少量の心嚢液排泄が有効であった肺水腫の1例

A Difficult Case to Diagnose by Ultrasonography in Cardiac Tamponade

　早期血栓閉鎖型大動脈解離に対して保存的に経過観察中，肺水腫より呼吸不全を併発し人工呼吸管理を要した症例において，少量の心嚢液の排泄を行うことにより尿排泄の著明な増加を認め呼吸状態が改善した症例を経験した．患者は54歳，男性．突然の胸背部痛より発症したDeBakey IIIb型胸部大動脈解離にて入院．上行，弓部は早期血栓閉鎖しており，降圧剤投与による内科的治療を行った．経過中，呼吸器系の感染症が一因と考えられる肺間質への透過性の亢進よる肺水腫となり，人工呼吸管理を必要とした．心臓超音波検査では心タンポナーデの所見は乏しかったが，利尿剤に対する反応が悪く，十分な尿量の確保が得られないため心嚢ドレナージを行い約80m1の心嚢液を排出したところ，術直後より尿量の著明な増加を認め，呼吸状態は改善し人工呼吸器から離脱可能であった．超音波検査上は典型的な心タンポナーデの所見は認められないが，臨床所見上はタンポナーデに近い状態であったと考えられた．

A 54-year-old male visited our hospital with severechest and back pain. Colltrast enhanced conmputed tomo-graphy (CECT) revealed a Stanford type A acute aorticdissection. We diagnosed it as early thrombosed-typeaortic dissection because the false lumen of the ascend-ing aorta and arch had not been enhanced. The patientwas hospitalized and began conservative treatment withblood pressure control. One week later, his respiratoryfunction had gradually worsened. The cardiac ultra-sonography (UCG) showed a very small amount of peri-cardial effusion,good cardiac function and no typicalsigns of cardiac tamponade.The thoracic CT demon-strated bilateral lung edema with air bronchogram andPleural effusion.We perforlned steroid pulse therapy butthe patients's condition did not improve.Mechanicalventilation was needed.The urine discharge was 50-80ml per hour but the patient experienced a negativediuretic reaction.We carried out pericardial drainage inspite of the diagnosis of cardiac tamponade by UCG.After the operation his urine volume increased remark-ably alld his reaction to diuretic was positive, and therespiratory condition improved.

Based on our clinical views, we believe the patient hadexperienced cardiac tamponade but we have nodefinitive evidence from any examination.