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1 대한내과학회지 : 제 88 권제 2 호 인공심박조율기전극골절을전극수선및정맥성형술로치료한 1예 전남대학교의과대학전남대학교병원순환기내과 김지은 윤남식 박형욱 조정관 Pacemaker Lead Fracture Treated with Splinting and Venoplasty Ji Eun Kim, Nam Sik Yoon, Hyung Wook Park, and Jeong Gwan Cho Department of Cardiovascular Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea A 56-year-old man was admitted for pacemaker generator replacement. We identified a partial fracture in the proximal part of the lead just after the conjunction of the atrial and ventricular leads. The atrial lead sensitivity was stable even under intentional pulling and twisting. We deployed a splint made of a suture-sleeve in the fracture site. After burying the malfunctioning ventricular connector behind the pocket, we inserted only a new ventricular lead. However, another complication existed. Venogram showed a total occlusion between the brachiocephalic vein and superior vena cava. After meticulous wiring, we passed the target and dilated the vessel with 8 and 9 Fr dilators. Finally, a new ventricular lead and generator were inserted via a long peel-away sheath. In conclusion, we successfully treated a patient with a partial lead fracture and a brachiocephalic vein occlusion using splinting and venoplasty. (Korean J Med 2015;88: ) Keywords: Electrodes, Pacemaker, Artifical; Equipment failure; Therapeutics; Angioplasty 서론인공심박조율기전극기능은전극의임피던스확인을통해평가할수있다. 전극의임피던스가갑작스럽게증가할경우전극절연부위의단절을의심해야한다. 인공심박조율기의전극이늑쇄골각에위치했을때늑골과쇄골사이에 서압박손상을입기쉽다. 그러나전극이외부구조물에눌리는위치에놓이지않았더라도전극골절은때때로발생한다. 치료로는대부분의경우새로운전극의삽입이고려된다. 새로운전극을삽입하기로결정하면접근부위의정맥혈류에장애가있지않은지확인이필요하다. Received: Revised: Accepted: Correspondence to Nam Sik Yoon, M.D., Ph.D. Department of Cardiovascular Medicine, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju , Korea Tel: , Fax: , yoonnamsik@gmail.com 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.

- The Korean Journal of Medicine: Vol. 88, No. 2, 2015 - 증례 56세남성이심박발생기교체를위해내원하였다. 상기환자는 12년전완전방실차단으로 VDD (PRODIGY 8168, Medtronic Inc., Minneapolis, MN, USA) 영구형심박조율기를삽입받았다.

67 V로갑작스럽게감소했고그동안점검결과를비교해보았을때전지임피던스가 2,201 ohm에서 7,059 ohm으로갑작스럽게증가했으며심실전극임피던스가 469 ohm에서 3,881 ohm으로서서히증가했다. 흉부 X-선촬영에서는이상소견이없었다 (Fig. 1A). 심전도에서는심실포획실패없이 VVI mode 예비상태조율이분당 65회로확인되었다 (Fig. 1B).

2 - The Korean Journal of Medicine: Vol. 88, No. 2, 증례 56세남성이심박발생기교체를위해내원하였다. 상기환자는 12년전완전방실차단으로 VDD (PRODIGY 8168, Medtronic Inc., Minneapolis, MN, USA) 영구형심박조율기를삽입받았다. 삽입된전극선은 5,032-5,058 cm (Medtronic Inc., Minneapolis, MN, USA) 였다. 최근인공심박조율기점검시에전지전압이 2.73 V에서 2.67 V로갑작스럽게감소했고그동안점검결과를비교해보았을때전지임피던스가 2,201 ohm에서 7,059 ohm으로갑작스럽게증가했으며심실전극임피던스가 469 ohm에서 3,881 ohm으로서서히증가했다. 흉부 X-선촬영에서는이상소견이없었다 (Fig. 1A). 심전도에서는심실포획실패없이 VVI mode 예비상태조율이분당 65회로확인되었다 (Fig. 1B). 따라서심박발생기수명이다하고전극기능이상이발생했다고판단하여심박발생기교체및새로운전극선삽입을고려하였다. 심박발생기의 elective replacement indicator가발생하여심박조율기를분석할수없어수술전에전극기능이상유무를확인하지못했으므로인공심박동기시스템분석기 (pacemaker system analysis) 에서분명한전극선의기능이상이확인되면새로운전극선삽입을위해정맥조영술을시행하기로했다. 기존의심박조율기를제거한후기존전극선기능을점검하였다. 심방전극의민감도는 0.4 mv 이상으로정상적이었으나심실전극의민감도는 1.2 mv였고포획실패를보였다. 심방전극과심실전극의접합부바로아랫부분에부분적인 전극선골절이발견되었다 (Fig. 2A). 다행히심방전극의민감도는당기거나비틀었을때도안정적이어서심박동을감지하는심방전극은보존하고새로운심실전극선을삽입하기로하였다. 골절이심방전극선까지진행하는것을방지하기위해골절부위에 suture-sleeve 로만든부목을대었다 (Fig. 2B and 2C). 쓸모없어진심실연결부는새로운심박조율기가삽입될주머니아래에묻었다. 이어서시행한정맥조영술에서는좌측완두정맥과상대정맥사이의완전폐쇄가확인되어 (Fig. 2D) 정맥성형술을시행하였다. 환자가우측에심박조율기를삽입하는것을원치않았고우측에도정맥폐쇄가발생하면차후에접근할혈관통로를잃을수있어정맥성형술을시행하게되었다. 정맥성형술은국소마취하에진행하였으며액와정맥을통해 5 Fr 유도초를삽입하고정맥폐쇄말단부를확인하기위해폐쇄부위앞에서중심정맥조영술을시행하였다. 친수성가이드와이어 (Radifocus 0.035, Terumo, Zaventem, Belgium) 를사용하여수차례의정교한진입시도후에폐쇄부위를통과할수있었다 (Fig. 2E). 소량의조영제를주사하여폐쇄부위를안전하게통과하는것을확인하였다 (Fig. 2F). 하지만작은정맥성형술카테터가통과되지않아내강확장기를사용하여폐쇄부분을넓혀주었고추가적인풍선확장술없이도충분한내강이생겨폐쇄부위를통과하는긴유도초를삽입하고 (Fig. 2G) 이후새로운심실전극선과심박발생기 (ENPULSE E2VDD01, Medtronic Inc., Minneapolis, MN, USA) 를삽입하였다 (Fig. 3). A B Figure 1. (A) No abnormalities of the lead were visible on chest X-ray. (B) VVI mode back-up pacing of 65 beats/minute without ventricular capture failure on ECG. ECG, electrocardiogram

$A complex pacemaker lead fracture - A B C D E F G$ Figure 2.

$the fracture site and venoplasty was performed for$ $(A) The ventricular lead fracture was identified.$ $The black arrow indicates the fractured tip.$ $deployed on the fractured lead shaft.$ with Terumo wire.

3 - Ji Eun Kim, et al. A complex pacemaker lead fracture - A B C D E F G Figure 2. We deployed a splint made of a suture-sleeve in the fracture site and venoplasty was performed for a total occlusion between the brachiocephalic vein and superior vena cava. (A) The ventricular lead fracture was identified. The black arrow indicates the fractured tip. (B, C) A splint made of a suture-sleeve was deployed on the fractured lead shaft. (D) Venogram showed a total occlusion between the brachiocephalic vein and superior vena cava. (E) Wiring was performed with Terumo wire. (F) Successful passage was identified with dye injection. (G) A long sheath was introduced for a new ventricular lead insertion

- 대한내과학회지 : 제 88 권제 2 호통권제 654 호 2015 - A B Figure 3. (A) Final X-ray after implantation of a generator and lead. (B) Well-functioning pacemaker. 고찰전극선골절은인공심박조율기를삽입한환자의 1-4% 에서발생하는흔한합병증이다 [1,2].

늑쇄골공간은절연체손상이잘일어나는대표적인부위이다. 전극이상은일반적으로전극교체로해결한다. 하지만결함부위위치에따라, 특히협착이나폐쇄로정맥접근로가좋지않아새로운전극선을삽입하기어려울때는전극선수선이대안이될수있다. 이때전극선수선의안전성에대한의문이있을수도있다.

4 - 대한내과학회지 : 제 88 권제 2 호통권제 654 호 A B Figure 3. (A) Final X-ray after implantation of a generator and lead. (B) Well-functioning pacemaker. 고찰전극선골절은인공심박조율기를삽입한환자의 1-4% 에서발생하는흔한합병증이다 [1,2]. 쇄골과첫번째늑골사이나늑쇄골공간에서눌림으로인해쇄골하정맥입구의바깥쪽과같은고정점에서가장잘발생한다 [1,2]. 압박, 마찰, 꼬임, 신전과같은직접적인스트레스가전극골절의흔한원인이다 [3]. 전극을따라쉽게찾을수있는위치에서절연체손상이가장흔히일어나는데특히갑작스러운굴곡부위, 전극이통과하는마찰점이나심박발생기와봉합부의접촉점에서잘일어난다 [4]. 늑쇄골공간은절연체손상이잘일어나는대표적인부위이다. 전극이상은일반적으로전극교체로해결한다. 하지만결함부위위치에따라, 특히협착이나폐쇄로정맥접근로가좋지않아새로운전극선을삽입하기어려울때는전극선수선이대안이될수있다. 이때전극선수선의안전성에대한의문이있을수도있다. 그러나 Chambers 등 [4] 은수술이가능하다면전극선수선이전극선교체의대안이될수있고심박조율기전극선수명을연장시킬수있다고보고하였다. 따라서본환자에서도전체전극선교체대신전극선수선이치료대안이될수있고전극선수명도연장시킬수있다고판단하였다. 정맥접근로의폐쇄는전극삽입을어렵게할수있다. 중재술이필요한완전혈관폐쇄는전체정맥폐쇄의 20% 를차지한다 [5]. 하지만전극에의한혈관폐쇄의치료법에대해 서는합의된바가없다 [6]. 본환자에서도우측정맥으로접근하여새로운전극선을삽입하는것과좌측에서정맥성형술을시행하는것의두가지치료방법이있었고두가지중어떤방법이든선택할수있었다. 하지만추후양측정맥페쇄가일어날경우미래의정맥접근로를잃을수도있다 [7]. 환자의여명이 30년이라고가정할때앞으로 4회정도심박발생기교체가필요할수있고 10-20년내에심방세동이나동기능부전발생위험성이있다. 따라서이런상황에서는정맥접근로를보존하는것이매우중요하다. 만약향후우측정맥폐쇄가발생하고양심강심박조율기삽입이필요하다면어려운상황에이르게된다. 이것이우리가두개의전극선삽입이필요한 DDD 모드대신에기존의심방전극을사용할수있는 VDD 모드를삽입한이유이다. 최근지침은여러번의심박조율기교체가예상되는환자에서는 VDD 모드를추천하고있다 [8]. 본증례의경우정맥조영술결과를포함한상황에대한충분한토의후환자는정맥성형술을선호했다. 게다가환자는우측흉부에새로운흉터가생기는것을원치않았다. 완두정맥과상대정맥사이폐쇄에대한정맥성형술을시행하는동안혈관확장기를통해상대정맥을향하는힘이전달되는데이는유착된전극선제거술기와유사한상황이다. 시술자는상대정맥으로과도한힘이가해지지않도록주의를기울여야하며그렇지않으면개흉수술을해야하는상황이발생할수있다. 본증례에서는친수성가이드와이어를이용한정교한폐쇄부위진입, 혈관확장기를이용하여연속적인내강확장후풍선확장술없

5 - 김지은외 3 인. 인공심박조율기전극골절 - 이충분히넓은내강을확보하였다. 만약폐쇄가심했다면단계적인풍선확장술이필요했을수도있다. 개흉수술준비하에시행되는도관삽입, 내강확장, 풍선확장술을이용한정맥성형술은심박조율기전극선진입로를확보할수있는좋은치료방법이다. 요약인공심박조율기전극골절은압박, 마찰, 꼬임, 신전과같은스트레스에의해일어날수있는흔한합병증으로대부분의전극이상은전극교체로치료한다. 하지만정맥접근로의협착이나폐쇄로인해새로운전극을삽입하기어려운경우도있다. 이경우폐쇄로의정맥성형술과기존전극선의수선을통해추가적인전극교체를최소화하고불필요한수술을줄일수있다. 이에저자들은정맥폐쇄가있는인공심박조율기전극골절환자에서정맥성형술및전극수선을통해효과적으로치료한 1예를보고한다. 중심단어 : 인공심박조율기전극 ; 기기오작동 ; 치료법 ; 혈관성형술 REFERENCES 1. Alt E, Völker R, Blömer H. Lead fracture in pacemaker patients. Thorac Cardiovasc Surg 1987;35: Magney JE, Flynn DM, Parsons JA, et al. Anatomical mechanisms explaining damage to pacemaker leads, defibrillator leads, and failure of central venous catheters adjacent to the sternoclavicular joint. Pacing Clin Electrophysiol 1993;16(3 Pt 1): Noma M, Kuga K, Matsushita S, Hiramatsu Y, Sakakibara Y. Intracardiac lead fracture in an implantable cardioverter-defibrillator. Int Heart J 2005;46: Chambers S, Rusanov A, Spotnitz HM, Silver ES, Liberman L. Durability of repaired pacemaker leads in the pediatric population. J Interv Card Electrophysiol 2011;30: Worley SJ, Gohn DC, Pulliam RW, Raifsnider MA, Ebersole BI, Tuzi J. Subclavian venoplasty by the implanting physicians in 373 patients over 11 years. Heart Rhythm 2011;8: Zartner P, Toussaint-Goetz N, Wiebe W, Schneider M. Vascular interventions in young patients undergoing transvenous pacemaker revision. Catheter Cardiovasc Interv 2011; 78: McCotter CJ, Angle JF, Prudente LA, et al. Placement of transvenous pacemaker and ICD leads across total chronic occlusions. Pacing Clin Electrophysiol 2005;28: Gillis AM, Russo AM, Ellenbogen KA, et al. HRS/ACCF expert consensus statement on pacemaker device and mode selection. Developed in partnership between the Heart Rhythm Society (HRS) and the American College of Cardiology Foundation (ACCF) and in collaboration with the society of thoracic surgeons. Heart Rhythm 2012;9:

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ºÎÁ¤¸ÆV10N³»Áö A case of atrioventricular dissociation with interference ABSTRACT Interference dissociation is one of the most interesting arrhythmias. Once thought to be a rare arrhythmia, it is now considered a very