˘ˇˆ˙˝ 1 - marianna uigakukai.marianna-u.ac.jp/idaishi/www/366/06-36-4hiromitu sekizuka.pdf ·...

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腉腌腊腆 臱腫腬腥腮腩腲腽膉膾臆 Vol. 36, pp. 537544, 2008 腏腚腍腗腘腎腄腌腇腀 腋腓腊腏腖腐腉腈腕腒腑腔腃腅腆腙腛腁腂 1 腏腈腔腇 膭膬 腛腨腠腓 1 腟腓腡腕 腖腆 2 腈腌 腧腤腄腍 1 腆腋 膜膿 腉腃腐腄 1 腟腜腂 腌腤腄腙腎腉 1 腕膑 腩腑腖腞 腥腌腣腈 1 腗腌 腉腓腠 1 腥腘腢腟 腝腃 1 致臵 腃腌腇腩 1 腖腇 3 腟腓 腛腋 3 腚腦 腕腡 3 腠腢腉 膋腨 腜腠腛腊 1 : 20 11 29 45 2007 10 12 膪臶 10 臉膵臒腖腵腐腋腕腰臍腅腶腖腇膋膈腖膫腘膐 腣臋膈腊腎膛腲腣臔臨腊12 膂腚臩腒臦AF腣腙腓腛腎腎腛腽腣臠膁 臔臨腊腎10 15 腝腟膽臫臦腌腠膟膝臦臩膖腹臸臷腧腭腨腦腪腮 腝腵膮膙臐臲腝腵腣膆臂腊腎膆臂腖臖臥臶腕腘膐腣臋膈腊腎腎腛腧腭腨 腦腪腮腒自膄臦臩腣膖臸腊腎30 腘膐腖膫臞臣腗膢膅腊腎腎腛腍腖腘腘 腞腸腊腎臸臦臩膖腄腞腘膐腖膻腖臦臩腗臦臏腫腤 VT腓臅腢腡腠QRS 腫腣腤膽腒腀腐腎臎臧膽腖膓腸腗腔腄腐腎腅 腰臍腅腶腖腇膋膈腖膩腳腣 VT 腓膗 臰膸腺腏腒臦臺膕臯膧膸 EPS腣膏腚膧膸腴腓腊腎10 25 EPS 腒腗自腖臈臻臫臦臏腫腣腱腕膂腤腉腡腎10 30 dual chamber 膝臤膴腙膝臛膺ICD腣臤腃膴腤腏腈腖臉AF VT 腓腖膎腗腗腐腆腟腊腔腄腐腎腴膫VT 膽腕腌腠自膄腖 ICD 臮臢膽臩膖腝腟 VT 腖臏腴腒腚腫腖腅臚臹腼腌腠腈腓腅膇腉腡腎臉膲腕膖腉腡腎腧腭腨腦腪腮腕腝腟臈臻臫臦臏腫腣腖膫 AF 臯腅膇腒腆腎VT 腖臏腴腒腚腅膱腫腖腕腔腐腎膥腾腍腖臦腫腖臁膣腕腝 AF 膂腤腉腡腠腈腓腅臡腉腡腎腇腄腋腅 臦臏腫腣臸臦腂腀腃腁 臢臨膊臑腅腻腞腄腖臞臣腣膋腋腎腓 腆腕臦臩腖膖腅腒腆腠膔膂腗膚腛腑臜腔腇腖臇腅膽臫腖腣膷腕腊腑腁腠膶膄 腍腖腝腂腔腻腄腣膃膤腌腠臓腓腊腑膀膅 腔膟膝臦臩膖腹臸臷腧腭腨腦腪腮 腝腵 膮膙臐臲腝腵腖膖臤膴腙膝臛膺implantable cardioveter defibrillator; ICD腯腺 AF 腖膩腳腅臦臏腫腣 腯腺 VT 腖膱腫腖腴腒腚腕腝腠腈腓腅臡 腉腡腎臞腣膠膨腊腎腖腒膳腌腠1 臱腫腬腥腮腩腲腽腽膉 臗膌膒2 臱腫腬腥腮腩腲腽腾膆3 臵膼臄腶腪腽膉 臗膌膒537 25

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mg�day ������� �atrovastatin 5mg�day ���

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��� T. P 6.8g�dl� T. bil 0.4mg�dl� GOT 75IU�l�GPT 119IU�l� LDH 215IU�l� ALP 303IU�l� g-

GTP 274IU�l� BUN 16.2mg�dl� Cr 0.79mg�dl�U. A 5.7mg�dl� Na 141mEq�l� K 3.7mEq�l� Cl108mEq�l� Mg 2.0mg�dl� Glu 105mg�dl ������ CRP 0.03 mg � dl ����TSH 1.39 mU �ml�0.436�3.78�� T3 3.9 pg�ml �2.1�4.1�� T4 1.3 ng�dl�1.0�1.7�� BNP 58.3 pg�ml��)*+,'( �Fig. 3�: ��s������������54�40mm� 5������+��12�14mm� ����� �EF�51�� E�A0.82� DcT196 msec� ���� ��s����� E[8�����5�t� ��s���, ;.� �op����¡�pw.��-./01'(: �3 12�4567: PQM��� �80 msec��I�II�III�aVF �V4�6 �48 ST ¢j�A-H�M: 50 msec� H-V �M: 43 msec� Wencke-bach rate: 180 ppm� jump-up£¤��� Fast path-way ¥4¡¦§¥4��,¨�.�3 �5���©ª � J£�,«wQ¬­� VT®S¯5�C� �Nj Vf:���&�A°F.� ±�6²³C� 200J 8OP�Adenosine 10 mg iv 8 ATP )1� �| fast

pathway ¥4¡´F� A-H�M: 125 msec� H-V�M: 29 msec: A-H �M¡����.� µ � PQ M� 127 msec 8�w.�UVWXYZ8 °F.!¶ QRS "b �wide

Figure 1. Chest X-ray films and electrocardiograms at the first medical examination.

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26

Figure 2. Portable transtelephonic electrogram.

Portable transtelephonic electrogram can store 30 seconds of data per event.

This shows a portable transtelephonic electrogram during sinus rhythm.

Figure 3. Echocardiograms.

A: Parasternal long-axis view: IVSTd�PWTd�12 mm�14 mm, LVDd�Ds�54mm�40mm, and EF�51�B: Apical 3-chamber view: E�A�0.82, DcT � 196 msec, and E�E[�9.5

AF ���������� � 1� 539

27

QRS tachycardia� �������������: �� ���� �Fig. 4� �������������� !�� ��"#$%& '( �Fig. 5�� ���) 30*+,-./0�����12 !� 3�4456 � '(789%&�:� ���;�789�7<=>?@A�.BC QRSD�=>EF"G�� H:��IJKL����MIJ�NO�KLP��?QR-. wide QRS tachycardia �%& S?�:VT P Vf MET-.UVWMG�� S�!XYZ["7\8]T�^[_Y�EPS��`a_Y5b? � cd�: 2efg� EPS"��� 3h�7<ijkl�mnop�qMrst�#uv�7<=>MwE��� 7<x�/yz�wE���4� ��o{�|+"}.+,W7<=> �sus-tained VT� P~+,W7<=> �nonsutaiend VT;NSVT� �wE������ ��7�kl �burst kl� �mn AF� 7���� 3����<W=>�wE������ -�A�� �� ��"%&��=�EF������� 3�d�? AFET�������t"}���� � � op�q�rst�#uv� VTM��[yz���W�/��wE��S??� ��M���?/ 1$���M���NO��� ��.S??� wide

Figure 4. Portable transtelephonic electrograph �Cardio-phone�.Portable transtelephonic electrograph �Cardio-phone� is a compact device �mass: 63�24�106.5mm; weight: 120 g�. In use, hold cardio-phone in the right hand, place the probe’s

electrodes to a point close to the heart, push

button, record an electrocardiogram, and

make a phone call to the host computer at the

hospital with the acoustic coupler held to

transmission part of the phone, which stores

the electrocardiogram and print it as soon as

the computer receives the electrocardiogram

over the phone.

Figure 5. Portable transtelephonic electrogram during palpitation.

Portable transtelephonic electrogram on the 1st day showed a wide QRS tachycardia

with a heart rate of 300 beats�min during palpitation. Palpitation was severe; however,the level of consciousness was clear. It lasted approximately 30 minutes.

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QRS tachycardia ������������� ������� ��������������� VT!��� Vf�"��#$�%�&'(���)�� 5�*� dual chamber+ ICD Ovatia DR6550� �ela medical ,- USA� ./012� ���� �� carvedilol 10mg � candesartan

12mg 3�45�6� 789�:;< AF� VT��=���>?@� �>6� 89 ABC*�VT �"�D$�� ICD �EF"��GH�I6� ICD "���J3JKL���@ VT �JMN�'J��OP$�N� �M�QR���S'T��UV$���'W�XY6 �Fig. 6�� ZY����P[Y6\]^_`������ �Fig. 7�ab$�� VT�M�QR'(�S� >6cd� J�(�Sef'P[Y AF'��XY���'g�XY6� 3�� carvedilol � candesartan �V/� sotalol 120mg V/6*� 9BC�hijk; VT�D$�EF"�� 2H!�<��� �"&J�l��mno�p�q? � ��

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����� rs+JKL�tQuvw\]^_`�; AF��#x\yz{'��� � >6|}

��;!>6� \]^_`�~�������������� QuJKL���6 �Fig. 5����;!Y�� ���i����� 30�k��"&J�l�;� �������;��XY6����;!>6�<�Y �� ���� ���QuJKL���@���������' wide QRStachycardia � 200 msec� ;!����@/6��� wide QRS tachycardia ��P��'��� �� ���'�6Y ���J�G 300����� VT�6��M&����PQR�V[>6 QRS����'����/�Y6� VT2�$��� 300J������ 30�k�<7�����&�� &¡¢&JM�� �monomorphic ventricular tachy-cardia� ;!@ '�� �P����£�¤ �6Y �6��� �� <�� �M&��;!>6¥¦�� RRk§'A�;!>6������J�¨�� 1D 1�MQR�6����Mc©3Hª&��'«��� ¬'>6'� 300�������­�J�G� $�����J�¨�'�@�/�Y6� JM��;!>6�� <� J�¨�2�� < 1:1�MQR'®[Y� �¯Y< EPS �°±;²³´I ��)�61�� µ�!¶·¸¹"º� EPS �cd� µ�!�EF;� EPS ;J»#��� 3 �J

Figure 6. Portable transtelephonic electrogram while ICD activated.

Accelerated atrial conduction due to VT was observed.

AF ���'QuJK¼;���6 1� 541

29

�������������� � VT������������������ ��� ������ !"��# wide QRS tachycardia �$ ���%&� ������� VT '()*Vf ��+,(-���.)/0�123��� /�34356789:;�<(=�*>�0��?� ICD@AB0����ICD @ABC VT ��,(DEF�GICDH�H�I$ �Fig. 6� 0J�KH�L$ �Fig. 7� <&� VT�M�?�� ICD �NDEOP��Q&���(/0�<&����� 3:1�1:1R0ST��� .���H�����UV(/0�<�� AF�W�,(�X�Y ���� /���!Z�*�[\]^"#�<&$_`ab�c�(�� �����%d�&�'��������Me��* 40�90�0���)(2�� ��� .�f!�',(0F�H�P��gh AF!�()0!Z�'(3��5�� )!&��.�f!�',(/043� Hi��,(f*j�k�^k�+l,�����3?�)(0123�� F�H�P��!?^,)mn�o��)�0123�(� p�* VT�M�,(/0�<&� \]!"�q-�43rs?�tuvwx;yz�UV� �����ST��� .���H������(/0�<&H�P���(012�� {�B�� Fig. 7

� VT.C AF� f/C| QRS/}�0~�'(* AF�<& ICD�H��8�8�;9;���/?� maximum tracking rate �`�F�,(/0�<(H��89;��'(0123��� e�&� ���1�F�H�P��*�`wide QRS tachycardia �'��/0^�N AF��;��� VT ���0���)�-���ICD H�H�I$ 0J�KH�I$����2�<&� ?����!&�'����GJ�KH�I$����2 �t����;�

� Fig. 4 �'(� )!&��3?�J�KH�I$����2*�4 120 g� �5�I��?�6&���$ �63�24�106.5mm� �'(� 7��3� 58�-��'&� ��;����\]� �t����;)9�¡:�;���¢$ £¤;�¥?��3#� ¦�§¨�<N©�<&)9�ª«zt¬w�3)�H�I­8¤��®,(/0�<&�;¤8���$ ��3�(� /H�L*\]�¯34!"��°?����±0_�H�I�$ �_(0)#$_�=>�'(� ±!"����?4²�?�)³´*?�'3�'(� “��;���H�I$ �2” 0?�µ>43� J�KH�I$����2*��¤8KH�I0����@�'(� 24 ��0)#7�?�����%V(� ��%<¶�4�Y·*��¤8K

Figure 7. Portable transtelephonic electrogram while ICD activated.

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�������������� �� ����������������� ����� �ST-T ���������� ����������������� !�"��� #����$%��&'���()*+� ,������-./�0�1��2���"��.��23�� 45� 6�' �789�()*+� �6 ��:��,�����;<'=�()�>�� ,����$�?!"#$@AB#��:�'C%D) 56 �&� 'E 2.3 F��� �����GHC%D�IJ)"�� 36�J)6�� K)� (��>7��,����$�?!"#$'#)LM)NO 147F�)*PQR9@�(/� 45@������L!)��� 62F����'EG�+� 42.2�J)� S!@�(/� DiMarcoJP and Philbrick JT8� @A!T)*� .KU�VW"X.)YZ6�@����� ������[\����G�+�'E 22���>(/U�� ��]^���_U��"��� ,����$�?!"#$�PQR9������G�+�`U2��,I��K)� ab-�cd� .@#����$���e/C%���f0g-h�6",����$�?!"#$�1��i�2��23L!)�1�j�4*I klT� mn�5o(�Up

q�rstu� m6;v@wUwx7� 89�yz{��:|�*}��~j�8U��l !)��;� <�=>�U�? �� !�U2��!"��$�%��C%I �6@��K�@���J/U�U2�� �p9�8A�{���'B�(��CD��� %��OD��8��L!/U�� (I(� S!��@�EFG��H�L!/U��I@�U/����b�PQR9�J�K�@A�i��L�2���6 "��L!)�

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�F���� ,����$�?!"#$� VT�AF�C%�&� ��6;��/@A���2�'�()M��@����6 '��(�

�@S�6 ��E� �N¡�@&/"� OF¢P!Q@AJ/ AF��(��£'��()¤¥�6 J)��>()�2�,����$�?!"#$�� �cd����M��&� �� 2Rm¡�SI "A��B� ���T¦�§UL!�#$�2��V�()�

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1� ��¨©ª¡z �M��E� �NGH@v��«P¬tPR� 2004�2005W +X­®Y�>� Circ J 2006; 70 �Suppl. VI�; 1391�1462.

2� Josephson ME. Clinical Cardiac Electrophysi-ology, 2nd ed. Philadelphia � London, Lea &Febiger, 1993.

3� Kannel WB, Abbott RD, Savarge DD andMcNamara PM. Epidemiologic features of

chronic atrial fibrillation: The Framingham

Study. N Engl J Med 1982; 306: 1018�1022.4� Wolf PA, Benjmin EJ, Belanger AJ, KannelWB, Levy D and D[Agostino RB. Secular

trends in the prevalence of atrial fibrillation,

the Framingham Study. Am Heart J 1996; 131:

790�795.5� ��¨©ª¡z ��P¯)�6 �Z[�«P¬tPR� 2005W +X­®Y�>� Circ J 2006.

6� Shimada M, Akaishi M, Asakura K, Baba A,Iwanaga S, Asakura Y, Miyazaki T, Mitamura

H and Ogawa S. Usefulness of the newly

developed transtelephonic electrocardiogram

and computer-supported response system. J

Cardiol 1996; 27: 211�217.7� °±A\� ²]^{� ²]_�`� &abc�]d³� e]´µ� ¶·f� ·¸g¹: )*'ºh���6 @�»�#�Y¼�������=���� M��­®� 2003; 80: 1945�1949.

8� DiMarco JP and Philbrick JT. Use of ambula-tory electrocardiographic �Holter� monitoring.Ann Intern Med 1990; 113: 53�68.

AF �[\�!"���V�() 1 543

31

Abstract

Portable Transtelephonic Electrograph Identified

the Underlying Cause of Atrial Fibrillation

Hiromitsu Sekizuka1, Naoki Matsumoto2, Yukako Ishikawa1, Kihei Yoneyama1,

Satoshi Nishio1, Yoshiyuki Watanabe1, Shounosuke Ryu1, Keizou Osada1,

Ryouji Kishi1, Emi Nakano3, Hisao Matsuda3, Tomoo Harada3,

and Fumihiko Miyake1

A 45-year-old male felt faint while driving around 10:00 o[clock on October 12; after that, he su#ered

from palpitation. He was diagnosed as having atrial fibrillation �AF� from the results of 12-lead electrocar-diography performed at the clinic near his house. He was referred to our hospital. From October 15, the

patient started to use portable transtelephonic electrograph �PTE�. On the same day, PTE recorded andtransmitted the electrocardiograms several times due to palpitation occurring before sleep. After he was

relieved from approximately 30-minute palpitation, he went to sleep. PTE showed prolonged QRS duration

during palpitation. He had no history of syncope. However, he felt faint while driving. Accordingly, he was

suspected as having ventricular tachycardia �VT� and was admitted to our hospital for electrophysiologicalstudy �EPS�. On October 25, EPS induced sustained VT. On October 30, the dual chamber implantablecardioverter defibrillator �ICD� was implanted. At this point, the relationship between AF and VT was notfully clarified. After admission, ICD was frequently used due to VT. The intracardiac electrocardiograms

showed greater intraventricular conduction shortening with increased pacing output. PTE, which was

recorded at the same time, demonstrated the onset of AF after nonsustained VT. We concluded that a

shorter intraventricular conduction time with increased pacing output triggered AF.

1 Division of Cardiology, St. Marianna University School of Medicine2 Division of Pharmacology, St. Marianna University School of Medicine3 Division of Cardiology, Kawasaki Municipal Tama Hospital

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