PTCR後に心尖部Aneurysmal bulgingの消失がみられた急性心筋梗塞の1症例

A case of acute myocardial in farction with apical aneurysmal bulging which disappeared after percutaneous transluminal coronary recanalization

　Percutaneous Transluminal Coronary Recanalization（PTCR）は1979年に始められて以来，めざましい普及をみせているが，心筋梗塞発症後の開始時問に関する問題も含めて，その適応基準に関してはいまだコンセンサスが得られていない。今回私達は最初の胸痛発作50時間経過後で，最終の発作約3時間後にPTCRを行い，梗塞巣の著明な縮小とともに左室心尖部のAneurysmal　bulgingの消失がみられた症例を経験したので，若干の考察を加えて報告する。

A 59 year-old man was admitted because of recur-rent anterior chest pain which had occured two days before and had not dissapeared by sublingual admini-stration of NTG. On admission, ECG showed poor R progression in leads V_1-3, convex ST segment eleva-tion in leads V_2-6 with giant negative T wave. No abnormal emergent laboratory findings other leucocy-tosis were recognized. Echocardiography revealed aneu-rysmal bulging with wall thinning and dyskinesis in anteroseptalapical segments.

Three hours after the last onset of chest pain, emer-gent coronary arteriogram revealed subtotal stenosis of left anterior descendens, at which dilatation to 75% stenosis was achieved by PTCR. One month later, ECG showed marked progression of R wave in pre-cordial leads with coronary T wave in V_2-5. Echo-cardiography showed almost normal left ventricular motion except for akinesis of apical segment. In coro-nary cineangiography, left anterior descendens was pa-tent remaining about 75% stenotic lesion. So called dominant right coronary artery and left circumflex showed no significant stenosis. Left ventriculography as well as echocardiography showed akinesis in its apical wall and normokinesis in other segments. Aneurysmal bulging was not recognized. Consequently, PTCR was very successful in this case nevertheless we had hesi-tated to perform because the onset time of myocardial infarction had been obscure.

Recently in Japan, PTCR has become considerably widespread therapeutic method of acute myocardial infarction in many hospitals. But its criteria of indica-tion including the passing time from the attack has not been decided yet by common concent. This case showed the possibility of subacute phase from some informations for instance ECG or clinical course. On the other hand, it is reported that aneurysmal bulging with wall thinning and dyskinesis recognized in echo-cardiography is not always rare in acute phase.

As a result, active PTCR in cases like this may be fairly effective generally. This result exerts a great influence upon the criteria of indication for PTCR.