僧帽弁形成術後の溶血に対し再弁形成術を施行した１例

A Case of Mitral Valvular Re-repair in a Patient with Severe Mechanical Hemolytic Anemia

要旨

　僧帽弁閉鎖不全症(MR)に対する弁形成術後，高度の溶血性貧血を来し再形成術を施行した症例を経験した．患者は59歳，男性，主訴は労作時呼吸困難．精査にて僧帽弁前後尖の逸脱によるMRと診断した．前尖逸脱に対して腱索再建，後尖逸脱に対して矩形切除を行い，人工弁輪縫着を施行した．術後3日目に心エコーにて人工弁輪に衝突するMRが出現し，血清LDH値の上昇と貧血が出現，次第に増強した．末梢血塗抹標本にて破砕赤血球が観察され，MRによる溶血性貧血と診断した．保存的治療を行っていたが，貧血の進行，腎機能障害の出現が認められたため，初回手術後28日目に再手術を施行した．前尖のわずかな接合不全があり，新たな腱索再建を行うことなどにより再形成術とした．術後経過は良好で，貧血は速やかに改善した．

Summary

　A 59-year-old man with mitral regurgitation due to chordal rupture underwent valve repair by insertion of e-PTFE for the anterior leaflet and quadrangular resection of the posterior leaflet,followed by annuloplasty with a 28-mm Cosgrove-Edwards ring. Postoperatively,intraoperative transesophageal echocardiography suggested only a small regurgitant jet,which was hemodynamically insignificant. Three days later echocardiography revealed a turbulent regurgitation jet coming into collision with the prosthetic ring. The patient suffered progressive anemia with gross hemoglobinuria,and his lactic dehydrogenase level was elevated. Schistocytes were evident on the peripheral smear. The patient underwent a second repair operation four weeks after the initial one. Inspection showed that,although the prosthetic ring was well seated,mitral competence was not complete. Valvular re-repair including re-insertion of e-PTFE for the anterior leaflet,additional suture of the posterior leaflet,and covering of the ring with autologous pericardium was accomplished. Immediately after the second surgery,the patient did well with no evidence of hemolysis.