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1 대한내과학회지 : 제 88 권제 2 호 특집 (Special Review) - 심부전치료의최신지견 심부전환자에서기계적순환보조장치의임상적인역할 1 분당서울대학교병원순환기내과, 2 서울대학교병원순환기내과 박진주 1 ㆍ조현재 2 Mechanical Circulatory Support for Advanced Heart Failure Jin Joo Park 1 and Hyun-Jai Cho 2 Division of Cardiology, Department of Internal Medicine, 1 Seoul National University Bundang Hospital, Seongnam; 2 Seoul National University Hospital, Seoul, Korea Patients with end-stage heart failure or cardiogenic shock experience unacceptably high mortality despite advances in treatment made over the past 50 years. The effects of vasoactive drugs used to manage cardiogenic shock may be limited, being highly dependent on remaining heart function. Mechanical circulatory support improves cardiac output independent of heart function. Intra-aortic balloon pumps (IABPs) and extracorporeal membrane oxygenation (ECMO) are the devices most commonly used in Korea. Despite frequent use, the utility of IABPs in acute myocardial patients remains controversial, whereas ECMO affords sufficient systemic perfusion pressure to reverse end-organ dysfunction. Both can only be used as acute treatments, thus as a bridge-to-recovery or a bridge-to-transplantation. Percutaneous left ventricular assist devices (LVADs) such as TandemHeart and Impella are not in use in Korea. Implanted LVADs improve long-term outcomes and may also serve as destination therapies. In the present manuscript, we briefly review percutaneous and implantable devices currently used in Korea for the management of advanced heart failure. (Korean J Med 2015;88: ) Keywords: Heart failure; Intra-aortic balloon pumping (IABP); Extracorporeal membrane oxygenation (ECMO); Ventricular assist device (VAD) 서론말기심부전환자또는심인성쇼크상태의환자는적절한체액량을조절하더라도심장의기능저하로말초장기와조직의관류가충분하지않아장기의기능이상을초래하는상태를말한다 [1]. 심인성쇼크는혈류역학적으로는지속적 인저혈압 ( 수축기혈압 < 90 mmhg), 낮은심박출계수 (< 2.2 L/min/m 2 ), 심실충만압의상승 ( 좌심실충만압 > 18 mmhg, 우심실충만압 > mmhg) 등으로정의하고있다. 임상적으로핍뇨및신부전, 간부전, 염기성대사및유산혈증등이관찰될수있다. 심인성쇼크의가장흔한원인은급성심근경색에의한심기능감소이며그외판막질환, 말기심부전, Correspondence to Hyun-Jai Cho, M.D., Ph.D. Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul , Korea Tel: , Fax: , hyunjaicho@snu.ac.kr Copyright c 2015 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

$심인성쇼크는쇼크전단계 (pre-shock), 경증쇼크 (mild shock), 중등의진행형쇼크 (profound shock) 그리고중증의불응성쇼크 (severe refractory cardiogenic shock) 의 4단계로구분되며각단계를고려하여치료방향을결정하는것이도움이된다 (Fig. 1). 심인성쇼크환자의병원내사망률은 80% 까지보고된다.$ 특히쇼크초기단계는가역적이지만시간이지날수록비가역적인단계로도입하므로초기대응이중요하다. 심인성쇼크환자에서약물적치료의효과여부는잔여심장기능으로결정되는경우가많다. 이에약물적치료만으로심박출계수를충분히높게유지하지못하여다발성장기부전및환자의사망으로이어지는경우가많다.

특히쇼크초기단계는가역적이지만시간이지날수록비가역적인단계로도입하므로초기대응이중요하다. 심인성쇼크환자에서약물적치료의효과여부는잔여심장기능으로결정되는경우가많다. 이에약물적치료만으로심박출계수를충분히높게유지하지못하여다발성장기부전및환자의사망으로이어지는경우가많다.

2 - Jin Joo Park, et al. MCS in HF - 급성심근염, 스트레스유발성심근증등이있다. 심인성쇼크는쇼크전단계 (pre-shock), 경증쇼크 (mild shock), 중등의진행형쇼크 (profound shock) 그리고중증의불응성쇼크 (severe refractory cardiogenic shock) 의 4단계로구분되며각단계를고려하여치료방향을결정하는것이도움이된다 (Fig. 1). 심인성쇼크환자의병원내사망률은 80% 까지보고된다. 특히쇼크초기단계는가역적이지만시간이지날수록비가역적인단계로도입하므로초기대응이중요하다. 심인성쇼크환자에서약물적치료의효과여부는잔여심장기능으로결정되는경우가많다. 이에약물적치료만으로심박출계수를충분히높게유지하지못하여다발성장기부전및환자의사망으로이어지는경우가많다. 약물적치료의한계를극복하기위해최근개발되고있는기계적순환보조장치 (mechanical circulatory support, MCS) 는잔여심장기능과무관하게심박출계수를증가시키기에중증의심인성쇼크환자에서예후를개선할수있는가능성을열어주었다. 특히 MCS는심근허혈을유발하지않고심근의산소요구량을감소시키면서혈류를유지또는증가할수있는장점을가지고있다. 심인성쇼크의발생기전및속도에따라 MCS의선택및치료목적이달라지기에심인성쇼크의원인및단계를정확하게규명해야한다. 급성심근경색또는전격성심근염같은가역적인원인이있는경우 MCS를심기능이회복되는동안 (bridge to recovery) 일시적으로사용할수있다. 심장이식을대기중인만성말기심부전환자에서는심장이식술까지환자를지지해주거나 (bridge to transplantation) 평생심실보조장치 (destination therapy) 로사용될수도있다. 기계적심장보조 ( 대부분심실보조 ) 는기능상으로대동맥내풍선펌프 (intra-aortic balloon pumping, IABP), extracorporeal membrane oxygenator (ECMO), percutaneous cardiopulmonary support (PCPS), 좌심실및우심실보조장치 (left ventricular assist device [LVAD], right ventricular assist device [RVAD]) 및완전인공심장 (total artificial heart) 으로분류한다 (Fig. 2). 본고에서는심인성쇼크환자에서기계적순환보조치료술의역할에대해기술하고자한다. 본론 Intra-aortic balloon pumping (IABP) IABP 는이완기에하행대동맥내에위치한풍선을확장시켜관상동맥혈류를증가시키고수축기에풍선을감압시켜후부하를감소시키는기전으로좌심실을보조한다. 또한좌심실충만압을감소시켜심근의산소소모량을감소시키게된다. 혈류역학적으로 IABP 는심박출량 (cardiac output) 을약 L/min, 심구출률 (stroke volume) 을약 20-30% 가량증가시킬수있다 [2]. IABP 는급성심근경색환자에서심근손실, 급성승모판역류증또는심실중격결손등으로인해심부전이발생할경우에삽입을고려한다 (Table 1). 대부분대퇴동맥을천자해서풍선을삽입하는데풍선의끝 (balloon tip) 은왼쪽쇄골하동맥 (left subclavian artery) 직하부에위치시키며흉부단순촬영에서 2-3번째늑간 (intercostal space) 에풍선마커 (balloon marker) 가보이게된다. 풍선의크기는환자의키에따라선 A B C Figure 1. Mortality and treatment strategy according to the stage of shock. IABP, Intra-aortic balloon pumping; ECMO, extracorporeal membrane oxygenation. Figure 2. Mechanical circulatory support devices. (A) IABP. (B) ECMO. (C) LVAD. IABP, intra-aortic balloon pumping; ECMO, extracorporeal memrane oxygenator; LVAD, left ventricular assist device

- 대한내과학회지 : 제 88 권제 2 호통권제 654 호 2015 - Table 1. Indications for IABP Cardiogenic shock associated with AMI. To stabilize high-risk patients either before or after revascularization.

$IABP, intra-aortic balloon pumping; AMI, acute myocardial infarction; LV, left ventricle; EF, ejection fraction; MI, myocardial infarction. 택하게되는데적절한크기는신동맥 (renal artery) 의직상부가풍선의끝에위치하는경우이다 (Fig. 3).$

3 - 대한내과학회지 : 제 88 권제 2 호통권제 654 호 Table 1. Indications for IABP Cardiogenic shock associated with AMI. To stabilize high-risk patients either before or after revascularization. LV dysfunction (EF < 40%); the culprit vessel supplies > 40% of the myocardial territory. Mechanical complications of MI Mitral regurgitation. Ventricular septal defect. IABP, intra-aortic balloon pumping; AMI, acute myocardial infarction; LV, left ventricle; EF, ejection fraction; MI, myocardial infarction. 택하게되는데적절한크기는신동맥 (renal artery) 의직상부가풍선의끝에위치하는경우이다 (Fig. 3). IABP 를삽입후대부분항응고요법을시작하지만환자에서출혈이있거나출혈위험이높은경우상황에따라항응고요법을시행하지않을수도있다 [3]. 풍선의팽창은이완기의시작시점에시작하여감압은수축기직전시행되도록해야한다. 작동 (triggering) 방법으로는심전도에서 R-wave를기준으로하는방법이가장널리쓰인다. 그외동맥압커브 (arterial pressure curve) 에따라하는방법과심장박동기를가지고있는환자의경우에는 pacing spike를인식하는방법등이있다. 이상적인 counter-pulsation에의한대동맥압커브 (aorta pressure curve) 는그림과같다 (Fig. 4). 최근의기계들은자동적으로최적의팽창및갑압시기 (optimal inflation/deflation timing) 를선택하고있으나 IABP 삽입후에는우선 1:2 counterpulsation을실시하여팽창및감압시기 (inflation-deflation timing) 가적절하게설정되었는지확인이필요하다. 이후필요에따라 counter-pulsation setting을 1:1-1:4까지적용한다. 적절히 counter-pulsation이되고있는지를다음의순서로확인한다. 첫째로 IABP augmentation 에의한 peak diastolic pressure (PDP) 는 peak systolic pressure (PSP) 보다높게유지되는지확인이필요하다. PDP가 PSP보다낮다면 (i) 환자의크기에비해풍선크기가상대적으로작은지, (ii) 풍선의팽창장애가있는지, (iii) 풍선의위치가너무밑으로내려오지는않았는지 ( 단순흉부방사선촬영 ), (iv) 혈관내용적이부족한지등을확인하고필요시교정해야한다. 둘째로 1:2 setting 에서 non-augmentation 시보이는 dicrotic notch가 IABP augmentation 시보일듯말듯한지를확인한다. Dicrotic notch가확실히보이면 late inflation이므로 inflation timing을앞쪽으 Figure 3. Location of the IABP balloon. The distal marker of the balloon should be positioned between the second and third intercostal spaces (circle). IABP, intra-aortic balloon pumping. Figure 4. Ideal aorta pressure curve featuring counter-pulsation by IABP. IABP, intra-aortic balloon pumping. 로조정해야한다. 셋째로 augmentation 시 balloon aortic end diastolic pressure는 non-augmentation 시 patient aortic end diastolic pressure보다낮아야한다. 넷째로 augmentation 직후의 assisted peak systolic pressure (APSP) 는 non-augmentation 시의 patient PSP보다낮아야 augmentation이효과적이라고할수있다. APSP와 patient PSP가비슷하다면 augmentation의기간이짧을것을뜻하므로 deflation timing을뒤로조정한다. IABP 의임상적적응증은현재변하고있다. IABP 는 1968 년 Adrian Kantrowitz 박사가심인성쇼크를앓고있는 45세여자환자에서 7시간동안처음으로사용했으며 [4] 이후약 3백만이상의환자가 IABP 로치료를받았다. 현재가장많이사용되고있는 IABP 의적응증은심인성쇼크를동반한급성심근경색환자이다. 심근경색증환자에서 IABP 의효과는 (i) 재관류요법이불가능했었던시기, (ii) 혈전용해제를사용했던시기, (iii) 그리고일차적관동맥성형술이가능해

4 - 박진주외 1 인. 기계적순환보조 - 진시기등 3개의시기로나누어서평가해야한다. 재관류가가능하지않은시절에 IABP 사용은심근경색환자에서심근경색의크기를줄이지못하고환자의예후또한개선하지못했다 [5,6]. 관상동맥이막혀있는상태에서 IABP 를사용해도관상동맥의혈류를증가시킬수없기때문에예후를개선하지못하는것으로추정하고있다. 혈전용해제를사용하는시기에서 IABP 는심근경색환자의예후를개선시켰다 [7]. GUSTO 연구에서는 IABP 와혈전용해제를같이사용하는환자가혈전용해제를단독사용하는군보다 30일및 1년째사망률이낮음을보고하였다 [8]. 다른후향적연구에서는혈전용해제와 IABP 를같이사용하는군에서 1년사망률 (67% vs. 32%, p = 0.019) 이더낮다고보고하였다 [9]. 여러후향적연구에서도또한항응고제 (heparin, futhan 등 ) 를사용하는급성심근경색환자에서 IABP 사용은환자의예후를개선시킴을보고하였다 [7]. ST분절상승급성심근경색환자에서혈전용해제사용시재관류로인해관상동맥의혈류는개선되지만대부분 culprit lesion 에유의한협착이남아있다. IABP 는이완기시관상동맥의혈류및혈압을증가시키기에 culprit 에협착이남아있어도협착원위부심근으로더많은산소가전달될것으로기대되며이것이예후를개선시키는기전으로추정되고있다. 급성심근경색환자에서일차적관상동맥중재시술 (primary percutaneous coronary intervention, primary PCI) 이표준치료가된이후 IABP 의임상적역할을조사한연구들이있다. 미국급성심근경색레지스트리 (National Registry of Myocardial Infarction-2) 에따르면일차적관상동맥중재시술을받은환자에서 IABP 는사망률을감소시키지못했다 (45% vs. 47%) [7]. 심근경색환자들을대상으로한체계적문헌조사에서도 IABP 는 30일째사망률을혈전용해제를사용한환자에서 18% 감소시켰지만일차적관상동맥중재시술을받은환자에서는약 6% 만감소시켜 IABP 의효과가일차적관상동맥중재시술을받은환자에서제한적인것을시사하였다 [10]. 600명의심인성쇼크를동반한급성심근경색환자를대상으로한 IABP SHOCK II 다기간무작위배정연구에서 IABP 사용군과비사용군사이일차연구종말점은유의한차이가없었다 (30일째사망, 39.7% vs. 41.3%; p = 0.69) [11]. 이환자들을 12개월동안장기간추적관찰한후속연구에서도 IABP 는사망률을감소시키지못했다 [12]. 하지만 IABP-SHOCK 연구에서 10% 의환자는 Placebo군에서 IABP 군으로 cross-over 했으며 IABP 군에서혈역학적으로안정적인환자또한 IABP 를삽입받았을것등을고려하면서결과를해석해야한다. 일차적관상동맥중재시술은금속스텐트를사용하여성형술을시행한병변에서 recoil이발생하지않아혈역학적으로유의한협착을남기지않는다. 그러므로관상동맥성형술을받은환자에서 IABP 가관상동맥의혈류및혈압을추가적으로증가시킬수있는지확실하지않다. 하지만 IABP 는후부하를감소시고심벽의장력및산소요구량을감소시킨다. 또한심실감압효과가있기에환자를잘선별해서사용하면환자의예후를개선시킬수있을것으로기대하고있다. 최근미국심장학회에는 IABP 사용을 IIa, 유럽심부전학회에서는 class IIb로평가하고있다 (Table 2). Extracorporeal membrane oxygenator (ECMO), percutaneous cardiopulmonary support (PCPS) 심실보조장치는심실수축이없어도전신혈액순환에필요한심박출량을제공할수있다. 체외순환기 (ECMO) 란심폐기능을보조할목적으로수술장밖에서체외순환 (cardiopulmonary bypass) 기법을사용하는것을말한다. ECMO 는 1960년대개발되어호흡부전의치료에사용되었으나최근 ECMO 관련기술이발전되어급성심부전및심인성쇼크환자에서사용되고있다 (Table 3). 현재임상에서사용되는 ECMO 는장비의소형화로이동이편하고삽입까지준비시간이단축되어응급상황에서도사용할수있게되었다. 환자의상태에따라 ECMO 의종류를선택한다. 좌심실기능부전에의한쇼크가주된원인인경우정맥-동맥간체외순환 (veno-arterial ECMO, VA-ECMO) 을, 폐기능저하에의한급성호흡부전환자의경우정맥- 정맥간체외순환 (veno-veno ECMO) 을사용한다. 정맥-동맥간체외순환의경우심장수술후에발생한심인성쇼크나급성전격성심근염과같은가역적심부전환자에게심실기능이회복될때까지가교치료 (bridge to recovery) 로사용할수있고급성심근경색에동반된심인성쇼크에서일차적관상동맥중재시술에혈역학적보조장치로사용하여생존율을호전시켰다는보고가있다 [13-15]. ECMO 기기는 (i) circuit, pump, (ii) oxygenator, (iii) arterial cannula, (iv) venous cannula로구성된다. VA-ECMO 의경우대퇴정맥을통해우심방에거치한정맥관으로부터정맥피를뽑아체외에서 oxygenation/ventilator를시킨후대퇴동맥

- The Korean Journal of Medicine: Vol. 88, No. 2, 2015 - Table 2.

5 - The Korean Journal of Medicine: Vol. 88, No. 2, Table 2. Evidence-based recommendations for mechanical circulatory support ACC/AHA/SCAI guidelines ESC/EACTS guidelines IABP Class IIa A hemodynamic support device is recommended for patients with cardiogenic shock after STEMI who do not quickly stabilize upon pharmacological therapy. Class IIb IABP insertion is recommended for patients with hemodynamic instabilities (particularly those in cardiogenic shock and with mechanical complications). ECMO Not recommended No recommendation Not recommended ECMO implantation should be considered for the temporary support of patients with acute heart failure who may potentially experience functional recovery after revascularization. Tandemheart Class IIb Same as IABP Class IIb The routine use of percutaneous centrifugal pumps is not recommended. Impella Class IIb Same as IABP Not recommended No recommendation ACC/AHA, American College of Cardiology/American Heart Association; SCAI, Society for Cardiovascular Angiography and Interventions; ESC, European Society of Cardiology; EACTS, European Association for Cardio-Thoracic Surgery; IABP, intra-aortic balloon pumping; STEMI, segment elevation myocardial infarction; ECMO, extracorporeal membrane oxygenation. Table 3. Indications for veno-arterial ECMO support Inadequate cardiopulmonary support even after IABP. SBP < 80 mmhg even under full support with catecholamines. Oliguria (< 1 ml/kg/h). Low cardiac output (< 1.8 L/min/m 2 ) Low PaO 2 (< 60 mmhg) Intractable but reversible cardiopulmonary arrest caused by either MI/failed angioplasty or a pulmonary embolus. Uncontrollable VF/VT. ECMO, extracorporeal membrane oxygenation; IABP, intraaortic balloon pumping; SBP, systolic blood pressure; MI, myocardial infarction; VF, ventricular fibrillation; VT, ventricular tachycardia. 을통해장골동맥에거치한동맥관으로역순환 (retrograde circulation) 을시키게된다. VA-ECMO 환자에서혈액의역순환및체외순환에따른여러가지합병증이발생할가능성이높아면밀한관찰이필요하다. 특히좌심실기능저하로증가한확장기말압 (left ventricular end-diastolic pressure) 을효과적으로낮출수없어폐부종이지속될수있다. 좌심실감압 (left ventricle decompression) 을위해추가적인심방중격천자 (atrial septostomy) 또는 IABP 를삽입하여좌심실확장기말압의감소를시도할수있다 [16]. 또한대퇴정맥및대퇴동맥을통해큰도관이이루어지므로하지에심각한허혈을초래할수있다. 따라서 ECMO 를사용한경피적심폐보조장 A B C D Figure 5. Collision between retrograde flow from ECMO (gray) and antegrade flow from patient s left ventricle (dark gray). Gradual recovery of patient s left ventricular systolic function. (A) Minimal LV function with cerebral blood supply via retrograde flow from ECMO. (B) Beginning recovery of LV systolic function. (C) Rt carotid artery receives blood via anterograde flow from LV and lt carotid artery via retrograde flow from ECMO. (D) Both carotid arteries receive blood supply via anterograde flow from LV. ECMO, extracorporeal membrane oxygenator; Rt., right; LV, left ventricle. 치는일시적인심실보조를위해응급상황에서심기능의회복 (bridge to recovery) 이나심장이식까지가교치료 (bridge to transplantation) 로단기적으로사용할수는있으나장기간의심실보조를위해서는적합하지않다. VA-ECMO 를삽입한환자에서 (i) 뇌에산소가적절하게공급되는지, (ii) 혈압은적절하게유지되는지, (iii) 항응고요법이적절하게유지되고있는지에대한지속적인평가가필

- Jin Joo Park, et al. MCS in HF - 요하다. VA-ECMO 를삽입한환자에서는좌심실에서나오는 antegrade flow와 ECMO 동맥관에서나오는 retrograde flow가공존한다. Antegrade flow의산소량은좌심실기능및폐기능으로결정된다.

6 - Jin Joo Park, et al. MCS in HF - 요하다. VA-ECMO 를삽입한환자에서는좌심실에서나오는 antegrade flow와 ECMO 동맥관에서나오는 retrograde flow가공존한다. Antegrade flow의산소량은좌심실기능및폐기능으로결정된다. 또한 antegratde flow와 retrograde flow가만나는지점은환자의좌심실기능에따라결정된다 (Fig. 5). 좌심실기능이매우저하되어있는경우 retrograde flow에의한 right cerebral perfusion이가능하므로인공호흡기는폐보호 (lung protection) 에초점을맞추어흡입산소농도 (fraction of inspired oxygen, FiO 2), 일회호흡량 (low tidal volume), 호흡수 (frequency) 를낮게설정한다. 좌심실기능이회복되기시작하면환자본인의 antegrade flow와 ECMO 의 retrograde flow가부딪히게된다. 이러한경우에는인공호흡기조정을통해폐를통한산소공급 (oxygenation) 을증가시켜허혈성뇌손상이발생하는것을예방해야한다. VA-ECMO 삽입환자에서산소공급이적절하게되는지평가하기위해서는 ECMO 삽입초기에는오른쪽요골동맥 (right radial artery), 중심정맥관및 ECMO 동맥관세군데에서 arterial blood gas analysis (ABGA) 검사를시행해야한다. 특히오른쪽요골동맥의산소포화도는우뇌의관류 (right cerebral perfusion) 를가장근접하게반영한다. 목표산소포화도는 mixed venous saturation > 70%, ECMO arterial line PaO 2 > 300 mmhg, patient right arterial saturation > 90% 이다. VA-ECMO는심박박출지수가 2.2 L/min/m 2 로유지된다고해도조직의관류를유지하기위해평균동맥혈압 (mean arterial pressure) 을 mmhg 로유지되도록강심제및승압제를적절하게사용해야한다. 혈압이너무높을경우두개 골내출혈의위험성이높아진다. Heparin 또는 futhan 을사용해서 activated partial thromboplastin time (aptt) s 또는 activated clotting times (ACT) s를목표로항응고요법을시행해야한다. 항응고요법이충분치않을경우 retrograde flow의특성상여러장기에색전경색증발생위험이높아진다. 환자의혈역학적상태가호전되어 ECMO 를제거해야하는시점이되면동맥관을삽입한부위에수술적봉합이필요하며 (manual compression 시 pseudo-aneurysm의발생위험성이높다 ) 정맥관삽입부위는 manual compression과단순피부봉합을하게된다. Ventricular assist device 약물치료에불응하는심부전환자에게가장근본적인치료는심장이식이다. 하지만말기심부전환자의증가와함께기증자부족현상이발생하여서구에서는기계적심실보조장치가일찍부터개발되었다. 심실보조장치는크게경피적과삽입형보조장치로구분된다. TandemHeart (Cardiac Assist, Inc., Pittsburgh, PA, USA) 와 Impella Recover 2.5 (Abiomed, Inc., Danvers, MA, USA) 등이경피적좌심실보조장치들이며현재국내에서는사용되지않고있다. 경피적좌심실보조장치는삽입후좌심실충만압을낮추고심박축률을정상화하는등혈역학적개선이뚜렷하지만 [17] 환자의예후를개선시키는효과는입증되지않았다 [18-20]. 삽입형심실보조장치는장기적인심실보조역할을위해사용되고있다. 1994년 HeartMate가미국 FDA 승인을받 A B Figure 6. HeartMate II and Heartware. (A) HeartMate II. (B) Heartware

7 - 대한내과학회지 : 제 88 권제 2 호통권제 654 호 으면서관련된연구및임상경험이비약적으로증가했다. 이는기본적으로좌심실 ( 또는우심실 ) 에서혈액을뽑아대동맥 ( 또는폐동맥 ) 으로혈액을보내주어심실의부하를줄임으로써심박출량증가및심실재형성을유도하는기계적장치이다. 심실보조장치는혈류의특성 (pulsatile 또는 continuous), 펌프의기능 (axial 또는 centrifugal), 거치위치 (intracorporeal 또는 extracorporeal), 접근법 (percutaneous 또는 surgical), 지지심실 ( 좌 우 양심실 ) 등의기준으로분류할수있다. Non-pulsatile continuous flow 형태로 2010년말기심부전 ( 좌심실부전 ) 환자에사용이허가된 HeartMate II가가장많이사용되고있다. 현재펌프의크기를줄여 pericardial space 안에장착이가능한기종들에대한임상연구가진행중이다 (Fig. 6). 또한개흉술을동반하는외과적수술없이경피적으로장착이가능한기종들도개발되고있다. 삽입형심실보조장치는적응증으로는내과적- 외과적치료에반응하지않은말기심부전환자를대상으로하여심장이식까지가교 (bridge to transplant) 목적으로가장많이사용되어왔다. 하지만심장이식의대상이되지않는말기심부전환자들에게박동형펌프를사용하는 HeartMate XVE 가약물치료보다생존율을호전시킨다는것이확인되어삽입형심실보조기는궁극적인치료 (destination therapy) 로사용되기시작하였다 [21]. 박동형펌프는내구성이좋지않아 2년이내기기이상을일으키고있으며이후연속파형펌프 (continuous flow pump) 심실보조장치가개발되었다. HeartMate II는구조가간단하고내구성이좋다. 연속파형심실보조장치의 1년및 2년생존율이각각 68%, 55% 로박동형좌심실보조장치 (1년생존율 55%, 2년생존율 24%) 에비해월등한성적을보인다 [22]. 이에최근에는여러가지이유로심장이식이불가능한환자를대상으로하는궁극적치료 (destination therapy) 가최근증가하고있다. 이에더나아가많은말기심부전환자에서급격한심부전악화로타장기손상이발생하거나생명이위협받는상황에서좌심실보조장치를삽입하는경우가있다. 환자의상황에따라추후심장이식이필요한경우도있고또는심실기능이호전되어기계장치를뗄수있는경우도있으나당장급한상황에서좌심실보조장치를넣는경우 bridge to recovery 또는 bridge to decision을목적으로한치료라할수있다. 보조장치삽입후에는항응고요법 (prothrombin time-international normalized ratio [PT-INR] 2-3) 을시행해야하며이에따른출혈의위험성, 감염, 신경학적이상및혈전생성등의기계관련합병증유무를잘관찰해야한다. 결 약물치료에불응하는말기또는급성심부전환자에서 MCS는환자의예후를개선시킬수있는여지가충분히있다. 아직까지국내에서는대부분경피적순환보조장치인 IABP 와 ECMO 를심인성쇼크나급성심부전환자가회복할때까지, 또는말기심부전환자가심장이식을받을때까지가교치료로일시적으로사용하고있다. 국내에서심장이식술이활발하게진행되면서공여자부족현상이발생하고있다. 아직국내에서활성화되지않았지만장기적으로사용할수있는삽입형심실보조장치를사용하면심장이식을대기하는말기심부전환자에서효과적으로사용할수있는치료수단이될것이다. 하지만 MCS는많은합병증을일으킬수있어삽입시에는특별한관리와면밀한모니터링이필요하다고볼수있겠다. 중심단어 : 심부전 ; 대동맥내풍선펌프 ; 기계적순환보조 ; 심실보조장치 론 REFERENCES 1. Hollenberg SM, Kavinsky CJ, Parrillo JE. Cardiogenic shock. Ann Intern Med 1999;131: Scheidt S, Wilner G, Mueller H, et al. Intra-aortic balloon counterpulsation in cardiogenic shock. Report of a co-operative clinical trial. N Engl J Med 1973;288: Pucher PH, Cummings IG, Shipolini AR, McCormack DJ. Is heparin needed for patients with an intra-aortic balloon pump? Interact Cardiovasc Thorac Surg 2012;15: Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL Jr. Initial clinical experience with intraaortic balloon pumping in cardiogenic shock. JAMA 1968; 203: O Rourke MF, Norris RM, Campbell TJ, Chang VP, Sammel NL. Randomized controlled trial of intraaortic balloon counterpulsation in early myocardial infarction with acute heart failure. Am J Cardiol 1981;47: Flaherty JT, Becker LC, Weiss JL, et al. Results of a randomized prospective trial of intraaortic balloon counter

8 - 박진주외 1 인. 기계적순환보조 - pulsation and intravenous nitroglycerin in patients with acute myocardial infarction. J Am Coll Cardiol 1985;6: Barron HV, Every NR, Parsons LS, et al. The use of intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2. Am Heart J 2001;141: Anderson RD, Ohman EM, Holmes DR Jr, et al. Use of intraaortic balloon counterpulsation in patients presenting with cardiogenic shock: observations from the GUSTO-I Study. Global utilization of streptokinase and TPA for occluded coronary arteries. J Am Coll Cardiol 1997;30: Kovack PJ, Rasak MA, Bates ER, Ohman EM, Stomel RJ. Thrombolysis plus aortic counterpulsation: improved survival in patients who present to community hospitals with cardiogenic shock. J Am Coll Cardiol 1997;29: Sjauw KD, Engström AE, Vis MM, et al. A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines? Eur Heart J 2009;30: Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012;367: Thiele H, Zeymer U, Neumann FJ, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. Lancet 2013;382: Maejima Y, Yasu T, Kubo N, et al. Long-term prognosis of fulminant myocarditis rescued by percutaneous cardiopulmonary support device. Circ J 2004;68: Gariboldi V, Grisoli D, Tarmiz A, et al. Mobile extracorporeal membrane oxygenation unit expands cardiac assist surgical programs. Ann Thorac Surg 2010;90: Arlt M, Philipp A, Voelkel S, et al. Hand-held minimised extracorporeal membrane oxygenation: a new bridge to recovery in patients with out-of-centre cardiogenic shock. Eur J Cardiothorac Surg 2011;40: Elesber A, Lerman A, Bybee KA, et al. Myocardial perfusion in apical ballooning syndrome correlate of myocardial injury. Am Heart J 2006;152:469.e9-e Meyns B, Dens J, Sergeant P, Herijgers P, Daenen W, Flameng W. Initial experiences with the Impella device in patients with cardiogenic shock-impella support for cardiogenic shock. Thorac Cardiovasc Surg 2003;51: Engström AE, Cocchieri R, Driessen AH, et al. The Impella 2.5 and 5.0 devices for ST-elevation myocardial infarction patients presenting with severe and profound cardiogenic shock: the Academic Medical Center intensive care unit experience. Crit Care Med 2011;39: Seyfarth M, Sibbing D, Bauer I, et al. A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction. J Am Coll Cardiol 2008;52: Lauten A, Engström AE, Jung C, et al. Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EURO- SHOCK-registry. Circ Heart Fail 2013;6: Miller LW, Pagani FD, Russell SD, et al. Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 2007;357: Starling RC, Naka Y, Boyle AJ, et al. Results of the post- U.S. Food and Drug Administration-approval study with a continuous flow left ventricular assist device as a bridge to heart transplantation: a prospective study using the INTER- MACS (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol 2011;57:

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