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1 대한내과학회지 : 제 77 권부록 5 호 2009 증례 임시형심박조율기삽입후발생한조율허용성다형심실빈맥 1예 왈레스기념침례병원내과 박재영 곽성동 임주견 정재식 천재홍 최성열 정준훈 A case of pacing-permitted polymorphic ventricular tachycardia after insertion of a temporary pacemaker Jae Young Park, M.D., Seong Dong Kwak, M.D., Ju Kyeon Yim, M.D., Jae Shik Jeong, M.D., Jae Hong Chun, M.D., Sung Yeol Choi, M.D., and Joon Hoon Jeong, M.D. Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea A 74-year-old man was admitted with sudden-onset chest pain. Electrocardiography showed ST segment elevation in leads II, III, and avf; in addition, the levels of several cardiac enzymes were elevated. The patient received a VVI temporary pacemaker due to bradycardia (45 beats/min) and was subjected to primary percutaneous coronary intervention. After percutaneous coronary intervention for the RCA infarction, the patient was admitted to the coronary care unit. Six hours later, polymorphic ventricular tachycardia occurred following a short-long-short sequence. This is the first case of temporary pacemaker-permitted ventricular tachycardia in Korea. Here we present a case of pacemaker-permitted polymorphic ventricular tachycardia in a patient with inferior acute myocardial infarction. (Korean J Med 77:S1157-S1161, 2009) Key Words: Pacemaker, artificial; Tachycardia, ventricular 서론임시형심박조율기는 Paul Zoll 이 1952년처음으로임상에도입한후심장무수축, 방실차단, 각차단및급성심근경색환자와수술환자에서의심장박동수조절을위해서사용되어지고있다 1). 급성심근경색환자에서의임시형심박조율기사용은전체임시형심박조율기사용빈도의약 13% 를차지하고 2), 임시형심박조율기를삽입한환자들중에서 14~ 20% 가합병증을경험하며삽입한환자들중약 0.1에서 2.0% 에서심실빈맥이발생하는것으로알려져있다 3-5). VVI 방식의심박조율기는 DDD 및다른방식의심박조율보다부정맥의발생이드물다 6). 저자들은급성심근경색환자에게 VVI 방식의임시형심박조율기삽입후발생한다형심실빈맥을경험하였기에보고하는바이다. 증례환자 : 추 동, 남자, 72세 Received: Accepted: Correspondence to Joon Hoon Jeong, M.D., Department of Internal Medicine, Wallace Memorial Baptist Hospital, Namsan-dong, Geumjung-gu, Busan , Korea jjhoon69@yahoo.co.kr - S

- The Korean Journal of Medicine: Vol. 77, Suppl. 5, 2009 - Figure 1.

2 - The Korean Journal of Medicine: Vol. 77, Suppl. 5, Figure 1. Electrocardiography performed in the emergency room showed ST segment elevation in leads II, III, and avf, with ST segment depression in leads V2~V4 and a T inversion in leads I and avl. 주소 : 쥐어짜는듯한가슴통증현병력 : 병원방문당일점심경에벌초하던중가슴통증발생하여본원응급실에방문하였다. 과거력 : 특이사항없었다. 가족력 : 특이사항없었다. 사회력 : 매일한갑씩 50년간흡연력이있었으나, 음주력은없었다. 이학적소견 : 내원당시혈압은 80/50 mmhg, 맥박수분당 50회, 체온 36.7 였다. 이학적소견상급성병색을보였고, 흉부검사상심잡음은없었으며청진상수포음등은들리지않았다. 복부및하지진찰에서는특이소견없었다. 방사선소견 : 내원시촬영한흉부단순촬영에서특이소견관찰되지않았다. 심전도소견 : 내원시심전도에서 II, III, avf 에 ST 분절의상승이관찰되었으며 I, avl에 T파역위가, V2~V4 에 ST 분절의하강이관찰되었다 ( 그림 1). 검사실소견 : 말초혈액검사상백혈구 9,800/mm 3, 혈색소 13.8 g/dl, 혈소판 220,000/mm 3 이었으며혈청생화학검사에서 AST 25 IU/L, ALT 22 IU/L, BUN 14.7 mg/dl, creatinine 1.4 mg/dl, CK 493 IU/L, CK-MB 95 IU/L, troponin-i 2.41 µg/l, probnp pg/ml, 혈청나트륨 147 meq/l, 혈청칼륨 3.7 meq/l, 혈청이온화칼슘 1.00 mmol/l, 혈청이온화마그네슘 0.50 mmol/l이었다. 지질검사상총콜레스테롤 182 mg/dl, 고밀도지단백콜레스테롤 48 mg/dl, 중성지방 50 mg/dl, 저밀도지단백콜레스테롤 123 mg/dl로고지혈증양상은없었다. 심장초음파소견 : 좌심실구혈률은 48% 였고, 심근하벽과중격의하부에서운동성이현저히감소되어있었다. 경과 : 응급실에서 aspirin 300 mg, clopidogrel 300 mg을투여하였고, 미분획헤파린 5,000 IU을일시정주투여하고 1,000 IU/hr로지속적인점적주사를시작하였다. 내원 30분후의식저하와분당 45회의동서맥관찰되어 atropine 투여하였으나심박수상승보이지않았다. 즉시우측넙다리정맥을통해임시형심박조율기를우심실에삽입하여 VVI 방식, 전압 5 V, 역치 2.0 mv, 민감도 1.0 mv, 심박수는분당 60회로설정후일차적관상동맥조영술과중재술을시행하였다. 오른관상동맥의근위부에 90% 협착이있었으며 ( 그림 2A) 왼관상동맥의근위부에 70% 협착이있어오른관상동맥부위에관상동맥성형술시행후약물방출스텐트삽입하였다 ( 그림 2B). 관상동맥중재술중에분당 35회정도의심박수저하와의식저하한차례관찰되었으며최저맥박수를 40 회로조정후임시형심박조율기를유지하여환자는중환자실로입원하였다. 중환자실입원 6시간경과후에환자의의식저하와함께심전도에서다형심실빈맥 (polymorphic ventricular tachycardia) 이관찰되었다. 심장제세동시행한후에분당 65회의동율동으로회복되었다. 흉부방사선검사상에 - S

- Jae Young Park, et al. Temporary pacemaker-induced ventricular tachycardia - A B Figure 2. Coronary angiography (CAG). (A) Initial CAG showed 90% occlusion of the proximal right coronary artery.

Electrocardiography performed in the coronary care unit showed pacing-permitted polymorphic ventricular tachycardia following a short-long-short sequence.

3 - Jae Young Park, et al. Temporary pacemaker-induced ventricular tachycardia - A B Figure 2. Coronary angiography (CAG). (A) Initial CAG showed 90% occlusion of the proximal right coronary artery. (B) Final angiography revealed a successfully revascularized right coronary artery. Figure 3. Electrocardiography performed in the coronary care unit showed pacing-permitted polymorphic ventricular tachycardia following a short-long-short sequence. Arrows indicate mechanical pacing within five cycles before initiation. VT, ventricular tachycardia. 서임시심박조율기는정상적인위치에자리잡고있었다. 심전도기록상에서환자는분당약 70회의정상동율동을유지하고있었으나임시심박조율기의이상조율에이은심실조기박동이반복되고있었으며, 이후 short-long-short sequence에이은심실빈맥이발생하였음을확인하였다 ( 그림 3). 동율동으로회복후즉시임시심박조율기제거하고경 과를관찰하였다. 임시심박조율기를재검토해본결과분당 40회로설정되어있었던최저심박수가 75회로설정되어있었으며그이유는전원이꺼진후자동적으로다시켜지면서최저심박수가재설정되었기때문으로확인되었다. 이후환자의흉통없었고, 심전도에서동율동유지되어퇴원하였으며외래추적검사상특이소견보이지않고있다. - S

4 - 대한내과학회지 : 제 77 권부록 5 호 고찰급성심근경색환자에서임시형심박조율기는무수축, 증상이있는서맥, 양각차단 (Bilateral bundle branch block), 새로이발생한삼중섬유속차단, 모비츠 II형이상의방실전도차단이있는경우에사용이고려되어진다 7). 임시형심박조율기의삽입으로심실성빈맥 (0.1에서 2.0% 로 ), 심실세동 (0.5% 에서 1.6% 로 ), 심장천공 (0.06%) 및정맥혈전이나감염의위험성이증가하게되고 8), Lewis 등은급성심근경색환자에서우심실에임시형심박조율기를삽입시심실세동의빈도가 6배정도증가한다고보고하였다 9). 심박조율기매개성빈맥 (pacemaker-mediated tachycardia) 종류중에서가장흔한것은 endless loop tachycardia (ELT) 에의한것이다 6). ELT는심방불응기이후에여러가지유발인자들에의해역행전도성심방활성화가유발되고이것이심박조율기의감지회로에감지된후다시심실자극을일으키고이것이계속적으로반복되는회귀회로가형성되어발생하게된다. 두번째심박조율기매개성빈맥의기전은심전도소견상 ELT와유사하지만 ELT처럼회귀회로를형성하지않고심방조동이나심방세동등의이소성심방빈맥에의해발생되는 pseudoendless loop tachycardia이다 10). Sweeney 등은두개의 ICD (Implantable cardioverter defibrillator) trial (PainFree Rx II, EnTrust trial) 을분석하여심박조율기의자극과이어서발생하는심실부정맥과의관계를네가지로분류하여다음과같이제시하였다 6). 그분류는 1조율비연관성 (non-pacing associated) 2조율연관성 (pacing associated) 3조율허용성 (pacing permitted) 4조율촉진성 (facilitated) 으로구성되어있다. 조율비연관성부정맥은심실빈맥또는심실세동시작전의 5회의맥박이내에조율이없는경우이다. 조율연관성부정맥은심실빈맥또는심실세동시작전의 5회의맥박이내에조율이있으면서 shortlong-short sequence가없는경우이며이는 VVI 방식의심박조율기에서는드물며 DDD 방식의심박조율기에서가장흔한것으로알려져있다. 조율허용성부정맥은심실빈맥또는심실세동이 short-long-short sequence에의해시작되며조율자극이원인이되지않는경우이다. 조율허용성부정맥과조율비연관성부정맥과의차이점은 short-long-short sequence의유무이다. 마지막으로조율촉진성부정맥은단독의심실조율자극이휴기 (pause) 를일으키거나종결시킨후에 short-long-short sequence를만들어내고이어서심실빈맥또는심실세동이발생하는경우이며, DDD 방식의심박조율 기에서가장흔하며 VVI 방식의심박조율기에서는드물게발생하고 MVP (managed ventricular pacing) 방식의심박조율기에서는거의생기지않는다. VVI 방식의심박조율기에서발생하는조율촉진성심실빈맥은심실조기탈분극이짧은휴지를만들며이어서 QRS군사이의긴간격이발생하는데이때조율자극이 short-long sequence를방해하고이것이 short sequence와심실빈맥을발생시키는기전으로발생하게된다 11). 본증례에서저자들은심전도기록상임시형심박조율기가재작동되면서감지실패 (sensing failure) 에의한 R-on-T 현상이발생하기시작했고, 심실빈맥발생 5맥박이내에 2차례의비정상적인조율이있었으며이후 short-long-short sequence에이은다형심실빈맥이시작되었음을확인할수있었다 ( 그림 3). 이는환자의심실빈맥이심박조율기로인한조율허용성심실빈맥이었음을보여주는증거이다. 급성심근경색환자에서의심실빈맥또는심실세동의발생은잘알려진합병증이나위증례와같이임시형심박조율기를삽입한환자에서는그원인이혼돈되어질수있다. 아직까지임시형심박조율기에서조율과부정맥과의연관성에대한분류가다양하고불명확하여심전도의판독에어려움이있다 6). 임시형심박조율기를삽입받은환자는지속적인심전도관찰을받아야하고, 의료진은계속적으로심박조율기유지여부를판단하여야한다. 이것만으로도심박조율기로인한불필요한합병증을상당부분예방할수있다. 하지만임시형심박조율기를삽입한환자에서부정맥발생시그것이조율연관성인지비연관성인지를빠르게파악하는것이중요하며조율연관성부정맥이의심될때는심박조율기를즉시제거하여야한다. 요 저자들은하벽의급성심근경색증환자에서 VVI 방식의임시형심박조율기를삽입한후심박조율기오작동으로인한조율허용성다형심실빈맥을경험하였기에문헌고찰과함께이를보고하는바이다. 약 중심단어 : 인공심박조율기, 심실빈맥 REFERENCES 1) Gammage MD. Temporary cardiac pacing. Heart 83: , S

5 - 박재영외 6 인. 임시형심박조율기삽입후발생한심실빈맥 1 예 - 2) Lopez Ayerbe J, Villuendas Sabate R, Garcia Garcia C, Rodriguez Leor O, Gomez Perez M, Curos Abadal A, Serra Flores J, Larrousse E, Valle V. Temporary pacemaker: current use and complications. Rev Esp Cardiol 57: , ) Harrigan RA, Chan TC, Moonbaltt S, Vilke GM, Ufberg JW. Temporary transvenous pacemaker placement in the emergency department. J Emerg Med 32: , ) Palmo AR, Schwartz AM, Trohman RG, Chahine RA, Myerburg RJ, Kessler KM. Cardiac arrhythmias associated with prophylactic pacing during coronary angiography. Am J Cardiol 58: , ) Lehmann MH, Cameron A, Kemp HG Jr. Increased risk of ventricular fibrillation associated with temporary pacemaker during coronary arteriography. Pacing Clin Electrophysiol 6: , ) Fisher JD. Pacemaker pro-arrhythmia: beyond spike-on-t and endless loop tachycardia. J Am Coll Cardiol 50: , ) Francis GS, Williams SV, Achord JL, Reynolds WA, Fisch C, Friesinger GC 2nd, Klocke FJ, Akhtar M, Ryan TJ, Schlant RC. Clinical competence in insertion of a temporary transvenous ventricular pacemaker: a statement for physicians from the ACP/ ACC/AHA Task Force on Clinical Privileges in Cardiology. Circulation 89: , ) Lee SY, Gwon HC, Kim HJ, Jeong JO, Ahn KJ, Lee SC, Cho WH, Park SW, Kim JS, Kim DK, Lee SH, Hong KP, Park JE, Seo JD, Lee WR. Safety of percutaneous right coronary intervention without temporary pacemaker: prospective study. Korean Circ J 29: , ) Johnson LW, Bowser MA, Lozner EC. Use of temporary pacemakers during coronary angiography: an evolving experience with ventricular fibrillation in 400 cases. Cathet Cardiovasc Diagn 15: , ) Lee KW, Choue CW, Kim WS, Kang HS, Kim KS, Song JS, Bae JH. Three cases of pacemaker-mediated tachycardia. Korean Circ J 30: , ) Sweeney MO, Ruetz LL, Belk P, Mullen TJ, Johnson JW, Sheldon T. Bradycardia pacing-induced short-long-short sequences at the onset of ventricular tachyarrhythmias: a possible mechanism of proarrhythmia? J Am Coll Cardiol 50: , S

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ºÎÁ¤¸ÆV10N³»Áö case of brugada syndrome presented as chest pain STRCT rugada syndrome was described in 1992 as a new clinical entity characterized by electrocardiographic STsegment elevation in the right precordial leads