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1 Original ORIGINAL Article ARTICLE Korean Circulation J 2005;35: ISSN c 2005, The Korean Society of Circulation 급성 ST 절상승심근경색환자에서일차적스텐트삽입술시행시시로리무스용출성스텐트의효과와안전성 인제대학교의과대학내과학교실, 1 울산대학교의과대학서울아산병원내과학교실, 2 서울위생병원 3 양태현 1 홍명기 2 박경하 2 김미정 2 최봉룡 2 오성주 3 이봉기 2 김영학 2 한기훈 2 이철환 2 강덕현 2 송재관 2 김재중 2 박성욱 2 박승정 2 Primary Sirolimus-Eluting Stent Imlantation for Patients with Acute ST-Segment Elevation Myocardial Infarction Tae-Hyun Yang, MD 1, Myeong-Ki Hong, MD 2, Kyoung-Ha Park, MD 2, Mi-Jeong Kim, MD 2, Bong-Ryong Choi, MD 2, Sung-Ju Oh, MD 3, Bong-Ki Lee, MD 2, Young-Hak Kim, MD 2, Ki-Hoon Han, MD 2, Cheol Whan Lee, MD 2, Duk-Hyun Kang, MD 2, Jae-Kwan Song, MD 2, Jae-Joong Kim, MD 2, Seong-Wook Park, MD 2 and Seung-Jung Park, MD 2 1 Deartment of Medicine, Inje University College of Medicine, Busan, 2 Deartment of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, 3 Deartment of Medicine, Seoul Adventist Hosital, Seoul, Korea ABSTRACT Background and Objectives:Sirolimus-eluting stents () have been shown to significantly inhibit neointimal hyerlasia, resulting in reduced restenosis comared with bare metal stents (). However, the efficacy and safety of imlantation for atients with acute ST-segment elevation myocardial infarction (STEMI) remain unclear. Subjects and Methods:Primary stenting was erformed using in 74 atients (mean age: 58.0± 12.7 years, 59 males) and in 88 atients (mean age: 59.3±10.7 years, 63 males) between Aril 2003 and July We retrosectively comared the incidence of 6-month angiograhic restenosis and the major adverse cardiac events (MACE) defined as cardiac death, non-fatal myocardial infarction and target lesion revascularization (TLR), between the grou and the grou. Results:The grou had smaller vessels (3.04± 0.47 mm vs. 3.24±0.56 mm, resectively, =0.02) and a longer stent length (33.7±14.3 mm vs. 25.0±9.6 mm, =0.00). The rocedural success rate (87.8% vs. 92.0%, resectively, =0.37) and the eak creatine kinase-mb (239±196 ng/ml vs. 274±188 ng/ml, =0.26) were similar. The 6-month angiograhic restenosis rate (0.0% vs. 30.4%, resectively, =0.00) and late loss (-0.03±0.55 mm vs. 1.28±0.58 mm, =0.00) were significantly lower in the grou comared with the grou. Stent thrombosis develoed in only 1 case of the grou (1.4% vs. 0.0%, resectively, =0.45). At 6 months, imlantation significantly reduced the incidence of MACE (6.9% vs. 19.5%, resectively, =0.04), because of a reduction in the incidence of TLR (1.4% vs. 11.5%, =0.01). Likewise, the MACE-free survival rate was significantly higher in the grou (93.06% vs %, resectively, =0.03). Conclusion:Comared with the, the was effective in reducing the incidence of 6-month angiograhic restenosis and MACE without any increased risk of stent thrombosis in the atients with STEMI who received rimary stenting. (Korean Circulation J 2005;35: ) KEY WORDS: Sirolimus;Stents;Myocardial infarction;thrombosis. 논문접수일 :2005 년 2 월 28 일수정논문접수일 :2005 년 6 월 23 일심사완료일 :2005 년 8 월 09 일교신저자 : 박승정, 서울송파구풍납동 울산대학교의과대학서울아산병원내과학교실전화 :(02) 전송 :(02) sjark@amc.seoul.kr 672

2 Tae-Hyun Yang, et al: Imlantation for Patients with STEMI 673 서 흉통발생초기에병원을방문한급성 ST절상승심근경색환자의재관류치료로일차적경피적관상동맥성형술은혈전용해제보다우수한치료방법이다. 1) 그중스텐트삽입술은풍선확장술에비해시술성공률이높고임상결과가우수하다. 2)3) 그러나스텐트재협착은양호한임상경과의일정부분을상쇄하며재시술의빈도를증가시킨다. 4) 현재사용되고있는시로리무스용출성스텐트 (sirolimus-eluting stent)(cyher stent, Johnson & Johnson Comany, Waren, New Jersey, USA) 는일반금속스텐트에비해스텐트내신생내막의성장을현저히억제하여재협착의발생빈도를상당히감소시켰다. 5-7) 하지만이러한대규모임상연구들은비교적간단한병변을대상으로한예정된시술 (elective rocedure) 을통하여이루어져, 급성 ST절상승심근경색환자의일차적스텐트삽입술 (rimary stenting) 에서시로리무스용출성스텐트의효과와안전성에대해서는아직까지잘알려져있지않은상태이다. 이에본연구에서는급성 ST절상승심근경색환자를대상으로시로리무스용출성스텐트를이용한일차적스텐트삽입술후 6개월추적조영술및임상결과를일반금속스텐트삽입후결과와후향적으로비교분석하였다. 론 대상및방법 대상환자 2003 년 4월부터 2004 년 7월까지흉통발생 12시간이내에서울아산병원에내원하여일차적스텐트삽입술을시행한급성 ST절상승심근경색환자 162 명을대상으로하였다 년 1월부터는약물용출성스텐트 (drug-eluting stent) 를일차선택스텐트로사용하여시로리무스용출성스텐트는 74명에서삽입되었다. 88명은일반금속스텐트를시술받았으며 S7 스텐트 (Medtronic Inc, USA) 32%, Jo flex 스텐트 (Jo Med, USA) 15%, Exress 스텐트 (Boston Scientific Cor, Natick, USA) 14%, Arthos inert 스텐트 (AMG international, Germany) 13%, Tsunami 스텐트 (Terumo Cor, Jaan) 10%, 그외스텐트가 16% 에서각각삽입되었다. 본연구에서는응급실방문당시심인성쇽 ( 지속적으로수축기혈압이 90 mmhg 미만이거나, 수축기혈압을 90 mmhg 이상유지하기위해혈관수축제나대동맥내풍선펌프가필요한경우 ) 을포함하여일차적스텐트시술을받은대부분의환자가포함되었으나, 파클리탁셀용출성스텐트 (aclitaxel-eluting stent)(taxus stent, Boston Scientific Cor, Natick, Minnesota, USA) 를삽입한 3명과, 혈전용해제투여후구조경피적관상동맥중재술 (rescue ercutaneous coronary intervention) 을시행한환자들은제외되었다. 시술방법모든병변에대하여표준중재시술법이사용되었다. 최종스텐트삽입방법및시술전후혈소판당단백 IIb/IIIa 길항제 (latelet glycorotein IIb/IIIa antagonist) 의사용여부는시술자의판단에따랐다. 기저및시술후선행혈류 (antegrade flow) 는 Thrombolysis In Myocardial Infarction(TIMI) 기준에맞추어평가하였다. 8) 항혈소판제제로는아스피린 ( 매일 200 mg 영구적사용 ) 과 cloidogrel (300 mg 부하용량, 매일 75 mg을가능한 6개월간사용 ) 이주로사용되었고 cloidogrel 을복용하지못하는경우에는 cilostazol(200 mg 부하용량, 매일 200 mg) 이대신사용되었다. 추적검사추적관상동맥조영술은스텐트삽입 6개월후혹은관상동맥허혈을시사하는증상이나심근스트레스검사양성일경우시행하였으며, 조영술결과는 off-line QCA 시스템 (ANCOR V2.0, Siemens, Solna, Sweden) 을사용하여유도도관 (Guiding catheter) 과혈관내경의비율을이용하여분석하였다. 추적조영술에서스텐트내혹은스텐트근위부및원위부말단 5 mm 이내가 50% 이상협착이있는경우재협착으로진단하였고, 급성획득 (acute gain) 은시술전후혈관최소직경 (minimal luminal diameter, MLD) 의차이로정의하였다. 후기소실 (late loss) 은시술후와 6개월추적조영술에서혈관최소직경의차이로정의하였고, 후기소실지수는후기소실을급성획득으로나누어계산하였다. 정기적외래방문이나전화면담을통하여임상적추적관찰을하였으며, 관찰기간중심인성사망 (cardiogenic death), 비치명적심근경색 (non-fatal myocardial infarction), 표적병변재개통술 (target lesion revascularization, TLR) 을포함하는주요심장사건 (major adverse cardiac events, MACE) 의발생률을조사하였다. 재경색은심한흉통이나심전도상새롭게생긴변화가심근효소 (creatine kinase-mb) 의상승 ( 시술 48시간이내에 1.5 배이상, 혹은 48시간이후에 3배이상 ) 과연관되었을경우로, 표적병변재개통술은동일병변에대해경피적관상동맥중재술을다시하거나관상동맥우회로수술 (coronary artery byass surgery, CABG) 을한경우로정의하였다. 혈전이관상동맥조영술에서확인된경우나특별한원인없이심인성사망이발생한경우에스텐트혈전증으로진단하였다. 통계적분석연속형변수는평균 ± 표준편차로, 범주형변수는빈도및백분율로나타내었다. 연속형변수는 Student t-test 로, 범주형변수는 Chi-square 혹은 Fisher s exact test를시행하여시로리무스용출성스텐트군과일반금속스텐트군을

3 674 Korean Circulation J 2005;35: 비교하였다. 추적기간중표적병변재개통술과주요심장사건은 Kalan-Meier method 로분석하였고, 양군의생존율은 Log-rank test 를통하여비교하였다. 결 임상적특성및시술관련변수좌심실박출율, 심인성쇼크의빈도, 재관류에소요된시 Table 1. Baseline clinical characteristics 과 Age (years) 58.0± ± Men (%) Hyertension (%) Diabetes mellitus (%) Hyercholesterolemia* (%) Current smoking (%) Previous myocardial infarction (%) Previous ercutaneous intervention (%) Previous coronary byass surgery (%) LV ejection fraction (%) 50.6± ± Multivessel disease (%) Cardiogenic shock (%) Reerfusion time (hr) 5.7± ± Peak creatine kinase-mb (ng/ml) 239± ± *: total cholesterol >200 mg er deciliter, : time from symtom onset to balloon. : sirolimus-eluting stents, : bare metal stents, LV: left ventricle Table 2. Procedural characteristics Lesion location (%) 0.27 Left main Left anterior descending artery Left circumflex artery Right coronary artery Byass graft TIMI flow baseline (%) 0.33 Grade 0/I Grade II Grade III TIMI flow after rocedure (%) 0.54 Grade 0/I Grade II Grade III Glycorotein IIb/IIIa inhibitor (%) Number of stents (n) 1.23± ± : sirolimus-eluting stents, : bare metal stents, TIMI: thrombolysis in myocardial infarction 간등의임상적특성은시로리무스용출성스텐트군과일반금속스텐트군에서차이가없었다 (Table 1). 경색발생후 2 시간이내에풍선확장술이시행된경우가시로리무스용출성스텐트군 10명 (13.5%), 일반금속스텐트군 13명 (14.8%) (=0.89) 이었고, 6시간이후인경우는각각 20명 (27.0%), 26명 (29.5%)(=0.82) 으로양군간차이가없었다. 경색발생혈관의분포및시술중사용된혈소판당단백 IIb/IIIa 길항제사용빈도는양군에서차이가없었다. 시술후 TIMI 3 혈류의획득으로정의된시술성공률 (87.8% vs. 92.0%, =0.37) 역시차이는없었다 (Table 2). 관상동맥조영소견의정량적분석양군에서혈관병변길이의차이는없었으나스텐트의총길이는시로리무스용출성스텐트군에서의미있게길었으며참조혈관 (reference vessel) 의직경은시로리무스용출성스텐트군에서작았다. 6개월추적관상동맥조영술은시로리무스용출성스텐트군 42 명 (56.8%), 일반금속스텐트군 46 명 (52.3%)(=0.57) 에서시행되었다. 추적조영술상시로리무스용출성스텐트군에서혈관최소직경이의미있게컸고결과적으로혈관협착비율 (diameter stenosis) 은낮았다. 재협착률은시로리무스용출성스텐트군에서의미있게낮았으며 (0.0% vs. 30.4%, <0.01), 후기소실및후기소실지수역시시로리무스용출성스텐트군에서의미있게작았다 (Table 3). 경과관찰 6개월임상적경과관찰은시로리무스용출성스텐트군 72명 (97.3%), 일반금속스텐트군 87명 (98.9%) 에서가능하 Table 3. Six-month follow-u quantitative coronary angiograhic analysis Lesion length (mm) -25.4± ± Stent length (mm) -33.7± ± Reference diameter (mm) -3.04± ± Minimal luminal diameter (mm) Pre rocedure -0.24± ± Post rocedure -2.81± ± Follow-u* -2.84± ± Diameter stenosis (%) Pre rocedure.92.0± ± Post rocedure 1 6.3± ± Follow-u* 12.6± ± Acute gain (mm) -2.57± ± Late loss (mm) -0.03± ± Late loss index -0.02± ± Binary restenosis* (%) *: values related to atients who underwent angiograhic follow-u. : sirolimus-eluting stents, : bare metal stents

4 Tae-Hyun Yang, et al: Imlantation for Patients with STEMI 675 Table 4. Six-month clinical follow-u 였다 (=0.59). 심인성사망은시로리무스용출성스텐트군에서 4예, 일반금속스테트군에서 7예발생하였으며모두심인성쇼크의상태로내원하여시술중혹은시술후입원기간중에사망하였다. 사망환자는대부분심인성쇼크로사망하였으며그중감염성심내막염, 심실중격결손에따른심부전에의한사망이일반금속스텐트군에서각각 1예있었다. 그외시로리무스용출성스텐트군에서스텐트삽입 8일째발생한아급성스텐트내혈전증으로표적병변재개통술이 1명에서시행되었다. 표적병변재개통술 (1.4% vs. 11.5%, =0.04) 및주요심장사건발생률 (6.9% vs. 19.5%, =0.04) 은시로리무스용출성스텐트군에서의미있게낮았다 (Table 4). 주요심장사건발생이없는생존율역시시로리무스용출성스텐트군에서낮았다 (93.06% vs %; =0.03)(Fig. 1). 고 (n=72) 본연구는시로리무스용출성스텐트가급성 ST절상승심근경색환자에서도효과적이며안전하게사용될수있음을 찰 (n=87) Cardiac death 4 (5.6%) 07 (08.0%) <0.76 Non-fatal myocardial infarction 1 (1.4%) 01 (01.1%) <1.00 Cardiac death or non-fatal 5 (6.9%) 08 (09.2%) <0.77 infarction Target lesion revascularization 1 (1.4%) 10 (11.5%) <0.01 Major adverse cardiac events 5 (6.9%) 17 (19.5%) <0.04 In hosital 5 (6.9%) 05 (05.7%) <0.76 U to 6 months 0 (0.0%) 12 (13.8%) <0.01 Stent thrombosis (%) 1 (1.4%) 00 (00.0%) <0.45 In hosital 1 (1.4%) 00 (00.0%) <0.45 U to 6 months 0 (0.0%) 00 (00.0%) <1.00 : sirolimus-eluting stents, : bare metal stents Free from MACE 100% 90% 80% 70% 60% Sirolimus-eluting stents Bare metal stents =0.03 0% Time after initial rocedure (days) 93.06% 80.46% Fig. 1. MACE-free survival curve. MACE: major adverse cardiac events. 보여준다. 시로리무스용출성스텐트를시술받은환자들은일반금속스텐트시술군과비교하여 1) 6개월추적관상동맥조영술에서혈관재협착률이의미있게낮았고, 2) 6개월임상적경과관찰기간중혈관재개통술의빈도역시낮았으며, 3) 입원기간중스텐트혈전증을포함하여주요심장사건의빈도는별다른차이가없었다. 본연구의결과들은시로리무스용출성스텐트를이용한 RESEARCH Registry 9)10) 및 STENT Registry 11) 의결과들과대동소이하다. 6개월간주요심장사건은시로리무스용출성스텐트군에비해일반금속스텐트군에서많이발생하였다. 하지만비치명적심근경색과심인성사망률은양군에서별다른차이가없어주요심장사건발생률의차이는표적혈관재개통술의차이에서기인하였다. 이러한표적혈관재개통술의차이는재협착률의차이에서발생하였으며, 시로리무스용출성스텐트군에서는재협착이발생하지않았다. 본연구에포함된시로리무스용출성스텐트군환자들이일반금속스텐트군환자에비해참조혈관의직경이작고스텐트길이가길어재협착발생의관점에서보면불리한조건을가졌지만실제결과는시로리무스용출성스텐트군에서낮은재협착률을보였다. 이와같은현상은스텐트에도포된시로리무스의강력한내막증식억제작용을시사하며, 이러한억제작용은여러혈관내초음파연구에의해잘알려져있다. 12)13) 하지만이러한임상연구들은비교적간단한병변을대상으로한예정된시술의결과들이다. 대규모임상연구들이시행되기전실험실연구결과들에서는시로리무스가내막세포의작용을감소시키며, 14) 작용제 (agonist) 에의한혈소판응집을촉진시키고, 15) 혈관치유를지연시킨다고하였다. 16) 이러한특성들은급성심근경색발생의병태생리를고려하면시로리무스용출성스텐트삽입후혈전의발생가능성이증가될수도있음을시사한다. 하지만본연구에서는시로리무스용출성스텐트군 1예 (1.4%) 에서만스텐트삽입 8일후스텐트혈전증이발생하였다. 또한 RESEARCH Registry(9.4% vs 17.0%, =0.02) 에서는 300일추적기간중오히려약물용출성스텐트군에서스텐트혈전증이적게발생하였고, 10) STENT Registry(0% vs 1.7%, =NS) 에서는 90일동안스텐트혈전증발생률에차이가없었다. 11) 하지만급성 ST절상승심근경색환자의일차적스텐트삽입술에서시로리무스용출성스텐트가일반금속스텐트와비교하여스텐트혈전증을비롯한주요합병증의증가없이효과적이며안전하게시술될수있다고확정되기까지는 TYPHOON 과같은대규모전향적무작위연구의결과들이필요하리라판단된다. 본연구의제한점본연구는몇가지제한점이있다. 첫째, 단일병원에서시행된일차적스텐트삽입술을시행받은환자를대상으로한후향적연구이며둘째, 본연구에포함된환자의수가적

5 676 Korean Circulation J 2005;35: 어결과를일반화하기에는한계가있으리라생각된다. 셋째, 6개월추적조영술을시행받은환자들의비율이적어전체환자의재협착률을의미한다할수없다는점이다. 요약 배경및목적 : 시로리무스용출성스텐트는일반금속스텐트에비해스텐트내신생내막의성장을현저히억제하여재협착의발생빈도를상당히감소시켰다. 하지만급성 ST절상승심근경색환자의일차적스텐트삽입술에서시로리무스용출성스텐트의효과와안전성에대해서는아직까지잘알려져있지않은상태이다. 방법 : 흉통발생 12시간이내에서울아산병원에내원하여일차적스텐트삽입술을시행받은급성 ST절상승심근경색환자 162 명 ( 시로리무스용출성스텐트 74명, 일반금속스텐트 88명 ) 을대상으로스텐트삽입술후 6개월재협착률과 6개월추적기간중주요심장사건 ( 심인성사망, 비치명적심근경색, 표적병변재개통술 ) 의발생률을후향적으로비교분석하였다. 결과 : 참조혈관의직경은시로리무스용출성스텐트군에서작았으며 (3.04±0.47 mm vs. 3.24±0.56 mm, =0.02), 스텐트의총길이는시로리무스용출성스텐트군에서길었다 (33.7±14.3 mm vs. 25.0±9.6 mm, =0.00). 시술성공률 (87.8% vs. 92.0%, =0.37), 최고효소수치 (239±196 ng/ml vs. 274±188 ng/ml, =0.26) 는양군에서차이가없었다. 6개월재협착률은시로리무스용출성스텐트군에서의미있게낮았으며 (0.0% vs. 30.4%, =0.00), 후기소실 (-0.03±0.55 mm vs. 1.28±0.58 mm, =0.00) 역시시로리무스용출성스텐트군에서작았다. 스텐트혈전증은시로리무스용출성스텐트군의 1예에서만발생하였다 (1.4% vs. 0.0%, =0.45). 6개월주요심장사건발생률 (6.9% vs. 19.5%, =0.04) 은시로리무스용출성스텐트군에서의미있게낮았으며이는표적병변재개통술 (1.4% vs. 11.5%, =0.01) 의차이에서기인하였다. 주요심장사건발생이없는생존율은시로리무스용출성스텐트군에서높았다 (93.06% vs %, =0.03). 결론 : 급성 ST절상승심근경색환자의일차적스텐트삽입술에서시로리무스용출성스텐트는일반금속스텐트와비교하여스텐트혈전증발생의증가없이재협착률과주요심장사건의발생을효과적으로낮추었다. REFERENCES 1) Keeley EC, Boura JA, Grines CL. Primary angiolasty versus intravenous thrombolytic theray for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003; 361: ) Grines CL, Cox DA, Stone GW, et al. Coronary angiolasty with or without stent imlantation for acute myocardial infarction. N Engl J Med 1999;341: ) Son MS, Son JW, Park GS, et al. Long-term outcomes of rimary stenting in acute myocardial infarction. Korean Circ J 2001; 31: ) Stone GW, Grines CL, Cox DA, et al. Comarison of angiolasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 2002;346: ) Moses JW, Leon MB, Poma JJ, et al. Sirolimus-eluting stents versus standard stents in atients with stenosis in a native coronary artery. N Engl J Med 2003;349: ) Regar E, Serruys PW, Bode C, et al. Angiograhic findings of the multicenter Randomized Study With the Sirolimus-Eluting Bx Velocity Balloon-Exandable Stent(RAVEL): sirolimus-eluting stents inhibit restenosis irresective of the vessel size. Circulation 2002;106: ) Seung KB. Drug eluting stent and ercutaneous coronary intervention. Korean Circ J 2003;33: ) TIMI Study Grou. The Thrombolysis In Myocardial Infarction (TIMI) trial: hase I findings. N Engl J Med 1985;312: ) Saia F, Lemos PA, Lee CH, et al. Sirolimus-eluting stent imlantation in ST-elevation acute myocardial infarction: a clinical and angiograhic study. Circulation 2003;108: ) Lemos PA, Saia F, Hofma SH, et al. Short-and long-term clinical benefit of sirolimus-eluting stents comared to conventional bare stents for atients with acute myocardial infarction. J Am Coll Cardiol 2004;43: ) Guta N, Debsikdar J, Brodie BR, et al. Drug-eluting stents vs bare metal stents in atients with ST elevation myocardial infarction: results from the STENT registry. Am J Cardiol 2004;94: 11E. 12) Sousa JE, Costa MA, Abizaid AC, et al. Sustained suression of neointimal roliferation by sirolimus-eluting stents: one-year angiograhic and intravascular ultrasound follow-u. Circulation 2001;104: ) Serruys PW, Degertekin M, Tanabe K, et al. Intravascular ultrasound findings in the multicenter, randomized, double-blind RAVEL(RAndomized study with the sirolimus-eluting VElocity balloon-exandable stent in the treatment of atients with de novo native coronary artery Lesions) trial. Circulation 2002; 106: ) Jeanmart H, Malo O, Carrier M, Nickner C, Desjardins N, Perrault LP. Comarative study of cyclosorine and tacrolimus vs newer immunosuressants mycohenolate mofetil and raamycin on coronary endothelial function. J Heart Lung Translant 2002;21: ) Babinska A, Markell MS, Salifu MO, Akoad M, Ehrlich YH, Kornecki E. Enhancement of human latelet aggregation and secretion induced by raamycin. Nehrol Dial Translant 1998; 13: ) Virmani R, Farb A, Kolodgie FD. Histoathologic alterations after endovascular radiation and antiroliferative stents: similarities and differences. Herz 2002;27:1-6. 중심단어 : 약물 ; 스텐트 ; 심근경색 ; 혈전.

Microsoft Word - 순11-7.doc

Microsoft Word - 순11-7.doc 원저 Korean Circulation J 2004;34(11):1063-1069 급성심근경색증환자에서혈소판당단백 IIb/IIIa 수용체차단제 (Abciximab:ReoPro ) 부착관상동맥스텐트의장기임상결과 전남대학교병원심장센터, 전남대학교의과학연구소, 1 전남대학교공과대학응용화학공학부 2 김원 1 정명호 1 홍영준 1 박형욱 1 이민구 1 정선영 1 김인수