頚動脈洞マッサージ（CSM)

Up To Dateを少し見てみましたところ、CSMの左右の優位性に関しては明確
には言及されていませんでしたが、以下のようにやはり右のほうが有効との報告は記
載されておりました。左右の優位性よりも、バルサルバ手技の優位性の記載があり、
上室性頻拍の治療には、CSMよりバルサルバ手技が有効である、とのことが示唆され
ているようです。

頻脈性不整脈に対する迷走神経刺激手技で、最も有効だったのがバルサルバ手技
（54％）、ついで、右CSM（17％）、左CSM(５％）。
In a study of 35 patients with SVT inducible by programmed electrical
stimulation mentioned above, of the four vagal maneuvers studied for their
ability to terminate the tachycardia, investigators found that the supine
Valsalva maneuver was successful in more instances (54 percent) than right
carotid sinus massage (17 percent), left carotid sinus massage (5 percent),
or the diving reflex (17 percent) [7]

[7]Mehta, D, Wafa, S, Ward, DE, Camm, AJ. Relative efficacy of various
physical maneuvers in the termination of junctinal tachycardia. Lancet 1988;
1:1181.

頻脈性不整脈に対しCSMが無効であったいくつかのケースで、バルサルバ手技が有効
であった。
In a study of 68 consecutive patients with recurrent SVT, investigators
compared various vagal techniques, including carotid sinus massage and the
Valsalva maneuver, for the termination of the arrhythmia. The authors found
that several patients who were unresponsive to multiple applications of
carotid sinus massage terminated their arrhythmia with the Valsalva maneuver
[5]

[5]Waxman, MB, Wald, RW, Sharma, AD, et al. Vagal techniques for termination
of paroxysmal supraventricular tachycardia. Am J Cardiol 1980; 46:655.

◯◯先生御指摘のように、Up To Dateにも、右迷走神経は通常SA結節に，また左迷走
神経はAV結節に優位に影響を与えている、との報告がある、と記載されていました
が、しかしながら、結局のところ明確に説明できるものではないと、否定的見解もあ
るようでした。

Previous investigations have suggested that right-sided carotid stimulation
may preferentially impact the SA node and left-sided carotid stimulation may
preferentially impact the AV node [14] , but this effect has never been
demonstrated clearly [6] .

[14]]Cohn, AE, Fraser, RF. Paroxysmal tachycardia and the effect of
stimulation of the vagus nerves by pressure. Heart 1913; 5:93.
[6] Schweitzer, P, Teichholz, LE. Carotid sinus massage. Its diagnostic and
therapeutic value in arrhythmias. Am J Med 1985; 78:645.

私自身、ACLSに関わり初めの頃から、◯◯先生の”優位半球、、、”という理由も、
多くのインストラクターからお聞きしていました。しかしながら、個人的にはどうも
違和感があって、コースではあまり言及はしていません。あくまでも個人的見解です
が、ACLSにおいては、CSMは、命にかかわりのない上室性頻拍に行う手技で、かつ
20％程度しか効果が期待できない手技ですから、脳梗塞は100％起こしてはいけない
と思っています。僅かでも脳梗塞のリスクが潜在しているようであれば、施行を控え
るように説明しています。最近は３０代でもAMIが珍しくないですから、◯◯先生御
指摘のように頚動脈プラークが潜在している方も少なくないと思います。CSMの対象
は若年女性くらいになってしまうかもしれません（しつこいようですが、個人的見解
です）。

Up To Dateに記載されているある研究では、頚動脈雑音がなく、脳梗塞、心筋梗
塞、心室性不整脈の既往がないひとを対象とした、CSMの神経学的合併症は0.28％で
した。合併症を生じた方の多くは、症状は一過性であり、完全に回復したようです。

Neurologic complications - Neurologic complications are most commonly
associated with CSM, although the incidence of serious adverse events is low
if patients are appropriately screened [13,40,41] .

A series of 4000 patients (mean age 74 years) representing 16,000 episodes
of CSM, demonstrated that serious neurologic events are rare in
appropriately selected patients [40] . Patients were screened prior to CSM
and the maneuver was not performed if any of the following exclusion
criteria were present:

A carotid bruits were present
A history of stroke or transient ischemic attack
A history of myocardial infarction with in the previous six months
A history of ventricular tachycardia or ventricular fibrillation
Of the 4000 patients, 11 (0.28 percent) had neurologic complications. Of
these 11 patients, seven made a complete recovery within 24 hours, with an
additional two recovering within two months.

Similar safety was reported in a series of 1000 consecutive patients age 50
years or older presenting to an emergency department for unexplained falls
in whom CSM was performed to evaluate for the presence of carotid sinus
hypersensitivity. Patients were screened prior to CSM and the maneuver was
not performed if any of the following exclusion criteria were present:

Immobility
Blindness
Cognitive impairment
Carotid bruit
Previous ventricular arrhythmia
Stroke within the preceding three months
Myocardial infarction within the preceding three months
Presence of a pacemaker
A total of 3805 carotid sinus massages were performed. Nine patients (0.90
percent) reported symptoms. Of these nine patients, symptoms lasted less
than 10 minutes in seven patients, and in one patient a right homonymous
hemianopia for less than 24 hours. The remaining patient had persistent
hemiplegia and expressive dysphasia [13] .


[13]Richardson, DA, Bexton, R, Shaw, FE, et al. Complications of carotid
sinus massage--a prospective series of older patients. Age Ageing 2000;
29:413.
[40] Davies, AJ, Kenny, RA. Frequency of neurologic complications following
carotid sinus massage. Am J Cardiol 1998; 81:1256.
[41] Munro, NC, McIntosh, S, Lawson, J, et al. Incidence of complications
after carotid sinus massage in older patients with syncope. J Am Geriatr Soc
1994; 42:1248.