大動脈炎症候群，左冠動脈主幹部閉塞，大動脈弁および僧帽弁閉鎖不全症例での術前に生じた呼吸循環停止からの蘇生―Olprinone最大量投与による後負荷軽減療法下にPCPSからの離脱に成功した１例

Weaning from Percutaneous Cardiopulmonary Support with Olprinone in a Patient with Severe Left Ventricular Dysfunction associated with Aortic Regurgitation

要旨

　患者は54歳の男性で，弓部大動脈からの頸部3分枝狭窄病変，左冠動脈主幹部閉塞，大動脈弁閉鎖不全および僧帽弁閉鎖不全を伴う大動脈炎症候群と診断された．冠動脈バイパス手術と大動脈弁置換術の適応として手術を待機していたが，開心術に先立ち，両側総頸動脈血管拡張術とステント留置術を行った2日後に突然，呼吸循環停止となった．経皮的心肺補助装置(PCPS)を装着し，蘇生に成功したが，その後，急性肺水腫を来し重篤な状態が続いた．そこで後負荷軽減療法を目的にolprinoneを併用し，その量を段階的に最大投与量0.4μg/kg/minまで増加させた結果，心臓超音波検査上，大動脈弁逆流量は有意に減少し，また左室駆出率も改善してPCPSからの離脱につながった．本症例では，olprinoneの投与による後負荷軽減療法の徹底が弁逆流の軽減をもたらしPCPSからの離脱への一助となったと考えられた．

Summary

　Percutaneous cardiopulmonary support system (PCPS) is one of the most powerful modalities of treatment for patients with acute heart failure. The system,however,can fail to improve hemodynamics in a patient with aortic valve insufficiency resulting in left ventricular overdistension. We present a 54-year-old patient who was slated for coronary artery bypass grafting and aortic valve replacement for left main coronary artery occlusion and aortic valve regurgitation due to aortitis syndrome. Prior to cardiac surgical procedures,balloon catheter dilatation was performed to treat bilateral carotid artery stenosis. Two days after the catheter intervention,the patient suddenly presented with cardiopulmonary collapse and was resuscitated with PCPS and maximal pharmacological therapy. Immediately after the resuscitation,he suffered severe lung edema. Transthoracic echocardiogram revealed an overdistended left ventricle along with worsened aortic regurgitation. Aggressive afterload reduction therapy was conducted with a maximal dose of olprinone together with other catecholamines. After introduction of olprinone,the fraction of aortic regurgitation was reduced,and left ventricular contractility was improved,which,at least in part,helped the patient to become independent of extracorporeal circulation devices.