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1 대한내과학회지 : 제 91 권제 2 호 In-depthreview 우심부전양상및진단 가천대학교의학전문대학원심장내과학교실 신미승 Clinical Manifestations and Diagnosis of Right Ventricular Failure Mi-Seung Shin Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea Right ventricular (RV) failure is a complex clinical syndrome characterized by impaired RV filling and ejection. RV function is altered in the setting of either pressure overload or volume overload. RV failure may result from a primary reduction of myocardial contractility caused by ischemia, cardiomyopathy, or arrhythmia, but left ventricular (LV) failure remains the leading cause. As RV dysfunction progresses to RV failure, the RV chamber becomes more spherical and tricuspid regurgitation is aggravated, leading to increasing venous congestion. Ventricular interdependence may result in impaired LV filling, a decrease in LV stroke volume, and low cardiac output. The important clinical manifestations of RV failure are fluid retention, decreased systolic reserve, low cardiac output, or arrhythmias. The initial diagnosis is based on clinical history and physical examination. A chest X-ray, electrocardiogram, and biochemical tests should be routinely obtained to evaluate the underlying causes and comorbidities. Bedside echocardiography provides valuable information on cardiac structure and function. RV ejection fraction is the most commonly used index of RV function although it is a highly load-dependent index. (Korean J Med 2016;91: ) Keywords: Right ventricle; Heart failure; Diagnosis 서론우심부전은복잡한임상증후군으로서, 우심실이혈액으로채워지고혈액을우심실밖으로내보내는기능을저해하는다양한구조적, 기능적심혈관질환들에의해발생할수있는데, 폐고혈압, 선천성심장질환, 관상동맥질환, 좌심부전및판막질환에서나타날수있다. 우심부전의정의는안 정을취할때나운동할때폐순환계로최적화된혈류를내보내지못하고정맥압의상승이동반되거나동반되지않은상태를일으키는우심순환계의구조적, 기능적변화로인한임상증후군이다 [1,2]. 우심실이우심순환계의매우중요한부분이지만전신정맥에서폐모세혈관까지순환계의어떤부분이라도기능장애를일으키면우심부전의증상이나타날수있다. 우심부전의주요임상특징들은 1) 체액저류, Correspondence to Mi-Seung Shin, M.D., Ph.D. Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel: , Fax: , msshin@gilhospital.com Copyright c 2016 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.

2 - The Korean Journal of Medicine: Vol. 91, No. 2, ) 감소된수축기예비력또는적은심장박출량, 3) 심방또는심실성부정맥인데, 체액저류는말초부종, 복수및전신부종을일으킬수있고, 심장박출량감소는운동불내성과피로를유발할수있다. 우심부전을일으키는원인에따라병태생리의차이가있지만각각의질환과연관되어다루게될것이므로여기서는주로우심부전의양상과진단에대해논하고자한다. 정상우심실정상우심실은얇은벽으로된초승달모양의구조이고우심실외벽 (free wall), 심실중격및우심실유출로로구성되어있다. 심실중격이좌심실과심근섬유를공유하고있어서 좌심실이우심실수축기능의 40% 까지담당하게된다 [2-4]. 외벽의횡축운동에비해심실중격은효과적인종축수축과비틀림수축을통해전체우심실기능에가장많이기여한다 [5]. 우심부전의원인과병태생리우심실은압력이나용적과부하, 허혈, 심근질환이나심장막에의한제한등에영향을받게된다. 우심실의기능장애는심근손상이나스트레스에의해시작되고이렇다할새로운손상이없어도진행할수있다. 우심부전의원인이많고다양하지만가장흔한원인은좌심부전이다 (Table 1). 좌심부전을일으키는같은요인들이우심실에영향을줄수있 Table 1. Etiology of right ventricular failure Increased afterload (Pressure overload) Volume overload Decreased preload Right ventricular myocardial abnormality Left-sided heart failure Pulmonary hypertension Increased left ventricular end-diastolic pressure Mitral valve disease Hypoxic pulmonary vasoconstriction Acute or chronic pulmonary thromboembolism Pulmonary embolism (septic, amniotic, fat, air, injectate, other) Right ventricular outflow tract obstruction Pulmonary valve stenosis Vaso-occlusive sickle cell crisis Mechanical ventilation Systemic right ventricle Transposition of the great arteries following an atrial level switch Corrected transposition of the great arteries Tricuspid regurgitation Pulmonary regurgitation Atrial septal defet Anomalous pulmonary venous return coronary artery fistula to right atrium or right ventricle Sinus of Valsalva rupture into the right atrium Hypovolemia Systemic vasodilatory shock (anaphylaxis, extensive burn injury, sepsis, other) Cardiac tamponade Constrictive pericarditis Superior vena cava syndrome Tricuspid stenosis Right ventricular infarction Infiltrative and restrictive cardiomyopathy Arrhythmogenic right ventricular dysplasia Cardiomyopathy, in particular left ventricular systolic dysfunction Right ventricular ischemia in setting of right ventricular pressure overload Microvascular diseases and capillary rarefaction

3 - Mi-Seung Shin. Right ventricular failure - 는데, 우심실자체의기능장애를일으킬수있고, 우심실이기능의상당부분을좌심실에의존하기때문에우심실수축력이더욱감소하게된다. 우심실은정상적으로낮은후부하, 즉쉽게확장될수있는동맥순환으로혈액을내보낸다. 따라서후부하가증가하면, 특히급성으로증가하면, 우심실기능의현저한감소가일어날수있다 (Fig. 1). 상승된좌측충만압은폐순환계의압력을올릴뿐만아니라혈관탄성을낮추어서우심실후부하를증가시킨다 [6]. 시간이흐르면좌심부전은폐동맥혈관수축과재형성을촉발해서후부하를더욱상승시키게된다. 후부하가만성적으로또는서서히진행하면서증가하는만성적압력과부하상태에서는우심실이비교적잘적응하는데, 아이젠멩거증후군과선천성폐동맥판협착증이그예이다. 아이젠멩거증후군의경우일생동안좌우심실벽의두께가같으면서우심실의탄력이유지되고, 운동할때처럼전신저항에대한폐동맥저항의상대적비율이증가할때우심실에서전신순환으로션트가이루어지면서우심부전이나중에나타난다 [7]. 선천성폐동맥판협착증의경우심실비대가폐쇄의정도에따라다양하지만우심실은비교적잘적응하는데, 장기간치료받지않은심한폐쇄는우심부전과삼첨판역류증을유발한다 [8]. 일반적으로우심실은압력과부하보다는용적과부하에더잘적응한다. 심방중격결손증과삼첨판역류증에서우심실은오랫동안우심실수축기능의유의한감소없이용적과부하에잘견딘다 [8]. 이와대조적으로성인에서중등도 Figure 1. Pathophysiology of acute right ventricular failure. TR, tricuspid regurgitation; PR, pulmonary regurgitation; RV, right ventricular; RA, right atrial; CV, central venous; LV, left ventricular. 내지중증의새로생긴폐고혈압은우심실확장과우심부전을일으킨다. 우심실의압력과부하는또한우심실허혈을일으키고우심실기능장애를악화시킬수있다 [9]. 동물실험과인간대상연구에서관찰된것처럼심근의결합조직의밀도가증가하는등조직학적변화도우심실압력과부하상태에서더욱확연하다 [10,11]. 폐동맥색전증같은급성압력과부하상태에서그전에정상이었던우심실은급성으로상승된평균폐동맥압 40 mmhg 이상인상태에견디지못하고우심부전이조기에발생한다. 그런데같은정도의폐동맥압에서도사람에따라서우심부전이발생하는시기가다른것을보면유전자발현이나신경호르몬활성이관여한다는것을생각할수있다 [12]. 우심실이적응하는과정은복잡하며많은요인들에영향을받는다. 가장중요한요인은심근손상이나스트레스의형태와심한정도, 질환의시간경과, 질환이시작한때등이다. 이외의중요한요인들은신경호르몬계활성화, 유전자발현의변화, 심실재형성의형태등이다. 이들이상호작용하여우심실기능장애를일으킨다. 많은연구들이우심부전환자에서자율신경계, 레닌-앤지오텐신-알도스테론계통, 나트륨이뇨펩티드, 엔도텔린계, 사이토카인의역할을논하였다. 우심부전의단계와예후인자우심부전의발생은좌심부전과같이점진적으로진행해서무증상우심실기능장애에서증상이있는우심부전을거쳐난치성우심부전으로진행한다. 폐동맥고혈압과연관된난치성우심부전의많은환자들이폐이식후에우심실기능의유의한개선을보이는것은우심실의회복가능성과흔히사용되는우심실수축기능지표들의부하의존성을나타낸다. 우심부전의진행정도는원인이되는기저질환에따라다른데, 우심실용적과부하, 폐동맥판협착증, 아이젠멩거증후군에서가장좋은장기예후를나타낸다. 폐고혈압이나선천성심장질환과연관된우심부전환자에서감소된운동능력은사망이나입원에대한가장중요한예후인자중하나이다. 다른예후인자들은우심실수축기능장애의정도, 우심실이완기능장애, 신경호르몬계활성의정도, 심박동수변동부전, 부정맥, 좌심실수축기능장애, 혈청요산과빌리루빈등이다

4 - 대한내과학회지 : 제 91 권제 2 호통권제 672 호 우심부전의임상양상 우심부전의증상으로는하지부종, 복부팽만감, 소화장애, 식욕부진, 오심, 전신쇠약감, 피로감, 전신부종및호흡곤란등이나타날수있는데, 좌심부전의증상과함께나타나기도한다. 이외에도간비대, 비장비대, 복수등우심부전의임상양상은근본원인과동반질환에따라다양하게나타난다 (Table 2). 선천성심장질환에의한우심부전의경우호흡곤란이가장흔한증상이며산소수요가증가할때심장박출량의증가가따라가지못하고산소공급이충분하지못해서생긴다. 우심방확장에따른부정맥발생으로심계항진과빈맥을느낄수있으며, 우심부전으로인한청색증, 곤봉지, 실신등이발생할수있다. 경정맥이확장되고간비대, 복수, 말단부종을보일수있다. 심잡음은삼첨판역류로흉골좌하연에서수축기심잡음이들리며, 제2심음중폐음이증가하고, 제3, 4심음이들릴수있다 [13]. 대부분의우심부전의증상은전신에서들어오는정맥혈이대정맥에정체되어생기는증상인데, 정맥압이증가하면발목또는정강이부위가붓는하지부종이생기고, 간이나비장이커져복부팽만감과소화불량을호소하거나심하면 Table 2. Clinical manifestations of right ventricular failure Clinical manifestations Hypoxemia Signs of systemic congestion Jugular venous distension Hepatojugular reflux Peripheral edema Pericardial effusion Congestive hepatomegaly/splenomegaly Ascites Lower extremity edema anasarca Signs of right ventricular dysfunction Third heart sound Systolic murmur of tricuspid regurgitation Hepatic pulse Signs of concomitant left ventricular dysfunction Paradoxical pulse Signs of low cardiac output Hypotension Tachycardia Cool extremities Central nervous system abnormalities Oliguria 복수가생기게되고, 간기능이상으로황달이나타날수있다. 심장박출량이감소하면심기능저하에따른보상기전이작동하게되는데, 1) 교감신경이활성화되어심장수축력과맥박수를증가시키고, 말초혈관이수축하여혈압을유지하려고하고, 2) 신장으로가는혈액량이감소하므로신장에서배설되는수분량을감소시켜혈액의양을적절하게유지하려는보상기전이작동된다. 따라서, 이런보상기전에의해빈맥, 발한및소변량의감소등이나타날수있다. 우심부전의진단 우심부전의진단에서병력청취와신체검사는우심부전과그원인질환및동반질환을평가하기위해중요하다. 흉부방사선촬영이필요하고때때로특징적인변화를찾을수있다. 다른폐실질성질환이없는지잘평가해야하고심장윤곽의전체혹은어느한부분이커져있는지여부가진단지표가될수있다. 심전도검사에서우심부전초기에는우측편위, 우심방확대 (P pulmonale), 우심실비후, 우심실긴장형을보인다. 우심실압력이전신압력정도이거나약간낮을정도로높으면심장앞유도에서 R파가우세하면서바로선 T파를보이며, 전신압력보다더높을경우에는우측흉부유도에서긴장형태로나타나 T파역위와 J파하강으로나타난다. 우심부전에특징적인생화학적표지자는없지만몇가지도움이되는생화학적표지자들이있다 (Table 3). B 형나트륨이뇨펩티드와심장트로포닌의변화는급성우심부전이생긴원인질환에따라달라진다. 이러한표지자는우심부전과심근손상의신속한진단에도움이된다 [14-17]. 우심부전의진단을위한새로운생화학적표지자가평가되고있다 [18-21]. 우심실기능의정확하고포괄적인평가는어렵다. 우심실 Table 3. Helpful biochemical markers of right ventricular failure Biochemical markers Elevated natriuretic peptides (BNP or NT-proBNP) Elevated cardiac troponin I or T Abnormal liver biochemistry (e.g. elevated transaminases, bilirubin, prolonged prothrombin time) Increased lactate levels in acute right ventricular failure Abnormal renal function (blood urea nitrogen, creatinine) D-dimer levels in suspected pulmonary embolism BNP, brain natriuretic peptide; NT-proBNP, N-terminal pro brain natriuretic peptide

5 - 신미승. 우심부전양상및진단 - 은기능적으로형상화하기어려울수있고우심실의후부하의존도는우심실의고유기능을잘못해석하게할수도있다. 비침습적인방법으로심초음파검사와자기공명영상 (magnetic resonance imaging, MRI) 이가장많이쓰이는방법이다 [22]. 심초음파검사심초음파검사는우심실의크기, 기능및부하상태를평가하기위해사용할수있는첫번째검사이고, 침상심초음파검사는심장의구조와기능에대한빠른정보를주며응급실이나중환자실에서도사용할수있다. 즉각적인치료를요하는급성우심부전의외적원인들을배제하고하대정맥의직경을측정하고호흡에따른변화를평가하기위해사용될수있다. 경삼첨판압력차를구하여폐동맥수축기압을계산하는것은침습적인방법과비교할때믿을만한방법이다. 우심실확장, 구형도및좌심실확장과비교한우심실확장의정도를정확하게평가하기위해서는우심실에초점을맞춘심첨4방도와늑골하부창등우측심장에대한모든가능한장면을활용해야한다. 우심실확장, 우심실비후, 삼첨판역류를평가할수있고, 양심실이보이는단축면에서심실중격의모양을보아우심실압력과폐동맥협착이없을경우는폐동맥압력의정도를예측할수있다. 만일좌심실이어느정도동그란모양을가지고있다면우심실압력은좌심실압력또는전신수축기혈압의 50% 이하이고, 심실중격이평평해서거의 D자모양의좌심실형태를지니면우심실압력은좌심실압력혹은전신압력에근사하며, 심실중격이좌심실쪽으로밀려있으면우심실압력이전신압력이상으로상승했다는것을추측할수있다. 기술발달로 3차원심초음파기기를이용한우심실용적및기능평가가훨씬용이해졌다. 우심실의수축기및확장기기능은우심실유출로, 삼첨판유입부와정맥에서의여러도플러지표에의해간접적으로평가할수있다. M 모드와조직도플러영상을이용해서삼첨판륜에서심근속도와시간을측정하여우심실의확장기와수축기의움직임의지표로서사용하고있다. 삼첨판의유입혈류속도와는달리삼첨판륜의확장기속도는침습적으로측정된우심실압력과상관관계가있다. 기하학적구조및과부하와는무관하게도플러를이용한전체적인심근기능을정량적으로측정할수있는, 즉심근수행지표 (myocardial performance index) 혹은삼첨판륜의등용적가속 (tricuspid annular isovolumic acceleration) 등은우심실기능평가를위하여유용하다. 우심실수축기능이상이있으면등용적수축기시간은길어지고, 우심실박출시간은짧아진다. 우심실확장기능이상으로등용적확장기시간은길어진다. 그러므로전체적으로우심실기능이상이있으면심근수행지표가증가한다. 심근의변형 (strain) 과변형속도 (strain rate) 을이용한조직도플러영상은심근기능의정량적분석을가능하게하며, 심근벽에서국소적인수축기능을평가하여우심실기능에관한많은정보를준다. 초음파기법의발전에따라우심실전체또는분절에대한질적평가에서양적평가로바뀌고있다 [23]. 미국심초음파학회와유럽심혈관영상학회의최신권고안은다음지표들중최소한하나를하여서전체적인우심실기능의양적평가를하도록하였는데 [24], 우심실분획면적변화 (right ventricular fractional area change, RVFAC); 삼첨판륜평면수축이동 (tricuspid annular plane systolic excursion, TAPSE); 조직도플러영상을이용한삼첨판륜의수축기 S 속도, 또는우심실심근수행지표이다. TAPSE 와 S 속도에추가적으로우심실전체또는국소적인종축수축을변형심초음파검사로평가할수있다. 우심실박출률 (right ventricular ejection fraction, RVEF) 은부하상태에매우의존적이지만, 가장많이사용되는우심실기능지표이다. 이면성심초음파검사로평가한 RVEF는권하지않으며경험이많고적절하게장비를갖춘센터에서는상당히정확한 3차원우심실용적과박출률을측정하고있다. 가장흔히사용되는우심부전의심초음파적특징들을표에기술하였다 (Table 4) [22,24,25]. 우심실기능의대부분이종축수축을통해이루어지기때문에 TAPSE가우심실기능평가의매력적인후보자이다. TAPSE는폐동맥고혈압과좌심부전환자들의여러코호트에서임상결과와연관성이있음을보여주었다. 그러나다른연구결과들은 TAPSE 의변화가질병경과의믿을만한표시자가되지못하며선천성심장질환이나심장수술후전체우심실기능을나타내지못한다는것을시사하였다. 수술후에심실중격기능저하와심장막제약의소실로인해우심실의종축수축은저하되고우심실은외벽의횡축수축에더의존하게된다. 종축기능감소에도불구하고, 특히후부하가작은경우에, RVFAC 와 RVEF는유지될수있다 [26,27]. RVEF는평범한심초음파검사로는해석하기어렵지만, RVFAC 와 TAPSE는폐고혈압환자의최신연구에서 MRI로구한 RVEF와좋은상관관계를보여주었다 [28]. 변형영상

6 - The Korean Journal of Medicine: Vol. 91, No. 2, Table 4. Echocardiographic parameters in the assessment of right ventricular failure Echocardiographic parameters Pericardial fluid in diastole > 5 mm Right ventricular wall thickness > 5 mm Inferior vena cava diameter >21 mm, inspiration collapse < 50% suggesting high RA pressure Peak systolic velocity of tricuspid regurgitation > 2.8 m/s Tricuspid annular plane systolic excursion (TAPSE) < 17 mm Right ventricular dilation: RVEDD/LVEDD > 1.0, right ventricular basal diameter > 41 mm Right ventricular fractional area change (RVFAC) < 35% Ventricular interdependence: septal shift, D shaped LV Systolic S velocity of tricuspid annulus < 9.5 cm/s by Doppler tissue imaging Longitudinal strain of right ventricular free wall < 20% Right ventricular index of myocardial performance > 0.54 by Doppler tissue imaging 3D right ventricular ejection fraction < 45% RA, right atrium; RVEDD, right ventricular end-diastolic diameter; LVEDD, left ventricular end-diastolic diameter; LV, left ventricle. (strain imaging) 은우심실기능평가를위해서사용이증가되고있다. 변형은우심실부하와기능장애의복합측정이가능하고, 비정상변형패턴은미세혈관허혈이나우심실확장에의한심근혼란 (myocardial disarray) 으로부터발생하게된다. 좌심실보조기구 (left ventricular assist device) 삽입후에우심부전을예측하기위한위험도평가는보통임상지표들에초점을맞추어왔지만, 최근에는심초음파검사를이용한변형을측정해서평가하려고하고있다. 우심실변형패턴은임상위험도평가에추가적인도움을주었다 [29]. 앞으로는우심부전의성향이있는위험인자나질환이있는환자에서우심실변형의일상적평가가심초음파실에서발전해야할필수적인술기가될것이다. 심장 MRI 심장 MRI는우심실기능의비침습적평가의최적표준이되었고우심실질량, 용적및박출률을측정하는데가장정확한방법이다. 3차원으로재조합한심실구조및용적평가가가능하고, 우심실기능, 판막의폐쇄부전을평가할수있고자기공명혈관조영술을가능하게한다. 그런데, 숨을참아야하고, 심장리듬이규칙적이어야하고, 금속으로만든장치를이식한환자에게는사용할수없고, 많은비용이드 는단점이있다. 한연구에서는 MRI로측정한 RVEF의변화가폐동맥고혈압치료를받는환자들의임상결과를가장잘예측하는변수라고하였다 [30]. 심장컴퓨터단층촬영 (computed tomography, CT) 심장 CT는금속으로만든장치를이식한환자에게사용가능하나, 심장박동수가낮아야한다는단점이있다. 그렇지만비침습적검사로쉽고신속하게촬영할수있으며, 3차원영상화하여용적측정및기능평가가가능하다. 침습적혈류역학적평가침습적혈역학적평가는설명되지않는경우나치료에저항하는우심부전의경우권고된다. 좌우심방압, 심장박출량, 폐혈관저항에대한정확한정보를제공한다. 일반적으로침습적모니터링은가능한짧은기간동안사용해야하는데, 우심도관삽입에의해얻은혈역학적지표들은우심기능평가에도움이된다. 상승된우심방압과낮은심장박출지수는폐동맥고혈압코호트에서더나쁜생존과연관이있었다 [31]. 폐혈관저항의증가 (> 3 우드단위 ) 는좌측심장질환과폐동맥고혈압에서불량한예후와상관이있다. 일회박출량을폐맥압으로나누어서 (stroke volume/pulmonary pulse pressure) 구한폐혈관순응도 (compliance) 가좌심부전과폐동맥고혈압의예후인자로알려져있다 [32,33]. 그러나, 폐혈관저항과순응도는모두후부하의측정이고우심실기능을직접반영하지는않는다. 우심실 -폐동맥결합 (coupling) 의측정심실기능과후부하의효과를평가하는최적표준은심실압력과용적의관계를통해서이루어진다. 이러한분석은좌심실에서많이이루어졌지만같은원칙이우심실에도해당된다 [34]. 다양한전부하또는후부하에의해일련의압력- 용적고리 (pressure-volume loop) 가생성되고, 각고리의용적에대한압력의최대비율이결정된다. 정상우심실압력-용적고리는, 혈관계의낮은저항을나타내서, 박출기간내내압력이감소하는삼각형모양이다 (Fig. 2A). 따라서압력과용적의최대비율은수축기말근처에서나타나지않고압력 -용적평가를어렵게한다. 그러나경도의폐고혈압에서는우심

- Mi-Seung Shin. Right ventricular failure - A B C Figure 2.

For (B) and (C), pressure rises throughout ejection and peaks near end-systole. 실의압력- 용적고리의모양이좌심실처럼보다직각형모양으로변하거나 (Fig. 2B), 더심한폐고혈압에서는사다리꼴모양으로 (Fig. 2C) 바뀌어서박출기간내내지속적으로압력이상승하게된다 [35].

elastance) 이다. 그에비해 TAPSE, RVFAC 및 RVEF 는모두부하에의존적이고우심실고유의수축력을직접적으로측정하지않는다. 그러나이러한침습적측정법은특수장비와상당한전문기술이필요해서일상진단용으로는실용적이지않다. 결론우심부전은우심실충만장애와박출량감소로인해정맥계의울혈이생기는임상증후군이다.

7 - Mi-Seung Shin. Right ventricular failure - A B C Figure 2. Examples of human right ventricular (RV) pressure-volume loops (A) under normal loading conditions, (B) in mild pulmonary hypertension, (C) in more severe pulmonary hypertension. For (B) and (C), pressure rises throughout ejection and peaks near end-systole. 실의압력- 용적고리의모양이좌심실처럼보다직각형모양으로변하거나 (Fig. 2B), 더심한폐고혈압에서는사다리꼴모양으로 (Fig. 2C) 바뀌어서박출기간내내지속적으로압력이상승하게된다 [35]. 나중의두경우에는압력과용적의최대비율은좌심실처럼수축기말근처에서나타나서, 수축기말압력-용적관계 (end-systolic pressure-volume relationship) 는각각의압력- 용적고리의수축기말압력 (end-systolic pressure) 점을연결하여결정되는데, 그기울기는비교적부하에독립적인수축력측정법인수축기말탄성도 (endsystolic elastance) 이다. 그에비해 TAPSE, RVFAC 및 RVEF 는모두부하에의존적이고우심실고유의수축력을직접적으로측정하지않는다. 그러나이러한침습적측정법은특수장비와상당한전문기술이필요해서일상진단용으로는실용적이지않다. 결론우심부전은우심실충만장애와박출량감소로인해정맥계의울혈이생기는임상증후군이다. 따라서체액저류에의한말초부종, 복수및전신부종이나타날수있고감소된수축기예비력또는적은심장박출량으로인해운동불내성과피로를유발할수있으며, 우심방또는우심실의확장으로인해부정맥을유발할수있다. 우심부전의진단에는병력청취와신체검사가중요하고정량적평가를위해비침습적방법인심초음파검사와심장 MRI 검사를많이사용하고있으며, 이를이용하여우심실구조, 용적, 질량및수축기능을평가한다. 또한원인질환, 악화요인, 우심부전의심한정도및심장기능을평가하는것도우심부전의진단에중요하다. 중심단어 : 우심실 ; 심부전 ; 진단 REFERENCES 1. Mehra MR, Park MH, Landzberg MJ, Lala A, Waxman AB. Right heart failure: toward a common language. Pulm Circ 2013;3: Ryan JJ, Tedford RJ. Diagnosing and treating the failing right heart. Curr Opin Cardiol 2015;30: Damiano RJ Jr, La Follette P Jr, Cox JL, Lowe JE, Santamore WP. Significant left ventricular contribution to right ventricular systolic function. Am J Physiol 1991;261(5 Pt 2):H1514-H Markel TA, Wairiuko GM, Lahm T, et al. The right heart and its distinct mechanisms of development, function, and failure. J Surg Res 2008;146: Buckberg GD; RESTORE Group. The ventricular septum: the lion of right ventricular function, and its impact on right ventricular restoration. Eur J Cardiothorac Surg 2006;29 Suppl 1:S272-S Tedford RJ, Hassoun PM, Mathai SC, et al. Pulmonary capillary wedge pressure augments right ventricular pulsatile loading. Circulation 2012;125: Hopkins WE, Waggoner AD. Severe pulmonary hypertension without right ventricular failure: the unique hearts of patients with Eisenmenger syndrome. Am J Cardiol 2002;89: Davlouros PA, Niwa K, Webb G, Gatzoulis MA. The right ventricle in congenital heart disease. Heart 2006;92 Suppl 1:i27-i Chin KM, Kim NH, Rubin LJ. The right ventricle in pulmonary hypertension. Coron Artery Dis 2005;16: Marino TA, Kent RL, Uboh CE, Fernandez E, Thompson EW, Cooper G 4th. Structural analysis of pressure versus volume overload hypertrophy of cat right ventricle. Am J Physiol 1985;249(2 Pt 2):H371-H Kasimir MT, Seebacher G, Jaksch P, et al. Reverse cardiac remodelling in patients with primary pulmonary hyper

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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