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Kokyu to Junkan Volume 35, Issue 9 （September 1987）

呼吸と循環 35巻9号（1987年9月発行）

Japanese English

症例

PTCRが著効を示した急性心筋梗塞の1例—Recanalizationと同時にショック状態を離脱し，救命し得た1例 A patient of acute nmyocardial infarction who was recovered from shock simmultaneously with recamalization by PTCR 片桐誠 ¹ , 福沢茂 ¹ , 稲垣雅行 ² , 工藤一彦 ¹ , 小沢俊 ¹ , 茂又祐 ¹ , 高原善治 ³ , 遠藤毅 ³ , 中村常次郎 ³ Makoto Katagiri ¹ , Shigeru Fukuzawa ¹ , Masayuki Inagaki ² , Kazuhiko Kudoh ¹ , Shun Ozawa ¹ , Shinyuh Momata ¹ , Zenji Takahara ³ , Takeshi Endoh ³ , Tsunejiroh Nakamura ³ ¹船橋市立医療センター ²現帝京大学医学部附属市原病院 ³千葉県立鶴舞病院 ¹Funabashi Municipal Medical Center ²Ichihara Hospital, Teikyoh University of Medicine ³Chiba Prefecture Tsurunmai Hospital pp.999-1003

発行日 1987年9月15日 Published Date 1987/9/15

DOI https://doi.org/10.11477/mf.1404205124

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Abstract 文献概要
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　CCUおよびECGモニター設備の普及により心筋梗塞急性期の心室細動などの不整脈死亡は滅少した。しかし、ショックおよび心不全などのポンプ失調による死亡率は依然として高くカテコラミン，血管拡張剤，大動脈バルーンパンピングなどを駆使しても治療が難行することが多い。この点に関し血栓溶解療法，PTCR（Percutaneus Transluminal Coronary Recanalization）は，途絶した病変部に血流を再開することにより梗塞巣を最小限におさえ，さらに残序機能心筋の保護による心機能の改善の強力な治療法として登場した。本邦でもPTCRは急速に普及しつつある。最近ショックを伴った急性心筋梗塞患者にPTCRを施行し，recanalizationと同時に血圧が上昇し救命しえた1例を経験したので報告する。

A 58-year old male patient had had recurrent ang-inal attack, but has not been medicated. On May 30, 1985, at 8 o'clock he experienced severe chest pain, nausea and vomiting, he lost consiousness.

Physical examination on admission revealed cyano-sis, cold sweating and unconsciousness. Radial artery was not pulsated. His blood pressure could not be read and heart rate was 60/min.

Electrocardiogram showed ST elevation in II, III, aV_F leads and ST depression in V_2-5 leads. In labo-ratory data, WBC was 19, 100/mm³, CPK was 166 U/ l, GOT was 68 U/l.

He was diagnosed as inferior myocardial infarction with cardiogenic shock. Soon he was medicated by Dopamin 10μg/kg/min, keeping systolic blood pre. ssure above 90 mmHg.

Total occlusion on right coronary artery (AHA classification seg. 1) was demonstrated by emergency coronary arteriogram, performed using Judkins tech-nique at 13: 00.

Initially after application of NTG (0. 2mg) into RCA and 3 min later, there was no change of the RCA lesion. So vasospasms was denied.

Intracoronary application of urokinase was begun with continuous infusion of 240,000 us over period 10 min. RCA was recanalized in total amount of480, 000 us, which was followed by transient idio-ventricular tachycardia and ST elevation.

Blood pressure was raised simultaneously with recanaliza tion, so he was free from dopamine soon. Addisionally subtotal lesion was demonstrated in LAD and CX. Cardiac output was measured using thermodilusion technique with Swan-Ganz catheter. Cardiac index was 1.99l/min/m² and PAEDP was 8 mmHg, his hemodynamics was grouped in Forrester's subset III.

Peak CPK was 8,000 U/l at 14 : 30, 5 hours after onset.

He was medicated by digitalis, nifedipine, ISDN (isosorbite dinitrate), heparin and warfarin. After abusolute rest, cardiac rehabilitation was performed for him. But electrocardiogram on single Master showed ST depression in V_4-6 leads. He was exa-mined in cardiac catheterization again on July 2, 1985. Ninety% lesion in seg. 1.99% lesion in seg. 4 and 7 were demonstrated on coronary angiogram. Aneurysm in seg. 3, hypokinesis in seg. 4 and 7 were demonstrated on left ventriculogram. Ejection fraction was 47%. Consequently we concluded he had indication for CABG to seg. 2 and 8, so he was operated on CABG at Chiba Prefecture Tsurumai Hospital. The operation was successful and he was progressing favourably.