正常冠動脈造影像を呈した心室中隔穿孔の1例

A Case of Ventricular Septal Perforation with a Normal Coronary Artery

要旨　患者は77歳，女性．65歳時に安静時胸痛を認め精査施行．心エコーでは軽度左室壁厚の増大を認めるものの，他に異常所見はなく，冠動脈造影では器質的狭窄は認めなかった．今回，失神と呼吸苦のため当院へ救急搬送となる．胸部聴診上，全収縮期雑音を聴取し，心電図は完全房室ブロックに完全右脚ブロック，胸部X線写真上心拡大と肺うっ血，心エコー上は全体的に左心室の壁運動は良好であったが，左室から右室に向かう短絡血流を認めた．体外式ペースメーカ挿入後の緊急冠動脈造影では器質的有意狭窄は認めなかったが，心筋逸脱酵素の上昇もあり，急性心筋梗塞による心室中隔穿孔と考え，心室中隔穿孔部閉鎖術を施行した．術後は経過良好である．本症例は冠動脈に器質的有意狭窄のない急性心筋梗塞に合併した極めて稀な心室中隔穿孔例であり，若干の文献的考察を加え報告する．

　A 77-year-old-woman was admitted to our hospital because of syncope and dyspnea. On physical examination, pansystolic murmur was auscultated. The electrocardiogram showed complete atrioventricular block with right ventricular block. The chest radiography indicated cardiomegaly with congestion in her bilateral lung fields. The echocardiography revealed, by the color Doppler method, the left-to-right shunt flow through the interventricular septum. We immediately inserted a temporary transvenous pacemaker, and performed coronary angiography where no abnormality was revealed. The serum levels of AST, ALT and CPK were slightly elevated, so we made a diagnosis of ventricular septal perforation(VSP) induced by acute myocardial infarction with a normal coronary artery. Closure of VSP was performed by cardiac surgery. Thereafter, the improvement in congestive heart failure was satisfactory. It was considered that the herein reported patient represents a very rare case of VSP with a normal coronary artery.