Twenty-Year Experience of Heart Transplantation: Early and Long-Term Results

BACKGROUND: We evaluated early and long-term results after heart transplantation (HTPL). METHODS: One hundred five consecutive patients (male:female=80:25) who underwent HTPL between 1994 and 2013 were enrolled. Based on the changes in immunosuppressive regimen, the study patients were divided into two groups. Early and long-term clinical outcomes were evaluated and compared between the patients who underwent HTPL before (group E, n=41) and after July 2009 (group L, n=64). The group L patients were older (p<0.001), had higher incidence of hypertension (p=0.001) and chronic kidney disease (p<0.001), and more frequently needed preoperative mechanical ventilation (p=0.027) and mechanical circulatory support (p=0.014) than the group E patients. RESULTS: Overall operative mortality was 3.8%, and postoperative morbidities included acute kidney injury (n=31), respiratory complications (n=16), reoperation for bleeding (n=15) and wound complications (n=10). There were no significant differences in early results except acute kidney injury between group E and group L patients. Overall survival rates at 1, 5, and 10 years were 83.8%, 67.7%, and 54.9%, respectively, with no significant difference between the two patient groups. Rejection-free rates at 1 and 5 years were 63.0% and 59.7%, respectively; rates were significantly higher in group L than in group E (p<0.001). CONCLUSION: Despite increased preoperative comorbidities, group L patients showed similar early and long-term outcomes and significantly higher rejection-free rates when compared with group E patients.

Primary Cardiac Angiosarcoma Presenting With Cardiac Tamponade

Primary cardiac angiosarcoma is a very rare disease with a poor prognosis. We report a case of a patient with a primary cardiac angiosarcoma who presented with cardiac tamponade; the angiosarcoma was successfully resected surgically.

Right Coronary Artery to Left Ventricular Fistula with a Giant Right Coronary Artery Aneurysm: A case report / 대한흉부외과학회지

A right coronary artery to left ventricular fistula with a giant right coronary artery aneurysm is a very rare condition. This requires surgical treatment because of the possibility of rupture of aneurysm, heart failure and infective endocarditis. A 47 years old male patient with dyspnea on exertion for 3 months was diagnosed as having a right coronary artery to left ventricular fistula with a giant right coronary artery aneurysm according to the CT and coronary artery angiography. We resected the aneurysm and performed a coronary artery bypass graft.

Effect of Low Dose Norepinephrine Infusion on Myocardial Oxygen Consumption and Lactate Metabolism / 대한마취과학회지

BACKGROUND: Norepinephrine infusion has been reported to be associated with adverse events in ischemic heart disease due to elevation of afterload and cardiac oxygen consumption. During coronary artery bypass graft, we observed changes of hemodynamic and laboratory parameters in low dose norepinephrine infusion. Also, we investigated effects of norepinephrine on cardiac oxygen metabolism by calculating oxygen consumption and lactate extraction ratio. METHODS: Fifteen patients, ASA PS class IV-V, scheduled for elective coronary artery bypass graft were enrolled in this study. All of the operations were performed under general anesthesia. During harvesting of graft vessels, norepinephrine was infused at the rate of 0.02microgram/kg/min, and then at the rate of 0.05microgram/kg/min. We measured various hemodynamic and laboratory parameters in three periods (baseline, NE 0.02microgram/kg/min, NE 0.05microgram/kg/min). Also we calculated oxygen consumption and lactate extraction ratio of myocardium. RESULTS: In the baseline period(no norepinephrine infusion), oxygen consumption (VO2) is 159.2 +/- 78.6 ml/min, lactate extraction ratio (LER) is 33.1 +/- 13.0%. After norepinephrine infusion at the rate of 0.02microgram/kg/min, VO2 is 157.6 +/- 55.7 ml/min, LER is 29.9 +/- 10.7%. After norepinephrine infusion at the rate of 0.05microgram/kg/min, VO2 is 212.5 +/- 134.5 ml/min, LER is 27.9 +/- 13.4%. Although VO2 and LER are changed in relation to the rate of norepinephrine infusion, there was no statistical significance. CONCLUSIONS: In conclusion, infusion of low dose norepinephrine during coronary artery bypass graft did not produce significant differences in myocardial oxygen consumption and lactate extraction ratio associated with myocardial oxygen balance.

Nuss Operation with Simultaneous Intracardiac Repair: A case report / 대한흉부외과학회지

There are still some controversies regarding one stage repair of pectus deformity with congenital heart disease due to probable complications after extensive resection of deformed cartilages. We performed Nuss operation with simultaneous intracardiac repair in 8 year old patient with pectus excavatum and partial atrioventricular septal defect. The result of operation was satisfactory without prolongation of operation time, bleeding or instability of chest wall.

Changes of Coagulability after Off-pump CABG: Comparison with On-pump CABG / 대한흉부외과학회지

BACKGROUND: Hemostatic function is regarded to be preserved after an off-pump coronary artery bypass grafting (CABG), compared to conventional CABG, and the preserved hemostatic function may increase thrombotic occlusion of the graft. We studied the changes of hemostatic variables in patients undergoing off-pump CABG, and compared to those of on-pump CABG. MATERIAL AND METHOD: We studied the changes of coagulation function in 11 patients who underwent off-pump CABG (group I), and compared them with those of 11 patients who underwent on-pump CABG and Dor procedure (group II). Coagulation status was evaluated by thromboelastography and blood coagulation test preoperatively, postoperative 1st day, 2nd day, 3rd day, and 5th day, respectively. RESULT: Among the variables measured by thromboelastography (such as r time, k time, alpha angle, and MA value) and blood coagulation test (such as factor VII, protein S, protein C, antithrombin III, activated protein C resistance test, plasminogen, D-dimer, prothrombin time, activated partial thromboplastin time, platelet count, hemoglobin, and fibrinogen), there were significant differences in the MA value, alpha angle, and platelet counts between the two groups. MA values were 140+/-72% and 153+/-98% in group I, and 87+/-27% and 78+/-28% in group II, at postoperative 3rd and 5th days, respectively (p<0.05). alpha angle was 122+/-92% in group I and 69+/-23% in group II at postoperative 3rd day (p=0.09). Platelet count was 63+/-55% in group I and 33+/-13% in group II at postoperative 3rd day (p<0.05). CONCLUSION: Patients who underwent off-pump CABG showed increased coagulability during postoperative periods, compared to those who underwent on-pump CABG. Our data suggest that aggressive perioperative anticoagulation therapy is warranted in patients undergoing off-pump CABG.

Biocompatibility and Histopathologic Changes of the Acellular Xenogenic Pulmonary Valved Conduit Grafted in the Right Ventricular Outflow Tract / 대한흉부외과학회지

BACKGROUND: The xenogenic or allogenic valves after in vitro repopulation with autologous cells or in vivo repopulation after acellularization treatment to remove the antigenicity could be used as an alternative to synthetic polymer scaffold. In the present study, we evaluated the process of repopulation by recipient cell to the acellularized xenograft treated with NaCl-SDS solution and grafted in the right ventricular outflow tract. MATERIAL AND METHOD: Porcine pulmonary valved conduits were treated with NaCl-SDS solution to make the grafts acellularized and implanted in the right ventricular outflow tract of the goats under cardiopulmonary bypass. After evaluating the functions of pulmonary valves by echocardiography, goats were sacrificed at 1 week, 1 month, 3 months, 6 months, and 12 months after implantation, respectively. After retrieving the implanted valved conduits, histopathologic examination with Hematoxylin-Eosin, Masson's trichrome staining and immunohistochemical staining was performed. RESULT: Among the six goats, which had been implanted with acellularized pulmonary valved conduits, five survived the expected time period. Echocardiographic examinations for pulmonary valves revealed good function except mild regurgitation and stenosis. Microscopic analysis of the leaflets showed progressive cellular in-growth, composed of fibroblasts, myofibroblasts, and endothelial cells, into the acellularized leaflets over time. Severe inflammatory response was detected in early phase, though it gradually decreased afterwards. The extracellular matrices were regenerated by repopulated cells on the recellularized portion of the acellularized leaflet. CONCLUSION: The acellularized xenogenic pulmonary valved conuits were repopulated with fibroblasts, myofibroblasts, and endothelial cells of the recipient and extracellullar matrices were regenerated by repopulated cells 12 months after the implantation. The functional integrity of pulmonary valves was well preserved. This study showed that the acellularized porcine xenogenic valved conduits could be used as an ideal valve prosthesis with long term durability.

Relationship of Hemodynamic Changes during Off-Pump Coronary Bypass Grafting and Their Effects on Postoperative Outcome / 대한흉부외과학회지

BACKGROUND: During the Off-Pump Coronary Arterial Bypass surgery (OPCAB), the manipulation of the heart can depress cardiac contractility and cause hemodynamic instability. In this study, hemodynamic parameters were measured during operation and the laboratory and clinical data were investigated to evaluate their effects on postoperative outcome. MATERIAL AND METHOD: From March 2001 to August 2002, 50 consecutive patients who underwent OPCAB were included in this study. During the same period, total number of CABG was 71. The blood pressure, pulmonary artery pressure, mixed venous oxygen saturation, and cardiac index were measured before manipulation, after application of stabilizer, and at the end of anastomosis. Postoperatively, we measured the cardiac enzymes such as CK-MB, troponin I and checked the amount of inotropes required, chest tube drainage, the amount of transfusion, duration of ventilator support, and duration of ICU stay. RESULT: The number of mean distal anastomoses was 2.8+/-0.9 per patient. On elevation and stabilization of the heart, systolic blood pressure was depressed and pulmonary artery pressure was elevated significantly, but during each anastomosis no significant changes were detected. The peak level of cardiac markers was 29.2+/-46.7 for CK-MB, 0.69+/-0.86 for troponin I on postoperative day 1. Among the intraoperative hemodynamic parameters, the ischemic change of EKG and bolus injection of inotropes significantly affected the posteroperative cardiac enzymes. But, no difference other than the level of cardiac enzymes between the two groups with or without the ischemic change of EKG and bolus injection of inotropes was noticed. CONCLUSION: The significant hemodynamic changes occurred when the heart was elevated and stabilized, however during anastomoses there were no significant changes. Serum cardiac enzymes rose significantly in the group that showed the ischemic change of EKG or needed the bolus injection of inotropes for maintaining hemodynamic stability intraoperatively, but it did not affect the postoperative outcome. In conclusion, the ischemic change of EKG and the need for bolus injection of intropes during operation may be very indicative for probable ischemia.

Thoracodorsal Artery as an Alternative in Complete Arterial Coronary Revascularization: 3 Cases / 대한흉부외과학회지

It is now widely accepted that the complete arterial coronary revascularization has better short and long term results compared to coronary bypass surgery using arterial graft mixed with vein graft mainly due to its superior patency rate. However, sometimes the internal thoracic artery and other conventionally used grafts might be unavailable or it may require caution in using bilateral internal thoracic artery especially in diabetic patient because of the possible risk of the mediastinitis or other associated morbidities. Moreover, there could also be a shortage for arterial graft in case of coronary reoperation. We report our first three cases using thoracodorsal artery(TDA) as an alternative graft in complete arterial coronary revascularization.

Mechanical Obstruction of Right Coronary Artery during Aortic Valve Replacement / 대한흉부외과학회지

Although the incidence is very low, acute mechanical obstruction of the right coronary artery may occur as a cause of right ventricular failure during aortic surgery. In a 67-year-old woman with severe aortic regurgitation, acute right ventricular failure was noticed at the end of cardiopulmonary bypass weaning after an aortic valve replacement with a Hancock II 19 mm bioprosthesis. We suspected mechanical obstruction of the right coronary artery and consequent coronary artery bypass graft to the right coronary artery with right internal mammary artery was performed with success in weaning the bypass. On the postoperative 9th day, the right coronary angiogram revealed obstruction at proximal right coronary artery by plaque emboli. We herein report a clinical case in which the acute right ventricular failure occurred due to mechanical obstruction of the right coronary artery was recovered by coronary artery bypass graft to the right coronary artery.

Modification of the Cox-Maze III Procedure / 대한흉부외과학회지

BACKGROUND: The extended operative time needed for surgery in complicated atrial incision may preclude application of the Cox-Maze III procedure(CM-III) as a concomitant operation with standard open heart surgery. MATERIALS AND METHOD: We have modified the CM-III by : (1) obliterating the left atrial(LA) appendage instead of excising it, (2) cryoablating the bridge between the LA appendage and margin of pulmonary vein encircling incision, (3) extending the lateral incision of right atrium(RA) onto the RA appendage without excising the RA appendage, and (4) omitting the T-incision of the RA from the lower portion of posterior longitudinal right atriotomy. To assess the simplicity and efficiency of our modifications, we compared the clinical results of the conventional CM-III(group I) with those of the modified CM-III(group II) performed in patients with rheumatic mitral valve(MV) disease. RESULT: In group I(n=18), the combined procedures were mitral valve replacement(MVR) in 10, MV repair in 3, MVR and tricuspid annuloplasty(TAP) in 3, and redo-MVR in 2 patients. In group II(n=23), the combined procedures were MVR in 7, MV repair in 5, MVR and TAP in 1, and redo-MVR in 10 patients. Mean aortic cross clamp(ACC) times were 135 +/-29 minutes and 104 +/-18 minutes, and cardiopulmonary bypass(CPB) times were 240 +/-33 minutes and 185 +/-42 minutes in group I and group II, respectively. All patients were followed for a mean duration of 47 +/-14 and 29 +/-4 months after the operation in group I and group II, respectively. In group I, sinus rhythm was restored in 16 patients(88.9 %). One patient remained in AF and another patient needed pacemaker implantation due to sick sinus syndrome. In group II, sinus rhythm was restored in 21 patients(91.3 %) and AF in 2 patients. In group I, RA contractility was demonstrated in 100% of patients(16/ 16) and LA contractility in 75%(12/ 16) in the latest follow-up echocardiography. In group II, RA contractility was demonstrated in 100 % of patients(21/22) and LA contractility in 76.2% (16/21). CONCLUSION: Our modified CM-III showed comparable sinus conversion rates and incidence of atrial contractility restoration with significantly shorter ACC time(p<0.005) and CPB time(p<0.001) than the conventional CM-III.

Off-Pump Coronary Artery Bypass Grafting / 대한흉부외과학회지

BACKGROUND: We analyzed the result of the "Off-Pump" Coronary Artery Bypass grafting (OPCAB) performed to minimize inflammatory responses to cardiopulmonary bypass and myocardial ischemia during the aortic cross-clamp period. MATERIAL AND METHOD: The preoperative diagnosis operative procedure mortality complication and postoperative course of the 50 patients who underwent OPCAB between January 1998 and September 1998 were analyzed. There were 34 males and 16 females with mean age of 60+/-9 years. Preoperative clinical diagnoses were unstable angina in 31(62%) stable angina in 16(32%) and clinical diagnoses were unstable angina in 31(62%) stable angina in 16(32%) and postinfarction angina in 3(6%) patients. Preoperative angiographic diagnoses were three-vessel disease in 25(50%) two-vessel disease in 5(10%) one-vessel disease in 7(14%) and left main disease in 13(26%) patients. There were elective operation in 37 cases and urgent operation in 13 cases. RESULT: The mean number of grafts was 3.2+/-1.2 per patient. Grafts used were unilateral internal thoracic artery in 43 greater saphenous vein in 37 radial artery in 7 bilateral internal thoracic arteries in 4 and right gastroepiploic artery in 2 cases Forty sequential anastomoses were performed in 18 cases. Vessels accessed were left anterior descending artery in 48 diagonal branch in 41 obtuse marginal branch in 30 right coronary artery in 24 posterior descending artery in 9 ramus intermedius in 5 and posterolateral branch in 5 anastomoses. Predischarge coronary angiography performed in 44 patients demonstrated the patency rate of 89.5%(128/143) Operative mortality was 2%(1/150) Postoperative complications were arrhythmia in 5 graft occlusion that needed reoperation in 4. perioperative myocardial infarction in 2 femoral artery thromboembolism developed after the application of IABP in 1 postoperative transient delirium in 1 peripheral compression neuropathy in 1 case. Sixteen patients(32%) were extubated at the operating room and the other patients were extubated at the mean 13+/-20 hours after the operation. Mean duration of stay in intensive care unit was 49+/-46 hours. Thirteen patients(26%) required blood transfusions perioperatively and the amount of perioperative blood transfusion was mean 0.70+/-1.36 pack/patient. CONCLUSIONS: OPCAB is suggested to be the ideal technique with less postoperative complication less hospitalization time and less cost.

Effect of Serum magnesium Concentration on Postoperative Arrhythmias after Open Heart Surgery / 대한흉부외과학회지

BACKGROUND: Magnesium is one of the important intracellular cations. Hypomagnesemia is common after an open heart surgeryand may affect the development of posoperative arrhythmias. The aims of this study were to identify 1) the severity of the hypomagnesemia 2) the adequate dose of the magnesium replacement and 3) the effect of magnesium replacement on the postoperative arrhythmias. MATERIAL AND METHOD: The serum magnesium level was measured in 20 patients in whom magnesium was replaced postopertively(6gm at the operative day 4gm at the 1st postoperative day and 2gm at the 2nd postoperative day) and compared with that of the 13 patients in whom magnesium was not replaced postopertively The serum magnesium level was normalized after magnesium replacement. We analyzed the development of arrhythmias in the patients groups who did not receive magnesium and were operated on between Oct. 1994 and Oct. 1995(Group I; n=206) and who received the magnesium postoperatively and were operated on between Nov. 1995 and Aug. 1996(Group II; n=133) RESULT: There were no differences in the preoperative risk factors and the rate of postoperative supraventricular or ventricular tachyarrhythmia occurrences irrespectivel of the magnesium replacement. Magnesium replacement could prevent the aggrevation of the occurrence of postoperative arrhythmias in high risk groups of ventricular tachyarrhytnmia in old age but magnesium could not prevent postoperative arrhythmia in other high risk groups. CONCLUSIONS: The magnesium replacement after open heart surgery could prevent the development of ventricular tachyarrhythmias especially in old age groups but could not prevent atrial tachyarrhthmias.

Analysis of Exploratory Thoracotomy in Non-Small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: The purpose of this study is to improve the quality of the diagnostic procedures in the preoperative evaluation so as to reduce the unnecessary thoracotomy and to ensure resectability in non-small cell lung cancer. MATERIAL AND METHOD: Of 616 patients who underwent thoracotomy for primary lung cancer from January 1990 to December 1996, 59 patients(9.6%) turned out to have inoperable lesions after the thoracotomy. We reprospectively reviewed the bronchoscopic findings, methods of tissue diagnosis, CT scans, pulmonary function test and lung perfusion scan, reasons for nonresectability, and adjuvant therapy, and then followed up on the survival rate after exploratory thoracotomy. RESULT: The cell types were squamous cell carcinoma in 38, adenocarcinoma in 15, large cell carcinoma in 3 and others in 3. Primary loci were RUL in 20, RML in 6, RLL in 8, LUL in 13, LLL in 4 and others in 8. The reasons for non-resectability were various; direct tumor invaison to mediastinal structures(n=41), seeding on pleural cavity(n=8), poor pulmonary function(n=2), invasions to extranodal mediastinal lymph node(n=2), technical non- resectability due to extensive chest wall invasion (n=3), small cell carcinoma (n=1), malignant lymphoma(n=1), and multiple rib metastases(n=1). In the follow-up of 58 patients, 1-year survival rate was 55.2% and 2-year survival rate was 17.2% and the mean survival time was 14 months. When compared according to cell types or postoperative adjuvant therapeutic modalities, no significant difference in the survival rates were found. The squamous cell carcinoma was frequently accompanied by local extension to contiguous structures and was the main cause of non-resectability. In adenocarcinoma, pleural seeding with malignant effusion was frequently encountered, and was the major reason for non-resectability. CONCLUSION: These data revealed that if appropriate preoperative diagnostic tools had been available, many unnecessary thoracotomies could have been avoided. Both the use of thoracoscopy in selected cases of adenocarcinoma and the more aggressive surgical approach to the locally advanced tumor could reduce the incidence of unnecessary thoracotomies for non-small cell lung cancers.

Time-dependent expression of ICAM-1 & VCAM-1 on coronaries of the heterotopically transplanted mouse heart

To investigate the pathogenesis of accelerated graft atherosclerosis after rdiac transplantation, a genetically well-defined and reproducible animal del is required. We performed heterotopic intraabdominal heart transplantation tween the two inbred strains of mice. Forty hearts from B10.A mice were ansplanted into B10.BR mice. Recipients were sacrificed at 1, 3, 5, 7, 14, 28, d 42 days after implantation. The specimens from both donor and recipient were amined with fluorescent immunohistochemistry and the serial histopathologic anges were evaluated. In the donor hearts, ICAM-1 and VCAM-1 expressions were nimal at day 1 and they gradually increased, reaching their peaks on day 5 or and remained unchanged by day 42. However, there were very little expressions the recipients' hearts. Mean percent areas of intima in the donor coronaries vealed progressive increase by day 42. However, those in the recipients cupied consistently less than 5% of the lumen. In conclusion, we demonstrated at a heterotopic murine heart transplantation model was a useful tool to oduce transplantation coronary artery disease and that adhesion molecules on e cardiac allografts were activated very early and remained elevated at all me-points, nonetheless the arterial lesion was detected after day 28 and its ogression was accelerated thereafter.

Systemic Pulmonary Arteriovenous Fistula: 1 Case Report / 대한흉부외과학회지

This is a case report of an operation for the pulmonary arteriovenous fistula supplied from the systemic arteries instead of the pulmonary artery. The operation of systemic arteriovenous pulmonary fistula has formidable technical challenges due to its extensive collateral circulations. A 16 year-old female patient, diagnosed as systemic arteriovenous fistula with multiple tortuous feeding vessels and with hereditary hemorrhagic telangiectasia, was initially managed with arterial embolization before the operation. A 15x8cm sized huge vascular malformation was removed by RML and RLL bilobectomy. During the operation, we encountered annoying massive bleeding and pulmonary congestion originated in its extensive collateral circulation. The patient was discharged after conservative management without specific problem on the 15th postoperative day. For the safe operation as well as good operative result, it seemed that meticulous ligation of the multiple collateral vessels should be performed prior to that of pulmonary veins.

A Case Report of Heart-Lung Transplantation / 대한흉부외과학회지

We report a case of heart-lung transplantation in a 32 year-old female with Eisenmenger syndrome secondary to patent ductus arteriosus. She has been suffered from congestive heart failure since June 1996 and repeatedly treated at Intensive Care Unit with intravenous inotropic support since July 1997. Preoperative echocardiography showed a patent ductus arteriosus with right to left shunt, severe regurgitation of tricuspid valve and estimated right ventricular systolic pressure of 100mmHg. The brain-dead donor was an 18 year-old male with head trauma from traffic accident 3 days ago. Heart-lung block procurement was performed at another general hospital and was transported to the Seoul National University Hospital by ambulance. Total ischemic time of the transplanted heart and lung were 249 minutes and 270 minutes, respectively. The immunosuppressive therapy was commenced preoperatively with cyclosporine and azathioprine. Corticosteroid was not used until postoperative 3 weeks in order to avoid infection and delayed healing at the tracheal anastomotic site. The patient was discharged at 31st postoperative day, and has been regularly followed up at outpatient clinic without specific complication. The follow-up bronchoscopy, performed 2 weeks and 4 months after surgery, revealed no evidence of cellular rejection.