完全房室ブロックと急性肺水腫を伴った左主幹部慢性閉塞の1例

A Case of Chronic Total Occlusion of the Left Main Trunk with Complete Atrio-ventricular Block and Acute Lung Edema

　患者は65歳，男性．1998年9月より労作時胸痛があり，近医で投薬を受けていた．1999年1月初旬より倦怠感，1月25日完全房室ブロックを認めたため，翌日当院に入院した．入院直後，急性肺水腫およびショックとなり，人工呼吸器，体外式一時ペーシングおよびIABPを開始した．心電図，心筋逸脱酵素ともに急性心筋梗塞を示唆する所見はなかったが，心エコーは前壁の広範囲な壁運動の低下を認めた．入院19日目に冠動脈造影を行い，左主幹部の閉塞を認めた．また，右冠動脈からは左前下行枝と左回旋枝への側副血行路が発達し，右冠動脈自体にも有意狭窄を有していた．本例は左主幹部の閉塞による陳旧性心筋梗塞および慢性心筋虚血と診断し，待機的冠動脈バイパス術と恒久的ペースメーカ植込み術を行い，その後の経過は良好であった．

A 65-year-old man was referred to our departmentfor complete atrio-ventricular block. He had a 5-monthhistory of effect angina and had been treated withisosorbide dinitrate. Soon after admission, the patientdeveloped acute lung edema followed by cardiogenicshock. We immediately connected him to an artificialrespirator and performed pacing and intra aortic bal-loon pumping. The results of electrocardiography andlaboratory data were not compatible with the diagnosisof acute myocardial infarction. Echocardiographyrevealed severe hypokinesis over a wide area in theanterolateral wall of the left ventricle. After recoveryfrom congestive heart failure and cardiogenic shock,coronary angiography (CAW was carried out. It showedtotal occlusion of the left main coronary artery, and theleft anterior descending artery and the left circumflexartery were supplied by good collaterals from the rightcoronary artery. Coronary aorto bypass grafting andpermanent pacemaker implantation was undertaken.This is a rare case of chronic total occlusion of the leftmain trunk with complete atrio-ventricular block andacute lung edema.