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1 Case Report J Lipid Atheroscler 2016 December;5(2): pissn eissn Major Trauma induced Left Ventricular Thrombus after Acute Myocardial Infarction Dong Wook Lee, Ju Hee Ha, Jun Ho Kim, Ki Beom Park, Jae Joon Lee, Han Il Choi, Jin Hee Kim Department of Internal Medicine, Busan Medical Center, Busan, Korea JLA 급성심근경색치료후장기적으로안정된환자에서중증외상이후발생한좌심실혈전 이동욱, 하주희, 김준호, 박기범, 이재준, 최한일, 김진희 부산의료원내과 Left Ventricular Thrombus (LVT) formation after acute myocardial infarction is a serious complication. And the most feared complication of LVT is the systemic thromboembolic events, especially to the brain. Nowadays patients with acute myocardial infarction are treated with primary PCI and more aggressive anticoagulation therapies, resulting in the lower incidence of LVT. Early detection of LVT is very important, and echocardiography is the definitive test for detecting intracardiac thrombus. However, the need for serial echocardiography remains controversial. In this case report, we describe a 55-year-old man with major trauma induced LVT after acute myocardial infarction who underwent successful therapy. (J Lipid Atheroscler 2016 December;5(2): ) Key Words: Left Ventricular Thrombus, Echocardiography, Major Trauma 서론 좌심실벽의국소또는전반에걸친운동장애는혈류정체의원인이되며, 때때로좌심실혈전 (Left Ventricular Thrombus) 을유발하기도한다. 좌심실혈전은급성심근경색 (Acute Myocardial Infarction) 이있는환자와스트레스유발심근증 (Stress Induced Cardiomyopathy) 이있는환자에서각각 5% 정도에서발생된다고알려져있고, 1 말기의확장성심근병증 (End Stage Dilated Cardiomyopathy) 환자의 11-44% 정도에서도발생하는것으로알려져있다. 2 임상에서는좌심실혈전생성여부의선별검사로심장초음파가 널리사용되고있다. 3 하지만급성심근경색이후발생할수있는중요한합병증중에하나인, 좌심실혈전여부의확인을위한연속적이고반복적인심장초음파검사의시기및필요성에대해서는논란이있다. 4 본증례에서는급성심근경색으로관상동맥중재술을시행받고, 이후정기적인심장초음파검사에서좌심실혈전이관찰되지않았던장기간의안정적인환자에서중증외상이후좌심실혈전이확인되었고, 약물치료통해혈전의호전을경험하였기에보고하는바이다. Received: Revised: Accepted: May 30, 2016 August 23, 2016 August 25, 2016 Corresponding Author: Jin Hee Kim, Division of Cardiology, Department of Internal Medicine, Busan Medical Center, Geoje 2-dong, Yeonje-gu, Busan , Korea Tel: , Fax: , yoplait83@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c 2016 The Korean Society of Lipidology and Atherosclerosis 163

J Lipid Atheroscler 2016;5(2):163-167 JOURNAL OF LIPID AND ATHEROSCLEROSIS 증례 환자 : 우OO, 55세남자주소 : 허리통증현병력 : 내원이틀전 1.

2 J Lipid Atheroscler 2016;5(2): JOURNAL OF LIPID AND ATHEROSCLEROSIS 증례 환자 : 우OO, 55세남자주소 : 허리통증현병력 : 내원이틀전 1.5 m 가량의높이에서추락이후발생한허리통증을주소로타병원내원이후수술을위해서 2014년 7월 2일본원정형외과로전원되었고, 수술전심장기능평가를위해서심장내과로협진의뢰되었다. 과거력 : ST 분절상승심근경색증 (ST-Segment Elevation Myocardial Infarction) 으로좌전하행지중간부경피적관상동맥중재술 (2007년 4월 ) 시행하였고, 당시시행한경흉부심장초음파검사에서심첨부전벽 (Apical anterior), 전중격 (Anteroseptal), 전측부 (Anterolateral), 하중격 (Inferoseptal) 에서얇아짐 (Thinning) 과좌심실류 (Left Ventricular Aneurysm) 가관찰되었다. 좌심실구혈률 (Ejection Fraction) 은 41% 로중등도의좌심실수축부전 (LV Systolic dysfunction) 이관찰되었고, 하중격, 하벽, 전벽에서의무운동성 (Akinesia) 과좌심방과좌심실의확장이관찰되었다. 가족력 : 특이사항없음사회력 : 과거흡연병력, 2007년부터금연상태진찰소견 : 두부외상소견은없었고, 의식은명료한상황이었으나통증및자세교정을위해서절대안정및자세고정을유지하는상황이었고, 생체징후는혈압은 110/70 mmhg, 맥박 81회 / 분, 호흡수 20회 / 분, 체온 36.0 로관찰되었으며, 흉부청진과신경학적검진등다른이학적검사에서특이소견은없었다. 검사실소견 : 말초혈액검사에서백혈구 11,800/mm 3, 혈색소 12.5 g/dl, 혈소판 204,000/mm 3 였고, 생화학검사에서 AST 23 IU/L, ALT 28 IU/L, BUN 12.4 mg/dl, Cr 0.7 mg/dl, 소변검사에서는특이소견관찰되지않았다. CRP mg/l 로경한상승소견관찰되었고, CK-MB 1.8 ng/ml, Troponin-I ng/ml로정상소견을보였다. 심전도및흉부방사선 : 내원시심전도에서분당 65회의정상동율동이었으며 ST 분절변화는보이지않았고, V4~V6 lead에서 T파역전 (inversion) 이관찰되었으나, 이전심전도와의차이는없었다. 흉부촬영에서심비대및폐울혈등의이상소견은관찰되지않았다. 척추자기공명영상 : 요추손상여부및정도를확인하기위해서척추자기공명영상 (Spinal Magnetic Resonance Imaging) 을실시하였다. 그결과 3번째요추의방출성골절소견및척추관협착이확인되었다 (Fig. 1). 경흉부심장초음파검사 : 2007 년경흉부심장초음파검사에서중등도이상의좌심실수축부전과좌심실류가관찰되어이후 2년간격으로경흉부심장초음파검사를정기적으로추적관찰시행해왔다. 외상이있기전, 마지막추적검사였던 2013년의경흉부심장초음파검사에서좌심실구혈률과국소벽운동장애 (Regional Wall Motion Abnormality) 는기존추적검사와큰 A B Fig. 1. Spinal magnetic resonanace imaging at coming to the orthopedics. Images show burst fracture of the 3rd lumbar. (A) Coronal view, (B) Sagittal view

Echocardiographic findings at apical 4 chamber view.

3 Dong Wook Lee, et al.: Major Trauma induced Left Ventricular Thrombus Fig. 2. Coronary angiography images show that there was no change compared with the previous results in Left Anterior Descending coronary artery middle part. A B Fig. 3. Echocardiographic findings at apical 4 chamber view. (A) Two days after trauma, large thrombus measuring 24 mm 15 mm in size were detected at the apex of the left ventricle, (B) Nine months treatment of thrombus, thrombus disappeared at the apex of the left ventricle. 변화가관찰되지않았다 년 7월, 외상이있은지 2일이경과한후에시행한경흉부심장초음파검사에서좌심실구혈률 35% 로오래된심근경색후 (Old Myocardial Infarction) 에전형적으로보이는국소벽운동이상에의한좌심실수축기기능저하와더불어, 2013 년경흉부심장초음파에서관찰되지않았던심첨부에혈전이새로이관찰되었다. 관상동맥조영술 : 좌심실혈전의확인이후, 급성심근경색의합병증에의한좌심실혈전의발생여부에대해서확인하기위해서 관상동맥조영술을시행하였다. 하지만이전마지막으로시행한 2010년과비교해서 4년만에시행한관상동맥조영술검사에서는의미있는혈관의변화는관찰되지않았다 (Fig. 2). 치료및경과 : 경흉부심장초음파검사결과를바탕으로환자의수술위험성높다고판단되었다. 하지만환자의주호소가허리통증이고, 척추자기공명영상에서제3요추부방출성골절및 50% 이상의척주관침범으로인한하지마비가능성높다고판단되어수술위험성등에대해서고지하고좌심실혈전을치료하기위해, 165

4 J Lipid Atheroscler 2016;5(2): JOURNAL OF LIPID AND ATHEROSCLEROSIS 헤파린 (Heparin) 정맥주사로투여하는항혈전요법과더불어척추고정술시행하였다 (2014년 7월 ). 수술이후허리부위의통증을제외한기타이상소견은관찰되지않고, 안정적으로유지되어, 헤파린에서와파린 (Warfarin) 으로항응고제약물의단계적교체를시행하였고, 국제정상화비율 (International Normalized Ratio) 을 2-3으로유지치료하였다. 3주의입원치료이후통원치료로전환하였으며, 연속적인경흉부심장초음파검사를시행하였다. 좌심실혈전의크기감소를확인할수있었으며, 수술이후대략 9개월정도의약물치료이후좌심실혈전은관찰되지않았다 (Fig. 3). 본원정형외과와협진통해서통원치료유지중이며, 현재까지특이소견및자가보행에문제없는상태로외래추적관찰중이다. 고찰 현대사회에서심혈관질환은중요한사망원인으로알려져있다. 최근급성심근경색에서항혈소판제, 항응고제, 경피적관상동맥중재술사용의보편화로인해서사망률과합병증의빈도가줄어들고있는실정이나, 그럼에도불구하고급성심근경색증이후발생하는합병증들은여전히많은환자들에게치명적인결과를주고있다. 5 가장심각한합병증으로는좌심실혈전의기동성으로인한전신혈전색전증으로뇌졸중유발의원인이될수있다. 좌심실혈전발생의기전은급성관상동맥증후군 (Acute Coronary Syndrome) 으로인한응고항진 (Hypercoagulability), 심내막하의염증성변화, 그리고좌심실벽의수축기능장애로인한혈액의정체로설명하고있다. 6 발생위험인자로는경색의크기, 심실수축기능장애, 좌심실류, 전벽의심근경색등이있다. 7 2차원경흉부심장초음파검사는좌심실혈전여부의확인에있어서높은특이도 (85-90%) 와민감도 (95%) 를나타낼뿐만아니라, 혈전의크기및모양을평가하는데가장유용하게사용되는검사이다. 8 또한좌심실내혈전의진단에서심장초음파검사는혈전의유무뿐만아니라자연경과및치료에대한반응을평가하는데있어서간편하고매우유용하게사용된다. 9 좌심실혈전의치료는헤파린과와파린을사용하는적절한항혈전및항응고요법을통하여혈전형성의진행을막고색전증을예방하는데있다. 특히심장초음파에서색전의위험성이높은혈전으로판단되는경우에는조기에항응고요법을하고, 적어도 3개월에서 6개월은와파린사용이권장되고있으며, 10 최근에는저분자량헤파린도효과가있고안전하다고보고되었다. 11 급성심근경색의중요한합병증인좌심실혈전발생은급성심근경색발생이후첫 3개월이내에발생하는경우가가장많다고알려져있다. 6 하지만본증례에서는 2007년 4월좌전하행지경피적관상동맥중재술시행이후정기적으로추적검사해오던심장초음파검사에서 7년동안좌심실혈전이관찰되지않았던환자였으나, 중증외상이후시행한심장초음파검사에서좌심실혈전이확인되었다. 혈전발생의위험성을증가시킬수있는응고항진은암, 임신, 피임약복용, 당뇨, 감염등의상황에서발생할수있고, 두부외상이나, 골절과같은중증외상환자에서도혈전발생의위험성은증가할수있다. 12 한문헌에서는가슴부위의외상이후발생한관상동맥혈관폐쇄에따른좌심실혈전의발생을보고한바있다. 13 중증외상은트롬빈 (Thrombin) 의생성을증가시키고, 유지하여혈전발생의위험성을증가시킨다고알려져있다. 14 본증례의경우급성심근경색이후의정기적심장초음파검사에서큰변화없이유지되던환자에서중증외상이후좌심실혈전이확인되었고, 약물치료통해뇌졸중과같은중요한전신혈전색전증없이혈전의호전을경험하였기에보고하는바이다. 급성심근경색이후, 좌심실혈전여부의확인을위한연속적이고반복적인심장초음파검사의시기및필요성에대해서는아직정확하게정해진지침이없는실정이다. 본증례의환자에서는 2007년급성심근경색이후에 2년간격으로시행하여마지막 2013년까지시행한정기적인추적경흉부심장초음파검사에서 7년동안장기간안정적인상태로유지되었으나, 특별한증상이나검사상의이상소견이없었음에도불구하고중증외상이후치명적인합병증을야기할수있는좌심실혈전이발생한경우이다. 따라서, 급성심근경색이후심장초음파의주기적인검사에대한필요성과구체적인가이드라인설정에대한추가적인연구가필요한것으로사료된다. REFERENCES 1. Lee HJ, Kim HL, Hwang D, Park CS, Lim JS, Kang E, et al. Huge left ventricular thrombus and apical ballooning associated with recurrent massive strokes in a septic shock patient. Korean J Crit Care Med 2016;31:

5 Dong Wook Lee, et al.: Major Trauma induced Left Ventricular Thrombus 2. de Gregorio C. Cardioembolic outcomes in stress-related cardiomyopathy complicated by ventricular thrombus: a systematic review of 26 clinical studies. Int J Cardiol 2010;141: Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003;108: Keren A, Goldberg S, Gottlieb S, Klein J, Schuger C, Medina A, et al. Natural history of left ventricular thrombi: their appearance and resolution in the posthospitalization period of acute myocardial infarction. J Am Coll Cardiol 1990;15: Porter A, Kandalker H, Iakobishvili Z, Sagie A, Imbar S, Battler A, et al. Left ventricular mural thrombus after anterior ST-segment-elevation acute myocardial infarction in the era of aggressive reperfusion therapy--still a frequent complication. Coron Artery Dis 2005;16: Delewi R, Zijlstra F, Piek JJ. Left ventricular thrombus formation after acute myocardial infarction. Heart 2012; 98: Weinsaft JW, Kim HW, Crowley AL, Klem I, Shenoy C, Van Assche L, et al. LV thrombus detection by routine echocardiography: insights into performance characteristics using delayed enhancement CMR. JACC Cardiovasc Imaging 2011;4: Srichai MB, Junor C, Rodriguez LL, Stillman AE, Grimm RA, Lieber ML, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J 2006;152: Barbera S, Hillis LD. Echocardiographic recognition of left ventricular mural thrombus. Echocardiography 1999;16: Hirsh J, Fuster V, Ansell J, Halperin JL; American Heart Association; American College of Cardiology Foundation. American Heart Association/American College of Cardiology Foundation guide to warfarin therapy. Circulation 2003;107: Meurin P, Tabet JY, Renaud N, Weber H, Grosdemouge A, Bourmayan C, et al. Treatment of left ventricular thrombi with a low molecular weight heparin. Int J Cardiol 2005;98: Gando S. Disseminated intravascular coagulation in trauma patients. Semin Thromb Hemost 2001;27: Kim JH, Kang TS. A case of distal embolization of left ventricular thrombus due to blunt chest trauma-induced coronary artery occlusion. Korean Circ J 2011;41: Selby R, Geerts W, Ofosu FA, Craven S, Dewar L, Phillips A, et al. Hypercoagulability after trauma: hemostatic changes and relationship to venous thromboembolism. Thromb Res 2009;124:

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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