心筋梗塞症を4度発症した冠動脈主要3枝完全閉塞の1例

A Case with a History of Acute Myocardial Infarction on four Separate Occasions and with Total Occlusion of the three Main Coronary Arteries

　症例は78歳，男性．1987年左前下行枝が責任病変の急性心筋梗塞症を，1990年右冠動脈閉塞による急性心筋梗塞症を発症している．また，1991年に高位側壁梗塞症も生じた．1996年8月2日，前胸部圧迫感あり，当科を受診した．心電図上完全右脚ブロックとV_1〜6でST上昇を認めた．慢性期の冠動脈造影では，左前下行枝，左回旋枝とも最近位部で完全閉塞していた．鈍縁枝から前下行枝へ側副路が発達していた．右冠動脈造影も最近位部で完全閉塞し，橋渡し側副路と左冠動脈からの側副路を認めた．左室駆出率は22％と低値であった．本人および家族の希望で保存的加療で経過観察中である．本例は良好な側副路のため3枝閉塞の低心機能例にもかかわらず長期生存できている稀な症例と考えられた．

We report a rare case of an aged patient who has suffered from acute myocardial infarction four times over a 10-year-period and is still alive. The patient, a 78 -year-old man, has a history of an acute miocardial infarction of the anterior area in 1987, of the inferior area in 1990 and of the high lateral area in 1991. In 1996, he consulted us because of an oppressive sensation of the anterior chest. His electrocardiography revealed ST eleviation in V_1-6 and aV_L The coronary angiography in the chronic stage showed complete occlusion in a loca-tion just proximal to the three major coronary branches. These involve the collateral circulation from the large obtuse marginal artery to the left anterior descending artery branch and to the right coronary artery. The right coronary artery has also bridge collateral circula-tion. The left ventricular ejection fraction was 22%. The patient and his family have rejected invasive therapies such as PTCA or CABG. We suggest that, in this case,well-developed collateral circulation and the patient's long history of an ischemic condition may make it possible for him to survive under these severe circum-stances.