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1 대한내과학회지 : 제 76 권제 1 호 2009 좌심방점액종수술후발생한동기능부전및심방빈맥 1 예 부산대학교의과대학 1 내과학교실, 2 흉부외과학교실 안성규 1 김준 1 이상권 2 박태익 1 이태근 1 홍택종 1 신영우 1 A case of sinus node dysfunction and atrial tachycardia after the excision of a left atrial myxoma Sung Gyu An, M.D. 1, Jun Kim, M.D. 1, Sang Kwon Lee, M.D. 2, Tae Ik Park, M.D. 1, Tae Kun Lee, M.D. 1, Taek Jong Hong, M.D. 1 and Young Woo Shin, M.D. 1 Departments of 1 Internal Medicine and 2 Thoracic and Cardiovascular Surgery, Pusan National University College of Medicine, Busan, Korea Atrial myxoma is the most common primary cardiac tumor, and surgical removal is the treatment of choice. Atrial flutter-fibrillation is common after the surgical excision of such tumors, whereas sinus node dysfunction is a rare complication. We detected postoperative sinus node dysfunction and atrial tachycardia after the excision of a left atrial myxoma in a 63-year-old woman. The patient underwent the implantation of a permanent pacemaker two weeks after the operation. The patient underwent successful catheter ablation of macroreentrant right atrial tachycardia 16 months after the operation with no recurrence of atrial tachycardia over the next four months. (Korean J Med 76: , 2009) Key Words: Left atrial myxoma; Sinus node dysfunction; Atrial tachycardia; Catheter ablation 서론심장의원발성종양중약 75% 가양성종양이며 50% 가점액종이다 1). 심장점액종의 75~80% 는좌심방에위치한다 1). 심장초음파를통한비침습적진단의발전및수술기법의향상으로, 심장점액종의예후는개선되었지만수술후일시적인심방부정맥이나타날수있으며지속적인서맥으로인해영구형인공심장박동기를삽입하는경우도보고되고있다 2). 저자들은좌심방점액종을수술적으로제거한환자에서이후발생한어지럼증을동반한동기능부전으로영구형인공심장박동기를시술하였으며, 항부정맥제치료에불응하는 발작성심방빈맥을전극도자절제술로치료한 1예를경험하였기에보고하는바이다. 증례 63세여자환자가약 5년전부터 NYHA functional class II 의노작성호흡곤란이있었고, 내원약 2주전부터 NYHA functional class III의호흡곤란이발생하여내원하였다. 어지럼증, 실신, 심계항진의증상은호소하지않았다. 이학적검사에서신체활력징후는혈압 100/60 mmhg, 맥박수는분당 60회, 호흡수는분당 20회, 체온은 36.8 였다. 심음은규칙적이었으며, 심첨부에서 Grade III의확장기심잡음이들렸고, 호흡음은정상이었다. 심전도는정상동율동이었다 ( 그림 1A). Received: Accepted: Correspondence to: Jun Kim M.D., Department of Internal Medicine, Pusan National University Hospital, Ami-dong 1-10 Seo-gu, Busan , Korea mdjunkim@yahoo.co.kr

2 - Sung Gyu An, et al. sinus node dysfunction and atrial tachycardia after excision of the myxoma - A B C D Figure 1. Surface electrocardiograms (lead II) recorded before surgery (A), on postoperative day 3 (B), postoperative day 8 (C), and onemonth after surgery (D). 이면성및도플러심초음파에서좌심방내에 cm 의종괴가관찰되었다. 양심실의크기및수축력은정상이었으며, 판막의모양및기능은정상이었다 ( 그림 2). 수술전관상동맥조영술은정상이었다. 모든시술과수술은환자로부터고지된동의서를받고시행하였다. 입원 3일째전신마취하에정중흉골절개술을시행하고체외순환을시작한후좌심방절개하여좌심방을채우고있는 cm의종양이심방중격에유착되어있는것을확인하였다. 유착제거술및심방중격절개후 mass stalk가좌심방천장에붙어있어우심방절개시행후종양을적출하였다. 심방중격절개부위를복원한후좌심방절개부위및우심방절개부위를복원하였다. 체외순환시간은 90분, 총수술시간은 3시간 30분이었다. 병리소견에서 cm 크기의유경형의갈색종괴가관찰되었고, 중심부출혈을동반한점액양간질이풍부한세포들이관찰되어점액종으로진단하였다. 수술후 3일째심방조동 ( 그림 1B) 이발생하였고, 수술후 8일째어지럼증을동반한방실접합부이탈박동 ( 그림 1C) 이보였으나회복되지않아수술후 14일째영구형인공심장박동기 (DDDR, Kappa KDR903, Medtronic, Minneapolis, MN, USA) 를시술하였다. 수술 1년후이면성및도플러심초음파및흉부전산화단층촬영에서점액종의재발소견은없었다. 수술후추적관찰중에 propaferone 사용에조절되지않는발작성심방조동 ( 그림 1D) 이재발하였다. 환자는수술 16개월후항부정맥제의반감기 5배이상의기간동안약제투여를중지후금식상태에서 midazolam과 Figure 2. Apical four-chamber echocardiogram showing a movable echogenic mass ( cm) attached to the interatrial septum. LA, left atrium LV, left ventricle RA, right atrium RV, right ventricle. Figure 3. A 12-lead electrocardiogram produced during induced tachycardia. The flutter wave was biphasic in II and negative in III, while lead avf was positive in I and V1, which is inconsistent with the morphology of a typical or reverse-typical flutter. fentanyl로안정시킨후전기생리학검사를시행하였다. 국소마취후양대퇴정맥을통하여우심방, His속근처, 관정맥동에다전극카테터를삽입하였으며 20극전기카테터를삼첨판륜에위치시켰다. 우심방에서신속조율 (A1A1=280 ms) 로심방빈맥이유발되었다 ( 그림 3). 심방빈맥의주기는 240 ms이었다. 우심방의 activation time이 200 ms로빈맥주기의 83% 를차지하고있어서우심방에서기원하는빈맥임을알수있었다. Distal tip이 3.5 mm인 external irrigation catheter (Celsius thermocouple catheter, Cordis, Diamond Bar, CA, USA) 를이용하여우심방지도화를시행하였다. Mapping

- 대한내과학회지 : 제 76 권제 1 호통권제 581 호 2009 - Figure 4. Surface lead electrocardiograms and intracardiac electrograms produced during induced tachycardia.

$There was a long-duration, fractionated potential on the MAPd and an 87-ms local conduction delay between the MAPp and MAPd.$

3 - 대한내과학회지 : 제 76 권제 1 호통권제 581 호 Figure 4. Surface lead electrocardiograms and intracardiac electrograms produced during induced tachycardia. Surface ECG leads I, II, III, and V1 together with high right atrium (HRA), proximal-to-distal electrograms from duodecapolar catheter (TA), proximal-to-distal electrograms from mapping catheter (MAPp and MAPd), proximal-to-distal electrograms from Hiscatheter (HBp and HBd), and proximal-to-distal electrograms from the coronary sinus (CSpand CSd) were displaced from top to bottom. There was a long-duration, fractionated potential on the MAPd and an 87-ms local conduction delay between the MAPp and MAPd. catheter를우심방후하방측벽에위치시켰을때 wide fractionated potential이관찰되었으며 mapping 중에 mapping catheter의근위부및원위부에서전도지연이확인되어서우심방절개부위로회귀하는거대회귀심방빈맥으로진단하였다 ( 그림 4). Cavotricuspid isthmus에서 entrainment mapping 을시행하였을때 post-pacing interval과빈맥주기의차이가 100 ms여서전형적심방조동을배제하였다. 고주파에너지 (infusion rate 17 ml/min, power 30 W, temperature 50 ) 를투여한후심방빈맥은종료되었으며 ( 그림 5, 6), 고주파에너지를하대정맥까지선형으로투여하였다. 총고주파에너지투여기간은 20분이었다. 전형적인모양의심방조동이기록되었으므로삼첨판륜- 하대정맥협부에도도자절제술 (infusion rate 17 ml/min, power 40 W, temperature 50, 총투여기간 11분 ) 을시행하였으며우심방하측벽및관정맥동개구부에서심조율을시행하여양방향전도차단을확인하였다 ( 그림 7). 기저시및 isoproterenol 2 μg/min 정주후신속심방조율 (A1A1=280~180 ms) 에서심방빈맥이더이상유발되지않아시술을종료하였다. 환자는항부정맥제투여없이시술후 4개월간빈맥재발없이경과관찰중이다. Figure 5. Termination of the atypical atrial flutter during the delivery of radiofrequency energy at the inferoposterolateral wall of the right atrium, where the fractionated potential was recorded as in Figure 5. Tachycardia was terminated by a conduction block from MAPd to MAPp. The abbreviations are the same as in Figure 4. 고 본증례는좌심방점액종수술후발생한동기능부전및심방빈맥을심박동기이식및전극도자절제술을성공적으로시행한국내첫보고이다. Mustard 수술, Senning 수술, MAZE 수술, 심장이식, 판막수술, 관상동맥우회술후동기능장애가각각 35%, 22%, 15%, 8%, 2~4%, 0.8~3.4% 에서발생할수있으며, 주로심방절개를시행하는수술에서보고되나 3-5), 심장점액종수술후동기능장애가발생하는경우는드물게보고된다 2). 심장점액종은수술적치료가원칙으로수술에의한사망률은 0~3% 정도이며수술후합병증으로종양색전, 수술후출혈, 패혈증, 부정맥등이보고되고있다 6). Laurent 등 7) 은 112명의좌심방점액종수술후가장흔한합병증으로 29명 (26%) 에서일시적인부정맥 ( 심실상성부정맥혹은심방세동 ) 이발생하였고, 2명 (1.8%) 에서지속적인서맥이발생하여영구형인공심장박동기를삽입하였다고보고하였다. 또한 Shyamal 등 2) 은 35명의심장점액종수술후심실상성부정맥과심방세동이 5명에서발생하였다고보고하였다. 심방세동치료로 1명은디곡신을투여하였고다른 1명은심율동전환을시행하였으며또다른 1명은지속적인서맥으로영구형인공심장박동기를삽입하였다. 2002년황등 8) 은 21명의심장점액종수술후심실조기박동이 2명 (9.6%) 에서심방세동이 1명 (4.8%) 에서발생하였다고보고하였다. 그리고 2006년유등 9) 은 74명의심장점 찰

Verification of the bidirectional conduction block across the cavotricuspid isthmus.

4 - 안성규외 6 인. 점액종수술후발생한부정맥치료 1 예 - A B Figure 6. Fluoroscopic position of the mapping catheter from the right (6A) and left anterior oblique views (6B). RA, atrial lead positioned in the right atrial appendage RV, ventricular lead positioned in the right mid ventricular septum; otherwise, the abbreviations are the same as in Figure 4. Figure 7. Verification of the bidirectional conduction block across the cavotricuspid isthmus. There were widely split double potentials (D1 and D2) along the ablation line from the inferior vena cava to the tricuspid valve (A-C). During pacing from the coronary sinus ostium, there was a clockwise propagation around the tricuspid annulus (A-C). In addition, there was a counterclockwise propagation around the tricuspid annulus when pacing was done from the low lateral right atrium (D). The abbreviations are the same as in Figure 4. 액종환자중심방세동이 2명 (2.9%) 에서발생하였다고보고한바있다. 점액종에서수술후전도장애가발생할수있는이유로수술시방실결절이손상받을가능성, 양심방의절개와심 방중격이절개될때심방사이전도계장애가초래될가능성, 수술중동방결절손상과동방결절동맥의손상이제시되고있다 10). 수술후심방부정맥이발생할수있는이유는심방및심방중격의절개와심방내견인기와흡인기의사용으로인해심방조직내치유반흔이남아서국소화되어심방의전위변화가초래될가능성이있기때문이다 10). 또한수술후부정맥이발생할위험요인으로좌심방의크기가 4 cm보다작은경우, 점액종이측벽에비해심방중격에부착되어있는경우, 수술시좌심방절개술에비해양심방절개술과심방중격절개술을동시에하는경우가수술후부정맥이나전도장애가더높은빈도로발생한다고보고한다 10, 11). Sellke 등 12) 은심장점액종수술시경중격절개를통해심방중격절개시심방세동과심방조동이수술직후약 46% 에서발생하였다고보고한바있다. 우심방거대회귀빈맥은심방절개가시행된개심술후에흔히발생한다. 우심방절개후발생하는거대회귀빈맥은반흔주위의회귀, 반흔내회귀, 반흔주위및삼첨판륜회귀또는삼첨판륜회귀에의한것으로알려져있으며, 자세한지도화를통하여회귀회로를규명하고전극도자절제술로좋은성적을얻을수있다고알려져있다 13). 본증례에서는좌심방및우심방절개가모두시행되었으나, 지도화

5 - The Korean Journal of Medicine: Vol. 76, No. 1, 를통하여빈맥이우심방에서기원함을확인하였고, 도자절제술로치료한예이다. 본연구의제한점으로 3차원지도화시스템을사용하였다면좀더정확히우심방에서의회귀로를규명하고적은고주파에너지를투여하여빈맥을종료시키고재발을방지하였을가능성이있다. 두번째로고주파에너지투여후빈맥이종료된곳에서 entrainment mapping을시행하지않은점, 세번째로고주파에너지를선형으로하대정맥까지투여하였지만반흔에서하대정맥까지의 linear lesions의완벽성-detour activation-을전기생리학적으로확인하지않은점및상대적으로짧은추적관찰기간을들수있다. 하지만 3 차원지도화시스템을이용하지않고 20극전기카테터를이용하여우심방거대회귀빈맥을치료할수있다는보고가있으며 14), 도자절제술후빈맥이종료되고, 더이상유발되지않고항부정맥제투여없이 4개월간재발이없었다는것이효과적인도자절제술이시행되었음을뒷받침한다. 요 점액종의외과적절제후발생하는동기능부전증후군은드문합병증으로보고된다. 저자들은좌심방점액종을수술한 63세여자환자에서어지럼증을동반한동기능부전및심방빈맥이발생하여영구형인공심장박동기를시술하였으며, 항부정맥제로조절되지않는심방빈맥을전극도자절제술로치료한증례를경험하였기에문헌고찰과더불어보고하는바이다. 중심단어 : 좌심방점액종 ; 동기능부전 ; 심방빈맥 ; 전극도자절제술 약 REFERENCES 1) Reynen K. Cardiac myxoma. N Engl J Med 333: , ) Premaratne S, Hasaniya NW, Arakaki HY, Mugiishi MM, Mamiya RT, McNamara JJ. Atrial myxomas: experiences with 35 patients in Hawaii. Am J Surg 169: , ) Chung MK. Cardiac surgery: postoperative arrhythmias. Crit Care Med 28(10 Suppl):N136-N144, ) Gillinov AM, Wolf RK. Surgical ablation of atrial fibrillation. Prog Cardiovasc Dis 48: , ) Deanfield J, Camm J, Macartney F, Cartwrighy T, Douglas J, Drew J, De Leval M, Stark J. Arrhythmia and late mortality after Mustard and Senning operation for transposition of the great arteries: an eight-year prospective study. J Thorac Cardiovasc Surg 96: , ) Bjessmo S, Ivert T. Cardiac myxoma: 40 years' experience in 63 patients. Ann Thorac Surg 63: , ) Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma: a series of 112 consecutive cases. Medicine 80: , ) Hwang ES, Kim YS, Choi JO, Chae IH, Sohn DW, Kim CH, Oh BH, Lee MM, Park YB, Choi YS, Lee YW. Clinical observation of cardiac myxoma. Korean J Med 62:49-57, ) Yu SH, Lim SH, Hong YS, Yoo KJ, Chang BC, Kang MS. Clinical experiences of cardiac myxoma. Yonsei Med J 47: , ) Bateman TM, Gray RJ, Raymond MJ, Chaux A, Czer LS, Matloff JM. Arrhythmias and conduction disturbances following cardiac operation for the removal of left atrial myxomas. J Thorac Cardiovasc Surg 86: , ) Jones DR, Warden HE, Murray GF, Hill RC, Graeber GM, Cruzzavala JL, Gustafason RA, Vasilakis A. Biatrial approach to cardiac myxoma: a 30-year clinical experience. Ann Thorac Surg 59: , ) Sellke FW, Lemmer JH Jr, Vandenberg BF, Ehrenhaft JL. Surgical treatment of cardiac myxomas: long-term results. Ann Thorac Surg 50: , ) Zipes DP, Haïssaguerre M. Catheter ablation of arrhythmias. 2nd ed. p , New York, Armonk, ) Anné W, van Rensburg H, Adams J, Ector H, van de Werf F, Heidbüchel H. Ablation of post-surgical intra-atrial reentrant tachycardia. Eur Heart J 23: ,

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ºÎÁ¤¸ÆÃÖÁ¾ MAIN TOPIC REVIEWS Young-Keun On, MD, PhD Division of Cardiology, Department of Medicine Cardiac & Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Catheter