田端 智香¹, 岡田 昌子², 森 智美³, 寺本 美穂³, 小笠原 延行¹, 三好 美和¹, 佐伯 一¹, 中川 雅美¹, 酒井 晋介⁴, 長谷川 新治¹

Tomoka TABATA¹, Masako OKADA², Tomomi MORI³, Miho TERAMOTO³, Nobuyuki OGASAWARA¹, Miwa MIYOSHI¹, Hajime SAEKI¹, Masami NAKAGAWA¹, Shinsuke SAKAI⁴, Shinji HASEGAWA¹

¹地域医療機能推進機構大阪病院循環器内科, ²地域医療機能推進機構大阪病院臨床検査科, ³地域医療機能推進機構大阪病院臨床検査部, ⁴地域医療機能推進機構大阪病院内科

¹Department of Cardiovascular Medicine, Japan Community Healthcare Organization Osaka Hospital, ²Department of Laboratory, Japan Community Healthcare Organization Osaka Hospital, ³Clinical Laboratory, Japan Community Healthcare Organization Osaka Hospital, ⁴Department of Internal Medicine, Japan Community Healthcare Organization Osaka Hospital

キーワード : intramyocardial dissecting hematoma, echocardiography, CT, RI, coronary angiography

患者は74歳の慢性腎不全の男性で，透析中の全身倦怠感と呼吸困難を主訴に紹介となった．来院時，低酸素血症と胸部レントゲン上で心陰影の拡大，両肺野のうっ血像を認め，急性心不全と診断した．血液透析による体液量の調節で心不全は改善したが，経胸壁心エコー図検査で左室駆出率の低下，解離性心筋内血腫を認めた．明らかな原因は不明であったが，冠動脈造影検査で左前下行枝の末梢に壁不整像を認め，アデノシン負荷タリウム心筋シンチグラフィで心尖部の貫璧性梗塞の所見を認めたことから，無症候性心筋梗塞に伴ったものと考えた．繰り返し施行した経胸壁心エコー図検査で血腫の増大や心嚢液の増加を認めず，循環動態も安定していたことから，保存的加療で経過観察した，第32病日に軽快退院となった．その後も12ヵ月間外来で経胸壁心エコー図検査による観察で血腫は不変であり，外科的な治療を要することなく安定した経過を得ることができた．解離性心筋内血腫は心破裂に進展する可能性のある危険な病態であるが，経胸壁心エコー図検査を繰り返し，注意深く観察することによって保存的加療が可能な場合もあることが示唆された．

A 74-year-old male with a chronic kidney disorder was admitted to our hospital because of general malaise and dyspnea during hemodialysis. On his initial visit, he was hypoxic. A chest X-ray showed bilateral congestion shadow and dilatation of heart shadow. He had a diagnosis of acute heart failure. Transthoracic echocardiography (TTE) revealed reduced cardiac ejection fraction and an intramyocardial dissecting hematoma (IDH) at the apical lesion. Based on coronary angiography and myocardial scintigraphy, the hematoma was assumed to have been induced by pre-existing asymptomatic myocardial infarction. This was not a case of acute myocardial infarction, and repeated TTE did not show enlargement of the hematoma or increase in pericardial effusion. Therefore, we treated him conservatively. The fluid volume was controlled with hemodialysis and his symptom improved. He was discharged within about one month. After discharge, the hematoma was invariant for 12 months on TTE, and the patient made steady progress. Although IDH is a potentially lethal disease, we concluded that surgery was not always essential for all patients with IDH based on frequent observations.