Original Articles 심실조기흥분증후군에서역방향방실회귀성빈맥의 Abstract 임상적및전기생리학적특성 * 최동훈 이문형 안신기 김성순 Electrophysiologic and Clinical Characteristics of Antidrom

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1 Original Articles 심실조기흥분증후군에서역방향방실회귀성빈맥의 Abstract 임상적및전기생리학적특성 * 최동훈 이문형 안신기 김성순 Electrophysiologic and Clinical Characteristics of Antidromic Reentrant Tachycardia in Ventricular Preexcitation Syndrome Dong Hoon Choi, M.D., Moon Hyoung Lee, M.D., Shin Ki Ahn, M.D., Sung Soon Kim, M.D. Cardiology Division, Yonsei Cardiovascular Center, Yonsei University, Seoul, Korea BackgroundAntidromic reentrant tachycardiaart, in which an accessory atrioventricular pathway is used as the anterograde limb of an atrioventricular reentrant tachycardia, has been documented clinically in less than 10 of patients with the Wolff-Parkinson-WhiteWPW syndrome. The wide QRS complex makes the distinction between antidromic AV reentrant tachycardia and ventricular tachycardia somewhat difficult. The purpose of this study is to evaluate the clinical and electrophysiologic characteristics of the antidromic reentrant tachycardia. Methods and ResultsDuring the electrophysiologic study of 355 patients, from December 1986 to April 1995, referred for evaluation of Wolff-Parkinson-White syndrome, patients had preexcited reciprocating tachycardia. 1 The age of the antidromic reentrant tachycardia patients ranged from 15 to 53 years2812, and the mean age was younger than that of orthodromic reentrant tachycardiaort patientsp Thirteen were male patients, five were females. 3There were associated heart diseases in 3 cases. Two patients had Ebstein s anomaly and one had valvular heart disease. 4 The locations of accessory pathwaysaps documented on surface ECG were 7 left side39, 9 right side50, 1 posteroseptal side5.5 and 1 anteroseptal side. 5 Multiple bypass tracts were documented by electrophysiologic study in 7/ cases with ART, more common than cases with ORT20/3375.9p accessory pathways were documented by EPS in 18 patients10 left side, 11 right side, 2 posteroseptal side and 2 anteroseptal side. ART patients had more right sided AP11/25, 44 than those with ORT98/357, 27.5, but ART patients had less posteroseptal AP2/25, 8 than those with ORT63/357,

2 7 The types of ECG patterns naturally occurred were LBBB11 cases, RBBB6 cases, and atrial fibrillation4 cases. 8 The types of induced tachycardia in electrophysiologic study were 11 antidromic reentrant tachycardia, 10 orthodromic reentrant tachycardia, 7 reentrant tachycardia using two accessory bypass tracts, 3 AV nodal reentrant tachycardia, and 5 atrial fibrillations. ConclusionART patients were younger and had more multiple bypass tracts than those with ORT. ART patients had less posteroseptal AP than ORT patients and more right sided AP than ORT patients. The posteroseptal AP was used as retrograde limb only. KEY WORDSWolff-Parkinson-White syndrome Antidromic reentrant tachycardia. 서 론 연구대상및방법 1. 연구대상 395

3 2. 방법 1) 전기생리학검사 (Electrophysiologic study) 2) 전기생리학검사상의용어의정의 396

4 3) 통계처리 결과 1. 대상환자의임상적특성 Table 1. Clinical characteristics of patients with antidromic reentrant tachycardiaart and orthodromic reentrant tachycardiaort ART ORT p-value SexMF NS Ageyears Symptom duration years NS Symptom frequency year NS Total number 185.1% % % NSNot Significant Table 2. Clinical characteristics of patients with antidromic reentrant tachycardia during electrophysiologic study No. AgeyrsSex OHD Clinical arrhythmia Therapy Result Follow-up 1 24/F ART Op Success Asymp3mo 2 15/F ART Op Success Asymp12mo 3 20/F ART Op Success Asymp63mo 4 38/M A-Fib DCRF Fail Med, Lost to follow up 5 20/M ART DCRF Success Asym2mo 6 50/F ART DCRF Success Asym with med 7 34/M ART, AVNRT RF Success Asym44mo 8 48/M ART, A-Fib Op Success Asym with med 9 31/M A-Fib RF Success Asym /M ART DCRF Success Asym /F ART, A-Fib DCRF Fail Asym with med 12 15/M ART RF Success Asym24mo 13 17/M ART RF Success Asym24mo 14 53/M ART, ORT RF Success Asym12mo 15 29/M ART RF Success Asym12mo 16 22/M ART RF Success Asym12mo 17 22/M ART DCRF Success Asym1mo 18 22/M ART Diagnostic Fail Asym with med OHDOrganic heart diseaseebstein s anomaly7, 11 Mitral valve replacement6 ARTAntidromic reentrant tachycardia ORTOrthodromic reentrant tachycardia AVNRTAV nodal reentrant tachycardia A-FibAtrial fibrillation OpOperation DCDirect current cardioversion RFRadiofrequency ablation 397

의 진단 및 치료시의 연령은 15세부터 53세까지로 다 고 1예에서는 과거에 승모판 협착증으로 승모판 치환 양하였는데 평균 28±12세였고 이는 정방향의 방실 술을 받았었다(Table 2). 회귀성빈맥의 35±15세와 비교해 볼 때 훨씬 젊은 연 령에서 병원을 찾고 치료를 받은 것을 알 수 있다.

5 의 진단 및 치료시의 연령은 15세부터 53세까지로 다 고 1예에서는 과거에 승모판 협착증으로 승모판 치환 양하였는데 평균 28±12세였고 이는 정방향의 방실 술을 받았었다(Table 2). 회귀성빈맥의 35±15세와 비교해 볼 때 훨씬 젊은 연 령에서 병원을 찾고 치료를 받은 것을 알 수 있다. 환 자들의 증상이 처음 있은 후로부터 치료받기까지의 기 간은 7개월부터 40년까지로 평균 8.6년이었는데 정 방향 방실회귀성빈맥과 차이는 없었다. 빈맥의 빈도는 하루에 한번 이상 있었던 예로부터 1년에 한번까지 평 균 연간 약 10회였다. 이는 정방향 방실회귀성빈맥의 평균 연간 약 4회보다 통계학적으로 의의는 없지만 많 은 경향을 보였다(Table 1). 동반된 심장 질환이 있었 던 경우는 3예로 두 명에서는 Ebstein s anomaly였 Table 3. Distributions of accessory pathways on surface ECG Accessory pathway location 2. 우회로의 위치 안정시의 표면심전도를 이용한 우회로의 위치 예측 은 표면 심전도 전극 중 우회로의 좌우측 여부에 대해 서는 V1 전극의 우각 혹은 좌각차단, 전 후 여부에 대 해서는 Ⅲ와 avf 전극의 델타파 및 우회로의 내외측 및 우회로의 중격성 여부에 대해서는 V3, V4, V5 전 극에서의 V3와 V4 혹은 V4와 V5의 QRS 편 위의 양극성 여부 및 V2의 양극성 여부를 골자로 하였다. 안정시의 우회로의 위치는 좌측이 7예(39%), 우측이 9예(50%), 후중격과 전중격이 각각 1예로 나타났다 (Table 3). Fig. 1과 2는 좌측 우회로와 우측 우회로 를 가진 환자의 안정시 표면 심전도이다. 반면에 전기 ART(N=18) 생리학 검사로 나타난 우회로는 25예로 다발성 우회로 Right side 9(50.0%) 를 보인 예는 전체 환자 18예중 7예(38.9%)로 정방 Left side 7(39.0%) Septal group Posteroseptal 1( 5.5%) Left paraseptal 0 Anteroseptal 1( 5.5%) Midseptal 0 ART Antidromic reentrant tachycardia 향 방실회귀성빈맥에서의 337명의 환자에서 20예(5. 9%)와 유의한 차이를 보였다(Table 4, 5). 전기생리 학 검사로 확인된 전체 우회로의 위치는 왼쪽이 10예 (40.0%) 오른쪽이 11예(44.0%) 후중격과 전중격이 각각 2예(8.0%)였는데 이는 정방향 방실 전도 빈맥에 서 오른쪽 우회로가 27.5%로 왼쪽 우회로(47.6%)에 Fig. 1. Surface ECG of a patient with left lateral accessory pathway. 398

Fig. 2. Surface ECG of a patient with right posterior accessory pathway. Table 4. Frequency of atrial fibrillation and multiple bypass tracts in ART and ORT patients ART ORT P-value A-Fib 5/1827.

6 Fig. 2. Surface ECG of a patient with right posterior accessory pathway. Table 4. Frequency of atrial fibrillation and multiple bypass tracts in ART and ORT patients ART ORT P-value A-Fib 5/1827.8% 70/ % NS Multiple bypass tracts 7/1838.9% 20/ % p0.05 Table 5. Distributions of accessory pathways on electrophysiologic study in ART and ORT patients Accessory pathway ARTN25 ORTN357 location Right side % % Left side % % Septal group Posteroseptal 2 8.0% % Left paraseptal % Anteroseptals 2 8.0% % Midseptal % ARTAntidromic reentrant tachycardia ORTOrthodromic reentrant tachycardia Table 6. Distributions of accessory pathways on electrophysiologic study in ART patients Accessory pathway Single11 Multiple14 location Right side 763.6% 428.6% Left side 436.4% 642.8% Septal group Posteroseptal % Left paraseptal 0 0 Anteroseptal % Midseptal 0 0 ARTAntidromic reentrant tachycardia Table 7. Kinds of naturally occurred wide QRS tachycardia Number Wide QRS, LBBB 11AVNRT 1 RBBB 6 A-Fib 4 LBBBLeft bundle branch block RBBBRight bundle branch block AVNRTAV nodal reentrant tachycardia 399

보인 경우가 고 심방세동만으로 발현된 경우가 2명, 역방향 방실회 4예였다(Table 7). Fig.

7 3. 빈 맥 형과 우각 차단형의 빈맥을 보여준다. 임상적으로 진단 빈맥발작시의 표면 심전도상 wide QRS 좌각차단형 된 빈맥의 종류는 역방향 방실회귀성빈맥이 16명이었 이 11예, 우각 차단형이 6예, 심방세동을 보인 경우가 고 심방세동만으로 발현된 경우가 2명, 역방향 방실회 4예였다(Table 7). Fig. 3과 4는 wide QRS 좌각차단 귀성빈맥과 심방세동이 동반된 경우가 2명 있었다(Ta- Fig. 3. Maximum preexcitation in Fig. 2 patient(wide QRS LBBB pattern). Fig. 4. Maximum preexcitation in a Fig. 1 patient(wide QRS RBBB pattern). 400

8 Table 8. Types of induced tachycardia in electrophysiologic study True antidromic tachycardia 11/18 AP, AVN Two bypass tractsap, AP 7/18 OrthodromicAVN, AP 19/18 AVNRT 3/18 A-Fib. 5/18 Atrial tachycardia 1/18 APAccessory pathway AVNAV node Fig. 5. Schematic presentation of mechanisms of antidromic reentrant tachycardia. 401

9 Table 9. Electrophysiologic study parameters in ART and ORT patients ART patients ORT patients n Valuemsec n Valuemsec P-value AVBCLK AVKERP NS AVNERP NS AERP NS VABCLK NS VABCLN NS VACSERP NS VAKERP NS VERP NS VTR NS AVBCLAV block cycle length AVKERPAV Kent effective refractory period AVNERPAV nodal effective refractory period AERPAtrial effective refractory period VABCLKVA block cycle length-kent VABCLNVA block cycle lenght-node VACSERPVA coronary sinus effective refractory period VAKERPVA Kent effective refractory period VERPVentricular effective refractory period VTRVentricular tachycardia rate Table 10. Tachycardia cycle length in the same patients ART CLmsec ORT CLmsec P-value NS 4. 전기생리학적특성 5. 치료 고안 402

10 403

11 요약 연구배경 : 404

12 방법 : 결과 : 결론 : References 1) Smith RF:The Wolff-Parkinson-White syndrome as an aviation risk. Circulation 29: , ) Orinius E:Preexcitation. Studies on criteria, prognosis, and heredity. Acta Med Scand 465(suppl) :24-35, ) Krahn AD, Manfreda J, Tate RB, Mathewson FAL, Cuddy TE:The natural history of electrocar-diographic preexcitation in men. The Manitoba follow-up study. Ann Intern Med 116: , ) Gallagher JJ, Pritchett ELC, Sealy WC, Kasell J, Wallace AG:The preexcitation syndromes. Prog Cardiovasc Dis 20: , ) Robinson K, Rowland E, Krikler DM:Latent preexcitation:exposure of anterograde accessory pathway conduction during atrial fibrillation. Br Heart J 59:53-55, ) Josephson ME:Preexcitation syndromes. In Josephson ME, ed. clinical cardiac electrophysiology:techniques and interpretations. Pennsylvania, Lea and Febiger, 199 3, pp ) Bardy GH, Packer DL, German LD, Gallagher JJ:Preexcited reciprocating tachycardia in patients with Wolff- Parkinson-White syndrome:incidence and mechanisms. Circulation 70: , ) Kuck KH, Brugada P, Wellens HJJ:Observations on the antidromic type of circus movement tachycardia in the Wolff-Parkinson-White syndrome. J Am Coll Cardiol 2: , ) Kent AFS:Illustrations of the right lateral auriculoventricular junction in the heart. J Physiol 48:63-64, ) Wolff L, Parkinson J, White PD:Bundle-branch block with short P-P interval in healthy young people prone to paroxysmal tachycardia. Am Heart J 5: ,

13 11) Wellens HJJ, Durrer D:Wolff-Parkinson-White syndrome and atrial fibrillation:relation between refractory period of accessory pathway and ventricular rate during atrial fibrillation. Am J Cardiol 34: , ) Campbell RWF, Smith RA, Gallagher JJ, Pritchett ELC, Wallace AG:Atrial fibrillation in the preexcitation syndrome. Am J Cardiol 40: , ) Berkman NL, Lamb LE:The Wolff-Parkinson-White syndrome. A follow-up study of five to twenty-eighty years. N Engl J Med 278: , ) Zardini ZM, Yee R, Thakur RK, Klein GJ:Risk of sudden arrhythmic death in the Wolff-Parkinson-White syndrome: Current perspectives. PACE 17: , ) Benditt DG, Pritchett ELC, Gallagher JJ:Spectrum of regular tachycardias with wide QRS complexes in patients with accessory atrioventricular pathways. Am J Cardiol 42: , ) Gallagher JJ, Smith WM, Kasell JH, Benson DW Jr, Sterba R, Grant AO:Role of Mahaim fibers in cardiac arrhythmias in man. Circulation 64: , ) Smith WM, Gallagher JJ, Kerr CR, Sealy WC, Kasell JH, Benson DW Jr, Reiter MJ, Sterba R, Grant AO:The electrophysiologic basis and management of symptomatic recurrent tachycardia in patients with Ebstein s anomaly of the tricuspid valve. Am J Cardiol 49: , ) Kastor JA, Goldreyer BN, Josephson ME, Perloff JK, Scharf DL, Manchester JH, Shelburne JC, Hirshfield JW: Electrophyssiologic characteristics of Ebstein s anomaly of the tricuspid valve. Circulation 52: , ) Smith WM, Broughton A, Reiter MJ, Benson DW Jr, Grant AO, Gallagher JJ:Bystander accessory pathway during AV node reentrant tachycardia. PACE 6: , ) Klein GJ, Bashore TM, Sellers TD, Pritchett ELC, Smith WM, Gallagher JJ:Ventricular fibrillation in the Wolff- Parkinson-White syndrome. N Engl J Med 301: , ) Packer DL, Gallagher JJ, Prystowsky EN:Physiological substrate for antidromic reciprocating tachycardia. Circulation 85: , ) Kreiner G, Heinz G, Siostrzonek P, Radosztics S, Gossinger HD:Alterations of orthodromic circus movement tachycardia by dual atrioventricular nodal pathways in a patient with Wolff-Parkinson-White syndrome. PACE 1 6: , ) Durrer D, Roos JP:Epicardial excitation of the ventricles in a patietn with Wolff-Parkinson-White syndrome (type B). Circulation 35:15-21, ) Cobb FR, Blumenshein SD, Sealy WC, Boineau JP, Wagner GS, Wallace AG:Successful surgical interruption of bundle of Kent in a patient with Wolff-Parkinson-White syndrome. Circulation 38: , ) Morady F, Scheinmann MM:Transvenous catheter ablation of a posteroseptal accessory pathway in a patient with the Wolff-Parkinson-White syndrome. PACE 10: , ) 김성순 : 심장부정맥에대한전극도자절제술. 대한의학협회지 5: , ) Calkins H, Langberg J, Sousa J, El-Atassi R, Leon A, Kou W, Kalbfleisch S, Morady F:Radiofrequency catheter ablation of accessory atrioventricular connections in 250 patients;abbreviated therapeutic approach to Wolff-Parkinson-White syndrome. Circulation 85: ,

Original Articles Wolff-Parkinson-White 증후군의임상상및 전기생리학적소견 * Abstract 안신기 1 이문형 1 장양수 1 오동진 2 최인석 3 하종원 1 임세중 1 김병옥 4 정남식 1 심원흠 1 조승연 1 김성순 1

Original Articles Wolff-Parkinson-White 증후군의임상상및 전기생리학적소견 * Abstract 안신기 1 이문형 1 장양수 1 오동진 2 최인석 3 하종원 1 임세중 1 김병옥 4 정남식 1 심원흠 1 조승연 1 김성순 1 Original Articles 27 9 1997 Wolff-Parkinson-White 증후군의임상상및 전기생리학적소견 * Abstract 안신기 1 이문형 1 장양수 1 오동진 2 최인석 3 하종원 1 임세중 1 김병옥 4 정남식 1 심원흠 1 조승연 1 김성순 1 Clinical and Electrophysiologic Characteristics of