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1 대한내과학회지 : 제 86 권제 5 호 영구형심박동기삽입후유의한삼첨판역류증발생의예측인자 전남대학교병원순환기내과 이경진 김계훈 임이랑 박혁진 이승헌 김지은 정형기 윤현주 윤남식 홍영준박형욱 김주한 안영근 정명호 조정관 박종춘 Predictors of the Development of Significant Tricuspid Regurgitation after Permanent Pacemaker Implantation Kyoung Jin Lee, Kye Hun Kim, Yi Rang Yim, Hyuk Jin Park, Seung Hun Lee, Ji Eun Kim, Hyung Ki Jeong, Hyun Ju Yoon, Nam Sik Yoon, Young Joon Hong, Hyung Wook Park, Ju Han Kim, Yongkeun Ahn, Myung Ho Jeong, Jeong Gwan Cho, and Jong Chun Park Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea Background/Aims: We sought to identify predictors of significant tricuspid regurgitation (TR) after successful permanent pacemaker (PPM) implantation in Korean patients. Methods: Of 404 patients who underwent PPM implantation, 187 patients who had both baseline and follow-up echocardiographic examinations were assigned to one of two groups: no development or change in TR (Group I, n = 172, 65.5 ± 13.7 years) versus the development of significant TR (Group II, n = 15, 72.1 ± 8.3 years). Clinical, laboratory, and echocardiographic variables were compared between the two groups. Results: Overall, the grade of TR was significantly aggravated from 0.46 ± 0.73 to 0.81 ± 0.84 (p < 0.001) during 3.1 ± 1.8 years of follow-up (0.49 ± 0.75 to 0.69 ± 0.74 in Group I, p < 0.001; 0.13 ± 0.35 to 2.27 ± 0.46 in Group II, p < 0.001). The de novo development or aggravation of TR was observed in 66 patients (35.3%), and significant TR developed in 15 patients (8.0%). The presence of atrial fibrillation (AF) was significantly higher (53.3 vs. 18.6%, p = 0.002), and the implantation of a ventricle pacing, ventricle sensing, inhibited by ventricular event (VVI) type pacemaker was more frequent in Group II than in Group I (46.7 vs. 15.1%, p = 0.002). Other variables were not different between the groups. Conclusions: The development or aggravation of TR was not rare after successful PPM implantation, even though the development of significant TR was uncommon. The presence of AF and the implantation of a VVI type pacemaker were predictors of the development of significant TR. Together, the results of this study suggest that the development or aggravation of TR should be monitored carefully after PPM implantation. (Korean J Med 2014;86: ) Keywords: Pacemaker; Tricuspid valve insufficiency; Atrial fibrillation Received: Revised: Accepted: Correspondence to Kye Hun Kim, M.D., Ph.D. The Heart Center of Chonnam National University Hospital, 42 Jaebong-ro, Dong-gu, Gwangju , Korea Tel: , Fax: , christiankyehun@hanmail.net Copyright c 2014 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 - The Korean Journal of Medicine: Vol. 86, No. 5, 서론 1958년 Furman 등 [1] 에의해처음인공심박동기가도입된이후, 인공심박동기는서맥성부정맥환자의주요한치료법으로사용되고있다. 최근인공심박동기는완전방실차단이나고도방실차단, 증상을동반한동기능부전증후군과같은부정맥질환의주요한치료로사용되고있으며점차적으로적응증이확대되고있다. 인공심박동기치료에의해동기능부전증후군환자와방실전도차단환자의수명연장및삶의질은높아졌다. 그러나인공적인심실조율을위해사용하는전극선의위치는우심실첨부를선호하는경우가많고심실내자극의전달이정상적인히스- 푸르킨예체계 (His-Purkinje system) 를통해이루어지지않아서반대방향으로심조율이되므로이에따른문제가발생할수있다. 그중인공심박동기삽입후삼첨판역류증의악화에대한관심이높아지고있으며이에대한보고가최근이루어지고있다. Lin 등 [2] 은인공심박동기나제세동기를삽입한환자에서중등도의삼첨판역류증의발생으로삼첨판치환술이필요했던환자에대해보고를하였으며 Sakai 등 [3] 은우심실조율을시행한인공심박동기환자에서발생한삼첨판역류에대해부검연구를통해관련된인자로전극에의한판막구조의변형및심건삭의구조적장애를기술하여인공심박동기삽입후발생한삼첨판역류증의관련인자를규명하려하였다. 이외몇몇연구 [4-6] 에서인공심박동기를삽입한후발생한삼첨판역류증에대한연구를통해판막의불완전한폐쇄를유발하는기계적인판막의작용부전에의한삼첨판역류의발생을설명하였으나 Vaturi 등 [7] 이시행한연구에서는이러한전극선에의한판막의기계적인장애와관계없이우심실조율을시행시삼첨판역류증의발생이높아짐을기술하여기계적인요인이외의다른관련인자에의해삼첨판역류증이발생할수있음을시사하였다. 특히 Nath 등 [8] 은삼첨판역류증은좌심실구혈률또는폐동맥압력과관계없이사망률의증가와관련되며중등도이상의삼첨판역류증은삼첨판역류증이없거나경한환자에비해생존율이감소된다고보고하여삼첨판역류증과관련된예측인자를연구시에향후인공심박동기를삽입한환자에서의예후판정에도움이될것임을시사하였다. 우리나라에서는 Kim 등 [9] 에의해시행된연구에서인공심박동기 를삽입한환자에서심실동기화이상과관련된지표로삼첨판역류증을제시한연구가있으나인공심박동기삽입후삼첨판역류증의발생빈도나예측인자및삼첨판역류증의발생이미치는임상적영향에대한연구가드물다. 따라서본연구에서는인공심박동기를이식한환자에서심초음파를이용하여삼첨판역류증의발생유무와악화여부를평가한후삼첨판역류증의발생에관련된예측인자를알아보고자하였다. 대상및방법연구대상 2005년 1월부터 2010년 12월까지전남대학교병원에서인공심박동기를삽입한 404명의환자들중인공심박동기삽입전심장초음파가이루어지지않았거나심초음파영상이좋지않아분석하기어려웠던환자 157명과인공심박동기삽입을이전시행했던자로재삽입술을시행한환자 60명을제외한총 187명을대상으로하였다. 평균 3.1 ± 1.8년의심장초음파추적관찰기간중삼첨판역류증이악화되지않거나 grade 1 이하의변화를보인환자를무변화군 (1군, 172명, 65.5 ± 13.7세, 남자 74명 ) 으로, 삼첨판역류증의정도가 grade 2 이상유의하게변화된환자를악화군 (2군, 15명, 72.1 ± 8.3세, 남자 9명 ) 으로하여두군간에임상적특징이나예후의차이를비교분석하였다. 연구방법심초음파도심초음파도소견은인공심박동기삽입당시와심박동기삽입후최종적으로검사된심장초음파검사결과를분석하였다. 심장초음파검사및측정은 American Society of Echocardiography에서제시한표준지침 [10] 에따라 VIVID 7 (GE, USA) 과 Acuson Sequoia C512 (Siemens, USA) 심초음파기를이용하여좌측측와위 (left lateral decubitus position) 에서시행하였다. 삼첨판역류증은심첨 4방상에서우심방내에서색채 Doppler로관찰되는삼첨판역류증의면적을구하여그심한정도에따라다음의 4단계로정량화하였다 : grade 1 = 2 cm 2 이하, grade 2 = 2-4 cm 2, grade 3 = 4-10 cm 2, grade 4 = 10 cm 2 이상 [11]

3 - Kyoung Jin Lee, et al. Pacemaker and tricuspid regurgitation - 통계분석자료의분석은 Statistical Package for Social Sciences (SPSS) for Windows, version 18.0 (Chicago, IL, USA) 을사용하였다. 모든자료는평균 ± 표준편차로표시하였다. 비연속형변수간의비교평가에는카이제곱검정 (Chi-square test) 을사용하였으며연속형변수간의차이분석에는독립표본 t-검정 (independent t-test) 을통해분석하였다. 삼첨판역류증의 grade 변화값을비교시대응표본 t-검정 (paired t-test) 을사용하였고유의한삼첨판역류증과관련된독립된연관인자를분석하기위해로지스틱회귀분석 (logistic regression analysis) 을이용하였다. 모든분석에서 p 값이 0.05보다작은경우를통계적으로유의하다고판정하였다. 결과임상적특징평균 3.1 ± 1.8년의추적관찰기간동안삼첨판역류증이악화되지않거나 grade 1 이하의변화를보인 I군은 172명이 었고삼첨판역류증의 grade가 2 이상유의하게악화된 II군은 15명이었다. 환자들의임상적특징들은표 1에요약하였다. 두군간에나이, 성별, 심혈관질환의위험인자등은유의한차이가없었으나심방세동환자가 II군에서유의하게많았으며인공심박동기의형태도 VVI형심박동기가 I군에서유의하게많이시술되었다 (Table 1). 심초음파검사소견의특징두군간의시술전심초음파검사상좌심실의크기나수축기및이완기기능등에큰차이는없었으나좌심방크기가 II군에서 I군에비해유의하게증가되어있었다 (Table 2). 인공심박동기삽입후삼첨판역류증의변화정도추적관찰기간동안전체환자에서삼첨판역류증의 grade 는 0.46 ± 0.73에서영구형인공심박동기를삽입후 0.81 ± 0.84로유의하게악화소견을보였다 (p < 0.001). 전체환자에서심박동기시술전후각각의 TR grade 에따른변화는그림 1에제시하였다. 삼첨판역류증의정도는 I군에서는 0.49 ± Table 1. Baseline characteristics of the patients Group I (n = 172) Group II (n = 15) p value Age (yr) 65.5 ± ± BMI (kg/m 2 ) 23.6 ± ± Males (%) 74 (43.0) 9 (60) Diabetes mellitus (%) 33 (19.2) 4 (26.7) Hypertension (%) 91 (53.0) 7 (46.7) Ischemic heart disease 23 (13.4) 0 (0) Atrial fibrillation (%) 32 (18.6) 8 (53.3) Total cholesterol (mg/dl) ± ± Triglycerides (mg/dl) ± ± LDL cholesterol (mg/dl) ± ± HDL cholesterol (mg/dl) 47.1 ± ± Indication for PPM (%) Sick sinus syndrome 51 (29.7) 8 (53.3) Atrioventricular block 121 (70.3) 7 (46.6) Pacemaker type VVI type (%) 26 (15.1) 7 (46.7) Non-VVI type (%) 146 (84.9) 8 (53.4) Group I, aggravation of tricuspid valve insufficiency grade < 1; Group II, aggravation of tricuspid valve insufficiency grade > 2; BMI, body mass index; LDL, low-density lipoprotein; HDL, high-density lipoprotein; PPM, permanent pacemaker; VVI, ventricle pacing, ventricle sensing, inhibited by ventricular event

4 - 대한내과학회지 : 제 86 권제 5 호통권제 645 호 에서 0.69 ± 0.74로 (p < 0.001), II군에서는 0.13 ± 0.35에서 2.27 ± 0.46로 (p < 0.001) 두군모두에서유의하게증가하였으며 II군에서의증가정도가더심하였다 (Fig. 2). 인공심박동기삽입후유의한삼첨판역류증발생과관련된인자들유의한삼첨판역류증의독립적인예측인자를찾기위해이분형로지스틱회귀분석을이용한다변량분석을시행하였다. 인공심박동기삽입전심방세동 (adjusted OR 3.653, p = 0.044) 과 VVI형심박동기 (adjusted OR 4.434, p = 0.033) 가여러변수들을보정한후에도인공심박동기삽입후발생 한유의한삼첨판역류증과독립적으로관련성있는유의한인자로나타났다 (Table 3). 인공심박동기삽입의임상적영향인공심박동기삽입후평균 3.1 ± 1.8년의임상적경과관찰동안인공심박동기삽입후임상적경과에대해서는표 4에요약하였다 (Table 4). 좌심실구혈률은심박동기삽입전 64.7 ± 10.0% 에서심박동기삽입후 61.7 ± 9.6% 로유의하게감소하였으며 (p < 0.001), 인공심박동기삽입전정상좌심실구혈률을보였던환자중인공심박동기삽입후 6명의환자에서새로이좌심실수축기기능의저하 ( 구혈률 45% 미 Figure 1. Impact of pacemaker implantation on tricuspid regurgitation (TR) during clinical follow-up. Figure 2. Changes in tricuspid regurgitation (TR) between the groups during clinical follow-up. Group I, aggravation of tricuspid valve insufficiency grade < 1; Group II, aggravation of tricuspid valve insufficiency grade > 2. Table 2. Echocardiographic findings Group I (n = 172) Group II (n = 15) p value EF (%) 64.7 ± ± LVEDd (mm) 51.4 ± ± LVESd (mm) 32.6 ± ± LAD (mm) 39.8 ± ± RVSP (mmhg) 38.4 ± ± E 0.72 ± ± A 0.79 ± ± E/A 0.96 ± ± DT ± ± E/E' ± ± Group I, aggravation of tricuspid valve insufficiency grade < 1; Group II, aggravation of tricuspid valve insufficiency grade > 2; EF, ejection fraction; LVEDd, left ventricular end-diastolic dimension; LVESd, left ventricular end-systolic dimension; LAD, left atrial dimension; RVSP, right ventricular systolic pressure; DT, deceleration time; E, early diastolic mitral inflow velocity; A, late diastolic mitral inflow velocity; E', early diastolic septal annular velocity

5 - 이경진외 15 인. 심박동기와삼첨판역류증 - Table 3. Multivariate analysis of factors associated with the development of significant tricuspid regurgitation Exp (B) 95% CI p value yr yr Sex (Female) Atrial fibrillation VVI pacemaker LAD > 40 mm CI, confidence interval; Exp, exponentiation of the B coefficient; VVI, ventricle pacing, ventricle sensing, inhibited by ventricular event; LAD, left atrial dimension. Table 4. Clinical events following pacemaker implantation Group I (n = 172) Group II (n = 15) p value De novo LV dysfunction (%) 9 (5.2) 2 (13.3) Death (%) 9 (5.2) 0 (0) New onset AF (%) 16 (9.3) 1 (6.7) Stroke (%) 4 (2.3) 1 (6.7) Group I, aggravation of tricuspid valve insufficiency grade < 1; Group II, aggravation of tricuspid valve insufficiency grade > 2; LV, left ventricular; AF, atrial fibrillation. 만 ) 가새로발생하였다. 인공심박동기를삽입후이전에심방세동이없었던환자 147명중 17명에서심방세동이새로발생하였으며이중 4명은지속적인심방세동을보였다. 임상경과중 5명의환자에서는뇌경색증이발생하였으며 9명의환자가사망하였다. 사망의원인은 3명은심근경색증, 3 명은심부전증의악화, 1명은다발성뇌색전증, 1명은진행성위암, 1명은패혈증이었다. 이러한주요임상사고의발생에있어두군간에유의한차이를보이지는않았다. 고찰본연구는인공심박동기를삽입한환자의치료에있어몇가지임상적으로고려하여야할중요한결과를보여주었다. 첫째, 본연구에서는인공심박동기를삽입후 66명 (35.3%) 에서삼첨판역류증의악화소견을보였으며 grade 2 이상삼첨판역류증이유의하게악화된환자도 15명 (8%) 으로적지않은환자에서삼첨판역류증의악화를보이므로이에대한주의깊은추적관찰이필요하다는것을시사하였다. 둘째, 이러한유의한삼첨판역류증의악화에는인공심박동기삽입전심방세동의존재여부와 VVI 형태의심실조율이 연관되어있어이러한환자에서특히삼첨판역류증의발생이나악화에대한세심한추적관찰이필요함을시사하였다. 셋째, 비록삼첨판역류증의악화와연관은없었으나인공심박동기삽입후에좌심실기능의악화를포함한다양한임상적문제들이발생할수있음을보여주었다. 인공심박동기의삽입이삼첨판막역류증을악화시키는것에여러가지요인이관여된다고제시되고있다. 인공심박동기를삽입한후추적관찰한기간이길어질수록삼첨판역류증이악화된다는연구가있으나 [2] 본연구에서는삼첨판역류증의유의한악화를보인그룹과악화를보이지않은그룹간분석에서두군간추적관찰기간에유의한차이를보이지않아삼첨판역류증의악화가단순히심장조율기간에의해서만결정되지않고여러복합적인인자에의해결정됨을알수있었다. 심박동기의형태도삼첨판막역류증의발생과연관된다고보고되고있는데본연구에서는 VVI 형태의심박조율기가다른형태의심박조율기에비해유의한삼첨판막역류증의발생에관여함을보여주었다. Dong 등 [12] 이시행한연구에서도 VVI pacemaker와 dual chamber pacemaker를비교했을때 VVI 형태의심박동기에서유의한삼첨판역류증의증가가있었음을보여주었다. VVI 형태의

6 - The Korean Journal of Medicine: Vol. 86, No. 5, 심박동기는심방과심실간의조화로운수축이허용되지않으며또한좌-우심실간의정상전도로를통한순차적수축이일어나지못하게되어심실간이상수축 (dyssynchronous contraction) 을하게되어다른형태의심박동기에비해삼첨판막역류증의증가에더관여할것으로생각된다. 우심실조율은심실간조화로운수축을방해할뿐아니라우심실일부벽이먼저수축하면서삼첨판의세판엽의긴장도를유지하는시점이달라져심장내동기이상이발생하면서삼첨판막역류의악화를더조장할것으로생각된다. 또한이러한문제로 VVI 형태의심박동기는심방세동의발생에도영향을준다고보고되고있다. Hesselson 등 [13] 은 ventricular inhibited pacing이 dual chamber pacing에비해심방세동의발생률이유의하게높고 survival도낮음을보고했다. 따라서인공심박동기의적응증이되는환자에서는인공심박동기를삽입시가급적심방조율이나양심실조율이가능한심박동기를선택하여가능하다면생리적인조율을시행하는것이향후삼첨판역류증의발생이나악화및심방세동의발생예방에중요하다고할수있겠다. 본연구에서는유의한삼첨판역류증과관련된다른인자로인공심박동기삽입전심방세동의존재가유의하게나타났다. 여러연구에서인공심박동기를삽입한환자에서심방세동이심장기능의악화를일으킨다고알려져있으며 [14,15], Najib 등 [16] 이시행한연구에서도인공심박동기를삽입전에발생한심방세동이유의한삼첨판역류증의발생과관련됨을보고했다. 따라서심방세동이있는환자에서인공심박동기를삽입하는경우지속적인심장초음파추적관찰및심방세동에대한치료를병행하는것이중요함을시사한다. 또한심장초음파소견에서중등도이상의삼첨판역류증이악화된환자에서유의한좌심방확장증소견이관찰되었고좌심방확장이독립적인심방세동의관련요인이며좌심방확장증이심방세동이동반된환자에서뇌졸중의발생가능성을증가시킨다는점에서심방세동과삼첨판역류증의악화및예후에대한관련성을추정해볼수있었다 [17-20]. 본연구에서는삼첨판역류증의 grade가 4인환자는없었고인공심박동기삽입후추적관찰시에도수술을필요로하는심한 grade 4의삼첨판역류증은발생하지않았다. 인공심박동기삽입후사망, 심부전증, 새로발생한심방세동, 뇌경색증과같은주요한유해사건의발생에삼첨판역류증의유의한악화가영향을줄것으로예상하였으나두 군간에주요유해사건에서유의한차이를보이지않았다. 이는평균추적관찰기간이 3.1 ± 1.8년밖에이루어지지않았고초음파추적관찰이이루어지지않은다수의환자가본연구에서는제외되었으며또한두군간에대상환자수의차이가커서유의한차이를보이지않았을가능성이있으므로추후전향적으로다수의환자를대상으로하는연구가필요할것으로생각된다. 본연구에서는몇가지제한점이있다. 2005년부터 2010 년까지인공심박동기를삽입한환자중에인공심박동기의삽입전과후에심초음파검사가시행되지않았던환자를제외하였으며인공심박동기를다시삽입했던환자의경우도연구결과에영향을미칠가능성이있어제외하여심초음파검사가시행되지않은다수의환자가제외가되었다. 심초음파검사가상대적으로자주시행되었던환자가대상이되었을가능성이있어대상환자의선택편향오류가작용했을가능성이있다. 또한 Lin 등 [2] 이시행한연구에서도유의한삼첨판역류증이있는경우우심실과우심방사이의수축기압력의차이가작아삼첨판역류증의제트면적이과소평가될수있음을고려했을때유의한삼첨판역류증환자의수가과소평가되었을가능성이있다. 또한본연구는인공심박동기가삽입된환자에대해후향적으로시행된연구로삼첨판역류증의변화와관련성을보일수있는우심방과우심실의크기변화에대한분석은우심방과우심실의크기변화가측정되지않는환자가많아포함되지않았고초음파추적관찰이의사주관에의해시행되거나정기적추적관찰검사로시행된경우가많아초음파추적관찰의원인이명확하지않은경우가많았다. 심부전증악화시초음파추적관찰이되었을가능성도있을수있어연구의결과에영향을미쳤을가능성이있다. 이외추적관찰기간이짧고장기적인예후에대한확인이이루어지지않았다는점에서연구에제한점을생각해볼수있다. 따라서향후인공심박동기를삽입한환자에서장기적으로다기관적전향적연구가이루어진다면보다좋은연구결과를기대할수있을것으로생각된다. 결론적으로이러한제한점들에도불구하고본연구의결과는인공심박동기를삽입한환자에서 grade 2 이상의유의한역류증의발생이나악화는많지않으나삼첨판막역류증의악화나발생이비교적드물지않음을보여주었고유의한삼첨판역류증과관련된요인으로심박동기삽입전심방세

7 - Kyoung Jin Lee, et al. Pacemaker and tricuspid regurgitation - 동의존재및 VVI 형태의심박동기가관련함을보여주었다. 따라서영구형인공심박동기를삽입할때가급적생리적조율이가능한심박동기의삽입이필요하며심방세동이있는환자의경우인공심박동기를삽입시더면밀한추적관찰및심방세동에대한치료가병행되어야할것을시사하였다. 요약목적 : 본연구에서는성공적으로인공심박동기를삽입한환자에서유의한삼첨판역류증이발생하거나악화되는예측인자를분석해보고자하였다. 방법 : 전남대학교병원에서 2005년 1월부터 2010년 12월까지인공심박동기를삽입한총 404명의환자중심박동기삽입전후심장초음파검사가시행된 187명의환자를대상으로하였다. 삼첨판역류증의유의한변화가없는경우를 I군 (172명, 65.5 ± 13.7세, 남자 74명 ), 삼첨판역류증이 grade 2 이상유의하게악화된경우를 II군 (15명, 72.1 ± 8.3세, 남자 9명 ) 으로나누어임상적특성과심초음파검사를비교하였다. 결과 : 전체적으로 3.1 ± 1.8년의추적관찰기간동안삼첨판역류증의 grade는 0.46 ± 0.73에서 0.81 ± 0.84로유의하게악화되었다 (p < 0.001). I군에서는 0.49 ± 0.75에서 0.69 ± 0.74로 (p < 0.001), II군에서는 0.13 ± 0.35에서 2.27 ± 0.46으로악화되었다 (p < 0.001). 삼첨판역류증이새로발생하거나더악화된환자는 66명 (35.3%) 이었으며 grade 2 이상의유의한삼첨판역류증의악화는 15명 (8.0%) 에서발생하였다. II 군에서 I군에비해심박동기시술전에심방세동이많았고 (53.3% vs. 18.6%, p = 0.002), VVI 형인공심박동기시술이유의하게많았다 (46.7% vs. 15.1%, p = 0.002). 결론 : 한국인에서영구형인공심박동기를삽입후유의한삼첨판역류증의악화는자주발생하지않았으나삼첨판역류증은드물지않게발생했다. 인공심박동기삽입전심방세동의존재나 VVI 형태의심박동기의삽입이유의한삼첨판역류증의악화와연관되어있었다. 따라서본연구에서는영구형인공심박동기를삽입한환자에서삼첨판역류증에대한면밀한추적관찰이필요함을시사한다. 중심단어 : 심박동기 ; 삼첨판역류증 ; 심방세동 REFERENCES 1. Furman S, Robinson G. The use of an intracardiac pacemaker in the correction of total heart block. Surg Forum 1958;9: Lin G, Nishimura RA, Connolly HM, Dearani JA, Sundt TM 3rd, Hayes DL. Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol 2005;45: Sakai M, Ohkawa S, Ueda K, et al. Tricuspid regurgitation induced by transvenous right ventricular pacing: echocardiographic and pathological observations. J Cardiol 1987; 17: Kim JB, Spevack DM, Tunick PA, et al. The effect of transvenous pacemaker and implantable cardioverter defibrillator lead placement on tricuspid valve function: an observational study. J Am Soc Echocardiogr 2008;21: Seo Y, Ishizu T, Nakajima H, Sekiguchi Y, Watanabe S, Aonuma K. Clinical utility of 3-dimensional echocardiography in the evaluation of tricuspid regurgitation caused by pacemaker leads.circ J 2008;72: Klutstein M, Balkin J, Butnaru A, Ilan M, Lahad A, Rosenmann D. Tricuspid incompetence following permanent pacemaker implantation. Pacing Clin Electrophysiol 2009; 32(Suppl 1):S Vaturi M, Kusniec J, Shapira Y, et al. Right ventricular pacing increases tricuspid regurgitation grade regardless of the mechanical interference to the valve by the electrode. Eur J Echocardiogr 2010;11: Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol 2004;43: Kim SS, Cho JG, Kim HK, et al. The factors influencing ventricular dyssynchrony in patients with permanent pacemaker. Korean J Med 2010;78: Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16: Miyatake K, Okamoto M, Kinoshita N, et al. Evaluation of tricuspid regurgitation by pulsed Doppler and two-dimensional echocardiography. Circulation 1982;66: Dong YX, Guo M, Yang YZ, et al. Effects of ventricular demand and dual-chamber pacing models on the long-term clinical outcome and cardiac remodeling in patients with symptomatic bradycardia. Zhonghua Yi Xue Za Zhi 2011; 91: Hesselson AB, Parsonnet V, Bernstein AD, Bonavita GJ. Deleterious effects of long-term single-chamber ventricular

8 - 대한내과학회지 : 제 86 권제 5 호통권제 645 호 pacing in patients with sick sinus syndrome: the hidden benefits of dual-chamber pacing. J Am Coll Cardiol 1992; 19: Lampe B, Hammerstingl C, Schwab JO, et al. Adverse effects of permanent atrial fibrillation on heart failure in patients with preserved left ventricular function and chronic right apical pacing for complete heart block. Clin Res Cardiol 2012;101: Sweeney MO, Hellkamp AS, Ellenbogen KA, et al. Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation 2003;107: Najib MQ, Vinales KL, Vittala SS, Challa S, Lee HR, Chaliki HP. Predictors for the development of severe tricuspid regurgitation with anatomically normal valve in patients with atrial fibrillation. Echocardiography 2012;29: Henry WL, Morganroth J, Pearlman AS, et al. Relation between echocardiographically determined left atrial size and atrial fibrillation. Circulation 1976;53: Sanfilippo AJ, Abascal VM, Sheehan M, et al. Atrial enlargement as a consequence of atrial fibrillation: a prospective echocardiographic study. Circulation 1990;82: Takahashi N, Imataka K, Seki A, Fujii J. Left atrial enlargement in patients with paroxysmal atrial fibrillation. Jpn Heart J 1982;23: Caplan LR, D'Cruz I, Hier DB, Reddy H, Shah S. Atrial size, atrial fibrillation, and stroke. Ann Neurol 1986;19:

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar