3弁置換術（三尖弁，僧帽弁，大動脈弁）により治癒し得た心室中隔欠損症に伴う活動性感染性心内膜炎の1例

A Case of Ventricular Septal Defect Associated with Active Infective Endocarditis Which was Successfully Treated by Triple Valve Replacement and Ventricular Septal Defect Patch Closure

　症例は47歳男性．6歳時に心室中隔欠損症を指摘された．抜歯後労作時の息切れ，発熱，起坐呼吸が出現したため当科に入院した．血液培養でα-Streptococcus検出．心エコー検査で三尖弁，僧帽弁，大動脈弁の3弁にvegetationを認めた．感染性心内膜炎と診断し，ペニシリンG2,000万単位／日，ゲンタマイシン100万単位／日を投与開始した．心不全に対してはフロセミド80mg／日を用いた．心不全症状は改善したが，炎症所見は改善せず，活動性炎症期にあると考えたが，三尖弁，僧帽弁，大動脈弁の3弁置換術および心室中隔欠損孔閉鎖術を施行した．病変は右室内膜から三尖弁全体におよび，心室中隔欠損孔を介して大動脈弁，僧帽弁に帯状に進展していた．薬剤抵抗性の活動性感染性心内膜炎に対する手術時期の決定については諸論のあるところであるが，脳塞栓症など重篤な合併症が発症する以前に，可及的早期に実施することが重要と考えられた．

A 47-year-old man was hospitalized in May, 1990, because of breathlessness and continuous fever which appeared about 4 weeks after he had had his per-iodonitic tooth removed in December, 1989. He had been diagnosed as having ventricular septal defect (VSD) at the age of 6 years. When he was hospitalized, he was in a condition of class Ⅳ by NYHA classification, with a white blood cell count of 17,300/mm³, an increase in CRP, a red blood cell sedimentation rate of 108 mm/hr, and positive α-streptococcus in blood culture. His car-diothoracic ratio was 64% with signs of pulmonary congestion on a chest X-ray film.