日本小児循環器学会雑誌 Pediatric Cardiology and Cardiac Surgery

Online ISSN: 2187-2988 Print ISSN: 0911-1794
特定非営利活動法人日本小児循環器学会 Japanese Society of Pediatric Cardiology and Cardiac Surgery
〒162-0801東京都新宿区山吹町358-5アカデミーセンター Japanese Society of Pediatric Cardiology and Cardiac Surgery Academy Center, 358-5 Yamabuki-cho, Shinju-ku, Tokyo 162-0801, Japan
Pediatric Cardiology and Cardiac Surgery 32(6): 527-533 (2016)
doi:10.9794/jspccs.32.527

症例報告Case Report

Melody valve留置術後9年目にvalve-in-valveを実施した一成人例A Case of Valve-in-valve Procedure 9 years after Initial Melody Valve Implantation

1東邦大学医療センター大森病院小児科Department of Pediatrics, Toho University Omori Medical Center ◇ Tokyo, Japan

2東邦大学医療センター大橋病院循環器内科Department of Cardiology, Toho University Ohashi Medical Center ◇ Tokyo, Japan

3Cardiac Catheterization Lab, CHOC Children’s HospitalCardiac Catheterization Lab, CHOC Children’s Hospital ◇ Orange, CA, USA

受付日:2016年3月3日Received: March 3, 2016
受理日:2016年11月4日Accepted: November 4, 2016
発行日:2016年11月1日Published: November 1, 2016
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症例は米国籍の32歳男性で,息切れを主訴に来院した.米国で出生し完全大血管転位の診断でRastelli手術,2度の右室流出路再建術および胸郭形成術の既往がある.その後再び右室流出路狭窄が高度になったため,24歳の時ニューヨークでMelody valve留置術を受けた後に来日した.当院受診時,第三肋間胸骨左縁を最強点とするLevine 3度の収縮期駆出性雑音を聴取し,胸部単純X線では胸郭形成術の際に植え込まれた3枚の金属プレートを認めた.心エコーでは心室中隔の奇異性運動と圧排された左室を認め,右室–右房圧較差は55~60 mmHgであった.血漿hANPとBNPは各々54.1,54.7 pg/mLと軽度上昇していた.数度の手術歴から外科的右室流出路再建術は危険性が高いと考えたが,幸いロサンゼルスでvalve-in-valve法によるMelody valve再留置術を受けることができ,1ヶ月後に再度来院した.術前胸部単純X線正面像では明らかではなかったが,カテーテルインターベンション時にステント損傷が右室流出路再狭窄の原因であることが確認された.本邦においてもMelody valveの認可が待たれる.

A 32-year-old American man visited our outpatient clinic for a chief complaint of exertional dyspnea. His medical history was remarkable for the diagnosis of d-TGA, Rastelli operation, right ventricular outflow tract (RVOT) reimplantation of the conduit twice, and plastic surgery for a thoracic deformity. Because of the progression of RVOT stenosis, a Melody valve was implanted when he was 24 years old and living in New York. On physical examination, harsh systolic ejection murmur of Levine 3/VI at his third left sternal border was audible. Chest X-ray demonstrated three metal plates bridging his bilateral thorax. Echocardiography revealed paradoxical movement of the interventricular septum, flattened left ventricular cavity, and 55–60 mmHg pressure gradient due by tricuspid regurgitation. The stenotic site of his RVOT was not apparent because of the artifact. The plasma hANP and BNP levels were 54.1 and 54.7 pg/ml, respectively. Because of his past medical history of multiple cardiovascular and thoracic surgeries, surgical reconstruction of his stenotic RVOT was assessed to be too risky. A Melody valve-in-valve implantation was performed in Los Angeles, California, and he returned to our hospital 1 month later. His quality of life has significantly improved, and his heart murmur changed to a soft murmur. During the procedure, the stent fracture was confirmed to be responsible for RVOT restenosis, although the frontal view chest X-ray failed to reveal it. Approval is awaited for clinical use of the Melody valve in Japan.

Key words: melody valve; valve-in-valve; catheter intervention; right ventricular outflow tract stenosis

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