급성 심근경색으로 인한 심인성 쇼크 환자에 대한 경피적 순환 보조장치(EBS) 적용의 초기경험 = Initial Experience of the Emergency Bypass System (EBS) for the Patients with Cardiogenic Shock due to an Acute Myocardial Infarction

국문 초록 (Abstract)

배경: 경피적 순환 보조장치는 다른 수단으로는 소생이 불가능한 심인성 쇼크 환자에 있어서 매우 효과적인 생명유지 장치이다. 특히 심근경색 및 고위험군의 관상동맥중재술, 심장수술 후 심인성 쇼크 등 다양한 임상상황에서 사용되며, 사용이 손쉬운 장점을 가지고 있다. 저자들은 급성 심근경색으로 입원한 환자 중 심인성 쇼크가 발생하여 경피적 순환 보조장치를 사용한 환자들의 초기경험을 분석하였다. 대상 및 방법: 2005년 1월부터 2006년 12월까지 급성 심근경색에 의한 심인성 쇼크 환자 8명에게 경피적 순환 보조장치(CAPIOX emergent bypass system, EBS, Terumo Inc., Tokyo, Japan)를 적용하였다. Seldinger 방법을 사용하여 대퇴정맥에 20Fr의 유입관을 우심방까지 거치하고, 대퇴동맥에 16Fr의 유출관을 거치하면서 동시에 자가 충진을 완료하였다. 혈류량을 2.5∼3.0 L/min/m2으로 유지하였고, 헤파린을 정주하면서 ACT를 200초 이상으로 유지하였다. 결과: 환자의 평균나이는 61.1±14.2세(39∼77세)였다. 관상동맥중재술(PCI) 시행 이전에 거치한 경우가 3예, 중재술 도중 발생하여 거치한 경우가 3예, 중재술 후가 1예, 관상동맥우회술 후가 1예였다. 평균 EBS가동시간은 47.5±27.9시간(8∼76시간)이었으며, 이 중 EBS 이탈이 가능하였던 경우가 5명(62.5%)으로 이들은 모두 퇴원이 가능하였다. EBS 적용으로 인한 합병증은 모두 3예로 급성 신부전이 2예, 위장관 출혈이 1예 있었다. 사망한 3명의 환자 중 2명은 EBS 적용 전 심정지가 와 있었던 경우였으며, 1명은 난치성 심실세동이 있었던 경우였다. 퇴원한 환자는 모두 생존하여 평균 16.8±3.1개월(12∼20개월)째 외래 추적관찰 중이다. 결론: 다른 방법으로 소생이 힘든 급성 심근경색으로 인한 심인성 쇼크 환자에게 EBS를 적용함으로써 환자의 생명을 구할 수 있었고, 일단 회복된 환자들은 별다른 후유증 없이 생존하였다. 향후 EBS의 적절한 적용시기와 적용방법에 대해서는 보다 많은 경험 및 임상연구가 필요할 것으로 생각된다.

다국어 초록 (Multilingual Abstract)

Background: Percutaneous cardiopulmonary support (PCPS) has the potential to rescue patients in cardiogenic shock who might otherwise die. PCPS has been a therapeutic option in a variety of the clinical settings such as for patients with myocardial infarction, high-risk coronary intervention and postcardiotomy cardiogenic shock, and the PCPS device is easy to install. We report our early experience with PCPS as a life saving procedure in cardiogenic shock patients due to acute myocardial infarction. Material and Method: From January 2005 to December 2006, eight patients in cardiogenic shock with acute myocardial infarction underwent PCPS using the CAPIOX emergency bypass system (EBSⓇ, Terumo, Tokyo, Japan). Uptake cannulae were inserted deep into the femoral vein up to the right atrium and return cannulae were inserted into the femoral artery with Seldinger techniques using 20 and 16-French cannulae, respectively. Simultaneously, autopriming was performed at the EBSⓇ circuit. The EBSⓇ flow rate was maintained between 2.5∼3.0 L/min/m2 and anticoagulation was performed using intravenous heparin with an ACT level above 200 seconds. Result: The mean age of patients was 61.1±14.2 years (range, 39 to 77 years). Three patients were under control of the EBSⓇ before percutaneous coronary intervention (PCI), three patients were under control of the EBSⓇ during PCI, one patient was under control of the EBS after PCI, and one patient was under control of the EBSⓇ after coronary bypass surgery. The mean support time was 47.5±27.9 hours (range, 8 to 76 hours). Five patients (62.5%) could be weaned from the EBSⓇ after 53.6±27.2 hours (range, 12 to 68 hours) of support. All of the patients who could successfully be weaned from support were discharged from the hospital. There were three complications: one case of gastrointestinal bleeding and two cases of acute renal failure. Two of the three mortality cases were under cardiac arrest before EBSⓇ support, and one patient had an intractable ventricular arrhythmia during the support. All of the discharged patients are still surviving at 16.8±3.1 months (range, 12 to 20 months) of follow-up. Conclusion: The use of EBSⓇ for cardiogenic shock caused by an acute myocardial infarction could rescue patients who might otherwise have died. Successfully recovered patients after EBSⓇ treatment have survived without severe complications. More experience and additional clinical investigations are necessary to elucidate the proper installation timing and management protocol of the EBSⓇ in the future.

참고문헌 (Reference)

1 이일, "허혈성 심질환으로 인해 병원 내에서 발생한 심정지 혹은 심인성 쇼크에 있어서의 경피적 심폐 보조장치의 치료 경험" 대한흉부외과학회 39 (39): 201-207, 2006

2 Yamashita C, "Usefulness of postoperative percutaneous cardiopulmonary support using a centrifugal pump: retrospective analysis of complications" 23 : 360-365, 1998

3 Keeley EC, "Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials" 361 : 13-20, 2003

4 Suarez de Lezo J, "Percutaneous cardiopulmonary support in critical patients needing coronary interventions with stents" 57 : 467-475, 2002

5 Sung K, "Improved survival after cardiac arrest using emergent autopriming percutaneous cardiopulmonary support" 82 : 651-656, 2003

6 Reichman RT, "Improved patient survival after cardiac arrest using a cardiopulmonary support system" 49 : 101-105, 1990

7 Schwarz B, "Experience with percutaneous venoarterial cardiopulmonary bypass for emergency circulatory support" 31 : 758-764, 2003

8 Hill JG, "Emergent applications of cardiopulmonary support: a multiinstitutional experience" 54 : 699-704, 1992

9 Matsuwaka R, "Emergency cardiopulmonary bypass support in patients with severe cardiogenic shock after acute myocardial infarction" 11 : 27-29, 1996

10 Vanier J, "Elective high-risk percutaneous interventions supports by extracorporeal life support" 99 : 771-773, 2007

11 Orime Y, "Clinical experiences of percutaneous cardiopulmonary support: its effectiveness and limit" 22 : 498-501, 1998

12 Sakamoto S, "Clinical effects of percutaneous cardiopulmonary support in severe hear failure: early results and analysis of complications" 9 : 105-110, 2003

13 Burkle CM, "Cardiopulmonary bypass support for percutaneous coronary interventions: what the anesthesiologist needs to know" 19 : 501-504, 2005

14 William DC, "Analysis of clinical trends in a program of emergent ECLS for cardiovascular collapse" 43 : 65-68, 1997

15 Antman EM, "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)" 110 : 588-636, 2004

16 Andersen HR, "A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction" 349 : 733-742, 2003

17 임상엽, "75세 이상 고령 급성 심근경색증 환자에서 일차적관상동맥 중재술 후 장기적 임상 경과" 대한심장학회 35 (35): 613-619, 2005