한국인 심장 질환의 임상적 고찰 및 심낭액단백에 관한 연구

Abstract

[한글]

1929년 Forssmann이 수뇨관 도자를 이용하여 자기의 우심에 삽입하여 우심도자법을 시도한 이후 Cournand 및 Ranges(1941)는 이 방법을 심장질환진단 목적으로 이용하였고, Zimmerman등 (1950)은 좌심도자법에 성공하였으며, Sodi-Pollaries등 (1954)은 전극도자를

이용 좌우심장에 혈역학적 변동을 비교적 정확히 이해할 수 있게 하였다.

대부분의 심장질환은 심장내 혈역학적 변호를 초래하여 심장내의 혈류 및 압력등을 변동시키고 이 변화는 심질환의 진단, 수술의 적응, 수술후 예후를 추정하는데 지침이 되고 있다. 이와 같은 혈역학적 변동으로 인한 혈관의 압력변화는 심낭액의 분비 흡수 및 그

생화학적 성분의 변동을 관계하고 있는 것으로 생각된다. 심낭액의 분비 및 흡수기전 그 생화학적 성분 및 그 변동에 관하여 계통적 연구보고는 없다.

Mellins등 (1970)에 의하면 동물실험에서 폐 및 체정맥의 압력이 상승하면 심낭액의 삼출증가를 가져온다고 하였고 Miller등 (1971)은 심장의 정맥과 임파관을 차단하여 epicardium(visceral pericardium)으로부터 심낭액이 유출되는 것을 관찰 보고하였으며, Hutchin 등 (1971)은 환자의 심낭액과 동맥혈의 전해질, 산염기조성 등에 관하여 비교 검토하였다. 즉 심낭액의 삼출 및 흡수기전, 그 생화학적 성분등은 심장 임파액의 유입 및 유출과정, 폐 동정맥 및 체 동정맥의 압력 및 plasma colloid osmotic pressure등등 여러 요소

가 관계하는 것으로 생각된다.

저자는 1963년부터 1975년까지 세브란스병원 심장검사실에서, 심도자검사에 의하여 심질환이 확진된 환자 1,252예와, 이 환자중 외과적 수술을 시행한 508예를 대상으로 심도자검사에 의한 심질환의 분포, 수술 성적, 심낭액 단백과 폐 동정맥의 혈류양 및 압력과

의 관계를 검색하는 동시에 단백분리에 있어 가장 예민한 원반전기 영동법(disc electrophoresis) 및 isoelectic focusing법을 이용하여 심낭액을 분획시도 하였다.

이상의 실험결과를 요약하면 다음과 같다.

1. 과거 12년간 (1963-1975) 세브란스 병원에서 심도자 검사로 진단한 심장질환 1,252예중 절반이 선청성(640예)이며 이 선천성 심질환예중 심실중격결손이 20.47%로 가장 많았고 활로씨 4증후는 17.66%로써 서구의 보고에서 보다 빈도가 높았다. 그러나 서구에서

적지않은 대동맥 교약증은 과거 12년간에 발견되지 않았고 심한 폐동맥 전색증은 1예에 불과하였다.

2. 개심술 265예의 사망률은 14%(37예), 비개심술 243예의 사망률은 4.5%(11예)로 총 심장수술 508예중 9.5%(48예)가 사망하였다.

3. 활로씨 4증후 및 심방중격결손증 환자의 심낭액 단백량은 정상이었으나 승모판 협착증에서는 심낭액단백량이 현저히 증가하였으며 이는 폐동맥 또는 좌심방의 압력이 정상보다 상승되면 단백량도 증가하는 것으로 해석된다.

4. 원반 전기영동법에 의한 심낭액단백의 분획상은 9-20개로 평균 13.7개의 분핵으로 나타났으며 그 양상이 혈청의 분획상과 거의 유사하였다.

5. Isoelectric focusing에 나타난 심낭단백 분획수는 19개로 나타났다.

Clinical Studies on the Hear Diseases and Pericardial Fluid Protein in Korean

Bum Koo Cho,

Department of Medical Science The Graduate School, Yonsei University

(Directed by Professor Woo Choo Lee)

Since 1929, Forssmann attempted originally the method of right heart

catheterization by the insertion of the catheter into his own heart, it was

developed as a diagnostic methods by Cournand and Ranges(1941). In 1950, the left

heart catheterization was developed by Zimmermann, and it was popularized with the

aid of electrode catheter which was modified by Sodi-Pollaries(1954).

The hemodynamic changes in cardiac disoders in of great value to dertermine the

status of the disoder, the surgical indication or its prognosis. Often the

hemodynamic changes lead to elicit the accumulation of the pericardial fluid and

bring about biochechemical changes of its contents. Little was known on the

mechanism of pericardial fluid accumulation and resorption. Recently, Mellins et al

(1970) reported some studies on the pericardial fluid accumulation during combined

pulmonary and systemic venous hypertention. Hutchin et al (1971) reported on the

changes of electolyte and Acid-Base composition of pericardial fluid. Miller et al

suggested that the obstruction of the venous blood and lymph outflow from the heart

muscle might lead to the formation of a pericardial effusion originating primarily

from the epicardial surface of the heart(the visceral pericardium). Many factors

have been identified as causing a pericardial effusion, but little attention has

been given the mechanism by which pericardial fluid forms and accumulates.

The present study was undertaken to observe 1) the incidence of the cardiac

disease in 1,252 Korean patients who were diagnosed by the invasive technique, 2)

the results of the heart surgery in 508 patients including open cardiac surgery, 3)

the effects on pericardial fluid protein concentration due to pulmonary and left

atrial hypertension in various cardiac disease, 4) results of fractionation of

pericardial fluid by disc electrophoresis or isoelectric focusing.

The results are summarized as follows;

1. Among 1,252 Korean heart disorders confirmed by invasive technique, one-half

(640 cases) were congenital. In these congenital diseases 20.47% (131 cases) were

revealed Ventricular Septal Defect and 17.66% (113 cases) were Tetralogy of Fallot,

These incidences are higher than those of western and none of Coarctation of Aorta

and only a case of severe Pulmonary Embolism was noted during past 12 years.

2. Overall hospital morality of cardiac surgery among 508 patients is 9.4%, and

mortality of open cardiac surgery (14%) is higher than closed procedure (4.6%).

3. Protein concentration of pericardial fluid is normal in Tetralogy of Fallot

and Atrial or Ventricular Septal Defect, but significantly increased in mitral

stenosis which has pulmonary arterial and left arterial hypertension.

4. By means of disc electrophoresis, the human pericardial fluid separated into

9-20 fractions and the pattern of fraction is similar between protein in serum and

pericardial fluid.

5. By isoelectric focusing of the human pericadial fluid, 19 fractions are

identied.

This study is Partially supported by the Faculty Grant(1975) of Yonsei University

College of Medicine.

[영문]

Since 1929, Forssmann attempted originally the method of right heart catheterization by the insertion of the catheter into his own heart, it was developed as a diagnostic methods by Cournand and Ranges(1941). In 1950, the left heart catheterization was developed by Zimmermann, and it was popularized with the

aid of electrode catheter which was modified by Sodi-Pollaries(1954).

The hemodynamic changes in cardiac disoders in of great value to dertermine the status of the disoder, the surgical indication or its prognosis. Often the hemodynamic changes lead to elicit the accumulation of the pericardial fluid and bring about biochechemical changes of its contents. Little was known on the

mechanism of pericardial fluid accumulation and resorption. Recently, Mellins et al (1970) reported some studies on the pericardial fluid accumulation during combined pulmonary and systemic venous hypertention. Hutchin et al (1971) reported on the changes of electolyte and Acid-Base composition of pericardial fluid. Miller et al suggested that the obstruction of the venous blood and lymph outflow from the heart muscle might lead to the formation of a pericardial effusion originating primarily from the epicardial surface of the heart(the visceral pericardium). Many factors have been identified as causing a pericardial effusion, but little attention has been given the mechanism by which pericardial fluid forms and accumulates.

The present study was undertaken to observe 1) the incidence of the cardiac disease in 1,252 Korean patients who were diagnosed by the invasive technique, 2) the results of the heart surgery in 508 patients including open cardiac surgery, 3) the effects on pericardial fluid protein concentration due to pulmonary and left

atrial hypertension in various cardiac disease, 4) results of fractionation of pericardial fluid by disc electrophoresis or isoelectric focusing.

The results are summarized as follows;

1. Among 1,252 Korean heart disorders confirmed by invasive technique, one-half (640 cases) were congenital. In these congenital diseases 20.47% (131 cases) were revealed Ventricular Septal Defect and 17.66% (113 cases) were Tetralogy of Fallot,

These incidences are higher than those of western and none of Coarctation of Aorta and only a case of severe Pulmonary Embolism was noted during past 12 years.

2. Overall hospital morality of cardiac surgery among 508 patients is 9.4%, and mortality of open cardiac surgery (14%) is higher than closed procedure (4.6%).

3. Protein concentration of pericardial fluid is normal in Tetralogy of Fallot and Atrial or Ventricular Septal Defect, but significantly increased in mitral stenosis which has pulmonary arterial and left arterial hypertension.

4. By means of disc electrophoresis, the human pericardial fluid separated into 9-20 fractions and the pattern of fraction is similar between protein in serum and pericardial fluid.

5. By isoelectric focusing of the human pericadial fluid, 19 fractions are identied.

This study is Partially supported by the Faculty Grant(1975) of Yonsei University College of Medicine.