Main Topic Reviews 박동기합병증의예방및처치 연세대학교의과대학내과학교실정보영 Boyoung Joung, MD, PhD Cardiology Division, Department of Internal Medicine, Yonsei University Colle

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박동기합병증의예방및처치 연세대학교의과대학내과학교실정보영 oyoung Joung, MD, PhD Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine bstract Pacemaker complications can be divided into

1 박동기합병증의예방및처치 연세대학교의과대학내과학교실정보영 oyoung Joung, MD, PhD Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine bstract 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 ccepted: September 14, 2014 Correspondence: oyoung 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

showing that the location of the ventricular pacing lead changed (). Perforation of right ventricular lead ().

2 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 (). Perforation of right ventricular lead (). C D Figure 2. flare suggesting pocket infection of the pacemaker ( and ). Skin erosion above the external surface of the pacemaker (C). Skin erosion in the pacemaker lead region (D). Vol.15 No.3 51

3 Figure 3. The extracted lead with adhesion of surrounding tissue (). The main regions where tissue adheres to the leads (indicated by arrows) (). 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

C D E F Figure 4. 2.4 1.1 cm vegetation attached to the TV posterior leaflet and a 2.2 1.3 cm vegetation attached to the R free wall (). Septic embolisms in the brain () and liver (C).

4 C D E F Figure cm vegetation attached to the TV posterior leaflet and a cm vegetation attached to the R free wall (). Septic embolisms in the brain () and liver (C). Disappearance of vegetation after treatment (D). Chest radiographs before (E) and after device removal (F). L, left atrium; LV, left ventricle; R, 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 3에관찰되는것과같이제거한유도의여러부위에 조직과유착이됨을알수있다. 3 주로유착되는위치는 Figure 3에서화살표표시부위와같이쇄골하정맥부분, 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

5 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. uch E, oyle NG, elott 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. Implantable cardioverter-defibrillator lead extraction by conventional traction and counter-traction technique. Korean Circ J. 2011;41: Wilkoff L, uricchio, rugada J, Cowie M, Ellenbogen K, Gillis M, Hayes DL, Howlett JG, Kautzner J, Love CJ, Morgan JM, Priori SG, Reynolds DW, Schoenfeld MH, Vardas PE, Heart Rhythm S, European Heart Rhythm, merican College of C, merican Heart, European Society of C, Heart Failure ssociation of ESC, Heart Failure Society of. HRS/EHR 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 C, rinker J. How to prevent, recognize, and manage complications of lead extraction. Part I: voiding lead extraction--infectious issues. Heart Rhythm. 2008;5: Cho H, Kim M, Uhm JS, Pak HN, Lee MH, Joung. Transvenous pacemaker lead removal in pacemaker lead endocarditis with large vegetations: report of two cases. Korean Circ J. 2014;44: The Official Journal of Korean Heart Rhythm Society

Case Reports Korean Circulation J 1999;29 10 : 제세동역치가높았던특발성심실세동에시술한 삽입형심실제세동기 ICD 1 예 송창석 김형주 박현용 박희백 장영광 차태준 주승재 이재우 Implantation of ICD in

Case Reports Korean Circulation J 1999;2910:1138-1143 제세동역치가높았던특발성심실세동에시술한 삽입형심실제세동기 ICD 1 예 송창석 김형주 박현용 박희백 장영광 차태준 주승재 이재우 Implantation of ICD in a Ventricular Fibrillation Patient with a High Defibrillation