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서론

심근염은대부분바이러스감염에의해발생하며증상은

가벼운흉통이나호흡곤란에서부터심인성쇼크와사망에이

르기까지다양하다. 가벼운증상인경우대부분저절로심근

염에서회복되나때로는심근염이계속되어확장성심근증으

로진행하여만성심부전으로나타나기도한다. 또한심근염

이심장근육을침범하여심전도에서ST절의상승이나하강

으로나타나심근경색등관상동맥질환과구별하기힘든경

우가 있으며 심장의 전기전도체계(electrical conduction

system)를침범하면전도체계에장애를일으켜동결절과방

실결절의기능이상, 각차단등의장애를초래하기도한다.1

본증례는심근염이시간이지나면서회복되지않고광범

위하게심장전체에손상을주어심장기능의저하와함께고

도방실차단, 완전방실차단, 어떤치료에도반응하지않은심

실빈맥등여러부정맥이장기간지속된아주드문예이다.

증례

59세여성환자가본원방문전날어지럼증을주증상으로

동네병원에들 다가심전도이상으로본원으로전원되었

다. 환자의과거력은특이소견이없었으며평소복용하는약

물도없었다.

치료에반응하지않은심실빈맥이장기간지속된심근염

아주대학교 의과대학 내과학교실 황 교 승Gyo-Seung Hwang MD, PhDDepartment of Internal Medicine, Ajou University College of Medicine, Suwon, Korea

Myocarditis with long-standing uncontrolled ventricular tachycardia

ABSTRACTMyocarditis has a wide range of symptoms, ranging from mild chest pain and dyspnea to cardiogenic shock

and death. We encountered a case of fatal myocarditis with various arrhythmia, including uncontrolled

ventricular tachycardia (VT), a high degree atrioventricular block with a long pause, and a complete

atrioventricular block. The patient had deteriorated even though conservative heart failure therapy,

antiarrhythmic drugs, and pacing therapy were given. Long-lasting and various types of VT in patients with

myocarditis might reveal an electrically unstable status of the myocardium due to extensive invasion of

myocarditis. In the case of fatal myocarditis, an aggressive medical approach that includes immune therapy

sometimes seems needed.

Key words: ■ myocarditis ■ ventricular tachycardia

Received: October 9, 2011Accepted: December 27, 2011Correspondence: Gyo-Seung Hwang MD, PhD, Department of InternalMedicine, Ajou University College of Medicine, San 5, Wonchon-dong,Yeongtong-gu, Suwon 443-721, KoreaTel: 82-31-219-5719, Fax: 82-31-219-5708E-mail: hwanggs@ajou.ac.kr

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내원당시심전도소견은분당30회의완전방실차단소견

이보 고, 흉부유도V1에서부터V3까지는ST상승, 하부유

도II, III, aVF에서는T하강소견이보 다(Figure 1). 당시

혈액 검사에서 CK-MB가 15.2 ng/L, troponin T가

0.954 ng/mL, pro-BNP가 5488 pg/mL로관찰되어급

성심근경색의심하에응급으로관상동맥조 술을시행하

고결과는정상소견이었다. 당시심장초음파에서좌심실

구혈률은45% 다. 이상의소견들을종합하여급성심근염

으로진단하 다. 내원2일째부터심실빈맥이지속되었고심

박수는분당90~150회로비교적느렸으며, QRS파의모양

이계속바뀌는양상이었다(Figure 2). 심실빈맥이중간에

20초이상의심정지가관찰되었고(Figure 3) 그때마다환

자는일시적으로실신하 다. 내원당시임시형심박동기를

삽입한상태 으나제대로율동되지않았다. 환자는간간히

나타나는완전방실차단과동정지시에는어지럼증과반복되

는실신으로인해매우힘들어했으나심실빈맥시오히려편

안한상태 고혈압도수축기가90~100 mmHg로안정적이

었다. 이러한양상은계속반복되었다. 심실빈맥조절을위해

전기충격과amiodarone, lidocaine, flecainide 등항부정

맥약물을단독혹은병합투여하 으나효과가없었다. 호흡

곤란등심부전증상을조절하기위해carvedilol, angiotensin

receptor blocker는 소량으로유지하다혈압저하로중단

을반복했고이뇨제는지속적으로투여했다.

내원 11일째심실빈맥과완전방실차단, 긴휴지기를동반

한고도방실차단등소견이계속반복되었고그동안임시형

심박동기의전극위치를여러번조정했음에도불구하고긴

휴지기동안박동기가작동하지않는경우가많았다. 동결절

과방실결절의회복을충분히기다렸다고판단되어DDD형

의 구형심박동기를삽입하 다. 구형박동기삽입전심

실빈맥이 short-long-short 혹은R on T 양상으로시작

되는(Figure 1A) 양상을자주보여이를방지해보고자율동

심박수를분당 110회나 120회로조절하여도심실빈맥은계

속나타났다. 심실빈맥의모양은계속바뀌는양상이었으며

내원 15일째 시행한 Holter 심전도에서 다형심실빈맥

(polymorphic VT)도관찰되었다(Figure 4).

환자의호흡곤란은계속되었으며내원 15일째시행한심

초음파에서좌심실구혈률은25%로더저하된상태 다. 또

한심근효소(CK-MB)는 2주이상지속적으로상승되어있

었다. 이후심기능의회복을위해digoxin을추가로투여하

다. 임시형심박동기삽입할때부터해파린정주를계속해

왔으나하지정맥에혈전소견관찰되고심초음파에서좌심

방에도혈전소견보여폐색전증등을확인하기위해흉부

CT를시행했고CT 소견에서는많은양의양쪽늑막삼출액

외에특이소견은없었다.

Figure 1. ECG on admission. The ECG showed ST elevation in leads V1 to V3, ST depression in leads II, III, aVF, and acomplete atrioventricular block.

ECG; Electrocardiogram

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내원47일째호흡곤란이심해지고의식이혼미해지는양상

보여 ECMO (extracorporeal membrane oxygenation)

를시작하 다당시의좌심실구혈률은17% 다. 스테로이드

치료를시작했으며치료5일째좌심실구혈률은22%로약간

호전된양상이었고심실빈맥의발생은현저히줄었다. 하지만

심장이식은 여의치 않은 상황이었고 환자 보호자가 ECMO

치료의연장을거부했고내원55일째환자는사망하 다.

고찰

이환자의경우심근염이심장전체에광범위하게침윤되

어심장수축기능저하와함께, 방실결절등심장의전기전도

체계에손상이왔고, 여러가지모양의심실빈맥이내원할때

부터사망할때까지55여일간지속과중단이반복되었다. 심

실빈맥을조절하기위해항부정맥약물과심박동기로심박수

를조절하는등여러시도를해봤지만효과적으로심실빈맥

을조절할수없었다. 이는심근염이광범위하게계속진행하

면서심근세포가전기적으로불안정해져서다양한모양의심

실빈맥이발생한것이라위의치료방법에반응이없었던것

으로추정된다. 일반적으로심근염에동반되는부정맥은심근

염이치유되면서같이사라지기때문에부정맥시술등적극

적인치료보다는보존적치료가원칙이나2 본예의경우심근

염이계속지속되고방실결절의기능이내원후 11일이지났

는데도회복되지않아 구형심박동기를삽입하게되었다.

Figure 2. Various types of VT. (A) VT is initiated with R on T phenomenon (black arrow). (B) VT morphology is changedduring VT ongoing.

VT; ventricular tachycardi.

A

B

Lead II

Lead II

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심근염에대한치료는심부전에대한보존적치료3, 4 외에

항바이러스치료, 면역억제치료등이시도되었으나확실히

효과적이라고증명된치료법은없다.1 하지만본예의경우에

서도보듯이스테로이드투여후심실빈맥의발생이줄고심

장수축기능이어느정도호전된양상으로보아조기에스테

로이드를투여했었으면하는아쉬움이많이남는다. 스테로

이드투여를주저한이유는급성심근염환자에게스테로이

드를투여할경우사망률을오히려높인다는보고도있고,5

이뇨제투여후환자의심부전증세가어느정도호전되는양

상이어서심장기능회복여부를좀더지켜보자는생각이

있었으며중간에고열이나폐렴의발생을배제할수없는상

태 기때문이다. 하지만본예와같이심실빈맥등심실내

전기적불안정상태를시사하는소견이오랜기간계속된다

면심근염에대해보다적극적이고과감한치료법을시도해

보는것도좋다고생각된다.

Figure 3. ECG during syncope. ECG shows a high degree atrioventricular block with a long pause.

ECG; electrocardiogram

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References

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Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, PrioriSG, 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, Blanc JJ,Budaj A, 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 HeartAssociation Task Force; European Society of CardiologyCommittee for Practice Guidelines; European Heart RhythmAssociation; Heart Rhythm Society. ACC/AHA/ESC 2006 guidelinefor management of patients with ventricular arrhythmias and theprevention of sudden cardiac death: a report of the AmericanCollege of Cardiology/American Heart Association Task Force andthe European Society of Cardiology Committee for PracticeGuidelines (writing committee to develop guidelines formanagement of patients with ventricular arrhythmias and theprevention of sudden cardiac death): developed in collaborationwith the European Heart Rhythm Association and the HeartRhythm Society. Circulation. 2006;114:e385-e484.

3. Hunt S. ACC/AHA 2005 guideline update for the diagnosis andmanagement of chronic heart failure in the adult: a report of theAmerican College of Cardiology/American Heart Association TaskForce on Practice Guidelines (Writing Committee to Update the2001 Guidelines for the Evaluation and Management of HeartFailure). J Am Coll Cardiol. 2005;46(6):e1-e82. [Erratum, J AmColl Cardiol. 2006;47:1503-1505.]

4. Dickstein K, Cohen-Solal A, Fil ippatos G, McMurray JJ,Ponikowski P, Poole-Wilson PA, Strömberg A, van Veldhuisen DJ,Atar D, Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG,Swedberg K; ESC Committee for Practice Guidelines (CPG). ESCguidelines for the diagnosis and treatment of acute and chronicheart failure 2008: the task force for the diagnosis and treatmentof acute and chronic heart failure 2008 of the European Societyof Cardiology. Developed in collaboration with the Heart FailureAssociation of the ESC (HFA) and endorsed by the EuropeanSociety of Intensive Care Medicine (ESICM). Eur J Heart Fail.2008;10:933-989.

5. Costanzo-Nordin MR, Reap EA, O’Connell JB, Robinson JA,Scanlon PJ. A nonsteroid anti-inflammatory drug exacerbatesCoxsackie B3 murine myocarditis. J Am Coll Cardiol.1985;6:1078-1082.

Figure 4. Holter ECG on 15th day after admission. The ECG shows polymorphic ventricular tachycardia with intermittentpacing beats.

ECG; electrocardiogram