Eisenmenger症候群患者の非心臓手術における周術期合併症の発生リスクは高く，死亡率も3.8～24%と高い。周術期管理では，右左短絡の増加をきたさないように体血管抵抗と肺血管抵抗のバランスを考慮し，心拍出量を保つ必要がある。今回，未修復の房室中隔欠損症に伴う重症肺高血圧症を合併した50歳台のダウン症患者の大腿骨骨折手術に対して，末梢神経ブロックによる鎮痛とデクスメデトミジンによる鎮静の併用により安全に麻酔管理を行うことができた1例を経験したので報告する。

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A Case believed to be an Eisenmenger Complex of a 25 year old female patient was reported.

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チアノーゼとは皮膚・粘膜の青紫色変化で，中枢性ないし末梢性チアノーゼでは毛細血管内血液の還元ヘモグロビン濃度が5 g/dl以上になると出現し，血液性チアノーゼでは異常ヘモグロビン血症が原因となる．チアノーゼの出現に際しては，様々な要素に影響されるため，必ずしも低酸素血症と同義ではない．チアノーゼが長期間持続するチアノーゼ性心疾患やでは，種々の全身合併症が発生するため，適切な管理が必要となる．

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　分娩2カ月後の9歳3カ月齢の雌のホルスタイン種乳牛が起立難渋を主訴に診察を受けた．病歴として3 年前に鼻出血と心雑音があったこと，また，身体検査で心雑音，頸静脈怒張，胸垂浮腫および胸壁の巨大膿瘍が認められ，血液および血液生化学検査で慢性炎症像が認められたことから，心内膜炎が強く疑われた．心電心音図解析にて右側で全収縮期雑音を，左側で収縮期前期雑音と拡張期雑音が確認された．心臓超音波検査では，僧帽弁・三尖弁・大動脈弁・肺動脈弁に疣贅物はみられず，心室中隔欠損（VSD）が確認された．病理学的検査ではVSD に加えて心房中隔欠損，右心室壁肥厚および大動脈と肺動脈の拡張が認められた．生産に供されていた成牛のVSD 症例で9 歳齢での症状発現は調べる限りでは最高齢であった．

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Eisenmenger's syndrome is defined as the process through which an established left-to-right cardiac shunt caused by a congenital heart defect results in pulmonary hypertension and eventual reversal of the shunt into a cyanotic right-to-left shunt. The risk of mortality associated with non-cardiac surgery in patients with Eisenmenger's syndrome is considerable. We describe a patient with Eisenmenger's syndrome who required the extraction of several teeth under general anesthesia.

　A 45-year-old woman was referred to our department because of a toothache and decreased dietary intake. Some teeth in the upper and lower jaws were decayed and required extraction. However, the patient had Down's syndrome as a complication, and she strongly refused to treat her teeth. We decided that it was too difficult for us to extract her teeth under local anesthesia. We planned to extract the teeth with the patient under general anesthesia by closely coordinating the procedure with her pediatrician and an anesthesiologist.

　Consequently, the patient was treated without substantial changes in her cardiovascular dynamics or aggravation of hypoxemia, and the perioperative period was rendered suitable by close cooperation with her pediatrician and anesthesiologist.

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By recording heart sounds and murmurs of 102 cases from mitral valve disease and functional murmur groups in frequency bands of 12.5, 25, 50,100,200, and, 400c/sec. by mingograph, phonocardiographic studies were carried out. The results are as follows : 1) In the mitral stenosis group, loud and high frequency components in the first heart sound were evident when compared to the second sound. The ratio of thd greatest amplitude of the first and second sounds was significant for a differentiation from steno-insufficieny group. The systolic murmurs in mitral steno-insuffiency cases were not recorded satisfactory from channel 4 (100c/sec) and over. Good recordings of diastolic murmurs were obtained in the low frequency bands in both groups, but above channel 4 poor recordings were also seen. The channels 2 and 3, i.e. 25 to 50c/sec showed a most clear characteristic picture of both groups, but the presystolic murmurs showed a tendency to appear in a some what higher freqnency bands. 2) The diastolic murmurs of aortic insufficiency were recorded satisfactory up to the high frequency bands and its characteristic forms were most clearly seen in channels 3 and 4 (50 to 100 c/sec). 3) The second sounds of the congenital heart disease group all showed loud and high frequency components, but this was most evidedt in A.S.D. All types of congenital cases showed a similar tendency of possesing compoents of relattively high frequency in systolic murmurs when compared to the first sound. The durations of murmurs were long in V.S.D. and Eisenmeger type and short in A.S.D. and pulmonary stenosis. 4) Functional systolic murmurs were soft and short and their frequency were low. A rapid reduction of satisfactory recording were seen over channel 4 (100c/sec).

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53歳男性 (体重52kg, 身長151cm) のアイゼンメンジャー症候群患者の歯科治療に対する全身管理を経験した。患者は右上顎の痛みを訴えて来院した。患者は41歳時に血尿と息切れの為に内科を受診し, 心室中隔欠損症, 肺高血圧症を指摘され, アイゼンメンジャー症候群の診断を受けた。根治術の適応外と診断され40日間入院し, 投薬治療が行われた。51歳時には心不全のため40日間入院し, それ以後フロセミド (ラシックス(R)), スピロノラクトン (アルダクトンA(R)), 塩酸ジルチアゼム (ヘルベッサー(R)) を内服しており, NYHA II～III度と考えられた。血圧115-140/65-70mmHg, 脈拍は68-89回/分と正常範囲内であったが, 動脈血酸素飽和度は88～93%と低値であった。内科の担当医からは突然死の可能性もあると伝えられていた。口腔内精査の結果, 全顎の歯周炎が認められ, 7〓78〓の抜歯と全顎の除石が必要と考えられた。
術前には担当医と連絡をとり病状を把握し, 患者と家族に病状を説明し承諾を得た。入院させて処置を4回にわたって行うこととし, 1, 2回目は抜歯を, 3, 4回目は除石を行った。術前より感染性心内膜炎予防のために抗菌剤を投与し, 術中は心血管系作動薬と抗ショック薬と救急蘇生器具を準備した。患者を処置室に入室させ, 血圧計, 心電図計, パルスオキシメータを装着し, 静脈路を確保した。局所麻酔は表面麻酔奏効後にフェリプレシン0.03単位添加3%プロピトカインを用いて浸潤麻酔を行った。4回とも術中経過は順調で, 術後も30分間パルスオキシメータによる観察と注意深い管理を行った。なお, 術後3日間抗菌剤を投与し, 術後も合併症もなく無事に経過した。

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症例1は42才, 1回径産. ASDに細菌性心内膜炎と僧帽弁口逆流が加わり, 35週より妊娠中毒症が追加. 入院の上, 利尿剤とジギタリス急速飽和で肺水腫をまぬがれたが, 分娩後約18時間低拍出性心不全が持続.
症例2は26才, 初産婦. ASDに軽度のMRあり. 月経不順で280日目を仮予定日とし, 自然陣痛なく41週で入院. 43週3日, 血清HPL, E₃が低下したため帝切分娩. 術後数時間低拍出性心不全軽度あり.
ASDは妊娠・分娩による事故の少い心疾患であるが, 肺うっ血のため逆シヤントが生じると, 肺水腫や右心不全を来す. また, 心疾妊婦は細菌性心内膜炎や血栓の危険あり, 非観血的心機能検査としてプレシスモグラムを用いた.

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多脾症候群の50例について,経年的に(一人平均7年の経過)心電図450記録を調べた.全例に先天性心疾患または血管奇形が合併した.多脾症候群の診断は主に肺動脈造影所見,すなわち両側の肺動脈と気管支の関係が左肺型を示す所見によった.心電図記録の多い例では通常同一個体に複数の心房調律が認められた.最も多い調律は心房下部からの調律であった.全体の50%に上室性ペースメーカー機能の低下,すなわち,心房拍数の減少(徐脈化)が認められた.徐脈は40%では一過性,反復性であり,10%では永続性であり,40%では接合部調律が生じていた.徐脈例の頻度は年齢に進むにつれて増加し,その頻度は1歳以下で22%,15歳以上では65%であった.心房調律が複数ある症例では,単一の心房調律の場合より徐脈になる事がかえって多く,本症候群の複数の心房調律は不安定な複数のペースメーカーの存在を示していた.

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The Studies on pulmonary arterial pressure were made by the pulmonary arterial catheterization on 53 patients with chronic pulmonary emphysema, and the following results were obtained.
1) The pulmonary arterial mean pressures of these patients were 9-66mmHg, the pulmonary arterial systolic pressures 9-121mmHg, the pulmonary arterial diastolic pressures 0-36mmHg.
The fluctuation of the pulmonary arterial pressure by respiration was in the rarge of 0-20mmHg in systole and 0-25mmHg in diastole and was marked in the patients with high total pulmonary vascular resistance.
No significant relation between the age of the patients and level of pulmonary arterial pressure was recognized.
2) Many patients with high pulmonary arterial pressure had high ratioes of residual volume and dead space ventilation. However, the patients with high ratioes of residual volume and dead space ventilation had not high pulmonary arterial pressure.
3) The relationships of the haematocrit, the O₂ saturation and the CO₂ pressure of the arterial blood with the pulmonary arterial pressure were nearly same as the reports of many other authors.
The pulmonary arterial pressures increased during low O₂ inhalation and decreased during high O₂ inhalation.
4) During the low O₂ inhalation the elevated pulmonary and systemic arterial pressures were decreased by the injection of C₆ and then the total pulmonary vascular resistances resulted in decrease hand in hand. From these results, it is considered that the autonomic nervous system would be concerned with the rise of pulmonary arterial pressure during low O₂ inhalation.
5) The degree of the elevation of the pulmonary arterial pressure compared with the decrease of the arterial blood O₂ saturation were greater during exercise than during low O₂ inhalation.
The elevation of the pulmonary arterial pressure during exercise may be not only due to the influence of the low O₂ saturation of the arterial blood, but also due to the increased pulmonary blood flow by exercise.
6) The patients with pulmonary hypertension have not always systemic hypertension, and the patients with systemic hypertension have not always pulmonary hypertension.

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