The Official Journal of Korean Heart Rhythm Society 목적과개요 부정맥 은 부정맥과관련된새로운임상지식, 진료지침, 증례등을소개하여부정맥연구회회원및개원의의지속적인의학교육에이바지하고자발행되는학술지입니다. 부정맥 은부정맥의진단과치료,

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1 편집자문위원 ( 가나다순 ) 고재곤 / 울산의대 곽충환 / 경상의대 김대경 / 인제의대 김대혁 / 인하의대 김성순 / 연세의대 김영훈 / 고려의대 김유호 / 울산의대 김윤년 / 계명의대 김종윤 / 연세의대 김준 / 울산의대 김준수 / 성균관의대 김진배 / 경희의대 남궁준 / 인제의대 노태호 / 가톨릭의대 박경민 / 인제의대 박상원 / 고려의대 박형욱 / 전남의대 배은정 / 서울의대 성정훈 / 차의과학대 신동구 / 영남의대 오동진 / 한림의대 오용석 / 가톨릭의대 이경석 / 전북의대 이만영 / 가톨릭의대 이명용 / 단국의대 이문형 / 연세의대 임홍의 / 고려의대 장성원 / 가톨릭의대 정중화 / 조선의대 조용근 / 경북의대 조정관 / 전남의대 최기준 / 울산의대 최윤식 / 서울의대 최의근 / 서울의대 최인석 / 가천의대 최종일 / 고려의대 한상진 / 한림의대 허준 / 성균관의대 현명철 / 경북의대

2 The Official Journal of Korean Heart Rhythm Society 목적과개요 부정맥 은 부정맥과관련된새로운임상지식, 진료지침, 증례등을소개하여부정맥연구회회원및개원의의지속적인의학교육에이바지하고자발행되는학술지입니다. 부정맥 은부정맥의진단과치료, 임상연구와관련된원저, 종설, 논평, 증례보고등의원고를공모하며, 제출된원고는편집위원회의검토를거쳐게재됩니다. 발행사 발행일 엠엠케이커뮤니케이션즈 대표 : 이영화편집 : 양관재, 김지현디자인 : 유은영서울시강남구논현로 523 노바빌딩 3 층 Tel Fax inquiry@mmk.co.kr 2014 년 9 월 18 일 부정맥은대한심장학회부정맥연구회가주관하며엠엠케이커뮤니케이션즈에서발행하고있습니다. 본지와관련된문의사항이나건의사항이있으시면발행사인엠엠케이커뮤니케이션즈로연락하여주시기바랍니다.

3 The Official Journal of Korean Heart Rhythm Society Vol 15. No. 3 통권 50 호 September 2014 Contents Cover: Newspaper report of permanent pacemaker implantation in 1975 performed by Kim in a 17-year-old girl with Adams-Stokes syndrome (Page 27). Original Articles Prognosis of Atrial Flutter Alone Ablation in Patients who Show Typical Atrial Flutter with or without Rarely Documented Paroxysmal Atrial Fibrillation 조은정, 이성호, 박승정, 김준수, 온영근 04 Relationship between Genetic Polymorphisms of Angiotensin-Converting Enzyme and the Degree of Electroanatomical Remodeling of the Atrium in Patients with Non-valvular Atrial Fibrillation 김숙경, 박재형, 박용두, 박희남 13 Main Topic Reviews Bradyarrhythmia 우리나라의영구심박동기과거와현재 노태호 24 서맥성부정맥에서박동기치료의적응증 오용석 31 인공심박동기시술테크닉 김준수 35 박동기추적검사및프로그래밍 김준 42 박동기합병증의예방및처치 정보영 50 Article Review 대동맥판막협착증환자에서경피적대동맥판막치환술후 인공심박동기삽입의예측인자 김남호 55 ECG & EP Cases Transvenous Extraction of 30-year-old Pacemaker Leads in a Patient with Eisenmenger Syndrome 엄재선 / 정보영 57 Anatomical Obstacles to Catheter Ablation for Atrioventricular Nodal Reentrant Tachycardia 노승영 / 박상원 62 Right Heart Penetration Injury by Screw-In Pacing Leads 박종성 69 Intractable Ventricular Tachycardia Associated With Stress Cardiomyopathy 진은선 72 자율학습문제 76

4 Original Articles Prognosis of Atrial Flutter Alone Ablation in Patients who Show Typical Atrial Futter with or without Rarely Documented Paroxysmal Atrial Fibrillation 성균관대학교의과대학내과학교실조은정, 이성호, 박승정, 김준수, 온영근 Eunjeong Cho, Sung Ho Lee, Seung-Jung Park, June Soo Kim, Young Keun On Division of Cardiology, Department of Internal Medicine, Cardiac and Vascular center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Abstract Introduction: Cavotricuspid isthmus (CTI)-dependent typical atrial flutter (AFL) is often accompanied by paroxysmal or subclinical atrial fibrillation (AF). Herein, we assessed the prognosis of only CTI ablation in patients with typical AFL with or without rarely documented paroxysmal AF (PAF) episodes. Methods: CTI ablation alone was performed in 36 consecutive patients (age, 63.3 ± 1.3 years; 34 men), of whom 26 had typical AFL alone (AFL-alone group) and 10 had mainly typical AFL with rarely documented PAF episodes (mixed group) prior to ablation. Recurrence of AF/AFL was assessed using 12-lead and Holter electrocardiograms during the follow-up period (mean, 21 months) after CTI ablation. Results: The mean follow-up duration was 20.8 ± 17.3 months. In the AFL-alone group, recurrence of atrial tachyarrhythmia was noted in 9 (34.6%) patients. AFL recurrence and new-onset AF were noted in 8 (30.8%) and 2 (7.5%) patients, respectively. In the mixed group, atrial arrhythmia was noted in 9 (90%) patients. AFL and AF recurrence were noted in 5 (50%) and 5 (50%) patients, respectively. Concomitant AF at baseline, increased left atrial diameter, and dyslipidemia were associated with the recurrence of atrial tachyarrhythmia. Conclusion: Close, regular follow-up might be needed for patients with typical AFL after CTI ablation because of the high recurrence of atrial tachyarrhythmia. In addition to CTI ablation, more aggressive treatment such as pulmonary vein isolation might be needed for patients presenting with mainly typical AFL and rare PAF episodes. Key Words: prognosis atrial flutter atrial fibrillation ablation Introduction Received: May 19, 2014 Revision Received: September 4, 2014 Accepted: September 14, 2014 Correspondence: Young Keun On, MD, PhD, Division of Cardiology, Department of Internal Medicine, Cardiac and Vascular center, Samsung Medical Center, Sungkyunkwan University School of Medicine, #50 Irwon-dong, Gangnam-gu, Seoul, , Korea Tel: , Fax: yk.on@samsung.com Atrial fibrillation (AF) and atrial flutter (AFL) are the most common sustained atrial arrhythmias and often coexist. Both arrhythmias have similar pathological features including electrical remodeling 1 and shortened action potential duration 2 as well as similar clinical predictors such as hypertension, 4 The Official Journal of Korean Heart Rhythm Society

5 heart failure, and pulmonary disease. 3,4 The AFL macroreentrant circuit is localized in the right atrium between the tricuspid valve and the crista terminalis. 5 Therefore, in a majority of patients, a line of block (LOB) is needed between both vena cavae to prevent short-circuiting. 6,7 Ablation of AFL interrupts the circuit at its narrowest portion the cavotricuspid isthmus (CTI). Current guidelines established CTI ablation as Class I therapy for recurrent AFL. 8 In a previous study, 12 26% of patients developed AF during the follow-up period after ablation of typical AFL, which was performed within 2 years after CTI ablation. 9,10 AF and AFL are known to coexist. Waldo et al. 11,12 hypothesized that burst episodes of AF initiate AFL by creating an LOB between the vena cavae. Thus, ablation of the CTI may unmask underlying episodes of AF. Ablation of AF and AFL in patients with both arrhythmias is beneficial, 13 but data on prophylactic AF ablation in patients with AFL alone are lacking. Therefore, the purposes of this study were (1) to examine the longterm outcome after ablation of typical AFL with or without rarely documented paroxysmal AF, and (2) to investigate the predictors of recurrent atrial arrhythmia after catheter ablation of the CTI. Methods Study Population Patients were enrolled between March 2010 and June The inclusion criterion was symptomatic persistent typical AFL or typical AFL with rarely documented paroxysmal AF (PAF). AFL recognition was based on the typical saw-tooth appearance on the surface 12-lead electrocardiogram (ECG). AFL was considered persistent if it sustained for at least 1 week. Rarely documented PAF was defined as the occurrence of ECG or Holter monitoring-proven short runs of AF less than three times. All patients underwent chemical or electrical cardioversion. Failure of at least one antiarrhythmic drug or postcardioversion was required before performing catheter ablation. Exclusion criteria were inability or unwillingness to take warfarin, left ventricular (LV) dysfunction on echocardiogram (ejection fraction [EF] <40%), pregnancy, and non-inducible typical AFL at the electrophysiological study. Because sinus rhythm could be the presenting rhythm during the electrophysiological study, it was considered an inclusion criterion and used to induce AFL and demonstrate CTI participation. Study Design CTI ablation alone was performed in 36 consecutive patients (age, 63.3 ± 1.3 years; 34 men), of whom 26 had typical AFL alone (AFL-alone group) and 10 showed mainly typical AFL with rarely documented PAF episodes (mixed group) prior to ablation. The procedure was performed under conscious sedation with midazolam or propofol. For patients who were in sinus rhythm at the time of the ablation, AFL was induced by atrial burst pacing. Typical AFL was confirmed by entrainment mapping maneuvers. Lack of demonstration of CTI-dependent flutter during the electrophysiological study was considered an exclusion criterion. Surface ECG signals and intracardiac electrograms were filtered at Hz and recorded simultaneously using the Prucka Cardiolab EP system (General Electric Co., Fairfield, CT, USA). All antiarrhythmics were discontinued 5 half-lives before the procedure. Patients were administered warfarin for at least 1 month before ablation to achieve effective oral anticoagulation. Administration of warfarin was stopped at admission Original Articles Vol.15 No.3 5

6 Original Articles and replaced by intravenous heparin before the ablation; heparin administration was continued for 2 days after the procedure. Warfarin was restarted on the night of the procedure and continued for at least 2 months to maintain an international normalized ratio between 2 and 3. Ablation of AFL Intracardiac catheters were placed percutaneously under fluoroscopic guidance. Two standard quadripolar catheters (inter-electrode spacing mm; St. Jude Medical, Inc., MN, USA) were placed at the right ventricle and right atrium through the right femoral vein. Coronary sinus recordings were taken using a 6-Fr decapolar catheter (inter-electrode spacing mm; St. Jude Medical, Inc., MN, USA) advanced through the right jugular vein. A standard quadripolar catheter (inter-electrode spacing mm; St. Jude Medical, Inc., MN, USA) was placed at the His bundle region through the left femoral vein. CTI ablation was performed using a bidirectional 4-mm tip catheter (Cool Path Duo mid curve, St. Jude Medical, Inc., MN, USA) in a dragging motion every 10 seconds, targeting a power of up to 30 W and temperature of 35 C. The procedure endpoint was a bidirectional block, which was assessed by an activation detour by pacing either side of the line and by differential pacing techniques as described in the literature. 10,14 Post-ablation Follow-up After ablation, all patients were followed up at our clinic. When the patients experienced symptoms suggestive of tachycardia, ECG, 24-hour Holter monitoring, or cardiac event recording were performed again to define the cause of clinical symptoms. A questionnaire including the following questions was then administered to the patients: (1) Did the patient still have clinical symptoms suggestive of arrhythmias? (2) Were the symptoms the same as those experienced before ablation? (3) When did the symptoms first appear after ablation? (4) Did the patient go to the clinic, undergo ECG examination, and receive a diagnosis? (5) What kind of therapy was used to treat the symptoms? The responses to the questionnaire were reviewed, and the medical history of all patients was obtained. Statistical Analysis Continuous variables are expressed as mean ± standard deviation and were compared using the Mann Whitney test. A Chi-square test or Fisher s exact test was used to compare categorical variables. A P value <0.05 was considered statistically significant. SPSS 17.0 (statistical package for Mac, Chicago, IL) was used for statistical analysis. Results CTI ablation alone was performed in the 36 consecutive patients (age, 63.3 ± 1.3 years; 34 men), of whom 26 had typical AFL alone and 10 showed mainly typical AFL with rarely documented PAF episodes prior to ablation. Baseline characteristics were not significantly different between the AFL-alone group and the mixed group; the social history, associated diseased, and past medical history are presented in Table 1. Further, the baseline echocardiographic parameters did not differ in interventricular septal wall 6 The Official Journal of Korean Heart Rhythm Society

7 Table 1. Baseline clinical characteristics of patients with typical atrial flutter alone (AFL-alone group) and typical AFL with rarely documented paroxysmal atrial fibrillation episodes (mixed group) AFL alone group (n=26) Mixed group (n=10) P-value Age (yrs) 64.65± ± Sex (M/F) 25/1 9/ Height (cm) ± ± Weight (Kg) 71.08± ± Alcohol Smoking CHA 2 DS 2 (under 1/above 1) 17/9 7/ Follow-up duration (month) 19.42± ± Associated diseases Hypertension DM CAD CHF CRF Dyslipidemia PCI Hx CABG Hx HCMP DCMP ICMP VHD LVH Medications Amiodarone Beta-blocker Dronedarone Sotalol Propafenon Original Articles Data are listed as numbers (percentage of the group) and median (minimum value-maximum value). The P value denotes statistical significance on comparing the AFL-alone group and mixed group. *p<0.05 by Mann Whitney (continuous variable), Chi-square, or Fisher s exact test (categorical variables). CABG, coronary artery bypass graft; CAD, coronary artery disease; CHF, congestive heart failure; CRF, chronic renal failure; DCMP, dilated cardiomyopathy; DM, diabetes mellitus; HCMP, hypertrophic cardiomyopathy; ICMP, ischemic cardiomyopathy; LVH, left ventricular hypertrophy; PCI, percutaneous coronary intervention; VHD, valvular heart disease. Vol.15 No.3 7

8 Original Articles Table 2. Baseline echocardiographic parameters of patients with typical atrial flutter alone (AFL-alone group) and typical AFL with rarely documented paroxysmal atrial fibrillation episodes (mixed group) AFL alone group (n=26) Mixed group (n=10) P-value LVEDD (mm) 50.77± ± LVESD (mm) 32.35± ± LVEF (%) 55.15± ± LAD (mm) 44.31± ± Aorta diameter (mm) 36.00± ± IVSd (mm) 11.23± ± LVPWd (mm) 9.42± ± LAVI (ml/m 2 ) 44.23± ± LVMI (g/m 2 ) ± ± Data are listed as median (minimum value-maximum value). The P value denotes statistical significance on comparing the AFL-alone group and mixed group. *p<0.05 by Mann Whitney (continuous variable) and Chi-square or Fisher s exact test (categorical variables). IVSd, diastolic interventricular septum thickness; LAD, left atrial dimension; LAVI, left atrial volume index; LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; LVMI, left ventricular mass index; LVPWd, diastolic left ventricular posterior wall thickness. thickness, LV posterior wall thickness, left atrial (LA) dimensions, and LV EF (Table 2). The mean follow-up duration was 20.8 ± 17.3 months. In the AFL-alone group, atrial tachyarrhythmia recurred in 9 (34.6%) patients. AFL recurrence and new-onset AF were noted in 8 (30.8%) and 2 (7.5%) patients, respectively. In the mixed group, atrial arrhythmia was noted in 9 (90%) patients. AFL and AF recurrence was noted in 5 patients each (50% for both). Further, AFL and AF recurrence within 1 year was noted in 4 patients each (15.3% and 40%, respectively) (Table 3). In the subgroup analysis of the AFL-alone group, those who experienced recurrence had larger LA dimensions (42.24 ± 2.09 mm vs ± 2.24 mm, p=0.05) and a higher incidence of dyslipidemia (0% vs. 33.3%, p=0.01) than those who did not experience recurrence (Table 4). Concomitant AF at baseline, increased left atrial diameter, and dyslipidemia were significantly associated with the recurrence of atrial tachyarrhythmia. Discussion In the present study, atrial tachyarrhythmia was noted in 9 (34.6%) patients in the AFL-alone group, and atrial arrhythmia was noted in 9 (90%) patients in the mixed group. During the follow-up period, 8 The Official Journal of Korean Heart Rhythm Society

9 Table 3. Recurrence of atrial tachyarrhythmia in patients with typical atrial flutter alone (AFL alone group) and typical AFL with rarely documented paroxysmal atrial fibrillation episodes (mixed group) Total (n=36) AFL alone group (n=26) Mixed group (n=10) AFL recurrence 13 (36.1) 8 (30.8) 5 (50) AF recurrence 7 (19.4) 2 (7.5) 5 (50) Atrial tachyarrhythmia recurrence 18 (50) 9 (34.6) 9 (90) Atrial tachyarrhythmia within one year 8 (22.2) 4 (15.3) 4 (40) Original Articles recurrent AFL was noted in 30.8% and AF, in 7.5% of the patients in AFL-alone group. AFL ablation is very effective when a bidirectional block is achieved at the CTI. 15,16 The occurrence of AFL after successful CTI ablation in typical AFL patients has been reported to be approximately 30%. Moreover, spontaneous AF prior to CTI ablation and structural heart disease has been consistently associated with an increase in the recurrence of AF after the procedure. 17,18 Therefore, AFL ablation is traditionally considered more effective in patients with AFL alone. 19,20 Since the prior history of AF plays an important role in the prediction of early or late AF occurrence after AFL ablation, we analyzed the risk of AF during the follow-up period in patients with or without a prior history of rarely documented PAF after AFL ablation. Previous studies demonstrated that successful ablation of AFL decreased the AF recurrence in 50 75% of patients with a prior history of AF. 21 The underlying mechanism of the effects of AFL ablation on AF is still unknown. Some studies reported that AFL transformed into AF, which provides a basis for AF eradication after CTI ablation. 3,22,23 Thus, CTI ablation seemed to modify the atrial substrate for AF and changed the natural course of AF in patients with typical AFL. We further analyzed the risk of AF during the follow-up period in patients without a prior history of AF after the ablation of AFL alone. Subgroup analysis of the AFL-alone group showed that those who experienced recurrence had larger LA dimensions than those who did not experience recurrence. In a previous study, CTI ablation failed in only 3% of the patients, and atrial enlargement was the only predictor of unsuccessful ablation. A larger atrium has a wider isthmus, thus leading to a higher failure rate in these patients. 24,25 Therefore, if the patients with typical AFL were treated with CTI ablation before the LA dimension was not enlarged, the recurrence of atrial tachyarrhythmia might have reduced. The occurrence of AF is still a major problem after successful ablation of the CTI. Previous studies have reported that 12 26% of patients developed AF during the follow-up period after successful ablation of typical AFL. 9,10 The electrical isolation of the 4 PVs (pulmonary veins) in addition to CTI ablation in patients with mainly typical AFL with intermittent PAF episodes might reduce the recurrence of AF. Despite the important findings, our study has a few limitations that need to be acknowledged. It is difficult to estimate the incidence of AF in patients with typical AFL. Therefore, the incidence of prior AF may be underestimated. After ablation of AFL, we did not perform Holter monitoring or event Vol.15 No.3 9

10 Original Articles Table 4. Baseline characteristics of patients with AFL alone depending on the recurrence of atrial arrhythmia Recurrence group (n=17) Not recurrence group (n=9) P-value Echocardiography LVEDD (mm) 51.06± ± LVESD (mm) 33.24± ± LVEF (%) 57.88± ± LAD (mm) 48.22± ± Aorta diameter (mm) 36.59± ± IVSd (mm) 11.35± ± LVPWd (mm) 9.76± ± LAVI (ml/m 2 ) 41.47± ± LVMI (g/m 2 ) ± ± Associated diseases Hypertension DM CAD CHF Dyslipidemia Data are listed as median (minimum value-maximum value). The P value denotes statistical significance on comparing the recurrence group and non-recurrence group. *p<0.05 by Mann Whitney (continuous variables) and Chi-square or Fisher s exact test (categorical variables). CAD, coronary artery disease; CHF, congestive heart failure; DM, diabetes mellitus; IVSd, diastolic interventricular septum thickness; LAD, left atrial dimension; LAVI, left atrial volume index; LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; LVMI, left ventricular mass index; LVPWd, diastolic left ventricular posterior wall thickness. recording routinely to detect asymptomatic AF, and patients with asymptomatic recurrence of atrial arrhythmias may be lost to follow-up. Therefore, the incidence of recurrent AF or AFL may be underestimated. Because this was a retrospective study, we could not ensure a balance between genders. As a result, the number of women in the study population was very less (only 2), which could have led to a selection bias. And there was a limitation that ECG monitoring before ablation could not be adequate to detect short-run of AF. In conclusion, close, regular follow-up might be needed for patients with typical AFL after CTI ablation owing to a high recurrence of atrial tachyarrhythmia. In addition to CTI ablation, more aggressive treatment such as pulmonary vein isolation might be needed for patients presenting with mainly typical AFL and rarely documented PAF episodes. 10 The Official Journal of Korean Heart Rhythm Society

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Conduction block in the inferior vena cavaltricuspid valve isthmus: association with outcome of radiofrequency ablation of type I atrial flutter. J Am Coll Cardiol 1996; 28: Cauchemez B, Haissaguerre M, Fischer B, Thomas O, Clementy J, Coumel P. Electrophysiological effects of catheter ablation of inferior vena cava-tricuspid annulus isthmus in common atrial flutter. Circulation 1996; 93: Philippon F, Plumb VJ, Epstein AE, Kay GN. The risk of atrial fibrillation following radiofrequency catheter ablation of atrial flutter. Circulation 1995; 92: Paydak H, Kall JG, Burke MC, Rubenstein D, Kopp DE, Verdino RJ, Wilber DJ. Atrial fibrillation after radiofrequency ablation of type I atrial flutter: time to onset, determinants, and clinical course. Circulation 1998; 98: Luria DM, Hodge DO, Monahan KH, Haroldson JM, Shen WK, Asirvatham SJ, Hammill SC, Munger TM, Glikson M, Gersh BJ, Packer DL, Friedman PA. Effect of radiofrequency ablation of atrial flutter on the natural history of subsequent atrial arrhythmias. J Cardiovasc Electrophysiol 2008; 19: Natale A, Newby KH, Pisano E, Leonelli F, Fanelli R, Potenza D, Beheiry S, Tomassoni G. Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. J Am Coll Cardiol 2000; 35: Movsowitz C, Callans DJ, Schwartzman D, Gottlieb C, Marchlinski FE. The results of atrial flutter ablation in patients with and without a history of atrial fibrillation. Am J Cardiol 1996; 78: Kumagai K, Tojo H, Noguchi H, Yasuda T, Tamari H, Matsumoto N, Gondo N, Nakashima H, Saku K. Effects of cavotricuspid Original Articles Vol.15 No.3 11

12 Original Articles isthmus catheter ablation on paroxysmal atrial fibrillation. Jpn Heart J 2001; 42: Roithinger FX, Karch MR, Steiner PR, SippensGroenewegen A, Lesh MD. Relationship between atrial fibrillation and typical atrial flutter in humans: activation sequence changes during spontaneous conversion. Circulation 1997; 96: Ohba Y, Shimoike E, Ueda N, Maruyama T, Kaji Y, Fujino T, Niho Y. Influence of right atrial structure on outcome of radio-frequency catheter ablation for common atrial flutter. Jpn Circ J 2000; 64: Heidbuchel H, Willems R, van Rensburg H, Adams J, Ector H, Van de Werf F. Right atrial angiographic evaluation of the posterior isthmus: relevance for ablation of typical atrial flutter. Circulation 2000; 101: The Official Journal of Korean Heart Rhythm Society

13 Relationship between Genetic Polymorphisms of Angiotensin-Converting Enzyme and the Degree of Electroanatomical Remodeling of the Atrium in Patients with Non-valvular Atrial Fibrillation Original Articles 고려대학교의과대학의공학교실김숙경 / 연세대학교의과대학내과학교실박재형, 박용두, 박희남 Sook Kyoung Kim, PhD 1 ; Jae Hyung Park, PhD 2 ; Yong Doo Park, PhD 2 ; Hui-Nam Pak, MD, PhD, FHRS 2 1 Division of Biomedical Engineering, Korea University, Seoul Republic of Korea 2 Yonsei University Health System, Seoul, Republic of Korea Abstract Objectives: The renin-angiotensin system (RAS) has been known to be related to the fibrosis and structural remodeling of atrial fibrillation (AF). We hypothesized that the degrees of left atrial (LA) and left ventricular (LV) remodeling are associated with genetic polymorphisms of angiotensin-converting enzyme (ACE) in patients with non-valvular lone AF. Methods: Polymorphisms of the ACE gene were determined by direct DNA sequencing and their frequencies were compared with the LA volume, LA/LV ratio, and LA voltage in 351 patients with non-valvular lone AF (age: 54.2 ± 11.1 years, males: 80.3%). Results: 1. The frequency of genotypes differed significantly between the patients with an LA volume 125 ml and <125 ml. The F1129F C (p=0.024), P405P T (p=0.029), T-3927C T (p=0.029), and A-262T A alleles occurred more frequently in patients with an LA volume of 125 ml. 2. The F1129F C (p=0.013) and P405P T (p=0.026) alleles were more common in patients with a high LA/LV end-diastolic dimension (LVEDD) ratio ( 0.80) than in those with a low LA/LVEDD ratio (<0.80). 3. We observed a significantly higher frequency of the F1129F T and ACE D alleles in patients with a low LA voltage 0.7 mv (p=0.045) than in those with a high LA voltage. Conclusion: This study demonstrated the association between ACE polymorphisms and structural remodeling of the LA in patients with non-valvular AF. A genetic predisposition to specific ACE genotypes may predict LA remodeling and provide the basis for a therapeutic strategy. Key Words: atrial fibrillation angiotensin-converting enzyme genotype remodeling Introduction Received: July 9, 2014 Revision Received: Aug 26, 2014 Accepted: September 14, 2014 Correspondence: Hui-Nam Pak, MD, PhD, Yonsei University Health System 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea Tel: , Fax: hnpak@yuhs.ac Atrial fibrillation (AF) is the most common clinical arrhythmia. It is associated with cardiovascular morbidity and is related to increased disability. 1,2 Vol.15 No.3 13

14 Original Articles A B C D E Figure 1. 3D-spiral CT merged NavX electroanatomical voltage map of the LA (A and B) and apical 4 chamber views of echocardiography images (C and E) depending on the ACE allele (D) in patients with non-valvular AF. In patients with significant LA remodeling, the LA size is bigger, the LA voltage is lower (A), and the LA/LV end-diastolic dimension ratio is higher (C) than in patients with a less remodeled LA (B and E). In the NavX voltage map, the gray color indicates an endocardial voltage 0.2 mv and the purple color indicates a voltage >5 mv. The pathophysiology of AF is heterogeneous, 3 and long-standing AF is associated with changes in left atrial (LA) morphology. AF alters the electrophysiological properties of atrial myocytes and causes alterations in the structure of the atrial myocardium. 4,5 The longer the duration of AF, the more persistent it becomes due to atrial remodeling. Both electrical remodeling and structural remodeling beget AF, and an increase in AF burden leads to more vulnerable substrates. 6 The structural remodeling is related to interstitial fibrosis, downregulation of gap junctions, and enlargement of atrial chamber size (critical mass). 7,8 The degree of structural remodeling as measured by LA size affects the clinical outcome of rhythm control strategies in patients with AF. 9 LA scarring is also an independent predictor of procedure failure after radiofrequency catheter ablation (RFCA) of AF. 10 The renin-angiotensin system (RAS) is involved in many cardiovascular diseases, including myocardial fibrosis and hypertrophy, and AF is associated with activation of the RAS in the atria. 11 Angiotensinconverting enzyme (ACE) stimulates fibroblast proliferation, collagen synthesis, and atrial structural remodeling in patients with AF. 12 Ravn et al. 13 reported that the angiotensinogen (AGT) A-20C genotype in combination with the ACE I/D genotype predicts an increased risk of AF, but few studies 14 The Official Journal of Korean Heart Rhythm Society

15 Table 1. ACE gene polymorphisms analyses related to the degree of structural remodeling of the LA LA Volume 125 ml LA Volume <125 ml p-value ACE F1129F (CC+CT) 89.1% 74.5% ACE P405P (TT+TC) 88.9% 75.0% ACE C3927T (TT+TC) 88.8% 75.0% ACE A-262T (AA+AT) 89.1% 75.0% LA Voltage <0.7 mv LA Voltage 0.7 mv ACE F1129F (TT +CT) 77.8% 56.8% ACE I/D (DD+ID) 77.8% 56.8% LA/LVEDD 0.80 LA/LVEDD <0.80 ACE F1129F (CC+CT) 23.8% 8% ACE P405P C (TT+TC) 21.0% 7.8% Original Articles ACE, angiotensin-converting enzyme; LA, left atrial; LA/LVEDD, LA/LV end-diastolic dimension; LV, left ventricular. have searched for a genetic predisposition to LA structural remodeling in patients with AF. Therefore, we hypothesized that ACE polymorphisms are associated with the degree of atrial structural remodeling in patients with AF. We investigated the relationship between ACE polymorphism and LA volume measured by a 3D-spiral computed tomography (CT) scan or LA voltage calculated by 3D-electroanatomical mapping in Korean AF patients who underwent RFCA. Methods Patient Selection The study protocol was approved by the Institutional Review Board of our institute. All patients provided written informed consent. The study enrolled 351 patients with AF (male:female=282:69, mean age=54.2±11.1 years) who underwent RFCA. Among them, 235 patients had paroxysmal AF (PAF), and 116 had persistent AF (PeAF). The exclusion criteria were as follows: (1) permanent AF refractory to electrical cardioversion; (2) LA sizes >50 mm measured by echocardiogram; (3) AF with rheumatic valvular disease; (4) associated structural heart disease; (5) prior AF ablation; and (6) sinus rhythm not maintained for LA voltage mapping before RFCA. Patients with the presence of an LA thrombus were excluded by transesophageal echocardiography. We imaged all patients with a 3D-spiral CT (64 Channel, Light Speed Volume CT, Philips, Brilliance 63, Amsterdam, Netherlands) to visually characterize the anatomy of the LA and LVs. Transthoracic echocardiography was performed in all patients and the anterior-posterior (AP) diameter of the LA, left ventricular ejection fraction (LVEF), LV diastolic function measured by E/E, LV end-systolic dimension (LVESD), and LV diastolic dimension (LVEDD) were measured. Electrophysiological Mapping Intracardiac electrograms were recorded using a Prucka CardioLab TM Electrophysiology system (General Electric Health Care System Inc., Vol.15 No.3 15

16 Original Articles Milwaukee, WI, USA). For AF RFCA (n=351), we used 5 mapping catheters and a deflectable 3.5-mm, 7 Fr open irrigation tip ablation catheter (Celsius, Johnson & Johnson Inc., Diamond Bar, CA, USA). The catheter ablation procedures were performed using 3D electroanatomical mapping (NavX system, St. Jude Medical Inc., Minneapolis, MN, USA) in all patients. Before the catheter ablation, we generated an LA 3D electroanatomical map and voltage map by obtaining contact bipolar electrograms from approximately points throughout the LA endocardium of the high right atrium with pacing cycle lengths of 500 ms. The bipolar electrograms were filtered between Hz. Color-coded voltage maps were generated by recording bipolar electrograms and measuring the peak-to-peak voltage. Analyses of LA Remodeling: 3D-Spiral CT and Electroanatomical Voltage Map The 3D-spiral CT images of the LA were analyzed on an imaging processing workstation (Aquarius, Terarecon, Inc, Concord, MA, USA). The curvilinear lengths of the LA were measured at the following linear ablation sites: the bilateral antral ablation line, roof line, posterior inferior line, left lateral isthmus line, and anterior line. Each LA image was divided into the following parts according to embryological origin: the venous LA (posterior LA including the antrum and posterior wall), LA appendage (LAA), and anterior LA (excluding the LAA and venous LA). 14 We also measured the curvilinear lengths of circumferential pulmonary vein ablation, the roof line, posterior inferior line, anterior linear line, and left lateral isthmus line as described in a previous study. 15 We analyzed the color-coded LA electroanatomical voltage maps in the AP and posterior-anterior (PA) views. The low voltage areas 0.2 mv were coded with a gray area and the high voltage areas >5.0 mv were colored purple. The reference distance was measured by the inter-electrode distances of coronary sinus catheters (Duodecapolar Catheter, St. Jude Medical Inc. Minnetonka, MN, USA). The LA was divided into 4 quadrants in each of the views. To quantify the mean voltage of the LA, the percent area represented by each color was calculated using customized software (Image-Pro) with reference to a color scale bar. 15 Genetic Polymorphism Analyses We selected haplotype-tagging single nucleotide polymorphisms (SNPs) of the ACE gene using the HapMap Japanese (JPT) data bank ( hapmap.org) and NCBI SNP database ( ncbi.nlm.nih.gov/projects/snp/). To identify eligible tag SNPs in our population, we carried out a pilot study by genotyping for 16 selected SNPs in 48 Korean subjects. We identified 7 candidate SNPs (C-3927T, A-262T, P405P, T776A, ACE I/D, F1129F, and C2359). Genomic DNA was extracted from whole blood samples using a commercially available kit (Qiagen, Valencia, CA, USA). Genotyping for 6 of the SNPs was conducted by a single-base extension method using the SNaPShot Assay kit (Applied Biosystems, Foster City, CA, USA), and genotyping of the I/D polymorphism was performed with polymerase chain reaction as described previously. 16 Data Analyses We selected ACE variants that were related to the degree of structural remodeling, as indicated by the 16 The Official Journal of Korean Heart Rhythm Society

17 Table 2. ACE F1129F polymorphism and electroanatomical remodeling of LA in patients with AF Remodeling Parameter F1129F (TT) (n=65/351, 18.5%) F1129F (CC+CT) (n=286/351, 81.5%) F1129F (CC) (n=116/351, 33.0%) F1129F (TT+CT) (n=235/351, 67.0%) Age (years old) 53.4± ± ± ±10.8 Sex (male %) 89.2% 78.3% 82.1% 76.6% Original Articles BMI 24.6± ± ± ±7.1 Echocardiography LA size/bsa (mm) 19.7± ± ± ±7.9 LA/LVEDD 0.31± ± ± ±0.41 E/E (LV diastolic) 7.9± ± ± ±2.9 LVEF (%) 53.0± ± ± ±7.6 LVESD/BSA (mm/m 2 ) 14.7± ± ± ±4.7 LVEDD/BSA (mm/m 2 ) 23.6± ± ± ±6.6 CT Volume/BSA (ml/m 2 ) Mean LA volume/bsa (ml/m 2 ) 57.4± ±27.3* 74.6± ±25.8 Anterior LA/BSA (ml/m 2 ) 33.0± ±19.1* 44.8± ±17.7 Venous atrium/bsa (ml/m 2 ) 18.7± ± ± ±8.1 LA appendage/bsa (ml/m 2 ) 5.8± ± ± ±2.8 CT Length/BSA (mm/m 2 ) Rt. antral circumference/bsa (mm/m 2 ) 47.3± ±9.5* 54.4± ±10.5 Lt. antral circumference/bsa (mm/m 2 ) 48.4± ± ± ±12.6 Roof/BSA (mm/m 2 ) 13.5± ± ± ±4.6 Posterior inferior line/bsa (mm/m 2 ) 19.2± ± ± ±4.6 Anteroseptal line/bsa (mm/m 2 ) 24.1± ± ± ±6.6 Anterolateral line/bsa (mm/m 2 ) 23.1± ± ± ±5.6 Left lateral isthmus line /BSA (mm/m 2 ) 16.7± ±4.0* 20.9± ±4.4 AF voltage (mv) Mean LA voltage 0.73± ± ± ±0.29 Anterior LA voltage 0.65± ± ± ±0.24 Venous LA Voltage 0.68± ± ± ±0.40 LAA 1.35± ± ± ±0.96 *, p<0.01 vs. ACE F1129F (CC);, p<0.05 vs. ACE F1129F (CC);, p<0.05 vs. ACE F1129F (TT) ACE, angiotensin-converting enzyme; AF, atrial fibrillation; BMI, body mass index; BSA, body surface area; CT, computed tomography; LA, left atrial; LAA, LA appendage; LV, left ventricular; LVEDD, LA/LV end-diastolic dimension; LVEF, left ventricular ejection fraction; LVESD, LV end-systolic dimension. Vol.15 No.3 17

18 Original Articles entire LA volume, regional LA volume, regional curvilinear LA lengths, mean and regional LA voltage, and the LA/LVEDD ratio measured by echocardiography. Statistical analyses were performed using the SPSS statistical package release (SPSS, Inc., Chicago, IL, USA). Data were expressed as means ± standard deviations (SDs). Between-group data for baseline characteristics were compared with the Student s unpaired t-test for continuous data and the χ 2 test for categorical data. For statistical analyses, we defined the cutoff as the median rounded to 0.1 decimal places and validated it by a receiver-operating characteristic (ROC) curve analysis. All genotype frequencies were in Hardy-Weinberg equilibrium (HWE) (p>0.05). HWE of the genotype frequencies was evaluated using a χ 2 test. In single-locus analyses, we first compared the allele and genotype frequencies between the cases and controls with the χ 2 test or Fisher s exact test. Statistical significance was defined as p<0.05. Results ACE Variants Associated with LA Structural Remodeling in Patients with AF Figure 1 shows representative examples of highly remodeled (Figures 1A and 1C) and less remodeled LAs (Figures 1B and 1E) in patients with AF, and their ACE genotypes (Figure 1D). The patients with significant electroanatomical remodeling of the LA show an enlarged LA volume, a low endocardial voltage (Figure 1A), and a high LA/LVEDD ratio (Figure 1C). In contrast, the patients with a less remodeled LA had a relatively small LA volume with a high endocardial voltage (Figure 1B) and a low LA/ LVEDD ratio (Figure 1E). Among the 7 SNPs evaluated, 5 polymorphisms of the ACE gene were associated with structural remodeling of LA in the 351 patients with nonfamilial non-valvular AF. Table 1 summarizes the relationships between the ACE variants and the degree of structural remodeling of the LA. The F1129F C (p=0.024), P405P T (p=0.030), T-3927C T (p=0.030), and A-262T A (p=0.027) ACE alleles were associated with an enlargement of LA volume. LA enlargement relative to LV size (LA/LVEDD) measured by echocardiography was significantly higher in patients with the ACE F1129F C allele (p=0.039) and the P405P T allele (p=0.026) than in other patients. The ACE F1129F T allele (p=0.021) and ACE D carriers (DD+ID) allele (p=0.021) were the predominant genotypes in patients with low mean LA voltage. ACE Variants Related to LA Structural Remodeling Measured by LA Volume Table 2 summarizes the segmental volume and segmental curvilinear length of the LA adjusted for body surface area (BSA) with respect to the F1129F genotype. We also compared the mean and regional LA voltage and echocardiography parameters. Generally, patients with the F1129F C allele had larger total and regional LA volumes (p<0.01) and longer regional curvilinear lengths of the LA (p<0.05) than those with the F1129F TT genotype. In contrast, patients with the F1129F T allele had a lower LA voltage than those with the F1129F CC genotype (p<0.05). The characteristics of LA remodeling in patients with the ACE P405P allele, T-3927 T allele, and A-262T allele are listed in Table The Official Journal of Korean Heart Rhythm Society

19 Table 3. Other ACE polymorphisms and electroanatomical remodeling of LA in patients with AF Remodeling Parameter F1129F (TT) (n=65/351, 18.5%) F1129F (CC+CT) (n=286/351, 81.5%) F1129F (CC) (n=116/351, 33.0%) F1129F (TT+CT) (n=235/351, 67.0%) ACE A-262T (TT) (n=64/351, 18.2%) ACE A-262T (AA+AT) (n=287/351, 81.8%) Original Articles Age (years old) 53.5± ± ± ± ± ±11.3 Sex (male %) 86.6% 78.9% 80.9% 80.2% 82.8% 79.8% BMI 23.7± ± ± ± ± ±6.0 Echocardiography LA size/bsa (mm) 20.0± ± ± ± ± ±6.7 LA/LVEDD 0.27± ± ± ± ± ±0.42 E/E (LV diastolic) 7.1± ± ± ± ± ±3.2 LVEF (%) 51.7± ±6.2* 52.3± ±6.3* 52.2± ±6.2* LVESD/BSA (mm/m 2 ) 14.1± ± ± ± ± ±4.6 LVEDD/BSA (mm/m 2 ) 22.6± ± ± ±6.2* 22.5± ±6.1 CT Volume/BSA (ml/m 2 ) Mean LA volume/bsa (ml/m 2 ) 59.0± ± ± ± ± ±27.5 Anterior LA/BSA (ml/m 2 ) 34.0± ± ± ± ± ±19.1 Venous atrium/bsa (ml/m 2 ) 19.2± ± ± ± ± ±9.1 LA appendage/bsa (ml/m 2 ) 5.9± ± ± ± ± ±3.0 CT Length/BSA (mm/m 2 ) Rt. antral circumference/bsa (mm/m 2 ) 47.9± ±9.7* 47.7± ±9.7* 48.2± ±9.8 Lt. antral circumference/bsa (mm/m 2 ) 49.8± ± ± ± ± ±10.4 Roof/BSA (mm/m 2 ) 13.3± ± ± ± ± ±4.1 Posterior inferior line/bsa (mm/m 2 ) 18.8± ± ± ± ± ±4.2* Anteroseptal line/bsa (mm/m 2 ) 24.7± ± ± ± ± ±6.8 Anterolateral line/bsa (mm/m 2 ) 22.8± ± ± ±5* 22.1± ±5.0* Left lateral isthmus line /BSA (mm/m 2 ) 16.8± ±4.0* 16.8± ±4.0* 16.8± ±4.0* AF voltage (mv) Mean LA voltage 0.68± ± ± ± ± ±0.30 Anterior LA voltage 0.63± ± ± ± ± ±0.24 Venous LA Voltage 0.64± ± ± ± ± ±0.41 LAA 1.20± ± ± ± ± ±0.99 *, p<0.01 vs. composite genotype;, p<0.05 vs. composite genotype ACE, angiotensin-converting enzyme; AF, atrial fibrillation; BMI, body mass index; BSA, body surface area; CT, computed tomography; LA, left atrial; LAA, LA appendage; LV, left ventricular; LVEDD, LA/LV end-diastolic dimension; LVEF, left ventricular ejection fraction; LVESD, LV end-systolic dimension. Vol.15 No.3 19

20 Original Articles ACE Variants and Clinical Outcomes after Catheter Ablation of AF The clinical recurrence rate of AF after a 3-month blanking period was 20.45% during the 28.29±5.83 month follow-up. We did not find ACE-related polymorphisms associated with long-term clinical recurrence after catheter ablation. However, the ACE F1129F T allele, which was related to a low endocardial LA voltage, was associated with a higher early recurrence rate (within 3 months) (44.9%) after RFCA than the ACE F1129F CC genotype (27.5%, p=0.0217). Discussion This study demonstrated the association between ACE polymorphisms and structural remodeling of the LA measured by LA volume and endocardial voltage. ACE polymorphism also affected early recurrence after catheter ablation of AF. A genetic predisposition of specific ACE genotypes predicts atrial remodeling and may provide the basis for a treatment strategy. The Mechanisms of Electroanatomical Remodeling of AF AF begets AF. Wijffels et al. 6 reported that the higher the AF burden, the more persistent it becomes owing to atrial remodeling. There are two kinds of atrial remodeling. Electrical remodeling is a process of ion channel adaptation to tachyarrhythmia, 4,6 and structural remodeling is the change in LA volume, voltage, and conduction velocity by matrix remodeling. 15,17 The former is reversible by maintaining a sinus rhythm, while the latter is irreversible. 18 Because structural remodeling changes the morphology and endocardial voltage of the atrium, clinicians call it electroanatomical remodeling. Electroanatomical remodeling is provoked by mechanical stretch-related extracellular matrix genes. 19,20 Profibrotic signals including angiotensin II, 21 TGF-β, 22 platelet-derived growth factor (PDGF), 23 or connective tissue growth factor (CTGF) 24 are known to proceed extracellular matrix remodeling. Those profibrotic signals also induce the proliferation of myofibroblasts. 25 Myofibroblasts contribute to collagen deposition with apoptosis or necrosis of cardiomyocytes, 20 electroanatomical remodeling, 15,17 and the non-reentrant mechanism of AF by automaticity. 20,26 Recently, we reported a higher LA volume, slower conduction velocity, lower endocardial voltage, and poorer clinical outcome after catheter ablation in patients with significant electroanatomical remodeling than those with a less remodeled LA. 15,17 However, there are individual differences in the degree and rate of electroanatomical remodeling of the LA in patients with AF. Therefore, we determined the ACE polymorphisms related to angiotensin II, one of the profibrotic signals, and their association with the degree of electroanatomical remodeling of AF. Genetic Polymorphisms of Renin-Angiotensin System and Matrix Remodeling The RAS is involved in many cardiovascular diseases, including heart failure and myocardial infarction related to oxidative stress, inflammation, or mechanical overload. 27,28 The ACE D allele (DD+ID) is more common in patients with significant LV remodeling after myocardial infarction. 29,30 The ACE DD genotype and the AT1R A1166C (AC+CC) genotype are associated with the LV mass index and diastolic heart failure. 31 However, genetic studies of 20 The Official Journal of Korean Heart Rhythm Society

21 the RAS related to AF or atrial remodeling are limited. Recently, Tsai et al. 32 reported that the ACE I/D polymorphism and several variants in the angiotensinogen and angiotensin II type I receptor are associated with nonfamilial structural AF. Watanabe et al. 33 reported that the ACE D allele is associated with a longer PR interval in patients with lone AF. In this study, we reported several ACE polymorphisms associated with electroanatomical remodeling of the LA in patients with AF. Specifically, it was associated with LA enlargement, reduced endocardial voltage, and early recurrence after catheter ablation. These ACE polymorphisms might be useful for the detection of patients with AF who are susceptible to structural remodeling. Although we found an association of these genes with LA remodeling, they were not significantly associated with LV size or LV systolic and diastolic function in this highly selected and relatively homogeneous patient group with non-valvular AF. selected group referred for rhythm control, and the number of patients was limited. The exclusion of patients with large atria (greater than 50 mm) may influence the results and clinical outcomes. Because we acquired voltage maps by point-by-point contact mapping, they did not reflect a spatiotemporally homogeneous distribution. We analyzed 3D voltage maps using 2D measurements. Conclusion We demonstrated the association between ACE polymorphisms and structural remodeling of the LA as measured by LA volume and endocardial voltage. Individuals with specific ACE genotypes are predisposed to atrial remodeling and these genotypes may provide the foundation for a therapeutic strategy. Acknowledgements Original Articles Clinical Implications ACE polymorphisms associated with electroanatomical remodeling of the LA might be useful for the early detection of susceptible patients and prevention of the progression to chronic permanent AF with electroanatomical remodeling. Upstream therapy with an ACE inhibitor or angiotensin II receptor blocker prevents LA remodeling and is used as a tailored management. 34,35 Those variants also may justify the early intervention with catheter ablation and improve the prognostic value and clinical outcome. This work was supported by grants from the Korea Health 21 R&D Project, the Ministry of Health and Welfare (A085136) and the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (MSIP; ). Conflicts of Interest The authors have no conflict of interest disclosures. References Study Limitations The patients included in this study were a highly 1. van den Berg MP, van Gelder IC, van Veldhuisen DJ. Impact of atrial fibrillation on mortality in patients with chronic heart failure. Eur J Heart Fail. 2002;4: Khairy P, Nattel S. New insights into the mechanisms and Vol.15 No.3 21

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24 Main Topic Reviews 우리나라의영구심박동기과거와현재 가톨릭대학교의과대학내과학교실노태호 Tai Ho Rho, MD Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Abstract In the 1960s, modern pacemakers were first used to treat bradycardia in the Western world. In Korea, the first pacemaker was implanted by a doctor from Norway in a 17-year-old girl who exhibited asystole. Seo Jungsam, Kim Samsoo, and Kim Chongseol are the first Korean doctors to have implanted permanent pacemakers in Korea. In 1975, Park reported 17 cases of temporary and permanent pacemaker and anesthesia in the Korea Anesthesia Journal; his report was the first official report of such cases. By 1982, Kim implanted 44 permanent pacemakers. Permanent pacemakers were widely used in Korea in the early 1980s. In 2012, 3,484 permanent pacemakers were implanted in Korea; this number includes the number of replacements. The number of new implants per million population was 53, which is a very small number as compared with that in the Western and other Asian nations. Further, AV blocks account for 56% of all implantations, while DDD (dual chamber pacing, dual chamber sensing, dual function) and DDDR (dual chamber rate-responsive) account for 67% of all implantations. In Korea, 127 medical institutions have facilities for pacemaker implantation. The average number of pacemaker implantations per institution is Key Words: pacemaker bradycardia Korea 서론 영구심박동기가현재의모습을갖추고서맥성부정맥환자에게도움을주기시작한것은서양에서도 1960 년대에들어서이며, 우리나라도그리늦지않다. Received: June 9, 2014 Accepted: September 14, 2014 Correspondence: Tai Ho Rho, MD, Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul , Korea Tel: , Fax: tairho@catholic.ac.kr 초창기우리나라의영구심박동기시술은기록이남아있지는않지만여러증언에의하면 1960년스칸디나비아의료원에서한외국의사와김종설이최초로시술한것으로알려져있다. 순수한우리의료진에의한시술은서정삼, 김삼수등이시술한것이기록으로남아있다. 그이후커다란발전을거듭해 2012년총 3,484례의영구심박동기가우리나라에서시술되었고, 2013년에는 4,000례를돌파한것으로보인다. 그러나이러한양적확대에도불구하고우리나라의영구심박동기시술건수는서구는물론다른아시아국가에비해서도설명이어려울정도로매우적은편이다. 24 The Official Journal of Korean Heart Rhythm Society

25 심장전기자극의초기연구 이미 18 세기중반유럽의선배의학자들은인간을 포함한생체에서발생하는전기현상에대해연구하고 있었다. 이탈리아의사인 Galvani 는해부용칼로죽은 개구리의다리신경을건드리는순간다리근육이 수축하며구부러지는것을관찰하여생명과전기 현상과의관련성을발견하게되었고이것이결국현재 전기생리학 (electrophysiology) 의시초가되었다 년 McWilliam 은 British Medical Journal 에 "Electrical Stimulation of the Heart" 라는논문을발표하였는데 미주신경을자극하여조성한무수축 (asystole) 상태에서심실을전기적으로자극하면심실수축이 발생한다는사실을보여주었다. 2 동시대의 Einthoven ( ) 은엄청난크기의심전도기계를 발명하였으며, 심전도를통해심장의전기현상을 직접적으로기록할수있게되었다 년호주의 Mark Lidwell 은교류전류를이용하여바늘의한쪽은 피부에다른한쪽은심장에넣어심장을자극하는 방법을개발했고, 이를이용하여사산아의심장을 10 분간자극하여구조한기록이남아있다. 3 이를최초의 임시박동기로인정하고있다 년에는미국의 생리학자인 Albert Hyman 이수동으로구동하는전기 기계적도구를고안, 제작하여처음 인공심박동기 (artificial pacemaker)' 란이름을붙였으며, 심장이 정지하면우심방에바늘전극을넣고자극하면 심박동이회복할수있다는주장을하며이를 상품화시켰다. 4 현시점의의학관점에서보면 황당하고비과학적인면이있지만당시우리의선배 의사들은이를믿었다. 심박동기의발달 - 경피적심장조율 (external pacing) 심박동기가현재의모습을갖추기시작한것은 1950 년대에들어서이다. 그이전에는심장안으로전극을 집어넣고자극하는것이기술적으로어렵고위험성이 있어다른방법을모색하게되었다. 그결과피부를 통한자극방법을개발하게되었는데, 엔지니어인 John Hopps 와흉부외과의사 WG Bigelow 그룹과 PM Zoll 이여기에공헌하였다. 5 Hopps 와 Bigelow 는 캐나다의토론토병원에서 1950 년경피적심장자극용 심박동기를개발하고같은해외과학회에서발표하여 심박동기에 토론토기계 (Toronto machine)' 란별명을 얻게되는영예를누렸다. 그러나감전과심실세동 유발의위험성으로크게사용되지는못하였다. Zoll 은 직후인 1952 년에완전방실차단으로심정지가생기는 환자에서경피적심장자극을 52 시간지속했다는 기록을남기고있다. Hopps 는캐나다의국립연구소인 NRC 에서관련된여러연구를했으며, 외부자극 외에도개심수술에서사용하는제세동기의초기 모델을개발하는등심박동기개발에있어커다란 역할을하였다. 심박동기의발달 - 심외막조율 (epicardial pacing) 1950 년대에는심장수술이발전하며심장수술과 함께심장표면을전기적으로자극하는심외막조율이 가능해졌다. 그러나이당시심박동기는크기가커서 이동이어려웠고더구나자체전원이없어벽에붙어 있는전원을이용할수밖에없었다. 이시점에 심박동기의역사에큰흐름을바꾸는사건이 발생하였다 년 10 월 31 일흉부외과의사 Walton Lillehei 가수술한선천성심장병어린아이에게불행한 일이발생하였다. 이아이는수술후임시박동기에 의존하고있었는데, 도시에정전사태가발생해 박동기가작동하지못하였고, 아이는결국사망하게 되었다. 6 이사건이계기가되어 Lillehei 는엔지니어 Earl Bakken 에게부탁해배터리로작동하고 트랜지스터를사용하는임시박동기를개발하게 되었는데, 그크기나모양은현재의임시박동기와 유사할정도이다. 심박동기의발달 - 수술을통한이식형심박동기 (implantable pacemaker) Main Topic Reviews Vol.15 No.3 25

26 Main Topic Reviews 1958 년스웨덴 Karolinska 연구소에서최초의 이식형심박동기가개발되었다. 엔지니어 Rune Elmqvist 와외과의사 Ake Senning 은개흉술을통해 심외막에완전이식형영구심박동기를시술하였다. 그러나최초의이식형심박동기는 3 시간밖에지속되지 못하였다. 세계에서최초로영구심박동기를시술받은 사람은 Arne Larsson 이라는사업가인데, 평생 26 개의 영구심박동기를시술받았으며, 2001 년에 86 세의 나이로사망하였다. 최초로이수술을집도했던 Senning 과개발자인 Elmqvist 는 Larsson 보다먼저 세상을떠났다. 7 심박동기의발달 - 경정맥이식형심박동기 (transvenous implantable pacemaker) 1959 년에는 Seymour Furman 과 John Schwedel 이 정맥을통한임시박동기를선보였고, 8 여기에힘입어 1960 년우르과이의 Fiandra 와 Rubio 가경정맥이식형 심박동기를삽입수술하였다는기록이있다. 그이후 1962 년에서 1963 년에걸쳐미국의 Parsonnet, 스웨덴의 Lagergren, 프랑스의 Welti 등이이방법을 이용하여영구심박동기를시술하였다고한다. 9 전극을 방사선투시하에정맥을통해우심실첨에위치시키는 현재의방식이정립된것이바로이시점이다. 또 기계적발전도크게이루어졌는데, 엔지니어 Wilson Greatbatch 가심박동기에수은전지를사용해수명을 대폭증가시키게되었다. 그이후심박동기의발달 현재와거의같은영구심박동기가개발되어사용된 것은 1960 년대이후이며, 그이후에도기술적발달은 지속되었다. 단실 (single chamber) 에서양실 (dual chamber) 로, 조율반응성 (rate response) 의도입, MVP (managed ventricular pacing) 기능의도입, MR (magnetic resonance) 저항성심박동기등이다. 거기에더해최근에는유도가필요없는 (leadless) 심박동기에이르게되었다. 우리나라의영구심박동기역사 우리나라는당시의학을주도했던유럽과교류가전무한상태였고, 의학서적은 1620 년허준의동의보감정도가전해진다. 여기에부정맥과연관이있는맥의기술이있다. 즉, 맥이빠르고때때로한번멈추고다시뛴다는促 ( 촉맥 ), 맥이느리고때때로한번멈추고다시뛴다는結 ( 결맥 ), 맥이멈추고는한참만에다시뛴다는代 ( 대맥 ) 정도의기술이다. 불행히도우리나라첫번째영구심박동기삽입술은기록이남아있지않다. 김종설에의하면 1960년국립중앙의료원의전신인스칸디나비아의료원에서한노르웨이의사와김종설이무수축 (asystole) 을보인 17세여성환자를개흉하여심외막에초기의영구심박동기를시술하였다고한다. 이환자의경우 1년반이후유도선 (lead) 에문제가생겨재수술을하게되었는데, 서울대학교병원에서이름이확인되지않은미군군의관에의해경정맥영구심박동기시술을받았다고전해진다. 그이후공식적인기록으로확인이가능한것은세브란스병원서정삼, 성모병원김삼수, 예수병원 Dr. Chu 이다 년박육등이대한마취과학회지에발표한논문에서 1968 년부터 1975 년에걸쳐 17례의심박동기시술과관련한마취사례를보고하였다 례에서영구형과임시형을구분하지않고있어파악이어려우나사례를읽어보면대부분은임시형이고, 일부가영구형으로생각되며, 1969년에처음영구심박동기를시술했다고한다 (Figure 1). 1975년중앙일보보도에서김삼수가아담스스톡스증후군 (Adams Stokes syndrome) 을보인 16세소녀에게영구심박동기를시술한이야기가보도되었다 (Figure 2). 11 이후에 1975 년부터 1981 년까지김삼수는 44례의영구심박동기시술을했다는보도가발표되었다. 그리고 1983년예수병원의 Dr. 추가 5례의영구심박동기를시술한보고가있다 (Figure 3). 12 저자가심장의사초년시절인 1983 년심장학회장에서영구심박동기와관련하여김삼수와이웅구간에날카로운토론이있었던것을기억하는데, 이를보면당시에우리나라에도영구심박동기가서맥치료로서완전히 26 The Official Journal of Korean Heart Rhythm Society

27 Main Topic Reviews Figure 1. "Cardiac pacemaker and Anesthesia, the first official report on pacemaker implantation in Korea by Park and Oh, published in Figure 2. Newspaper report of permanent pacemaker implantation in 1975 performed by Kim in a 17-year-old girl with Adams- Stokes syndrome. 자리를잡고있었던것으로생각된다. 참고로가톨릭의대성바오로병원의경우 1980 년 14례, 1981 년 8 례, 1982 년 13례, 1983 년 20례, 1984 년 29례, 1985 년 20 례의영구심박동기시술이시행된기록이있으며, 연세대학교세브란스병원의경우 1983 년에 6례, 1984 년에 22례, 1985 년에 33례의영구심박동기를시행한기록이남아있다. 전남대의경우 1983 년 5례, 1984 년 6 례, 1985 년 7례의시술이있었다고한다. 이로미루어볼때우리나라에서영구심박동기가광범위하게사용되기시작한것은 1970 년대후반에서 1980 년대초반으로생각된다. 우리나라의영구심박동기현황 - 시술수 우리나라의영구심박동기현황을추적하고있는필자의자료에의하면 2000 년전체삽입숫자는 1,120 건으로매년 10% 이상성장하고있다 년연간총 3,484 례의영구심박동기가우리나라에서시술되었고, 2013 년최종집계가되지는않았으나 4,000 례를돌파한것으로보인다. 총시술수의 20-25% 는교체에해당한다 년 3,484 건중 837 건이교체이다 (Figure 4) 년부터 2012 년까지영구심박동기시술수를국제적비교기준인인구 100만명당시술수로나타낸다면, 2000년 19.3건에서 2012년 53.1건으로증가세는현저하다. 국제적인비교를발표하고있는 World Registry 는 5년에한번발표가되고있어최근의데이터는 2009 년데이터이다. 이자료에의하면아시아국가들의영구심박동기시술수가서양의여러나라에비해절반도되지못할정도로적은데, 일본이 272 건, 타이완이 172건, 홍콩이 124건, 싱가포르가 94건, 우리가 42건정도이다. Vol.15 No.3 27

28 Main Topic Reviews 높은대부분의나라에서는방실차단보다동기능장애로심박동기를시술하는경우가많다. 2009년 World Registry에의하면방실차단이차지하는비율이우리나라 58%, 일본 46%, 싱가폴 39%, 타이완 36%, 벨기에 23% 로우리나라는방실차단이차지하는비율이월등하게높은것을알수있다. 방실차단은진단이쉽고영구심박동기결정이단순하지만동기능장애는상대적으로진단이어렵기도하며, 심박동기시술이생명보다는증상호전에목적이있어삶의질을중시하는나라에서시술이많은데, 그런면에서아직우리사회는모자란면이있다. 우리나라의영구심박동기현황 - 심박동기모드 Figure 3. "Five Cases of Sick Sinus Syndrome and Implantation of Pacemaker, an article by Dr. Chu, et al. published in the Korean Circulation Journal in 우리나라의영구심박동기현황 - 시술기관수 저자가자료를수집하기시작한 2000 년에 우리나라에서영구심박동기를시술하는기관의수는 69 개였는데, 2012 년에는 127 개로늘었다 년한 기관당평균영구심박동기시술수는 28.9 건이었다 년한해에 201 례이상시술한기관은 1 개, 례를시술한기관은 6 개, 례를시술한기관은 12 개, 례를시술한기관은 61 개, 2-10 례를시술한 기관수는 38 개, 단 1 례를시술한기관은 9 개였다. 우리나라의영구심박동기현황 - 적응증 역사적으로심박동기의기술적발달은우심실만인식, 자극하는심실감지자극형 (ventricle pacing, ventricle sensing, inhibited by ventricle event, VVI) 에서심방과심실을모두인식, 자극하는방실동시감지자극형 (dual chamber pacing, dual chamber sensing, dual function, DDD) 으로발달했고, 이어 R 모드가도입되는단계를밟아왔다. 그결과심박동기시술이많은나라일수록 DDD(R) 를많이사용한다. 우리나라의경우심박동기모드는선진국형이다 년 DDDR 이 40% 를차지하고 DDD 가 27% 로거의 70% 가심방심실순차형 (AV synchrony) 을유지하는박동기이다. 반면 VVI는 2000 년 24% 를차지했으나 2012 년에는 10% 수준으로감소하였다 년 World Registry 에의하면우리나라는 DDD 와 DDDR 이전체의 60% 를차지하는데비해미국은 80%, 벨기에는 78% 로우리나라보다높지만타이완 62%, 일본 51% 를보면아시아에서는선진국형이라고할수있다. 우리나라의영구심박동기현황 - 성별 가장최근의자료인 2012 년교체가아닌신환에서 영구심박동기적응증을보면 56% 가방실차단으로 동기능장애를압도한다. 전세계적으로국민소득이 일반적으로심장을침범하는질환은남성에많다. 부정맥도다르지않고영구심박동기시술역시 남성에서더많이이루어진다. 세계적으로비슷한 28 The Official Journal of Korean Heart Rhythm Society

29 Pacemaker - New & Replace, Main Topic Reviews Figure 4. Pacemaker trend in Korea in the last 13 years. 현상이다. 그러나우리나라는다르다. 영구심박동기를시술받는환자중여성이 50% 이상을차지하는나라는극히드문데 60% 를여성이차지하는나라는우리가유일하다 년 World Registry 에의하면우리나라는 61% 가여성인데비해일본 47%, 뉴질랜드 46%, 이탈리아 46% 정도이다. 그이유를설명하는것은불가능하다. 우리나라의영구심박동기시술의평균연령은다른나라에비해상대적으로매우낮은편이다. 한예로 2009 년 World Registry 에의하면 80세이상의비율이우리나라는 16% 에비해덴마크는 40%, 홍콩은 36%, 싱가포르는 26% 로매우높다. 결론 우리나라의영구심박동기현황 - 평균연령 2012 년우리나라에서영구심박동기시술을받은환자의평균연령은 68.8 세 ( 남성 67.8 세, 여성 69.5 세 ) 로서 2008 년의 65.7 세에비해증가하고있다. 이런증가현상은상당기간지속될것으로생각된다 년에서 2012년에걸친최근 5년간의변화를보면 2008년 세구간이전체의 10% 를차지하던것이 5년후 2012 년에는 15% 를차지할만큼증가하고있다. 그러나 우리나라의영구심박동기시술을요약한다면몇가지특징을들수있다. 우선시술이지속적으로증가하고는있으나서양은물론다른아시아국가와비교하면시술률은매우낮은편이다. 또상대적으로젊은연령층에서시술이이뤄지고있으며, 특징적으로여성의시술이남성보다높다. 영구심박동기를시술하는의료기관의수는좁은국토를감안할때충분하다고판단할수있고, 전체적인시술수가적기도하지만한기관당시술수도적은편이다. 심박동기의 Vol.15 No.3 29

30 Main Topic Reviews 적응증중에선진국형인동기능장애로인한시술이상대적으로적은점, 그러나심방, 심실을조율하는 DDD/DDDR의사용은높은점등이특징적이다. 우리나라의영구심박동기시술이적은데에는여러가지이유가있겠지만몇가지설명을빼놓을수없다. 즉, 까다로운보험심사의문제점, 시술에대해상대적으로소극적인의사의태도, 고령층유교문화의특성, 서맥의증상을노화로만인식하는질병인식의문제점, 상대적으로적은노령인구층, 확실하지는않으나낮은전도장애의유병률을들수있다. References 1. Marco B. Medicine and science in the life of Luigi Galvani. Brain Res Bull. 1998;46: McWilliam JA. Electrical stimulation of the heart in man. Br Med J. 1899;1: Lidwell MC. Cardiac Disease in Relation to Anaesthesia. in Transactions of the Third Session, Australasian Medical Congress, Sydney, Australia, Sept. 2 7, 1929, p Furman S, Szarka G, Layvand D. Reconstruction of Hyman's second pacemaker. Pacing Clin Electrophysiol. 2005;28: Zoll PM, Linenthal AJ, Norman LR, Paul MH, Gibson W. Treatment of unexpected cardiac arrest by external electric stimulation of the heart. N Engl J Med. 1956;254: Weirich W, Gott V, Lillehei C. The treatment of complete heart block by the combined use of a myocardial electrode and an artificial pacemaker. Surg Forum. 1957;8: Lawrence A. Arne H. W. Larsson, 86; Had First Internal Pacemaker. New York Times. 18 Jan Furman S, Schwedel JB. An intracardiac pacemaker for Stokes- Adams seizures. N Engl J Med. 1959;261: Parsonnet V, Zucker IR, Gilbert L, Asa MM. An intracardiac bipolar electrode for interim treatment of complete heart block. Am J Cardiol. 1962;10: 박육, 오홍근. 심장박동기와마취. 대한마취과학회지. 1975;8: 심장박동기이식수술받아. 중앙일보. 1975년 1월 17일. 12. 윤석희, 신대균, 김민철외. Sick-Sinus 증후군에대한인공심박동기의임상적경험. 순환기. 1983;2: The Official Journal of Korean Heart Rhythm Society

31 서맥성부정맥에서박동기치료의적응증 Main Topic Reviews 가톨릭대학교의과대학내과학교실오용석 Yong-Seog Oh MD, PhD Director of Electrophysiology, Division of Cardiovascular Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea Abstract Cardiac pacing is an essential therapy in bradyarrhythmia, and it has improved the survival and quality of life in patients with bradyarrhythmia. The indications for cardiac pacing in patients with bradyarrhythmia were noted in the ACC/AHA/HRS 2008 and ESC 2013 guidelines for device-based therapy of cardiac rhythm abnormalities. Key Words: cardiac pacing bradyarrhythmia guidelines 서론 영구형심박동기의삽입에관한임상지침은 2008 년 ACC/AHA/HRS 에서제정하고배포한지침이가장널리알려져있고, 년에일부개정되었다. 2 유럽심장학회에서도 2013년에 ESC guideline을발표하였다. 3 그내용이서로대동소이하므로여기서는 ACC/AHA/HRS 지침을기준으로기술하고자한다. 권고수준 (class) 과증거수준 (level of evidence, LOE) 은여러임상지침을통해제시된바와같다. 동기능부전 (sinus node dysfunction) 에서영구형심박동기삽입의적응증 동기능부전에서영구형심박동기삽입의가장중요한결정인자는증상의유무이다. 증상은서맥으로인한어지러움이나실신등을말한다. 또한증상과서맥또는동휴지 (sinus pause) 의관련성을입증하는것이필요하다. 임상적으로증상과연관된서맥을입증하기어려운경우가많은데, 이런경우각성상태에서심박수가분당 40회미만인경우동기능부전증후군을의심해볼수있다. 반면, 무증상의서맥의경우에는 class III 로심박동기삽입의적응증이되지않는다. Received: May 28, 2014 Accepted: September 14, 2014 Correspondence: Yong-Seog Oh, MD, PhD, Direc tor of Electrophysiology, Division of Cardiovascular Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, 505 Banpo-Dong, Seocho-Ku, Seoul, , Republic of Korea Tel: , fax: oys@catholic.ac.kr 1. Class I 가 ) 증상을동반한서맥이나증상을동반한동휴지가입증된경우 (LOE C) 나 ) 증상을동반한심박수변동부전 (chronotropic incompetence) 이있는경우 (LOE C) Vol.15 No.3 31

32 Main Topic Reviews 다 ) 의학적상태로인하여투여가필요한약물에 2. Class IIa 의해증상을동반한서맥이입증된경우 (LOE C) 가 ) 임상적으로의미가있는서맥관련증상이 있으나증상과서맥과의관련성이검사에서 입증되지않았을때, 각성상태에서심박수가 분당 40 회미만인경우 (LOE C) 나 ) 원인을알수없는반복적인실신인경우에 임상적으로의미있는동기능부전이 전기생리학적검사에서발견되거나유발된경우 (LOE C) 3. Class IIb 가 ) 경도의증상이있으면서각성시심박수가 4. Class III 지속적으로분당 40 회미만인경우 (LOE C) 가 ) 무증상의동기능부전의경우 (LOE C) 나 ) 서맥에의한증상이서맥의증거가없을때 발생한경우 (LOE C) 성인에서발생한후천성방실차단 (acquired atrioventricular block) 에서영구형심박동기삽입의적응증 방실차단의경우에도서맥과증상의연관성을 입증하는것이가장중요하다. 또한동기능부전 증후군과마찬가지로약물이나허혈성심질환, 고칼륨혈증등교정가능한원인이있는지확인하는 것이필요하다. 증상이없다고하더라도서맥및 방실차단으로인한방실부조화로인해좌심실 확장이나기능부전이있다면인공심박동기의 적응증이된다. 1 도방실차단이라고하더라도이로 인한증상이뚜렷하면인공심박동기를고려할수 있다. 1. Class I 가 ) 증상이있는서맥이나심실성부정맥을초래하는 3도또는고도 2도방실차단 (LOE C) 나 ) 부정맥또는다른의학적상태로인하여서맥을유발할수있는약물치료가필요한 3도또는고도 2도방실차단 (LOE C) 다 ) 각성상태에서증상이없는 3도또는고도 2도방실차단에서 3초이상의무수축심정지가증명되었거나이탈박동이분당 40회미만이거나방실결절아래부위에서나오는이탈박동이있는경우 (LOE C) 라 ) 각성상태에서증상이없는심방세동에서 5초이상의무수축심정지가증명된경우 (LOE C) 마 ) 방실접합부에대한전극도자절제술을시행한후발생한 3도또는고도 2도방실차단의경우 (LOE C) 바 ) 심장수술후발생한 3도또는고도 2도방실차단이호전되기를기대하기어렵거나, 수술후지속되는경우 (LOE C) 사 ) 3도또는고도 2도방실차단이신경근병증 ( 예, myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb's dystrophy, peroneal muscular atrophy 등 ) 과관련된경우 (LOE B) 아 ) 서맥증상이있는 2도방실차단의경우 (type 또는차단위치와무관 )(LOE B) 자 ) 각성시심박수가 40회미만이거나방실결절하방에서차단이있으면서좌심실기능부전이있는무증상의지속적인 3도방실차단의경우 (LOE B) 차 ) 심근허혈의증거가없으면서운동시 2도또는 3 도방실차단이발생하는경우 (LOE C) 2. Class IIa 가 ) 심비대가없는무증상의지속성 3도방실차단에서이탈박동이분당 40회이상인경우 (LOE C) 나 ) 무증상의 2도방실차단에서전기생리학적검사상히스속하방이나히스속안 (infra-his) 32 The Official Journal of Korean Heart Rhythm Society

33 의차단이확인된경우 (LOE B) 다 ) Pacemaker syndrome 이나혈역학적인 불안정과유사한증상이있는 1 도방실차단혹은 2 도방실차단의경우 (LOE B) 라 ) 무증상의 II 형의 2 도방실차단이면서 QRS 가 좁은경우 (LOE B) 3. Class IIb 가 ) 증상여부와무관한방실전도장애 (1 도방실차단 포함 ) 가신경근병증 ( 예, myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb's dystrophy, peroneal muscular atrophy 등 ) 과 관련된경우 ( 방실전도장애를예측할수없기 때문에 )(LOE B) 나 ) 약의투여를중단한후에도약의투여혹은약의 4. Class III 독성으로방실차단재발이예상되는경우 (LOE B) 가 ) 무증상의 1 도방실차단의경우 (LOE B) 나 ) 무증상의 I 형 2 도방실차단의경우 (LOE C) 다 ) 무증상의 1 도방실차단과동반된섬유속차단 (LOE B) 만성양섬유속차단 (bifascicular block) 에서영구형심박동기삽입의적응증 1. Class I 가 ) 고도 2 도방실차단또는간헐적인 3 도 방실차단의경우 (LOE B) 나 ) II 형 2 도방실차단이있는경우 (LOE B) 다 ) 교차하는각차단 ( 우각차단과좌각차단 ) 을 보이는경우 (LOE C) 100 milliseconds 이상인경우 (LOE B) 다 ) 전기생리학적검사에서박동조율유발성 (pacing-induced) 히스속하방의차단이 발생하는경우 (LOE B) 3. Class IIb 가 ) 증상유무와무관하게신경근병증 ( 예, myotonic 4. Class III muscular dystrophy, Kearns-Sayre syndrome, Erb's dystrophy, peroneal muscular atrophy 등 ) 과관련된 양섬유속차단이나어떠한섬유속차단이있는 경우 (LOE C) 가 ) 방실차단이나증상이없는섬유속차단의경우 (LOE B) 나 ) 무증상의 1 도방실차단을동반한섬유속차단의 경우 (LOE B) 과민성경동맥동증후군과신경심장성실신에서의영구형심박동기삽입의적응증 1. Class I 가 ) 경동맥동의자극으로인해자발적으로 2. Class IIa 발생하고, 경동맥동에압력을가했을때 3 초 이상의심실무수축이유발되는반복적인 실신의경우 (LOE C) 가 ) 분명한유발사건은없으면서과민성심장억제 (cardioinhibitory) 반응이 3 초이상지속되는 실신인경우 (LOE B) Main Topic Reviews 2. Class IIa 가 ) 심실빈맥과같은원인을제외하고방실차단의증거가명확하지않은실신인경우 (LOE B) 나 ) 무증상이나전기생리학적검사에서 HV 간격이 3. Class IIb 가 ) 기립경검사에서서맥이증명되고, 이에따른유의한증상이있는신경심장성실신이발생한경우 (LOE B) Vol.15 No.3 33

34 Main Topic Reviews 4. Class III 가 ) 경동맥동의자극에대하여증상이없거나모호한증상이있는과민성심장억제반응이있는경우 (LOE C) 나 ) 회피행동이효과적인상황성실신의경우 (LOE C) 결론일반적으로서맥은어지럼증, 호흡곤란, 실신등의증상을유발할뿐사망률을증가시키는경우는없지만, 지나친서맥의경우 long QT에의한 torsades de pointes 가생길수있으므로유의해야한다. 또한 vagal tone이상승하는밤에만생기는서맥은증상을유발하지않기때문에임상적으로의미가없다. 인공심박동기의가장큰합병증은감염인데대략 1% 정도에서발생하며, 인공심박동기시술시에이득과위험에대해환자와충분히상담하는것이중요하다. 인공심박동기의자세한적응증은복잡하지만, 증상을유발하는서맥 으로요약할수있다. 즉, 증상, 증후를유발하지않으면완전방실차단이라고하더라도좀더경과를관찰할수있는반면, 단순한 1도방실차단, 심박수변동부전이라고하더라도증상을유발하는것이면인공심박동기를고려할수있다. 증상과의연관성이애매한경우각성시분당 40회미만, 3초이상의동정지가기준이될수있으며, 심방세동의경우에는 5초이상의 pause 가기준이된다. 고령화시대가되면서서맥성부정맥의유병률은상승할것이며그로인해영구형심박동기의삽입은증가할것이다. 정확한임상지침의숙지를통해심박동기의삽입이필요한환자를잘선별하여시술할필요가있으며, 또한우리나라의실정에맞는임상지침의제정도고려해야할것이다. References Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices); American Association for Thoracic Surgery; Society of Thoracic Surgeons. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery a n d S o c i e t y o f Th o ra c i c S u r g e o n s. C i r c u l a t i o n. 2008;117:e350-e Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NA 3rd, Ferguson TB Jr, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AJ, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD, Ellenbogen KA, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hayes DL, Page RL, Stevenson LW, Sweeney MO; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; Heart Rhythm Society ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2012;126: Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE; ESC Committee for Practice Guidelines (CPG), Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S; Document Reviewers, Kirchhof P, Blomstrom-Lundqvist C, Badano LP, Aliyev F, Bänsch D, Baumgartner H, Bsata W, Buser P, Charron P, Daubert JC, Dobreanu D, Faerestrand S, Hasdai D, Hoes AW, Le Heuzey JY, Mavrakis H, McDonagh T, Merino JL, Nawar MM, Nielsen JC, Pieske B, Poposka L, Ruschitzka F, Tendera M, Van Gelder IC, Wilson CM ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34: Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC Jr, Jacobs AK, Adams CD, 34 The Official Journal of Korean Heart Rhythm Society

35 인공심박동기시술테크닉 Main Topic Reviews 성균관대학교의과대학내과학교실김준수 June Soo Kim, MD Department of Internal Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Abstract The first artificial cardiac pacemaker implantation was reported in Cardiac pacemaker implantation procedures were performed exclusively by a cardiac surgeon. Early pacemaker implantation involved extensive surgery and required an open-chest procedure for the placement of epicardial pacing electrodes. From epicardial cardiac pacemaker implantation, the technique of pacemaker implantation has undergone dramatic changes. Transvenous cephalic cutdown was initially introduced. Then, subclavian vein access by the Seldinger technique and the introduction of the peel-away sheath allowed for easy transvenous pacing lead insertion. Since 1980, diminishing cardiac pacemaker size and the introduction of smaller and diverse types of pacing leads have contributed to the easier implantation of cardiac pacemakers by physicians in the cardiac catheterization room. Key Words: pacemaker artificial implantation technique 서론 인공심박동기는 1959 년심장외과의사에의해 처음으로환자에게시술되었다. 1 그러나 1980 년대정맥 절개 (venous cutdown) 에의한머리정맥 (cephalic vein) 천자기법과셀딩거기법 (Seldinger technique) 에의한 쇄골밑정맥 (subclavian vein) 천자와분리가능유도관 (peel-away introducer sheath) 의도입으로인공 심박동기시술이용이하게되었다. 2-4 그후의공학 Received: May 12, 2014 Revision Received: September 10, 2014 Accepted: September 14, 2014 Correspondence: June Soo Kim, MD, Department of Internal Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea ( ) Tel: , Fax: , juneskim@skku.edu 기술발전으로인공심박동기맥발생기 (pulse generator) 장치가소형화되고, 배터리수명이연장되었으며, 조율유도 (pacing lead) 의직경도축소되었다. 이렇게발전되어온인공심박동기의시술테크닉에대하여알아보고자한다. 5 인력 인공심박동기의주시술자는심장내과의사또는심장외과의사로 1년에적어도 12회정도의시술경험을필요로한다. 주시술자를직접보조하는인력으로전임의또는전공의가있고, 시술당시환자의상태, 약물주입등을도와주는순환간호사, 시술당시엑스레이투시나혈관조영을도와주는방사선사, 시술당시심장내위치한조율유도를평가하는전문기술인이필요하 Vol.15 No.3 35

36 Main Topic Reviews Figure 1. Pacemaker implantation room 다 (Figure 1). 시술방및장비 인공심박동기는일부특수한상황을제외하고는심혈관조영실에서대부분시행하고있다. 심혈관조영실에서시행되는다른중재적시술과달리인공심박동기시술시감염되지않도록철저하게노력해야한다. 인공심박동기시술을하기전심혈관조영실을깨끗하게청소하고시술자나보조인력들은반드시시술전모자와마스크를착용해야한다. 그리고시술하는동안불필요한인력들이출입하지않도록해야한다. 심혈관조영실내에는환자의혈압과산소분압을측정하고모니터링할수있는장비, 응급상황발생시대처할수있는응급카 트, 제세동기, 조명장치, 전기소작기, 심조율분석장비등이비치되어있어야한다 (Figure 1). 시술기구및재료 인공심박동기시술시피부절개, 피하조직박리, 시술부위뒤당김 (retraction) 및지혈, 봉합등을위해여러가지시술기구및재료가필요하다 (Figure 2). 인공심박동기시술전평가와조치 인공심박동기시술을결정하기전환자의증상이서맥성부정맥에의한것인지를증명할수있는심전도소견을반드시확인해야한다. 그리고환자에게적절한인 36 The Official Journal of Korean Heart Rhythm Society

37 Main Topic Reviews Figure 2. Surgical tray displaying the required surgical instruments and supplies. From the top left and clockwise: Weitlaner self-retaining retractor, two Army-Navy retractors, nontoothed forceps, toothed forceps, iris scissors, suture scissors, suture materials, straight and curved hemostats and clamps, scalpel blade and handle, Metzenbaum scissors, and needle holders. 공심박동기종류를선택하기위하여심방빈맥또는심방세동유무, 방실전도상태, 심박수변동성을평가해야한다. 현재복용중인약물중시술시출혈을초래할수있는항혈전제나항응고약물을복용하고있는지도확인해야한다. 시술전사전검사로헤모글로빈혈액검사, 12 유도심전도, 흉부엑스선촬영, 심초음파검사등을시행한다. 그리고시술전적어도 6시간정도금식이필요하고, 인공심박동기시술부위쪽팔정맥혈관을확보하여시술전충분히수액을공급한다. 서맥성부정맥중방실차단환자의경우에는시술도중에임시형심조율이필요할수있다. 시술장에들어가기직전환자로하여금소변을보게하고예방적차원에서항생제를정맥주사한다. 시술장에서소독및드래핑 (draping) 환자를시술대에눕힌후포비돈으로환자의양쪽어깨와상완을포함하여가슴젖꼭지부위에서목의턱부위까지광범위하게소독을시행후수분간기다린다. 포비돈의멸균효과는마르면서증가한다. 그후알코올로이차소독을하고소독부위를타월과외과용시트로드래핑한다. 정맥천자 조율유도를심장내위치시키기위한정맥천자를위해서머리정맥, 겨드랑정맥 (axillary vein), 쇄골밑정맥이이용될수있으나그중에쇄골밑정맥이가장많이이용된다. 쇄골밑정맥천자시그주위의 Vol.15 No.3 37

38 Main Topic Reviews A Costoclavicular ligament Subclavius muscle B Sternum Axillary vein Figure 3. The technique of subclavian vein puncture. Anatomical orientation for subclavian vein puncture. A more lateral approach is recommended to avoid lead entrapment within the costoclavicular ligament or subclavius muscle. The tip of the puncture needle is placed lateral to the subclavius muscle (A). Fluoroscopic image of the needle entrance into the subclavian vein during subclavian vein puncture. An arrow indicates the site of subclavian vein puncture (B). 해부학적구조물을이해하고천자시바늘의위치를 X 선투시로확인해야한다 (Figure 3). 쇄골밑정맥천자전 lidocaine 으로천자부위피부, 피하조직, 쇄골의뼈막 (periostium) 부위를마취한다. 쇄골밑정맥천자시천자를용이하게하기위해서환자의등뒤견갑골 (scapula) 사이에타월을두고시행하는경우가있는데, 이러한조치는환자에게불편감을초래하고천자에큰도움을주지않는다. 전통적인쇄골밑정맥천자부위는쇄골을 3등분했을때안쪽 1/3과중간 1/3의경계부위를천자하였다. 이러한천자방식은흉곽내존재하는동맥천자로인한출혈, 기흉발생위험이있고, 삽입된조율유도가갈비빗장인대 (costoclavicular ligament) 나쇄골밑근 (subclavius muscle) 안에끼이는죄임 (entrapment) 이발생하여나중에조율유도에손상이초래될수있다. 이러한문제점을방지하기위해서새롭게추천되는쇄골밑정맥천자테크닉이나왔다. 시술자가왼쪽 집게손가락으로쇄골을 3등분했을때안쪽 1/3 과중간 1/3 경계부위의쇄골상방에대고, 왼쪽엄지손가락으로쇄골하방을눌러서그아래위치한쇄골밑근이천자되지않도록한다. 그후오른손을사용하여흉골 (sternum) 과견갑골의코라코이드프로세스 (coracoid process) 를연결하는선을 3 등분했을때중간 1/3과바깥쪽 1/3의경계부위를바늘로천자한다. 6 심방및심실조율유도 2개를삽입해야하는경우에쇄골밑정맥천자를 1번만하고첫번째조율유도와유도철사 (guide wire) 를수용할수있는큰집 (sheath) 을사용해서두번째조율유도를삽입할수있다. 그러나천자를각각독립적으로하는것이조율유도를심장내위치시킬때조율유도끼리의마찰에의한어려움이나천자부위의출혈우려가덜하다. 38 The Official Journal of Korean Heart Rhythm Society

39 A B Main Topic Reviews C D Figure 4. Fluoroscopic image of pacemaker leads. Anteroposterior view (A). Right anterior oblique view (B). Left anterior oblique view (C). Left lateral view (D). 심실조율유도의삽입및고정 심실조율유도를우심실첨부에위치시킬때는우심방에위치한심실조율유도속으로원위부를구부린소침 (stylet) 을집어넣은후심실조율유도를삼첨판막을통과시켜우심실유출로 (right ventricular outflow tract) 에위치시킨다. 그후구부리지않은소침으로바 꾼후심실조율유도를시계반대방향으로돌리면서천천히빼다가심실조율유도끝이우심실첨부로향하면천천히끝까지밀어넣은후조율유도의위치를 X선투시로확인한다 (Figure 4). 심실조율유도를살짝당겨보아서잘걸려있는것이확인되면다시밀어넣어심실조율유도가심장내충분한곡선을유지하도록한다. 심실조율유도를우심실중격에위치시킬때는단순심실 Vol.15 No.3 39

40 Main Topic Reviews 조율유도가아닌그끝부위에나사 (screw) 가있는형태를사용하여적절한위치에도달하면그첨부를나사로고정한다. 심실조율유도의감지신호수치, 조율역치, 저항값을측정하고, 10 V로심실조율을하면서 X선투시로횡격막 (diaphragm) 자극유무를확인후그결과들이만족스러우면심실조율유도의심장내충분한곡선을유지하는것을확인하면서조심스럽게소침을제거한다. 쇄골밑정맥바깥에나와있는심실조율유도를싸고있는봉합소매 (suture sleeve) 를흡수되지않는 2.0 봉합실로피하조직에심실조율유도가밀려나오지않게단단히고정한다. 심방조율유도의삽입및고정 심방조율유도는그원위부가 J 모양으로구부러진것과똑바른형태이나그끝부위에나사 (screw) 가있는것이있다. 원위부가 J 모양인심방조율유도를사용하는경우에는곧은소침을심방조율유도속으로끝까지넣어 J 모양을곧게펴서우심방내에위치한심방조율유도를 X선투시로보면서소침을조금빼서심방조율유도의원위부가 J 모양이되도록한다 (Figure 4). 그후심방조율유도를살짝당기면서그첨부가우심방귀 (right atrial appendage) 에잘걸리도록한다. 심방조율유도가우심방귀에잘걸리게되면 X선투시의앞뒤촬영상 (anteroposterior view) 에서특징적으로좌우로움직이게된다. 나사형태의끝부위를가진심방조율유도를사용하는경우에는곧은소침을심방조율유도속으로끝까지넣은후심방내로심방조율유도를위치시킨다. 그후곧은소침을빼고 J 모양의소침을심방조율유도속으로집어넣어 X선투시로 J 모양의첨부가우심방귀에위치하도록조정후나사로그위치에고정한다. X선투시의좌측측면촬영상 (left lateral view) 에서환자로하여금심호흡을시킬때심방조율유도원위부의곡선이펴지면시술이후심방조율유도가이탈될수있으므로심방조율유도를좀더심장내로밀어넣어충분한곡선이유지되도록한후고정하는것이좋다. 심방조율유도의감지신호수치, 조율역치, 저항값을측정하고그결과들이만족스러우면심방조율유도의심장내충 분한곡선을유지하는것을확인하면서조심스럽게소침을제거한다. 쇄골밑정맥바깥에나와있는심방조율유도를싸고있는봉합소매 (suture sleeve) 를흡수되지않는 2.0 봉합실로피하조직에심방조율유도가밀려나오지않게단단히고정한다. 시술시측정수치 조율유도를심방혹은심실에위치시킨후조율시스템분석장비 (pacing system analyzer) 를사용하여조율역치, 감지신호, 저항을측정한다. 0.5 msec 파폭 (pulse width) 에서적절한심실조율역치는 1.0 V 이하이고, 심방조율역치는 1.5 V 이하이다. 적절한감지신호의크기는심실에서는 5 mv 이상이고, 심방에서는 1.0 mv( 가능하면 2.0 mv) 이상이어야한다. 적절한저항수치는 0.5 msec 파폭과 5 V에서심조율시 250-1,500 ohm 범위에속해야하나최근에는고저항조율유도가도입되어 1,500 ohm 이상인경우도있어적절한상한범위는인공심박동기제조사에문의해야한다. 맥발생기삽입부위공간및삽입 Lidocaine 으로피부와피하조직을국소마취후쇄골 2 cm 아래쇄골과평행하게세손가락정도너비로피부를절개한다. 그후조심스럽게맥발생기가들어갈피하조직공간을손가락과 Metzenbaum 가위를사용하여만든후에출혈부위를전기소작기를사용하여지혈한다. 그공간을항생제가녹아있는식염수로소독하고조율유도의근위부를맥발생기연결부위에집어넣고나사로고정한후만든공간속에집어넣고맥발생기를피하조직에흡수되지않는 2.0 봉합실로고정한다. 피하조직및피부봉합 피하조직은흡수되는 2.0 혹은 3.0 봉합실로촘촘히봉합한후피부는 4.0 나일론실로봉합하고시술을마무리한다. 40 The Official Journal of Korean Heart Rhythm Society

41 시술후관리 인공심박동기시술후병실에서원격심전도감시 (telemetry) 를시행하면서적절하게심조율이되는지확인하고, 환자로하여금적절하게안정을취하게하며, 매일맥발생기삽입부위를소독하면서혈종발생유무를확인한다. 특별한합병증이없으면시술이후 2일정도에퇴원하고 7-10 일뒤외래에서피부봉합사를제거한다. 그때흉부 X선뒤앞촬영상 (posteroanterior vew) 과좌측측면촬영상 (left lateral view) 을찍는다. 인공심박동기시술시합병증 쇄골밑정맥천자시기흉, 쇄골밑동맥천자, 혈흉, 공기혈전등의합병증이생길수있으나충분한수액공급을해주고, 천자시바늘을조심스럽게같은방향으로밀어넣고어느정도들어가도혈액이나오지않으면천천히뺀후다시다른방향으로 X선투시를보면서조심스럽게천천히시행하면이러한합병증발생을최소화할수있다. 그외발생하는합병증으로는시술이후맥발생기삽입부위의혈종, 감염이있다. 결론 인공심박동기시술은셀딩거기법에의한쇄골밑정 맥천자테크닉, 분리가능유도관과다양한형태의조 율유도도입으로서맥성부정맥환자에서쉽게시행되 고있다. References 1. Furman S, Schwedel JB. An intracardiac pacemaker for Stokes- Adams seizure. N Engl J Med. 1959;261: Furman S. Venous cutdown for pacemaker implantation. Ann Thorac Surg. 1986;41: Feiesen A, Kelin GJ, Kostuck WJ, Ahuja SP. Percutaneous insertion of a permanent transvenous pacemaker electrode through the subclavian vein. Can J Surg. 1977;10: Littleford PO, Parsonnet V, Spector SD. Method for rapid and atraumatic insertion of a permanent endocardial electrodes through the subclavian vein. Am J Cardiol. 1979;43: Belott PH, Reynolds DW. Permanent pacemaker and implantable cardioverter-defibrillator implantation. In: Clinical cardiac pacing, defibrillation, and resynchronization therapy. 3rd ed. Philadelphia, PA: Elsevier Saunders, 2007; Magney JE, Staplin DH, Flynn DM, hunter DW. A new approach to percutaneous subclavian venipuncture to avoid lead fracture or central venous catheter occlusion. Pacing Clin Electrophysiol. 1993;16: Main Topic Reviews Vol.15 No.3 41

42 Main Topic Reviews 박동기추적검사및프로그래밍 울산대학교의과대학내과학교실김준 Jun Kim, MD Department of Internal Medicine (Cardiology), University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Abstract Permanent cardiac pacing is not different from other therapeutic modalities. Once initiated, it is essential to periodically assess the continued appropriateness of the pacemaker programming, mechanical integrity of the leads, electrical performance of the pulse generator including battery status, and overall performance of the pacing system. The diagnostic information integral to the pacemaker including noninvasive programmability, measured data, event marker, and electrogram telemetry, especially the data on the atrial and ventricular high-rate episodes have greatly helped clinicians perform these periodic assessments and make changes in antiarrhythmic drugs or antithrombotic management. The information can be obtained in a standard office environment with pacemaker programs. In this review, the follow-up of patients with pacemaker and optimal pacemaker programming will be discussed. Key Words: pacemaker follow-up device monitoring 서론 심박동기이식환자의추적평가를할때심박동기기계자체에대한평가뿐만아니라환자에대한종합적인평가가필요하다. 환자상태에대한평가로심계항진, 심부전, 실신에대한평가와더불어기본적인활력증후에대한계측, 심박동기이식부위에대한진찰과, 심박동기이식동측의상완의부종또는정맥확장에대한평가가필요하다. 또한 cannon A wave, 악설음 (crackle), 제 일심음의변화에대한시진및청진이필요하다. 내인성율동또는자발율동 (intrinsic rhythm) 에대한평가로심박동기의존성 (pacemaker dependency) 에대한평가와기술이포함되어야하며, 현재심박동기프로그램의적절성에대한평가가필요하다. 심박동기프로그램평가에는조율또는포착역치 (capture threshold) 와안전역 (safety margin), 감지역치 (sensing threshold) 와안전역, 심박수변조, 특수알고리즘의필요성및적절성, 배터리상태에대한평가가필요하다. 증상과진찰 Received: July 2, 2014 Accepted: September 14, 2014 Correspondence: Jun Kim, MD, Department of Internal Medicine (Cardiology), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, Korea, mdjunkim@gmail.com 심박동기이식전에있었던증상이재발한적이있었 는지확인해야하고, 심계항진이발생하였을경우이전 에없었던부정맥의발생, 심박동기매개성빈맥, 심박 42 The Official Journal of Korean Heart Rhythm Society

43 Main Topic Reviews Figure 1. Example of pacemaker dependency. When the programmed mode was temporarily VVI 30 bpm in patients with complete atrioventricular block, the escape beat was not observed and cardiac pacing was 30. Electrocardiogram I, II, marker, atrial bipolar electrogram, from top to bottom. 동기증후군, 센서에대한부적절한심박수반응을감별진단해야하며, 동반된구조적심질환의증상에대한평가가필요하다. 흉통의발생은전극선에의한물리적합병증의가능성, 심박수상승에따른협심증발생을감별진단해야한다. 심박동기환자의진찰에서기본적인신체진찰이외에도심박동기이식부위에대한진찰이진료시마다시행되어야하며, 감염의소견, 압박괴사 (pressure necrosis), 미란 (erosion) 등에대한평가가필요하다. 심박동기이식부위주위의확장된정맥들의존재는쇄골하정맥의완전폐색을시사하며, 다수의심박동기전극선을삽입한경우편측상완의부종이관찰되기도한다. 심박동기의존성 (pacemaker dependency) 심박동기의존성에대한표준화된정의는없으나, 전극선의물리적원인, 과감지에의한억제, 심박동기자체의결함등어떤원인에의해서심박동기시스템이갑작스럽게작동하지않을때실신또는전실신을초래하는 경우심박동기의존성이있다고할수있다. 환자를눕힌상태에서심박동기테스트를시행하며일시적으로 DDI (dual chamber pacing, dual chamber sensing, inhibited by ventricle event), AAI (atrial pacing, atrial sensing, inhibited by atrial event), 또는 VVI (ventricle pacing, ventricle sensing, inhibited by ventricle event) 로 30회로일시심조율을시행하였을때 30회로심조율이되거나, 이탈박동이나오면서증상이발생한다면심박동기의존성이있다고진단할수있다 (Figure 1). 완전방실차단에의한간헐적심정지가있거나매우심한동기능부전이있을경우도심박동기의존성이있다고할수있다. 조율역치 (capture threshold) 국소심근을자극시키는자극을심근을포착 (capture) 하였다고표현하며, 이런반응을유발하는최소한의자극을포착또는조율역치라고한다. 1 Vol.15 No.3 43

44 Main Topic Reviews Figure 2 Strength-duration curve. With increasing pulse width, the threshold decreased, and there was no difference of more than 1.0 ms in the pulse width. Reducing pulse width increased the threshold. 조율역치는자극의맥폭 (pulse duration) 에따라서역비례하며맥폭이길수록자극역치는감소한다. 맥폭이무한대로길어질경우조율역치가최소화되며이를기전류 (rheobase, 基電流 ) 라고부르고기전류진폭의두배가되는맥폭을전기시치 ( 電氣時直 ) 또는시치 ( 時直 ), 크로낙시 (chronaixe) 라고부른다 (Figure 2). 심박동기시스템의출력을상승시키면안전역은충분해지나심박동기수명이감소하는단점이있다. 안전역과심박동기수명을최대화시키는적절한출력프로그램은안전역을 % 로하는것이다. 일반적으로는전압진폭으로측정한조율역치의두배또는맥폭으로측정한조율역치의세배로프로그래밍 ( 조율역치가 1.0 V/0.40 ms인경우, 2.0 V/0.40 ms, 3.0 V/0.03 ms인경우, 3.0 V/0.09 ms) 하는것이일반적이다 (Figure 3, 4). 최근에는자동화포착 (automated capture) 프로그램이여러회사의심박동기제품에장착되어있으며, 우심방, 우심실, 좌심실조율에사용할수있다. 포착출력을심박동기가스스로측정하고출력을최소화하여결정하는것이심박동기배터리수명을연장시키는장점도있으나, 이프로그램에대한이해가부족하거나적절히프로그램을하지않은경우오히려환자에게해를미칠수있으므로심박동기제품별로프로그램에대한자세한이해가선행되어야한다. 감지 감지 (sensing) 는심방또는심실의탈분극을감지하고반응하는능력을말하며, 감지역치는심장내전기도의 44 The Official Journal of Korean Heart Rhythm Society

45 Main Topic Reviews Figure 3. Ventricular capture threshold test. Stimulus threshold of the right ventricle in a patient who had a dual chamber ICD. ECG and intracardiac electrogram showed that right ventricular stimulus was detected at 0.75 V/0.50 ms. There was no ventricular stimulation when the output was reduced to 0.5V/0.50 ms. Electrocardiogram I, II, atrial electrogram, ventricular electrogram, and marker channel, from top to bottom. Figure 4. Atrial capture threshold test. Measurement of atrial stimulus threshold in a patient with sick sinus syndrome. P wave was observed at 1.0 V/0.40 ms by atrial stimulation. No P wave indicated that atrial stimulation disappeared at 0.75 V/0.40 ms. This is a common method for evaluating the P wave in order to estimate atrial stimulus threshold. When the P wave is too small to estimate threshold, atrial bipolar electrogram can be used. Additionally, QRS wave or ventricular bipolar electrogram can be used for evaluation in cases of normal AV conduction. Electrocardiogram I, II, marker channel, and atrial and ventricular bipolar electrograms, from top to bottom. Vol.15 No.3 45

46 Main Topic Reviews Figure 5. Atrial sensing threshold test. While the atrial sensitivity gradually increased from 0.1 mv, it determines whether the atrial sensing functions properly. Atrial sensing was observed at 1.0 mv, but the second atrial signal was not detected at 1.25 mv. After no detection, atrial pacing was performed. Electrocardiogram I, II, marker channel, and atrial and ventricular bipolar electrograms, from top to bottom. peak to peak amplitude 를측정하거나감수성 (sensitivity) setting 을점차감소하면서심박동기의반응을관 찰하며측정할수있다 (Figure 5). 조율전극선임피던스를측정하는것이반드시필요하며임피던스가 200 Ω 미만인경우절연피폭손상 (lead insulation break), 2,000 Ω 이상인경우전극선단락으로진단할수있다. 심박동기이식수개월내에임피던스수치가변동이심한경우 loose setscrew 로진단할수있으며, 수술적치료가필요하다. 심박동기배터리는 lithium-iodine 을사용하거나 lithium silver vanadium oxide with carbon monofluoride 를사용하여제조되며, 배터리전압뿐만아니라배터 리임피던스, remaining longevity 에대한기록의자세 한검토가필요하다. 조율전극선임피던스와배터리 Pacemaker diagnositics 2 심박동기추적관찰시심박동기에기록된진단정보에대한검토도필요하다. 동율동및완전방실차단으로영구형심박동기를이식한환자에서사건히스토그램 (event hisotogram) 과심박수히스토그램 (heart rate histogram) 을검토하여 AsVp (atrial sensed ventricular paced event) 가 99% 이상이고심박수히스토그램이정상적인분포를보인다면동기능은정상이라고진단할수있다. 반면 ApVp 가 99% 이고심박수가프로그램된최소 46 The Official Journal of Korean Heart Rhythm Society

47 Main Topic Reviews Figure 6. Heart rate histogram and event histogram. Since the last follow-up about 1 year ago, the heart rate histogram showed a normal distribution in a patient whose programmed base rate was 50/min and rest rate was 50/min. Event histogram indicates that the AsVp was 99% and Vp, 1.2%. 심박수로만관찰된다면동기능은비정상이거나환자가거의활동하지않는상태로추정할수있다. Figure 6은 VDD 를이식받은환자에서심박수히스토그램과사건히스토그램이며, 심실조율사건이 1.2% 임을볼수있는데, 심박동기클리닉에서측정한 P wave 가 1.0 mv이고감수성은 0.4 mv이었으나, 일상생활에서는 P wave 가 0.4 mv 이하인경우가발생하였거나최소심박수인 55회보다동율동이느려졌을가능성이 1.2% 임을알수있으며, nonphysiologic Vp를최소화하기위해서는심방감수성을최대화하거나최소심박수를 40회로낮추는것을고려해볼수있다. 또한심박수히스토그램을검토하여센서심박수가적절한지도평가할수있다 (Figure 7). 심박수변조 ( 變調, rate modulation) 기능을활성화하였을경우센서심박수가정상적인분포를하는지에대한평가가필요하며, 최소심박수로만조율이된다면센서프로그램이부적절하거나, 환자의활동이제한적인경우일수있다. 환자가운동을하지않는비활동적인경우에센서심박수가낮은것을근거로센서프로그램을좀더예민하게변경한경우오히려빈맥발생에따른심계항진과심부전발생을초래할수있다. 심박동기환자의진단정보를이용하여심방세동을정확하게진단할수있다. 자동모드전환에피소드 (automatic mode switch episode) 가반드시심방세동, 심방빈 맥은아니므로기록된에피소드의전기도를직접검토하는것이필요하다. 심박동기이식환자중심인성급사의고위험군인경우라면 ventricular high rate episode 를설정하고모니터하는것이심인성급사의위험인자인비지속성심실빈맥또는지속성심실빈맥을진단하는데도움이될수도있다. 하지만진단기능을활성화하면심박동기에너지소모의증가로배터리수명감소를초래할수있다. 심박동기모드선택 2013 년유럽심장학회의진료지침에따르면지속적동기능부전이있는경우 chronotropic incompetence 가있다면 DDDR+AVM (AV management), chronotropic incomptence 가없다면 DDD+AVM 이추전되며, 간헐적동기능부전이있는경우 DDDR+AVM 이추천된다. 지속적방실차단인경우동기능부전이있거나, 없는경우, 심방세동에존재에따라서각각 DDDR, DDD, VVIR 이추천되며, 간헐적방실차단의경우 DDD+AVM 이추천된다. 3 시술전평가에서동기능이정상이더라도시술이후약물또는노화로인해동기능부전이발생하는경우가있으므로시술시에는영구형심방세동이없다면심박수변조기능이있는심박동기를이식하고, DDD 로프로그램 Vol.15 No.3 47

48 Main Topic Reviews Figure 7. Diagnostic information about patients with sinus syndrome or tachycardia-bradycardia syndrome who underwent pacemaker implantation. Atrial heart-rate histogram showed appropriate sensor response and no atrial fibrillation, during the follow-up period of approximately 1 year, and indicated that the Vp was <0.2% on the activation of the AV interval. 한이후경과관찰중동기능부전이발생하면센서기능을활성화하는것이필요하다. 심박동기프로그래밍 심박출량이최대화되는심박수는 회 / 분으로알려져있고 70회 / 분이상으로증가함에따라서심박출량이감소하는것으로알려져있다. 또한심박수가 60회 / 분이상으로증가함에따라심방의기계적효율성 (left ventricular work/myocardial oxygen demand) 이감소하는것으로알려져있다. 따라서심박출량을최대화시키며기계적효율성을유지하는최적의심박수는 회 / 분으로볼수있다. 운동시심박출량증가는심박수증가가가장크게기여하는것으로알려져있다. 따라서운동시심박수가증가하지않는심박동기를이식한경우에운동능력저하 가발생할수있다. 동기능부전이있다면심박수변조기능이있는심박동기이식이필수적이다. 심박수변조를위한센서가개발되어있지만동기능자체가정상인경우에는심방신호를감지하는심박동기가생리적심조율이라고할수있다 ( 즉, 완전방실차단환자에서 VVIR 보다 DDD 가좀더정상생리반응에가깝다 ). 심박수변조가필요한경우적절한센서에대한프로그램이필요하며적절한최고센서심박수는좌심실기능이정상이고, 허혈성심질환이없다면 86% (220- 나이 ), 좌심실기능이저하되어있거나허혈성심질환이있다면최대예측심박수의 75% 이하로설정하는것이안전하다. 비교적젊은연령에서방실차단이발생한경우에도 maximal tracking rate 를최대심박수의 80-90% 로설정하는것이운동능력유지에도움이될수있다. 적절한 AV timing 을설정하는것이심방압력을최소 48 The Official Journal of Korean Heart Rhythm Society

49 화하고, 심방의보조펌프기능을최대화하며, 이완기충만기간을최적화하는것으로알려져있다. 최적의 AV timing 이심실이완기말압력을최소화, 신경호르몬활성의최소화, 심실전부하의최소화, 보상상재구도의최소화, 뇌졸중위험도를감소시킬수있는것으로알려져있다. 최적의 AV timing 을결정하는방법은정립되어있지않으며, ritter method, LVOT VTI ( 속력- 시간적분, velocity-time integral) 가최대화이거나, mitral inflow VTI 가최대화이거나, stroke work 가최대화이거나, LV dp/dt 가최대화인 AV interval 로정의할수있다. 모든환자에서최적의 AV interval 을측정하는것이번거로울수있으며, 심박동기이식후심부전이발생한경우에선택적으로 AV interval 을최적화하거나, 심부전발생의위험이높은경우 ( 좌심실비후, 좌심실기능의경도저하, 심방확장, 이완기기능부전이있는경우 ) 에국한하여선별적으로시행하는것도방법이다. 3. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE; ESC Committee for Practice Guidelines (CPG), Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S; Document Reviewers, Kirchhof P, Blomstrom-Lundqvist C, Badano LP, Aliyev F, Bänsch D, Baumgartner H, Bsata W, Buser P, Charron P, Daubert JC, Dobreanu D, Faerestrand S, Hasdai D, Hoes AW, Le Heuzey JY, Mavrakis H, McDonagh T, Merino JL, Nawar MM, Nielsen JC, Pieske B, Poposka L, Ruschitzka F, Tendera M, Van Gelder IC, WilsonCM ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34: Main Topic Reviews 결론 심박동기환자의추적관찰은심박동기의배터리, 전극선의임피던스, 조율및감지역치를측정하는것만으로끝나는것이절대아니며, 환자에대한종합적인평가, 기저서맥질환의평가, 새로운서맥질환의발생여부, 새로운빈맥성질환의발생에대한체계적인평가가필요하며, 환자의기저심장질환, 서맥의종류, 미주신경성실신의유무, 동반된내과적질환을종합적으로평가하여적절한프로그래밍을하는것이반드시필요하다. References 1. Kay GN, Shepard RB. Cardiac electrical stimulation. In: Ellenbogen KA, Kay GN, Lau CP and Wilkoff BL, editors. Clinical cardiac pacing, defibrillation and resynchronization therapy. 3 rd ed. Saunders Company 2007, p Love CJ. Pacemaker troubleshooting and follow-up. In: Ellenbogen KA, Kay GN, Lau CP and Wilkoff BL, editors. Clinical cardiac pacing, defibrillation and resynchronization therapy. 3 rd ed. Saunders Company 2007, p Vol.15 No.3 49

50 Main Topic Reviews 박동기합병증의예방및처치 연세대학교의과대학내과학교실정보영 Boyoung Joung, MD, PhD Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine Abstract Pacemaker complications can be divided into early complications of components of the implanted system and late complications related to the patient or system. The emergence of pacing and implantable cardioverterdefibrillator (ICD) systems, along with expanding indications for these devices (e.g., cardiac resynchronization therapy and sudden cardiac death prevention), increasing infection rates, and device recalls have created the need for removing and upgrading these systems. This article will review the prevention and treatment of pacemaker complications. Key Words: pacemaker complication treatment prevention 서론 삽입과연관된합병증 심박동기및제세동기최근에는심장재동기화치 료 (cardiac resynchronization therapy, CRT) 등다양 한 cardiac electric device (CED) 를이용한심장박동 이상치료방법이시도되고있다. 미국의경우매년약 400,000 개의새로운심박동기및제세동기등의장치 (device) 가심장에삽입되고있으며, 현재 300 만명이상 이심장장치를가지고있다고한다. 1 Device 를이용한 치료는매우효과적인데반하여이에따른문제점도발 생할수있다. 2 CED 의합병증으로는삽입과연관된합 병증및나중에발생하는만성적인문제로나눌수있다. Received: 22 May, 2014 Revision Received: September 3, 2014 Accepted: September 14, 2014 Correspondence: Boyoung Joung, MD, PhD, Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, 250 Seungsanno, Seodaemun-gu, Seoul, Republic of Korea Tel: , Fax: cby6908@yuhs.ac 혈종은항혈소판제제나헤파린등을복용하는환자에서흔히발생한다. 와파린을투약하면서 INR 을 2.5 이하로조절하면시술시혈종발생이심각하지는않다. 대부분의혈종은제거술 (evacuation) 없이해결되며, 심한혈종으로통증, 봉합부손상, 항응고제를다시사용해야하는환자의경우는혈종제거술이필요한경우가있다. 쇄골하정맥천자에따른합병증으로기흉, 혈흉, 공기색전증, 동맥정맥루등이발생할수있다. 외측에서천자를하거나 cephalic acess 를통하여이런합병증은줄일수있다. 간혹조율 lead 가심방및심실의결손을통하여좌심실에위치하는경우가있으며, 이경우는우각차단의심전도가보인다. 드물게천공이발생하는경우가있으며, 이경우조율역치의증가, 횡격막수축, 심낭염, 심낭삼출등이발생할수있다. Figure 1은심실조율 lead 에따른심장천공의흉부방사선소견및수술소견이다. 50 The Official Journal of Korean Heart Rhythm Society

51 A B Main Topic Reviews Figure 1. Pacemaker lead perforation. Chest radiographs immediately after implantation of the pacemaker system (left) and after 2 months (right) showing that the location of the ventricular pacing lead changed (A). Perforation of right ventricular lead (B). A B C D Figure 2. A flare suggesting pocket infection of the pacemaker (A and B). Skin erosion above the external surface of the pacemaker (C). Skin erosion in the pacemaker lead region (D). Vol.15 No.3 51

52 Main Topic Reviews A B Figure 3. The extracted lead with adhesion of surrounding tissue (A). The main regions where tissue adheres to the leads (indicated by arrows) (B). 정맥혈전증은대부분경미하며, 부종통증등의증상을보이는경우팔을올리거나, 항응고치료를하면일반적으로호전된다. 정맥혈전증은너무쇄골하정맥외측을통하여유도를위치시킨경우또는여러개의유도를넣은경우발생위험도가높은것으로되어있다. 유도와연관된합병증 유도와연관된합병증으로는유도위치변화 (migration), 연결부문제, 유도의손상, 절연부손상등이있다. 위치변화는심실유도의경우 1%, 심방유도의경우 2-3% 정도에서발생할수있다. 연결부문제의경우조율이간헐적으로혹은완전히안될수있다. 원인은시술당시연결이확실히안되는것이며, 방사선촬영으로이를확인할수있다. 유도나연결부문제시 noise 발생으로 oversensing 현상이발생하는데, 박동기의경우 inhibition 이되어서조율이안되는현상이발생한다. 제세동기의경우세동발생으로오인하여부적절한쇼크 (inappropriate shock) 가나갈수있다. Twiddler syndrome 은박동기 generator 를환자가만져서포켓안에 서 lead 가꼬이거나위치가바뀌는현상으로드물게발생한다. 박동기감염 박동기 generator 피부의 erosion 은마른환자에서호발한다. Impending erosion 의경우응급상황이며, generator 를대흉근밑으로옮기는수술을통해서막을수있다. 피부가손상되면감염이되므로 generator, lead 전체시스템의제거가필요하다. 박동기감염의위험인자로는고령, 당뇨병, 여성, 말기신부전, 만성적도관삽입, 스테로이드, 삽입부의피부염등의환자요인이있다. 시술과관련된요인으로는 pocket 조작횟수, 박동기교환, pocket 개방시간, 혈종형성, 예방적항생제를투여하지않은경우, 시술전 24 시간내에발열이있었던경우를들수있다. 감염시기는처음 1달동안 25%, 1년이내가 33%, 그리고 1년이후가 42% 정도로보고되고있다. 감염은특히박동기를처음삽입할때 1.4% 인데반하여교환할때 6.5% 로훨씬높아서주의가필요하다. 박동기교환시감염이호발하는이 52 The Official Journal of Korean Heart Rhythm Society

53 A B C Main Topic Reviews D E F Figure 4. A cm vegetation attached to the TV posterior leaflet and a cm vegetation attached to the RA free wall (A). Septic embolisms in the brain (B) and liver (C). Disappearance of vegetation after treatment (D). Chest radiographs before (E) and after device removal (F). LA, left atrium; LV, left ventricle; RA, right atrium; TV, tricuspid valve 유는이미생성된 capsule 에혈관형성이없고, 딱딱해서감염원이될수있기때문이다. 박동기시스템의일부가감염이되면전체하드웨어를제거하지않고감염을치료하는것은거의불가능하다. Lead 를제거하는적응증은감염, 만성통증유발, 유도에의한색전증및정맥협착, 유도에의한치명적인부정맥발생, 심장에치명적인손상이우려되는등의경우꼭필요하다. 감염은 lead extraction 의가장중요한적응증이며, 전체 lead extraction 24-60% 의원인으로알려져있다. Figure 2는다양한박동기 pocket 감염소견을사진으로보여주고있다. 삽입된 lead 는시간이오래지나면서혈관및심장조직과유착을하게된다. Figure 3A에관찰되는것과같이제거한유도의여러부위에 조직과유착이됨을알수있다. 3 주로유착되는위치는 Figure 3B에서화살표표시부위와같이쇄골하정맥부분, 상대정맥부분, 그리고우심실과 lead 가붙는부분이다. 단순히 lead 를잡아당기는방법으로는정맥의유착된부위와심장의 lead 가붙은심첨부가심하게잡아당겨져심장이찢어지거나뒤집어지는합병증이발생한다. Lead 제거시시술자의숙련도가중요한데시술자가첫번째시술을하는경우 12% 이상 lead 제거에실패하는데반하여, 10건이상의시술경험이있으면 lead 제거에실패하는경우가약 2% 정도로낮아지는것으로알려져있다. 일반센터와경험이많은센터의시술사망률은각각 0.5% 와 0.2% 로보고되고있다. 숙련된시술자이외에도흉부외과의사, 마취과의사, 심초음파전문의, 방 Vol.15 No.3 53

54 Main Topic Reviews 사선사등인력의준비가필요하다. 시술에필요한장비의경우도화질이좋은 fluoroscopy, extraction tools, extraction snares, 삽입 tools, 심초음파등다양한장비가필요하다. 4 감염된 lead 를제거한후새로운 lead 의삽입은최소 3일정도후에, 그리고패혈증이있었던경우에는최소 7일정도혈액균주동정에서음성이된후새로운심박동기를삽입하는것이재감염의예방에적절하다. 5 Large vegetation 을동반한감염의경우에도 lead extraction 은효과적인것으로되어있다. Figure 4는 3 cm 정도의 large vegetation, 뇌의 septic emboli 에의한뇌졸중, 간, 폐에 septic emboli 가있었던환자로경피적 lead extraction 과항생제요법으로성공적으로치료된증례를보여주고있다. 6 결론 박동기와관련된합병증은삽입당시시스템과연관된조기합병증, 이후추적관찰기간중에발생하는만성합병증으로분류할수있다. 대부분의합병증이시술시주의및적절한치료로예방및치료가가능하다. 특히박동기감염은박동기전체시스템의제거가필요한위험한합병증으로 impending erosion 의적절한치료, 수술당시감염의주의등으로예방을하려는노력이필요하다. References 1. Buch E, Boyle NG, Belott PH. Pacemaker and defibrillator lead extraction. Circulation. 2011;123:e Scher DL. Troubleshooting pacemakers and implantable cardioverter-defibrillators. Curr Opin Cardiol. 2004;19: Park JS, Pak HN, Lee MH, Kim SS, Joung B. Implantable cardioverter-defibrillator lead extraction by conventional traction and counter-traction technique. Korean Circ J. 2011;41: Wilkoff BL, Auricchio A, Brugada J, Cowie M, Ellenbogen KA, Gillis AM, Hayes DL, Howlett JG, Kautzner J, Love CJ, Morgan JM, Priori SG, Reynolds DW, Schoenfeld MH, Vardas PE, Heart Rhythm S, European Heart Rhythm A, American College of C, American Heart A, European Society of C, Heart Failure Association of ESC, Heart Failure Society of A. HRS/EHRA expert consensus on the monitoring of cardiovascular implantable electronic devices (CIEDS): Description of techniques, indications, personnel, frequency and ethical considerations. Heart Rhythm. 2008;5: Henrikson CA, Brinker JA. How to prevent, recognize, and manage complications of lead extraction. Part I: Avoiding lead extraction--infectious issues. Heart Rhythm. 2008;5: Cho H, Kim M, Uhm JS, Pak HN, Lee MH, Joung B. Transvenous pacemaker lead removal in pacemaker lead endocarditis with large vegetations: A report of two cases. Korean Circ J. 2014;44: The Official Journal of Korean Heart Rhythm Society

55 대동맥판막협착증환자에서경피적대동맥판막치환술후인공심박동기삽입의예측인자 article REVIEW 원광대학교의과대학내과학교실김남호 Nam-Ho Kim, MD Division of Cardiology, Department of Internal Medicine, Wonkwang University Medical School, Jeonbuk, Korea Predictors of Permanent Pacemaker Implantation in Patients with Severe Aortic Stenosis Undergoing TAVR: A Meta-Analysis Siontis GC, Juni P, Pilgrim T, Stortecky S, Bullesfeld L, Meier B, Wenaweser P, Windecker S. J Am Coll Cardiol. 2014;64: 배경 방법 경피적대동맥판막치환술 (transcatheter aortic valve replacement, TAVR) 후영구적심박동기를삽입 해야하는방실전도차단의발생이때때로발생한다. 하 지만어떤환자에서인공심박동기가삽입될지예측하 는연구는주로소규모연구에불과하여명확하지않다. 목적 이연구의목적은 TAVR 후인공심박동기삽입에서 임상적으로유용한예측인자를추정하는데있다. Received: July 29, 2014 Accepted: September 14, 2014 Correspondence: Nam-Ho Kim, MD, Division of Cardiology, Department of Internal Medicine, Wonkwang University Medical School, Shinyong-dong, Iksan, Jeonbuk , Korea Tel: , Fax: cardionh@wonkwang.ac.kr TAVR 후인공심박동기삽입술의빈도와그예측인자에대한자료들을제공한연구를찾기위해체계적인검색을실시하였다. 연구결과, 환자, 그리고시술적인특성에대한자료를추출하였다. 위험비 (RR) 와각예측인자를위한 95% 신뢰구간은임의효과모델을이용하여계산하였다. 이식된판막의유형에따라계층화된분석을실시하였다. 결과 41개의연구에서총 11,210 명의 TAVR 환자를대상으로자료를획득하였다. 이중 17% 에서인공심박동기를시술하였다. 각각의연구에서인공심박동기삽입률은 2-51% (Medtronic CoreValve Revalving System, MCRS 중앙값 28%, Edwards SAPIEN Valve, ESV 중앙값 6%) 였다. TAVR 시행후인공심박동기삽입은기저상태에서시술중발생한방실전도차 Vol.15 No.3 55

56 article REVIEW 예측인자 연령 >80 세 No. of studies 1 No. of participants RR (95% CI) P-value 1, ( ) 0.09 I-squared - 남성 17 3, ( ) <0.01 0% 심방세동 15 3, ( ) % 1 도방실전도차단 6 1, ( ) <0.01 4% 좌전섬유속차단 5 1, ( ) <0.01 0% 좌후섬유속차단 ( ) 시술중방실전도차단 ( ) < 좌각차단 16 2, ( ) % 우각차단 17 2, ( ) < % PR >200 ms ( ) MCRS (versus ESV) 9 5, ( ) < LVEF 정상 ( ) % 위험감소 위험증가 Figure 1. Predictors of pacemaker implantation undergoing TAVR ESV, Edwards SAPIEN valve; LVEF, left ventricular ejection fraction; MCRS, Medtronic CoreValve Revalving System; TAVR, transcatheter aortic valve replacement. 단 (RR 3.49; p<0.01) 이있는경우에가장위험하였고, 우각차단 (RR 2.89; p<0.01), 좌전섬유속차단 (RR 1.62; p<0.01), 1도방실전도차단 (RR 1.52; p<0.01) 이있는경우와남성 (RR 1.23; p<0.01) 에서위험성이증가하였다. 이러한인자들은 MCRS (Medtronic CoreValve Revalving System) 를시술한환자만고려했을때유의한예측인자로작용하였고, ESV (Edwards SAPIEN valve) 에서는제한된자료때문에유의하지않았다. MCRS 를시행받은환자가 ESV 를시행받은환자보다인공심박동기삽입률이 2.5 배높았다. 전도차단이 TAVR 시행후인공심박동기삽입의중요한예측인자였다. 이연구를통해 TAVR 시술후인공심박동기를삽입해야할고위험군을찾을수있었고, 잘정립된예측인자들은시술전과후에임상적인결정을하는데유용한도구로작용할것으로생각된다. 결론 남성, 기저상태에서전도장애, 그리고시술중발생한 56 The Official Journal of Korean Heart Rhythm Society

57 Transvenous Extraction of 30-year-old Pacemaker Leads in a Patient with Eisenmenger Syndrome ECG & EP Cases 연세대학교의과대학내과학교실엄재선 / 정보영 Jae-Sun Uhm, MD, PhD; Boyoung Joung, MD, PhD Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Abstract Extraction of old pacemaker leads is particularly challenging owing to the high level of adherence to adjacent tissue. We report a case of transvenous extraction of 30-year-old pacemaker leads by conventional traction and counter-traction techniques, combined with a snaring method. A 42-year-old man presented with erythema and purulent discharge from a pacemaker scar. He had undergone DDD (dual chamber pacing, dual chamber sensing, dual function) pacemaker implantation 30 years previously for complete atrioventricular block after incomplete atrioventricular septal defect repair. Following diagnosis of pacemaker infection, we extracted the pacemaker leads transvenously using locking stylets, telescoping dilator sheaths, and a snare catheter. Key Words: extraction infection lead pacemaker Introduction Case With increasing rates of pacemaker implantation, pacemaker infection rates have risen in parallel. 1 In cases of infection, pacemaker removal and lead extraction are necessary, 2 though the difficulty of extraction increases in line with pacemaker age. We report a case of transvenous extraction of 30-year-old pacemaker leads via the subclavian vein using conventional traction and counter-traction techniques, and via the femoral vein using a snaring technique. Received: July 20, 2014 Revision Received: September 5, 2014 Accepted: September 14, 2014 Correspondence: Boyoung Joung, M.D, Ph.D, Associate Professor of Medicine, Yonsei University Health System, 50 Yonsei-ro, Seodaemungu, Seoul, Republic of Korea Tel: , Fax: cby6908@yuhs.acm-suk Ko, MD, PhD, Division of Cardiology A 42-year-old man presented with erythema and purulent discharge from a pacemaker pocket site in the left pectoral area (Figure 1). Symptoms had arisen 1 week previously. The patient had been diagnosed with incomplete atrioventricular (AV) septal defect at the age of 12, and had undergone surgical repair. Complete AV block had subsequently occurred, and a DDD pacemaker (unknown manufacturer) was implanted with a screw-type unipolar atrial lead and a tined unipolar ventricular lead (unknown manufacturer). At the age of 20, the patient was fitted with a new VDD (ventricular pacing, dual chamber sensing, dual function) pacemaker (Thera VDD, Medtronic, Minneapolis, MN, USA) in the right pectoral area, due to pacing failure of the DDD Vol.15 No.3 57

58 ECG & EP Cases Figure 1. Erythema around the pacemaker pocket site. Figure 2. Chest radiograph prior to pacemaker lead extraction. The screw-type unipolar atrial lead (arrow head) and tined unipolar ventricular lead (arrow) are evident in the radiograph. Figure 3. The ventricular lead was been extracting by traction and counter traction force via a locking stylet and a telescopic dilator sheath. pacemaker. At that time, the DDD generator was removed, but the atrial and ventricular leads were left in place. On the first day of the current admission, the patient s blood pressure was 110/82 mmhg and his body temperature was 37.2 C. Laboratory analysis revealed a white blood cell count of 13,600/μL, a neutrophil count of 89.6%, and C-reactive protein levels of 15.3 mg/l. A chest radiograph showed cardiomegaly, the VDD pacemaker in the right pectoral area, and the atrial and ventricular leads in the left pectoral area (Figure 2). Echocardiography revealed residual interatrial shunt, severe pulmonary hypertension, severe tricuspid regurgitation, and no vegetation. These findings were consistent with Eisenmenger syndrome. Cefazolin 1 g three times a day was administered intravenously. Attending physicians and surgeons recommended repeat open heart surgery for repair of the AV septal defect and tricuspid valve, and for pacemaker lead 58 The Official Journal of Korean Heart Rhythm Society

59 A B ECG & EP Cases Figure 4. The extracted atrial lead (A). The partially extracted ventricular lead (B). Figure 5. Chest radiograph following pacemaker lead extraction. The remaining distal part of the ventricular lead (arrow) is evident in the radiograph. extraction, though the patient refused surgery. Although blood cultures were negative, clinical and laboratory findings were consistent with pacemaker pocket infection. We therefore decided to extract the pacemaker leads transvenously on the 2 nd day of hospitalization. A skin incision was made under general anesthesia, and a sample of discharge was collected from the inside of the pacemaker pocket for bacterial culture. Following dissection of surrounding soft tissue, atrial and ventricular pacemaker leads were exposed. Two locking stylets (Liberator Beacon Tip Locking Stylet, Cook Vascular Inc., Vandergrift, PN, USA) were inserted into each hole of the atrial and ventricular leads and locked. Traction force was gently applied to the locking stylets, and two 12 Fr polypropylene telescoping dilator sheaths (Byrd Dilator Sheath, Cook Vascular Inc.) were inserted and advanced over the atrial and ventricular leads (Figure 3). Counter-traction force was gently applied to the dilator sheaths and soft Vol.15 No.3 59

60 ECG & EP Cases tissue surrounding the leads was dissected away. The atrial lead was extracted successfully (Figure 4A); the ventricular lead was cut at the level of the superior vena cava during extraction. A snare catheter (PFM Medical, Nonnweiler, Germany) was inserted into the right ventricle, via the right femoral vein, to retrieve the remaining section of the ventricular lead (Figure 4B). The lead was cut at the level of the right ventricle, and the middle portion removed, though a distal 4-cm section was left in place (Figure 5). The wound was sutured, and the procedure was completed with no acute complications. No evidence of infection was observed during out-patient follow-up. Discussion We have presented a case of transvenous extraction of old unipolar pacemaker leads via the subclavian vein using conventional traction and counter-traction techniques, and via the femoral vein, using a snaring method. Pacemaker or implantable cardioverter-defibrillator lead extraction is generally considered to be a difficult and high-risk procedure. The main source of risk is adhesion of the pacemaker leads to a major vein, the right atrium or ventricle, or the tricuspid valve. The most common sites of severe adhesion are the subclavian vein, the superior vena cava, and the apex of the right ventricle. 3 Major complication rates following pacemaker lead extraction are approximately 2%. 4 Major complications include cardiac avulsion, vascular laceration, hemopericardium, hemothorax, and acute tricuspid regurgitation. 4,5 Complication rates are especially high in patients with pacemaker infection, cerebrovascular disease, low ejection fraction, low platelet count, prolonged prothrombin time, and mechanical or powered sheaths. 4 During the pacemaker lead extraction procedure, adhesiolysis around the leads is critical. Many new kinds of lead extraction device are emerging, including laser sheaths. However, traction and counter-traction techniques, using locking stylets and telescoping dilator sheaths, are most commonly employed in Korea. 6,7 Locking stylets supply traction force to the pacemaker lead tip and decrease the risk of severing the lead. Telescoping dilator sheaths can be used to supply counter-traction force and adhesiolysis around the pacemaker lead; they additionally decrease the risk of cardiac avulsion. The snaring technique via a femoral approach can be used for rescue purposes, in cases where the pacemaker lead is cut during extraction. The femoral approach can additionally provide an alternative vector of traction force. Because adherence of pacemaker leads to adjacent tissue increases dramatically with age, extraction of old pacemaker leads is particularly challenging. Furthermore, old unipolar leads are easily severed because there is no supporting core in the lead body. Although the distal part of the ventricular lead was left in place in this case, no further evidence of infection was observed during follow-up. Consequently, open heart surgery for complete removal was not considered necessary. We are aware of only one previous report describing extraction of pacemaker leads over 30 years old, published in the USA. 4 Although the extraction in our case was not entirely successful, we believe the pacemaker leads in this study were the oldest to be extracted in Korea. We have demonstrated that extraction of pacemaker leads over 30 years old is feasible, but meticulous and gentle manual technique is essential. 60 The Official Journal of Korean Heart Rhythm Society

61 References 1. Voigt A, Shalaby A, Saba S. Continued rise in rates of cardiovascular implantable electronic device infections in the United States: temporal trends and causative insights. Pacing Clin Electrophysiol. 2010;33: Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH 3 rd, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Wazni OM. Heart Rhythm. 2009;6: Buch E, Boyle NG, Belott PH. Pacemaker and defibrillator lead extraction. Circulation. 2011;123:e378-e Brunner MP, Cronin EM, Duarte VE, Yu C, Tarakji KG, Martin DO, Callahan T, Cantillon DJ, Niebauer MJ, Saliba WI, Kanj M, Wazni O, Baranowski B, Wilkoff BL. Clinical predictors of adverse patient outcomes in an experience of more than 5000 chronic endovascular pacemaker and defibrillator lead extractions. Heart Rhythm. 2014:11: Gomes S, Cranney G, Bennett M, Li A, Giles R. Twenty-year experience of transvenous lead extraction at a single centre. Europace doi: /europace/eut Park JS, Pak HN, Lee MH, Kim SS, J B. Implantable cardioverterdefibrillator lead extraction by conventional traction and countertraction technique. Korean Circ J. 2011;41: Cho H, Kim M, Uhm JS, Pak HN, Lee MH, Joung B. Transvenous pacemaker lead removal in pacemaker lead endocarditis with large vegetations: a report of two cases. Korean Circ J. 2014;44: ECG & EP Cases Vol.15 No.3 61

62 ECG & EP Cases Anatomical Obstacles to Catheter Ablation for Atrioventricular Nodal Reentrant Tachycardia 고려대학교의과대학내과학교실노승영 / 박상원 Seung-Young Roh, MD / Sang Weon Park, MD, PhD Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea Abstract Atrioventricular nodal reentrant tachycardia (AVNRT) is one of the most common forms of arrhythmia. The first line of treatment is typically radiofrequency catheter ablation (RFCA), though the efficacy and safety of this procedure can be limited by anatomic variations. We present two cases of patients with anatomic variations undergoing RFCA for AVNRT. These variations were: first, a diverticulum in the right atrial (RA) septum, and second, heart distortion caused by a tuberculosis-destroyed lung. Despite efforts to normalize the procedure, both variations complicated the execution of RFCA. Key Words: atrioventricular nodal reentrant tachycardia catheter ablation diverticulum complication Introduction Case 1 Radiofrequency catheter ablation (RFCA) is the first choice of treatment for symptomatic AVNRT. 1 However, its use in patients with anatomic variations can be complicated. Here, we present two cases of catheter ablation for AVN- RT in patients with anatomic variations: an RA septal diverticulum, and lung-disease-induced heart distortion, respectively. Received: May 23, 2014 Revision Received: September 10, 2014 Accepted: September 14, 2014 Correspondence: Sang Weon Park MD, PhD, Department of Cardiology, Korea University Anam Hospital, 73, Inchon-ro, Seongbuk-gu, Seoul , Korea Tel: , Fax: swparkmd@gmail.comm-suk Ko, MD, PhD, Division of Cardiology A 22-year-old woman presented with paroxysmal palpitation. Electrocardiography (ECG) revealed narrow QRS tachycardia with a pulse rate of 160 beats/min during palpitation (Figure 1). The patient s blood pressure was 110/80 mmhg during tachycardia. QRS rhythm was regular and pseudo R wave was observed in the precordial lead from V1 to V3. Sinus rhythm was restored following rapid administration of intravenous adenosine (6 mg). The patient had no history of disease or operations. A transthoracic echocardiogram (TTE) showed normal left ventricular ejection fraction (60%) and no structural abnormalities. For electrophysiological (EP) investigation, a 2-mm and a 4-mm quadripolar catheter were used to record His and right ventricular (RV) activity, respectively. Unfortunately, placement 62 The Official Journal of Korean Heart Rhythm Society

63 ECG & EP Cases Figure 1. ECG for Case 1. The patient presented with palpitations. The observed narrow QRS tachycardia was attributed to AVNRT following EP investigation. Pseudo R' was observed in precordial lead from V1 to V3 (arrows). A B Figure 2. Right atrial angiogram for Case 1. A pouch-like structure with contractility was observed in the lower septum of the RA (indicated by dot line in A and arrows). It was not definitely separated in RAO view. (A) LAO view. (B) RAO view. a, duodecapolar catheter for RA; b, quadripolar catheter for His; c, quadripolar catheter for RV; d, pigtail catheter for dye injection Vol.15 No.3 63

64 ECG & EP Cases A B Figure 3. Coronary sinus angiogram by retrograde approach for Case 1. The pouch-like structure (indicated by arrows) in the right atrial septum was not enhanced. a, duodecapolar catheter for RA; b, quadripolar catheter for His; c, quadripolar catheter for RV; d, pigtail catheter for dye injection; e, Judkins catheter for left coronary angiogram *, coronary sinus ostium Figure 4. ECG for Case 2. The patient presented with palpitation. The observed narrow QRS tachycardia was attributed to AVNRT following EP investigation. 64 The Official Journal of Korean Heart Rhythm Society

65 A B ECG & EP Cases Figure 5. (A) Chest radiography for Case 2. The right lung was destroyed by prior tuberculosis infection. (B) Chest computed tomography for the same patient. The heart was rotated counter-clockwise and distorted by the destroyed lung. RV, right ventricle; LV, left ventricle; RA, right atrium of a duodecapolar catheter into the coronary sinus (CS) failed as it could not be advanced into the CS ostium. A right atrial (RA) angiogram was performed for structural analysis (Figure 2). A pouch-like structure was observed in the lower septum of the RA, near the CS ostium. As this structure exhibited contractility, it was diagnosed as a diverticulum, rather than a septal aneurysm. A CS angiogram revealed no association between the diverticulum and the CS (Figure 3). Attempts to place the duodecapolar catheter in the CS were impeded by the diverticulum. An EP study was subsequently performed using a duodecapolar catheter positioned at the RA. Tachycardia was induced after an atrio-his (AH) jump, and atrioventricular and ventriculoatrial conduction exhibited decremental properties. Clinical tachycardia was attributed to slow-fast AVNRT after differential diagnostic maneuvers. A deflectable ablation catheter with a 4-mm tip was positioned at the anterior margin of the CS to ablate the slow pathway. The ablation catheter was found to be unstable yet it was easily moved up and down at the margin of the septal diverticulum. As a result, successful RFCA was only achieved after a considerable time interval. Case 2 A 71-year-old man with a tuberculosis-destroyed lung presented with palpitation and dyspnea. Electrocardiography (ECG) revealed narrow-qrs tachycardia with a short RP interval and a pulse rate of 170 beats/min during palpitation (Figure 4). The patient s blood pressure was 100/70 mmhg at the time of recording, and QRS rhythm was regular. Sinus rhythm was restored following rapid administration of intravenous adenosine (6 mg). The patient had diabetes mellitus, hypertension, and a history of pulmonary Vol.15 No.3 65

66 ECG & EP Cases A B C D Figure 6. Electrogram (A) and catheter position (B) for Case 2. Before ablation, the lowest point for detection of His potential (indicated by arrows) was identified using the ablation catheter (d). (C) Electrogram and (D) catheter position at the time of ablation. Ablation was actually carried out at a lower point than that depicted in (B). His potential was not seen on the electrogram from the ablation catheter. a, duodecapolar catheter for right atrium and His; b, quadripolar catheter for His; c, quadripolar catheter for right ventricle 66 The Official Journal of Korean Heart Rhythm Society

67 tuberculosis. A TTE showed preserved left ventricular ejection fraction (55%) and no structural abnormality. Chest radiography and chest computed tomography showed a severely distorted lung (Figure 5), and counter-clockwise rotation of the heart. In RA angiography, the RA exhibited erect morphology. An EP investigation was subsequently performed using a 2-mm and a 4-mm quadripolar catheter to record His and RV activity, respectively. A duodecapolar catheter was positioned at the CS and the RA. Clinical tachycardia was attributed to slow-fast AVNRT on the basis of EP investigation. Due to the high risk of atrioventricular (AV) block, owing to the patient s advanced age and distorted heart structure, the ablation focus was carefully considered. First, the lowest level for detection of His potential was identified (Figure 6A, B). Next, a posterior approach was taken, via the middle or posterior septal region near the CS ostium (Figure 6D). His potential was not observed on the electrogram of the ablation catheter (Figure 6C). Energy delivery resulted in successful induction of junctional rhythm, though ablation was immediately aborted on observing ventriculoatrial (VA) conduction block some seconds later. A high degree of AV block with concurrent hypotension occurred. The AV block was initially sustained but eventually recovered after eight hours; the PR interval normalized after two weeks. Discussion AVNRT is one of the most common tachyarrhythmias, and can be treated by catheter ablation. This can be hazardous when the slow pathway is in close proximity to the normal conduction system. Thus, a clear understanding of cardiac anatomy is essential before AVNRT ablation. We have reported two complicated AVNRT cases related to right heart anatomic abnormalities. In the first case, an RA septal diverticulum compromised the positioning and stability of the catheter. Binder et al. analyzed 103 cases of congenital malformations of the RA and the CS. 2 Of the 103 cases studied, 13 were associated with an RA single diverticulum and these were predominantly asymptomatic. The presentation of symptoms such as supraventricular tachycardia was frequently induced by arrhythmia. We present the first reported case of a single diverticulum in the RA septum. Previous studies have reported cases of RA diverticula predominantly localized to the RA free wall or the CS. 2-7 The RA septal diverticulum described in this case was separated from the CS, as demonstrated by the angiogram. Because the diverticulum exhibited contractility consistent with the heartbeat, we ruled out the alternative diagnosis of septal aneurysm, in which contractility would not be observed. 8 Acquired anatomic distortions can also interfere with RFCA for AVNRT. In the second case, safety was ensured by using numerous methods: (1) RA angiogram, (2) confirmation of the lowest point for detection of His potential, (3) a posterior approach near the CS ostium, and (4) vigilant observation of VA conduction. A contemporary transient high degree AV block was nevertheless seen to occur. For effective and safe catheter ablation in patients with anatomic obstacles, an overview of the precise anatomy is critical. Angiograms and careful mapping can facilitate the identification of anatomic variants, and can confirm precise catheter positioning. ECG & EP Cases Vol.15 No.3 67

68 ECG & EP Cases Conclusion We have reported two difficult AVNRT cases related to right heart anatomic variation: the first, an RA septal aneurysm, and the second, heart distortion due to tuberculosis-destroyed lung. Anatomic obstacles can compromise successful catheter ablation for AVNRT. Reference 1. Katritsis DG, Camm AJ. Atrioventricular nodal reentrant tachycardia. Circulation. 2010;122: Binder TM, Rosenhek R, Frank H, Gwechenberger M, Maurer G, Baumgartner H. Congenital malformations of the right atrium and the coronary sinus: an analysis based on 103 cases reported in the literature and two additional cases. Chest. 2000;117: Morrow AG, Behrendt DM. Congenital aneurysm (diverticulum) of the right atrium. Clinical manifestations and results of operative treatment. Circulation. 1968;38: Di Segni E, Siegal A, Katzenstein M. Congenital diverticulum of the heart arising from the coronary sinus. Br Heart J. 1986;56: Pastor BH, Forte AL. Idiopathic enlargement of the right atrium. Am J Cardiol. 1961;8: Morishita Y, Kawashima S, Shimokawa S, Taira A, Kawagoe H, Nakamura K. Multiple diverticula of the right atrium. Am Heart J. 1990;120: Sheldon WC, Johnson CD, Favaloro RG. Idiopathic enlargement of the right atrium. Report of four cases. Am J Cardiol. 1969;23: Mugge A, Daniel WG, Angermann C, Spes C, Khandheria BK, Kronzon I, Freedberg RS, Keren A, Denning K, Engberding R, Sutherland GR, Vered Z, Erbel R, Visser CA, Lindert O, Hausmann D, Wenzlaff P. Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and transesophageal echocardiography. Circulation. 1995;91: The Official Journal of Korean Heart Rhythm Society

69 Right Heart Penetration Injury by Screw-In Pacing Leads ECG & EP Cases 동아대학교의과대학내과학교실박종성 Jong Sung Park, MD Heart Center, Dong-A University Hospital, Busan, Korea Abstract A 45-year-old male patient complained of chest pain after dual chamber implantable cardioverter defibrillator implantation. No abnormal findings were detected by fluoroscopy and echocardiography examinations. Chest computed tomography (CT) showed the screw of the active fixation lead penetrating the right atrial pericardium. Chest pain disappeared after removal of the right atrial lead. A 65-year-old male patient complained of chest pain and epigastric pain after dual chamber pacemaker implantation. No abnormal findings were detected by fluoroscopy and echocardiography examinations. Chest CT showed the right atrial and ventricular lead tips very close to the pericardium, suggestive of pericardial penetration by the screws of the active fixation leads. The chest pain disappeared after reinsertion of the right atrial and ventricular tined leads. Key Words: pacemaker complication perforation Introduction Right heart perforation is a rare (<1%) complication of cardiac pacemaker implantation procedures. 1 We report two cases of right heart microperforation related to the use of screw-in pacing leads. Case 1 A 45-year-old male patient with Brugada Received: 13 August, 2014 Revision Received: September 10, 2014 Accepted: September 14, 2014 Correspondence: Jong Sung Park, MD, Heart Center, Dong-A University Hospital, 26 Daesingongwon-ro, Seo-gu, Busan, Korea Tel: , Fax: thinkmed@dau.ac.krm-suk Ko, MD, PhD, Division of Cardiology syndrome underwent dual chamber implantable cardioverter defibrillator (ICD) implantation for secondary prevention of sudden cardiac arrest. A screw-in pacing lead (CapSure R, Medtronic, MP, USA) was actively fixed at the right atrial appendage under fluoroscopic guidance. During ICD implantation, the patient did not complain of any chest discomfort. The procedure was completed without immediate or overt complications. However, 3 days later the patient began to complain of mild chest pain radiating towards the right shoulder. The patient described the chest pain as usually triggered by deep inspiration, coughing, or a change in body position. The sensing and pacing parameter values were normal. No abnormal findings were detected by physical, chest radiography, fluoroscopy, and Vol.15 No.3 69

70 ECG & EP Cases Figure 1. Chest computed tomography shows penetration of the right atrium by the screw (arrow) of the right atrial lead. No pericardial effusion and pneumothorax are shown. Figure 2. Chest computed tomography shows the tips of the right atrial (arrow) and ventricular (arrowhead) leads very close to the pericardium. echocardiography examinations. The intensity of the chest pain increased gradually despite ibuprofen and cefazolin administration over 2 weeks. Chest computed tomography (CT) performed 2 weeks after the implantation procedure showed the screw of the pacing lead penetrating the right atrial pericardium (Figure 1). We tried to reposition the right atrial lead to reduce chest pain and avoid overt perforation. Unfortunately, active fixation of the screw lead at other sites within the right atrium repeatedly induced chest pain, which was aggravated by deep inspiration and coughing. Therefore, the right atrial lead was removed. Subsequently, the chest pain decreased gradually and completely disappeared 2 weeks later. The patient was discharged without any other complications. Case 2 A 65-year-old male patient underwent dual chamber pacemaker implantation for sick sinus syndrome. Screw-in pacing leads (CapSure R, Medtronic, MP, USA) were actively fixed at the right atrial appendage and upper interventricular septum under fluoroscopic guidance. During the pacemaker implantation procedure, the patient did not complain of any chest discomfort and the procedure was completed without overt complications. One day after the implantation procedure, the patient began to complain of leftsided chest pain and epigastric pain. The patient described the chest and epigastric pain as being exacerbated upon standing up. The sensing and pacing parameter values were normal. No abnormal findings were detected by physical, chest radiography, fluoroscopy, echocardiography, or endoscopy examinations. The intensity of the pain increased gradually despite ibuprofen, cefazolin, and esomeprazole administration over 2 weeks. Chest CT performed 2 weeks after the implantation procedure showed the right atrial 70 The Official Journal of Korean Heart Rhythm Society

71 (arrowhead) and ventricular (arrow) lead tips very close to the pericardium, suggestive of pericardial penetration injury by the screws (Figure 2). Although no other complications were detected by chest CT, we had to remove the old screw leads and reinsert the new tined leads for differential diagnosis of the chest and epigastric pain. Immediately after the lead reinsertion procedure, the chest and epigastric pain decreased dramatically. Penetration of the pericardium by the screws of the right atrial or ventricular leads was regarded as the cause of chest and radiating epigastric pain. The patient was discharged without other complications. Discussion Overt right heart perforation, which requires invasive intervention is a rare complication of cardiac pacemaker implantation procedures. Asymptomatic cardiac perforation detected by chest CT is much more common (up to 15% of the patients with pacemaker or ICD) than symptomatic cardiac perforation. 2 Right atrial leads, right ventricular ICD leads, and the use of active fixation leads are related with a higher incidence of cardiac perforation. 2,3 If cardiac perforation is mild and not complicated by major vascular complications such as cardiac tamponade, it can be difficult to evaluate for perforation using routine chest radiography, fluoroscopy, and echocardiography examinations. The sensing and pacing parameter values may be normal. Although chest CT can detect pericardial penetration, it is not always possible. If a patient complains of chest pain with clinical characteristics indicative of pericardial origin after a cardiac device implantation procedure, the probability of perforation should be strongly suspected. We report 2 cases of pericardial penetration by the screw of an active fixation lead to remind physicians to consider cardiac perforation as a cause of new onset chest pain in patients who underwent cardiac device implantation. References 1. Carlson MD, Freedman RA, Levine PA. Lead perforation: incidence in registries. Pacing Clin Electrophysiol. 2008;31: Hirschl DA, Jain VR, Spindola-Franco H, Gross JN, Haramati LB. Prevalence and characterization of asymptomatic pacemaker and ICD lead perforation on CT. Pacing Clin Electrophysiol. 2007;30: Danik SB, Mansour M, Singh J, Reddy VY, Ellinor PT, Milan D, Heist EK, d'avila A, Ruskin JN, Mela T. Increased incidence of subacute lead perforation noted with one implantable cardioverter-defibrillator. Heart Rhythm. 2007;4: ECG & EP Cases Vol.15 No.3 71

72 ECG & EP Cases Intractable Ventricular Tachycardia Associated With Stress Cardiomyopathy 경희대학교의과대학내과학교실진은선 Eun-Sun Jin, MD, PhD Cardiovascular Center, Kyung Hee University Hospital at Gangdong, Seoul, Korea Abstract A 75-year-old woman presented with medically intractable wide QRS tachycardia. She had experienced chest discomfort during a vertebral procedure and was transferred to our hospital. Electrocardiography showed sustained wide QRS tachycardia, which persisted in various QRS axes despite the repeated administration of electrical shock. Through amiodarone infusion and repeated shock delivery, the cardiac rhythm was stabilized to a sinus rhythm. Thereafter, the sustained ventricular tachycardia, for which electrical shock was necessary, occurred repeatedly for 12 hours, but then decreased in frequency and disappeared in 3 days. Echocardiography revealed akinesia of the entire left ventricular apical segment, and coronary angiography showed minimal coronary disease, which was compatible with a diagnosis of stress-induced cardiomyopathy. The patient recovered with general supportive care. Follow-up echocardiography revealed normalized left ventricular wall motion and systolic function. Key Words: Takotsubo cardiomyopathy tachycardia ventricular Introduction Received: 14 August, 2014 Revision Received: September 11, 2014 Accepted: September 14, 2014 Correspondence: Eun-Sun Jin, MD, PhD, Cardiovascular Center, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, Korea. Tel: , Fax: esjin@khu.ac.krm-suk Ko, MD, PhD, Division of Cardiology Stress cardiomyopathy (SCM) also known as Takotsubo cardiomyopathy is a common clinical condition with a clinical presentation that similar to acute myocardial infarction. Such patients may present with chest pain, ST changes on electrocardiography (ECG), elevated cardiac enzyme levels, and regional wall motion abnormalities of the left ventricular wall. However, the coronary arteries appear normal in such cases and the prognosis is good. Patients with SCM also present with QT prolongation on ECG. However, only a few cases of SCM presenting with ventricular tachycardia (VT) associated with long QT have been reported. In the present report, we describe a case of a 75-year-old patient with medically intractable monomorphic VT associated with SCM. Case A 75-year-old woman was transferred to the emergency room of our hospital for chest dis- 72 The Official Journal of Korean Heart Rhythm Society

73 ECG & EP Cases Figure 1. Sustained wide QRS tachycardia even after an electrical shock. Occasionally, the QRS axis changed after an electrical shock. Figure 2. Spontaneous QRS axis changes during wide QRS tachycardia. comfort that developed during neuroplasty for lumbar spinal stenosis. She was receiving medication for diabetes mellitus and hypertension. Upon arrival to the emergency room, her ECG showed a sustained wide QRS tachycardia of 150 bpm. Her blood pressure was 90/50 mmhg. We suspected the presence of monomorphic VT, and hence, electrical shock was delivered. After repeated administration of electrical shock, the QRS axis changed, but the wide QRS tachycardia persisted (Figure 1). Most of the VTs were monomorphic, but occasionally, the QRS axis changed spontaneously (Figure 2). The patient underwent electrical shock more than 30 times within 12 hours to terminate the recurrent VT. Because the QT interval of the sinus rhythm was normal (Figure 3), amiodarone was infused for the recurrent VT. Subsequently, VT changed to the nonsus- Vol.15 No.3 73

74 ECG & EP Cases A B Figure 3. Electrocardiography in sinus rhythm showed no QT prolongation (A). 1 month later, ECG showed better R wave progression and T wave change without QT prolongation in precordial leads (B). Figure 4. Coronary angiography showing no significant stenosis. 74 The Official Journal of Korean Heart Rhythm Society

75 tained form and then gradually resolved. Thereafter, echocardiography showed akinesia of the middle and apical wholesegments. Extensive ischemia of the left anterior descending artery was suspected, but the findings were also compatible with stress-induced cardiomyopathy. In addition, coronary angiography indicated no significant stenosis (Figure 4). Amiodarone administration was discontinued because of the development of QT prolongation during drug infusion. With supportive treatment, the left ventricular function and wall motion normalized, and VT did not recur. The patient was discharged without any medication. ECG which was taken 1 month after discharge showed better R wave progression with T wave change without QT prolongation in precordial leads (Figure 3B). Discussion SCM is a commonly encountered disease, characterized by its initially severe presentation, followed by a mild clinical course. On presentation, it is often misdiagnosed as myocardial infarction. The most distinguishable clinical aspects of this disease are the absence of coronary artery stenosis and a good prognosis. Although myocardial infarction is the most common cause of sudden cardiac death, the mortality rate of SCM in hospitals ranges from 1% to 2%. 1,2 A potentially dangerous clinical presentation of SCM is torsades de pointes coinciding with QT prolongation, which is often accompanied by hypokalemia. 3 However, cases of sustained VT causing cardiac death are uncommon. In the present case, the patient showed recurrent, sustained VT of both the monomorphic and polymorphic forms, with the monomorphic form occurring more frequently. In the sinus rhythm, QT was not prolonged and the serum potassium level was 3.5 mmol/l. Although prolonged QT with polymorphic VT is a common ECG finding in cases of SCM, monomorphic VT may also develop. Because the proposed mechanism of SCM involves microvascular myocardial ischemia. 4,5 Medical treatment for sustained VT can be adjusted according to the VT mechanism. Amiodarone infusion is not used for treating cases of torsades de pointes with long QT, but can be used for treating cases of monomorphic VT with no QT prolongation that may be associated with microvascular myocardial ischemia. Although a patient may experience life-threatening sustained VT resulting from SCM, placement of an implantable cardioverter-defibrillator is not recommended because SCM is considered a reversible, self-limited disease. Nevertheless, 11% of patients experience symptom recurrence after a 4-year follow-up period. 6 Thus, large-scale, longterm follow-up data are needed to estimate the recurrence of life-threatening VT caused by SCM. References 1. Sharkey SW, Windenburg DC, Lesser JR, Maron MS, Hauser RG, Lesser JN, Haas TS, Hodges JS, Maron BJ. Natural history and expansive clinical profile of stress (takotsubo) cardiomyopathy. J Am Coll Cardiol. 2010;26;55: Dib C, Prasad A, Friedman PA, Ahmad E, Rihal CS, Hammill SC, Asirvatham SJ. Malignant arrhythmia in apical ballooning syndrome: risk factors and outcomes. Indian Pacing Electrophysiol J. 2008;1;8: Kawano H1, Matsumoto Y, Arakawa S, Satoh O, Hayano M. Premature atrial contraction induces torsades de pointes in a patient of Takotsubo cardiomyopathy with QT prolongation. Intern Med. 2010;49: Galiuto L, De Caterina AR, Porfidia A, Paraggio L, Barchetta S, Locorotondo G, Rebuzzi AG, Crea F. Reversible coronary microvascular dysfunction: a common pathogenetic mechanism in Apical Ballooning or Takotsubo Syndrome. Eur Heart J. 2010;31: Afonso L, Bachour K, Awad K, Sandidge G. Takotsubo cardiomyopathy: pathogenetic insights and myocardial perfusion kinetics using myocardial contrast echocardiography. Eur J Echocardiogr. 2008;9: Elesber AA, Prasad A, Lennon RJ, Wright RS, Lerman A, Rihal CS. Fouryear recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol. 2007;50: ECG & EP Cases Vol.15 No.3 75

76 자율학습문제 부정맥연구회지에서는매호자율학습문제를수록합니다. 해당호에실린원고를바탕으로출제된문제로선생님들의자기계발에도움이되시길바랍니다. 많은참여부탁드립니다. 모범답안은다음호에게재합니다. 1. 다음중영구형심박동기의적응증으로적당하지않은것은? 1 증상을동반한동휴지가입증된경우 2 증상을동반한심박수변동부전 (chronotropic incompetence) 이있는경우 3 심실성부정맥을초래하는고도 2도방실차단 4 증상이없는심방세동에서 3초이상의무수축심정지가증명된경우 2. 영구형인공심박동기삽입시적절한심방의조율역치와감지신호의크기가맞는조합은? V 이하 5.0 mv 이상 V 이하 2.0 mv 이상 V 이하 5.0 mv 이상 V 이하 2.0 mv 이상 3. 심박동기시술후추적관찰중에갑자기임피던스가 2,200 Ω 소견이관찰되었다. 이경우의심할수있는것은? 1 박동기이식 site 감염 2 박동기이식한정맥의폐색 3 전극선단락 4 전극선절연피폭손상 4. 인공심박동기감염의위험인자가아닌것은? 1 말기신부전 2 일시형심박동기삽입 3 박동기교환 4 혈종형성

77 Vol.15 No.2 통권 49 호 자율학습문제 [ 모범답안 ] 1. 심인성색전증에대한임상적인특징으로적당하지않은것은? 1 갑작스럽게발병한다. 2 증상이빠르게진행한다. 3 뇌피질부의국소신경학적증상은드물다. 4 갑작스럽게증상이호전될수있다. 정답 : 3 기타뇌경색과달리시야장애나무시증후군, 실어증과같이뇌피질부의국소신경학적결손을보이는경우가많다. 2. 심인성색전증에대한영상학적인특징으로적당하지않은것은? 1 다양한뇌동맥의영역에동시에발생한다. 2 뇌경색후출혈변성이동반된다. 3 뇌내혈관의폐색이초기에재개통된다. 4 소대뇌혈관영역에서발생한다. 정답 : 4 뇌색전증환자중약 75% 에서는중대뇌혈관영역의뇌경색이발견되었다. 3. 원인을알수없는뇌졸중환자에서심방세동의가능성은어느정도인가? 1 5% 2 15% 3 25% 4 35% 정답 : 3 이식형루프기록기를이용한연구에서 26-27% 정도로보고되었다. 4. 뇌손상환자에서발생할수있는심장에대한설명으로적절한것은? 1 지주막하출혈에서허혈성뇌손상보다더많이발생한다 2 QT interval shortening 에의해급사의원인이된다. 3 Epinephrine 의과도한분비가 neurogenic stunned myocardium 의원인이다. 4 우반구의뇌손상시좌반구보다서맥, 빈맥이더많이발생한다. 정답 : 4 1 허혈성뇌졸중보다는지주막하출혈에서더빈번하게관찰된다. 2 QTc interval의연장이뚜렷한경우뇌손상후에발생하는심인성급사의원인이될수있다. 3 Myocardia sympathetic nerve terminals에서과도한 norepinephrine의분비가원인으로알려져있다.

78 투고및윤리규정 목적과개요 부정맥 (The Official Journal of Korean Heart Rhythm Society) 은대한심장학회부정맥연구회의주관으로발행되며, 부정맥과관련된새로운임상지식, 진료지침, 증례등을소개하여부정맥연구회회원및개원의의지속적인의학교육에이바지하고자발행되는최신학술지이다. 본지는부정맥의진단과치료, 임상연구와관련된원저, 종설, 논평, 증례보고등을편집위원회에서검토후게재한다. 연구및출판윤리규정 본규정은대한심장학회부정맥연구회지 (The Official Journal of Korean Heart Rhythm Society) 회원들의학술활동중연구윤리를확보하는데필요한역할과책임에관하여기본적인원칙과방향을제시하기위하여제정되었으며, 각회원은연구활동중정직성, 진실성, 정확성이연구결과의신뢰성확보를위한필수조건임을인식하고모든연구활동을수행함에있어이규정을준수하도록한다. 1. 저자들은 Uniform Requirements for Manuscripts Submitted to Biomedical Journals( org/) 에서규정한윤리규정을준수해야한다. 2. 본학술지에투고하는원고의연구대상이사람인경우는헬싱키선언 (Declaration of Helsinki [ 의윤리기준에일치해야하며, 기관의윤리위원회또는임상시험심사위원회 (Institutional Review Board) 의승인을받고, 필요한경우에연구대상자의동의서를받았음을명시해야한다. 3. 동물실험연구는실험과정이연구기관의윤리위원회의규정이나 NIH Guide for the Care and Use of Laboratory Animals의기준에합당해야한다. 4. 간행위원회는필요시환자동의서및윤리위원회승인서의제출을요구할수있다. 5. 이해관계명시 (Disclosure of conflict of interest): 연구에소요된연구비수혜내용은감사의글에필히기입해야한다. 연구에관계된주식, 자문료등이해관계가있는모든것은표지하단에밝혀져야하며, 이를모두명시했음을원고의저자전원의자필서명이있어야한다. 6. 원칙적으로타지에이미게재된같은내용의원고는게재하지않으며, 본지에게재된것은타지에게재할수없다. 단, 독자층이다른타언어로된학술지에게재하기위한경우등의중복출판은양측간행위원장의허락을받고, 중복출판원고표지에각주로표시하는등, 다음문헌에서규정한요건을갖춘경우에만가능하다 (Ann Intern Med 1997;126:36-47). 7. 윤리규정및표절 / 중복게재 / 연구부정행위등모든연구윤리와연계되는사항에대한심사및처리절차는대한의학학술지편집인협의회에서제정한 ' 의학논문출판윤리가이드라인 ( kamje.or.kr/publishing_ethics.html)' 을따른다. 원고범위 1. 원저 (Original Article) 는인간을대상으로한연구 ( 임상적조사및보고서 ) 와동물을이용한실험및생체외실험에대한연구 ( 기초과학보고서 ) 로한다. 2. 종설 (Review Article) 은특정분야나주제에관해간결하고포괄적으로평가한논문으로위촉된종설에한하여게재하는것을원칙으로하나편집진의재량에따라위촉되지않은종설도게재가능하다. 3. 논평 (Editorial) 은타학술지에게재된논문에대한저자의견해를기술한것으로, 편집진의의뢰하에쓰여진다. 4. 증례보고 (Case Report) 의요건은국내첫증례또는희귀증례로제한한다. 집필규정 1. 원저와증례보고는영어, 종설과논평은한글을사용하여맞춤법에맞게작성하며모든학술용어는대한의사협회에서발간한의학용어집의최신판에수록된용어를사용한다. 2. 한글로작성하는원고는원어의적당한한글용어가없는경우한글뒤 ( ) 안에원어는표기할수있다. 부득이외국어를사용할때는대소문자의구별을정확히해야한다 ( 예 : 고유명사, 지명, 인명은첫글자를대문자로하고그외에는소문자로기술함을원칙으로한다 ). 적절한번역어가없는의학용어, 고유명사, 약품명, 단위등은원어를그대로사용한다. 3. 번역어가있으나의미전달이명확하지않은경우에는그용어가최초로등장할때번역어다음소괄호속에원어로표기하고그이후로는번역어만사용한다. 4. 검사실검사수치의단위는 SI 단위 (International System of Units) 를사용하고, 편집위원회의요구나필요에따라괄호안에비SI 단위수치를첨부할수있다. 5. 약자는가능한한사용하지않는것이좋지만, 본문에일정용어가반복사용됨으로인해부득이약자를사용해야하는경우에는그용어가처음나올때괄호안에약자를함께표기하고다음부터약자를사용할수있다. 6. 원고는컴퓨터문서작성프로그램 (MS 워드또는한글 ) 을사용

79 하여작성한다. 글자의크기는명조계통의 10 point, 정렬은좌측정렬을하며, 줄간은한글의경우 160%, 워드의경우 1줄간격으로하며좌우및위아래여백은 3 cm로한다. 원고면의번호는제목쪽부터시작하여차례대로중앙하단에표시한다. 원고의형식 1. 원저 (Original Article) 표지, 초록과키워드, 본문, 감사문, 참고문헌, 도표, 그림 / 사진설명, 그림및사진의순으로하며, 제목쪽과초록및참고문헌은각각분리된쪽으로작성한다. 1) 표지 (Title Page) 1 제목, 소속, 저자명, 영문제목및영문소제목 ( 빈칸을포함하여 50자이내 ), 영문저자명, 영문소속순으로하며, 표지하단에교신저자 (corresponding author) 의이름, 주소, 소속, 전화번호, 팩스번호, 주소등을명시해야한다. 2 저자들의소속이다수인경우소속명을같은행에연이어나열하며, 아라비아숫자의어깨번호로소속과저자명을일치시킨다. 영문저자명뒤의 MD나 PhD 등에는글자다음에구두점을찍지않는다. 2) 초록과키워드 (Abstracts and Key Words) 모든원고에는영문초록을첨부해야하며, 초록은 250단어이내로한다. Background and Objectives, Subjects (Materials) and Methods, Results, Conclusion 의순으로구분하여소제목에따라줄바꿈없이작성한다. 증례보고인경우소제목없이가능하며, 초록은 150단어이내로한다. 단논평의경우초록과 key words 를첨부하지않는다. 그리고각초록의말미에 Index medicus 에등재된용어 5개이내로영문 key words 를삽입한다. 3) 본문 (Text) 서론, 대상 ( 재료 ) 및방법, 결과, 고찰, 요약, 중심단어순으로작성한다. 1 서론에는연구와관련된간략한배경과연구의목적이언급되어야한다. 2 대상 ( 재료 ) 및방법은매우상세히기재해야하며결과의통계적검증방법도밝혀야한다. 3 고찰은연구결과와연관된새롭고중요한측면에대한내용으로제한한다. 4 요약은결과와고찰로부터유도되고, 서론에서언급한연구목적과부합되어야하며, 결과의단순한요약은금한다. 요약의구성은배경및목적, 방법, 결과, 결론의순으로구 분하여소제목에따라줄바꿔작성한다. 그리고국문논문은요약다음에한글중심단어를초록의영문중심단어와일치시켜삽입한다. 4) 감사문 (Acknowledgments) 감사문에는본연구의연구비지원기관, 본연구를수행하는데여러가지로도움을주었던분들에대한사항을기술한다. 5) 참고문헌 (References) 1 원저는 30개이하, 증례보고는 20개이하로제한한다. 종설은참고문헌수를제한하지않는다. 2 참고문헌은본문에나타난것만인용한다. 본문에서는인용순서에따라아라비아숫자로저자명뒤또는문장끝에어깨번호로표시한다. 참고문헌의배열도인용한순서대로작성한다. 동일저자의경우연도순으로나열하며, 국내문헌도영문표기를원칙으로한다. 3 참고문헌의저자는모두기재한다. 저자표기는 last name 은다쓰고, first name 과 second name 은첫글자를대문자로붙이고 initial 에마침표 (. ) 는사용하지않는다. 저자명사이에는쉼표 (, ) 로구분하고, 마지막저자명뒤에는마침표 (. ) 를찍는다. 4 잡지명은 List of Journals Index Medicus 에의거약어로기재하며, 인용학술지명뒤에는마침표를찍는다. 인용논문의제목중첫글자는대문자로하고, 부제목이있는경우쌍점 (:) 을붙인후소문자로기재하며제목뒤에는마침표 (. ) 로표시하며, 연도를표시한후쌍반점 (;) 으로붙여서구분후, 권 : 시작쪽-끝쪽의전체페이지를기재하며, 마지막에마침표를찍는다. 예 ) Smith HJ, Allen S, Yu W, Fard S. This is the title. Circulation. 2004;104: ) 표 (Table) 1 표는영문과아라비아숫자로기록하며표의제목을명료하게절혹은구의형태로기술한다. 문장의첫자를대문자로한다. 2 분량은 4줄이상의자료를포함하여 1쪽을넘지않는다. 3 본문에서인용되는순서대로번호를붙인다. 4 약어를사용할때는해당표의하단에알파벳순으로풀어서설명한다. 5 기호를사용할때는 *,,,,,, **,, 의순으로하며이를하단각주에설명한다. 6 표의내용은이해하기쉬워야하며, 독자적기능을할수있어야한다. 7 표를본문에서인용할때는영문 (Table 1과같이 ) 을사용한다.

80 7) 그림및사진 (Figure) 1 그림및사진은 ppt 파일형식으로원문과별도의파일을만 들어서제출한다. 2 동일번호에서 2 개이상의그림이필요한경우에는아라비아 숫자이후에알파벳글자를기입하여표시한다 ( 예 : Figure 1A, Figure 1B). 3 그림을본문에서인용할때에는한글 (Figure 1 과같이 ) 을사 용한다. 4 최종통과시그림및사진은 jpg 파일형식으로 1장씩 10메가이내로파일을만들어서제출한다. 8) 그림및사진설명 (Figure Legends) 1 본문에인용된순으로아라비아숫자로번호를붙인다. 2 모든그림및사진은설명이있어야하며, 별지에영문으로구나절이아닌문장형태로기술한다. 3 현미경사진의경우배율을기록한다. 2. 원저이외의원고 일반사항은원저에준한다. 1) 종설 (Review Article) 종설은특정제목에초점을맞춘고찰로서편집위원회에서위촉혹은투고에의하여게재한다. 단, 투고된원고는심사를거쳐게재여부를결정한다. 2) 증례보고 (Case Report) 1 전체분량이 A4 용지 10 매이내로작성한다. 4 참고문헌의수는 20개이내, 그림은 5장이내로한다. 5 저자수는 7명이내로한다. 3) 논평 (Editorial) 학회지에출판된특정논문에대한논평을의뢰받아집필되는부문으로학회의의견을반영하는것은아니다. 원고는 A4 용지 4 매이내로작성하고참고문헌은 10개이내로제한한다. 기타사항 1. 본학회지는연간 4회 (3, 6, 9, 12월말일 ) 발간한다. 2. 필요할경우원문에영향을미치지않는범위내에서자구와체제를편집방침에따라편집위원이수정할수있다. 3. 원고의게재여부는원고심사후편집위원회에서결정하며본규정에맞지않는원고는개정을권유하거나게재를보류할수있다. 4. 학회지의게재는원고의저작권이저자로부터학회지로이양되는것을저자가승인한것으로인정한다. 5. 원고제출처 부정맥연구회온라인논문투고사이트 엠엠케이커뮤니케이션즈 ( 주 ) jhkim@mmk.co.kr 주소 : 서울시강남구논현로 523, 노바빌딩 3층 ( ) 전화 : 팩스 : 영문초록은항목구분없이 150 단어이내로한다. 3 고찰은증례가강조하고있는특정부분에초점을맞추며장황한문헌고찰은피한다.

81 저자점검표 저자 ( 소속 ): 논문제목 : 다음은귀하가본부정맥연구회지 (The Official Journal of Korean Heart Rhythm Society) 에투고하는논문이투고규정에맞도록각 항목별로충실히작성되어있는지점검하는저자점검표입니다. 논문투고시해당칸에표시하여논문과함께반드시제출하여주십시오. 일반사항 1. 본논문의내용은다른학회지에게재되지않았고, 게재예정도없다 2. 원고는 A4용지 10포인트크기로여백상, 하, 좌, 우 3.5, 3, 3, 3 cm, 줄간격 1 기준으로작성하였다 3. 원저는표지, 영문초록, 서론, 본론, 결론, 참고문헌, Table, Figure 순서의양식으로구성하며, 본론은소제목으로구분한다 4. 증례는표지, 영문초록, 서론, 증례, 고찰, 참고문헌, Table, Figure 순서의양식으로구성한다 5. 일련쪽수를하단에기재하였다 표지 1. 논문제목 2. 저자소속, 이름 3. 영문제목, 영어저자명, 영어소속 4. 요약제목 (Running title) - 국문제목 30자이상, 영문제목 12단어이상 5. 책임저자이름, 주소, 전화, Fax, 전자우편주소 6. 연구비에대한사항을각주에적었다 ( 해당되는경우 ) 영문초록 1. 영문제목이한글제목과일치하도록작성, 영문성명, 영문소속의올바른기재 2. 원저는내용을 Background, Objective, Method, Result, Conclusion 으로규정된형식으로작성하였다 3. 증례는내용을한단락 (paragraph) 으로작성하였다 4. Key Words 3-5개를 MeSH 에맞게작성하였다 본문 1. 한글로사용가능한용어는한글로기재하였다 2. 본문중해당참고문헌의어깨번호를표시하였다 참고문헌 1. 투고규정준수에맞게모두영문으로작성하여 PubMed 와 KorMed 에서확인하였다 2. 참고문헌의모든공저자를기재하였다 3. 학술지표기는 Index Medicus 의공인된약어를사용하였다 4. 학술지를이탤릭체로표기하였다 Table 과 Figure 1. Table 과 Figure 는중복되지않도록작성하였다 2. Table 과 Figure 는투고규정에맞도록작성하였다 3. 제목및설명모두영문으로기재하였다 4. 제목에서약자를사용하지않으며, Table 과 Figure 에사용된약자는하단에설명을기재하였다 본논문의저자 ( 들 ) 은부정맥연구회지 (The Official Journal of Korean Heart Rhythm Society) 의투고규정에따른위의사항들을확인하였으며, 논문게재를요청합니다. 20 년 월 일 저자대표 ( 서명 )

82 저작권이양동의서 논문제목 국 영 문 문 본논문의저자 ( 들 ) 은본논문의부정맥연구회지 (The Official Journal of Korean Heart Rhythm Society) 게재를바라며, 이에다음사항들에대하여동의합니다. 1. 본논문의저자 ( 들 ) 은본논문이창의적이며, 다른논문의저작권침해, 비방, 혹은사적침해등내포하지않음을확인합니다. 2. 본논문의저자 ( 들 ) 은본논문에실제적이고지적인공헌을하였으며, 본논문의내용에대하여공적인책임을공유합니다. 3. 본논문은과거에출판된적이없으며, 현재다른학술지에게재를목적으로제출되었거나제출할계획이없습니다. 4. 본논문의저자 ( 들 ) 은본논문이부정맥연구회지 (The Official Journal of Korean Heart Rhythm Society) 에게재될경우, 저작권에관한모든권리, 이익및저작권에대한모든권한행사등을대한심장학회부정맥연구회에이양하기로동의합니다. 이는저자 ( 들 ) 이향후다른논문에본논문의자료를사용할경우대한심장학회부정맥연구회로부터서면허가를받아야하며, 이경우자료가발표된원논문을밝혀야하다는것을의미합니다. 년월일 저자성명서명저자성명서명 책임저자 제 5 저자 제 1 저자 제 6 저자 제 2 저자 제 7 저자 제 3 저자 제 8 저자 제 4 저자 제 9 저자

83 The Official Journal of Korean Heart Rhythm Society

84 The Official Journal of Korean Heart Rhythm Society