帝京大学 医学部心臓血管外科学講座

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機械的合併症と心破裂
Mechanical complications of acute myocardial infarction

急性心筋梗塞の急性期に発症する機械的合併症として、心室中隔穿孔、僧帽弁乳頭筋断裂、左室自由壁破裂、あるいはこれらの合併がある。いずれも突然発症し、血行動態の急激な破綻に至り自然予後は不良である。

  心室中隔穿孔 僧帽弁乳頭筋断裂 左室自由壁破裂
頻度 1-5% 1%
後乳頭筋>前乳頭筋
3-10%
発症時期 24時間以内と3-5日 24時間以内と3-5日 24時間以内と3-5日
症状 胸痛,呼吸困難,低血圧 突然の呼吸困難と肺水腫,低血圧 胸痛,失神,低血圧,不穏,突然死
身体所見 粗い汎収縮期雑音、振戦、Ⅲ音、肺水腫 柔らかい汎収縮期雑音,肺水腫 頸静脈怒張,奇脈、心原性ショック
心エコー検査 左- 右シャント
右室負荷所見
乳頭筋・腱索の断裂,重症僧帽弁逆流 心嚢液貯留,心膜腔内の高エコー輝度
右心カテーテル 右房から右室での酸素飽和度の上昇 v 波増大,肺動脈楔入圧上昇 心タンポナーデの所見は常には現れず
治療 IABP(+PCPS)
緊急外科的修復術
同時CABGを考慮
IABP(+PCPS)
緊急外科的修復術
同時CABG を考慮
IABP(+PCPS)
緊急心嚢ドレナージ
+外科的修復術
参考文献
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