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The Official Journal of Korean Heart Rhythm Society

The Official Journal of Korean H

eart Rhythm Society

부정맥Vol.12 No.4

December 2011

ISSN 2005-9728

삽입형제세동기(ICD) (I )

Main Topic Reviews제세동의기전

ICD Technology

Zen and the Art of ICD Rhythm Discrimination

삽입형심박동조절장치의이식방법

삽입형제세동기환자추적(심리적관점)

Article Review심장재동기화치료의심실재형성에의한심실빈맥억제효과

ECG & EP Cases원인불명의실신환자에서삽입형사건기록기로진단된심실빈맥

Lead fracture의진단및치료

지속성좌상대정맥환자에서성공적인제세동기삽입술

치료에반응하지않은심실빈맥이장기간지속된심근염

Vol.12 No.4

●통권39호

●D

ecember 2011

부정

맥

편집위원회

편집위원장

차태준 / 고신의대

편집위원 (가나다순)

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


© Copyright 2011 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 anymeans, electronic, mechanical, photocopying, recording or otherwise without permission in written form from the copyright holder. Thispublication is published by MMK Co., Ltd.

편집자문위원 (가나다순)

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

김성순 / 연세의대 김 훈 / 고려의대 김유호 / 울산의대 김윤년 / 계명의대

김종윤 / 연세의대 김 준 / 부산의대 김준수 / 성균관의대 김진배 / 경희의대

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

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

오동진 / 한림의대 오용석 / 가톨릭의대 온 근 / 성균관의대 이경석 / 전북의대

이만 / 가톨릭의대 이명용 / 단국의대 이문형 / 연세의대 이 수 / 대구가톨릭의대

임홍의 / 고려의대 장성원 / 가톨릭의대 정보 / 연세의대 정중화 / 조선의대

조용근 / 경북의대 조정관 / 전남의대 최기준 / 울산의대 최윤식 / 서울의대

최의근 / 서울의대 최인석 / 가천의대 최종일 / 고려의대 한상진 / 한림의대

허 준 / 성균관의대 현명철 / 경북의대

부정맥은 대한심장학회 부정맥연구회가 주관하며 엠엠케이커뮤니케이션즈에서 발행하고 있습니다. 본지와 관련된 문의사항이나 건의사항이 있으시면 발행사인 엠엠케이커뮤니케이션즈로 연락하여 주시기 바랍니다.

발행사 엠엠케이커뮤니케이션즈㈜대 표 : 정현모편 집 : 남대디자인 : 강연우서울시 강남구 역삼동 641-3 노바빌딩Tel 02-2007-5400 Fax 02-2179-8431 http://www.medimedia.co.kr E-mail: [email protected]

발행일 2011년 12월 31일

The OfficialJournal of Korean

Heart RhythmSociety

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.

Main Topic Reviews

제세동의 기전 ······································· 황교승 ········· 4

ICD Technology ·························· Timothy A. Fayram/류경무········· 10

Zen and the Art of ICD Rhythm Discrimination ··········· Eliot L. Ostrow/류경무 ········· 16

삽입형 심박동 조절장치의 이식 방법 ···························· 박상원 ········ 24

삽입형 제세동기 환자 추적(심리적 관점) ·························· 윤지회 ········ 30

Article Review

심장재동기화 치료의 심실재형성에 의한 심실빈맥 억제 효과 ················ 남기병 ········ 34

ECG & EP Cases

원인 불명의 실신 환자에서 삽입형 사건기록기로 진단된 심실빈맥 ············ 오세일 ········· 36

Lead fracture의 진단 및 치료 ······························ 정보 ········· 39

지속성 좌상대정맥 환자에서 성공적인 제세동기 삽입술 ··············· 심재민/박희남 ········· 43

치료에 반응하지 않은 심실빈맥이 장기간 지속된 심근염 ·················· 황교승 ········· 47


Vol.12 No.4●통권 39호● December 2011

삽입형제세동기(ICD) (I)

Contents

Cover: The first post-shock activation aftera failed defibrillation(p.7).

서론

제세동(defibrillation) 기전을 이해하기 위해서는 우선

심실세동(ventricular fibrillation, VF)에 대한 전반적인

이해가필요하다. 즉심실세동의기본적인전기적특징이나,

심실세동이유지되는기전이전기적회귀(reentry) 혹은국

소적활동성(focal activity)에의한것인지, 제세동중인심

장 조직의 활동전위(action potential, AP)와 흥분도

(excitability)는어떠한양상인지등광범위한이해를필요

로한다.

심실세동의양상

심실세동은발생후심전도와심실수축양상에따라총4기

로분류한다.1 제1기는심실세동발생후첫1~2초간을말하

며 3~6번의 거의 정상에 가까운 심실 수축을 보인다.

Undulatory 혹은 tachysystolic stage라고도한다. 이

어나타나는2기는심실의작은 역들이각자수축하는양

상으로경련이일어난것처럼보이기때문에 convulsive

incoordination으로표현된다. 체내제세동기(implantable

cardioverter defibrillator) 치료는심실세동발생후보통

10~20초지난후이루어지는데이시기에해당된다. 제3기

는심실이떠는양상으로보이는데 4기가나타나기전까지

2~4분정도지속되며tremulous incoordination으로표

현된다. 이어4기인atonic fibrillation이나타나는데아주

미미한전기파가작은 역에서느리게전도되는양상이다.

심근허혈이심실세동발현후3~4기로의진행에중요한역

할을하는것으로알려져있는데동물실험에서관상동맥에

산소를공급해주면심실세동이2기에서더진행되지않고계

속유지되는것이관찰되었다.2

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4 The Official Journal of Korean Heart Rhythm Society

제세동의기전

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

Mechanism of defibrillation

ABSTRACTVentricular fibrillation (VF) is the most common cause of sudden cardiac death (SCD). Even though a

defibrillator is frequently used to terminate VF, the mechanism of defibrillation remains unclear, and several

hypotheses have been suggested to explain it. The remarkable development of an experimental tool can

make it possible to examine the mechanism of defibrillation.

Key words: ■ defibrillation ■ ventricular fibrillation

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: [email protected]

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VOL.12 NO.4

심실세동의발생과지속기전

심실세동은 여기저기 떠돌아 다니는 wavelet의 회귀에

의해지속된다는가설이여러연구에서제시되었다. 이러한

wavelet의 멋대로인 움직임 속에서 어느 정도 조직화

(organization)된양상을관찰할수있는데이를설명하는

가설로‘mother rotor’가설과‘restitution’가설이있다.

‘Mother rotor’가설은심실에서전기적활동도가가장

빠른부위에하나의고정된회귀회로즉mother rotor가

있고여기서 activation front가다른부위로퍼져나가일

방향차단(unidirectional block) 지역을만나면보다작고

이동속도가느린wavelet으로쪼개진다는가설이다.3 하지

만이가설은guinea pig나토끼와같이크기가작은심장에

서는증명되었으나큰심장에서는명확히입증되지않았다.

심장의 restitution은 활동전위기간(action potential

duration, ADP)과직전이완기간(diastolic interval)과의

상관관계를나타내는개념으로이완기간이짧으면활동전위

기간이짧고이완기간이길면활동전위기간이길다. 이들관

계를restitution curve로나타낼수있고이curve의기울

기가클수록심실세동의유발과유지가용이하다고알려져있

다.4 하지만이가설은율동리듬에서는잘증명되었으나심실

세동에서는그렇지못하다. 따라서두가설모두심실세동의

유발과유지하는기전을완벽하게설명하지는못한다.

이 두 가설을 실제 임상에 적용해 보면 심실세동이

mother rotor에의해유지된다면전기충격이나심박동기

율동을mother rotor 부위에가하여심실세동을성공적으

로 제세동할 수 있을 것이고 restitution에 의한 것이면

restitution curve의기울기를감소시킬수있는약을투여

하여성공적인제세동을할수있을것이다.

제세동의기전

제세동의기전에대해서지금까지많은연구가진행되어

왔으나모든현상을설명할수있는기전은아직정립되지못

했다. 하지만비약적인연구기기의발전으로여러어려운가

설들을설명할수있게되었고획기적인새로운가설의등장

도기대된다. 제세동의기전을이해하기위해서는우선취약

성의상한계(upper limit of vulnerability, ULV)와제세

동역치(defibrillation threshold, DFT)에대한이해가필

요하다.

1. ULV와DFT의정의

심장에전기충격(electrical shock)을 가할때심실세동

이유발될수있는심장주기중일정기간을 shock에대한

취약기간(vulnerable period)이라고 한다. 이는 활동전위

의상대적불응기(relative refractory period)에해당하며5

심전도에서는보통T파의정점을기준으로±20 ms에해당

하는구간이다.6 ULV는취약기간에shock을가했을때심

실세동이유발되지않는가장낮은전기에너지로정의되며

놀랍게도이개념은이미 19세기에정립되었다.7 DFT는제

세동이가능한최저에너지로정의되며ULV와DFT는통계

적으로서로 접한상관관계가있고보통ULV가DFT보다

낮다.8, 9

따라서전기충격을심장에가했을때심실세동이유발되

기위해서는심실세동을유발시킬수있는가장낮은에너지

인VF threshold와 ULV 사이에해당하는적당한전기에

너지가필요하며 shock은 반드시심장주기중취약기간에

가해져야한다. X축에취약기간, Y축에shock 에너지를놓

고심실세동의유발이가능한 역을나타내면VF zone을

그릴수있다(Figure 1).

2. ULV와DFT에대한가설

1980년대초Winfree는전기충격에의해VF가유발

되기 위해서는 적절한 refractoriness와 전기충격에 의

한 voltage gradient로 만들어지는 시공간적 개념의

‘critical point’가필요하며이를중심으로일방향차단과

회귀가발생한다고하 다.10 이 critical point는전기충격

에너지의세기가VFT에서ULV로상승함에따라전기충격

을가하는전극으로부터점점멀어지며ULV에도달하거나

ULV를넘어서게되면심실전체를벗어나심실세동을유발

할수없게된다.11

이후 optical mapping system을 이용한 연구에서

critical point는 전기충격에 의해 형성되는 가상전극

(virtual electrode)에의한‘phase singularities’로설명

되었다.12 Phase singularities는 완전한 탈분극에서부터

완전한재분극까지모든 phase가 연속되어공존하는상태

를말하며회귀발생의중심이된다.

전기파(electrical wave)는 활동전위의 upstroke 즉

phase 0에해당하는‘wavefront’와rapid repolarization

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즉phase 3에해당하는‘waveback’으로구성되어있으며

wavefront와waveback 사이의길이인wavelength (WL)

는활동전위기간과전도속도(conduction velocity, CV)로

결정된다(WL = APD ×CV). 따라서정상적으로전기파가

심장조직을 지나갈 때 wavefront와 waveback이 만나는

것은불가능하다. 하지만‘wavebreak’가발생하면이둘이

접할 수 있게 되고 optical mapping study에서 phage

singularities의양상을보인다.

3. ULV Hypothesis of Defibrillation

이 가설은 심실세동이 지속되어도 심실에는 지엽적으로

취약기간이존재하며심실세동중ULV와정상박동일때의

ULV가거의일치한다는내용이다.8, 13 성공적인제세동을위

해서는shock으로VF의모든wavefront를차단해야하고

또한재발이없어야되므로, 전기충격에너지는적어도심실

세동의ULV이상이어야한다. 따라서VF시의ULV는VF의

모든wavefront를차단할수있는전기충격에너지보다작

아야한다. ULV hypothesis에서DFT 바로아래의에너지

세기로제세동전기충격을가했을경우심실세동을종료시킬

수없고같은에너지로정상박동이나조율박동시취약기간

에전기충격을가했을때심실세동이유발되는것으로보아

ULV와DFT 사이에는어떤공통된기전을공유하고있음을

유추해볼수있다.

제세동실패의기전

제세동실패의기전(mechanism of failed defibrillation)

은아직까지완전히밝혀지지않았다. 대표적인가설로

는 앞에서 언급한‘critical point’가설과‘virtual

electrode’가설이있다. Critical point 가설은제세동

후 심실세동의 재발 여부는 전기충격에 의해 생긴

voltage gradient와 local refractoriness의 critical

value가동일시공간에서일치하느냐않느냐에따라결정

된다는 가설이다.14‘Virtual electrode’가설에 의하면

ULV보다 강한 전기충격이 심장에 가해졌을 때

‘deexcitation’다른표현으로‘hyperpolarization’즉활

성화되지 않은 평상시 막전위(membrane potential)보다

Figure 1. The vulnerable zone is represented by a uniformly gray-colored region that is defined by the shock timeinterval and strength. The vulnerable zone matches up with a T wave on an electrocardiogram and phase 3 on actionpotential.

ULV; upper limit of vulnerability, VFT; ventricular fibrillation threshold

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더 음전압화(negative polarization)된 부분이 발생하여

virtual anode를 형성한다. 이 부위에서의 wavefront의

진행속도는매우빨라virtual cathode 즉탈분극된주위

심근세포가다시회복하기에는시간이충분하지않다. 따라

서심실세동의재발에관여하는회귀가형성될수없어제세

동에성공한다. 반면에 shock에너지가충분하지않을때는

회귀기전에의해심실세동이재발한다는내용이다.15 하지만

모든wavefront를없애기에충분한에너지의강한 shock

이가해졌음에도불구하고 critical point가형성되어심실

세동이재발하는경우가종종있고, 전기충격후에일시적으

로심실세동이종료된상태인‘isoelectric window’를거친

후심실세동이재발하는경우microreentry가아니라국소

적인breakthrough 형태로나타나므로제세동의실패기전

을위두가설만으로는충분히설명할수가없다. 따라서ULV

가설과 연계하여‘triggered activity’나‘progressive

depolarization’이제세동실패의기전으로제시되기도하

다.

최근에는 심근섬유의 방향(myocardial fiber orientation)

이ULV를결정하는중요기전임이컴퓨터시뮬레이션으로

증명되었다. 심근섬유의특정배열각도에의해국소적비균

질성(inhomogeity)이형성되면ULV가존재하지만민무늬

근육섬유(smooth muscle fiber)의형태로시뮬레이션하면

전기충격의세기에상관없이wavefront는퍼져나가고회

귀를유발하는것이관찰되었다. 따라서심근섬유방향의비

균질성이ULV와제세동의기전에중요하게관여함을알수

있다.16

제세동과칼슘역학(Calcium dynamics inDefibrillation)

칼슘은 심장의 excitation-contraction (E-C)

coupling에관여하여myofilament activation을유발하

고 ionic currents를조절하여정상박동이나치사성부정

맥을일으키기도한다. Ca2+이Ca2+ current (ICa)에의해세

포 내로 유입되면 sarcoplasmic reticulum (SR) 표면에

있는ryanodine receptors (RyRs)를통해Ca2+ release를

유발하여 심근수축이 일어난다. 심근이완은 세포질 내의

Ca2+이 SR Ca2+ ATPase (SERCA)에의해다시 SR 내로

유입되거나 Na+ -Ca2+ exchange에 의해 sarcolemmal

membrane을통해세포밖으로나가면서일어난다. 두종

류의 ICa가 심근세포 내에 존재하는데 membrane

potential (Vm) ＞-40 mV에서활성화되는L-type (ICaL)

과 Vm ＞-60 mV에서활성화되는T-type (ICaT)이있다.

Inward ICaL와 ICaT는심장의정상적, 비정상적탈분극에중

요한역할을하고ICaL는모든심근세포의E-C coupling에

필수적으로관여한다. 반면에ICaT는심실근육세포에는없고

신생아의 심실세포나 심방근육세포, 전기자극 전달이나 조

율(conducting and pacemaker) 세포에만 존재한다.

Figure 2. The first post-shock activation after a failed defibrillation. Twenty-five milliseconds after a failed defibrillationshock, there is a heterogenous Cai distribution. The white arrow shows a region of low cai surrounded by tissues whereCai transient is still present (Cai sinkhole).

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Intracellular Ca2+ (Cai)이감소하면Vm이탈분극상태임

에도불구하고ICaL이불활성화상태에서부분적으로회복될

수있다. 이는활동전위가완전히재분극되기도전에ICaL이

reactivation되어 유발(trigger) 기전 중 하나인 early

afterdepolarization (EAD)을유발할수있음을의미한다.

정상E-C coupling 동안에 ICaL을통한Ca2+의유입은SR

Ca2+ release (Ca2+ sparks)를 유발한다. local Ca2+이나

intra-SR Ca2+가증가함에따라Ca2+ sparks가일어날가

능성이높고SR Ca2+ load가충분할때spontaneous SR

Ca2+ release가 발생하여 delayed afterdepolarization

(DAD)을야기한다.17

최근 optical mapping study와 같이 membrane

potential과 calcium dynamics를동시에기록할수있는

방법이 개발됨에 따라 제세동시 발생하는 calcium

dynamics의 변화를 관찰할 수 있게 되었고 calcium

dynamics가제세동의결과를결정하는중요기전임이밝혀졌

다. 이들 연구에 의하면 배양된 심근세포에 전기충격을 가할

경우Cai은감소하 다.18 또한심실세동지속시에는Cai이증

가하 고제세동전기충격을가하면증가된Cai이다시감소하

다. 이때Cai의감소가충분하지않으면심실세동이재발하

다.19 Voltage에 상관없이 spontaneous Ca2+ release가

선행하고뒤따라서nondriven electrical activity가발현되

는reverse E-C coupling (prefluorescence) 소견역시전

기충격후에간혹관찰되는데20 이들소견은모두 calcium

dynamics가제세동의결과를결정하는중요기전임을시사

한다.

제세동이실패한경우 isoelectric window 기간동안에

특이한모양의calcium dynamics를관찰할수있는데low

Cai area가 high Cai에둘러싸인양상이다(Figure 2). 이

를‘Cai sinkhole’이라명명하 는데제세동후심실세동이

재발할 때 발생하는 첫 electrical activation은 항상 Caisinkhole에서발생하 다. Cai sinkhole은전기충격을취

약기간에가해(shock on T) 심실세동이유발될때도관찰되

었다. 전기충격후Cai sinkhole에서 focal activation이유

래하는기전은첫째, spontaneous (voltage-independent)

SR calcium release에의한reverse E-C coupling이다.

Cai sinkhole 내low calcium은주위조직에비해보다SR

calcium uptake가완성된것을의미하고SR에calcium이

많이축적될수록spontaneous calcium release가일어나

기쉬운상태가된다. Spontaneous SR calcium release

가일어나면DAD가발생한다. 둘째, Cai sinkhole은주위

조직에비해활동전위기간이짧으므로주위high calcium

area로부터electrotonic current가Cai sinkhole로유입

되면서sinkhole내에서impulse가형성된다. 이현상은주

위 세포간 활동전위기간의 차이에 의해 생기는 phase 2

reentry 혹은reflection 현상과비슷하다. 또한ryanodine

receptor blocker인 ryanodine과Ca ATPase inhibitor

인 thapsigargin을 투여하여 SR에서의 모든 calcium

transient를차단하면약물투여전에비해ULV와DFT

가 의미 있게 감소된다.21 이러한 소견 역시 calcium

dynamics가제세동과 vulnerability의결과를결정하는

주요기전임을시사한다.

결론

제세동의기전을밝히기위해지금까지critical point 가

설과 virtual electrode 가설, ULV가설과 연계하여

‘triggered activity’나‘progressive depolarization’

현상, 심근섬유방향의비균질성, 칼슘역학등여러가설과

현상으로설명하려는시도가있었고연구의획기적인발전도

있었다. 하지만제세동시나타나는모든현상을완벽하게설

명할수있는이론은아직까지정립되지못했다. 향후실험기

기의비약적인발전으로이전에는증명할수없었던여러현

상들을설명하는것이가능해질것이므로조만간제세동의

기전을완벽하게이해할수있게되기를기대해본다.

References

1. Wiggers CJ. Studies of ventricular fibrillationcaused by electricshock. Cinematographic and electrocardiogrphic observations ofthe natural process in the dog’s heart: Its inhibition by potassiumand the revival of coordinated beats by calcium. Am Heart J.1930;5:351-365.

2. Worley SJ, Swain JL, Colavita PG, Smith WM, Ideker RE.Development of an endocardial-epicardial gradient of activationrate during electrically induced, sustained ventricular fibrillationin the dog. Am J Cardilol. 1985;55:813-820.

3. Jalife J, Gray RA, Morley GE, Davidenko JM. Self-organizationand the dynamical nature of ventricular fibrillation. Chaos.1998;8:79-93.

4. Huang J, Zhou X, Smith WM, Ideker RE. Restitution propertiesduring ventricular fibrillation in the in situ swine heart.Circulation. 2004;110:3167-3167.

5. Ferris LP, King BG, Spence PW, Williams HB. Effect of electric

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shock on the heart. Electr Eng. 1936; 55:498-515.6. Swerdlow C, Shivkumar K, Zhang J. Determination of the upper

limit of vulnerability using implantable cardioverter-defibrillatorelectrograms. Circulation. 2003;107:3028-3033.

7. Battelli F. Le mécanisme de la mort par les courants électriqueschez l’homme. Revue Med Suisse Romande. 1899;10:605-618.

8. Chen PS, Shibata N, Dixon EG, Martin RO, Ideker RE. Comparisonof the defibrillation threshold and the upper limit of ventricularvulnerability. Circulation. 1986;73:1022-1028.

9. Chen PS, feld GK, Kriett JM, Mower MM, Tarazi RY, Fleck RP,Swerdlow CD, Gang ES, Kass RM. Relation between upper limitof vulnerabil ity and defibri l lation threshold in humans.Circulation. 1993;88:186-192.

10. Winfree AT. Sudden cardia death: A problem in topology. SciAm. 1983; 248:144-149.

11. Shibata N, Chen P-S, Dixon EG, Wolf PD, Danieley ND, SmithWM, Ideker RE. Influence of epicardial shock strength and timingon the induction of ventricular arrhythmias in dogs. Am J Physiol.1988;255:H891-H901.

12. Efimov IR, Gray RA, Roth BJ. Virtual electrodes and deexcitation:New insights into fibrillation induction and defibrillation. J Cardiovasc Electrophysiol. 2000;11:339-353.

13. Chen P-S, Wolf PD, Melnick SD, Danieley ND, Smith WM,IdekerRE. Comparison of activation during ventricular fibrillationand following unsuccessful defibrillation shocks in open chestdogs. Circ Res. 1990;66:1544-1560.

14. Chen P-S, Wolf PD, Ideker RE. The mechanism of cardiacdefibrillation: A different point of view. Circulation. 1991;84:913-919.

15. Efimov I, Ripplinger C. Virtual electrode hypothesis ofdefibrillation. Heart Rhythm. 2006; 3:1100-1102.

16. Mazeh N, Roth BJ. A mechanism of the upper limit ofvulnerability. Heart Rhythm. 2009;6:361-367.

17. Cheng h, Lederer MR, Lederer WJ, Cannell MB. Calcium sparksand [Ca2+] waves in cardiac myocytes. Am J Physiol.1996;270:C148-C159.

18. fast VG, Check ER, Pollard AE, Ideker RE. Effects of electricalshocks on Ca2+ and Vm in myosites cultures. Circ Res. 2004;94:1589-1597.

19. Zauzz CE, Wu ST, Barbosa V, Buser PT, Wikman-Coffelt J,Parmley WW, Lee RJ. Ventricular fibrillation-induced intracellularCa2+ overload causes failed electrical defibrillation and post-shockreinitiation of fibrillation. J Mol Cell Cardiol. 1998;30:2183-2192.

20. Boyden PA, barbhaiya C, Lee T, Kers HE. Nonuniform Ca2+

transients in arrhythmogenic Purkinje cells that survive in theinfarcted canine heart. Cardiovasc Res. 2003;57:681-693.

21. Hwang GS, hayashi H, Tang L, Ogawa M, Hernandez H, Tan Y,Li H, Karagueuzian HS, Weiss JN, Lin SF, Chen PS. Intracellularcalcium and vulnerability to fibrillation and defibrillation inLangendorff perfused rabbit ventricles. Circulation. 2006;114;2595-2603.

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Background

The Implantable Cardioverter Defibrillator (ICD)

is an implantable medical device that is used to

treat ventricular tachycardia and fibrillation with

high voltage therapy. It has the capability to deliver

low voltage pacing therapy as well. The device has a

basic onboard micro-computer that serves as the

overall controller of all diagnostic and therapeutic

functions, a high voltage charging section, a high

voltage output section, and a connector top header

that connects the device to the cardiac leads.

While the basic conceptual work on a fully

automatic implantable defibrillator began in the

1950s, the practical embodiment of the device only

began to take shape in 1971 with the work of Michel

Mirowski and Morton Mower. After overcoming the

skeptics, Mirowski and Mower demonstrated a

prototype in a canine subject in 1979. This led to

efforts to develop the device in the early 1980s by

Intec Systems, which produced the AID™, and then

by Cardiac Pacemakers Inc., which produced the

Ventak .1 These early devices were fully automatic

and implantable and had a displacement volume in

the range of 150 to 200 cubic centimeters (cc). Other

companies then began product development efforts

that led to widespread commercialization of the ICD

in the early 1990s.

ICD Technology

세인트쥬드메디칼 Timothy A. Fayram / 류 경 무Timothy A Fayram MS and Kyungmoo Ryu PhDResearch, Cardiac Rhythm Management Division, St. Jude Medical, InC., Sylmar, CA, USA

ABSTRACTThe Implantable Cardioverter Defibrillator (ICD) is a complex implantable medical device that treats

ventricular tachycardia and fibrillation. It is equipped with a basic micro-computer that serves as the overall

controller of all diagnostic and therapeutic functions. The ICD has a number of sections and components that

are unique to the device, such as a high voltage charging section and a high voltage output section. The

miniaturization asymptote for the minimum size of an ICD is probably 25 cubic centimeters. New

unconventional therapeutic options with reduced power levels may make further miniaturization and cost

reduction possible.

Key words: ■ ICD ■ ventricular fibrillation ■ ventricular tachycardia

Received: September 15, 2011Revision Received: November, 27, 2011Accepted: December 27, 2011Correspondence: Timothy A. Fayram MS Vice President, Research,Cardiac Rhythm Management Division, St. Jude Medical, 701 East EvelynAvenue, Sunnyvale, CA 94086, USATel: +1 408 522 6856, Fax: +1 408 522 6855, Mobile: +1 408 930 6605E-mail: [email protected]

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Technology Status

In devices that have Cardiac Resynchronization

Therapy (CRT) capability, devices that represent

the current state of the art in ICD technology have

an overall displacement volume in the range of

slightly less than 30 cc to over 40 cc. Various

physiological shapes are available to the designer to

minimize the pectoral pocket size, shape, and

bulge. The incision length for the insertion of the

device into the pocket can also be minimized. The

device shape is chosen to maximize the patient’s

comfort and to minimize pocket erosion over time

(Figure 1).

The devices are packaged in a biocompatible

enclosure that is formed from commercially

available pure Titanium sheet stock. A laser

welding process is used to seam-weld the

enclosure, which ensures that the components

packaged within it are hermetically sealed from

body fluids. A thermoplastic or thermoset epoxy

resin is used to form the connector top header,

which serves as a fixture for connection to the

endocardial leads.

The miniaturization of ICDs took place quite

rapidly in the 1990s. Significant technological

developments in commercial electronics facilitated

the miniaturization of ICD electronic packaging.

The ability to configure the unique larger

components into custom shapes that fit within the

device also helped to dramatically decrease its

overall volume. Currently manufactured ICDs

appear to be converging on an asymptote volume of

25 cc(Figure 2).2

Figure 1. Examples of ICDs (pictures are not to scale).

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Why is an ICD bigger and moreexpensive than a pacemaker?

The components and circuits within an ICD are

designed and shaped to fit quite efficiently within

the device to minimize wasted space and to conform

to the overall profile of the device enclosure. Very

dense electronics packaging techniques, a dense

circuit-to-circuit interconnect, and high

performance materials are employed to minimize

the size and maximize the device’s reliability.

However, the ICD has a number of unique

components that add to its overall size and

dramatically increase its cost of manufacture. A

special Lithium Sliver Vanadium Oxide (LI SVO)

battery is used as the charging supply for its high

voltage therapy function. This type of battery

typically adds approximately 3 cc of volume as

compared to a conventional pacemaker battery. A

special Aluminum Electrolytic capacitor set is

charged in order to serve as the high voltage energy

reservoir for defibrillation therapy. This capacitor

set, which is not present in a conventional

pacemaker, adds approximately 8 cc of volume to

the device. A special DC-to-DC converter takes the

low-voltage high-current input from the battery

Figure 2. ICD miniaturization trend over time.

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and converts it to a high-voltage low-current

source that charges the high voltage capacitor set.

This DC-to-DC Converter is also not present in a

conventional pacemaker, and it adds approximately

2 cc of volume to the device (Figure 3).

The most critical section of the ICD is the high

voltage output circuit(Figure 4). It controls the

delivery of defibrillation therapy to the patient. The

actual flow of current is typically controlled by 4

large Insulated Gate Bipolar Transistors (IGBT).

Because these transistors switch instantaneous

voltages that can be as high as 900 V, they must be

sized in accordance with high voltage standoff

design rules that prevent arcing and shorting

within the transistor during the switching

operation. In addition, each of the transistors must

be placed at a specific spacing from the other to

prevent arcing and shorting between transistors.

These (4) transistors are not present in a

conventional pacemaker, and together, they add

approximately 5 cc of volume to the device. In

addition, these special transistors, along with their

special electronics packaging, add a significant cost

to the device (Figure 4).

Future Generations of the ICD

The current state of the art in ICD packaging has

reached technological maturity. Increased miniaturization

will probably yield just a marginal decrease in the

overall displacement volume of the device, which

will be accompanied by a significant increase in

manufacturing cost. The cost of the precious metals

used in the device continues to rise. Because the

ICD has a number of components that are unique to

its application, it is doubtful that the current

advances being made in the high volume personal

electronics revolution would be of use in reducing

its size and cost.

If the clinical requirements for an ICD could be

modified or relaxed, it would be possible to conceive

of a new generation of devices that are smaller and

that cost less. Relaxation of the design constraints

could lead to the modification or complete

elimination of the components within the ICD.

Special batteries, high voltage capacitors, and high

voltage output circuits could become smaller and

less costly to manufacture.

The first example of a future generation ICD is

Figure 3. Inside a typical ICD.DC: direct current, HV: high roltage, SVO: siver vanadium oxide

Displacement Volume= 30 to 40 cc (Delta to PM = approx. +20 cc)

SVO Battery

(2) HV Capacitors

Header

DC-DC Converter

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one that allows for a significant increase in its

charge time in preparation for the delivery of

therapy to the patient. The device would charge at

a lower input power. A reduction in the maximum

target charging voltage would make possible a

significant reduction in the size of the device

circuits and their respective components. In this

case, alternative battery chemistries could be

employed, such as Carbon Monofluoride (CFx). The

size of the battery, the high voltage capacitor set,

and the high voltage output circuit could also be

reduced, bringing about a significant cost reduction

as well. It is recognized that this new ICD may not

be suitable for all patients.

The second example of a future generation ICD is

one that is more disruptive and unconventional in

its design approach. This device is able to sense and

detect tachyarrhythmias just before their onset.

One class of therapy regime would consist of low

voltage pace trains that would decelerate the

arrhythmia into a normal sinus rhythm.3 Another

class of therapy regime would stimulate the

autonomic nervous system via thoracic spinal cord

stimulation in a way that would prevent the onset

of an arrhythmia.4 This new generation of devices

has the function of a low voltage implantable pulse

generator, and it looks more like a pacemaker or a

spinal cord stimulator. It would make possible a

significant size and cost reduction relative to the

design of the conventional ICD.

Summary

The current state of the art in ICD technology has

reached its maturity. The ICD has a number of

components and circuits that are unique to its

application, and a significant size and cost

reduction of the conventional ICD is unlikely.

Changes in the clinical requirements of the ICD

could lead to the development of a future

generation of devices that would be much smaller

and less costly to manufacture.

Figure 4. High voltage output section demonstrating the generous spacing required between four large Insulated GateBipolar Transistors (IGBT) to prevent arcing and shorting between components.

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Employee: MS. Fayram is a board member of

Clinical Advisory Group of St. Jude Medical

International.

References

1. Hauser RG. Development and industrialization of the ImplantableCardioverter-Defibrillator :A personal and historical perspective.Card Electrophysiol Clin. 2009;1:117-127.

2. Gottlieb CD, Callans DL. New Devices: Functions and Features.Cardiac Electrophysiology Review. 1998;2:272-276.

3. Efimov IR, Kroll MW, Tchou PJ. Cardiac Bioelectric Therapy:Mechanisms and Practical Implications. Springer Science &Business Media. 2009:382-383.

4. Lopshire JC, Zhou X, Dusa C, Ueyama T, Rosenberger J, CourtneyN, Ujhelyi M, Mullen T, Das M, Zipes DP. Spinal cord stimulationimproves ventricular function and reduces ventricular arrhythmiasin a canine postinfarction heart failure model. Circulation.2009;120:286-294.

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What is rhythm discrimination?

The term rhythm discrimination is generally used

to describe the ability of an implantable

cardioverter-defibrillator (ICD) to distinguish

between tachyarrhythmias that the device should

treat and other detected rhythms for which therapy

should not be delivered. In practice, defining what

should and should not be treated is as much a

matter of philosophy as it is a technological issue.

The transition from secondary prevention

indications to primary prevention implants, and the

related changes in clinicians’and patients’

attitudes over the years have further complicated

the matter.

In the discussion that follows, the authors review

the discrimination features and algorithms

available in current ICD systems, and highlight the

choices faced by the practitioner when deciding

what to treat and what to consider when

programming an ICD system to achieve the desired

results. The potential for future enhancements will

also be discussed.

Basic building blocks of ICD rhythmdiscrimination

When a clinician looks at an ECG or intracardiac

Received: September 15, 2011Accepted: December 27, 2011Correspondence: Eliot L. Ostrow Fellow, Cardiac Rhythm ManagementDivision, St. Jude Medical, 701 East Evelyn Avenue, Sunnyvale, CA94086, USATel: +1 818 493 3061, Fax: +1 866 739 0040, E-mail: [email protected]

Zen and the Art of ICDRhythm Discrimination

세인트쥬드메디칼 Eliot L. Ostrow / 류 경 무Eliot L. Ostrow and Kyungmoo Ryu PhDResearch, Cardiac Rhythm Management Division, St. Jude Medical, InC., Sylmar, CA, USA

ABSTRACTToday’s implantable cardioverter-defibrillators (ICDs) are sophisticated systems that are equipped with a

variety of features and algorithms that discriminate between the rhythms that the device will treat and those

it will ignore. As ICD systems have evolved and the indications for their implantation have expanded,

clinicians are now faced with decisions that go beyond the application of the technology to distinguish

between ventricular and supraventricular arrhythmias, as they must now consider questions of a more

philosophical nature, such as when therapy is truly necessary. Future technological developments are likely,

and while they may provide users with additional tools, they may also raise new questions about their

appropriate applications.

Key words: ■ discrimination ■ implantable cardioverter-defibrillator

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electrogram (IEGM) to evaluate a rhythm, he or she

usually considers a variety of factors, such as:

● How fast is the rhythm?

● Is the rhythm sustained?

● What is the relationship between atrial and

ventricular events? Is there synchrony or

dyssynchrony? Is every P-wave associated with

an R-wave? Is the timing between P-waves and

R-waves relatively constant? Is there a

consistent pattern?

● How did it start? Was the onset abrupt? Was it

initiated by a premature ventricular contraction

(PVC) or a premature atrial contraction (PAC)?

● Is the ventricular rate regular or irregular?

● How do the R-waves look? Do they look like R-

waves during sinus rhythm, or different?

Today’s ICDs use features and algorithms that

attempt to mimic the clinicians’analytic approach

by attempting to answer these same questions.

These features and algorithms, which are

summarized in Table 1, are well known to

practitioners who regularly program ICDs, and will

not be discussed in detail here. Dual-chamber ICDs,

because they allow for the assessment of atrial

activity and the atrioventricular (AV) relationship,

provide an enhanced ability to distinguish

supraventricular tachycardia (SVT) from

ventricular tachycardia (VT). A schematic example

of how atrial activity and the AV relationship could

be integrated with the earlier discriminators is

shown in Figure 1.

Some ICD systems provide nearly infinite

programmability of each of the component features

of their discrimination algorithms. This enables the

system to be customized to the specific needs of an

individual patient, which may be particularly useful

when inappropriate therapies are delivered because

of atypical combinations of events. The system can

be confusing to program, however, particularly for

primary prevention patients, where nothing is

known a priori about the characteristics of the

patient’s tachyarrhythmias. Other ICD systems

seek to minimize the programming complexity by

creating ‘black box’algorithms. As the term

implies, the workings of these algorithms are

largely hidden from the user, and there may be

little programmability beyond the ability to turn

them on or off. They are simple to use, and they

work well most of the time, but there is little

recourse when they do not. ICD manufacturers are

continually seeking to improve the user interfaces

on their programmers in order to reach an ideal

compromise: an on/off feature that works well most

of the time, combined with the ability to

troubleshoot and fine-tune the algorithm when

patient conditions dictate that adjustments be

made.

What rhythms are we trying todiscriminate between?

When the earliest ICDs were implanted, the

philosophy implicit in the approach to detection and

discrimination was simple: when in doubt, shock.

Because these were patients who had already

experienced at least one episode of arrhythmic

sudden cardiac death (SCD) or had documented VT

or ventricular fibrillation (VF), every instance in

which a shock was withheld in the face of a fast

rhythm presented the risk of failing to treat a

potentially lethal arrhythmia. For this reason, these

devices required only simple detection and

discrimination strategies and were designed with

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Table 1. Common ICD features for discriminating between SVT and VT.

Parameter Name Description Uses Weaknesses & Challenges

• Ventricular

Rate/Interval

• Initial Duration

• Suddenness of

Onset

• Interval Regularity

• Morphology

• AV Relationship

• Sequence of Events

(black box)

• Chamber of Onset

• Sustained Duration

• How fast the rhythm is

• Defines border between

“sinus” rhythm (i.e., non-

tachycardia) and tachycardia

• How long (in number of

intervals or time) the fast

rhythm must be sustained

before treatment

• How abrupt the rate change is

between “sinus” rhythm and

tachycardia

• How stable the tachycardia is

interval-to-interval

• Similarity of electrogram

appearance during tachycardia

to sinus rhythm

• Atrial vs. ventricular rate

• 1:1 vs. n:1 relationship

• Fixed vs. random AV timing

• Sequence and timing of atrial

and ventricular events

• Chamber in which first fast

interval detected

• Ability to override other

discriminators if fast rate

persists long enough

• Treat vs. don’t treat

• Surrogate for hemodynamic

tolerance

• Application of different

discriminators or therapies

• Sustained rhythms to be treated

vs. non-sustained rhythms to be

ignored

• Distinguishes between sinus

tachycardia (gradual onset) and

pathologic tachycardias (abrupt

onset)

• AF with rapid ventricular

response vs. VT

• Rhythms conducted through

His-Purkinje system (sinus

tachycardia, SVT) vs. VT

• AV association vs. dissociation

• SVT with multiblock

• General SVT/VT discrimination

• General SVT/VT discrimination

• “Backup plan” to ensure that

VT misdiagnosed as SVT is

eventually treated

• SVT vs. VT

• Physiologically appropriate rates (e.g.,

sinus rhythm) vs. true arrhythmias

• Poor surrogate for hemodynamic

tolerance

• Arbitrary

• SVT and VT can both have sudden

onset

• Exercise-induced VT (fast sinus rhythm

transitions to VT) without significant

rate change

• Automatic tachycardias exhibiting

“warm-up”

• Ventricular response during AF can

regularize

• VT rate may not be absolutely stable

• Sensing of R wave can be variable

• Rate-related aberrancy

• Similar R-wave appearance of VT and

sinus rhythm on RV bipolar EGM in

patients with RBBB

• Bypass tracts

• VT with 1:1 retrograde conduction vs.

sinus tachycardia /SVT with 1:1

antegrade conduction

• Concomitant AF/AFl and VT vs. AF/AFl

with rapid ventricular response

• Black box nature of algorithm precludes

fine tuning when not effective

• Relies heavily on correct detection of

first fast interval

• Fast events may be masked by

refractory periods

• Rapidly conducted PACs or PVCs can

initiate tachycardia in opposite chamber

• If other discriminators correct (i.e.,

rhythm is SVT), therapy will be delivered

inappropriately

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the philosophy of ‘better a few shocks too many

than one shock too few’. With the advent of tiered-

therapy devices, which delivered antitachycardia

pacing (ATP) and cardioversion shocks to treat

slower, potentially better-tolerated VTs in addition

to hemodynamically unstable VT and VF, it became

desirable to be able to differentiate between VT and

VF, and also between rapid ventricular rates due to

ventricular arrhythmias and those associated with

SVT. Today, most ICDs are implanted for primary

prevention (i.e., prophylactically). Therefore, in

patients who are not as keenly aware of the need

for their ICD implantation, the tolerance for

inappropriate or unnecessary shocks has

Figure 1. Schematic of a generic dual-chamber discrimination algorithm. Information about atrial (A) and ventricular (V)rates, and the timing of A and V events, is combined with other discriminators to reach a final rhythm diagnosis anddetermine whether or not to deliver therapy. The relative A and V rates are used to make a differential diagnosis, afterwhich the appropriate discriminators are applied to make a final determination. Note that when the V rate exceeds the Arate, the only possible diagnosis is a ventricular rhythm, and no discriminators are applied.

Atrial Rate

SVT

No Therapy Shocks and/or ATP

VT

Comparison ofAtrial &

Ventricular Rate

DifferentialDiagnosis

Application ofDiscriminators

Rhythm Diagnosis

Therapy Decision

Atrial Rate > Ventricular Rate

AF AFL

SVT with n:1 multiblockAF/AFL with concomitant VT

AV timing relationshipInterval regularity

Morphology

Suddenness of onset Chamber of onset

MorphologyAV timing relationship

Sinus TachycardiaSVT with 1:1 AV ConductionVT with 1:1 VA Conduction

Atrial Rate = Ventricular Rate

Atrial Rate < Ventricular Rate

VTVF

None

Ventricular Rate

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diminished. The result has been a renewed

emphasis on the development of algorithms and

programming strategies that will result in the

delivery of ICD therapy, and shocks in particular,

only when absolutely necessary. Thus, for today’s

primary prevention patient, the implicit philosophy

can be summarized as ‘better one shock too few

rather than a few too many’.

The challenge in designing and programming ICD

discrimination algorithms is that it is not always

clear which rhythms are appropriate to treat, and

with what therapy. Many different factors must be

considered when deciding what device behavior is

appropriate and necessary, and this decision may

differ from patient to patient, and from physician

to physician. Some key considerations in the

decision-making process are as follows:

Is it SVT or VT?

In the era when ICDs were predominantly

implanted for secondary prevention, there was

general agreement in the device community that

every episode of VT or VF should be treated, and

that every shock delivered for anything other than

VT or VF was inappropriate. The discrimination

algorithms of this era, then, which were largely

based on the features listed in Table 1, were

generally effective in making these distinctions, but

were known and are known to be less than perfect.

Because the predominant philosophy was that it

was unacceptable to miss even a single episode of

VT, when the device was unsure whether a rhythm

was SVT or VT (for example, when different

discriminators reached different conclusions), the

algorithms were biased towards overtreatment,

with the result that patients received inappropriate

shocks (i.e., shocks for rhythms other than VT or

VF). Recent studies1,2 estimate that approximately

20% of ICD patients receive inappropriate shocks

within three years of receiving an implant.

Is a Shock Necessary?

As more patients receive their ICDs for primary

prevention, and because of concerns that the

shocks themselves may negatively affect their

survival, the delivery of shocks has become less

acceptable to patients and clinicians. This has led to

a distinction between appropriate shocks (i.e.,

shock delivered as a result of a correct device

diagnosis of VT or VF) and necessary shocks (i.e.,

shocks delivered only when shocks are the best

alternative).

Until recently, most ICDs were programmed with

relatively low VT detection rates (often in the range

of 150-160 bpm) and relatively short detection

durations (typically 10-15 intervals) Any VT that

remained above the programmed detection rate for

the programmed duration and met any other

programmed discrimination criteria would cause

the device to deliver therapy, most often in the

form of a shock. Several studies have shown,

however, that for primary prevention patients,

many shocks can be avoided by employing

alternative programming strategies.3,4,5,6 First, these

studies demonstrated that many VT episodes

would self-terminate (i.e., without any device

intervention) if they were allowed more time (up to

30-40 intervals) to run their course. Second, the

studies showed that the VT detection rate could be

programmed significantly faster (up to a range of

180-190 bpm) without compromising the patient’s

safety. Finally, the studies demonstrated that a

single burst of ATP could be very effective in

terminating even fast VTs. This combination of

higher detection rates, longer detection times, and

at least one ATP burst has been shown to reduce

the number of delivered shocks by as much as 50%.

As a result, many experts are now advocating that

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clinicians adopt a default programming strategy

based on the parameters that were shown to be

effective in these studies. Thus, the philosophy has

begun to evolve from, ‘The ICD must terminate

every episode of VT’, to ‘The ICD is meant to

prevent sudden death, not to treat non-lethal

rhythms’. Several manufacturers have recently

revised their default parameters to better reflect

this change in indications and attitudes, and the

analyses7,8 indicate that these revised parameters

may dramatically reduce the number of

inappropriate and unnecessary shocks.

Is the Device Correctly Detecting R-Waves and P-Waves?

ICD rhythm discrimination is predicated on the

assumption that the device accurately senses R-

waves, and that in the case of dual-chamber ICDs,

it detects P-waves as well, despite the fact that the

signal amplitudes may vary by more than one order

of magnitude as the patient’s rhythm transitions

between sinus rhythm, tachycardia, and

fibrillation. In addition, the device must not be

prone to oversensing anything other than R-waves

on the ventricular lead, and P-waves on the atrial

lead, whether they are of physiological or non-

physiological origin. To ensure proper sensing, all

modern ICDs employ bipolar sensing, either

between closely-spaced tip and ring electrodes

(standard bipolar configuration) or between a tip

electrode and the right ventricular shock coil

(integrated bipolar configuration). They also employ

sophisticated automatic gain control or automatic

sensitivity control algorithms in the ventricle (and,

in some cases, in the atrium) that rapidly adapt to

changes in signal amplitude, and frequency filters

designed to optimize the sensing of R-waves, P-

waves, and fibrillation, and to minimize the sensing

of physiological signals such as T-waves and

myopotentials, and the sensing of non-

physiological signals from various external

electromagnetic sources.

Noise generated by failing leads (either due to

breaches of a lead’s insulation or breaks in the

conductor wires) remains a troubling complication

of the sensing function. This often manifests as

oversensing, which results in the delivery of

inappropriate shocks, which, in the worst case, may

occur in clusters.9 While this was once considered

an unfortunate but unavoidable side effect of lead

failure, recent attention to this problem from ICD

manufacturers has led to advances that promise to

aid in the earlier detection of such lead-related

oversensing, thereby reducing the number of

inappropriate shocks that occur.

What Does the Future Hold?

As in every other aspect of ICD technology, ICD

rhythm discrimination will continue to evolve.

While it is impossible to predict exactly what

changes will be successfully implemented, certain

technological trends seem likely to have a positive

impact on the ICD’s ability to discriminate. Three of

the most promising trends are as follows:

● More processing power coupled with more

memory: This will result in smarter, more

powerful systems that can incorporate more

sophisticated signal processing, which could

facilitate the development of advanced

algorithms that could self-learn and adapt to

changes in a patient’s condition or physiology, or

could better deal with the incomplete or

conflicting data that the ICD must use to make

its decisions.

● Hemodynamic sensing: An ideal discrimination

system would be able to distinguish between

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hemodynamically stable and unstable rhythms,

and make treatment decisions accordingly.

Today’s devices use the rate as a surrogate for

hemodynamic tolerance, which allows

discrimination and therapy strategies to be

applied differently to different rate zones, based

on the assumption that arrhythmias in slower

zones will be better tolerated and will present

less of a risk if they go untreated. Unfortunately,

the rate is a far-from-perfect indicator of

hemodynamic tolerance, both among multiple

patients and in the same patient at various times and

under various conditions. Today, hemodynamic

sensors are being integrated into ICD systems for

non-discrimination purposes, such as for the

detection of the onset of acute heart failure

decompensation. It is thus entirely possible, and

even likely, that they will eventually be

evaluated for their ability to determine

hemodynamic tolerance.

● Integration of relevant patient data into device

operations: As the data from devices is merged

into electronic health records, the relationship

between changes in a patient’s condition and

treatment and their effect(s) on the device data

could be analyzed. This would result in

suggestions for programming changes that

would optimize the device performance as well as

patient outcomes.

Summary

Today’s ICDs provide a wide range of programmable

parameters and sophisticated algorithms that

effectively discriminate between VT/VF and SVT,

and also prevent inappropriate detection and

therapy delivery due to the oversensing of

physiological and non-physiological signals.

Despite the availability of this advanced

technology, or perhaps because of it, clinicians are

faced with the daunting task of programming these

systems to achieve goals that are sometimes

unclear. The ability to distinguish VT and VF from

every other manifestation, once considered the holy

grail of rhythm discrimination, is no longer

sufficient, particularly for patients who receive

their implants for primary prevention.

Philosophical decisions, including whether the

ultimate goal of ICD therapy is to treat every

ventricular arrhythmia or only to prevent sudden

death (or, stated another way, whether it is ever

acceptable to not detect and treat a true VT), and

when shocks are not only appropriate but are

necessary, must be decided for each patient, and

the devices must be programmed accordingly. While

it is likely that future developments will enhance

these systems’technological capability to detect

and distinguish between various rhythms, these

advances are equally likely to raise new

philosophical issues that the clinician must wrestle

with.

Employee: Dr. Ostrow is a board member of

Clinical Advisory Group of St. Jude Medical

International.

References

1. 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 JHfor the Defibrillators in Non-IschemicCardiomyopathy Treatment Evaluation (DEFINITE) Investigators.Prophylactic defibri l lator implantation in patients withnonischemic dilated cardiomyopathy. N Engl J Med. 2005;350:2151-2158.

2. Poole JE, Johnson GW, Hellkamp AS, Anderson J, Callans DJ,Raitt MH, Reddy RK, Marchlinski FE, Yee R, Guarnieri T, TalajicM, Wilber DJ, Fishbein DP, Packer DL, Mark DB, Lee KL, BardyGH. Prognostic importance of defibrillator shock in patients withheart failure. N Engl J Med. 2008;359:1009-1017.

3. Wathen MS, DeGroot PJ, Sweeney MO, Stark AJ, Otterness MF,Adkisson WO, Canby RC, Khalighi K, Machado C, Rubenstein DS,

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Volosin KJ; PainFREE Rx II Investigators. Prospective randomizedmulticenter trial of empirical antitachycardia pacing versus shocksfor spontaneous rapid ventricular tachycardia in patients withimplantable cardioverter-defibrillators: Pacing Fast VentricularTachycardia Reduces Shock therapies (PainFREE Rx II) trialresults. Circulation. 2004;110:2591-2596.

4.Wilkoff BL, Ousdigian KT, Sterns LD, Wang ZJ, Wilson RD, MorganJM; EMPIRIC Trial Investigators.A comparison of EMpiric toPhysician-tailored progRamming of Implantable Cardioverter-defibri l lators: results from the prospective randomizedmulticenter EMPIRIC trial. J Am Coll Cardiol. 2006;48:330-339.

5. Wilkoff BL, Williamson BD, Stern RS, Moore SL, Lu F, Lee SW,Birgersdotter-Green UM, Wathen MS, Van Gelder IC, HeubnerBM, Brown ML, Holloman KK for the PREPARE StudyInvestigators. Strategic programming of detection and therapyparameters in implantable cardioverter-defibrillators reducesshocks in primary prevention patients. J Am Coll Cardio.2008;52:541-550.

6. Gasparini M, Menozzi C, Proclemer A, Landolina M, Iacopino S,Carboni A, Lombardo E, Regoli F, Biffi M, Burrone V, Denaro A,Boriani G. A simplified biventricular defibrillator with fixed longdetection intervals reduces implantable cardioverter defibrillator(ICD) interventions and heart failure hospitalizations in patientswith non-ischaemic cardiomyopathy implanted for primary

prevention: the RELEVANT [Role of long dEtection windowprogramming in patients with LEft VentriculAr dysfunction, Non-ischemic eTiology in primary prevention treated with abiventricular ICD] study. Eur Heart J. 2009;30:2758-2767.

7. Deering TF, Epstein AE, Greenberg SM, et al. Performance ofoptimized SVT discriminators and detection rates in reducingtotal and inappropriate shocks. Heart Rhythm. 2011;8:AB26-2(abstract).

8. Exner DV, Wathen MS, Volosin KJ, Sherfesee L, Scinicariello AP,Gillberg JM, University of Calgary, Libin Cardiovascular Instituteof Alberta, Calgary, AB, Canada, None, Nashvil le, TN,Philadelphia Heart Institute, University of Pennsylvania,Philadelphia, PA, Medtronic Inc., Minneapolis, MN. Time courseand characterization of defibrillator shocks using a virtual ICDmodel. Heart Rhythm. 2010;7:P02-129 (abstract).

9. Krahn AD, Champagne J, Healey JS, Cameron D, Simpson CS,Thibault B, Mangat I, Tung S, Sterns L, Birnie DH, Exner DV,Parkash R, Sivakumaran S, Davies T, Coutu B, Crystal E, Wolfe K,Verma A, Stephenson EA, Sanatani S, Gow R, Connors S, ParedesFA, Essebag V; Canadian Heart Rhythm Society Device AdvisoryCommittee. Outcome of the Fidelis implantable cardioverter-defibrillator lead advisory: a report from the Canadian HeartRhythm Society Device Advisory Committee. Heart Rhythm.2008;5:639-642.

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인공심박동기, 삽입형제세동기및심장재동기화치료를

위한기구(cardiac rhythm device)는pulse generator와

한개이상의조율전극으로구성되어있다. 이들은심외막조

율전극을사용하기도하나, 대부분은심내막조율전극을이

용하게된다. 심외막조율전극은외과의사에의해시행되며,

대개는조율전극의안정성에있어서심내막조율전극에비해

문제가많은것으로알려져있다. 따라서대부분의경우중심

정맥을통한심내막조율전극을사용하며, 구조적문제또는

감염등에의해심내막조율전극을사용하기어려운경우에

한하여심외막조율전극을이용하게된다. 본저자는심내막

조율전극을이용한삽입형심박동조절장치의이식방법에

대해서논하고자한다.

이식전환자의준비

대부분입원하여시행하게되며, 시술전심전도, 혈액검

사, 흉부방사선검사등을시행하게된다. 시술6~8시간전

부터금식을하게되며시술부위와같은쪽의상완정맥에

정맥주사를하는데, 이는시술중적절한정맥의위치를찾기

위해조 제를사용할경우를대비하기위해서이다. 또한시

술전탈수가되지않게적절한수액을투여하여야한다. 특

히심장재동기화치료를위해시술을하는경우에는탈수가

되었을때, 시술중저혈압을경험하는경우가많으며, 수분

섭취가많은경우에는장시간누워서시술을받는경우심부

전의악화가우려되므로적절한수액상태를유지하는것이

중요하다.

삽입형심박동조절장치의이식방법

고려대학교 의과대학 순환기내과 박 상 원Sang-Weon Park MD, PhDDivision of cardiology, Korea University Anam Hospital, Seoul, Korea

Implantation technique of cardiac rhythm device

ABSTRACTCardiac rhythm devices are widely used for bradycardia, tachycardia, and congestive heart failure. The

techniques for their implantation are essentially similar, even though they are directed to achieve different

goals. Although the fundamentals of the implantation technique are well established, there remain many

related issues about which further understanding is needed; these include the preparation of the patient,

continued administration of anticoagulants, the lead position, and techniques to avoid device-related

infections.

Key words: ■ implantable cardioverter-defibrillator ■ implantable electronic device■ implantation technique, pacemaker

Received: September 26, 2011Revision Received: November 27, 2011Accepted: December 27, 2011Correspondence: Sang-Weon Park MD, PhD, Division of cardiology, KoreaUniversity Anam Hospital, Seoul, Korea Tel: 82-2-920-5445, Fax: 82-2-927-1478E-mail: [email protected]

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시술전복용하던약물은대부분복용을하게하나, 심부전

환자의경우혈압을강하시킬수있는약물은시술당일중단

하고시술하는것이필요할수있다. 항응고제를복용하고있

던환자의경우에는다음과같은방법을생각해볼수있다.

시술전 3~5일동안warfarin을중단하고, conventional

heparin 또는 low molecular weight heparin으로전환

하여투여하며, 그후conventional heparin은시술6시간

전, low molecular weight heparin의경우에는시술24

시간전중단한다. 시술 24시간후다시warfarin과 함께

재투여하고, prothrombin time을 측정하여 INR 수치가

2.0 이상되었을때warfarin 만으로유지한다.1 다른방법

은warfarin을 INR 수치 2.0~3.0 사이로유지한상태로

시술을시행하는것이다.

이두가지방법은최근연구에서전향적으로비교되었으

며, warfarin을유지한그룹에서오히려출혈과관련된합병

증이적은경향을보 다.2, 3, 4 다만, 항응고제복용이시술과

관련된감염을증가시킨다는보고가있어이에대해서는주

의가필요하다.5

Aspirin과 clopidogrel의 경우 aspirin만 단독으로 쓴

경우에는항혈소판제를사용하지않았던대조군과비교하여

출혈합병증의유의한차이가없었으나, clopidogrel과병합

하여사용했을때는출혈합병증의발생이증가하 다.6

따라서저자의경우에는시술전aspirin은그대로유지하

고, clopidogrel은적어도5일이상중단하는것을원칙으로

한다. Warfarin을 사용하는 경우에는 INR 수치가

therapeutic range를유지한상태로이식하고있으며, 시

술도중에도특별히출혈의정도가심하다고느낀적은없었

다. 그러나clopidogrel의경우에는시술도중출혈경향이

눈에띄게관찰된다.

시술전예방적항생제는반드시투여하는것이필요하다.

Device implantation은 안전한 시술이기 때문에 최근에

예방적항생제를사용하지않은군과전향적으로비교한연

구가 있었으며, 예방적 항생제를 사용하지 않은 군에서

device와관련한감염률이증가하 다는사실을보고하

다.7 대개 1세대 cephalosporin을 시술 직전에 사용하게

된다.

이식시술과정(implant procedure)

1. 시술부위

시술부위의선택은일반적으로좌측쇄골하부위를선택

하게된다. 그러나왼손을주로사용하는환자에게는우측쇄

골하부위를선택할수있다. 그러나삽입형제세동기의경우

에는왼쪽쇄골하부위에can을위치시키는것이제세동역

치(defibrillation threshold, DFT)를줄일수있는것으로

알려져있으므로,8,9 가능한왼쪽에위치시키도록한다.

2. Generator pocket

피부를절개한후에피하지방아래까지박리한다. 근육을

감싸고있는근막(fascia)이보이면그층을따라박리한다.

Pocket을만들때주의해야할점은 device를삽입하는데

필요한공간보다적어도 1.5배이상크게박리를하여야한

다는것이다. 여유가없이빡빡하게 device를 삽입하게되

면, 시술 후에 통증을 느끼는 경우가 많으며, 또한 후에

pressure necrosis에 의한 pocket erosion이 발생할 수

있다(Figure 1).

3. 정맥의접근

정맥접근은주로쇄골하정맥(subclavian vein)을 이용

하는경우가많으나, 겨드랑정맥(axillary vein), 노쪽피부

정맥(cephalic vein)을이용하기도한다(Figure 2).

Figure 1. A change in skin color was noted by pressureupon the pacemaker generator, which was implanted in asmall-sized pocket. The patient felt some pain, which wasrelieved by adjusting the pocket.

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1) 쇄골하정맥

쇄골하정맥은비교적해부학적구조가일정하여쉽게찾

을수있는장점이있다. 하지만, 쇄골과늑골사이의공간이

좁아조율전극의손상이쉽게올수있으며, 폐와의거리가

가까워천자도중기흉의발생이있을수있다. 따라서가능

한천자방향은외측으로하는것이필요하다.

2) 겨드랑정맥

겨드랑정맥은흉곽바깥에위치하므로기흉등의위험성

이없는장점이있다. 하지만주행경로가일정하지않아쇄

골하정맥에비하여천자하기가쉽지않은경우가많다. 따라

서대부분의경우같은방향의상박정맥에조 제를투여하

여 fluoroscopy상 위치를확인하면서천자하는경우가많

다. 경험이쌓이면fluoroscopy상첫번재늑골을보고천자

하거나, 노쪽피부정맥의위치를보고천자할수있다.

3) 노쪽피부정맥

대개cut down 방법을사용하여야한다. 또한혈관의크

기가작아여러개의조율전극도자를삽입하는것이힘들수

있다. 겨드랑정맥과마찬가지로흉곽바깥에위치하므로기

흉의위험성이없으며, 혈관이직접보이기때문에여러번

천자할필요가없어익숙해지면시간을절약할수있다.10

4. 조율전극의위치

1) 심방전극의위치

심방전극의경우안정성을위하여우심방이(right atrial

appendage)에위치시킨것이일반적이다. 다만, 우심방하

부중격또는Bachman’s bundle에위치시켰을때, 심방세

동의발생을줄이고, 혈류역학을증가시킨다는보고가있으

나아직일반적이지는않으며논란이있다.11, 12, 13

2) 심실전극의위치

전통적으로우심실은우심실첨부에위치시켰다. 하지만, 우

심실첨부에의한심실조율이심부전, 좌심실부전의발생및심

방세동의발생도증가시키는원인으로서지목됨에따라14,15,16,17,18

최근에는우심실첨부를제외한우심실의다른부위에심실

전극을 위치하는 것에 대한 연구가 진행되었다. His

bundle, 우심실유출로, 심실중격등이대안으로서제시되

고있으나, 적절한우심실전극의위치에대해서는아직많은

논란이있다. 현재 fluoroscopy와심전도를이용하여우심

실유출로의중격쪽에조율전극을위치시키는방법은Hary

Mond에 의해 기술되었으며,19 아직은 장기적 효과에 대한

논란이있다.

심장재동기화치료를위한좌심실전극의위치에대해서

Figure 2. Anatomical correlation with pectoral muscle and fluoroscopic findings of subclavianvein, axillaryvein andcephalic vein.

cephalic vein

pectoralis Minor

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는여러가지제한점이있다. 우선coronary sinus의해부

학적구조에의해제한을받게된다. 또한해부학적구조가

적절한 분지를 이용하여 위치시킨 후에도 가로막 신경

(phrenic nerve) 자극에의해횡격막을자극할수있다. 따

라서좌심실전극을위치시킨후에device가가지는최대치

의전류량으로횡격막자극이오는지를점검하여야하고, 횡

격막자극이있다면, 다른분지를찾아서전극을위치시키는

것이 최선의 방법이다. 만약 그것이 가능하지 않다면, LV

pacing polarity를바꾸거나, pulse amplitude를낮추고

pulse width를 늘리는 것도 대안이 될 수 있다. active

fixation lead를사용하거나, quadripolar 전극을사용하

여프로그래밍하는것을고려할수있으나, 현재우리나라에

서는사용할수없는실정이다.

이식과관련된합병증

대부분의환자가절개부위에약간의통증을호소하고, 반

상출혈이있을수있다. 또한 혈종(hematoma)이 발생할

수 있는데, 이는 대부분 clopidogrel을 복용하 거나,

heparin 또는low molecular weight heparin을시술후

다시시작하 을때발생하는경우가많다. 이식후에발생하

는가장중요한합병증은시술부위또는전극에발생하는감

염이다. 이들감염이의심되었을때는우선혈액배양을시행

하여혈류를통하여동정되는균이있는지를확인하는게중

Figure 3. Management of cardiac implantable electronic device (CIED) infection by 2010 updated AHA recommendation.

Implantation ofnew CIED

Valvevegetation

Leadvegetation

Blood cultures (+) TEE (+)

Repeat blood culturesafter device removal

Repeat blood culturesafter deviceexplantation

Implant if repeat bloodcultures are negative

for at least 72 h

Implantdevice after14 days of

first negativeblood culture

Implantrepeat blood

culturesnegative for

72 h

Implant once adequatedebridement is

achieved

Negative admissionblood cultures for 72 h

Blood cultures (+) TEE (-)

Generator pocketinfection/generator or

lead erosion

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요하며, 경식도초음파를시행하여심장판막및조율전극에

vegetation이 있는 지를 확인하는 것이 필요하다. 혈액에

동정되는균이있을시에는전체 system을제거하여야한

다. 제거후에도지속적으로항생제를사용해야하며, 심장

판막에vegetation이있었던경우에는혈액배양에균이동

정되지않은상태에서2주후에다시이식하는것이권장된

다(Figure 3).20

감염의연관인자는여러 가지이나, 이식 당시 주의해야

하는것은시술직전항생제를사용하고, 조기에전극이탈에

의한재시술을피해야한다. 또한혈종이발생되지않게해야

하고, 시술시간을가능한줄이는정도이다. 최근device를

감싸는antibiotic envelope가개발되어사용되고있으나,

아직장기간사용연구가보고되지는않았다.21

References

1. Michaud GF, Pelosi F, Jr., Noble MD, Knight BP, Morady F,Strickberger SA. A randomized trial comparing heparin initiation6 h or 24 h after pacemaker or defibrillator implantation. J AmColl Cardiol. 2000;35:1915-1918.

2. Cheng A, Nazarian S, Brinker JA, Tompkins C, Spragg DD, LengCT, Halperin H, Tandri H, Sinha SK, Marine JE, Calkins H,Tomaselli GF, Berger RD, Henrikson CA. Continuation of warfarinduring pacemaker or implantable cardioverter-defibrillatorimplantation: a randomized clinical trial. Heart Rhythm.2011;8:536-540.

3. Giudici MC, Paul DL, Bontu P, Barold SS. Pacemaker andimplantable cardioverter defibrillator implantation withoutreversal of warfarin therapy. Pacing Clin Electrophysiol : PACE.2004;27:358-360.

4. Tolosana JM, Berne P, Mont L, Heras M, Berruezo A,Monteagudo J, Tamborero D, Benito B, Brugada J. Preparationfor pacemaker or implantable cardiac defibrillator implants inpatients with high risk of thrombo-embolic events: oralanticoagulation or bridging with intravenous heparin? Aprospective randomized trial. Eur Heart J. 2009;30:1880-1884.

5. Lekkerkerker JC, van Nieuwkoop C, Trines SA, van der Bom JG,Bernards A, van de Velde ET, Bootsma M, Zeppenfeld K, JukemaJW, Borleffs JW, Schalij MJ, van Erven L. Risk factors and timedelay associated with cardiac device infections: Leiden deviceregistry. Heart. 2009;95:715-720.

6. Tompkins C, Cheng A, Dalal D, Brinker JA, Leng CT, Marine JE,Nazarian S, Spragg DD, Sinha S, Halperin H, Tomaselli GF, BergerRD, Calkins H, Henrikson CA. Dual antiplatelet therapy andheparin “bridging” significantly increase the risk of bleedingcomplications after pacemaker or implantable cardioverter-defibrillator device implantation. J Am Coll Cardiol. 2010;55:2376-2382.

7. de Oliveira JC, Martinelli M, Nishioka SA, Varejão T, Uipe D,Pedrosa AA, Costa R, D’Avila A, Danik SB. Efficacy of AntibioticProphylaxis Before the Implantation of Pacemakers andCardioverter-Defibril lators. Circulation: Arrhythmia andElectrophysiology. 2009;2:29-34.

8. Gold MR, Shih HT, Herre J, Breiter D, Zhang Y, Schwartz M.Comparison of defibrillation efficacy and survival associated withright versus left pectoral placement for implantable defibrillators.Am J Cardiol. 2007;100:243-246.

9. Roberts PR, Allen S, Betts T, Morgan JM, Urban JF, Whitman T,Euler DE, Kallok MJ. Increased Defibrillation Threshold withRight-sided Active Pectoral Can. J Interv Card Electrophysiol.2000;4:245-249.

10. Ussen B, Dhillon PS, Anderson L, Beeton IAN, Hickman M,Gallagher MM. Safety and Feasibility of Cephalic Venous Accessfor Cardiac Resynchronization Device Implantation. Pacing ClinElectrophysiol. 2011;34:365-369.

11. Bailin SJ, Adler S, Giudici M. Prevention of chronic atrialfibrillation by pacing in the region of Bachmann's bundle: resultsof a multicenter randomized trial. J Cardiovasc Electrophysiol.2001;12:912-917.

12. Hermida JS, Kubala M, Lescure FX, Delonca J, Clerc J, Otmani A,Jarry G, Rey JL. Atrial septal pacing to prevent atrial fibrillation inpatients with sinus node dysfunction: Results of a randomizedcontrolled study. Am Heart J. 2004;148:312-317.

13. Wang M, Siu CW, Lee KL, Yue WS, Yan GH, Lee S, Lau CP, TseHF. Effects of right low atrial septal vs. right atrial appendagepacing on atrial mechanical function and dyssynchrony inpatients with sinus node dysfunction and paroxysmal atrialfibrillation. Europace. 2011;13:1268-1274.

14. Sweeney MO, Hellkamp AS. Heart failure during cardiac pacing.Circulation. 2006;113:2082-2088.

15. Sweeney MO, Hellkamp AS, Ellenbogen KA, Greenspon AJ,Freedman RA, Lee KL, Lamas GA; MOde Selection TrialInvestigators. Adverse effect of ventricular pacing on heart failureand atrial fibrillation among patients with normal baseline QRSduration in a clinical trial of pacemaker therapy for sinus nodedysfunction. Circulation. 2003;107:2932-2937.

16. Tantengco MV, Thomas RL, Karpawich PP. Left ventriculardysfunction after long-term right ventricular apical pacing in theyoung. J Am Coll Cardiol. 2001;37:2093-2100.

17. Thambo JB, Bordachar P, Garrigue S, Lafitte S, Sanders P,Reuter S, Girardot R, Crepin D, Reant P, Roudaut R, Jaïs P,Haïssaguerre M, Clementy J, Jimenez M. Detrimental ventricularremodeling in patients with congenital complete heart block andchronic right ventricular apical pacing. Circulation. 2004;110:3766-3772.

18. Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, HsiaH, Kutalek SP, Sharma A; Dual Chamber and VVI ImplantableDefibrillator Trial Investigators. Dual-chamber pacing orventricular backup pacing in patients with an implantabledefibrillator: the Dual Chamber and VVI Implantable Defibrillator(DAVID) Trial. JAMA : the journal of the American Medical

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Association. 2002;288:3115-3123.19. Mond HG, Hillock RJ, Stevenson IH, McGavigan AD. The right

ventricular outflow tract: the road to septal pacing. Pacing ClinElectrophysiol : PACE. 2007;30:482-491.

20. Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME,Lockhart PB, Masoudi FA, Okum EJ, Wilson WR, Beerman LB,Bolger AF, Estes NA 3rd, Gewitz M, Newburger JW, Schron EB,Taubert KA; American Heart Association Rheumatic Fever,Endocarditis, and Kawasaki Disease Committee; Council onCardiovascular Disease in Young; Council on CardiovascularSurgery and Anesthesia; Council on Cardiovascular Nursing;

Council on Clinical Cardiology; Interdisciplinary Council onQuality of Care; American Heart Association. Update onCardiovascular Implantable Electronic Device Infections and TheirManagement. Circulation. 2010;121:458-477.

21. Bloom HL, Constantin L, Dan D, De Lurgio DB, El-Chami M,Ganz LI, Gleed KJ, Hackett FK, Kanuru NK, Lerner DJ, Rasekh A,Simons GR, Sogade FO, Sohail MR; COoperative Multicenterstudy Monitoring a CIED ANtimicrobial Device Investigators.Implantation Success and Infection in Cardiovascular ImplantableElectronic Device Procedures Utilizing an Antibacterial Envelope.Pacing Clin Electrophysiol. 2011;34:133-142.

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서론

삽입형제세동기는생명을위협하는심실부정맥을치료하

여심실세동으로인한심장돌연사를예방할수있다. 삽입형

제세동기는1980년Dr. Levi Watkins에의해최초로사람

에게삽입된이래치명적인심실부정맥의가장효과적인치

료이며부정맥치료제에대한그우월성이여러연구에의해

증명되었다. 삽입형 제세동기는 빈맥성 부정맥을 치료하기

위해두가지의치료방법을가지고있다. 첫번째방법은빈

맥의심박수보다빠른조율자극으로적은에너지를이용하

여 빈맥을 종료시키는 항빈맥 심박조율(antitachycardia

Pacing-ATP)이고두번째는보다빠르고불안정한빈맥

을치료하기위하여많은에너지를이용하여쇼크(shock)라

는전기충격을가하는방법이다. 두번째방법은삽입형제세

동기의주된치료방법으로환자들에게적지않은정신적, 심

리적인 향을 주고 있다. 최근에 발표된 ADVANCE-D

(Antitachycardia Pacing Delivery for Painless

Implantable Cardioverter Defibrillator Therapy),

PainFREE Rx II 와같은연구에서도보여주듯의료진들은

삽입형제세동기환자추적(심리적관점)

서울아산병원 심장검사실 간호사 윤 지 회Ji-Hae YunElectrocardiogram / Arrhythmia Exam Unit, Asan Medical Center

Tracking of the patients with ICD implanted (Psychological aspect)

ABSTRACTThe implantable cardioverter defibrillator (ICD) has proven to be superior to anti-arrhythmia medications in

treating life-threatening ventricular tachyarrhythmia. It has been used since 1980 to reduce mortality in

patients with a high risk of sudden cardiac death. Patients with ICDs, however, often experience

psychological distress and a poor quality of life. This psychological distress manifests in symptoms such as

anxiety, depression, and panic disorder. Heller et al. reported that 20~58% of ICD recipients are depressed,

and Pycha and Calabrese found that 15~30% of them were anxious and depressed during the first few years

following implantation. Experiences of the unpredictable firing of ICDs affect a patient’s psychological and

emotional state. Therefore, health care providers (e.g., physicians, nurses) have to take these responses into

consideration and provide medical care that increases their psychological health and quality of life. This

review summarizes the psychological dimension of ICD recipients.

Key words: ■ implantable cardioverter defibrillator ■ psychological distresses■ quality of life ■ ventricular arrhythmia

Received: October 5, 2011Accepted: December 27, 2011Correspondence: Ji-Hae Yun Electrocardiogram / Arrhythmia Exam Unit,Asan Medical CenterTel: 010-8201-8996, E-mail: [email protected]

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삽입형제세동기삽입환자에게전기충격의고통을최소화하

기위하여항빈맥심박조율치료방법을최대한이용하기위

한프로그램조절과연구에많은관심을가지고있다. 이러한

삽입형제세동기의삽입과치료를위한전기충격은환자들의

정신적인건강상태와삶의질에 향을주고있고, 이와관

련된많은연구들이있다.

삽입형제세동기의삽입과관련된심리적인 향

삽입형제세동기를삽입한환자들의정신적인고통은불

안, 우울, 두려움, 분노와더나아가정신적인질환으로나타

난다. 이중38% 이상의¹환자들이불안증상, 22% 이상에

서2 우울증상이나타나고, 일부환자들에게는정신적인장애

의가능성이있는불안, 우울수준을보이기도한다. 이러한

정신적인고통의원인으로는3 삽입형제세동기의기능부전

의가능성, 전지수명, 전기충격발생, 신체상의변화와불편

함등과관련이있다. 특히삽입형제세동기시술직후환자

들은심한정신적인변화와혼란을호소하는데여자가남자

보다4 더높은우울과불안을경험한다. Duru et al.의연구

에서는인공심박동기의삽입환자들도삽입형제세동기이식

환자들과같은비율의정신적인변화와혼란을경험한다고

보고하고있는데5 이는신체상의변화가환자들의정신적건

강에미치는 향이크다고볼수있다. 이러한정신적인변

화와혼란은이식후최초 1년동안지속적으로경험하는데

시간이지남에따라환자들은점차제세동기의이식을받아

들이고적응해나간다.4, 6, 7 특히아동이나청소년등젊은환

자들이성인보다불안과우울정도가더높다고보고되고있

고8, 9 이는젊은환자들의보다잦은전기충격치료와 접한

관련이있다. 또한50세이하의대상자들은고령자들에비해

삶의질이낮고, 대상환자들의89%에서수면장애가있으며,

사회적 고립의 증가(44%), 제한된 신체적 활동(33%) 등을

동반한다.8, 10

삽입형제세동기의전기충격치료와관련된심리적인 향

삽입형제세동기에의한전기충격은환자들에게한층더

높은정신적인고통을2, 11 야기한다. 이는더욱이전기충격의

횟수와도연관이있고, 많은전기충격과동시다발적또는예

상치못한전기충격을경험한환자들에게더높은정신적인

고통이나타나는것으로보고되고있다.4, 12 전기충격을경험

한환자들은주로‘몸안에서무언가가아주센힘으로가슴

을후려치는듯하고, 깜짝놀라고당황하며심한고통이있

다’라고표현한다.1 전기충격의전후증상은실신, 어지럼증,

메스꺼움, 가슴두근거림또는답답함, 무증상등이있다. 이

는삽입형제세동기의적절한치료및부적절한치료에따라

환자의증상이다르게나타날수있고, 이에상관없이전기충

격은놀람, 통증, 두려움, 불안, 피로감등의증상을동반하

며, 환자뿐만아니라가족들의정신건강에도 향을준다.13

이러한전기충격에대한불안은때로는환상쇼크(phantom

shock)라는증상으로나타난다. 환상쇼크는실제시행되지

않은전기충격을경험했다고하는것인데, Swygman et al.

연구에서대상자의 6.7%가 환상쇼크를경험한다고보고하

고있다.14, 15 반면삽입형제세동기를삽입시술후강한불편

함과거부감을호소하는환자들에게전기충격은삽입형제세

동기가치명적인심실부정맥으로부터생명을구하는치료임

을인식하는계기가되기도한다.

환자들의정신적인중재

삽입형제세동기를이식후환자들이갖는정신적인변화

는16 사회적인위축을초래하여대인관계회피, 직업활동의

중단, 성적활동감소, 정신적무기력현상과삶의질악화등

을초래하게된다. Samuel F Sears et al.의연구에의하면

적극적인중재활동이나교육이환자들에게전기충격치료를

받아들이고정신적인불안을완화하여궁극적으로삶의질을

높이는데많은도움이된다고한다.17 그는삽입형제세동기

의 전기충격과 스트레스 관리프로그램(ICD-SSMP-The

ICD Shock and Stress Management Program)을통한

정신적인중재를통해환자들의불안을감소하고삶의질을

높인다고보고하고있다.18 환자뿐아니라가족들이갖는정

신적인스트레스도높게나타나는데, Dr. Samuel Sears는

A. Garrett Hazeltonand et al.와의연구에서가족특히

배우자에게있을수있는다음과같은심리적조정의일반적

인문제를설명하고, 관리방법을제시하고있다.19 시술후

의료진의교육을통해환자들은불안과걱정등의심리적인

문제를표출하기도하고완화하기도한다. 교육은삽입형제

세동기의역할, 시술부위관리, 운전, 전자기파장애등과관

련된시술후주의사항, 전기충격이있을때의증상과대처방

법, 사회로의복귀, 임시카드제공과의료진의연락처를제

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공하는등의내용이다. 또한삽입형제세동기삽입환자들의

모임주최와홈페이지운 및환자들간의만남을주선함으

로그들이가지고있는불안과걱정을서로나누고정보를공

유하는것은심리적인문제를스스로해결하고적응해나가

는데많은도움이된다. 특히빈도가잦고동시다발적인전

기충격을경험한환자들의불안과두려움은정신적인위기와

질환으로나타나는데, 필요시정신과를통한상담과치료가

필요하다.

결론

AVID (Antiarrythmics Versus Implantable

Defibrillators), CASH (The Cardiac Arrest Study

Hamburg), CIDS (Canadian Implantable Defibrillator

Study), MADIT-II (Analysis of mortality events in

the multicenter automatic defibrillator implantation

trial) 연구등에서보고된바와같이삽입형제세동기는항

부정맥제와비교하여환자들의유병률과사망률감소에있어

우월한결과를가지고있다. 또한이식환자들의75%가심실

부정맥과급사를예방하기위해다른사람들에게추천하고,

88%의이식환자들이그들의생명과안녕을위해매우중요

한치료라고인지하고있다고보고되고있다.3 또한의료진도

경험을통하여서삽입형제세동기치료의중요성을잘인지

하고있다. 그러나환자들이겪고있는심리적인문제특히

22~38% 이상의심각한불안과우울과관계되는정신적인

고통은간과할수없는문제일것이다. 앞에서거론되고있는

연구들의삶의질조사에서는공통적으로삽입형제세동기를

삽입한환자들에게서우월한결과를가지지못하며오히려

전기충격을경험한환자들의삶의질은낮은것으로조사되

었다.20

환자들은몸안에삽입된삽입형제세동기에대해부담을

가지면서도또한평생의지하며살아가야한다. 시술후의료

진은환자와가족들에게예상되는정신적인충격과이에따

른개인적, 사회적변화에관심을가져야한다. 우리나라도

서양과같은생활패턴에서오는많은심장질환과그와관련

한심실부정맥과심장돌연사가매년증가하고있고, 이에따

른삽입형제세동기삽입시술도해마다증가하고있다. 환자

들의정신적건강문제는의학적인문제로만국한된것이아니

라환자들의삶의질과사회적인문제와도 접한관계가있

다. 따라서의료진들은환자들의삶의질을향상시키고심리

사회적인안녕을위한적극적인중재가필요하다고생각한다.

References

1. Christopher L. Soda DO, and J. Michael Bostwick, MDImplantable Cardioverter-Defibrillators, Induced Anxiety, andQuality of Life, Mayo Clin Proc. 2005;80:232-237.

2. H.C.M.Kamphuis, J.R.J.de Leeuw, R.Derksen, R.N.W.Hauer andJ.A.M.Winnubst Implantable cardiover defibri l latorrecipients:quality of life recipients with and without ICD shockdelivery, Europace. 2003;5:381-389.

3. 정가진, 삽입형 심실제세동기 이식 후 환자의 불안, 우울 수준 2005.10.4. Marshall P, Ketchell A, Maclean J. Comparison of male and

female psychological putcomes related to implantablecardioverter defibrillators(COMFORTID), Eur J Cardiovasc Nurs.2011.

5. Duru F, Buchi S, Klaghofer R, Mattmann H, Sensky T, BuddebergC, Candinas R. How different from pacemaker patients arerecipients of implantable cardioverter-defibrillators with respectto psychosocial adaptation, affective disorders, and quality oflife? Heart. 2001;85:375-379.

6. Chevalier P, Verrier P, Kirkorian G, Touboul P, Cottraux J.Improved appraisal of the quality of life in patients withautomatic implantable cardioverter defibrillator: a psychometricstudy. Psychother Psychosom.1996;65:49-56.

7. Kamphuis HC, Verhoeven NW, Leeuw R, Derksen R, Hauer RN,Winnubst JA.. ICD: a qualitative study of patient experience thefirst year after implantation. J Clin Nurs. 2004;13:1008-1016.

8. Sears SF, Todaro JF, Urizar G, Lewis TS, Sirois B, Wallace R, SotileW, Curtis AB, Conti JB. Assessing the psychosocial impact of theICD: a national survey of implantable cardioverter defibrillatorhealth care providers. Pacing Clin Electrophysiol. 2000;23:939-945.

9. Sears SF Jr, Burns JL, Handberg E, Sotile WM, Conti JB. Young atHeart: Understanding the Unique Psychosocial Adjustment ofYoung Implantable Cardioverter Defibrillator Recipients. PacingClin Electrophysiol. 2001;24:1113-1117.

10. Vitale MB, Funk M. Quality of life in younger persons with animplantable cardioverter defibrillator. Dimens Crit Care Nurs.1995;14:100-111.

11. Carroll DL, Hamilton GA. Quality of life in implanted cardioverterdefibrillator recipients: the impact of a device shock. Heart Lung.2005;34:169-178.

12. Heller SS, Ormont MA, Lidagoster L, Sciacca RR, Steinberg S.Psychosocial Outcome after ICD Implantation: A CurrentPerspective. Pacing Clin Electrophysiol. 1998;21:1207-1215.

13. Dougherty CM. Psychological reactions and family adjustment inshock versus no shock groups after implantation of internalcardioverter defibrillator. Heart Lung. 1995;24:281-291.

14. Prudente LA. Phantom Shock in a Patient With an ImplantableCardioverter Defibril lator: Case Report. Am J Crit Care.2003;12:144-146.

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15. Swygman CA, Link MS, Cliff DL, et al. Incidence of phantomshocks in patients with implantable cardioverter defibrillators.Pacing Clin Electrophysiol. 1998;21:789-994.

16. Pedersen SS, van den Broek KC, Sears SF Jr. PsychologicalIntervention Following Implantation of an ImplantableDefibrillator: A Review and Future Recommendations, Pacing ClinElectrophysiol. 2007;30:1546-1554.

17. Sears SF, Sowell LD, Kuhl EA, Kovacs AH, Serber ER, HandbergE, Kneipp SM, Zineh I, Conti JB. The ICD Shock and StressManagement Program: A Randomized Trial of PsychosocialTreatment to Optimize Quality of Life in ICD Patients. Pacing Clin

Electrophysiol. 2007;30:858-864.18. Sears Jr.,PhD. The ICD Shock and Stress Management Program:

Interview with Samuel F. EP Digest. sat 5/3/081.19. Hazelton AG, Sears SF, Kirian K, Matchett M, Shea J. Cardiology

Patient Page. Coping with my partner's ICD and cardiac disease.Circulation. 2009:120:e73-e76.

20. Noyes K, Corona E, Zwanziger J, Hall WJ, Zhao H, Wang H,Moss AJ, Dick AW; Multicenter Automatic Defibri l latorImplantation Trial II. Health-Related Quality of Life Consequencesof Implantable Cardioverter Defibrillators: Results From MADITII\. Medical Care. 2007;45:377-385.

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배경

제세동기를삽입한환자에서심실재동기화치료(cardiac

resynchronization therapy, CRT)의심실성부정맥에대

한효과는아직확실하게알려져있지않다. 본연구에서는

MADIT-CRT 연구환자에서심실재동기화에따른심초음

파지표의변화와심실성부정맥의빈도간상관관계를살펴

봄으로서재동기화가심실성부정맥의발생에미치는 향을

알아보고자하 다.

방법

제세동기치료의빈도를재동기화치료후좌심실수축기

용적(end-systolic volume, ESV)의회복정도에따라회

복정도가높은군(high-echocardiographic responder,

≥25% reduction)과 낮은 군(low responder, ESV,

＜25% reduction)으로나누어분석하 다.

결과

심초음파를통한좌심실회복정도에대한평가후2년간의

심실성부정맥의누적빈도를조사하 다. 심실성부정맥의빈

도는low responder에서가장높고(28%) high responder

에서가장낮았으며(12%), 재동기화없이제세동기치료만한

군에서는중간(21%) 정도의빈도를보 다(Table 1).

다변량분석에서 high responder는재동기화치료를받

지않은군에비하여약55%의부정맥발생감소효과를보

고, low responder는재동기화치료를받지않은군과유

의한차이가없었다. 또한, 좌심실수축용적이10% 감소할수

록이후발생하는심실성부정맥의빈도는20%, 심실성부정

맥혹은사망률의빈도는21%, 심실빈맥의빈도는20%, 심

실세동의빈도는25%씩감소하 다.

결론

좌심부전으로MADIT-CRT 연구에등록된환자에서심

실재동기화에따른심실재형성은심실성빈맥의발생을현저

한감소효과를보 다.

심장재동기화치료의심실재형성에의한심실빈맥억제효과

울산대학교 의과대학 내과학교실 남 기 병Gi-Byoung Nam MDAsan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea

Reverse Remodeling and the Risk of Ventricular Tachyarrhythmias in the MADIT-CRT (Multicenter Automatic

Defibrillator Implantation Trial-Cardiac Resynchronization Therapy)

Barsheshet A, Wang PJ, Moss AJ, Solomon SD, Al-Ahmad A, McNitt S, Foster E

Huang DT, Klein HU, Zareba W, Eldar M, Goldenberg I.

J Am Coll Cardiol. 2011;57:2416-2423.

Received: October 5, 2011Accepted: December 27, 2011Correspondence: Gi-Byoung Nam MD, Division of Cardiology, Departmentof Internal Medicine, University of Ulsan College of Medicine, 388-1Poongnap-dong, Songpa-gu, Seoul 138-736, KoreaTel: 82-2-3010-3159, Fax: 82-2-486-5918E-mail: [email protected]

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Table 1. Multivariate Analysis: Risk of Ventricular Arrhythmic Events by Percentage of Reduction in LVESV Among CRT-D Patients.

Hazard Ratio for Every 10%

Reduction in LVESV 95% Confidence Interval p Value

심실성빈맥(ventricular tachyarrhythmia) 0.80 0.71~0.91 <0.001

심실성빈맥(ventricular tachyarrhythmia) 혹은총 사망(death from any cause) 0.79 0.71~0.88 <0.001

심실세동/심실조동(ventricular fibrillation/flutter) 0.75 0.57~0.99 0.045

심실빈맥(ventricular tachycardia) 0.80 0.70~0.90 <0.001

ECG

& E

P C

ASES


실신을주소로온환자가이에대한평가를충분히했음에

도원인을알수없는경우담당임상의는딜레마에빠질수

있다. 가장중요한평가는돌연심장사의위험도로, 고위험

군인경우삽입형제세동기(ICD) 수술을고려해야한다. 대

한민국의국민건강보험요양급여적용기준에서ICD와관련

된항목은미국심장학회의가이드라인을상당히반 하고있

다. 하지만일부환자에서는적용기준에해당되지않아ICD

수술을미루게된다. 본증례는임상의의판단에서는고위험

군으로분류되어 ICD를권유했으나비용등의문제로수술

을미뤄오던환자에서실신의충분한평가를위해삽입형사

건기록기를이식하고경과관찰중심실빈맥으로인한심정

지가관찰되어ICD 수술을받게된경우이다.

증례

68세남성이본원외래대기도중갑자기의식을잃고쓰

러졌으며, 자발호흡과맥박이촉지되지않는상태로심폐소

생술후응급실을통해입원하 다.

환자는입원2년전운동중갑자기실신하 으며당시20

분정도의식소실이있었다고하 다. 대전C병원을거쳐환

자의희망에의해서울A병원으로의뢰되었다. 관상동맥조

술을위한입원대기중처방받은약물(plavix, aspirin,

원인불명의실신환자에서삽입형사건기록기로진단된심실빈맥

서울대학교병원 순환기내과 오 세 일Seil Oh MD, PhDDepartment of Internal Medicine, Seoul National University Hospital, Seoul, Korea

Ventricular tachycardia detected by an implantable loop recorder in apatient with syncope of unknown origin

ABSTRACTPatients with syncope of cardiac origin have poor outcome, therefore implantable cardioverter defibrillator

(ICD) therapy is indicated in most of cases. The implantable loop recorder (ILR) is useful in patients with

infrequent unexplained syncope when noninvasive testing is negative. The present case with unexplained

syncope showed only nonsustained ventricular tachycardia (VT) in the electrophysiological study (EPS). VT

associated with cardiac arrest was finally detected by the ILR, and the patient underwent ICD implantation.

Therefore, even nonsustained VT induced by EPS may have clinical significance in patients with unexplained

syncope in terms of occurrence of sudden cardiac death.

Key words: ■ implantable cardioverter defibrillator ■ implantable loop recorder ■ syncope

Received: October 23, 2011Accepted: December 27, 2011Correspondence: Seil Oh MD, PhD, FHRS, Associate Professor of InternalMedicine, Seoul National University College of Medicine and SeoulNational University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744,KoreaTel: 82-2-2072-2088, Fax: 82-2-762-9662E-mail: [email protected]

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simvastatin, dilitazem)을복용하면서쓰러질것같은느

낌이자주들어복용을모두중지하고, 대전C대학교병원을

방문하 다. 당시종종심박수가＜40회라들었고이후약1

년간 C대학교병원에서추적관찰하 다. 그러던중다시어

지럼증, 혈압감소, 흉통이있어대전C대학교병원에서홀터

를시행하 고, 검사결과고도방실차단으로심박동기수술

을권유받았다. 이에다시서울A병원을방문하 고재시행

한홀터에서간헐적인완전방실차단(최대RR간격3초)이관

찰되어심박동기수술이필요하다는말을듣고입원하여검

사를진행하 다. 심전기생리학검사에서안정시 1도방실

차단 소견을 보 고, 심실신속조율(조율간격 260 ms)에서

비지속성의심실빈맥이2회관찰되었다. 이에심박동기대신

전액환자부담으로삽입형제세동기수술을권유받았으나

2차의견을구하기위해9개월전본원에내원하 다. 재평

가를위해홀터, 심초음파, 관상동맥조 술(ergonovine 유

발검사포함) 등을시행하 으나1도방실차단및제1형2도

방실차단이외에는유의한소견이관찰되지않았다. 또한환

자가 구적인기기이식수술에대해회의적인반응을보여

심박동기수술은보류하고대신삽입형사건기록기를이용하

여감시하기로하 다(Figure 1). 이후7개월간특별한증상

의호소가없었으며삽입형사건기록기에도유의한부정맥이

관찰되지않고있었다.

환자는응급실에서심폐소생술로심박동이정상화되었고,

신경학적후유증을최소화하기위해저체온치료를시행받았

다. 환자의삽입형사건기록기를통해당시상황의원인이심

실빈맥에의한심정지임을확인할수있었다(Figure 2). 저

체온치료후후유증없이회복되었으며, 삽입형제세동기수

술후퇴원하여외래에서경과관찰중이다.

고찰

2011년 현재 국민건강보험 요양급여적용기준에서‘자

200-2 심율동전환제세동기삽입술(ICD)[경정맥]의 인정기

준중’라. 실신에대한충분한평가(evaluation)로도원인을

알수없는실신에서임상적으로연관되고혈역동학적으로

의미있는 심실빈맥이나 심실세동이 임상전기생리학적검사

(EPS)에의해유발되고약물치료는효과가없거나복용을

못하는경우로되어있다. 하지만본증례의환자처럼EPS

에서혈역학적의미가없는비지속성의심실빈맥만을보이는

경우ICD 수술을하게되면보험적용의혜택을받기가어려

운것이현실이다. 삽입형사건기록기는실신에대한평가를

충분히했는데도불구하고원인불명인환자에서고려해봐

야할평가방법이다.1 하지만삽입형사건기록기역시우리나

라건강보험에서급여항목이아니므로전액환자가부담해야

한다. 따라서현상태에서는비용-이득을분석했을때불리

한진단도구가될것이다. 본증례와같은환자를통해얻을

수있는교훈은, 구조적으로정상심장을가진환자에서도비

지속성심실빈맥만을보이는실신에서돌연심장사를예측

할수있는인자가무엇인지를규명하는연구가관상동맥질

환자에서처럼필요하다는것이다.2 그리고이와같은인자를

가진환자라면 ICD 수술의보험적용, 또는적어도삽입형

사건기록기의보험적용을고려할수있도록향후정책에반

되어야할것이다.

Disclosures: Dr. Oh is a board member of Clinical

Advisory Group of St. Jude Medical International.

Figure 1. Chest X-ray showing the loop recorder implantedin the patient's chest.

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References

1. Parry SW, Matthews IG. Implantable loop recorders in theinvestigation of unexplained syncope: A state of the art review.Heart. 2010;96:1611-1616.

2. Zimetbaum PJ, Buxton AE, Batsford W, Fisher JD, Hafley GE, LeeKL, O'Toole MF, Page RL, Reynolds M, Josephson ME.Electrocardiographic predictors of arrhythmic death and totalmortality in the multicenter unsustained tachycardia trial.Circulation. 2004;110:766-769.

Figure 2. Electrograms recorded in the loop recorder. Ventricular tachycardia followed by sinus arrest was detected.

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서론

심박동기, 삽입형제세동기(implantable cardioverter-

defibrillator) 및 최근에는 심장재동기화 치료(cardiac

resynchronization therapy, CRT) 등 다양한 device를

이용한심장박동이상치료방법이시도되고있다. Device

를이용한치료는매우효과적인데반하여이에따른문제점

도발생할수있다. 심박동기의유도와관련된문제점으로는

lead 위치변경, connector pin 연결이상, conductor coil

(lead) fracture 등의 문제가 있으며, 본 증례에서는 lead

fracture에대하여알아보고자한다.

증례1

57세 여성 환자로 1년 전 완전방실차단으로 본원에서

DDD형심박동기를삽입하 다. 그림 1A는지난번내원시

심전도인데심방감지, 심실조율을하는소견을보이고있

다. 하지만그림1B는이번내원시심전도인데P파와조율

에의해만들어진QRS의dissociation 소견을보이고있다.

그림1C는흉부방사선소견이고, 그림1D는확대소견인데

심방lead가쇄골을지나면서fracture된소견을보이고있

다. 이로인하여심방lead의감지및조율이모두이상소견

Lead fracture의진단및치료

연세대학교 의과대학 내과학교실 정 보Bo-Young Joung MD, PhDDivision of Cardiology, Yonsei University College of Medicine, Seoul, Korea

Diagnosis and treatment of lead fracture

ABSTRACTLead-related problems, including lead fracture, are not common. There is an extensive body of diagnostic

data regarding both device and lead function in the most recent generation of pacemakers and ICDs. Regular

measurement of lead impedance and pacing thresholds allow for the early detection of lead insulation

breaks, fracture, dislodgement, or other problems. The analysis of stored intracardiac electrograms (EGMs)

alerts the physician to problems with oversensing and undersensing, which may manifest as abnormal device

function, inappropriate arrhythmia detection, or inappropriate therapy. We have reported three patients

whose device experience included sensing and pacing problems, and inappropriate shock. In these cases,

fractured leads were replaced with new leads.

Key words: ■ inappropriate shock ■ lead fracture ■ sensing and pacing

Received: September 7, 2011Revision Received: November 29, 2011Accepted: December 27, 2011Correspondence: Bo-Young Joung MD, Ph.D, Yonsei University College ofMedicine, 250 Seungsanno, Seodaemun-gu, Seoul, Republic of Korea 120-752Tel: 82-2-2228-8460, Fax: 82-2-393-2041E-mail: [email protected]

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을보 고, 측정된심방lead의저항은3,000 Ω이상이었다.

Insulation material의손상은흔히발생하지는않는다.

임상적으로는심박동기의감지혹은조율이상으로나타나게

된다. Insulator의 손상과 conductor fracture는 crush

injury에 의해서 주로 발생한다. 흔히 발생하는 부위는

costoclavicular space이며 lead가쇄골하정맥천자를이

용하여삽입된경우에주로발생한다. 이환자는치료로새로

운심방lead를삽입하 다.

증례2

51세남성환자로내원전날밤부터약 15회의제세동기

shock을받고응급실로내원하 다. 환자는5년전급사로

본원에서제세동기를삽입하 고, 내원 1년전제세동기배

터리를새로교환하 다. 그림 2의A와B는손상된제세동

기 lead를 보여주고 있으며, costoclavicular space에

lead fracture가 관찰되었다. 그림 2C는제세동기를분석

하면서환자의팔을움직이게하 는데, 다수의noise를잘

못인지하는문제가관찰되었다. 치료를위해새로운제세동

기lead를삽입하 다.

증례3

46세 남성환자로내원당일 33회의제세동기 shock을

받고내원하 다. 환자는지속적인단형심실빈맥와좌심실

구출률이 30% 정도로저하되어있어서외부병원에서 3년

Figure 1. Atrial lead fracture. ECG lead II before (A) and after (B) atrial lead fracture. One year after implantation of a dualchamber pacemaker for complete AV block, this patient was found to have a complete loss of atrial sensing and bipolaratrial lead impedance that exceeded 2,000Ω. (C) Chest PA. (D) A magnified view of a boxed lesion in Figure 1C, showingthe fractured atrial lead (arrow). There is a clear fracture of the lead just before it enters the subclavian vein. The fracturemay have been due to the subclavian access that passed the lead through the costoclavicular ligament apparatus.

A B

C D

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전dual chamber 제세동기를삽입하 다. 그림3A는제세

동기분석상기록된 inappropriate shock을 보이고그림

3B는제세동기lead의저항이2,500 Ω이상으로최근에급

격히 상승한 소견을 보이고 있다. 치료로 손상된 제세동기

lead를제거하고새로운lead를다시삽입하 다.

심박동기혹은제세동기lead의제거는 lead와정맥및심

내막과의유착으로쉽지않고, 또한시술중치명적인합병증

이발생할수있다. 하지만lead 감염, pocket 감염, erosion,

inappropriate shock 등의문제시lead를제거하여야한다.

Lead의제거는intravascular countertraction 방법을사

용하며, 최근에는레이저, mechanical dilator sheath 등

이사용된다.1,2

고찰

Lead fracture는비교적드물게발생하는문제이다. 하지

만심박동기및제세동기의감지혹은조율의이상을발생시

킬수있다. 또한제세동기의경우치명적인 inappropriate

shock 혹은제세동기능의장애등이발생할수있다. 최근에

개발된심박동기및제세동기는device 및lead의기능에대

하여 광범위한 정보를 제공할 수 있다.3 정기적인 lead

impedance 및조율역치에대한검사는lead insulation

break, fracture, 위치변경, 혹은다른문제에대하여조

기 진단을 할 수 있게 한다. 또한 저장된 intracardiac

electrogram (EGMs)의 분석은 oversensing 및

undersensing 등의문제를발견할수있게한다.

Figure 2. ICD lead fracture. (A) Chest PA. (B) A magnified view of boxed lesion in Figure 2A, showing the fractured ICD lead (arrow). (C) Intracardiacventricular electrogram showing fast ventricular activities (FS) during movement of the left arm.

A

C

B

EGM

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References

1. Kantharia BK, Kutalek SP. Extraction of pacemaker andimplantable cardioverter defibrillator leads. Curr Opin Cardiol.1999;14:44-51.

2. Park JS, Pak HN, Lee MH, Kim SS, Joung B. Implantablecardioverter-defibrillator lead extraction by conventional tractionand counter-traction technique. Korean Circ J. 2011;41:164-166.

3. Scher DL. Troubleshooting pacemakers and implantablecardioverter-defibrillators. Curr Opin Cardiol. 2004;19:36-46.

Figure 3. Inappropriate shock, and ICD lead impedance trend and removal. (A) Intracardiac ventricular electrogram shows fast and irregular ventricular activities (VS) unmatched by normalventricular activities (regular QRS complexes on surface ECG). Noise sensing caused by the lead fracture was interpretedas ventricular fibrillation by the ICD. (B) Impedance of the RV-lead abruptly increased from baseline 650Ω to >2,500Ωwithin the most recent 3 weeks, suggesting a lead fracture. (C) The fractured RV-lead (tined type) of ICD was completelyremoved using a traction and counter-traction technique, employing a locking stylet and a 12Fr (diameter: 4 mm)polypropylene dilator sheath.

A

B

CICD interrogation Report

V-lead Impedance Trends Report

last 60 weeks (minmax per week) last 14 days

Lead II

V-EGM

Marker

Removed ICD lead

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서론

지속성상대정맥(persistent left superior vena cava,

PLSVC)은선천성혈관기형중의하나로좌측쇄골하정맥

의관삽입시술시드물게발견된다. PLSVC는 심박동기나

제세동기삽입술이다소어렵지만성공적인사례들이보고되

고있으며저자들도PLSVC가있는69세여성환자에서성

공적으로제세동기를삽입한증례를경험하 기에문헌고찰

과함께보고하고자한다.

증례

69세여성환자가심한어지럼증을동반한심계항진을주

소로응급실에내원하 다. 환자는89년에심방중격결손(정

맥동 결손형, sinus venosus type)으로 수복수술을 받았

고, 02년에중증류마티스성승모판역류증과관동맥질환으

로승모판치환술과관동맥우회로술을시행받아경과를관

찰하던중이었다. 내원2일전심계항진과함께어지럼증이

동반되어타병원에방문하여심전도시행결과심실빈맥소

견을보여전기적심율동전환술을시행후본원으로전원되

었다. 심초음파상기계판막의기능에는문제가없었으나좌

심실의전반적인운동저하와함께좌심실구혈률은30%로

측정되었고, 관동맥조 술 상 좌내유동맥(left internal

mammary artery, LIMA)은 폐쇄소견을보 으나좌전

하행지(left anterior descending artery, LAD)의혈류가

잘유지되고있었다. 입원6일째심계항진과어지럼증이재

지속성좌상대정맥환자에서성공적인제세동기삽입술

연세대학교 의과대학 내과학교실 심 재 민 / 박 희 남Jae-Min Shim MD / Hui-Nam Pak MD, PhDDivision of Cardiology, Yonsei Cariovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea

Successful implantation of a single chamber cardioverter defibrillatorsystem in a patient with persistent left superior vena cava

ABSTRACTWe report the case of a single-chamber cardioverter defibrillator (ICD) implantation in a 69 year-old female

patient with a persistent left superior vena cava (PLSVC). The patient presented a sustained ventricular

tachycardia with hemodynamic compromise, and she had a history of patch repair of an atrial septal defect,

mitral valve replacement, and coronary artery bypass graft. The appropriate use of a currently available, low

profile active fixation lead with proper shaping of the stylet allowed for safe implantation through the PLSVC

and coronary sinus.

Key words: ■ implantable cardioverter defibrillator ■ persistent left superior vena cava

Received: October 6, 2011Accepted: December 27, 2011Correspondence: Jae-Min Shim MD / Hui-Nam Pak MD, PhD, Division ofCardiology, Yonsei Cariovascular Center and Cardiovascular ResearchInstitute, Yonsei University College of Medicine, Seoul, KoreaTel: 82-2-2228-8460, Fax: 82-2-393-2041E-mail: [email protected]

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발하여시행한심전도(Figure 1) 상심실빈맥소견을보 으

나amiodarone 주입후종료되었고다음날제세동기삽입

을시행하 다. 좌측에제세동기삽입을계획하고좌측쇄골

하정맥을천자후유도철선을넣는과정에서PLSVC가발

견되었다(Figure 2A). 관정맥동기시부와삼첨판사이의각

도가급격하여평이한탐침(stylet)의각도로는전극의우심

실접근이어려웠다. 그러나해부학적인굴곡을고려하여탐

침의근위부에큰곡선(curve)을만들고원위부에는근위부

곡선과축이직각방향인또다른곡선을만들어, 우심실전

극(Durata Defibrillation Lead, St. Jude, USA)을 심

실 첨부에 성공적으로 위치시킬 수 있었다. 전극의 이탈

(lead dislodgement)을예방하기위하여우심실전극은나

사형(screw type)을사용하 다(Figure 2B). 전극을고정

하고 시행한 검사상 지표들은 이상적인 수치를 보 으며

(pacing threshold: 0.5 V × 0.4 ms, sensed R wave

amplitude: 18.0 mV, pacing lead impedance: 480 Ω,

shock impedance: 68 Ω), T shock (600/320 ms, 2 J)

으로 심실세동을 유발하여 시행한 제세동 역치 검사

(defibrillation threshold test)에서10 J로심실세동이종

료되었다. 환자는특별한합병증없이퇴원후3개월뒤어지

럼증과전기충격이2차례발생하여다시입원하 고당시전

기도(electrogram) 상심실빈맥에의한적절한치료로확인

되었으며2개월뒤6차례심실빈맥에의한전기충격이추가

로발생하여amiodarone 복용하 고이후로는더이상심

실빈맥없이외래에서추적관찰중이다.

고찰

PLSVC는가장흔한흉부정맥의선천성기형으로일반

인구의0.3~0.5%에서보고되며다른선천성심장기형을가

지고 있는 환자에서는 더 높아서 2.8~4.3%에서 발생하는

것으로알려져있다.1,2 상대정맥의변이는다음과같이4가지

로분류할수있다.3

1. 우상대정맥만 있는 정상적인 경우

2. 우상대정맥과 좌상대정맥이 모두 존재하고 두 정맥의

직경이 비슷한 경우

3. 우상대정맥과 좌상대정맥이 모두 존재하나 좌상대정맥

의 직경이 매우 작은 경우

4. 좌상대정맥만 존재하는 경우

대부분의경우에우상대정맥과좌상대정맥모두를가지고

Figure 1. This 12 lead electrocardiogram, which was taken when the patient complained of palpitation with dizziness,showed wide QRS tachycardia with a north-west axis and a cycle length of 266 ms.

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있지만전체인구의약0.1%에서는우상대정맥이없는경우

가발견된다.4 80~90%의환자에서PLSVC는확장된관정

맥동(coronary sinus)을 통하여 우심방으로 배출되고 약

10%에서는좌심방과연결되어단락(shunt)를만드는것으

로알려져있다.5

10년간심박동기또는제세동기를삽입한환자들을조사

한한연구에서PLSVC의유병률을심박동기환자와제세동

기환자에서각각0.34%와1.7%로보고하 다.2 PLSVC는

A BAP View RAO 25°

Figure 3. Follow-up chest PA and lateral radiography 1 day after implantation revealed stable lead positioning.

Figure 2. (A) Fluoroscopic view shows the J-tipped guidewire through the persistent left superior vena cava and thecoronary sinus to the right atrium. (B) Fluoroscopic view shows successful placement of the ventricular lead at the rightventricular apex through the PLSVC and CS.

CS; coronary sinus, PLSVC; persistent left superior vena cava

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좌측으로제세동기삽입을시도할경우기술적인어려움을

유발하고일부환자에서는우상대정맥이없기때문에우측으

로바꾸어서삽입하는것이불가능할수있다. 시술전심초

음파 검사에서 관정맥동 입구가 심하게 확장되어 있다면

PLSVC를의심해볼수있지만대개는시술중에우연히관

찰된다. PLSVC 환자에서 발생하는 가장 어려운 문제는

PLSVC와관정맥동에있는우심실전극을삼첨판막을통하

여우심실내에위치시키는것이다. 우심실전극이관정맥동

밖으로나오게되면대개삼첨판막에서멀어지는방향으로

우심방을향하게되므로전극을우심실첨부또는중격에위

치시키기위해서는탐침의모형만들기(shaping)가매우중

요하다. Biffi et al.은 stylet의근위부에 leftward sharp

bend를만들고원위부에는round L을만들면심첨부에위

치시키는데도움이된다고보고하 으며6 Zerbe 등은탐침

을3~4 cm 너비의pigtail 모양으로만들면어려움없이성

공적으로우심실에위치시킬수있다고보고하 다.7 하지만

탐침의모양은각환자의해부학적인특징에따라개별화하

는 것이 무엇보다도 중요하다고 하겠다. 또 한가지 방법은

PLSVC의약68%에서무명정맥(inonimate vein)에의해

우상대정맥과연결과연결되므로조 술후이정맥을찾아

서전극을우상대정맥으로넘겨서위치시키는것이다.8 제세

동기전극의종류에있어서는관정맥동내에상대정맥코일

이있을경우전극의조작을더힘들게하므로일반적으로없

는것이더선호되지만상대정맥코일이있는전극이라하더

라도제세동쇼크의배치를조정하여상대정맥코일을제외

할수있기때문에기능에는 향이없는것으로알려져있

다. 본환자에서는쇼크전극의재배치없이통상적인제세동

역치값을보 다. 또한전극의이탈의위험을최소화하기위

하여나사형의전극을사용하는것이일반적이다. 결론적으

로PLSVC가있는환자에서의제세동기삽입은우심실전극

을위치시킬때우상대정맥을통해삽입하는것보다기술적

으로힘들수있지만대부분의경우에성공적으로시술이가

능하고추적관찰시에도좋은결과를보인다.

References

1. Coblentz MG, Criscito MA, Cohn JD. Persistent left superior venacava complicating hemodynamic monitoring catheterization. CritCare Med. 1978;6:32-35.

2. Biffi M, Boriani G, Frabetti L, Bronzetti G, Branzi A. Left superiorvena cava persistence in patients undergoing pacemaker orcardioverter-defibrillator implantation: a 10-year experience.Chest. 2001;120:139-144.

3. Giebel J, Fanghanel J, Hauser S, Paul I. A case of a persistent leftvena cava superior with atresia of the right atrial ostium of thecoronary sinus. Ann Anat. 2000;182:191-194.

4. Lenox CC, Zuberbuhler JR, Park SC, Neches WH, Mathews RA,Fricker FJ, Bahnson HT, Siewers RD. Absent right superior venacava with persistent left superior vena cava: implications andmanagement. Am J Cardiol. 1980;45:117-122.

5. Soward A, ten Cate F, Fioretti P, Roelandt J, Serruys PW. Anelusive persistent left superior vena cava draining into left atrium.Cardiology. 1986;73:368-371.

6. Biffi M, Bertini M, Ziacchi M, Martignani C, Valzania C,Diemberger I, Branzi A, Boriani G. Clinical implications of leftsuperior vena cava persistence in candidates for pacemaker orcardioverter-defibri l lator implantation. Heart Vessels.2009;24:142-146.

7. Zerbe F, Bornakowski J, Sarnowski W. Pacemaker electrodeimplantation in patients with persistent left superior vena cava.Br Heart J. 1992;67:65-66.

8. Yi Z, Sidhu JS, Cheng J. A successful implantation of a dual-chambers cardioverter defibrillator for a patient with severetortuous persistent left superior vena cava. Int J Cardiol.2009;133:e109-110.

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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: [email protected]

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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

ECG

& E

P C

ASES


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

51

ECG

& E

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VOL.12 NO.4

References

1. Cooper LT. Myocarditis. N Engl J Med. 2009;360:1526-1538.2. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B,

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

목적과개요

부정맥(The Official Journal of Korean Heart Rhythm Society)은대한심장학회부정맥연구회의주관으로발행되며, 부정맥과관련된새로운임상지식, 진료지침, 증례등을소개하여부정맥연구회회원및개원의의지속적인의학교육에이바지하고자발행되는최신학술지이다. 본지는부정맥의진단과치료, 임상연구와관련된원저, 종설, 논평, 증례보고등을편집위원회에서검토후게재한다.

연구및출판윤리규정

본 규정은 대한심장학회 부정맥연구회지(The Official Journal ofKorean Heart Rhythm Society) 회원들의학술활동중연구윤리를확보하는데필요한역할과책임에관하여기본적인원칙과방향을제시하기위하여제정되었으며, 각회원은연구활동중정직성, 진실성,정확성이연구결과의신뢰성확보를위한필수조건임을인식하고모든연구활동을수행함에있어이규정을준수하도록한다.

1. 저자들은Uniform Requirements for Manuscripts Submitted toBiomedical Journals (http://www.icmje.org/)에서 규정한 윤리규정을준수해야한다.

2. 본학술지에투고하는원고의연구대상이사람인경우는헬싱키선언(Declaration of Helsinki [www.wma.net])의윤리기준에일치해야하며, 기관의 윤리위원회 또는 임상시험심사위원회(InstitutionalReview Board)의승인을받고, 필요한경우에연구대상자의동의서를받았음을명시해야한다.

3.동물실험연구는 실험 과정이 연구기관의 윤리위원회의 규정이나NIH Guide for the Care and Use of Laboratory Animals의기준에합당해야한다.

4. 간행위원회는필요시환자동의서및윤리위원회승인서의제출을요구할수있다.

5. 이해관계명시(Disclosure of conflict of interest): 연구에소요된연구비수혜내용은감사의 에필히기입해야한다. 연구에관계된주식, 자문료등이해관계가있는모든것은표지하단에밝혀져야하며, 이를모두명시했음을원고의저자전원의자필서명이있어야한다.

6. 원칙적으로타지에이미게재된같은내용의원고는게재하지않으며, 본지에게재된것은타지에게재할수없다. 단, 독자층이다른타언어로된학술지에게재하기위한경우등의중복출판은양측간행위원장의허락을받고, 중복출판원고표지에각주로표시하는등,다음문헌에서규정한요건을갖춘경우에만가능하다(Ann InternMed 1997;126:36-47).

7. 윤리규정및표절/중복게재/연구부정행위등모든연구윤리와연계되는사항에대한심사및처리절차는대한의학학술지편집인협의회에서

제정한 '의학논문 출판 윤리 가이드라인(http://kamje.or.kr/publishing_ethics.html)'을따른다.

원고범위

1. 원저(Original Article)는인간을대상으로한연구(임상적조사및보고서)와동물을이용한실험및생체외실험에대한연구(기초과학보고서)로한다.

2. 종설(Review Article)은특정분야나주제에관해간결하고포괄적으로평가한논문으로위촉된종설에한하여게재하는것을원칙으로하나편집진의재량에따라위촉되지않은종설도게재가능하다.

3. 논평(Editorial)은본학술지에게재되는논문에대한저자의견해를기술한것으로, 편집진의의뢰하에쓰여진다.

4. 증례보고(Case Report)의요건은국내첫증례또는희귀증례로제한한다.

집필규정

1. 논문은한 을사용하여한 맞춤법에맞게작성하며모든학술용어는대한의사협회에서발간한의학용어집의최신판에수록된용어를사용한다.

2. 원어의적당한한 용어가없는경우한 뒤( )안에원어는표기할수있다. 부득이외국어를사용할때는대소문자의구별을정확히해야한다(예：고유명사, 지명, 인명은첫 자를대문자로하고그외에는소문자로기술함을원칙으로한다). 적절한번역어가없는의학용어, 고유명사, 약품명, 단위등은원어를그대로사용한다.

3. 번역어가있으나의미전달이명확하지않은경우에는그용어가최초로등장할때번역어다음소괄호속에원어로표기하고그이후로는번역어만사용한다.

4.검사실검사수치의단위는SI 단위(International System of Units)를사용하고, 편집위원회의요구나필요에따라괄호안에비SI 단위수치를첨부할수있다.

5. 약자는가능한한사용하지않는것이좋지만, 본문에일정용어가반복사용됨으로인해부득이약자를사용해야하는경우에는그용어가처음나올때괄호안에약자를함께표기하고다음부터약자를사용할수있다.

6. 원고는컴퓨터문서작성프로그램(MS 워드또는한 )을사용하여작성한다. 자의크기는명조계통의10 point, 정렬은좌측정렬을하며, 줄간은한 의경우160%, 워드의경우1줄간격으로하며좌우및위아래여백은3 cm로한다. 원고면의번호는제목쪽부터시작하여차례대로중앙하단에표시한다.

투고및윤리규정

원고의형식

1. 원저(Original Article)

표지, 초록과키워드, 본문, 감사문, 참고문헌, 도표, 그림/사진설명, 그림및사진의순으로하며, 제목쪽과초록및참고문헌은각각분리된쪽으로작성한다.

1) 표지(Title Page)

①제목, 소속, 저자명, 문제목및 문소제목(빈칸을포함하여50자이내), 문 저자명, 문 소속순으로하며, 표지하단에교신저자(corresponding author)의 이름, 주소, 소속, 전화번호, 전송번호,E-mail 주소등을명시해야한다.

②저자들의소속이다수인경우소속명을같은행에연이어나열하며,아라비아숫자의어깨번호로소속과저자명을일치시킨다. 문저자명뒤의MD나PhD 등에는 자다음에구두점을찍지않는다.

2) 초록과 키워드(Abstracts and Key Words)

모든원고에는 문초록을첨부해야하며, 초록은250단어이내로한다. Background and Objectives, Subjects (Materials) and Methods,Results, Conclusion의순으로구분하여소제목에따라줄바꿈없이작성한다. 증례보고인경우소제목없이가능하며, 초록은150단어이내로한다. 단논평의경우초록을첨부하지않는다. 그리고각초록의말미에 Index medicus에등재된용어 5개이내로 문key words를삽입한다.

3) 본문(Text)

서론, 대상(재료) 및방법, 결과, 고찰, 요약, 중심단어순으로작성한다.

①서론에는연구와관련된간략한배경과연구의목적이언급되어야한다.

② 대상(재료) 및방법은매우상세히기재해야하며결과의통계적검증방법도밝혀야한다.

③고찰은연구결과와연관된새롭고중요한측면에대한내용으로제한한다.

④요약은결과와고찰로부터유도되고, 서론에서언급한연구목적과부합되어야하며, 결과의단순한요약은금한다. 요약의구성은배경및목적, 방법, 결과, 결론의순으로구분하여소제목에따라줄바꿔작성한다. 그리고국문논문은요약다음에한 중심단어를초록의문중심단어와일치시켜삽입한다. 임상화보의경우본문은250

단어를넘기지않으며, 사진에대한설명은따로작성하지않고, 증례에대한설명에포함한다.

4) 감사문(Acknowledgments)

감사문에는본연구의연구비지원기관, 본연구를수행하는데여러가지로도움을주었던분들에대한사항을기술한다.

5) 참고문헌(References)

①원저는30개이하, 증례보고는20개이하, 임상화보는5개이하로제한한다. 종설은참고문헌수를제한하지않는다.

②참고문헌은본문에나타난것만인용한다. 본문에서는인용순서에따라아라비아숫자로저자명뒤또는문장끝에어깨번호로표시한다. 참고문헌의배열도인용한순서대로작성한다. 동일저자의경우연도순으로나열하며, 국내문헌도 문표기를원칙으로한다.

③참고문헌의저자는모두기재한다. 저자표기는 last name은다쓰고, first name과second name은첫 자를대문자로붙이고initial에 마침표(.)는 사용하지않는다. 저자명사이에는쉼표(,)로 구분하고, 마지막저자명뒤에는마침표(.)를찍는다.

④ 잡지명은‘List of Journals Index Medicus’에의거약어로기재하며, 인용학술지명뒤에는마침표를찍는다. 인용논문의제목중첫자는대문자로하고, 부제목이있는경우쌍점(：)을붙인후소문

자로기재하며제목뒤에는마침표(.)로표시하며, 연도를표시한후쌍반점(；)으로붙여서구분후, 권：시작쪽-끝쪽의전체페이지를기재하며, 마지막에마침표를찍는다.

예) Smith HJ, Allen S, Yu W, Fard S. This is the title. Circulation.

2004;104:276-308.

6) 표(Table)

①표는 문과아라비아숫자로기록하며표의제목을명료하게절혹은구의형태로기술한다. 문장의첫자를대문자로한다.

②분량은4줄이상의자료를포함하여1쪽을넘지않는다.

③본문에서인용되는순서대로번호를붙인다.

④약어를사용할때는해당표의하단에알파벳순으로풀어서설명한다.

⑤기호를사용할때는*, †, ‡, §, ‖, ¶, **, ††, ‡‡의순으로하며이를하단각주에설명한다.

⑥표의내용은이해하기쉬워야하며, 독자적기능을할수있어야한다.

⑦표를본문에서인용할때는 문(Table 1과같이)을사용한다.

7) 그림 및 사진(Figure)

① 그림및사진은‘ppt’파일형식으로원문과별도의파일을만들어서제출한다.

② 동일번호에서2개이상의그림이필요한경우에는아라비아숫자이후에알파벳 자를기입하여표시한다(예: Figure 1A, Figure 1B).

③그림을본문에서인용할때에는한 (Figure 1과같이)을사용한다.

④ 최종통과시그림및사진은‘jpg’파일형식으로1장씩10메가이내로파일을만들어서제출한다.

⑤ 칼라사진은학회요청(흑백사진으로확인이잘되지않는경우) 및

저자의요청에의하여칼라로인쇄될수있으며비용은저자의부담으로한다.

8) 그림 및 사진 설명(Figure Legends)

①본문에인용된순으로아라비아숫자로번호를붙인다.

②모든그림및사진은설명이있어야하며, 별지에 문으로구나절이아닌문장형태로기술한다.

③현미경사진의경우배율을기록한다.

2. 원저 이외의 원고

일반사항은원저에준한다.

1) 종설(Review Article)

종설은특정제목에초점을맞춘고찰로서편집위원회에서위촉혹은투고에의하여게재한다. 단, 투고된원고는심사를거쳐게재여부를결정한다.

2) 증례 보고(Case Report)

① 전체분량이A4 용지10매이내로작성한다.

② 문초록은항목구분없이150단어이내로한다.

③고찰은증례가강조하고있는특정부분에초점을맞추며장황한문헌고찰은피한다.

④ 참고문헌의수는20개이내, 그림은5장이내로한다.

⑤저자수는7명이내로한다.

3) 논평(Editorial)

학회지에출판된특정논문에대한논평을의뢰받아집필되는부문으로학회의의견을반 하는것은아니다. 원고는A4 용지4매이내로작성하고참고문헌은10개이내로제한한다.

기타사항

1. 본학회지는연간4회(3, 6, 9, 12월말일) 발간한다.

2. 필요할경우원문에 향을미치지않는범위내에서자구와체제를편집방침에따라편집위원이수정할수있다.

3. 원고의게재여부는원고심사후편집위원회에서결정하며, 본규정에맞지않는원고는개정을권유하거나게재를보류할수있다.

4. 학회지의게재는원고의저작권이저자로부터학회지로이양되는것을저자가승인한것으로인정한다.

5. 원고제출처

부정맥연구회온라인논문투고사이트

http://arrhythmia.medimedia.co.kr

엠엠케이커뮤니케이션즈(주)

E-mail: [email protected]

주소 : 서울시 강남구 역삼동 641-3번지 노바빌딩 3층 (135-909)

전화 : 02-2007-5413 팩스 : 02-3452-5984

저자점검표저자(소속):

논문제목:

다음은귀하가본부정맥연구회지(The Official Journal of Korean Heart Rhythm Society)에투고하는논문이투고규정에맞도록각항목별로충실히작성되어있는지점검하는저자점검표입니다. 논문투고시해당칸에표시하여논문과함께반드시제출하여주십시오.

일반사항1. 본논문의내용은다른학회지에게재되지않았고, 게재예정도없다.

2. 원고는A4용지10포인트크기로여백상, 하, 좌, 우3.5, 3, 3, 3 cm, 줄간격1 기준으로작성하 다.

3. 원저는표지, 문초록, 서론, 본론, 결론, 참고문헌, Table, Figure 순서의양식으로구성하며, 본론은소제목으로구분한다.

4. 증례는표지, 문초록, 서론, 증례, 고찰, 참고문헌, Table, Figure 순서의양식으로구성한다.

5. 일련쪽수를하단에기재하 다.

표지1. 논문제목

2. 저자소속, 이름

3. 문제목, 어저자명, 어소속

4. 요약제목(Running title) - 국문제목30자이상, 문제목12단어이상시

5. 책임저자이름, 주소, 전화, Fax, 전자우편주소

6. 연구비에대한사항을각주에적었다(해당되는경우).

문 초록1. 문제목이한 제목과일치하도록작성, 문성명, 문소속의올바른기재

2. 원저는내용을Background, Objective, Method, Result, Conclusion으로규정된형식으로작성하 다.

3. 증례는내용을한단락(paragraph)으로작성하 다.

4. Key Words 3-5개를MeSH에맞게작성하 다.

본문1. 한 로사용가능한용어는한 로기재하 다.

2. 본문중해당참고문헌의어깨번호를표시하 다.

참고문헌1. 투고규정준수에맞게모두 문으로작성하여PubMed와KorMed에서확인하 다.

2. 참고문헌의모든공저자를기재하 다.

3. 학술지표기는Index Medicus의공인된약어를사용하 다.

4. 학술지를이탤릭체로표기하 다.

Table과 Figure1. Table과Figure는중복되지않도록작성하 다.

2. Table과Figure는투고규정에맞도록작성하 다.

3. 제목및설명모두 문으로기재하 다.

4. 제목에서약자를사용하지않으며, Table과Figure에사용된약자는하단에설명을기재하 다.

본논문의저자(들)은부정맥연구회지(The Official Journal of Korean Heart Rhythm Society)의투고규정에따른위의사항들을확인하 으며,논문게재를요청합니다.

20 년 월 일

저자대표________________________(서명)

저작권이양동의서

논문제목

국 문

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)은본논문에실제적이고지적인공헌을하 으며, 본논문의내용에대하여공적인책임을공유합니다.

3. 본논문은과거에출판된적이없으며, 현재다른학술지에게재를목적으로제출되었거나제출할계획이없습니다.

4. 본논문의저자(들)은본논문이부정맥연구회지(The Official Journal of Korean Heart Rhythm Society)에게재될경우, 저작권에

관한모든권리, 이익및저작권에대한모든권한행사등을대한심장학회부정맥연구회에이양하기로동의합니다. 이는저자(들)이향후다

른논문에본논문의자료를사용할경우대한심장학회부정맥연구회로부터서면허가를받아야하며, 이경우자료가발표된원논문을밝혀

야하다는것을의미합니다.

년 월 일

저자 성명

책임저자

제1저자

제2저자

제3저자

제4저자

서명 저자 성명 서명

제5저자

제6저자

제7저자

제8저자

제9저자

Korean Heart Rhythm Society

Room 805, Masters Tower #553, Dohwa-dong, Mapo-gu, Seoul 121-040, KoreaPhone 82-2-3275-5411 Fax 82-2-3275-5412 E-mail [email protected]

http://www.k-hrs.org

vol.12 no - medimediaarrhythmia.medimedia.co.kr/archive/archive/pdf/39.pdf · 2015-02-12 · the...

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