呼吸器外科術後の稀な原因による心不全の1例

A Rare Cause of Cardiac Failure after Lung Surgery

要旨

　患者は66歳，男性．肺癌に対する右肺下葉切除後の，2008年に同側の肺化膿症を発症し残存肺全摘術および心膜部分切除術を受けた．その半年後に労作時息切れや顔面浮腫などの心不全症状が進行してきたことから当科に入院した．血行動態上は心拍出係数(C.I)が1.6l/min/M²に低下し，同時圧測定で左室拡張期圧が右房圧・右室拡張期圧・肺動脈楔入圧と同一化していた．胸部CTでは心膜が肥厚していたが，悪性腫瘍の浸潤を示唆する所見はなかった．収縮性心膜炎の診断のもと，心膜剥離・切除および心外膜切開術を行ったところ，C.Iが2.0l/min/M²に向上して心不全症状が軽快した．医療行為に関連した収縮性心膜炎としては開心術後や放射線治療後のものが良く知られているが，呼吸器外科手術後のものは稀である．

　A 66-year-old man, who had undergone right lower lobectomy for lung cancer without radiotherapy, received complete pneumonectomy and partial pericardiectomy with patch repair because of an intractable pulmonary abscess in August 2008. Six months later, he was hospitalized for assessment of progressive heart failure, complaining of dyspnea on exertion and facial edema. Bilateral heart catheterization demonstrated low cardiac output〔cardiac index(C.I):1.6l/min/M²〕and near equalization of the diastolic pressures(LV, RV, RA, and PCWP). A chest CT scan showed a thickened pericardium and ruled out the possibility of pericardial tumor invasion. Upon diagnosis of constrictive pericarditis, radical pericardiectomy and cutting of the epicardium were performed. After the operation, cardiac output improved(C.I:2.0l/min/M²), and the clinical symptoms regressed. Constrictive pericarditis after cardiac surgery or radiotherapy is well known, but only on rare occasions, have cases been reported after pulmonary surgery alone. In the absence of radiotherapy or recurrence of tumor, this case is probably associated with postpericardiotomy syndrome induced by the previous partial pericardiectomy.