심부전의 기기 치료

박승정 대한의사협회 2022 대한의사협회지 Vol.65 No.1

Background: The incidence of heart failure (HF) is rapidly increasing, introducing a significant burden and challenges in clinical practice. Non-pharmacological cardiac device therapy has been established as an essential component of optimal HF management, particularly for the prevention of sudden cardiac death and the improvement of HF symptoms, left ventricular (LV) systolic function, quality of life, and eventually survival. Current Concepts: Cardiac resynchronization therapy (CRT) can correct atrioventricular or inter/intraventricular dyssynchrony, thereby improving LV systolic function. Recently, the concept of CRT is being expanded, including His bundle (HB), HB-optimized LV, left bundle branch (LBB), and LBB optimized LV pacing CRTs. Newly introduced CRT approaches by stimulating the cardiac conduction system are expected to correct dyssynchrony better and consequently exhibit better CRT outcomes than the conventional biventricular pacing CRT. The current versions of implantable cardioverter-defibrillators (ICDs) or CRT devices can continuously monitor multiple biosignals. CRT/ICD can calculate a single index by combining these multiple bio-signal data for early detection of HF aggravation. Recently, subcutaneous and transvenous ICDs showed comparable safety and efficacy in HF patients. In drug-refractory HF patients without LV dyssynchrony, cardiac contractility modulation therapy provides some promising results. Discussion and Conclusion: Recent technological advancements have improved the efficacy and safety of cardiac device therapy. Therefore, cardiac device therapy should be used more actively to manage HF patients better.

Cardiac Resynchronization Therapy Device Implantation in a Patient with Cardiogenic Shock under Percutaneous Mechanical Circulatory Support

임경희,최진오,양정훈,박승정,김선화,강지석,조현성,신선혜 대한심장학회 2017 Korean Circulation Journal Vol.47 No.1

A 65-year-old woman was admitted to our hospital with acute decompensated heart failure with reduced left ventricular ejection fraction and severe mitral regurgitation. Electrocardiography revealed a typical left bundle branch block and atrial fibrillation. Her condition deteriorated despite administering high-doses of inotropes and vasopressors. Pending a decision to therapy, venoarterial extracorporeal membrane oxygenation (ECMO) was performed when the patient underwent a cardiogenic shock. Although the hemodynamic status stabilized with ECMO support, weaning the patient from ECMO was not possible. Thus, we decided to perform cardiac resynchronization with defibrillator implantation as a “rescue” therapy. Five days post-implantation, the patient was successfully weaned from ECMO.

Advanced heart failure: a contemporary approach

Kyeong-Hyeon Chun,Seok-Min Kang 대한내과학회 2023 The Korean Journal of Internal Medicine Vol.38 No.4

Advanced heart failure (HF) is defined as the persistence of severe symptoms despite the use of optimized medical, surgical, and device therapies. These patients require timely advanced treatments, such as heart transplantation or long-term mechanical circulatory support (MCS). Inotropic agents are often used to reduce congestion and increase cardiac output, while renal replacement therapy may be beneficial if necessary. Cardiac resynchronization therapy has clear benefits in patients with HF with reduced ejection fraction, particularly with left bundle branch block (QRS duration > 130 ms). The role of implantable cardioverter-defibrillators in advanced HF patients requires further investigation considering the introduction of novel HF medications. In selected patients with significant secondary mitral regurgitation, transcatheter edge-to-edge repair can help delay heart transplantation or long-term MCS. In later stages, the appropriateness of heart transplantation should be evaluated, and the use of short- or long-term MCS may be considered. A multidisciplinary HF management program is crucial for patients with advanced HF. Recent treatment advances, including drugs, devices, and MCS, have broadened the options available to patients with advanced HF and this trend is expected to continue.

Perioperative management of patients with cardiac implantable electronic devices

Kim Minsu,Kwon Chang Hee 대한마취통증의학회 2024 Korean Journal of Anesthesiology Vol.77 No.3

The use of cardiac implantable electronic devices (CIEDs) has increased significantly in recent years. Consequently, more patients with CIEDs will undergo surgery during their lifetime, and thus the involvement of anesthesiologists in the perioperative management of CIEDs is increasing. With ongoing advancements in technology, many types of CIEDs have been developed, including permanent pacemakers, leadless pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy-pacemakers/defibrillators, and implantable loop recorders. The functioning of CIEDs exposed to an electromagnetic field can be affected by electromagnetic interference, potential sources of which can be found in the operating room. Thus, to prevent potential adverse events caused by electromagnetic interference in the operating room, anesthesiologists must have knowledge of CIEDs and be able to identify each type. This review focuses on the perioperative management of patients with CIEDs, including indications for CIED implantation to determine the baseline cardiovascular status of patients; concerns associated with CIEDs before and during surgery; perioperative management of CIEDs, including magnet application and device reprogramming; and additional perioperative provisions for patients with CIEDs. As issues such as variations in programming capabilities and responses to magnet application according to device can be challenging, this review provides essential information for the safe perioperative management of patients with CIEDs.

증례 : 비장티푸스성 살모넬라균에 의한 심율동전환제세동기 삽입부 감염 1예

이동준 ( Dong Jun Lee ),이승현 ( Seung Hyun Lee ),한재현 ( Jea Hyun Han ),이승준 ( Seung Jun Lee ),박희남 ( Hui Nam Pak ),이문형 ( Moon Hyoung Lee ),정보영 ( Bo Young Joung ) 대한내과학회 2013 대한내과학회지 Vol.84 No.3

Cardiac Resynchronization Therapy Defibrillator Treatment in a Child with Heart Failure and Ventricular Arrhythmia

김학주,조성규,김웅한 대한흉부외과학회 2016 Journal of Chest Surgery (J Chest Surg) Vol.49 No.4

Cardiac resynchronization therapy (CRT) is a new treatment for refractory heart failure. However, most patients with heart failure treated with CRT are adults, middle-aged or older with idiopathic or ischemic dilated cardiomyopathy. We treated a 12-year-old boy, who was transferred after cardiac arrest, with dilated cardiomyopathy, left bundle-branch block, and ventricular tachycardia. We performed cardiac resynchronization therapy with a defibrillator (CRT-D). After CRT-D, left ventricular ejection fraction improved from 22% to 4 4% a ssessed by e chocardiog ram 1 year p ostoperatively. On e lectrocardiog ram, Q RS d uration was shortened from 206 to 144 ms. The patient’s clinical symptoms also improved. For pediatric patients with refractory heart failure and ventricular arrhythmia, CRT-D could be indicated as an effective therapeutic option.

전기 기계 심장 모델을 이용한 심장 재 동기화 요법의 환자별 시뮬레이션

박민철(Min-Cheol Park),정의철(EuiCheol Jung),임철현(Chul Hyun Lim),최다솜(Da Som Choi),심은보(Eun Bo Shim),엄재선(Jae Sun Uhm) 대한기계학회 2019 대한기계학회 춘추학술대회 Vol.2019 No.11

Cardiac resynchronization therapy (CRT) is one of the treatment techniques to prevent cardiac arrest due to abnormal QRS waveform. The purpose of this study is to examine the new technological direction of ventricular resynchronization therapy, to establish a virtual surgical environment through future simulations, and to predict the function and state of the heart according to the shape of the heart after ventricular resynchronization therapy using computer simulation. In order to predict this, we developed an integrated cardiac model that takes into account the cellto-organ unit and will study the electrical conduction and contraction dynamics of patient-specific ventricular model. As a result, the data derived from the electrical conduction model of the patient and the contraction model obtained from the contraction, diastolic blood pressure and ejection fraction were compared and analyzed through three results. We propose a simulation technique that can predict the ventricular condition of patients after the actual procedure.

Cardiac Resynchronization Therapy Using a Dual Chamber Pacemaker in Patients with Severe Left Ventricular Dysfunction and a Left Bundle Branch Block

정재준,김인숙,정재한,이영탁,정동섭 대한흉부외과학회 2013 Journal of Chest Surgery (J Chest Surg) Vol.46 No.4

Through the use of a dual chamber (DDD) pacemaker, we achieved a cardiac resynchronization effect in a 51-year-old female patient who was transferred to our hospital from another hospital for an operation for three-vessel coronary artery disease. Her electrocardiogram showed a left bundle branch block (LBBB) and a prolonged QRS interval of 166 milliseconds. Severe left ventricle (LV) dysfunction was diagnosed via echocardiography. Coronary artery bypass grafting (CABG) was then performed. In order to accelerate left atrial activation and reduce the conduction defect, DDD pacing using right atrial and left and right ventricular pacing wires was initiated postoperatively. The cardiac output was measured immediately, and one and twelve hours after arrival in the intensive care unit. The cardiac output changed from 2.8, 2.4, and 3.6 L/min without pacing to 3.5, 3.4, and 3.5 L/min on initiation of pacing. The biventricular synchronization using DDD pacing was turned off 18 hours after surgery. She was transferred to a general ward with a cardiac output of 3.9 L/min. In patients with coronary artery disease, severe LV dysfunction, and LBBB, cardiac resynchronization therapy can be achieved through DDD pacing after CABG.

Cardiac Resynchronization Therapy planning을 위한 MDCT 활용 Coronary venous classification의 유용성

남태현(Tae Hyun Nam),권순안(Soon Ahn Kwon),민관홍(Kwan Hong Min),전은주(Eun Ju Chun) 대한CT영상기술학회 2018 대한CT영상기술학회지 Vol.20 No.1

목적 : Cardiac resynchronization therapy (CRT)는 뉴욕심장협회 (New York Heart Association, NYHA)의 기준 class III 및 IV에 해당하는 환자에게 적용하는 최신 치료 기법이다. 최신 Multi-detector CT (MDCT)로 촬영한 영상은 3차원 재구성을 통해 관상정맥의 평가가 가능해짐에 따라 CRT 계획을 위한 적절한 CT 검사 프로토콜을 제시하고 심장정맥을 표현하는 새로운 분류법을 제시하고자 한다. 대상 및 방법 : 2014년 3월부터 2016년 12월까지 본원을 내원하여 256 MDCT에서 CRT 프로토콜로 심장 CT를 촬영한 189명을 대상으로 하였으며, CT CRT 프로토콜은 Late arterial phase와 venous phase를 촬영하고 조영제는 두번 나누어 주입하는 방법을 사용하였다. 영상의 평가는 정성적 평가와 정량적 평가를 이용하였으며, 정성적 평가는 관상정맥에 대해 “0-5 points scale 평가법”을 사용하였고 정량적 평가는 관상정맥의 유무와 존재하는 각 혈관의 직경을 측정하고 결과값을 토대로 “LPM method”라 명명한 새로운 관상정맥 분류 표기법에 따라 구분해 보았다. “LPM method”는 세 개의 관상정맥을 유무 및 우세한 혈관을 앞으로 배치하여 표현하는 분류법으로 left marginal vein 은 [L, 1], posterior vein of left ventricle은 [P, 2], middle cardiac vein은 [M, 3]로 표기한다. 결과 : 본 논문에서 제시한 CT CRT 프로토콜로 촬영한 모든 환자의 영상에서는 관상정맥의 관찰이 가능했고 (135 excellent, 46 good, 8 fair), 관상정맥의 평가를 토대로 새로운 관상정맥 분류 표기법에 따라 구분해본 결과 189명 중 142명 (75.1 %)의 환자는 기준으로 하는 세관상정맥 (L, P, M)을 모두 관찰 할 수 있는 LPM 그룹으로 나타났으며, 18명 (9.5 %)의 환자는 두 관상정맥 (P, M)을 관찰 할 수 있는 PM그룹으로 나타났고, 23명 (12.2 %)은 두 관상정맥 (L, M)을 관찰 할 수 있는 LM 그룹으로 나타났으며, 2명 (1 %)의 환자가 두 관상정맥 (L,P)을 관찰 할 수 있는 LP그룹으로 나타났다. 분류법으로 표현하지 못한 환자는 4명 (2 %)으로 나타났다. 우세한 혈관의 분류 기준을 포함한 결과로는 LPM-3_1_2 (M>L>P)가 29.8 %로 가장 높게 나타났으며, LPM-3_2_1이 25.7 %, LM-3_1이 11.5 % 그리고 LPM-3_1,2가 10.5 %로 그 뒤를 따랐다. 결론 : 본 논문에서 제시한 CT CRT 프로토콜로 촬영한 환자 모두에게서 관상정맥을 관찰 할 수 있었을 뿐만 아니라 정성적 평과 결과 평균 4.7점으로 나타났다. CRT 시술을 진행하기 전에 MDCT를 활용하고 “LPM method”를 적용하여 시술에 사용되는 관상정맥을 분류하면 시술에 사용되는 fluoroscopy의 사용시간, 조영제의 사용량 그리고 전체 시술시간을 줄일 수 있을 것으로 사료된다. Purpose : Cardiac Resynchronization Therapy (CRT) is being used heart failure patients, category III and IV of NewYork Heart Association (NYHA). Multi-detector CT (MDCT) has allowed visualization of the 3-dimensional coronary venous anatomy. We aimed to evaluate the venous anatomy with coronary CT angiography using appropriate protocol and suggest the new classification for the coronary venous anatomy and anatomic variants. Materials and Methods : 189 patients underwent 256-row MDCT (Brilliance iCT, Philips Healthcare, Cleveland, OH, USA) were retrospectively involved for this study. We used CT protocol for CRT which has two phases scan (late arterial and venous phases) and split contrast agent injection technique. A volume rendering image set and a curved multi-planar reconstruction image set by 3D reconstruction workstations were used for identifying and measuring coronary veins. Image quality is graded with the 0-5 points scale method by a radiologist. We categorized the venous anatomy according to the presence of main 3 veins (left marginal vein [L, 1], posterior vein of left ventricle [P, 2] and middle cardiac vein [M, 3]) for CRT and order of their dominance. Results : The venous anatomy can be evaluated from all patients using this protocol. (135 excellent, 46 good and 8 fair). Depending on “Coronary Venous Anatomy Classification”, 142 out of 189 (75.1 %) patients had all 3 main veins (termed as “LPM” group), 18 patients (9.5 %) had P and M veins (termed as “PM” group), 23 patients (12.2 %) were “LM” group, 2 patients (1 %) were “LP” group. Only 4 out of 189 (2 %) patients were included in group “etc.” which cannot represent with this classification. According to the second category of dominant vein order, LPM_3_1_2 (M>L>P) is highest frequency (29.8 %), followed by LPM_3_2_1 (25.7 %), LM_3_1 (11.5 %) and LPM_3_1,2 (10.5 %). Conclusions : MDCT using two phase protocol can visualize the venous anatomy and variants with good image quality. By using the coronary venous anatomical information depend upon MDCT, simply categorized “Coronary Venous Anatomy Classification” can be useful prior to CRT implantation, it may save the procedure time.

Brachial Plexus Injury Caused by Indwelling Axillary Venous Pacing Leads

박종성,김소연,방정희,강은주 대한심장학회 2015 Korean Circulation Journal Vol.45 No.5

A 64-year-old male patient underwent cardiac resynchronization therapy (CRT) device implantation via the axillary venous approach. Two weeks later, the patient started complaining of “electric shock-like” pain in the left axillary area. During physical examination, typical pain in the left axillary area was reproduced whenever his left shoulder was passively abducted more than 60 degrees. Fluoroscopic examination showed that the left ventricle (LV) and right atrium (RA) leads were positioned at an acute angle directing towards the left brachial plexus whenever the patient’s shoulder was passively abducted. Brachial plexus irritation by the angulated CRT leads was strongly suspected. To relieve the acute angulation, we had to adjust the entry site of the LV and RA leads from the distal to the proximal axillary vein using the cut-down method. After successful lead repositioning, the neuropathic pain improved rapidly. Although transvenous pacing lead-induced nerve injury is not a frequent complication, this possibility should be kept in mind by the operators.