冠動脈左室瘻および左室心筋肥大を伴った冠攣縮性狭心症の1例

A Case of Vasospastic Angina with Coronary-Left Ventricular Fistula and Left Ventricular Hypertrophy

　心筋肥大を伴った冠動脈左室瘻の報告は散見されるが，詳細な発生機序などは明らかでない．また，冠動脈左室瘻と冠攣縮性狭心症の合併例の報告も非常に珍しい．今回われわれは心筋肥大および冠動脈左室瘻を伴った冠攣縮性狭心症を経験したので報告する．症例は57歳，男性．主訴は胸部圧迫感．ホルター心電図上，ST上昇発作および心室頻拍が認められ入院となった．冠動脈造影上，冠動脈左室瘻が認められた．心筋虚血の原因として冠攣縮またはcoronary steal現象が考えられた．Coronary steal現象は冠拡張薬が無効であるとの報告があり，本症例は冠拡張薬が非常に有効であったことから，冠攣縮が心筋虚血の原因となっていると判断した．また，本症例は心筋肥大を呈しており，冠動脈左室瘻と心筋肥大との関連性も疑われた．

　Coronary-left ventricular fistula with hypertrophic cardiomyopathy is reported sometimes, but detailed knowledge of how this occurs is not available. Coronary spasm with coronary-left ventricular fistula is also very unusual. Here, we report a case of vasospastic angina coronary-left ventricular fistula and hypertrophic cardiomyopathy which we encountred. A 57-year-old man suffered from chest oppression and faintness. ST rise fit and ventricular tachycardia were recognized in a Holter electrocardiogram, so the patient was hospitalized.

　Coronary-left ventricular fistula was recognized in the coronary angiogram. Coronary spasm or coronary steal phenomenon was suspected as a cause of the ischemia.

　The use of a coronary vasodilator is not an effective means for coronary steal phenomenon, but, in this case, a coronary vasodilator was very effective, so we judged that coronary spasm was the cause of ischemia in this case. This patient appeared to suffer from hypertrophic cardiomyopathy. Coexistence of coronary-left ventricular fistula and hypertrophic cardiomyopathy seems to be a causal association.