대상및방법 대상 방법 138 Fig. 1. Measurement of left atrial appendage area and volume. Korean Circulation J 2002;322:

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1 Original Articles Korean Circulation J 2002;322: 다면성경식도심초음파도를이용한좌심방이에관한연구 전성희 1 박성훈 2 Multiplane Transesophageal Echocardiographic Assessment of Left Atrial Appendage Seong Hee Jeon, MD 1 and Seong Hoon Park, MD 2 1 Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, 2 Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea ABSTRACT Background and ObjectivesTransesophageal echocardiography TEE allows a detailed evaluation of the structure and function of the left atrial appendage LAA by two-dimensional imaging and Doppler interrogation of appendage flow. LAA dysfunction has been associated with spontaneous echo contrast SEC, thrombus formation and thromboembolism. The purpose of this study was to define normal heart reference values of LAA maximal forward velocity LAAV, and to correlate LAAV with cardiac rhythm, mitral valve disease severity, SEC grade and left atrial thrombi development. Subjects and MethodsLAA volume measurement and pulse Doppler evaluation of LA appendage flow during TEE were undertaken in 95 subjects32 patients with normal heart and 63 patients with various cardiac diseases. ResultsMean LAAV was cm/s, mean LAA maximal backward velocity cm/s and mean LAA volume ml in those patients with normal heart n32. There was a negative correlation between LAAV and SEC grade, mitral stenosis severity, LA size and LAA volume. Among those patients with atrial fibrillation, LAAV was lower in the subgroup with LA thrombi than in the subgroup without thrombi cm/s n16, vs cm/s n33, p0.01. ConclusionReduced LAAV, SEC and mitral stenosis are all associated with LAA thrombus formation in patients with atrial fibrillation. Korean Circulation J 2002;322: KEY WORDSEchocardiography, transesophagealatrial appendageatrial fibrillationthromboembolism. 서 론 137

2 대상및방법 대상 방법 138 Fig. 1. Measurement of left atrial appendage area and volume. Korean Circulation J 2002;322:

$The maximal forward flow velocity of left atrial appendage LAAV was not correlated with left ventricular ejection fraction. Fig. 4.$

3 Fig. 2. Measurement of maximal forward and backward flow velocity of left atrial appendage in sinus rhythm. 통계분석 결 정상좌심방이의용적및혈류속도 과 Fig. 3. The maximal forward flow velocity of left atrial appendage LAAV was not correlated with left ventricular ejection fraction. Fig. 4. The maximal forward flow velocity of left atrial appendage LAAV was inversely correlated with left atrial appendage volume. 좌심방이최대전방혈류속도와좌심방이용적, 좌심방전후직경, 폐정맥수축기혈류속도, 좌심실구혈률과의상관성 139

4 Fig. 5. The maximal forward flow velocity of left atrial appendage LAAV was inversely correlated with the anteroposterior diameter of left atrium. Fig. 6. The maximal forward flow velocity of left atrial appendage LAAV was positively correlated with systolic flow velocity of right upper pulmonary vein RUPV. 전체환자에서자발에코영상, 승모판협착증및승모판폐쇄부전증의중증도및심방세동유무에따른좌심방이최대전방혈류속도의차이 좌심방이최대전방혈류속도와좌심방혈전과의관계 Table 1. Comparison of mean LAAV by SEC grade SEC grade 0 n39 1 n5 2 n4 3 n17 4 n5 p LAAV cm/sec LAAVthe maximal forward flow velocity of left atrial appendage, SECspontaneous echo contrast Table 2. Comparison of mean LAAV by MS grade MS grade 0 n54 Mild n2 Moderate n1 Severe n10 p LAAV cm/sec LAAVthe maximal forward flow velocity of left atrial appendage, MSmitral stenosis 140 Korean Circulation J 2002;322:

5 Table 3. Comparison of mean LAAV by MR grade MR grade 0 n29 n25 1 n8 2 n1 3 n5 4 n0 p LAAV cm/sec NS LAAVthe maximal forward flow velocity of left atrial appendage, MRmitral regurgitation, NSnot significant Table 4. Comparison of mean LAAV, LAA area and LAA volume by rhythm Sinus rhythm Atrial fibrillation p LAAV cm/sec n n LAA area cm n n LAA volume ml n n LAAVthe maximal forward flow velocity of left atrial appendage, LAAleft atrial appendage Table 5. The incidence of thrombi by SEC grade in patients with atrial fibrillation Thrombi No SEC Yes p0.05, % within SEC, LAAVthe maximal forward flow velocity of left atrial appendage, SECspontaneous echo contrast Table 6. The incidence of thrombi by MS grade in patients with atrial fibrillation Thrombi MS 0 Mild Moderate Severe No Yes p0.01, % within MS, MSmitral stenosis 심방세동환자군에서자발에코영상 (SEC), 승모판협착증및승모판폐쇄부전증의중증도 (severity) 와좌심방혈전과의관계 Table 7. The incidence of thrombi by MR grade in patients with atrial fibrillation Thrombi MR 0 Trace No Yes p0.06, % within MR, MRmitral regurgitation 고 정상심장의좌심방이최대전방혈류속도및용적 찰 141

6 좌심방혈전생성의예측 142 Korean Circulation J 2002;322:

An example of left atrial appendage flow recording in patients with atrial fibrillation and preserved left atrial appendage function.

7 우를 대표한다고 볼 수 있다. 본 연구에서 좌심방이의 최대 전방 혈류속도는 좌심 방이 용적, 좌심방 전후직경, 자발에코영상의 정도 및 승 모판 협착증의 정도와 유의한 음의 상관관계를 보이므 로 후자를 통해서 좌심방내의 혈전형성가능성을 어느정 도 예측할 수 있으리라 가정할 수 있다. 그러나 본 연구 에서 좌심방이의 최대 전방 혈류속도와 자발에코영상의 정도 및 승모판 협착증의 정도만이 좌심방혈전의 발생 과 유의한 상관관계가 있었으며, 좌심실구혈률과 좌심방 이 용적, 좌심방 전후직경 등은 혈전의 유무와 관련이 없 었다. 따라서 좌심방이 최대 전방 혈류속도는 좌심방혈 Fig. 7. An example of left atrial appendage flow recording in patients with atrial fibrillation and preserved left atrial appendage function. 전형성의 유무를 예측하는데 중요하며, 특히 다소 주관 성이 가미되어 평가되는 자발에코영상보다 객관적으로 측정할 수 있고 재현성이 높아 좌심방이나 좌심방내 혈 전형성의 가능성을 예측하는데 의의가 크다고 사료된다. 제한점 본 연구는 경식도 심초음파를 시행한 환자 중 좌심방 이의 최대 전방 혈류속도가 측정되었던 95명의 환자들 의 심초음파도 결과를 검토한 것으로, 45도와 90도 모 두에서 최대 전방 혈류속도가 측정되지 않았던 환자들 이 있었다. 즉 45도에서 좌심방이의 최대 전방 혈류속도 가 측정된 환자수는 70명이었고, 90도에서 좌심방이의 최대 전방 혈류속도가 측정된 환자수는 46명으로 mifig. 8. An example of left atrial appendage flow recording in patients with atrial fibrillation and left atrial appendage dysfunction. ssing value들이 있어 통계적 의미가 감소될 수 있다. 또 한 본 연구는 단면연구(cross-sectional study)로서 좌 심방이의 최대 전방 혈류속도와 좌심방혈전유무의 관련 성을 관찰한 것으로 일부 질환군의 수가 적어 통계처리 없었다. 이는 더 많은 환자를 대상으로 관찰한다면 동일 결과에 신뢰도가 감소될 수 있는 여지가 있다. 추후 대 한 결과를 얻을 수 있을 가능성을 시사한다. 규모의 환자를 대상으로하는 전향적 연구(prospective study)를 시행하여 좌심방이의 최대 전방 혈류속도와 좌 경식도 심초음파시 좌심방이 최대 전방 혈류속도 측정의 심방내의 혈전 발생과의 상관관계를 관찰할 필요가 있다. 의의 요 좌심방이의 최대 전방 혈류속도는 일반적으로 정상 동 약 17)21)22) 율동환자에 비해 심방세동환자에서 낮게 측정된다. 그러나 심방세동환자에서도 좌심방이의 최대 전방 혈류 배경 및 목적 속도는 그 범위가 매우 넓어 정상 동율동시처럼 높게 측 경식도 심초음파를 이용하여 정상심장 및 다양한 심장 정되기도 하며(Fig. 7) 좌심방이혈류을 가까스로 발견할 질환에서 좌심방이의 용적, 좌심방이의 혈류속도를 측정 수 있을 만큼 낮게 측정되기도 한다(Fig. 8). 이는 아마 하여 정상 좌심방이의 용적과 혈류속도에 대해 알아보고, 도 심방세동환자에서 좌심방이의 기능이 비교적 잘 보 좌심방이의 혈류속도와 심방세동의 유무, 좌심실구혈률, 존되어 있는 경우와 심한 좌심방이기능부전을 보이는 경 자발에코영상, 승모판 질환 등과의 관련성 및 좌심방 혈 143

8 방법 : 결과 : 144 결론 : 중심단어 REFERENCES 1) Jordan RA, Scheifley CH, Edwards JE. Mural thrombosis and arterial embolism in mitral stenosis a clinopathologic study of fifty-one cases. Circulation ) Shrestha NK, Moreno FL, Narcisco FV, Torres L, Calleja HB. Two dimensional echocardiographic diagnosis of left arterial thrombus in rheumatic heart disease a clinopathologic study. Circulation ) Veinot JP, Harrity PJ, Gentile F, Khandheria BK, Bailey KR, Eickholt JT, Seward JB, Tajik AJ, Edwards WD. Anatomy of the normal left atrial appendage a quantitative study of age-related changes in 500 autopsy hearts implications for echocardiographic examination. Circulation ) Fatkin D, Kuchar DL, Thorburn CW, Feneley MP. Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation evidence for atrial stunning as a mechanism of thromboembolic complications. J Am Coll Cardiol ) Suetsugu M, Matsuzaki M, Toma Y, Anno Y, Maeda T, Okada K, Konishi M, Ono S, Tanaka N, Hiro J. Detection of mural thrombi and analysis of blood flow velocities in the left atrial appendage using transesophageal twodimensional echocardiography and pulsed Doppler flowmetry. J Cardiol ) Manning WJ. Role of transesophageal echocardiography in the management of thromboembolic stroke. Am J Cardiol D-28D. 7) Li YH, Hwang JJ, Lin JL, Tseng YZ, Lien WP. Importance of left atrial appendage function as a risk factor for systemic thromboembolism in patients with rheumatic mitral valve disease. Am J Cardiol ) Ilercil A, Kondapaneni J, Hla A, Shirani J. Influence of age on left atrial appendage function in patients with nonvalvular atrial fibrillation. Clin Cardiol ) Agmon Y, Khandheria BK, Meissner I, Schwartz GL, Petterson TM, O Fallon WM, Gentile F, Whisnant JP, Wiebers DO, Covalt JL, Seward JB. Left atrial appendage flow velocities in subjects with normal left ventricular function. Am J Cardiol ) Tabata T, Oki T, Fukuda N, Iuchi A, Manabe K, Kageji Y, Sasaki M, Yamada H, Ito S. Influence of aging on left atrial appendage flow velocity patterns in normal subjects. J Am Soc Echocardiogr ) Mugge A, Kuhn H, Nikutta P, Grote J, Lopez JA, Daniel WG. Assessment of left atrial appendage function by biplane transesophageal echocardiography in patients with nonrheumatic atrial fibrillation identification of a subgroup of patients at increased embolic risk. J Am Coll Ca- Korean Circulation J 2002;322:

9 rdiol ) Song JK, Park SJ, Park SW, Kim WH, Doo YC, Kim JJ, Lee JK. Left atrial appendage flow in patients with tight mitral stenosis comparison with normal control and effect of successful percutaneous mitral balloon valvuloplasty. Korean Circ J ) Pollick C, Taylor D. Assessment of left atrial appendage function by transesophageal echocardiography implications for the development of thrombus. Circulation ) Ito T, Suwa M, Hirota Y, Otake Y, Moriguchi A, Kawamura K. Influence of left atrial function on Doppler transmitral and pulmonary venous flow patterns in dilated and hypertrophic cardiomyopathy evaluation of left atrial appendage function by transesophageal echocardiography. Am Heart J ) Manning WJ, Silverman DI, Gordon SP, Krumholz HM, Douglas PS. Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med ) Klein AL, Grimm RA, Murray RD, Apperson-Hansen C, Asinger RW, Black IW, Davidoff R, Erbel R, Halperin JL, Orsinelli DA, Porter TR, Stoddard MF. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med ) Pozzoli M, Febo O, Torbicki A, Tramarin R, Calsamiglia G, Cobelli F, Specchia G, Roelandt JR. Left atrial appendage dysfunction a cause of thrombosis? evidence by transesophageal echocardiography-doppler studies. J Am Soc Echocardiogr ) Daniel WG, Nellessen U, Schroder E, Nonnast-Daniel B, Bednarski P, Nikutta P, Lichtlen PR. Left atrial spontaneous echo contrast in mitral valve disease an indicator for an increased thromboembolic risk. J Am Coll Cardiol ) The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography. Transesophageal echocardiographic correlates of thromboembolism in highrisk patients with nonvalvular atrial fibrillation. Ann Intern Med ) Blackshear JL, Pearce LA, Asinger RW, Dittrich HC, Goldman ME, Zabalgoitia M, Rothbart RM, Halperin JL. Mitral regurgitation associated with reduced thromboembolic events in high-risk patients with nonrheumatic atrial fibrillation. Am J Cardiol ) Li YH, Lai LP, Shyu KG, Hwang JJ, Ma HM, Ko YL, Kuan P, Lien WP. Clinical implications of left atrial appendage function its influence on thrombus formation. Int J Cardiol ) Jue J, Winslow T, Fazio G, Redberg RF, Foster E, Schiller NB. Pulsed Doppler characterization of left atrial appendage flow. J Am Soc Echocardiogr

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<4D F736F F F696E74202D20BFA1C4DA5FC0D3BBF3C3CAC0BDC6C42E BC8A3C8AF20B8F0B5E55D> 심장 (Heart) 심초음파 서울대병원내과 김용진 심장은평생몇번이나뛸까요? 1) 3 백만번 2) 3 천만번 3) 3 억번 4) 30 억번 30 억박동, 2 억리터의혈액 Cause 심장질환 6.2 12.4 11.1 16.2 뇌졸중 4.3 8.5 7.7 11.3 기타심혈관질환 2.6 5.1 6.0 8.8 심혈관질환 13.1 26.0 24.8 36.3 총사망 50.4