非細菌性血栓性心内膜炎の巨大疣贅による，大動脈弁位生体弁の早期人工弁機能不全に対して再置換を施行した1例
症例は73歳男性．18カ月前に他院で重症大動脈弁閉鎖不全症に対して，生体弁を用いた大動脈弁置換術が行われた．経過観察の経胸壁心エコーで，生体弁弁尖の肥厚，弁解放制限，および弁尖への付着物を認めたため，精査加療目的に当科紹介となった．左室流出路に13×13 mmの疣贅を疑う異常構造物を認めた．疣贅は低輝度で，弁の開放に合わせて可動していた．弁輪部付近から連続し，人工弁自体の開放は保たれていたものの，この疣贅により左室流出路狭窄を呈し，重症大動脈弁狭窄症の血行動態を呈していた．疣贅が巨大であり，飛散し塞栓症を起こす可能性も否定できず，また人工弁機能不全の状態でもあり，ハートチームで協議し再弁置換手...
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| Published in | 日本心臓血管外科学会雑誌 Vol. 53; no. 4; pp. 188 - 192 |
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| Main Authors | , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
特定非営利活動法人 日本心臓血管外科学会
15.07.2024
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| Subjects | |
| Online Access | Get full text |
| ISSN | 0285-1474 1883-4108 |
| DOI | 10.4326/jjcvs.53.188 |
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| Abstract | 症例は73歳男性．18カ月前に他院で重症大動脈弁閉鎖不全症に対して，生体弁を用いた大動脈弁置換術が行われた．経過観察の経胸壁心エコーで，生体弁弁尖の肥厚，弁解放制限，および弁尖への付着物を認めたため，精査加療目的に当科紹介となった．左室流出路に13×13 mmの疣贅を疑う異常構造物を認めた．疣贅は低輝度で，弁の開放に合わせて可動していた．弁輪部付近から連続し，人工弁自体の開放は保たれていたものの，この疣贅により左室流出路狭窄を呈し，重症大動脈弁狭窄症の血行動態を呈していた．疣贅が巨大であり，飛散し塞栓症を起こす可能性も否定できず，また人工弁機能不全の状態でもあり，ハートチームで協議し再弁置換手術が妥当であると判断した．再胸骨正中切開でアプローチした．人工弁弁尖とその内側に，淡いピンク色と黒色混じりの脆弱な疣贅が付着していた．人工弁を取り外すと，右冠尖弁下にも同様の組織が連続していた．これらをすべて切除し，生体弁で再置換した．摘出した疣贅および人工弁の培養は陰性であった．疣贅は組織学的にはほぼすべてがフィブリン塊で，少量の赤血球と組織球の介在が見られた．菌は確認されなかった．疣贅の付着部位や組織学的所見から非細菌性血栓性心内膜炎の巨大疣贅による，早期人工弁機能不全と診断した．非細菌性血栓性心内膜炎は，早期人工弁機能不全の鑑別として考慮されるべきである． |
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| AbstractList | 症例は73歳男性．18カ月前に他院で重症大動脈弁閉鎖不全症に対して，生体弁を用いた大動脈弁置換術が行われた．経過観察の経胸壁心エコーで，生体弁弁尖の肥厚，弁解放制限，および弁尖への付着物を認めたため，精査加療目的に当科紹介となった．左室流出路に13×13 mmの疣贅を疑う異常構造物を認めた．疣贅は低輝度で，弁の開放に合わせて可動していた．弁輪部付近から連続し，人工弁自体の開放は保たれていたものの，この疣贅により左室流出路狭窄を呈し，重症大動脈弁狭窄症の血行動態を呈していた．疣贅が巨大であり，飛散し塞栓症を起こす可能性も否定できず，また人工弁機能不全の状態でもあり，ハートチームで協議し再弁置換手術が妥当であると判断した．再胸骨正中切開でアプローチした．人工弁弁尖とその内側に，淡いピンク色と黒色混じりの脆弱な疣贅が付着していた．人工弁を取り外すと，右冠尖弁下にも同様の組織が連続していた．これらをすべて切除し，生体弁で再置換した．摘出した疣贅および人工弁の培養は陰性であった．疣贅は組織学的にはほぼすべてがフィブリン塊で，少量の赤血球と組織球の介在が見られた．菌は確認されなかった．疣贅の付着部位や組織学的所見から非細菌性血栓性心内膜炎の巨大疣贅による，早期人工弁機能不全と診断した．非細菌性血栓性心内膜炎は，早期人工弁機能不全の鑑別として考慮されるべきである． |
| Author | 吉鷹, 秀範 平岡, 有努 近沢, 元太 岸本, 諭 |
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| References | 13) Dietrich M, Bois M, Ferrufino R et al. A tale of two valves: bioprosthetic aortic valve obstruction in systemic lupus erythematosus and antiphospholipid antibody syndrome. J Cardiothorac Vasc Anesth 2020; 34: 3462-6. 1) Asopa S, Patel A, Khan OA et al. Non-bacterial thrombotic endocarditis. Eur J Cardiothorac Surg 2007; 32: 696-701. 17) Mosesson MW, Colman RW, Sherry S. Chronic intravascular coagulation syndrome. N Engl J Med 1968; 278: 815-21. 18) Sack GH, Levin J, Bell WR. Trousseau's syndrome and other manifestations of chronic disseminated coagulopathy in patients with neoplasms: clinical, pathophysiologic, and therapeutic features. Medicine (Baltimore) 1977; 56: 1-37. PMID: 834136. 12) Puri R, Auffret V, Rodés-Cabau J. Bioprosthetic valve thrombosis. J Am Coll Cardiol 2017; 69: 2193-211. 4) Nagakane Y, Takezawa H, Katsura K et al. Multiple cerebral artery occlusion due to non-bacterial thrombotic endocarditis: an autopsy case report. Rinsho Shinkeigaku 2016; 56: 191-5. 7) Cremer PC, Rodriguez LL, Griffin BP et al. early bioprosthetic valve failure: mechanistic insights via correlation between echocardiographic and operative findings. J Am Soc Echocardiogr 2015; 28: 1131-48. 9) Egbe AC, Connolly HM, Schaff HV. Bioprosthetic valve thrombosis: what we know and what we need to know. J Thorac Cardiovasc Surg 2016; 152: 975-8. 10) Brown ML, Park SJ, Sundt TM et al. Early thrombosis risk in patients with biologic valves in the aortic position. J Thorac Cardiovasc Surg 2012; 144: 108-11. 6) Douin C, Marchetta S, Dulgheru R et al. Case report: aortic bioprosthesis marantic endocarditis. Acta Cardiol 2021; 76: 1143-4. 14) Rutledge R, Kim, BJ, Applebaum RE. Actuarial analysis of the risk of prosthetic valve endocarditis in 1,598 patients with mechanical and bioprosthetic valves. Arch Surg 1985; 120: 469-72. 8) Naser JA, Petrescu I, Ionescu F et al. Gradient changes in bioprosthetic valve thrombosis: duration of anticoagulation and strategies to improve detection. Open Heart 2021: 8. 11) Pislaru SV, Hussain I, Pellikka PA et al. Misconceptions, diagnostic challenges and treatment opportunities in bioprosthetic valve thrombosis: lessons from a case series. Eur J Cardiothorac Surg 2015; 47; 725-32. 15) Habib G, Lancellotti P, Antunes MJ et al. 2015 ESC guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36: 3075-128. 16) Biteker M, Ibrahim A, Ozcan B et al. Treatment of prosthetic valve thrombosis: current evidence and future directions. J Clin Med Res 2015; 7: 932-6. 3) Rogers LR, Cho ES, Kempin S et al. Cerebral infarction from non-bacterial thrombotic endocarditis. Clinical and pathological study including the effects of anticoagulation. Am J Med 1987; 83: 746-56. 2) Ram D, Armstrong G, Khanijow V et al. Nonbacterial thrombotic endocarditis of a bioprosthetic valve: questions to ponder before replacement of the valve. J Card Surg 2020; 35: 1142-4. 19) Lepour M, Grégoire JFG, Wieërs JV et al. Reversibility of valve regurgitation due to cancer-related non-bacterial thrombotic endocarditis after switching direct oral anticoagulation for heparin. BMJ Case Rep 2022; 15. https://doi.org/10.1136/bcr-2021-247672 5) Muramatsu K, Kawada N, Naganuma H et al. Recurrent nonbacterial thrombotic endocarditis the day after mitral valve replacement. J Cardiol Cases 2022; 25: 119-22. |
| References_xml | – reference: 16) Biteker M, Ibrahim A, Ozcan B et al. Treatment of prosthetic valve thrombosis: current evidence and future directions. J Clin Med Res 2015; 7: 932-6. – reference: 2) Ram D, Armstrong G, Khanijow V et al. Nonbacterial thrombotic endocarditis of a bioprosthetic valve: questions to ponder before replacement of the valve. J Card Surg 2020; 35: 1142-4. – reference: 11) Pislaru SV, Hussain I, Pellikka PA et al. Misconceptions, diagnostic challenges and treatment opportunities in bioprosthetic valve thrombosis: lessons from a case series. Eur J Cardiothorac Surg 2015; 47; 725-32. – reference: 19) Lepour M, Grégoire JFG, Wieërs JV et al. Reversibility of valve regurgitation due to cancer-related non-bacterial thrombotic endocarditis after switching direct oral anticoagulation for heparin. BMJ Case Rep 2022; 15. https://doi.org/10.1136/bcr-2021-247672 – reference: 14) Rutledge R, Kim, BJ, Applebaum RE. Actuarial analysis of the risk of prosthetic valve endocarditis in 1,598 patients with mechanical and bioprosthetic valves. Arch Surg 1985; 120: 469-72. – reference: 18) Sack GH, Levin J, Bell WR. Trousseau's syndrome and other manifestations of chronic disseminated coagulopathy in patients with neoplasms: clinical, pathophysiologic, and therapeutic features. Medicine (Baltimore) 1977; 56: 1-37. PMID: 834136. – reference: 3) Rogers LR, Cho ES, Kempin S et al. Cerebral infarction from non-bacterial thrombotic endocarditis. Clinical and pathological study including the effects of anticoagulation. Am J Med 1987; 83: 746-56. – reference: 10) Brown ML, Park SJ, Sundt TM et al. Early thrombosis risk in patients with biologic valves in the aortic position. J Thorac Cardiovasc Surg 2012; 144: 108-11. – reference: 12) Puri R, Auffret V, Rodés-Cabau J. Bioprosthetic valve thrombosis. J Am Coll Cardiol 2017; 69: 2193-211. – reference: 15) Habib G, Lancellotti P, Antunes MJ et al. 2015 ESC guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36: 3075-128. – reference: 17) Mosesson MW, Colman RW, Sherry S. Chronic intravascular coagulation syndrome. N Engl J Med 1968; 278: 815-21. – reference: 13) Dietrich M, Bois M, Ferrufino R et al. A tale of two valves: bioprosthetic aortic valve obstruction in systemic lupus erythematosus and antiphospholipid antibody syndrome. J Cardiothorac Vasc Anesth 2020; 34: 3462-6. – reference: 7) Cremer PC, Rodriguez LL, Griffin BP et al. early bioprosthetic valve failure: mechanistic insights via correlation between echocardiographic and operative findings. J Am Soc Echocardiogr 2015; 28: 1131-48. – reference: 9) Egbe AC, Connolly HM, Schaff HV. Bioprosthetic valve thrombosis: what we know and what we need to know. J Thorac Cardiovasc Surg 2016; 152: 975-8. – reference: 4) Nagakane Y, Takezawa H, Katsura K et al. Multiple cerebral artery occlusion due to non-bacterial thrombotic endocarditis: an autopsy case report. Rinsho Shinkeigaku 2016; 56: 191-5. – reference: 8) Naser JA, Petrescu I, Ionescu F et al. Gradient changes in bioprosthetic valve thrombosis: duration of anticoagulation and strategies to improve detection. Open Heart 2021: 8. – reference: 1) Asopa S, Patel A, Khan OA et al. Non-bacterial thrombotic endocarditis. Eur J Cardiothorac Surg 2007; 32: 696-701. – reference: 5) Muramatsu K, Kawada N, Naganuma H et al. Recurrent nonbacterial thrombotic endocarditis the day after mitral valve replacement. J Cardiol Cases 2022; 25: 119-22. – reference: 6) Douin C, Marchetta S, Dulgheru R et al. Case report: aortic bioprosthesis marantic endocarditis. Acta Cardiol 2021; 76: 1143-4. |
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| Snippet | 症例は73歳男性．18カ月前に他院で重症大動脈弁閉鎖不全症に対して，生体弁を用いた大動脈弁置換術が行われた．経過観察の経胸壁心エコーで，生体弁弁尖の肥厚，弁解放制... |
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| SubjectTerms | 大動脈弁 早期人工弁機能不全 非細菌性血栓性心内膜炎 |
| Title | 非細菌性血栓性心内膜炎の巨大疣贅による，大動脈弁位生体弁の早期人工弁機能不全に対して再置換を施行した1例 |
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