収縮性心外膜炎様の血行動態を呈し，胸水穿刺により劇的な改善を認めた難治性心不全の1例

Intractable Heart Failure with Large Bilateral Pleural Effusions Producing Signs of Cardiac Constriction Resolved by Thoracentesis: A case report

要旨　収縮性心外膜炎では，心外膜の肥厚・石灰化，および心筋との癒着が心腔の拡張を阻害し，円滑な心腔内への血液流入を障害して静脈圧の著明な上昇と心拍出量の減少を来す．一方，明らかな心外膜病変を有さないが，多量の胸水貯留が心腔の拡張を阻害することにより，難治性心不全を呈する症例も散見される．今回，多量の両側胸水貯留により収縮性心外膜炎様の血行動態を呈し，胸水穿刺によって著明に改善した難治性心不全の1例を経験したので報告する．症例は58歳男性，52歳時から拡張型心筋症で外来加療を受けていた．慢性心不全急性増悪のため地元の総合病院に緊急搬送され，心原性ショックに対し人工呼吸器管理および強心剤の投与を中心に加療されたが，治療抵抗性であり，入院から3カ月後に当院に搬送された．右心カテーテル検査では拡張期の右房圧，右室圧，および平均肺動脈楔入圧はほぼ等圧で，右房圧波形からはprominent y decentおよびKussmaul徴候が認められるなど，収縮性心外膜炎様の圧波形を呈した．明らかな心外膜病変はみられなかったが，多量の両側胸水が認められ，両側胸水の排液後には血行動態は著明に改善した．本症例は，多量の胸水貯留が心腔の拡張阻害を介して心血行動態を破綻させ得ることを認識させ，心不全診療における集学的治療の重要性を示唆する貴重な症例と考えられた．

　A 58-year-old man was diagnosed as having dilated cardiomyopathy, and had been treated with optimal medical therapy for 6 years. Despite an uneventful course, he complained of exertional dyspnea and was admitted to a local hospital. He was in a state of cardiogenic shock with pulmonary edema and treated with inotropic agents and mechanical ventilation. His heart failure was intractable, and he had been hospitalized for 3 months before being transferred to our hospital. His right heart catheterization demonstrated near equalization of the right atrial, right ventricular diastolic, and pulmonary capillary wedge pressure, and right atrial pressure tracing showed prominent 'y' descent and Kussmaul's sign, which mimicked cardiac constriction. His chest computed tomography demonstrated large bilateral pleural effusions without pericardial disorders. After evacuation of the bilateral pleural effusions, the signs of cardiac constriction were completely resolved. This phenomenon is rare, but the recognition has clinical implications for the assessment and treatment of intractable heart failure.