심실상성 빈맥의 기전 규명에 있어서 심전기생리학적 지표인 △VACT와 VACT Ratio 의 가치

조정관(Jeong Gwan Cho),박상진(Sang Jin Park),류제영(Jay Young Rhew),배열(Youl Bae),김성희(Sung Hee Kim),김준우(Jun Woo Kim),김주한(Ju Han Kim),길광채(Gwang Chae Gill),박주형(Joo Hyung Park),정명호(Myung Ho Jeong),박종춘(Jong Chun Pa 대한내과학회 1996 대한내과학회지 Vol.51 No.2

N/A Background: Electrophysiologic methods useful in determining the mechanism of paroxysmal supra- ventricular tachycardia (PSVT) accurately and easily have been continuously studied. Most studies were focused on the development of a method to differentiate AVNRT and AVRT using the septal atrioventricular bypass tract, since these two tachycardias are very difficult to differentiate even with electrophysiologic study (EPS). Several methods previously reported have some limitation in accuracy and/or applicability, Objectives: The purpose of this study is to develop a new electrophysiologic parameter by evaluating the usefulness of the difference (△VACT) and ratio(VACT ratio) of VA conduction time (VACT) during right ventricular pacing at the cycle length of supraventricular tachycardia (SVT) in determining the mechanism of SVT and localizing accessory pathways (AP) in AVBT. Methods: Total of 94 SVT patients undergoing EPS and radiofrequency (RF) catheter ablation for 35 AVNRT (17 male, 18 female; mean age 45.6±17.2 years) and 59 AVRT (36 male, 23 female; mean age 37.5 ±15.3 years) were included in this study, The electrophysiologic mechanism of SVT and the location of APs in A VRT were confirmed by RF catheter ablation in all the patients. AVNRT was typical form in 34 patients and atypical (slow-slow) form in one. Among 59 APs, 19 (32.2%) APs were right side (12: free wall, RFW group; 7: septum, SPT group), 40 (67.8%) APs were left side (37: free wall, LFW group; 3: septum, SPT group), EPS was performed using the standard technique. 6F multipolar electrode catheters were positioned at the high right atrium (HBA), atrioventricular junction (HIS), right ventricular apex (RVA) in all the patients, and coronary sinus if needed. SVT was induced in all the patients with programmed electrical stimulation. VA conduction time (VACT) was measured from the onset of QRS complex to the onset of atrial electrogram from the HRA during SVT (VACT-SVT) and during RVA pacing at the SVT cycle length (VACT-RVP). △VACT was calculated by subtracting VACT-SVT from VACT- RVP and VACT ratio by dividing VACT-RVP by VACT-SVT. AVNRT and AVRT were differentiated using the previously reported criteria and then RF catheter ablation was performed. RF was delivered at the target site through a 7F 4 mm-tipped deflectable ablation catheter using continuous unmodulated sine wave with 350 KHz or 500 KHz generated from RF generator (RFG-3B, Radionics, Burlington, Mass or HAT 200S, Osypka, Germany). Results: The preexcitation index (PI) could be measured with a single ventricular extrastimulus in 22 (62.9%) of 35 AVNRT patients and 49 (83.1%) of 59 AVRT patients. PI was 139±31 (range 90-200) in AVNRT, 30±11 (range 15-40) in RFW group, 29 20 (range 10-70) in SPT group, and 92±24 (range 55- 160) in LFW group, showing a significant difference between each groups, but considerable overlap (52.6% of 76) between each groups except between AVNRT and AVRT with right side AP, DVACT was 126±20 (range 76-168) ms in AVNRT, 179 (range 4-35) ms in RFW group, 29 ±25 (5-76) ms in SPT group, 79±16 (50-110) ms in LFW group, showing a significant difference between AVNBT and 3 groups of AVRT and between 3 groups of AVRT except between RFW group and SPT group (p<0.01). The frequency of the patients with overlap in AVACT was lower than that in PI(52.6% vs. 24.5%, p<0.05). △VACT with a cut-off value of 50 ms differentiated the sideness (right vs. left) of APs in 58 (98.3%) of 59 AVRT patients, VACT ratio was 3.671.22 (range 2.20-8.30) in AVNRT, 1.10,1 (range 1.03-1.29) in RFW group, 120.2 (range 1.03-1.29) in SPT group, and 1.5±0.1 (range 1.30-1,86) in LFW group, showing no overlap between AVNRT and AVRT. AVNRT and AVRT were completely differentiated with VACT ratio with a cut-off value of 2.0. Conclusion : It is concluded that the mechanism of SVT may be accurately differentiated into AVNRT or AVRT using VACT ratio with a cut-off value of 2.0 and the location of accessory pathwa

관상동맥 중재술을 시술받은 불안정형 협심증 환자에서 저분자량 헤파린의 장기 효과

홍영준(Young Joon Hong),정명호(Myung Ho Jeong),이승현(Seung Hyun Lee),박옥영(Ok Young Park),김주한(Ju Han Kim),김원(Weon Kim),류제영(Jay Young Rhew),안영근(Young Keun Ahn),조정관(Jeong Gwan Cho),박종춘(Jong Chun Park),서순팔(Soon Pa 대한내과학회 2002 대한내과학회지 Vol.63 No.2

배경: 급성 관동맥 증후군 환자에서 저분자량 헤파린은 기존의 미분획 헤파린에 비해 aPTT monitoring이 필요 없으며 피하주사로 쉽게 투여할 수 있다는 장점과 함께 주요 심장사고를 감소시키는 것으로 알려져 있다. 목적: 불안정형 협심증으로 내원하여 관상동맥 중재술을 시행한 환자 중 Dalteparin (Fragmin)을 사용했던 군과 미분획 헤파린을 사용했던 군 사이에 사망, 급성 심근경색증, 표적 병변 재개통술, 재협착률 등의 주요 심장사고 및 합병증에 대해 알아보기 위하여 본 연구를 시행하였다. 대상 및 방법: 1999년 1월부터 2001년 6월까지 전남대학교병원 심장센터에 입원하여 관상동맥 중재술을 시행 받고 6개월 이후에 추적 관상동맥 조영술을 시행한 불안정형 협심증 환자 180예를 대상으로 Dalteparin (Fragmin)을 사용했던 90예의 환자군을 I군(61.8±8.9세, 남:61, 여:29)으로, 미분획 헤파린을 사용했던 90예의 환자군을 II군(62.6±9.7세, 남:63, 여:27)으로 각각 분류하고 양군 사이에 임상적 및 관상동맥 조영술 특성과 주요 심장사고, 합병증에 대해 비교하였다. 결과: 1) I군에서 당뇨병 환자가 많았던 것 이외에(I군; 38/90명, 42.2% vs II군; 27/90명, 30.0%, p=0.021) 양 군 사이에 임상 양상에 있어서 유의한 차이는 없었다. 2) 병변 혈관의 수, 경색관련 혈관의 분포, TIMI flow, ACC/AHA 형태, 혈전 내재 병변, 스텐트 사용 여부, 병변 길이 등 관상동맥 조영술상 양군간에 유의한 차이는 없었다. 3) 재원 기간 중 급성 심근경색증, 표적 혈관 재개통술, 사망 등 주요 심장 사고에 있어서 양군간에 차이는 없었다. 4) 6개월 추적 관상동맥 조영술상 I군에 비해 II군에서 최소 혈관 내경의 유의한 감소 및 내경 협착률에 있어서 유의한 증가를 보였다(1.81±0.49 mm vs 1.64±0.44 mm, 32.2±14.5% vs 37.4±18.8%, 각각 p=0.035, 0.041). 5) 6개월 이후 추적 관상동맥 조영술상 재협착률은 I군에서 유의하게 낮았고(I군 26/90명, 28.8% vs II군 32/90명, 35.6%, p=0.041), 표적 혈관 재개통술에 있어서 I군에서 유의하게 낮았으나(I군 21/90명, 23.3% vs II군 27/90명, 30.0%, p=0.039), 사망률에 있어서 양군 사이에 유의한 차이는 없었다. 6) 합병증에 있어서 심각한 출혈성, 경미한 출혈성 부작용 및 허혈성 뇌졸중, 혈소판 감소증에 있어서 양군 사이에 유의한 차이는 없었다. 7) 관상동맥 중재술 후 재협착에 관여하는 인자는 스텐트 사용 여부, 병변 길이, 관상동맥 중재술 후 최소 혈관 내경, 내원 당시 CRP 수치, 당뇨병 동반 여부, 사용하였던 헤파린의 종류였다(p=0.032, 0.001, 0.001, 0.011, 0.022, 표 6). 결론: 불안정형 협심증 환자에서 저분자량 헤파린인 Dalteparin (Fragmin)을 사용했던 환자군에서 미분획 헤파린을 사용했던 환자군에 비해서 재협착률 및 관상동맥 재개통술이 유의하게 낮았다. Background: Antithrombotic therapy with heparin reduces the rate of ischemic events in patients with acute coronary syndrome. Low-molecular-weight heparin (LMWH), given subcutaneously twice daily, has a more predictable anticoagulant effect than standard unfractionated heparin, is easier to administer and does not require monitoring. Methods: We prospectively analyzed 180 patients with unstable angina who underwent percutaneous coronary intervention (PCI) between 1999 and 2001 at Chonnam National University Hospital to receive either 120 U/kg of Dalteparin (Fragmin), administered subcutaneously twice daily (group I; n=90, 61.8±8.9 years, male 67.8%), or continuous intravenous unfractionated heparin (group II; n=90, 62.6±9.7 years, male 70.0%). During hospitalization and at 6 month after PCI, major adverse cardiac events such as acute myocardial infarction, target vessel revascularization, death, or restenosis were examined. Results: During hospitalization, the incidence of acute myocardial infarction, target vessel revascularization and death were not different between two groups. At follow-up coronary angiography at 6 month after PCI, the incidence of restenosis was lower in group I than in group II (Group I; 26/90, 28.8% vs. Group II; 32/90, 35.6%, p=0.041) and the incidence of target vessel revascularization was lower in group I than in group II (Group I; 21/90, 23.3% vs Group II; 27/90, 30.0%, p=0.039). There was no difference in the rate of major and minor hemorrhage, ischemic stroke and thrombocytopenia between two groups. In the multivariate analysis, factors relating to restenosis were lesion length, postprocedural minimal luminal diameter, CRP on admission, diabetes mellitus, type of hepairn, stent use. Conclusion: Dalteparin, a LMWH, is superior to standard unfractionated heparin for reducing restenosis rate and target vessel revascularization without increasing bleeding complications. (Korean J Med 63:158-168, 2002)