대한내과학회지 : 제 93 권제 2 호 2018 https://doi.org/10.3904/kjm.2018.93.2.211 삼첨판교체술을받은환자에서경정맥삽입형제세동기의삽입 연세대학교의과대학내과학교실심장내과 이윤정 엄재선 김태훈 정보영 박희남 이문형 하종원 Transvenous Implantation of an Implantable Cardioverter Defibrillator in a Patient Who Had Undergone Tricuspid Valve Replacement Yun-Jeong Lee, Jae-Sun Uhm, Tae-Hoon Kim, Boyoung Joung, Hui-Nam Pak, Moon-Hyoung Lee, and Jong-Won Ha Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea Transvenous implantation of an implantable cardioverter defibrillator in patients with a prosthetic valve in the tricuspid position is difficult because a defibrillator lead cannot be implanted into the right ventricle through the prosthetic valve. Hence, there are three options: epicardial implantation, subcutaneous implantable cardioverter defibrillator implantation, and cardiac vein implantation. Here, we report the transvenous implantation of an implantable dual-chamber cardioverter defibrillator in a patient who had undergone tricuspid valve replacement with a prosthetic valve. The patient was a 70-year-old female with a prosthetic valve in the tricuspid position who had experienced two events of sudden cardiac arrest. We successfully performed the procedure by implanting the defibrillator lead into the middle cardiac vein. (Korean J Med 2018;93:211-215) Keywords: Implantable cardioverter-defibrillator; Tricuspid valve replacement; Cardiac vein 서론심정지에서회복된환자에있어서삽입형제세동기는돌연사의이차예방에있어효과적인방법이다 [1]. 게다가삽입형제세동기는좌심실수축기능이감소된심부전환자에있어서돌연사예방을위한일차적목적으로도중요하다 [2,3]. 최근삽입형제세동기삽입건수는빠르게증가하고있다. 그러나삽입형제세동기삽입은인공삼첨판막, Glenn 단락 그리고 Fontan 순환등의복잡한구조적심질환을가진환자에서는어렵다 [4]. 특히인공삼첨판막교체술을받은환자에서는인공판막기능부전의위험및전극선의손상위험으로인해인공판막을통과해서전극선을삽입할수없다. 저자들은인공삼첨판막교체술을받은 70세여자에서중간심장정맥 (middle cardiac vein) 을통해성공적으로삽입형제세동기를삽입하였기에보고하고자한다. Received: 2017. 4. 23 Revised: 2017. 9. 12 Accepted: 2017. 9. 12 Correspondence to Jae-Sun Uhm, M.D., Ph.D. Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-8441, Fax: +82-2-2227-7732, E-mail: jason@yuhs.ac Copyright c 2018 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution - 211 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- The Korean Journal of Medicine: Vol. 93, No. 2, 2018 - 증례이전돌연사를경험한적이있는 70세여자가갑자기의식이없어져응급실로이송되었다. 부엌에서집안일을하던중의식이소실되었고, 남편이발견후심폐소생술을시행하였다. 응급구조요원들이도착후자동제세동기를부착하였고심전도분석후전기충격이필요한리듬 (Fig. 1) 으로확인되어전기충격이들어갔고자발순환이회복되었다. 내원당시혈압은 110/76 mmhg 심박수는분당 84회였으며의식은명료하였다. 24년전과 14년전각각인공승모판막및삼첨판막교체술을받았으며약물은 furosemide 40mg qd, spironolactone 12.5 mg qd, digoxin 0.125 mg qd, warfarin 을복용 하고있었다. 심전도는분당 86회의심방세동소견을보였고경흉부심초음파에서는인공승모판막과삼첨판막의기능의이상은없었고좌심실수축기능은보존되어있었다. 심전도감시중에비지속성심실빈맥이발생하였다. 관상동맥조영술에서는관상동맥의유의한협착소견은관찰되지않았다. 저자들은갑작스런심실세동에의한심정지에대해이차적예방목적으로제세동기를삽입하기로결정하였고이에대해세가지방법이있다. 심외막삽입, 피하용제세동기삽입그리고심장정맥으로의삽입이그것이다. 그러나환자는이전두차례의심장수술을받은기왕력이있어서심외막삽입은유착및수술자체의위험으로인해시행하기가어려웠다. 피 Figure 1. Electrocardiographic data recorded using an automatic external defibrillator. A B Figure 2. Fluoroscopic images taken at the implantation site. (A) Selective venography of the middle cardiac vein (right anterior oblique view). (B) After placement of the defibrillator and atrial leads (right anterior oblique view). - 212 -
- Yun-Jeong Lee, et al. ICD in a patient with TVR - 하용제세동기는당시한국에도입되지않았다. 따라서저자들은심장정맥으로제세동기를삽입하기로결정하였다. 소독후부분마취를하고좌측가슴부분에삽입형제세동기전류발생장치삽입을위한피하주머니를만들었다. 좌측액와정맥을천자후 Seldinger 방법을이용하여관정맥동삽관카테터 (Multipurpose Right; St Jude Medical, Sylmar, CA, USA) 를액와정맥을통해우심방으로삽입하였다. 관정맥동삽관카테터를심장정맥굴 (coronary sinus) 에삽입하였고심장정맥조영술을시행하였다. 카테터내부용카테터 (St Jude Medical) 를유도용철선을통해중간심장정맥으로삽입후중간심장정맥의정맥조영술을선택적으로시행하였고가능한원위부로진입하였다 (Fig. 2A). 삽입형제세동기전극선 (Durata 7170Q/65 cm, tined type; St. Jude Medical) 을카테터내부용카테터의끝까지삽입후카테터내부용카테터와관정맥동삽관카테터를제거하였다 (Fig. 2B). 심방전극선 (Tendril MRI LPA 1200M/52 cm, screw type; St. Jude Medical) 은좌측액와정맥을통해우심방에삽입하였다. 삽입형제세동기전류발생장치를심방전극선및제세동전극선과연결하고우측가슴부위피하주머니에넣었다. 조율역치는 5.25 V 그리고임피던스는 780 ohm이었다. 심방전극선의 P파전압은 0.3 mv 임피던스는 540 ohm이었다. 제세동역치테스트를수면상태로 10 J, 20 J, 36 J에서시행하였고제세동역치는 10 J이 었다. 시술하는동안급성합병증은발생하지않았다. 심실세동영역은분당 200회이상, 심실세동에대한치료를항빈맥조율 1회후 36 J로 4회전기충격으로설정하였다. 시술후가슴엑스선사진에서제세동기전극선은안정적으로보였다 (Fig. 3). 환자는삽입형제세동기삽입후 3병일째합병증없이퇴원하였다. 삽입형제세동기를삽입한후 11개월동안심실빈맥은발생하지않았고 P와 R파의전압및조율역치, 심방전극선과제세동전극선의임피던스들은적절한범위내에있었다. 고찰본보고는인공삼첨판막교체술을시행받은환자에서중간심장정맥에전극선을삽입하여제세동기를삽입한증례이다. 전극선이인공판막사이에끼이면인공판막의움직임을제한할수있고인공판막의움직임에의해전극선이손상될수도있기때문에삼첨판교체수술을받은환자에서심박동기나제세동기전극선을넣는것은금기이다. 이러한환자에서삽입형제세동기삽입방법은세가지가있다. 첫번째심외막에전극선을넣는방법이있으나전신마취및흉골절제그리고유착박리술이필요하고이는수술위험도및입원기간을증가시킬수있다. 게다가심외막에삽입된전 A B Figure 3. A chest radiograph taken after implantation of the implantable cardioverter defibrillator. (A) Posterior-anterior view. (B) Left lateral view. - 213 -
- 대한내과학회지 : 제 93 권제 2 호통권제 681 호 2018 - 극선은기능부전의발생빈도가높다. 이러한전극선의기능부전은이전심장수술을받은환자에서더흔해서 4년내 7.5% 까지보고하고있다 [5,6]. 두번째피하용제세동기삽입방법이있으나당시에한국에도입되지않았다. 세번째방법은제세동기전극선을심장정맥에삽입하는경정맥삽입형제세동기삽입방법이있다 [7]. 이러한방법은수술적인방법에위하여위험도가낮은장점이있으나삽입형제세동기전극선이박동기 (pacemaker) 전극선보다직경이두껍기때문에심장정맥이작은경우에는기술적으로어려운문제점이있다. 이러한점을극복하기위해서는가장얇은제세동기전극선을선택해야한다. 또한일반적으로중간심장정맥이심장정맥들중에서가장두껍기때문에제세동기전극선을삽입하는데적절하다. 제세동기전극선을심장정맥에진입하기위해서심장재동기화치료에사용되는좌심실전극선을사용하는것이유용하다. 그러나심장재동기화치료의좌심실전극선과는달리제세동기전극선은유도용철선을따라삽입할수없다. 따라서제세동전극선을위치하기위해카테터를가능한원위부로삽입해야한다. 또한심장정맥에삽입형제세동기전극선을삽입한경우는제세동역치시험을시행해야하며본증례에서는적절한제세동역치값을얻을수있었다. 이전에보고되었던중간심장정맥에삽입형제세동기전극선을삽입한증례에서전류의벡터가제세동기전극선이우심실첨부에위치한일반적인삽입형제세동기와비슷하였다 [8]. 중간심장정맥에삽입형제세동기전극선을넣은경정맥삽입형제세동기삽입증례는한국에서보고된적은없었다. 한가지우려는중간심장정맥에삽입형제세동기전극선을위치시키는경우심장의정맥과동맥의혈류흐름을방해할수있다는점이다. 그러나심장의정맥은 thebesian venous system, arterioluminal vessels, venoluminal vessels 를포함하여그물망처럼서로연결되어있기때문에중간심장정맥에삽입된전극선의심장의동맥과정맥의흐름에대한영향은크지않을것으로생각된다. 결론적으로저자들은삼첨판막교체술을받은환자에서중간심장정맥에삽입형제세동기전극선을위치시켜성공적으로경정맥삽입형제세동기를삽입하였다. 요 삼첨판막위치에인공판막을가지고있는환자에서삽입형제세동기의경정맥삽입은인공판막을통해우심실첨부로전극선을삽입할수없기때문에어렵다. 이러한환자에서삽입형제세동기를삽입할수있는방법은세가지가있다. 심외막삽입, 피하용제세동기삽입그리고심장정맥으로의삽입이그것이다. 본증례에서저자들은삼첨판막교체술을받은환자에서경정맥으로삽입형제세동기를삽입하여보고하는바이다. 환자는 70세여자로삼첨판막교체술을시행받았고두차례의갑작스런심정지를경험하였다. 저자들은중간심장정맥 (middle cardiac vein) 으로제세동전극선을넣어성공적으로경정맥삽입형제세동기를삽입하였다. 중심단어 : 삽입형제세동기 ; 삼첨판막교체술 ; 심장정맥 약 REFERENCES 1. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter automatic defibrillator implantation trial investigators. N Engl J Med 1996;335:1933-1940. 2. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002;346:877-883. 3. Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg. Canadian Implantable Defibrillator Study. Eur Heart J 2000;21:2071-2078. 4. Cannon BC, Friedman RA, Fenrich AL, Fraser CD, McKenzie ED, Kertesz NJ. Innovative techniques for placement of implantable cardioverter-defibrillator leads in patients with limited venous access to the heart. Pacing Clin Electrophysiol 2006;29:181-187. 5. Brady PA, Friedman PA, Trusty JM, Grice S, Hammill SC, Stanton MS. High failure rate for an epicardial implantable cardioverter-defibrillator lead: implications for long-term follow-up of patients with an implantable cardioverterdefibrillator. J Am Coll Cardiol 1998;31:616-622. 6. Zipes DP, Roberts D. Results of the international study of the implantable pacemaker cardioverter-defibrillator. A comparison of epicardial and endocardial lead systems. The - 214 -
- 이윤정외 6 인. 삼첨판교체후경정맥제세동기삽입 - Pacemaker-Cardioverter-Defibrillator Investigators. Circulation 1995;92:59-65. 7. Schreiber C, Mehmanesch H, Kolb C, Schmitt C, Lange R. Modified implantation of a transvenous defibrillator in a patient after tricuspid valve replacement. Pacing Clin Electrophysiol 2000;23:1698-1699. 8. Lopez JA. Implantable cardioverter defibrillator lead placement in the middle cardiac vein after tricuspid valve surgery. Europace 2012;14:853-858. - 215 -