陳旧性心筋梗塞，心不全を伴った冠動脈肺動脈瘻にコイル塞栓術とPTCAを行った1例

Transcatheter Coil Embolization and Coronary Angioplasty in the Treatment of Coronary Arteriovenous Fistula in a Patient with Old Myocardial Infarction and Heart Failure: A case report

　患者は45歳，男性．呼吸困難を主訴に受診し，うっ血性心不全のため入院した．心電図ではI,aV_L，V_4〜6に異常Q波を認め，心臓超音波検査では左室心尖部の壁は非薄化し，壁運動は前壁中隔で低下，後側壁は無収縮であったが心筋逸脱酵素の上昇はなかった．冠動脈造影検査では主に左前下行枝近位部から肺動脈に流入する冠動脈瘻を認め，瘻血管の分岐より末梢の前下行枝の高度狭窄と第1,2対角枝，回旋枝の鈍縁枝の完全閉塞を認め，右冠動脈は低形成，左室駆出率は36％であった。右心カテーテル検査では左右シャント率は27％であった．陳旧性心筋梗塞と心不全を伴った冠動脈瘻と診断し，保存的薬物治療では心不全症状が残存したため，経カテーテル的コイル塞栓術にて瘻閉鎖を行い血行動態の改善を得た。90％狭窄であった左前下行枝にはPTCAを追加した．心不全，運動耐容能の改善を認め，冠動脈瘻に対するコイル塞栓術は安全かつ有用であると考えられた．

A 45-year-old man was admitted because of acute pulmonary edema. There were abnormal Q waves in I, aV_L. V_4~6 and reduced R wave amplitude in all leads on ECG. Echocardiography revealed apical wall thinning, postero lateral wall akinesis and anteroseptal hypo-kinesis. There was no increase of myocardial enzymes in his blood. Coronary angiograms disclosed hypoplastic right coronary artery, total occlusion on # 9,# 10 and # 12, severe stenosis with filling delay in # 7 and # 8. Multiple fistulae originating from the left coronary artery, mainly from # 6, and draining into the pulmonary trunk were also observed. The left ventricular ejection fraction was 36% and the left to-right shunt ratio was 27%. Transcatheter embolization using platinum mi-crocoils was performed because pulmonary edema remained in spite of medical therapy. After the closure of the main fistula, filling of the distal left anterior descending artery was improved. As severity of stenosis was estimated at 90%, coronary angioplasty was perfor-med. Exertional dyspnea and pulmonary edema disappeared soon after the procedures. Percutaneous closure of a coronary fistula can be performed safely. Combined with PTCA, it might have helped ameliorate heart failure in this case.