と陰性患者において術前検査結果と人工心肺時間などを比較検討した結果,総グロブリンのみが有意差を示した.術前総グロプリンは術後HIT抗体陽性群(2.89±0.33g/dl)において陰性群(2.42±0.50K/dl)より高値であった(p=0.030).また,術前総グロブリン値は術後HIT抗体陽性と関連性があった(p=0.048;オッズ比.12.09;95%信頼区間,1.02-144.06).Seroconversionの発生率は低く,術前総グロブリン高値は術後HIT抗体陽性の危険因子となる可能性があると考えられた., Heparin-induced thrombocytopenia (HIT) is a serious, immune system-mediated complication of heparin therapy. Antibody to the platelet factor 4/heparin complex is linked to the pathogenesis of HIT. However, there is insufficient information on anti-PF4/heparin antibody (HIT antibody) in cardiac surgery. In this study, we examined the occurrence of HIT and HIT antibody, seroconversion and the risk factors. We selected 28 patients who underwent cardiac procedure following catheterization within 3 months. An enzyme-linked immunosorbent assay (ELISA) for the antibody was measured using preoperative and postoperative serum samples. We could not identify patients with clinical HIT. The incidence of preoperative HIT antibody was 4%. Six of the 28 (21%) patients changed to positive postoperative assay from negative preoperative assay. Comparison of preoperative laboratory data and surgical details did not show significant differences between the patients with positive assays and those with negative assays on postoperative day 10, except total globulin. Preoperative total globulin of positive antibody assay was higher than that of negative antibody assay (2.89 ± 0.33 g/dl versus 2.42 ± 0.50 g/dl, p=0.030) and was related to positive postoperative antibody (p=0.048; odds ratio, 12.09; 95% confidence interval, 1.02-144.06). The rate of seroconversion was low, and elevated level of preoperative total globulin may be the risk factor for positive postoperative HIT antibody.

大動脈基部再置換術は手技的にも複雑であり困難である.今回我々は弁付き人工血管置換術後における大動脈基部再置換術の手術成績と手技的工夫について検討した.対象は1997年1月～2007年7月までに当院で施行した大動脈基部再置換術10例である.平均年齢は38.7±15.5歳で7例が男性であった.初回手術で使用した人工弁は全て機械弁であった.初回手術時の冠動脈再建法は,Inclusion法が7例(70.0%),Graft Interposition法が2例(20.0%),Button法が1例(10.0%)であった.再手術の原因は仮性動脈瘤形成が8例(80.0%),人工弁感染が2例(20.0%)であった.また初回手術時に使用した機械弁を再手術時に5例温存可能であった.再手術の成績については,手術死亡を認めなかった.平均観察期間は28.4(6～77)ヵ月で,遠隔期死亡を2例に認め,原因は敗血症と胸腹部大動脈瘤破裂であった.観察期間中に血栓塞栓症,再手術,冠動脈イベント,冠動脈吻合部瘤は認めなかった.再手術後の5年生存率は75.0±15.8%であった.大動脈基部再置換術の早期遠隔成績は満足のいくものであった.冠動脈吻合部瘤で再手術となったものに関しては初回手術時の人工弁を温存することが可能であった.また,大動脈基部再置換術に関して,Button法が施行できない場合,Separate Interposition法は選択肢の一つとなりえると考えられた., Redo aortic root replacement is technically challenging. We review our redo aortic root surgical results following composite valve graft replacement. Between January 1997 and July 2007,10 patients (mean age 38.7 ± 15.5 years, 70.0% men) underwent redo aortic root replacement. The coronary reconstruction techniques in the previous operation were the inclusion technique in 7 (70.0%), graft interposition in 2 (20.0%), and the coronary button technique in one (10.0%). The indications for reoperation were pseudoaneurysm formation in 8 patients (80.0%) and prosthetic valve endocarditis in 2 (20.0%). We could preserve the previous mechanical valve in 5 patients. There were no operative deaths. The mean follow-up was 28.4 months. There were 2 late deaths, one due to sepsis and the other due to thoracoabdominal aortic aneurysm rupture. During follow-up period, there were no thromboembolic events, reoperations, coronary events, or coronary pseudoaneurysms. The actuarial survival rate at 5 years was 75.0 ± 15.8%. Redo aortic root replacement can be performed with good early and late results. In cases of redo aortic root replacement, we consider coronary reconstruction using the separately interposition technique to be feasible as one of many modifications when the button technique is not able to performed.

過去30年間に渡って冠動脈再建術は人工心肺の使用が必要不可欠とされてきたが,またその使用が死亡率,合併症率を高める一因とも考えられてきた.現在では人工心肺非使用心拍動下冠動脈バイパス術は広く一般に行われつつあるが,依然としていずれの方法が優位性を持つかは議論が続けられている.[目的]人工心肺使用冠動脈バイパス術(on-pump CABG : on-pump群)と心拍動下冠動脈バイパス術(of-pump CABG : off-pump群)における優位性を比較検討した.[方法]2000年5月～2005年6月までに行われたすべての冠動脈再建術患者のうち,on-pump群患者20名とoff-pump群患者20名を無作為に抽出し,死亡率,合併症発生率,完全血行再建率,グラフト開存率,集中治療室滞在日数等を比較検討した.[結果]術後クレアチニンキナーゼのMB分圓(CK-MB)はon-pump群で36.9NG/Ml, off-pump群で18.35NG/Mlとoff-pump群で有意に低値であった(p=0.026).平均集中治療室滞在日数はon-pump群で4.5日長期であった(p=0.043).完全血行再建率は両群で有意差を認めなかった., [Background] For 3 decade's surgical coronary revascularization has been carried out with the use of cardiopulmonary bypass (CPB) as the gold standard. This is being challenged with the resurgence of an old technique involving operating on the beating heart, which is associated with lower morbidity. There is little longterm data on the success of off-pump coronary revascularization, hence this polarizing debate as to which surgery is superior continues. [Aims] To evaluate whether off-pump coronary artery bypass grafting (OPCAB) reduces postoperative morbidity compared to conventional coronary artery bypass grafting (CABG) and to compare completeness of revascularization in both groups. [Methods] Twenty patients who underwent OPCAB and 20 patients who underwent CABG with CPB were selected at random from May 2000-June 2005. Postoperative complications, completeness of revascularization and ICU stay were compared and analyzed. [Results] The CK-MB in the on-pump group was (36.9 NG/ML) compared to (18.35 NG/ML) in the off-pump group (p = 0.026). Mean ICU stay was significantly different in both groups (p = 0.043). The index of completeness of revascularization was similar with no significant difference in graft number and patency. [Conclusion] When compared to conventional CABG, OPCAB achieved significantly shorter ICU stay, less myocardial injury and similar completeness of revascularization indicating that it is an attractive alternative to conventional CABG.

CD25(+)CD4(+) regulatory T cells suppress T cell activation and regulate multiple immune reactions in in vitro and in vivo studies. To define the regulatory function of human CD25(+)CD4(+) T cells at various stages of maturity, we investigated in detail the functional differences of CD25(+)CD4(+) T cells from thymocytes, cord blood (CB), and adult peripheral blood (APB). CB CD25(+)CD4(+) T cells displayed low-FOXP3 protein expression level and had no suppressive activity. In contrast, CD25(+)CD4(+) T cells from thymocytes or APB expressed high expression level of FOXP3 protein associated with significant suppressive activity. Although CB CD25(+)CD4(+) T cells exhibited no suppressive activity, striking suppressive activity was observed following expansion in culture associated with increased FOXP3 expression and a shift from the CD45RA(+) to the CD45RA(-) phenotype. These functional differences in CD25(+)CD4(+) T cells from Thy, CB, and APB hence suggest a pathway of maturation for Treg in the peripheral immune system.