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Korean Heart Rhythm Society

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http://www.k-hrs.org

The Official Journal of Korean Heart Rhythm Society

Arrhythmia

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Vol.14 No.3September 2013

ISSN 2005-9728

Main Topic Reviews심실조기수축

특발성심실빈맥

허혈성심근증환자에서심실빈맥

확장성심근증환자에서심실빈맥

Article Review브루가다증후군에서milrinone그리고cilostazol이부정맥발생을억제하는세포기전

ECG & EP CasesVentricularTachycardiaOriginatingfromtheRightVentricularOutflowTract TerminatedbySteamPop

Acaseofleftbundlebranchblock-shapedwideQRScomplexTachycardia withdiagnosticAmbiguityonaSurfaceelectrocardiogram

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● Sep

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심실빈맥(I)

편집위원회

편집위원장

차태준/고신의대

편집위원 (가나다순)

김남호 / 원광의대 남기병 / 울산의대 박희남 / 연세의대 오세일 / 서울의대


© Copyright 2013 The Official Journal of Korean Heart Rhythm Society Editorial Board & MMK Co., Ltd.All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without permission in written form from the copyright holder. This publication is published by MMK Co., Ltd.

온영근 / 성균관의대 이영수 / 대구가톨릭의대 정보영 / 연세의대 황교승 / 아주의대

편집자문위원 (가나다순)

고재곤 / 울산의대 곽충환 / 경상의대 김대경 / 인제의대 김대혁 / 인하의대

김성순 / 연세의대 김영훈 / 고려의대 김유호 / 울산의대 김윤년 / 계명의대

김종윤 / 연세의대 김준 / 부산의대 김준수 / 성균관의대 김진배/ 경희의대

남궁준 / 인제의대 노태호 / 가톨릭의대 박경민 / 인제의대 박상원 / 고려의대

박형욱/ 전남의대 배은정/ 서울의대 성정훈 / 차의과학대 신동구 / 영남의대

오동진/ 한림의대 오용석 / 가톨릭의대 이경석 / 전북의대 이만영 / 가톨릭의대

이명용 / 단국의대 이문형 / 연세의대 임홍의/ 고려의대 장성원 / 가톨릭의대

정중화 / 조선의대 조용근 / 경북의대 조정관 / 전남의대 최기준 / 울산의대

최윤식 / 서울의대 최의근 / 서울의대 최인석 / 가천의대 최종일 / 고려의대

한상진 / 한림의대 허준 / 성균관의대 현명철 / 경북의대

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대 표 : 이영화

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발행일 2013년 9월 30일

The Official Journal of Korean

Heart Rhythm Society

목적과개요

‘부정맥’은부정맥과 관련된 새로운 임상지식, 진료지침, 증례 등을 소개하여

부정맥연구회 회원 및 개원의의 지속적인 의학교육에 이바지하고자

발행되는 학술지입니다.

‘부정맥’은 부정맥의 진단과 치료, 임상 연구와 관련된 원저,

종설, 논평, 증례 보고 등의 원고를 공모하며, 제출된 원고는

편집위원회의 검토를 거쳐 게재됩니다.

심실빈맥(I)

Main Topic Reviews

심실조기수축 ····································· 박경민 ········· 6

특발성 심실빈맥 ···································· 성정훈 ········ 10

허혈성 심근증 환자에서 심실빈맥 ··························· 김진배 ········· 16

확장성 심근증 환자에서 심실빈맥 ···························· 김진석 ········ 22

Article Review

브루가다 증후군에서 milrinone 그리고 cilostazol이 부정맥 발생을 억제하는 세포 기전 ······ 차태준 ········· 26

ECG & EP Cases

Ventricular Tachycardia Originating from the Righ Ventricular Outflow Tract

Terminated by Steam Pop ···························· 김기훈 ········· 28

A case of left bundle branch block-shaped wide QRS complex Tachycardia

with diagnostic Ambiguity on a Surface electrocardiogram ·········· 안민수 ········· 34

자율 학습 문제 ·················································· 40


Vol.14 No.3●통권46호●September 2013

Contents

Cover: Electrocardiograms of various premature ventricular contraction patterns (page 9).

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6 The Official Journal of Korean Heart Rhythm Society

건국대학교 의과대학 내과학교실 박 경 민

Kyoung-Min Park, MD, PhDDivision of Cardiology, Department of Internal Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea

서론

심실조기수축(prematureventricularcontraction,

PVC)은심실에서기원하는조기심장박동이다.PVC는

규칙적인심장박동전조기에발생하기때문에정상

맥박보다 이르게 발생하며, 이로 인해 증상이

나타나기도한다.PVC가일어나는동안동방결절(SA

node)로부터정상적으로전기적신호가도달되기전에

심실은정상보다이른신호를보낸다.이러한조기

신호는심실근의전기적인과민성때문이라고알려져

있으며심근경색,전해질의불균형,산소부족또는

약물에의해생길수있다.심실조기수축후심장의

전기적시스템은즉시 reset된다.이 resetting은

심장박동에서짧은휴지를일으키고,몇몇환자들은

PVC후에심장이짧은순간멈추는것을느낀다고

보고한다.

PVC의발생

PVC는 건강한 성인에서 흔하게 발견되는

부정맥이다.PVC가있지만증상이전혀없는경우도

많다. PVC는고령환자,고혈압환자,심장질환

환자에서더일반적이다.또한심장질환이나고혈압이

없는젊고건강한사람에서도발생한다.그러나최근의

여러보고에서는증상이없어도PVC가하루동안24%

이상발생할경우심근기능저하에이를수있다고

심실조기수축

Received: May 17, 2013Revision Received: September 2, 2013Accepted: September 28, 2013Correspondence: Kyoung-Min Park, MD, PhD, Department of Internal Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul 143-729, Republic of KoreaE-mail: [email protected]

Premature ventricular contraction

AbSTRACT

Premature ventricular contraction (PVC), also known as premature ventricular complex, ventricular

premature contraction/complex, ventricular premature beat, or ventricular extrasystole, is a relatively

common event where the heartbeat is initiated by Purkinje fibers in the ventricles rather than by the

sinoatrial node, the normal heartbeat initiator. The electrical events of the heart detected by an

electrocardiogram allow PVC to be easily distinguished from a normal heartbeat. This paper provides useful

information about PVC to physicians for understanding and managing clinical PVC

Key words: ■ arrhythmia ■ catheter ablation ■ premature ventricular contraction

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vol.14 no.3

지적하였다.1,2결국PVC로발생한심장의움직임이나

달라진혈액의흐름이심장근육에혈류역학적으로

좋지않은영향을주는것만은확실하다고판단된다.

PVC의원인

PVC의발생에는다음과같은원인이있다.

•심근경색

•고혈압

•심근증(울혈성심부전을포함)

•승모판일탈증후군과같은심장판막질환

•저칼륨혈증과저마그네슘혈증으로이뇨제를

복용하는환자에서발생할수있다.

•저산소증예를들면저산소증을일으키는

폐기종또는만성폐색성폐질환과같은

폐질환이심실조기수축을함께동반한다.

•Digoxin,aminophylline,tricyclic

antidepressants등의약물과ephedrine제제,

충혈완화제등

•지나친음주

•과도한카페인섭취

•Cocaine,amphetamines같은자극성약물사용

•심근염과심장타박상

PVC는심장질환이없는건강한사람에서도

나타날수있다.

PVC의증상

드물게PVC가있는환자들은종종증상이없다고

보고되며,PVC발생시증상을느끼지못한다.이런

경우PVC는주로일상적인신체검사또는수술전

검사로심전도를했을때발견된다.PVC환자들은

이따금 가슴과 목에 두근거림을 호소하며, 이

두근거림은강력한심장박동으로인한불편감으로

나타난다. 왜냐하면 PVC 직후 심장박동은 보통

정상보다더강해지기때문이다.일부PVC환자들은

심장이짧은순간멈추는것을느낀다고한다.이는

PVC 후 심장의 전기적 시스템이 reset될 때

심장박동에서짧은휴지기가있기때문이다.실제PVC

박동은 느끼지 못할지도 모른다. 왜냐하면

심실조기수축의경우심장박동전에혈액으로채워질

시간이없기때문이다.따라서PVC환자들은종종

건너뛰거나 빠진 박동이 있다고 호소한다.

Bigeminy, trigeminy, couplets또는triplets와

같은frequentPVC환자들은종종증상이없다고

보고된다(Figure 1).그러나드문경우힘이없음,

어지럼증,졸도증상이보고된다.이는잦은PVC에

의해심장이다른기관으로혈액을펌프질하는능력이

약화되기때문이다.3회또는그이상연이은PVC를

경험하는환자들은심실빈맥(ventriculartachycardia,

VT)으로분류한다.심실빈맥의지속은심장의output

감소, 저혈압 그리고 실신으로 이어진다. 또한

심실빈맥은심실세동(ventricularfibrillation,VF)으로

발전될수 있으며, 이는돌연사에이를수 있는

치명적인심장리듬이다.

PVC의위험성

고혈압이나심장질환이없는건강한사람에있어

PVC는건강위험인자가되지않는다.그러나심장질환

(심근경색,심부전,심장판막질환)환자들에있어서

PVC는심실빈맥발생위험증가와관련이있을수

있다.심실빈맥은빠른심실수축의지속이며,생명을

위협하는부정맥이다.그이유는다음과같다.

1)경고없이갑자기발생한다.

2)빈번히심실세동으로발전한다.

심실빈맥은심실이급격하게떨리는혼돈상태의

리듬이며,심실세동이있는심장은혈액을효율적으로

뇌와몸의나머지부분에공급할수없다.따라서

심실세동을치료하지않는다면수십분이내에사망할

수도있다.약250,000명의미국인들이매년이러한

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이유로사망한다.

많은의사들은PVC가심실빈맥이나심실세동을

항상일으키는것은아니라고여긴다.대신PVC는

심근경색으로부터진행되고있는심장손상과같은

심각한상태,저칼륨혈증,저산소증및 digoxin,

aminophylline독성상태의간접적이지만중요한

지표가될수있다.많은PVC가무해하고양성이라고

말할수있으려면우선구조적인심장질환이PVC

발생과연관이없음이확인되어야한다.만약근본적인

심장질환에대한이상소견이없다면PVC의예후가

좋다는것을확신할수있다.그러나최근PVC의

빈도가많은경우(›24%/24hrs)1,2그리고PVC의

넓이가넓은경우(›156msec)3에는심근기능을

저하시키는위험인자및예측인자가될수있다고

보고된바있다.

PVC의치료

PVC자체가양성부정맥이라하더라도치료를해야

하는이유는다음과같다.

•두근거리는증상완화

•PVC를발생시키는질환들은잠재적으로생명을

위협하기때문에해당질환치료

•심실빈맥과돌연사의발생을예방

심장질환이없는건강한사람에게있어증상이없는

PVC는 적극적으로 치료할 필요가 없다. 그러나

두근거림의완화를위해다음의방법을고려하는것이

좋다.

•음주,카페인섭취중단

•Pseudoephedrine을포함하는약물처럼

adrenaline을함유할가능성이있는비염완화제를

과다사용하지않을것(체중감소를위한보조제는

PVC를악화시킬가능성이있다)4

•Amphetamines,cocaine같은약물의남용을

줄일것

•금연

PVC를유발하는질환들은또한생명을위협할수

있다.이러한질환들이있는경우종종병원에서

사용되는telemetry로PVC,심실빈맥등을발견할수

있다.이러한질환과대처법을예로들면다음과같다.

•저칼슘혈증과저마그네슘혈증:칼슘과

마그네슘은정맥주사로투여할수있다.

•Digoxin,aminophylline의독성:약물을투여할

수있다.

•급성심근경색:약물,관상동맥조영술,

관상동맥중재술(percutaneous

transluminal coronary angioplasty)은

막힌관상동맥을개방하여심근에혈액공급을

회복시키기위하여응급으로사용할수있다.

•저산소증:산소를코로공급하고,근본적인

폐질환을치료하기위해약물을투여할수있다.

항부정맥제

항부정맥제는심실빈맥,심방세동,PVC를제어하는

데사용된다.예를들면베타차단제,procainamide,

flecainide/propafenone,amiodarone그리고몇몇

다른약제들이있다.그러나일부항부정맥제는실제로

심장의이상리듬을일으킬수있다는단점이있다.

따라서항부정맥제는심실빈맥과심실세동의고위험

환자에게만신중하게처방해야한다.잦은PVC와

심실성부정맥을유발하는중요한심장질환을가진

경우또는실신등중증의증상이있는환자들에게는

전기생리학검사를권고한다.전기생리학검사는

생명을위협하는심실성부정맥이있는지알아보기

위해하는검사이며,그결과악성부정맥이유발될

가능성이있다면항부정맥제또는이식형제세동기

(implantablecardioverterdefibrillator,ICD)로돌연사

예방치료를한다.

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전극도자절제술

일반적으로부정맥은약물치료를통하여억제할수

있지만,이는근본적인치료라기보다는임시로부정맥의

활동을억제하는것이며약물을중단하면재발될

가능성이있다.또한약물부작용이나타나는경우는

약물을지속적으로사용할수없으며,활동적인젊은

연령에서는약물을평생지속적으로복용하는것이

번거롭고경제적으로도상당한부담이된다.최근에는

심실조기수축을포함한심실성부정맥의경우에도

상심실성빈맥의시술처럼도관을이용한절제술(고주파

전극도자절제술,radiofrequencycatheterablation)을

할수있다.이는심도자검사와같은방법으로심장

내에여러개의전극도자를넣어심실조기수축발생

위치를정확하게찾아내고,전극도자를통해고주파

전류(radiofrequencyenergy)를주어그자리에열을

발생시켜심실조기수축의원인이되는병소를완전히

제거함으로써완치하는방법이다.

References

1. Bogun F, Crawford T, Reich S, Koelling TM, Armstrong W, Good E, Jongnarangsin K, Marine JE, Chugh A, Pelosi F, Oral H, Morady F. Radiofrequency ablation of frequent, idiopathic premature ventricular complexes: Comparison with a control group without intervention. Heart Rhythm. 2007;4:863–867.2. Baman TS, Lange DC, Ilg KJ, Gupta SK, Liu TY, Alguire C, Armstrong W, Good E, Chugh A, Jongnarangsin K, Pelosi F Jr, Crawford T, Ebinger M, Oral H, Morady F, Bogun F. Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm. 2010;7:865-869. 3. Deyell MW, Park KM, Han Y, Frankel DS, Dixit S, Cooper JM, Hutchinson MD, Lin D, Garcia F, Bala R, Riley MP, Gerstenfeld E, Callans DJ, Marchlinski FE. Predictors of recovery of left ventricular dysfunction after ablation of frequent ventricular premature depolarizations. Heart Rhythm. 2012;9:1465-1472.4. Upadhyay S, Afaq M, Upadhyay S, Zarich S, McPherson C. Weight loss supplement provoked idiopathic ventricular tachycardia. Indian Heart J. 2007;59(6):494-496.

Ventricular bigeminy

Ventricular trigeminy

Ventricular couplet

Ventricular triplet

Figure 1. Electrocardiograms of various premature ventricular contraction patterns.

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차의과학대학교 내과학교실 성 정 훈

Jung-Hoon Sung, MD, PhDDivision of Cardiology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Gyeonggi-do, Korea

특발성 심실빈맥

서론

특발성심실빈맥(idiopathicventriculartachycardia)

은심실빈맥(ventriculartachycardia,VT)이구조적으

로정상이며반흔이없는심장에서발생하는것이다.유

출로심실빈맥(outflowtractVT,OT-VT),섬유속심실

빈맥(fascicularVT),유두근심실빈맥(papillarymuscle

VT),윤상심실빈맥(annularVT),기타(miscellaneous)

로분류할수있다.1

유출로심실빈맥

1.유출로심실빈맥

1)메카니즘

유출로심실빈맥은catecholamine에의한delayed

afterdepolarization에의해이루어진다.이메카니즘에

의한tachycardia는adenosine,베타차단제,칼슘차단

제로종료시킬수있다.2

2)유출로의해부학적특징

우심실 유출로(right ventricular outflow tract,

RVOT)는좌심실유출로(leftventricularoutflowtract,

LVOT)에비해좌측및앞쪽방향으로위치한다.그리

고pulmonicvalve는aorticvalve의위쪽에위치한다.

Received: June 21, 2013Revision Received: September 2, 2013Accepted: September 28, 2013Correspondence: Jung-Hoon Sung, MD, PhD, Division of Cardiology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si, Gyeonggi-do 463-712, KoreaTel: 82-31-780-4864, Fax : 82-31-780-5584E-mail: [email protected]

Idiopathic ventricular tachycardia

AbSTRACTVentricular arrhythmias (VAs) in structurally normal hearts can be broadly considered under non-life-

threatening monomorphic and life-threatening polymorphic rhythms. VAs are commonly seen in young

patients and typically have a benign course. Monomorphic VAs are classified on the basis of the site of origin

in the heart, and the most common areas are the ventricular outflow tracts and left ventricular fascicles. The

morphology of the QRS complexes on an electrocardiogram is an excellent tool to identify the site of origin

of the rhythm. Treatment options include reassurance, medical therapy, and catheter ablation. Very frequent

ventricular ectopy may result in cardiomyopathy in a minority of patients.

Key words: ■ ablation ■ electrocardiogram ■ idiopathic ventricular tachycardia ■ normal hearts

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vol.14 no.3

RVOT는muscularinfundibulum으로둘러싸여있고,

LVOT는근육과섬유(fibrous)로이루어져있다.Aortic

sinusesofValsalva의오른쪽대부분과외쪽의일부분

은LVOT를덮고있고,AVnode,Hisbundle에가까

이있다.1임상적으로septalRVOT와자유벽(freewall)

RVOT는전방,중앙,후방으로구분할수있다(Figure

1).2전중격(anteroseptal)RVOT는LVepicardium근

처interventricularvein앞쪽에있다.Posteroseptal

RVOT는rightcoronarycusp근처에있으며,RVOT-

VT는주로anteroseptalRVOT에서발생한다.5

2.우심실유출로빈맥

RVOT-VT는특발성심실빈맥(idiopathicVT)중가

장흔하며심실빈맥의70%가량된다.이것은좌각차단

(leftbundlebranchblock,LBBB)패턴의하향축(infe-

rioraxis)을가진다.7

1)심전도특징

우심실유출로빈맥은좌각차단패턴QRS에하향축

을나타낸다.Precordialtransition은주로V4또는그

뒤에서이루어지고,V3보다일찍나타나지않으며,aVL

과aVR은음성이다.Septalorigin의심실빈맥은QRS

기간이짧다.6

폐동맥(pulmonaryartery,PA)기원의RVOT-VT에

대한심전도기준은거의없다.다만심전도상PAorigin

은하위유도(inferiorlead)에서좀더R파가크고,aVL/

aVR에서Q파가큰비율을차지하여,V2에서R/S비율

이크다.2

3.LVOT/Aorticcusptachycardia

1)해부학(anatomy)

후방RVOT는LVOT와대동맥근부(aortic root)의

앞쪽에있다.대동맥근부는심장의가운데에위치하

고좌,우,비관상판첨으로되어있다.비관상판첨(non-

coronarycusp)은심실과바로연결이되지않아심실빈

L R

A

P

LMCA

RAA

RVOT

RV Free wall

RV Septum

RCA

LA

RA

RN

L

A

P

Figure 1. Anatomy of the outflow tract. Anatomy of the typical right ventricular outflow tract (RVOT) of the heart.

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RVOT-VT LVOT/Aortic Cusp VT

Later precordial transition (V3 or later)With V3 transition:

VT transition later than sinus rhythmV2 transition ratio < 0.60

Narrower R-wave duration and greater R/S-wave amplitude ratio in V1 and V2

Earlier precordial transition (by V3)With V3 transition:

VT transition earlier than sinusV2 transition ratio ≥ 0.60

Broader R-wave duration and greater R/S-wave amplitude ratio in V1 and V2

Notch (qRS) in V1 or V2

Table 1. Electrocardiographic classification of right ventricular outflow tract ventricular tachycardia (RVOT-VT) versus left ventricular outflow tract (LVOT)/aortic cusp ventricular tachycardia (VT)

맥의발생은거의없다.좌우의판첨이심실과바로닿아

있고좌심실근섬유(musclefiber)는대동맥근부로뻗

어있어심실조기수축(prematureventricularcontrac-

tion,PVC)을만들수있다.1

대동맥판첨에서발생하는빈맥은좌판첨이가장

많고그다음이우판첨그리고좌우의판첨의접합부

(junction)에서많이발생한다.

2)심전도특징

LVOT또는대동맥판첨에서발생하는심실빈맥은좌

각차단패턴QRS에하향축을갖지만,RVOT위치보

다precordialtransition이좀더빠르다.Precordial의

R파는V3또는이보다먼저transition된다.좌판첨의

VT는V1/V2에서transition이있고우판첨은V2/3에

서나타난다.대동맥판첨에서발생하는심실빈맥은R

파가›0.5ms로좀더넓고V1,V2에서R/S파가좀더

크게나타난다.LVOT-VT는또한aorticvalve아래쪽

의LVendocardium에서도나타날수있다.빈도가낮

은LVOT-VT는aortomitralcontinuity에서나타난다

(Table1).2

4.심외막유출로심실빈맥

심실빈맥은심외막(epicardial)에서거의발생하지않

는다.MDI(maximumdeflectionindex,최초의QRS

시작에서흉부유도에서최대편향까지의시간을총

QRS기간으로나눈값)로정량화해서delayedinitial

precordialQRSactivation이0.55보다크면심외막

심실빈맥을제안한다.2LeadI의하향축인QS도심외

막임을가리킨다.Transition또는patternbreak라

해서V1toV2의R파가없어지는것(QS또는rS)이보

이고V3의R파가잘보이는것은aorticroot의앞쪽의

anteriorLV를가리킨다.이것이leadI의QS와같이보

이면심실간정맥(interventricularvein)근처의심외막

(epicardialorigin)을가리킨다.

5.예후

Outflowtract의VT는주로양성이며대부분은예후

가좋다.하지만두가지예외가있다.Shortcoupled

PVC가polymorphicVT를유발하거나죄심실기능장애

(LVdysfunction)가빈맥에의해일어나는경우이다.이

런환자들은전기생리학검사가필요하다.3

6.검사및치료

환자가전형적인monomorphicoutflowtractPVC를

보이면홀터와심초음파로진단이충분하다.만약mul-

tiplePVC가있거나위치가특이하면(freewall)MRI같

은검사를통해구조적인심장문제인 arrhythmo-

genic right ventricular dysplasia/cardiomyopathy

(ARVD/C)등이있는지고려해야한다.RVOT는be-

nign이나ARVD/C가있는경우는돌연심장사(sudden

cardiacdeath)의위험도및가족력을살펴봐야한다.4,5

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1)약물요법

증상이있는outflowtractVT에는베타차단제를일

차적으로쓴다.베타차단제를못쓰면non-dihydro-

pyridine칼슘차단제(verapamil또는diltiazem)를쓸

수있다.

2)전극도자절제술

전극도자절제술(catheterablation)은비교적안전하

고믿을만한치료방법이다.심전도localization이절제

술을시행하는데도움이되나,환자에게는위험도와치

료효과를설명해야한다.수면치료는심실빈맥을줄일

수있어서삼가야한다.Isoproterenol을이용한pacing

은심실빈맥을유발하는데도움이된다.3Dmapping

이절제술에도움이된다.Activationmapping은환자

에서PVC나VT가잘나오면사용할수있고,bipolar

electrogram의earliestactivation이surfaceQRS보다

20-40ms앞설때성공적인절제부위로고려할수있

다.Bipolarelectrogram으로는일반적으로날카로운신

속한초기편향을가지고있으며,sinusrhythm동안후

반편향의역전(reversalofalatecomponentpresent)

을보일수있다.Unipolarelectrogram은주로QS패턴

이뾰족하고아래로향하면서surfaceQRS앞에위치하

면고려할수있다.6

Pacemapping은PVC/VT가잘나오지않을때시도

할수있다.빈맥의속도와비슷하게mappingcatheter

를pacing한다.Pacemapping의surface12심전도를

임상의VT/PVC와비교하는것이중요하다.6LVOT에

서는intracardiacechocardiography(ICE)가도움이된

다.1전극도자절제술의부작용은다른부위의절제술

과비슷하다.혈관으로접근하면서발생할수있는합

병증,심장천공(cardiacperforation),심낭압전(cardiac

tamponade),뇌졸중,심근경색등이있다.

섬유속심실빈맥

특발성좌심실빈맥(idiopathicleftVT)또는섬유속

심실빈맥은좌각(leftbundlebranch)의섬유속(fasci-

cles)에서주로발생한다.이것은심전도모양및해당

되는섬유속(correspondingfascicles)에따라left

posteriorfascicularVT,leftanteriorfascicularVT,

leftupperseptalVT로나눈다.Leftposteriorfascicu-

larVT가가장흔하고그다음이leftanterior,leftup-

perseptal순이다.

1.메카니즘

VerapamilsensitiveleftVT는reentry에의한것으

로이는심실또는심방자극에의해유도,종결된다.

2.심전도특징

Fascicular VT는 우각 차단(right bundle branch

block,RBBB)패턴QRS에leftsuperioraxis를보인다.

이것은상대적으로좁아져SVT가BBB패턴QRS와같

이있을때와혼돈될수있다.Leftposteriorfascicular

VT는우각차단패턴QRS에좌향편위(leftaxisde-

viation,LAD)가관찰되며,leftanteriorfascicularVT

의경우는우각차단패턴QRS에우향편위(rightaxis

deviation,RAD)가관찰된다.중격(septal)심실빈맥은

불완전한우각차단패턴QRS에normalaxis를보인다.

3.약물치료

Verapamil이빨리종결시키는데효과적이다.만성적

인verapamil치료는전극도자절제술을원하지않을때

사용하며,베타차단제또한효과적이다.

4.전극도자절제술

전극도자절제술은성공률이높아90%이상효과가

있다.Fascicularpotential이PVC/VTwithF-F(fas-

cicularpotential-fascicularpotential)보다앞서는것

이중요하다.EarliestPurkinjepotential이심실빈맥동

안QRS앞에나오면성공적인절제부위로고려할수

있다.

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Table 2. Specific locations and electrocardiographic features2

Left cusp “M” or “W” pattern in V1Monophasic R by V1/2Tall R-wave amplitude in inferior leadsGreater R-wave II/III ratio or III/IILead I QS or rS

Right cusp Monophasic R by V2/3Larger R-wave amplitude in lead I

R/L cusp junction QRS in lead V1-V2 (notched downstroke), QS in lead V1 (notched downstroke)

Aortomitral continuity

qR in lead V1Rs/rs complex in lead IR-wave ratio < 1 in II/IIIqR in lead V1Rs/rs complex in lead IR-wave ratio < 1 in II/III

Epicardial MDI > 55%QS in lead IQS in II, III, avF (MCV)A Q-wave ratio in avL/avR >1.4 or an S-wave amplitude >1.2 mVA “transition break,” specifically a loss of R from leads V1 to V2 (QS or rS) with prominent R by V3 (AIV);

MDI >55%QS in lead IQS in II, III, avF (MCV)A Q-wave ratio in avL/avR >1.4 or an S-wave amplitude >1.2 mVA “transition or pattern break,” specifically a loss of R from leads V1 to V2 S or rS) with prominent R by V3 (AIV)

Pulmonary artery Tall R-wave in the inferior leadsLarger Q-wave ratio in avL/avR

Larger R/S amplitude in lead V2, larger R-wave amplitude in the inferior leadsLarger Q-wave ratio in avL/avRLarger R/S amplitude in lead V2

Tricuspid annular R- or r-wave lead IR or r with overall positive polarity in aVL or r-wave IR or r with overall positive polarity in aVL

Tricuspid inflow or para-Hisian

Large R-wave in I, R-wave or flat in aVL, large R-wave in I,R-wave or flat in aVL

MDI (maximum deflection index): measured as the time from the earliest QRS onset to the maximum deflection in precordial leads, divided by the total QRS duration.QRS duration.

유두근심실빈맥

유두근심실빈맥은주로운동에의해서일어나고,

catecholamine에민감해isoproterenol또는epineph-

rine에의해유도된다.발생기전은국소성이며회귀하

지는않는다.종종multipleQRS를보이고자연히바뀌

거나절제를통해바뀐다.3

윤상심실빈맥

승모판과 삼첨판륜(tricuspid annulus)에서도 심실

빈맥이발생한다.각각의발생률은비슷하여삼첨판은

5-8%,승모판은약5%이다.

승모판륜(mitralannular)심실빈맥

승모판륜심실빈맥은해부학적으로구분된다.주로

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vol.14 no.3

anteriormitralannulus에서나오며posteriororpos-

teroseptalannulus는드물다.심전도는우각전도차단

패턴의monophasicR또는RsinleadV2-V6가보인

다.전극도자절제술은매우성공적이고이는earliest

ventricularactivation또는12/12pacemapmatch를

통해된다.

삼첨판륜심실빈맥

삼첨판륜심실빈맥은8%에서나타나며우측심실빈

맥의5%에서보인다.Septalsite는자유벽보다더많다

고보고되었지만,다른결과를보인연구도있다.

기타

1.우심실에서발생하는부정맥

ARVD/C는다른심실빈맥과감별이중요하다.

2.CruxoftheHeart

이곳은중간심장정맥(middle cardiac vein)과관상

부비동(coronarysinus)의교차점에가깝게위치한심

외막지점이다.심전도는leftsuperioraxis및early

precordial transition과 delayed deflection을보인다

(Table2).2

결론

특발성심실빈맥은심실빈맥이구조적으로정상이며

반흔이없는심장에서발생하는경우이다.분류하면유

출로심실빈맥,다발성심실빈맥,유두근심실빈맥,윤

상심실빈맥,기타등으로구분된다.이런심실빈맥은주

로젊은환자에서비교적좋은예후를보인다.12-lead

심전도로일반적인발생위치를확인할수있고,특이한

유형의경우결정적으로구별하는데에도도움이된다.2

심실빈맥의기전을이해하고약물치료를하거나전극

도자절제술을시행하는것이도움이된다.

References

1. Prystowsky EN, Padanilam BJ, Joshi S, Fogel RI. Ventricular arrhythmias in the absence of structural heart disease. J Am Col Cardiol. 2012;59:1733–1744.2. Hoffmayer KS, Gerstenfeld EP. Diagnosis and management of idiopathic ventricular tachycardia. Curr Probl Cardiol. 2013;38: 131-158.3. European Heart Rhythm Association; Heart Rhythm Society,

Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC Jr, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL; American College of Cardiology; American Heart Association Task Force; European Society of Cardiology Committee for Practice Guidelines. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guide lines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol. 2006;48:e247-346.

4. Kiès P, Bootsma M, Bax JJ, Zeppenfeld K, van Erven L, Wijffels MC, van der Wall EE, Schalij MJ. Serial reevaluation for ARVD/C is indicated in patients presenting with left bundle branch block ventricular tachycardia and minor ECG abnormalities. J Cardiovasc Electrophysiol. 2006;17:586-593.

5. Lee HW, Kim JB, Joung B, Lee MH, Kim SS. Successful catheter ablation of focal automatic left ventricular tachycardia presentedwith tachycardia-mediated cardiomyopathy. Yonsei Med J.2011;52:1022-1024.

6. Takemoto M, Yoshimura H, Ohba Y, et al. Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract improves left ventricular dilation and clinical status in patients without structural heart disease. J Am Coll Cardiol. 2005;45:1259-1265.

7. Hasdemir C, Ulucan C, Yavuzgil O, Yuksel A, Kartal Y, Simsek E, Musayev O, Kayikcioglu M, Payzin S, Kultursay H, Aydin M, Can LH. Tachycardia-induced cardiomyopathy in patients with idiopathic ventricular arrhythmias: the incidence, clinical and electrophysiologic characteristics, and the predictors. J Cardiovasc Electrophysiol. 2011;22:663-668.

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서론

심장질환에서대표적인심근경색은심장에반흔(scar)

을형성하여이와관련한심실부정맥을유발한다.이러

한심근경색후발생하는심실빈맥(post-infarctven-

triculartachycardia)은발생시기에따라급성기와만

성기로나눠볼수있는데,심근경색의급성기에는심실

세동(ventricularfibrillation)으로이어지는다형성심실

빈맥(polymorphicventriculartachycardia)이흔하다.

경색후수주가지나면서경색부위에구조적인변화가

발생하는데,경색후발생되는섬유화는전도차단을일

으키고경색주위의경계부위(borderzone)에서는전

도속도가느려지는현상이일어나면서이로인한회귀

성경로가형성되는것으로알려져있다1.최근심근경색

에대한치료가발전하면서이에따라심근경색이후발

생하는심실빈맥의빈도가감소하게되었는데,경색초

경희대학교 의과대학 내과학교실 김 진 배

Jin-Bae Kim, MD, PhDCardiology Division, Department of Internal Medicine, Kyung Hee University College of Medicine, #1, Hoegi-dong, Dongdaemun-gu, Seoul, Korea

허혈성 심근증 환자에서 심실빈맥

Received: May 27, 2013Accepted: September 28, 2013Correspondence: Jin-Bae Kim, MD, PhD, Cardiology Division, Department of Internal Medicine, Kyung Hee University College of Medicine, #1, Hoegi-dong, Dongdaemun-gu, Seoul, Korea 130-702Tel: 82-2-958-8200, Fax: 82-2-968-1848E-mail: [email protected]

Ventricular tachycardia in ischemic cardiomyopathy

AbSTRACTDespite the decreased incidence of coronary artery disease, several studies showed that the

ischemic ventricular tachycardia (VT) are most common type of ventricular tachycardia. Ischemic

VTs have been known to arise in the ventricular scar or border zone, consisting of the reentry

circuit. Therefore, reentry has been accepted as the principal mechanism of ischemic VT. However,

recent studies showed a different background of the mechanism. In treatment, antiarrhythmic

agents and implantable cardioverter defibrillator (ICD) are the first line of therapy. However, some

cases require a more invasive approach, such as catheter ablation or cardiac surgery. The

techniques of these treatments have evolved for several decades, showing better clinical outcome

than before. Therefore, the management for ischemic VT should be tailored in patients with broad-

spectrum disease.

Key words: ■ cardiomyopathy ■ ischemic ■ ventricular tachycardia

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vol.14 no.3

기의연구에의하면약5%미만의심근경색생존자들에

서심실빈맥이발생하는것으로나타났다2.일반적으로

경색부위가넓고심기능저하가심한경우와경색후6

주이내에심실빈맥의발생과급사의위험이높은것으

로알려져있으며,급성기이후에발생하는심실빈맥이

전기적,구조적재형성(remodeling)에의한것인지아

니면또다른허혈손상(ischemicinsult)에의한것인지

는잘알려져있지않다.다만이시기에발생하는심실

빈맥은부정맥의기질(substrate)이형성되어있어회귀

에의한기전으로발생하며,약제로치료가어려운것으

로알려져있다.

허혈성심실빈맥의기전

서론에서 언급한 대로 허혈성 심실빈맥(ischemic

ventriculartachycardia)은심장의반흔과경색의경계

부위의회귀기전에의해서발생하는것이가장중요한

기전으로알려져왔다.심근경색에따른반흔의형성에

서정상심근과는달리정상적인혈액공급을받지못하

는상태에놓인경계부위가혼재하면서,서로다른성

질의기질이함께존재해회귀기전은당연한것처럼평

가되어왔다.2010년IndianaUniversity그룹의Das등

은9%정도가국소성(focaltype)이며대부분회귀기전

으로발생한다고보고하였으나,최근2012년에발표된

동물실험모델에기초한실험연구에의하면초기심실

빈맥의유도및유지는triggeredactivity에의한국소성

기전에의해발생하다가오래지속되면서심실벽간회

귀(intramuralreentry)에의해다형성심실빈맥이나심

실세동으로전환되는것으로밝혀졌다.3,4본실험은각

심실박동을3Dmapping하여얻은자료를기초로한

보고로초기심실빈맥의유발및유지는회귀가아닌국

소성기전에의한것임을시사하며,추후보다많은연

구를통해인간에게도같은기전이존재하는지확인해

야할것이다.

허혈성심실빈맥의치료

1.항부정맥제와이식형제세동기

회귀기전에결정적인역할을하는기질(substrate)

에대한항부정맥효과와빈맥발생의방아쇠(trigger)

를억제하는효과로인해항부정맥제가치료로흔히사

용된다.하지만약물치료2년내40%이상의환자가

재발을경험하게되고,심실빈맥의재발은급사의위험

도를증가시키게된다.5이런경우대안으로제시할수

있는것이이식형제세동기(implantablecardioverter

defibrilator,ICD)이다.1997년과2000년에발표된항

부정맥제와ICD의비교에대한연구들에서항부정맥제

에비해ICD가고위험군의생존기간을향상시킨것으

로나타나이후ICD가일차치료로인정받게되었고,항

부정맥제의부작용을줄이면서서맥에대한예방효과

를보여주었다.6-8하지만ICD가심실부정맥의발생을

예방하지는못하고,이미발생한부정맥에대한치료에

있어국한된역할을함으로써항부정맥제의사용이필

요하고,환자에따라서잦은전기충격(electricalshock)

으로인해삶의질문제를야기하기도한다.또항부정

맥제,특히amiodarone은심율동전환에너지의역치

(defibrillationthreshold)를증가시켜때로심율동전환

을더어렵게하는것으로입증되었다.따라서약물과

의료기에의한치료가아닌전극도자절제술의필요성

이부각되었다.

2.전극도자절제술

고주파절제술(radiofrequency ablation)은 전술

한것과같이자주재발되는심실빈맥에서부가적치

료(adjunctivetherapy)의의미가있으며,항부정맥제

를사용중임에도재발한허혈성심실빈맥의재발을75%

이상감소시키는것으로알려졌다.9-12허혈성심실빈맥

은혈역학적으로안정된상태인경우(hemodynamically

stablestate)와그렇지못한경우로나눠볼수있다.전

자의경우는빈맥의지도화(mapping of ventricular

tachycardia)및전극도자절제술(radiofrequencycath-

eterablation)이심실빈맥을유도한상태에서진행하기

때문에보다정밀한지도화와절제술로치료가용이한

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Figure 1. Illustration of the circuit of ischemic ventricular tachycardia

Outer loop

Entrance site

Common pathway

Inner loop

Exit site

Bystander 1

(scar tissue)

Bystander 2 Bystander 3

Table 1. The points of differential diagnosis of variable sites of the reentrant circuit.

SiteElectro-

gram tim-ing in VT

Entrain-ment with concealed

fusion

Entrained stimulus-

QRS

(S-QRS)VTCL

Post-pacing interval

Sinus rhythm pacemap

QRS vs VTStimulus-

QRS

Common pathway

diastolic present =Egm-QRS <0.7 =TCL Same† =Egm-QRS†

Inner loop systolic present <Egm-QRS >0.7 =TCL Same† =Egm-QRS†

Outer loop systolic absent <Egm-QRS >0.7 =TCL Different <Egm-QRS

Entrance site

early diastolic present* =Egm-QRS <0.7 =TCL Different <Egm-QRS

Exit site late diastolic present >Egm-QRS >0.7 >TCL Same =Egm-QRS

Bystander 1 mid-diastolic* present >Egm-QRS >0.7 >TCL Same >Egm-QRS

Bystander 2 late diastolic* present >Egm-QRS >0.7 >TCL Same >Egm-QRS

Bystander 3 early diastolic* present* >Egm-QRS >0.7 >TCL Same† >Egm-QRS

*variable †depends on whether captured orthodromically or antidromically

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vol.14 no.3

반면,혈역학적으로불안정한경우는빈맥에대한자세

한지도화가불가능하기때문에빈맥의발생과유지에

결정적역할을하는심실의기질에대한지도화및이

에대한절제술이진행된다.회귀기전에대한이해와

반흔사이의잠재적회귀로를확인하는방법등이발전

함에따라여러다른회귀로에의한심실빈맥이나불

안정형심실빈맥에대한전극도자절제술에의한치료

가확대되기에이르렀다(Figure1,Table1).9,10특히삼

차원입체전기해부학적지도화(3Delectroanatomical

mapping)는전기생리학적자료를3차원으로구현된

해부학적자료와결부함으로써,경색으로인한반흔의

부위와정상부위,경계부위를시술자에게직관적으로

Figure 2. Voltage mapping of substrate with 3D electroanatomic mapping system (CARTO®) not published data)

V1

MAPp

MAPd

V1

MAPp

MAPd

V1

MAPp

MAPd

V1

MAPp

MAPd

V1

MAPp

MAPd

V1

MAPp

MAPd

V1

MAPp

MAPd

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제공하여시술이더욱용이하게되었다(Figure2).최

근Michigan그룹에서발표한24명의심근경색환자를

대상으로하는후향적연구에의하면반흔사이의채널

이모두심실빈맥과관련되어있지않고,latepotential

과함께존재하는채널이심실빈맥과연결된결정적경

로(criticalpathway)임을확인하였다.13이보고는기존

의구조적질환과동반된심실빈맥의전극도자절제술

의연구와일관된결과를보여주고있다.예를들면부

정맥유발형우심실이형성증(arrhythmogenicright

ventriculardysplasia)이나브루가다증후군에서도

비슷한결과를보여주고있다.14-16또하나심내막뿐아

니라심외막에서도심실빈맥의유발이가능하기에동시

에두부위에접근할필요가있는경우도고려해야한다.

최근증례보고에서심장이식수술을받은심실빈맥환

자의전극도자절제술후심장병리소견을보면lesion

size를증폭시키는irrigationtipcatheter를사용했음에

도transmurallesion을얻지못하였음을알수있다.이

는심실빈맥치료시심내막으로의접근으로심외막에

서유래하는심실빈맥이나심외막을결정적경로로이

용하는심실빈맥을치료할수없음을반증하며,반드시

심외막에대한접근도고려해야함을시사한다.17또한

2013년UCLA의Tung등이발표한자료를보면비허혈

성심실빈맥환자에비해허혈성심실빈맥의경우심내

막,심외막양쪽으로모두전극도자절제술을시행한환

자군에서심실빈맥의재발이의미있게적었음을알수

있었다.이는허혈성심실빈맥의전극도자절제술을시

행하는경우반드시심내막과더불어심외막으로접근

하는것도함께고려해야함을뒷받침한다.18

3.심실빈맥의수술치료

심근경색후발생하는심근의재형성과심실류(ven-

tricular aneurysm)와관련하여발생하는심실부정

맥의치료목적으로수술적교정(surgical correction

or left ventricular aneurysmectomy)이시도되었다.

1970~1980년대초기성적은항부정맥제치료성적에

비해좋았으나수술후조기사망률이문제가되었고,

1990년대Dor등이수술법을변형한subtotalendo-

cardiectomy를시행하여좋은결과를얻었으며,이후

cryoablation이도입되면서수술후심기능향상및심실

부정맥을줄이는결과를얻을수있었다.19-22하지만수

술적응증에해당하지않는환자들에게는도움이되지

않고,수술경험이많은기관과적은기관의성적차이

가커치료법이확대되지는못하였다.현재에는관상동

맥질환에심한심근재형성이동반되어수술치료를고

려할때부가적인치료로받아들여지고있는실정이다.

결론

허혈성심실빈맥은관상동맥치료가발전함에따라

그발생빈도가줄었지만,아직도가장많은형태의심실

빈맥이며예후가좋지않아적극적인치료가필요하다.

현재ICD의보편화로허혈성심실빈맥으로인한사망률

은줄었으나이로인해더많은부정맥이발견되고ICD

shock으로인해환자불편감이증가한경우전극도자절

제술이부가적인의미로중요한치료법이될수있다.

현재시행되고있는전극도자절제술에대한이론적

발전과기술의발전으로인하여시술에대한성적이향

상되고있고,아직도많은부분에서발전할여지가있기

에보다더좋은결과가나올것으로예상된다.또한카

테터를이용한치료외에도국한된환자군에서는수술

적치료도고려해야할것이다.

References

1. Wit A, Janse MJ. The ventricular arrhythmia of ischemia and infarction: Electrophysiological mechanisms. Mount Kisco, NY: Futura; 1993.

2. Andresen D, Steinbeck G, Brüggemann T, Müller D, Haberl R, Behrens S, Hoffmann E, Wegscheider K, Dissmann R, Ehlers HC. Risk stratification following myocardial infarction in the thrombolytic era. J Am Coll Cardiol.1999;33:131–138.

3. Das MK, Scott LR, Miller JM. Focal mechanism of ventricular tachycardia in coronary artery disease. Heart Rhythm. 2010;7:305–311.

4. Johnson CM, Pogwizd SM. Focal initiation of sustained and nonsustained ventricular tachycardia in a canine model of ischemic cardiomyopathy. J Cardiovasc Electrophysiol. 2012;23: 543–552.

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5. The ESVEM investigators. Determinants of predicted efficacy ofantiarrhythmic drugs in the electrophysiologic study versus electrocar diographic monitoring trial. Circulation. 1993;87:323–329.

6. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. A comparison of antiarrhythmic-drug therapy with implanable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med. 1997;337:1576–1583.

7. Connolly SJ, Gent M, Roberts RS, Dorian P, Roy D, Sheldon RS,Mitchell LB, Green MS, Klein GJ, O'Brien B. Canadian implantable defibrillator study (CIDS); a randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation. 2000;101:1297–1302.

8. Kuck KH, Cappato R, Siebels J, Rüppel R. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest. The cardiac arrest study Hamburg (CASH). Circulation. 2000;102:748–754.

9. Marchlinski FE, Callans DJ, Gottlieb CD, Zado E. Linear ablationlesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy. Circulation. 2000;101:1288–1296.

10. Soejima K, Suzuki M, Maisel WH, Brunckhorst CB, Delacretaz E, Blier L, Tung S, Khan H, Stevenson WG. Catheter ablation in patients with multiple and unstable ventricular tachycardias after myocardial infarction: short ablation lines guided by reentry circuit isthmuses and sinus rhythm mapping. Circulation. 2001;104:664–669.

11. Stevenson WG, Friedman PL, Sweeney MO. Catheter ablation as an adjunct to ICD therapy. Circulation. 1997;96:1378–1380.

12. Strickberger SA, Man KC, Daoud EG, Goyal R, Brinkman K, Hasse C, Bogun F, Knight BP, Weiss R, Bahu M, Morady F. A prospective evaluation of catheter ablation of ventricular tachycardia as adjuvant therapy in patients with coronary artery disease and implantable cardioverter-defibrillator. Circulation.1997;96:1525–1531.

13. Mountantonakis SE, Park RE, Frankel DS, Hutchinson MD, Dixit S, Cooper J, Callans D, Marchlinski FE, Gerstenfeld EP. Relationship between voltage map "channels" and the location of critical isthmus sites in patients with post-infarction cardiomyopathy and ventricular tachycardia. J Am Coll Cardiol. 2013;61:2088-2095.

14. Jaïs P, Maury P, Khairy P, Sacher F, Nault I, Komatsu Y, Hocini M,

Forclaz A, Jadidi AS, Weerasooryia R, Shah A, Derval N, Cochet H, Knecht S, Miyazaki S, Linton N, Rivard L, Wright M, Wilton SB, Scherr D, Pascale P, Roten L, Pederson M, Bordachar P, Laurent F, Kim SJ, Ritter P, Clementy J, Haïssaguerre M. Elimination of Local Abnormal Ventricular Activities : A New End Point for Substrate Modification in Patients With Scar-Related Ventricular Tachycardia. Circulation. 2012;125:2184-2196.

15. Marcus FI, Abidov A. Arrhythmogenic right ventricular cardiomyopathy 2012: diagnostic challenges and treatment. J Cardiovasc Electrophysiol. 2012;23:1149–1153.

16. Nademanee K, Veerakul G, Chandanamattha P, Chaothawee L,Ariyachaipanich A, Jirasirirojanakorn K, Likittanasombat K, Bhuripanyo K, Ngarmukos T. Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium. Circulation. 2011;123:1270-1279.

17. Kelesidis I, Yang F, Maybaum S, Goldstein D, D'Alessandro DA, Ferrick K, Kim S, Palma E, Gross J, Fisher J, Krumerman A. Examination of explanted heart after radiofrequency ablation for intractable ventricular arrhythmia. Circ Arrhythm Electrophysiol.2012;5:e109 –110.

18. Tung R, Michowitz Y, Yu R, Mathuria N, Vaseghi M, Buch E, Bradfield J, Fujimura O, Gima J, Discepolo W, Mandapati R, Shivkumar K. Epicardial ablation of ventricular tachycardia: an institutional experience of safety and efficacy. Heart Rhythm. 2013;10:490–498.

19. Guiraudon G, Fontaine G, Frank R, Escande G, Etievent P, Cabrol C. Encircling endocardial ventriculotomy: A new surgical treatment for life-threatening ventricular tachycardias resistant to medical treatment following myocardial infarction. Ann Thorac Surg.1978; 26:438–444.

20. Josephson, M. E., Harken, A. H., Horowitz, L. N. Endocardial excision: A new surgical technique for the treatment of recurrent ventricular tachycardia. Circulation. 1979;60:1430–1439.

21. Cox JL, Gallagher JJ, Ungerleider RM. Encircling endocardial ventriculotomy for refractory ischemic ventricular tachycardia. Clinical indication, surgical technique, mechanism of action, and results. J Thorac Cardiovasc Surg. 1982; 83: 865–872.

22. Dor V, Sabatier M, Montiglio F, Rossi P, Toso A, Di Donato M. Results of nonguided subtotal endocardiectomy associated with left ventricular reconstruction in patients with ischemic ventricular arrhythmias. J Thorac Cardiovasc Surg. 1994;107:1301–1307.

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서론

확장성심근증(dilatedcardiomyopathy,DCM)은좌

심실또는양심실의확장과심근수축기능저하를특징

으로하는심근병증으로서울혈성심부전의중요한원

인이되며,질병의경과중심실성또는심방성부정맥

이잘생기고급사의발생이증가하는것으로알려져있

다.1,2특히심실빈맥은DCM이동반된환자에서급사와

연관되는주요한원인이다.본논문에서는DCM환자에

서의심실빈맥의임상양상,발생관련인자,발생기전,

DCM의예후와관련된예측인자,치료방법등에대해

요약해서다루고자한다.

DCM환자에서의심실빈맥및급사

전체심부전환자의약50%는부정맥에의한급사

이고나머지50%정도는심부전의악화로인해사망

하는것으로알려져있으며,심부전증상이심해질수

록부정맥에의한급사보다는진행되는심부전으로사

확장성 심근증 환자에서 심실빈맥

세종병원 심장내과 김 진 석

Jin-Seok Kim, MD.Department of Cardiology, Sejong Cardiovascular Center, Sejong General Hospital, Bucheon, Gyeonggi-do, Korea

Received: May 30, 2013Accepted: September 28, 2013Correspondence: Jin-Seok Kim, MD, Department of Cardiology, Sejong Cardiovascular Center, Sejong General Hospital, Bucheon, Gyeonggi-do, Republic of KoreaTel: 82-32-340-1154, E-mail: [email protected]

Ventricular tachycardia in patients with dilated cardiomyopathy

AbSTRACTDilated cardiomyopathy (DCM) is the most common cardiomyopathy characterized by left or

biventricular dilatation and systolic dysfunction. Ventricular tachycardia (VT) may be an important

cause of sudden death and morbidity in patients with DCM. Although advances in both drug and

device therapy have led to an improvement in overall survival of patients with DCM, symptomatic

VT and the risk of sudden death are still issues that must be considered. Recent advances in

catheter ablation technology have led to an improved success rate, and they have facilitated the

use of catheter ablation in VT related to DCM.

Key words: ■ ablation ■ dilated cardiomyopathy ■ implantable cardioverter defibrillator ■ ventricular tachycardia

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망한다.2그러나부정맥에의한급사또한NYHA(New

YorkHeartAssociation)class가높을수록증가하는것

으로알려져있다.3심실빈맥은DCM이동반된환자의

50~60%에서관찰되며,비지속형심실빈맥은80%까

지관찰되지만,심실빈맥이급사의유일한원인은아니

다.4Luu등에의하면말기심부전환자에서발생한심정

지의38%만이일차적심실빈맥에의한것이었고,나머

지62%는서맥또는전기기계해리(electromechanical

dissociation)등에의한것으로보고되었다.5

심실빈맥발생관련인자및발생기전

DCM에서심실성부정맥의발현에는DCM의병태생

리와관련된다양한인자들이기여하는것으로보인다.

저칼륨혈증이나저마그네슘혈증등의전해질이상,혈

전또는색전에의한심근허혈등이부정맥발생에관

여할수있다.DCM환자의부검을통한연구중대상

DCM환자의상당수에서좌심실심내막하반흔(sub-

endocardialscar)및섬유화가진행된다수의부위가관

찰되었는데,이들병변은회귀성부정맥의기질로작용

할수도있다.

DCM에서진행되는심실의구조적및역학적변화는

심실의다양한전기생리학적변화를초래하며,비정상

적자동능이나방아쇠활동등에의한부정맥이발생할

수도있다.체내catecholamine의상승은직간접적으로

부정맥의발생에기여할수있는것으로알려져있으며,

DCM의치료에사용되는다양한약제역시부정맥을야

기할수있다.실제임상에서DCM에서의심실빈맥발

생기전에대해서는많은이견이있으나심근의반흔등

에의한심근회귀빈맥(myocardialreentry),국소성심

실빈맥(focalorigin),각회귀심실빈맥(bundlebranch

reentry)등으로구분할수있다.

Pogwizd등은심장이식수술을받는DCM환자에서

수술중시행한mapping을통해심실빈맥이국소성기

전에의해발생함을주장했으나,6DCM에서의심실빈맥

은반흔과관련된심근내회귀기전에의한것이라고여

겨진다.7Soejima등은심실빈맥을보인28명의DCM

환자에대한전기해부학적mapping을통한연구에서

심실빈맥의79%는반흔과관련된심근회귀기전에의

한것이었고,17%는국소성이었으며,7%가각회귀에의

한것임을보고하였다.8

각회귀심실빈맥은DCM에서매우특징적이며His-

Purkinjesystem을포함하는대회귀(macro-reentry)

기전에의한빈맥으로,대체로전향전도(antegrade

conduction)는우각으로,역향전도(retrogradecon-

duction)는좌각으로이루어진다.이는전극도자절제술

로치료될수있는빈맥이므로DCM환자에서발생한

심실빈맥의QRS파의형태가동율동때의QRS파형태

와동일할경우,반드시각회귀심실빈맥을의심해보

아야한다.

DCM환자의사망률의예측인자와심실빈맥

DCM의예후는기저원인에따라차이가나는것으

로알려져있다.9특발성의경우5년사망률이약20%이

고,이중급사는약30%(8~51%)에해당한다.1,2DCM

의사망률을예측할수있는인자로는좌심실구혈률

이가장신뢰도가높으며,그외에도폐모세혈관쐐기

압(pulmonarycapillarywedgepressure,PCWP›20

mmHg),심박출계수(cardiacindex‹2.5L/min/m2),

폐고혈압,그리고중심정맥압상승등의혈역학적변수

들이있다.10또한NYHAclassIII/IV,S3sound등도

DCM환자의예후와관련이있으며,실신(syncope)은

급사의고위험과연관되어있다.

저나트륨혈증이나혈중norepinephrine,renin등의

상승또한예후와관련이있다.11,12DCM환자에서의조

직생검소견이나좌심실의확장정도등은DCM환자의

생존과관련성은없는것으로알려져있다.심전도에서

보이는좌각차단,1도또는2도방실차단,QRS파간격

의연장등은DCM의불량한예후와연관이있었다.13,14

비지속성심실빈맥(non-sustainedVT,NSVT)의경

우NYHAclassI,II의환자에서약15~20%,NYHA

classIV에해당하는환자의50~70%에서발견되지만,

이NSVT와DCM에서의사망률이나급사와의연관성은

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명확하지않다.또한NSVT를가진환자들에서급사의

고위험군을평가하기위한방법으로신호평균화심전

도(signalaverageelectrocardiogram),전기생리학검

사등이이용되어왔으나,DCM환자에서의그유용성

은아직확실하지않다.15

약물치료및device치료

DCM환자에서의안지오텐신전환효소억제제,안지

오텐신수용체차단제,베타차단제등을이용한약물치

료는좌심실기능저하를개선하여생존율을향상시키는

것으로알려져있다.하지만장기간의약물치료에도호

전이없는경우이식형제세동기(implantablecardio-

verterdefibrillator,ICD)나심장재동기화치료(cardiac

resynchronizationtherapy,CRT)등이도움이될수

있다.ICD는허혈성혹은비허혈성심근병증또는심

실기능이낮고증상을동반하는지속성심실빈맥을가

진환자의이차예방효과에서amiodarone보다우월

하다는것이입증되었다.16고위험군에서ICD의일차적

예방역할또한DEFINITE(DefibrillatorinNon-Is-

chemicCardiomyopathyTreatmentEvaluation)연구

와SCD-HeFT(SuddenCardiacDeathHeartFailure

Trial)연구등을통해긍정적으로보고되었다.DEFI-

NITE연구에서ICD는DCM환자에서부정맥에의한

사망률을80%낮추고,이러한사망률의감소는NYHA

classII보다는III의환자에서보다큰것으로보고되었

다.17SCD-HeFT연구에서는NYHAclassII혹은III의

심부전을가지고좌심실구혈률이35%미만인관상동

맥질환혹은비허혈성DCM환자에서표준약물치료와

amiodarone을사용한경우전체사망률개선효과는없

었으나,ICD를시술한군에서는5년후에7.2%의의미

있는사망률감소를보였다.18

DCM환자의30~50%에서심전도상심실내전도

장애 및 좌각차단이 동반되는 것으로 알려져 있다.

CRT의경우NYHAclassIII또는IV,좌심실구혈률

35%미만,QRS파의간격이120ms이상이면서좌심

실의dyssynchrony를가진심부전환자를대상으로

한 CARE-HF (CArdiac REsynchronisation in

HeartFailure)와COMPANION(Comparisonof

MedicalTherapy,Pacing,andDefibrillationin

HeartFailure)연구등에서사망률및유병률을낮추

는데효과가있음을보여주었다.19,20

전극도자절제술

ICD가DCM환자의사망률은감소시키지만,증상을

동반하는심실빈맥의재발을예방하지는못한다.또한

고위험도환자에서일차적예방목적으로ICD를삽입

한환자중2.5~12%가부정맥을경험하는것으로알려

져있다.21따라서전극도자절제술의역할이중요시되고

있으며,심실빈맥에대한전극도자절제술은3차원영상

의전기해부학적mapping시스템의도입등기술적발

전과더불어서그치료성공률또한향상되고있다.특

히전극도자절제술은DCM환자에서자주관찰되는각

회귀심실빈맥에효과적일수있다.

결론

DCM환자에서심실빈맥의치료목적은첫째,급사의

위험을줄이는것이고,둘째,증상을동반하는심실빈맥

발현을최소화하는것이다.DCM환자는좌심실의기능

저하가악화됨에따라급사및심부전과관련된사망이

증가하는것으로보고되었다.그러나베타차단제,안지

오텐신전환효소억제제및안지오텐신수용체차단제등

의약물치료및의료기치료가발전됨에따라전반적인

생존율이높아지고있다.이와함께DCM의유병률또

한높아지고,심실성부정맥의빈도가높아짐에따라이

에대한적절한치료가요구된다.최근전극도자절제술

의발전으로DCM에동반된심실빈맥에서이를이용한

치료성공률이점차높아지고있다.

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References

1. Komajda M, Jais JP, Reeves F, Goldfarb B, Bouhour JB, Juillieres Y,Lanfranchi J, Peycelon P, Geslin P, Carrie D, Grosgogeat Y. Factorspredicting mortality in idiopathic dilated cardiomyopathy. Eur Heart J. 1990;11:824-831.

2. Sugrue DD, Rodeheffer RJ, Codd MB, Ballard DJ, Fuster V, Gersh BJ. The clinical course of idiopathic dilated cardiomyopathy. A population-based study. Ann Intern Med. 1992;117:117-123.

3. Effect of metoprolol cr/xl in chronic heart failure: Metoprolol cr/xl randomised intervention trial in congestive heart failure (merit-hf).Lancet. 1999;353:2001-2007.

4. Larsen L, Markham J, Haffajee CI. Sudden death in idiopathic dilated cardiomyopathy: Role of ventricular arrhythmias. Pacing Clin Electrophysiol. 1993;16:1051-1059.

5. Luu M, Stevenson WG, Stevenson LW, Baron K, Walden J. Diversemechanisms of unexpected cardiac arrest in advanced heart failure. Circulation. 1989;80:1675-1680.

6. Pogwizd SM, McKenzie JP, Cain ME. Mechanisms underlying spontaneous and induced ventricular arrhythmias in patients with idiopathic dilated cardiomyopathy. Circulation. 1998;98:2404-2414.

7. Hsia HH, Marchlinski FE. Characterization of the electroanatomic substrate for monomorphic ventricular tachycardia in patients with nonischemic cardiomyopathy. Pacing Clin Electrophysiol.2002;25:1114-1127.

8. Soejima K, Stevenson WG, Sapp JL, Selwyn AP, Couper G, Epstein LM. Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy: The importance of low-voltage scars. J Am Coll Cardiol. 2004;43:1834-1842.

9. Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE,Howard DL, Baughman KL, Kasper EK. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med. 2000;342:1077-1084.

10. Dec GW, Fuster V. Idiopathic dilated cardiomyopathy. N Engl J Med. 1994;331:1564-1575.

11. Keogh AM, Baron DW, Hickie JB. Prognostic guides in patients with idiopathic or ischemic dilated cardiomyopathy assessed for cardiac transplantation. Am J Cardiol. 1990;65:903-908.

12. Lee WH, Packer M. Prognostic importance of serum sodium concentration and its modification by converting-enzyme inhibition in patients with severe chronic heart failure. Circulation. 1986;

73:257-267.13. Unverferth DV, Magorien RD, Moeschberger ML, Baker PB, Fetters

JK, Leier CV. Factors influencing the one-year mortality of dilated cardiomyopathy. Am J Cardiol. 1984;54:147-152.

14. Schoeller R, Andresen D, Buttner P, Oezcelik K, Vey G, Schroder R.First- or second-degree atrioventricular block as a risk factor in idiopathic dilated cardiomyopathy. Am J Cardiol. 1993;71:720-726.

15. Grimm W, Christ M, Bach J, Muller HH, Maisch B. Noninvasive arrhythmia risk stratification in idiopathic dilated cardiomyopathy: Results of the marburg cardiomyopathy study. Circulation. 2003;108:2883-2891.

16. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The antiarrhythmics versus implantable defibrillators (avid) investigators. N Engl J Med. 1997;337:1576-1583.

17. Kadish A, Dyer A, Daubert JP, Quigg R, Estes NA, Anderson KP, Calkins H, Hoch D, Goldberger J, Shalaby A, Sanders WE, Schaechter A, Levine JH, Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation I. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med. 2004;350:2151-2158.

18. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R, Domanski M, Troutman C, Anderson J, Johnson G, McNulty SE, Clapp-Channing N, Davidson-Ray LD, Fraulo ES, Fishbein DP, Luceri RM, Ip JH, Sudden Cardiac Death in Heart Failure Trial I. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352:225-237.

19. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L, Cardiac Resynchronization-Heart Failure Study I. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.

20. Saxon LA, Bristow MR, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, Feldman AM, Galle E, Ecklund F. Predictors of sudden cardiac death and appropriate shock in the comparison of medical therapy, pacing, and defibrillation in heart failure (companion) trial. Circulation. 2006;114:2766-2772.

21. Moss AJ, Greenberg H, Case RB, Zareba W, Hall WJ, Brown MW,Daubert JP, McNitt S, Andrews ML, Elkin AD, Multicenter Automatic Defibrillator Implantation Trial IIRG. Long-term clinical course of patients after termination of ventricular tachyarrhythmia by an implanted defibrillator. Circulation. 2004;110:3760-3765.

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배경

브루가다증후군은젊은남성에서주로발생하고심

실빈맥에의해서심장돌연사가일어나는유전질환이다.

Milrinone과cilostazol등의phosphodiesterase

(PDE)3억제제는Ltypecalciumcurrent(ICaL)를증

가시키고세포내cAMP농도를상승시킨다.Cilostazol

은혈소판응집을억제하며혈관을확장시키고특히다

리쪽혈관을확장시킨다.그렇기때문에cilostazol은간

헐적파행(intermittentclaudication)그리고뇌혈관동

맥경화증과뇌졸증의2차예방에사용된다.

Milrinone은심부전증에사용하며,cAMP를증가시

켜서심부전증심장의수축력을증가시키고혈관확장

기능이있다.이연구는브루가다증후군에서milrinone

을cilostazol대신사용할수있을것으로생각되어mil-

rinone의사용가능성에대해알아보았다.

방법

관상동맥관류를하는우심실wedgepreparation을

이용하여 epicardial 그리고 endocardial site에서활

동전위(action potential, AP) 그리고 electrocardio-

graphic기록을시행하였다.Transientoutwardcur-

rent(Ito)활성제NS5806(5μM)그리고칼슘차단제

verapamil(2μM)을사용하여인위적으로브루가다표

현형을유발하였다.

결과

NS5806+verapamil을 투여하니 all-or-none re-

polarization이epicardium어떤곳에서는발생하고또

브루가다 증후군에서 milrinone 그리고 cilostazol이 부정맥 발생을 억제하는 세포 기전

고신대학교 의과대학 내과학교실 차 태 준

Tae-Joon Cha, MD, PhDDivision of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, South Korea.

Received: September 10, 2013Accepted: September 28, 2013Correspondence: Tae-Joon Cha, MD, PhD, Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, 34 Amnam-Dong, Seo-Gu, Busan, 602-702, South Korea.Tel: 051-990-6105, Fax: 051-990-3047, E-mail: [email protected]

Cellular mechanism underlying the effects of milrinone and cilostazol to suppress arrhythmogenesis associated with brugada syndrome

Szél T, Koncz I, Antzelevitch C.

Heart Rhythm. 2013 Aug 1. pii: S1547-5271(13)00795-9. doi: 10.1016/j.hrthm.2013.07.047.

[Epub ahead of print]

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다른곳에서는발생하지않아서epicardium의ST분절

상승,epicardialdispersionofrepolarization(EDR),

transmuraldispersionofrepolarization(TDR)등의발

생증가가일어나게되었다.이런상태에서는epicardial

APdome이유지되는곳에서APdome이유지되지않

는곳으로phase2reentry가발생하여선행하는박동

과매우근접한시점에심실기외수축,심실빈맥등이발

생하였다.Epicardium의APdome의소실은endocar-

diumAPdome사이에서TDR이발생하게된다.이런

EDRTDR등이부정맥이잘발생하게되는위험한시

점(vulnerablewindow)을만들게된다.이런것을치유

하기위해서는활동전위2기에inwardcalciumcurrent

를활성화하게하면APdome이복원화되며부정맥발

생을억제하게된다.PDEinhibitor인milrinone(2.5

μM)혹은cilostazol(5~10μM)을관상동맥으로관류시

키니epicardialAPdome을회복시키고,dispersion을

감소시키며,기외수축과심실빈맥을유발시키는phase

2reentry를소멸시켰다.Milrinone과cilostazol은in-

wardcalciumcurrent를증가시키는효과가있어서심

근의수축력을증가시키고심장박동을빠르게한다.심

장박동수가빨라지면간접적으로Ito의감소를유발시

키며,특히cilostazol은고농도에서직접적으로Ito를억

제시키는효과가있다.

결론

이연구는브루가다증후군의심전도적그리고부

정맥적인 표현인 재분극의 결함을 반전시키기 위해

cilostazol과milrinone을사용할수있음을보여주었

다.이약들은우심실epicardium에서ICa를증가시켜

서APdome을복원시키며우심실심근의전기적이질

성(heterogeneity)의발생을억제시켰다.그래서PDE3

inhibitor특히cilostazol그리고milrinone이브루가다

증후군의치료약제로사용할수있음을실험적으로증

명하였다.

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Ventricular Tachycardia Originating from the Right Ventricular Outflow Tract Terminated by Steam Pop

Introduction

Steampopsare infrequent inradiofrequency

(RF) ablation for ventricular tachycardia (VT);

although they have been reported to occur in

only1~1.5%ofallRFablations,theycancause

cardiactamponade,especiallyintherightven-

tricularoutflowtract(RVOT).1-3

CaseReport

A57-year-oldwomanpresentedtoouremer-

gencydepartmentwitha1-weekhistoryofwax-

ingandwaningpalpitationsthatworsenedand

persistedonthedayofadmission,withassociat-

eddizzinessandchestdiscomfort.Hypertension

hadbeendiagnosed2yearsearlierandwascon-

trolledbyanangiotensinreceptorblocker.Her

familyandsocialhistorywereunremarkable.Her

initial blood pressure (BP)was 130/98mmHg,

withapulserateof170beats/minandarespi-

rationrateof22breaths/min.Herelectrocardio-

gramshowedawideQRStachycardiawithleft

bundlebranchblockmorphology,inferioraxis,

QRSwidth›140ms,aVLsizeslightlygreater

thanaVR,andasmallrwaveof›0.2mVinthe

V2 lead,whichsuggestedthatthetachycardia

originatedfromtheleftsuperiorfreewallofthe

RVOT(Figure1).Rapidadministrationofintra-

venousadenosineandslowlyrepeatedinfusions

ofdiltiazemandverapamilhadnoeffect.After

Ki-Hun Kim, MDCardiology Division, Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

Received: July 19, 2013Accepted: September 28, 2013Correspondence: Ki-Hun Kim, MD, Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Busan, KoreaTel: 82-51-797-3010, Fax: 82-51-797-3009E-mail: [email protected]

AbSTRACTSteam pops occur when tissue temperature exceeds 100°C. This can lead to tissue disruption and

sometimes subsequent cardiac tamponade, especially in thin-walled structures such as the right

ventricular outflow tract (RVOT). This event is potentially disastrous; however, in our case,

ventricular tachycardia originating from the RVOT was successfully terminated by a steam pop,

although it required pericardiocentesis and drainage.

Key words: ■ catheter ablation ■ complication ■ ventricular tachycardia

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sedation,biphasicdirectcardioversion(50J)was

performedtwice;however,thetachycardiacon-

tinued,andherBPdroppedto70/56mmHg.A

flecainideinfusionwasstarted,andthetachy-

cardia stopped during that infusion. Labora-

torytestresultswerewithinnormallimits,and

atransthoracicechocardiogramshowednormal

leftventricularejectionfraction(64%)andmild

Figure 1. Initial electrocardiogram of the ventricular tachycardia originating from the right ventricular outflow tract

A b

Figure 2. A, Catheter tip position on the ablation success point, targeting the ventricular tachycardia originating from the right ven-tricular outflow tract. Right anterior oblique view (30°). B, 3D electroanatomic mapping shows that the focus of ventricular tachycardia originated from the right ventricular outflow tract.

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Figure 4. Electrogram when the steam pop developed

Figure 3. Electrogram when the ventricular tachycardia originating from the right ventricular outflow tract was terminated. Presystolic potential at the ablation catheter (ABLd) was earlier than the surface QRS onset at lead V2 by approximately 22 ms.

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mitralregurgitation(gradeI).Thenextday,anelec-

trophysiologystudywasperformed.Withthepatient

fastingandunsedated,a6Frquadripolarcatheter

wasplaced in therightventricular (RV)apexand

a7Frdeflectablenon-irrigationcatheter(CelsiusTM,

BiosenseWebster,DiamondBar,CA,USA)viaan

SR-0sheath(St.JudeMedical,St.Paul,MN,USA)

wasplacedintheRVOTviatherightfemoralvein.

AfterperforminganangiogramoftheRVOTarea,3D

electroanatomicmapping(EnSiteTM,St.JudeMedical)

wasperformed.Thebaselinerhythmwassinuswith

occasionalventricularprematurecontractions(VPC),

whosemorphologywascompatiblewiththeclinical

VT.VToriginatingfromtheRVOT(cyclelength400

ms)wasrepeatedlyinducedbytheRVburstpacing.

Theearliestventricularpotentialwasrecordedatthe

left-superiorareabetweenthefreewallandseptum

oftheRVOT,andpace-mappingshowedanidenti-

calVTmorphology.Thepresystolicpotentialatthe

ablationcatheterwasearlierthanthesurfaceQRS

onsetatleadV2byapproximately22ms,andthe3D

mappingpointwascompatiblewiththepoint.Dur-

ingRFablationatthepointontheVTstate,VTwas

successfullyterminated(Figures2and3).However,

someVPCsandnon-sustainedVTsremainedafter

severaladditionalablations,whichmighthavebeen

associatedwithimproperpowerdeliverybecauseof

impedancesandtemperaturelimitations.Therefore,

wechangedtheablationcathetertoa7Frunidirec-

tionalirrigatedform(CelsiusTMThermocool®,BiosenseWebster)forincreasedpowerdelivery.RFablation

(45W,with themaximum catheter tip tempera-

turesetto50°C)wasrepeatedatthesameablated

site.Catheterirrigationwasstartedautomaticallyat

aflowrateof30mL/minatthestartoftheabla-

tion.Duringablation,asuddenaudiblesteampop

developed(Figure4).Energydeliverywasimmedi-

atelystoppedafterthepopoccurred.However,the

patient’sBPsuddenlydroppedandshebecamestu-

porous.Afterconfirmationofcardiactamponadeby

Figure 5. Final electrogram after the steam pop showing sinus rhythm

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portable transthoracic echocardiography, peri-

cardiocentesiswithdrainagewasperformed.Af-

terdrainage,thepatient’sBPimprovedto100/70

mmHg.Fortunately,afterthisevent,nomore

VPCsorVTswereobservedfor›30min(Figure

5).Wefinishedtheprocedure,keepingtheperi-

cardialdrainageinplace.After3daysofsup-

portivecare,shewasdischarged.Therewereno

furthereventsoverthe2-yearfollow-upperiod.

Discussion

RFablationcauseslesiondevelopmentbyin-

ducingcelldeathwhentissuetemperatureex-

ceeds 50°C; however, it can also cause steam

pops when the tissue temperature is ›100°C,

sometimesfarexceedingthecathetertiptem-

perature.1,3Whensteamexplosionsoccur,which

maybeaudible as steampops, they can cause

cardiac perforation. This dangerous situation

occursmore commonly in theRV than in the

leftventriclebecauseofthethin-walledstruc-

tureoftheRV.2,4ExternallyirrigatedRFablation

cancool thecatheter-tissue interface,making

itpossibletoincreasepowerdeliveryandreduce

coagulumformation.However,irrigatedRFalso

causesanimbalancebetweentissueandcatheter

tip temperaturesduringablation, causingdif-

ficultyinpredictingsteampops.3Cooperetal.

foundarelationshipbetweenpopsandelectrode

temperatureduringatrialablationandrecom-

mendedmaintainingacathetertiptemperature

‹40°Ctopreventsteampops.5However,steam

popswereobservedwhenthemeancathetertip

temperaturewas39°Cwithopenirrigationand

evenoccurredwithcathetertiptemperaturesas

lowas34°C.1Yokoyamaetal.demonstratedthat

steampopsoccurredmorefrequentlyaspower

wasincreasedfrom30to50W.6Hsuetal.sug-

gestedthatpopsoccurredwhenpowerexceeded

48W,andpopformationwaslimitedwhenpow-

erremainedunder42W.7However,Seileretal.

showednosignificantdifferencebetweenpower

settingsforlesionswithandwithoutpops,and

foundthatlimitingRFpowertoachieveanim-

pedancedecreaseof‹18Ωisafeasiblemethod

of reducing steam pops.1 Nonetheless, higher

maximum energies and larger impedance falls

areassociatedwithsteampops.4Koruthetal.

demonstratedthatsteampopscanbepredicted

bytherateoftemperatureriseandthemaximum

volumetrictemperaturemeasuredbymicrowave

radiometry during irrigated RF ablation.3 In-

creasing contact force also was proportionally

associatedwithmoresteampops.8Inourcase,

therelativelyhighpower(45W)andtechnically

increasingcontactforcemayhavebeenrelated

causesofthesteampops,butwecouldnotcheck

thespikeinimpedancebecauseoftheunstable

situation.WhethertheVTfocuswasabolished

byelevatedRFpowerdeliveryorthesteampop,

theinterpretationwastangled.Anywaycareful

handlingoftheablationcatheterandmonitor-

ingofimpedanceandcathetertiptemperature,

andpossiblyalowpowersetting,isrequiredto

preventsteampops.

References

1. Seiler J, Roberts-Thomson KC, Raymond JM, Vest J, Delacretaz E, Stevenson WG. Steam pops during irrigated radiofrequency ablation: feasibility of impedance monitoring for prevention. Heart Rhythm. 2008;5:1411-1416.

2. Tokuda M, Kojodjojo P, Epstein LM, Koplan BA, Michaud GF, Tedrow UB, Stevenson WG, John RM. Outcomes of cardiac perforation complicating catheter ablation of ventricular arrhythmias. Circ Arrhythm Electrophysiol. 2011;4:660-666.

3. Koruth JS, Dukkipati S, Gangireddy S, McCarthy J, Spencer D, Weinberg AD, Miller MA, D'Avila A, Reddy VY. Occurrence of

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Steam Pops During Irrigated RF Ablation: Novel Insights from Microwave Radiometry. J Cardiovasc Electrophysiol. 2013 [Epub ahead of print].

4. Tokuda M, Tedrow UB, Stevenson WG. Silent steam pop detected by intracardiac echocardiography. Heart Rhythm. 2012 [Epub ahead of print].

5. Cooper JM, Sapp JL, Tedrow U, Pellegrini CP, Robinson D, Epstein LM, Stevenson WG. Ablation with an internally irrigated radiofrequency catheter: learning how to avoid steam pops. Heart Rhythm. 2004;1:329-333.

6. Yokoyama K, Nakagawa H, Wittkampf FH, Pitha JV, Lazzara R, Jackman WM. Comparison of electrode cooling between internal

and open irrigation in radiofrequency ablation lesion depth and incidence of thrombus and steam pop. Circulation. 2006;113:11-19.

7. Hsu LF, Jais P, Hocini M, Sanders P, Scavee C, Sacher F, Takahashi Y, Rotter M, Pasquie JL, Clementy J, Haissaguerre M. Incidence and prevention of cardiac tamponade complicating ablation for atrial fibrillation. Pacing Clin Electrophysiol. 2005;28 Suppl 1:S106-109.

8. Yokoyama K, Nakagawa H, Shah DC, Lambert H, Leo G, Aeby N, Ikeda A, Pitha JV, Sharma T, Lazzara R, Jackman WM. Novel contact force sensor incorporated in irrigated radiofrequency ablation catheter predicts lesion size and incidence of steam pop andthrombus. Circ Arrhythm Electrophysiol. 2008;1:354-362.

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A Case of Left Bundle Branch Block-shaped wide QRS Complex Tachycardia with diagnostic Ambiguity on a Surface Electrocardiogram

Introduction

In cases of tachycardia with a broad QRS

complex, it is important to differentiate be-

tween supraventricular tachycardia (SVT) and

ventriculartachycardia(VT).Electrocardiogram

(ECG)-based differential diagnoses include VT

vs. SVTwith aberrant conduction, pre-exist-

ingbundlebranchblock(BBB),intraventricular

conduction disturbances, and pre-excitation.

Severalcriteriahavebeendescribedfordiffer-

entiationbetweenVTandSVTinthepresence

ofawideQRScomplex.Wereportacaseofwide

QRScomplextachycardiawithleftBBB(LBBB)

morphologyandaretrogradePwaveonthesur-

faceECG.

Casereport

A78-year-oldwomanpresentedtoourhos-

pitalwithpalpitationsandchestdiscomfort.She

hada6-yearhistoryofnon-STsegmenteleva-

tion myocardial infarction (MI); however, she

hadnotreceivedtreatment.Onphysicalexami-

nation,bloodpressure,pulserate,andrespira-

toryratewere94/63mmHg,171bpm,and18/

min,respectively.Echocardiographyrevealedan

enlargedleftventricle(5.7cm)andleftatrium

(5.0cm)withpreservedleftventricularsystol-

ic function (ejection fraction, 53%).Therewas

moderatehypokinesiaontheinferiorwallfrom

thebasetotheapexandfromthemid-postero-

lateralwalltotheapexoftheposterolateralwall.

Min-Soo Ahn, MD Cardiology Division, Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea

Received: July 7, 2013Revision Received: August 28, 2013Accepted: September 28, 2013Correspondence: Min-Soo Ahn, MD, Department of Internal Medicine, Wonju College of Medicine, Yonsei University, 162 Ilsan-dong, Wonju, 220-701. Korea. Tel: +82-33-741-0909 Fax: +82-33-741-1219E-mail: [email protected]

AbSTRACTA 78-year-old woman presented with palpitations and wide QRS complex tachycardia with left

bundle branch block morphology on an electrocardiogram (ECG). The Brugada algorithm

suggested that the tachycardia was supraventricular in origin. However, electrophysiological study

showed that the tachycardia was ventricular in origin with 1:1 ventriculoatrial conduction. Here,

we report a case of broad complex tachycardia with diagnostic ambiguity on a surface ECG.

Key words: ■ arrhythmia ■ catheter ablation ■ premature ventricular contraction a

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A12-leadECGshowedwideQRS tachycardia

withLBBBmorphology(Figure1A).Thedura-

tionoftheQRScomplexwas148ms,andthe

axiswasnormal.RScomplexeswereobservedin

leadsV2-3,andRtoSintervalsinthoseleads

were72and84ms,respectively.Aretrograde

Pwavewasobservedontheterminalportionof

theQRScomplex.TherewasnoSwaveinlead

V1,andthedurationoftheSwaveinleadV2

was40ms.InleadV6,therewasonlyanRwave

A

b

Figure 1. Initial surface 12-lead ECG (A) and the ECG after administration of diltiazem (B).

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Figure 3. Atrial pacing during tachycardia revealed atrioventricular dissociation. The response immediately after cessation of atrial pacing was a ventricular-ventricular-atrial response.

Figure 2. Surface electrodcardiogram with intracardiac electrograms was displayed from top to bottom. Wide tachycardia that was identical with clinical tachycardia was induced with ventricular pacing. Immediately after cessation of ventricular pacing, another mor-phology of PVC was observed and tachycardia was sustained. That was fusion beat. The arrow indicates a fusion beat.

⬅

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Vol.14 No.3

withnoQwave.Thetachycardiawasterminated

bya10mgintravenousdoseofdiltiazem(Fig-

ure 1B).Basedon theBrugadaalgorithm, the

ECGfindingsofthispatientstronglysuggesteda

tachycardiaofsupraventricularorigin.1

Afterinformedconsentwasobtained,thepa-

tient underwent a cardiac electrophysiological

study.Multipolarelectrodecathetersweread-

vancedintothefemoralveinandpositionedin

the right atrium, His-recording region, right

ventricularapex,andcoronarysinus.Retrograde

conductionwasexistedviatheatrioventricular

(AV)node.Afusionbeatwasobservedimmedi-

atelyaftercessationofventricularpacing,anda

sustainedtachycardia,whichwasmorphologi-

callyidenticaltothepatient’sclinicaltachycar-

dia,wasinduced.Duringtachycardia,theven-

tricularelectrogramprecededeachHispotential,

and1:1ventriculoatrialconductionwasobserved

(Figure2).Thistachycardiawasentrainedwith

ventricularpacingattherightventricularapex,

andthedifferencebetweenthepost-pacingin-

tervalandthetachycardiacyclelengthwas103

ms. Atrial pacing during tachycardia revealed

AVdissociationandaventricular–ventricular–

atrialresponse,whichwasobservedimmediately

afterthelastatrialpacedcomplex(Figure3).The

morphologyofthetachycardiawaschanged,and

thetachycardiawasterminated(Figure4).Be-

causethetachycardiahadbeenconsideredsu-

praventricularinoriginbeforeelectrophysiologic

study,a3Dmappingsystemwasnotprepared,

andtheprocedurewasfinished.

Discussion

WideQRScomplextachycardiastillpresentsa

diagnosticchallengewitha12-leadECG.ECG-

baseddifferentialdiagnosesincludeVTvs.SVT

withaberrantconduction,pre-existingBBB,in-

Figure 4. Change in tachycardia morphology

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traventricularconductiondisturbances,andpre-

excitation.VTisthemostimportantdifferential

diagnosisbecauseofitsunfavorableprognosis.

An accurate diagnosis with immediate treat-

mentisusuallyrequired.Adelayeddiagnosisof

VToramisdiagnosisfollowedbyinappropriate

intravenousadministrationofdrugsusedforthe

treatmentofSVT,suchasverapamilandadeno-

sine,cancauseseverehemodynamicdeteriora-

tionandmayprovokeventricularfibrillationand

cardiacarrest.

SurfaceECGmayprovideimportantcluesfor

theclassificationofatachycardiaaseitherSVT

orVT.In1978,Wellensetal.notedthatamong

LBBBtachycardias,QRorQScomplexesinlead

V6favoredadiagnosisofVT,althoughallother

QRSmorphologiesinthisleadwerenonspecific,

andsignificantQwavesinV6occurredinfre-

quentlyinpatientswithVT.2However,Kindwall

etal.determined thatSVTwithLBBBexhib-

itedfeaturesofintactrightbundlebranchcon-

duction, reflected in a frequent occurrence of

small,narrow(‹30ms)Rwavesintheanterior

precordial leads (V1andV2) followedbyrapid

andabruptnegativeSwaveswithcorrespond-

ingRtonadirofSintervalsof‹60ms.Incon-

trast,anRwaveduration›30ms,notchedand

slurreddownstrokestotheSwaves,and/orRto

nadirofSintervalsof›60msinleadsV1orV2

favoredthediagnosisofVT,asdidQwavesin

leadV6.3Basedonamodificationoftheseobser-

vations,Brugadaetal.developedanalgorithm

fordifferentiationofwidecomplextachycardia.

TheabsenceofanRScomplexoranRtonadir

ofSintervalof›100msinanyprecordiallead

strongly favorsVT. Ifneitherof thesecriteria

aresatisfied,thepresenceofAVdissociationor,

inthecaseofLBBBmorphologies,anotchedS

waveinV1orQwaveinV6alsosuggestVT.

Taken in sequence, the algorithm provides a

sensitivityandspecificityof98.7%and96.5%,

respectively,forthediagnosisofVT.However,in

additiontotheambiguityofdiagnosis,itisdif-

ficulttomeasureprecisefiguresatapaperspeed

of25mm/s,asthedifferencebetween30and

40msis0.25mm.Thesefactors,incombina-

tionwiththedifficultyindeterminingtheonset

oftheinitialdeflectionoftheQRScomplex,led

toadegreeof inter-observervariation inthis

study,therebyreducingtheobjectivediagnostic

potentialofthetechnique.In1991,Griffithetal.

performedamultivariateanalysisin102patients

toidentifywhichof15clinicalor11ECGvariables

are independent predictors ofVT. They found

thatthefollowingfactorsassisteddiagnosisof

VT:(i)PreviousMIisanindependentpredictor

ofVT.(ii)Apredominantnegativedeflectionin

leadaVFissuggestiveofVT,especiallywhena

QwaveispresentinrightBBB(RBBB)pattern

tachycardia.InLBBBpatterntachycardia,aQS

orqRwaveforminleadaVFishighlysuggestive

ofVT,whereasanRscomplexisspecificforSVT.

(iii)InRBBBpatterntachycardia,amonophasic

orbiphasicwaveforminleadV1suggestsVTand

atriphasicRSR,rSRconfigurationsuggestsSVT.

(iv)A≥40°changeinaxisbetweensinusrhythm

andtachycardiaisanindependentpredictorof

VT.Ifnoneoftheabovevariablesareobserved,

thediagnosisisalmostcertainlySVT.Ifonecri-

terionisnoted,thediagnosisisprobablySVT.If

2criteriawerenoted,thediagnosisisprobably

VT.If3or4criteriaareobserved,thediagnosis

isalmostcertainlyVT.Thepredictiveaccuracy

ofthismethodwas93%,whichincreasedto95%

withtheinclusionof2othercriteria:independ-

entPwaveactivityandventricularectopicbeats

duringsinusrhythmwiththesameQRSmor-

phology as that in tachycardia.4 According to

Griffith'scriteria,thehistoryofMIandpresence

ofaQSwaveinleadaVFinourcasefavorsadi-

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Vol.14 No.3

agnosisofVT.In2008,Vereckeietal.presented

asimplifiedalgorithmusingonlyleadaVR;this

algorithmshowedhighaccuracyintheanaly-

sisof313patients.ThecriteriaforVTinlead

aVRwereasfollows:(i)thepresenceofaninitial

Rwave,(ii)›40mswidthofaninitialRorQ

wave,(iii)notchingontheinitialdownstrokeof

apredominantlynegativeQRScomplex,and(iv)

Vi/Vt≤1.5Inthepresentcase,ViandVtwere

239and400μV,respectively,resultinginVi/Vt

≤1andthereforefavoringadiagnosisofVTby

Vereckei'scriteria.

Inconclusion,widecomplextachycardiaoften

exhibitsanindistinctmorphology,especiallyat

higher frequencies,making diagnosis difficult.

Despiteallavailablemorphologicalcriteria,wide

complex tachycardiasare stillmisdiagnosedor

canremainundiagnosed.Toachieveahighpos-

itivepredictivevalueof›95%intheidentifica-

tionofVT,asystemicapproachthatemploysa

combinationofvariousECGandclinicalcriteria

isneeded.

References

1. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with

a wide QRS complex. Circulation. 1991;83:1649-1659.2. Wellens HJ, Bar FW, Lie KI. The value of the electrocardiogram in

the differential diagnosis of a tachycardia with a widened QRS complex. Am J Med. 1978;64:27-33.

3. Kindwall KE, Brown J, Josephson ME. Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias. Am J Cardiol. 1988;61:1279-1283.

4. Griffith MJ, de Belder MA, Linker NJ, Ward DE, Camm AJ. Multivariate analysis to simplify the differential diagnosis of broad complex tachycardia. Br Heart J. 1991;66:166-174.

5. Vereckei A, Duray G, Szenasi G, Altemose GT, Miller JM. Newalgorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5:89-98.

자율 학습 문제

부정맥연구회지에서는매호자율학습문제를수록합니다.해당호에실린원고를바탕으로출제된문제로선

생님들의자기계발에도움이되시길바랍니다.많은참여부탁드립니다.모범답안은다음호에게재합니다.

1. 심실조기수축에 대한 설명으로 적당하지 않은 것은?

① 건강한성인에서흔히볼수있는부정맥이다.

②최근보고에서증상이없어도하루동안24%이상발생할경우심근기능저하를일으킬수있으나그간격은

의미가없다고보고되고있다.

③3회이상심실조기수축이생기는경우심실빈맥으로분류한다.

④이뇨제를투여중저칼륨혈증이생기면잘발생할수있다.

2. 특발성 심실빈맥에 대한 설명으로 적절한 것은?

① Catecholamine에의한earlyafterdepolarization에의해이루어진다

②Aorticcusp심실빈맥의경우non-coronarycusp에서가장빈도가높다.

③유출로심실빈맥의경우베타차단제는거의도움이되지않는다.

④Fascicular심실빈맥은verapamil이효과적이다.

3. 허혈성 심실빈맥의 전극도자절제술 시 reentrant circuit에서 entrainment with concealed fusion이 있고,

post-pacing interval과 tachycardia cycle length가 동일하며, mid-diastolic potential이 보이는 경우는 어느

point 인가?

① Commonpathway

②Innerloop

③Exitsite

④Bystander

4. 확장성 심근병증에서 발생한 심실빈맥에 대한 설명으로 적절하지 않은 것은?

① 확장성심근병증환자에서사망의원인중약50%가부정맥에의한급사이다

②확장성심근병증에서발생한심실빈맥의기전은myocardialscar와동반된reentry로보고되고있다.

③확장성심근병증을가진환자에서사망률의예측인자중가장신뢰할수있는것은생검소견이다.

④SCD-HeFT연구에서좌심실구혈률이35%미만인확장성심근병증환자에서적절한약물치료군과비교하여

ICD를시술한군에서만사망률의감소를보였다.

Vol.13 No.2 |통권45호 |자율 학습 문제 [모범 답안]

1. Amiodarone에 대한 설명으로 적당하지 않은 것은?

①Thyroxine의구조와비슷하며분자량의37%가요오드이다.

②CYP3A4의억제제로서warfarin과같이사용시prothrombintime을낮춘다.

③구조적심장질환이있는경우사용시사망률을낮춘다.

④Liverfunctiontest와thyroidfunctiontest를6개월마다시행해야한다.

☞ 정답 : ②Prothrombin time을 증가시킬 수 있다.

2. Flecainide에 대한 설명으로 적절한 것은?

①주로inwardrectifyingpotassiumchannel을차단한다.

②Hepaticfirst-passmetabolism을이용하여대사되므로투여용량과혈중농도에차이가있을수있다.

③Post-repolarizationrefractoriness를연장하여정상심박동수에서도심장세포의전도속도를감소시킨다.

④QT간격을증가시키나QRS간격을넓히지는않는다.

☞ 정답 : ③

① delayed rectifying potassium channel을 차단한다.

② hepatic first-pass metabolism을 이용하지 않으므로 투여 용량과 혈중 농도 사이에 좋은 상관관계를 보인다.

④ QT interval을 증가시키며, 이는 주로 QRS duration이 증가됨에 따라 생긴다.

3. Sodium 채널차단제이면서 동시에 β-adrenergic antagonist의 효과를 가지고 있는 약제는?

①Procainamide

②Lidocaine

③Propafenone

④Flecainide

☞ 정답 : ③Propafenone의 β-adrenergic blocking 효능은 propanolol의 1/20~1/80이다. S-propafenone만이

β-adrenergic blocking 작용을 가지고 있다

4. Pilsicanide에 대한 설명으로 적절하지 않은 것은?

①간에서대사되지않으므로신체내약물흡수도1~2시간으로빠르게이루어진다.

②PSTAF연구에서발작성심방세동에서도singleoraldose로효과적으로동율동으로전환시켰다.

③Sodiumchannelblocking이외에도potassiumchannelblocking효과도있다.

④Muscarinicacetylcholinereceptor를차단하여농도에의존한다.

☞ 정답 : ③ Pilsicanide는 pure sodium 채널차단제이다.

투고 및 윤리 규정

목적과개요

부정맥(TheOfficialJournalofKoreanHeartRhythmSociety)

은대한심장학회부정맥연구회의주관으로발행되며,부정맥과관

련된새로운임상지식,진료지침,증례등을소개하여부정맥연

구회회원및개원의의지속적인의학교육에이바지하고자발행

되는최신학술지이다.본지는부정맥의진단과치료,임상연구

와관련된원저,종설,논평,증례보고등을편집위원회에서검토

후게재한다.

연구및출판윤리규정

본규정은대한심장학회부정맥연구회지(TheOfficialJournalof

KoreanHeartRhythmSociety)회원들의학술활동중연구윤리

를확보하는데필요한역할과책임에관하여기본적인원칙과방

향을제시하기위하여제정되었으며,각회원은연구활동중정

직성,진실성,정확성이연구결과의신뢰성확보를위한필수조

건임을인식하고모든연구활동을수행함에있어이규정을준수

하도록한다.

1.저자들은UniformRequirementsforManuscripts

SubmittedtoBiomedicalJournals(http://www.icmje.

org/)에서규정한윤리규정을준수해야한다.

2.본학술지에투고하는원고의연구대상이사람인경우는헬

싱키선언(DeclarationofHelsinki[www.wma.net])의윤

리기준에일치해야하며,기관의윤리위원회또는임상시험심사

위원회(InstitutionalReviewBoard)의승인을받고,필요한경

우에연구대상자의동의서를받았음을명시해야한다.

3.동물실험연구는실험과정이연구기관의윤리위원회의규정

이나NIHGuide for theCareandUseofLaboratory

Animals의기준에합당해야한다.

4.간행위원회는필요시환자동의서및윤리위원회승인서의

제출을요구할수있다.

5.이해관계명시(Disclosureofconflictofinterest):연구에

소요된연구비수혜내용은감사의글에필히기입해야한다.

연구에관계된주식,자문료등이해관계가있는모든것은표지

하단에밝혀져야하며,이를모두명시했음을원고의저자전원

의자필서명이있어야한다.

6.원칙적으로타지에이미게재된같은내용의원고는게재

하지않으며,본지에게재된것은타지에게재할수없다.단,독

자층이다른타언어로된학술지에게재하기위한경우등의중

복출판은양측간행위원장의허락을받고,중복출판원고표지에

각주로표시하는등,다음문헌에서규정한요건을갖춘경우에만

가능하다(AnnInternMed1997;126:36-47).

7.윤리규정및표절/중복게재/연구부정행위등모든연구윤리와

연계되는사항에대한심사및처리절차는대한의학학술지편집

인협의회에서제정한'의학논문출판윤리가이드라인(http://

kamje.or.kr/publishing_ethics.html)'을따른다.

원고범위

1.원저(OriginalArticle)는인간을대상으로한연구(임상적조사

및보고서)와동물을이용한실험및생체외실험에대한연구(

기초과학보고서)로한다.

2.종설(ReviewArticle)은특정분야나주제에관해간결하고

포괄적으로평가한논문으로위촉된종설에한하여게재하는것

을원칙으로하나편집진의재량에따라위촉되지않은종설도게

재가능하다.

3.논평(Editorial)은본학술지에게재되는논문에대한저자의

견해를기술한것으로,편집진의의뢰하에쓰여진다.

4.증례보고(CaseReport)의요건은국내첫증례또는희귀

증례로제한한다.

집필규정

1.논문은한글을사용하여한글맞춤법에맞게작성하며모든학술

용어는대한의사협회에서발간한의학용어집의최신판에수록

된용어를사용한다.

2.원어의적당한한글용어가없는경우한글뒤()안에원어는

표기할수있다.부득이외국어를사용할때는대소문자의구별

을정확히해야한다(예：고유명사,지명,인명은첫글자를대

문자로하고그외에는소문자로기술함을원칙으로한다).적절

한번역어가없는의학용어,고유명사,약품명,단위등은원어를

그대로사용한다.

3.번역어가있으나의미전달이명확하지않은경우에는그용어

가최초로등장할때번역어다음소괄호속에원어로표기하고

그이후로는번역어만사용한다.

4.검사실검사수치의단위는SI단위(InternationalSystemof

Units)를사용하고,편집위원회의요구나필요에따라괄호안에

비SI단위수치를첨부할수있다.

5.약자는가능한한사용하지않는것이좋지만,본문에일정용어

가반복사용됨으로인해부득이약자를사용해야하는경우

에는그용어가처음나올때괄호안에약자를함께표기하고

다음부터약자를사용할수있다.

6.원고는컴퓨터문서작성프로그램(MS워드또는한글)을사용

하여작성한다.글자의크기는명조계통의10point,정렬은좌측

정렬을하며,줄간은한글의경우160%,워드의경우1줄간격

으로하며좌우및위아래여백은3cm로한다.원고면의번호

는제목쪽부터시작하여차례대로중앙하단에표시한다.

원고의형식

1. 원저(Original Article)

표지,초록과키워드,본문,감사문,참고문헌,도표,그림/사진

설명,그림및사진의순으로하며,제목쪽과초록및참고문

헌은각각분리된쪽으로작성한다.

1) 표지(Title Page)

①제목,소속,저자명,영문제목및영문소제목(빈칸을포함

하여50자이내),영문저자명,영문소속순으로하며,표지

하단에교신저자(correspondingauthor)의이름,주소,소속,

전화번호,전송번호,E-mail주소등을명시해야한다.

②저자들의소속이다수인경우소속명을같은행에연이어

나열하며,아라비아숫자의어깨번호로소속과저자명을

일치시킨다.영문저자명뒤의MD나PhD등에는글자다

음에구두점을찍지않는다.

2) 초록과 키워드(Abstracts and Key Words)

모든원고에는영문초록을첨부해야하며,초록은250단어이

내로한다.BackgroundandObjectives,Subjects(Materials)

andMethods,Results,Conclusion의순으로구분하여소제목

에따라줄바꿈없이작성한다.증례보고인경우소제목없이

가능하며,초록은150단어이내로한다.단논평의경우초록을

첨부하지않는다.그리고각초록의말미에Indexmedicus에등

재된용어5개이내로영문keywords를삽입한다.

3) 본문(Text)

서론,대상(재료)및방법,결과,고찰,요약,중심단어순으로

작성한다.

①서론에는연구와관련된간략한배경과연구의목적이언급

되어야한다.

②대상(재료)및방법은매우상세히기재해야하며결과의통

계적검증방법도밝혀야한다.

③고찰은연구결과와연관된새롭고중요한측면에대한내용

으로제한한다.

④요약은결과와고찰로부터유도되고,서론에서언급한연구

목적과부합되어야하며,결과의단순한요약은금한다.

요약의구성은배경및목적,방법,결과,결론의순으로구

분하여소제목에따라줄바꿔작성한다.그리고국문논문은

요약다음에한글중심단어를초록의영문중심단어와일치시

켜삽입한다.임상화보의경우본문은250단어를넘기지않으

며,사진에대한설명은따로작성하지않고,증례에대한설명에

포함한다.

4) 감사문(Acknowledgments)

감사문에는본연구의연구비지원기관,본연구를수행하는데

여러가지로도움을주었던분들에대한사항을기술한다.

5) 참고문헌(References)

①원저는30개이하,증례보고는20개이하,임상화보는5개

이하로제한한다.종설은참고문헌수를제한하지않는다.

②참고문헌은본문에나타난것만인용한다.본문에서는인용

순서에따라아라비아숫자로저자명뒤또는문장끝에어

깨번호로표시한다.참고문헌의배열도인용한순서대로작

성한다.동일저자의경우연도순으로나열하며,국내문헌도

영문표기를원칙으로한다.

③참고문헌의저자는모두기재한다.저자표기는lastname은

다쓰고,firstname과secondname은첫글자를대문자로

붙이고initial에마침표(.)는사용하지않는다.저자명사이

에는쉼표(,)로구분하고,마지막저자명뒤에는마침표(.)

를찍는다.

④잡지명은‘ListofJournalsIndexMedicus’에의거약어로

기재하며,인용학술지명뒤에는마침표를찍는다.인용논문

의제목중첫글자는대문자로하고,부제목이있는경우

쌍점(：)을붙인후소문자로기재하며제목뒤에는마침표

(.)로표시하며,연도를표시한후쌍반점(；)으로붙여서구

분후,권：시작쪽-끝쪽의전체페이지를기재하며,마지막

에마침표를찍는다.

예)SmithHJ,AllenS,YuW,FardS.Thisisthetitle.

Circulation.2004;104:276-308.

6) 표(Table)

①표는영문과아라비아숫자로기록하며표의제목을명료하게

절혹은구의형태로기술한다.문장의첫자를대문자로한다.

②분량은4줄이상의자료를포함하여1쪽을넘지않는다.

③본문에서인용되는순서대로번호를붙인다.

④약어를사용할때는해당표의하단에알파벳순으로풀어서

설명한다.

⑤기호를사용할때는*,†,‡,§,‖,¶,**,††,‡‡의

순으로하며이를하단각주에설명한다.

⑥표의내용은이해하기쉬워야하며,독자적기능을할수있

어야한다.

⑦표를본문에서인용할때는영문(Table1과같이)을사용한다.

7) 그림 및 사진(Figure)

①그림및사진은‘ppt’파일형식으로원문과별도의파일을만

들어서제출한다.

②동일번호에서2개이상의그림이필요한경우에는아라비아

숫자이후에알파벳글자를기입하여표시한다(예:Figure

1A,Figure1B).

③그림을본문에서인용할때에는한글(Figure1과같이)을사

용한다.

④최종통과시그림및사진은‘jpg’파일형식으로1장씩10메

가이내로파일을만들어서제출한다.

⑤칼라사진은학회요청(흑백사진으로확인이잘되지않는

경우)및저자의요청에의하여칼라로인쇄될수있으며비

용은저자의부담으로한다.

8) 그림 및 사진 설명(Figure Legends)

①본문에인용된순으로아라비아숫자로번호를붙인다.

②모든그림및사진은설명이있어야하며,별지에영문으로

구나절이아닌문장형태로기술한다.

③현미경사진의경우배율을기록한다.

2. 원저 이외의 원고

일반사항은원저에준한다.

1) 종설(Review Article)

종설은특정제목에초점을맞춘고찰로서편집위원회에서위촉

혹은투고에의하여게재한다.단,투고된원고는심사를거쳐게

재여부를결정한다.

2) 증례 보고(Case Report)

①전체분량이A4용지10매이내로작성한다.

②영문초록은항목구분없이150단어이내로한다.

③고찰은증례가강조하고있는특정부분에초점을맞추며

장황한문헌고찰은피한다.

④참고문헌의수는20개이내,그림은5장이내로한다.

⑤저자수는7명이내로한다.

3) 논평(Editorial)

학회지에출판된특정논문에대한논평을의뢰받아집필되는부

문으로학회의의견을반영하는것은아니다.원고는A4용지4

매이내로작성하고참고문헌은10개이내로제한한다.

기타사항

1.본학회지는연간4회(3,6,9,12월말일)발간한다.

2.필요할경우원문에영향을미치지않는범위내에서자구와

체제를편집방침에따라편집위원이수정할수있다.

3.원고의게재여부는원고심사후편집위원회에서결정하며

본규정에맞지않는원고는개정을권유하거나게재를보류할

수있다.

4.학회지의게재는원고의저작권이저자로부터학회지로이양

되는것을저자가승인한것으로인정한다.

5.원고제출처

•부정맥연구회온라인논문투고사이트

http://arrhythmia.medimedia.co.kr

•엠엠케이커뮤니케이션즈(주)

E-mail:[email protected]

주소:서울시강남구역삼동641-3번지노바빌딩3층

(135-909)

전화:02-2007-5413팩스:02-3452-5984

저자 점검표

•저자(소속): •논문제목:

다음은귀하가본부정맥연구회지(TheOfficialJournalofKoreanHeartRhythmSociety)에투고하는논문이투고규정에맞도록각

항목별로충실히작성되어있는지점검하는저자점검표입니다.논문투고시해당칸에표시하여논문과함께반드시제출하여주십시오.

일반사항

1.본논문의내용은다른학회지에게재되지않았고,게재예정도없다 ☐2.원고는A4용지10포인트크기로여백상,하,좌,우3.5,3,3,3cm,줄간격1기준으로작성하였다 ☐3.원저는표지,영문초록,서론,본론,결론,참고문헌,Table,Figure순서의양식으로구성하며,본론은소제목으로구분한다 ☐4.증례는표지,영문초록,서론,증례,고찰,참고문헌,Table,Figure순서의양식으로구성한다 ☐5.일련쪽수를하단에기재하였다 ☐

표지

1.논문제목 ☐2.저자소속,이름 ☐3.영문제목,영어저자명,영어소속 ☐4.요약제목(Runningtitle)-국문제목30자이상,영문제목12단어이상 ☐5.책임저자이름,주소,전화,Fax,전자우편주소 ☐6.연구비에대한사항을각주에적었다(해당되는경우) ☐

영문 초록

1.영문제목이한글제목과일치하도록작성,영문성명,영문소속의올바른기재 ☐2.원저는내용을Background,Objective,Method,Result,Conclusion으로규정된형식으로작성하였다 ☐3.증례는내용을한단락(paragraph)으로작성하였다 ☐4.KeyWords3-5개를MeSH에맞게작성하였다 ☐

본문

1.한글로사용가능한용어는한글로기재하였다 ☐2.본문중해당참고문헌의어깨번호를표시하였다 ☐

참고문헌

1.투고규정준수에맞게모두영문으로작성하여PubMed와KorMed에서확인하였다 ☐2.참고문헌의모든공저자를기재하였다 ☐3.학술지표기는IndexMedicus의공인된약어를사용하였다 ☐4.학술지를이탤릭체로표기하였다 ☐

Table과 Figure

1.Table과Figure는중복되지않도록작성하였다 ☐2.Table과Figure는투고규정에맞도록작성하였다 ☐3.제목및설명모두영문으로기재하였다 ☐4.제목에서약자를사용하지않으며,Table과Figure에사용된약자는하단에설명을기재하였다 ☐

본논문의저자(들)은부정맥연구회지(TheOfficialJournalofKoreanHeartRhythmSociety)의투고규정에따른

위의사항들을확인하였으며,논문게재를요청합니다.

20년월일

저자대표________________________(서명)

저작권 이양 동의서

논문 제목

•국 문

•영 문

본 논문의 저자(들)은 본 논문의 부정맥연구회지(The Official Journal of Korean Heart Rhythm Society) 게재를 바라며, 이에

다음 사항들에 대하여 동의합니다.

1.본논문의저자(들)은본논문이창의적이며,다른논문의저작권침해,비방,혹은사적침해등내포하지않음을확인합니다.

2.본논문의저자(들)은본논문에실제적이고지적인공헌을하였으며,본논문의내용에대하여공적인책임을공유합니다.

3.본논문은과거에출판된적이없으며,현재다른학술지에게재를목적으로제출되었거나제출할계획이없습니다.

4.본논문의저자(들)은본논문이부정맥연구회지(TheOfficialJournalofKoreanHeartRhythmSociety)에게재될경우,저작권에

관한모든권리,이익및저작권에대한모든권한행사등을대한심장학회부정맥연구회에이양하기로동의합니다.이는저자(들)이

향후다른논문에본논문의자료를사용할경우대한심장학회부정맥연구회로부터서면허가를받아야하며,이경우자료가발표된

원논문을밝혀야하다는것을의미합니다.

년월일

저자 성명 서명 저자 성명 서명

책임저자 제5저자

제1저자 제6저자




vol.14 noarrhythmia.medimedia.co.kr/archive/archive/pdf/46.pdf · 2015-02-12 · ecg & ep cases...

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