Relationship Between Interleukin-6 Production and Inflammatory Response during Cardiopulmonary Bypass / 대한흉부외과학회지

BACKGROUND: With open heart surgery(OHS), it has been recognized that many postoperative complications and postperfusion syndrome are associated with the activations of complements and leulocytes. Recently, some investigators also demonstrated that interlukin-6(IL-6) linked highly with postperfusion syndrome. The puropose of this study was to investigate the sequential changes of the IL-6 and to clarify each IL-6 relationship to the complements(C3, C4) and inflammatory response following cardiopulmonary bypass(CPB). MATERIAL AND METHOD: To determine serum levels of IL-6, complements, leukocytes, and biochemistric markers of liver and renal function, blood samples were taken from th radial artery in 30 adult patients undergoing OHS with CPB. RESULT: Serum IL-6 levels incrased significantly at 10 minutes after CPB-on(CPB-10) in comparison with the control levels and reached the peak at CPB-off(p<0.05). Serum complement levels declined rapidly at CPB-10 and remained at the lower levels during CPB(p<0.01). Sequential changes of IL-6 levels had positive correlations with the changes of total leukocytes and neutrophil fractions(p<0.05), but had negative correlations with lymphocyte fractions(p<0.05). Changes of C3 related postively to monocyte fractions(p<0.05). Postoperative levels of total protein and albumin, decreased significantly in comparison with the control levels(p<0.01), while the postoperative levels of AST(aspartate transaminase) and bilirubin increased (p<0.01). At CPB-off, IL-6 levels had negative correlations with total protein and albumin levels(r=-0.60, -0.47 respectively, p<0.05), whereas C3 levels had positive correlations with albumin levels(r=0.40, p<0.05). IL-6 levels, as well as neutrophil fractions, had positive correlations with aortic clamp time(ACT) and total bypass time(TBT) (IL-6; r=0.82, 0.79 respectively, neutrophil fractions; r=0.50, 0.56 respectively, p<0.05), wheres lymphocyte frations and albumin levels had negative correlations whith ACT and TBT(lymphocyte fractions; r=-0.52, -0.58 respectively, albumin; r=-0.58, -0.55 respectively, p<0.05). CONCLUSIONS: These data showed that elevated production of serum IL-6 during CPB may play a pivotal role in systemic inflammatory responses and prologed CPB period may be assosiated with more sever postperfusion syndromes.

Midterm results of aortic root enlargement with AVR in patients with narrow aortic root and AS / 대한흉부외과학회지

BACKGROUND: For AVR using conventional prosthetic valves in adult patients with a narrow aortic root, aortic root enlargement is necessary to reduce postoperative pressure gradient across the aortic valve (deltaP). An evaluation of early and mid-term results of aortic root enlargement with AVR and echocardiographic follow up of deltaP and left ventricular function was performed. METHOD: From Aug. 1991 to Feb. 1998, eighteen patients aged 17 to 59 years(mean, 38+/-12 years) underwent Manouguian procedure with AVR. Aortic annular circumstance was enlarged 10.0mm to 18.0mm(mean, 12.6+/-6.3mm). Eight patients(44.0%) had NYHA class III status before operation, and seven cases of them underwent concomitant MVR. Valve pathology was ASr in 6 cases, AS in 4 cases, nd ASr+MSr in 8 cases. Replaced valve size was 21mm in 8 cases and 23 mm in 10 cases, and St. Jude Medical mechanical valve was used in 10 cases and Carbomedics in 8 cases. RESULT: Follow-up duration was 6 to 57 months (mean, 26+/-18 months), and total follow-up was 287 patient-year. There were one hospital death and one late death, therefore, actuarial survival rate was 85.7% at 56 months. Peak deltaP wad decreased significantly at postoperative mid-term period as 13+/-5mmHg, compared with thepreoperative one (42+/-8mmHg) (p<0.01). LVM(gm/m(2)) was also diminished as 35.8%(115+/-36gm/m(2))at postoperative mid-term period, compared with preoperative one (179+/-56gm/m(2))(p<0.05). CONCLUSIONS: There were no specific complications related to the procedure. And we could have adequate enlargement of aortic annulus to suitable prosthetic valve that have no effect of patient-prosthese mismatch.

Clinical Study of Isolated and Combined Aortic Valve Replacement / 대한흉부외과학회지

BACKGROUND: To review the middle and long term results of aortic valve replacement(AVR) for 11 years, we surveyed and followed up the patients who underwent AVR. MATERIAL AND METHOD: Between Feb. 1986 and May 1997, 134 patients underwent AVR. The patients consisted of 71 men and 63 women whose mean age was 38.9 years, ranging from 17 to 70. RESULT: The concomitant operations were 62 mitral valve replacement(MVR), 14 MVR + tricuspid valve annuloplasty, 10 Cabrol operation, 16 aortic annulus widening, and so forth. We used 119 mechanical(75 St. Jude Medical, 38 CarboMedics, 6 Sorin) and 15 tissue (Carpentier-Edwards) valves. Early postoperative complications occurred in 35 cases; 9 congestive heart failure, 6 low cardiac output, 5 postoperative bleeding, 5 pleural effusion, and so forth. There were 13 early postoperative deaths(9.7%) due to low cardiac output(5), CHF (2), disseminated intravascular coagulopathy(2), and so forth. The cumulative total follow-up period was 452.7 patient-years with a mean of 3.4+/-3.1 years/patient. There were 9 cases of valve-related complications; anticoagulant-related bleeding(4), prosthetic valve endocarditis(2), thromboembolism(2) and prosthetic valve failure(1) occured at rate of 0.9, 0.4, 0.4, 0.2%/ pt-yr, respectively. Late valve-related death occurred in 3 cases(2.0%/pt-yr) associated with anticoagulant-related bleeding(2) and prosthetic valve endocarditis(1). CONCLUSION: Actuarial survival rate by Kaplan-Meier method was 91.0+/-4.3 % at 11 years.

Clinical Experience of Pectus Excavatum Corrected by Ravitch Method / 대한흉부외과학회지

BACKGROUND: The purpose of this study is to analyze the clinical results ad operative compatability by Ravitch methods with pectus excavatum. MATERIAL AND METHOD: From 1984 to 1997, were performed Ravitch operations in 40 patients of pectus excavatum and analyzed the effects of correction and postoperative complication according to time of operation retrospectively. The group comprised 35 mem and women whose mean age was 8.9+/-7.9 years(between 2 to 35 years). All patients had corrected with Ravitch operation or its modified operation. Modified fixations were accomplished with K-wire in 15 patients and internal plate in 2 and the materials were removed 3 months after operation. The result of correction was estimated with the degree of changed distance between inner surface of sternal body and vertebral in 3 months after correction. RESULT: Postoperative complications were wound disruption in 14 patients. Estimated distances after correction ranged 0.4 cm to 4 cm. The acceptability for chest wall correction was high(6 excellent, 29 good in criteria of Humphreys). CONCLUSION: We concluded that the benefits of Ravitch operation were a high acceptability of patients and their family, and sufficient correction with no specific complications related operation.

Minimally Invasive Cardiac Surgery: Lower half sternotomy / 대한흉부외과학회지

BACKGROUND: There are several advantages to the ministernotomy approach. The skin incision is much smaller than the traditional median sternotomy incision. This approach allows the patients to return to normal life more quickly and provide them with good self-image. MATERIAL AND METHOD: From April to July 1998, we performed a ministernotomy via lower half sternum in 25 patients. There were 10 males(40%) and 15 females(60%) with a mean age of 30+/-16 years(range 3 to 55 years). The body surface area ranged from 0.58 to 1.9 m2(mean 1.5 to 0.4 m2). A vertical skin incision of 11cm in mean length was made in the midline over the sternum extending inferiorly from the third intercostal space. The sternum was divided vertically in the midline from the xyphoid process to the level of second intercostal space using a standard saw and then transversely to the left(n=17) or to both sides(n=4) of the second intercostal space using an oscillating saw. The sternum was divided vertically only in children (n=4). RESULT: The ministernotomy was used in 25 consecutive patients undergoing mitral valve replacement(n=10), repair of ventricular septal defect(n=4) and atrial septal defect(n=11). There was no significant complication related to ministernotomy. The mean ICU stay time 20 hours. Patient and family acceptance was very high. CONCLUSION: We concluded that minimally invasive cardiac surgery via ministernotomy can be done safely. These methods may benefit the patients with lesser discomfort, smaller incision, and earlier ICU discharge than the traditional incision.

Reoperation of Failed Tricuspid Mechanical Prosthetic Valve Due to Pannus Formation / 대한흉부외과학회지

We performed a reoperation of failed tricuspid mechanical valve in a 63-year-old female patient because the overgrown endothelial pannus had entrapped the prosthetic leaflets. Four years ago, the patient underwent mitral and tricuspid valve replacements with 31 and 33 mm Carbomedics, respectively. The patient showed symptoms of neck vein distention, abdominal distention and peripheral edema. The chest film, echocardiography and cineangiography confirmed the diagnosis of tricuspid valve. During the operation, we found the entrapped leaflets of the tricuspid valve in a partially closed state and the endothelial pannus had overgrown into the leaflets. Carpentier-Edward bovine pericardial valve was inserted and the patient was discharged with no significant events.

Regression of Left Ventricular Hypertrophy after AVR in Aortic Valvular Stenosis / 대한흉부외과학회지

BACKGROUND: The regression of the left ventricular hypertrophy after prosthetic valve replacement in patients with aortic valvular stenosis is an important factor to determine the appropriateness of the replaced prosthetic valvular size. Methods: To assess the regression of myocardial hypertrophy, a retrospective analysis of Doppler echocardiographic and electrocardiographic data was undertaken before, soon after (7.5+/-2.1 day), and late after (10.7+/-1.8 months) surgery in 36 patients (22 males, 14 female, mean age 54+/-12.1 years, mean BSA 1.61+/-0.15m2) with predominant aortic valvular stenosis. The patients underwent St. Jude Medical aortic valve replacement. By the size of the valves used, the patients were divided into three groups (19, 21 and 23+). RESULTS: The mean body surface area (1.48+/-0.13) in the patients with the 19 mm valve was smaller than that in the other groups (1.63+/-0.12) (p<0.05). No significant changes of ejection fraction were detected in all groups over time. Left ventricular muscle mass index (gm/m2) was reduced significantly in the 21 and 23+ groups over time (p<0.05), but there were no significant changes in the 19 mm valve group. The electric voltage height on EKG at the period of late after surgery was reduced significantly in all groups (p<0.05). CONCLUSION: Despite clinical improvement, the LVH was not reduced significantly in 19 mm valve group. Thus we suggest that more attention and additional procedures such as annular enlargement should be taken in patients who will undergo the replacement of 19 mm prosthetic valve.

Clinical Experiences of Open Heart Surgery / 대한흉부외과학회지

BACKGROUND: From Sept. 1985 to Sept. 1997, 2,000 cases of open heart surgery (OHS) were performed in the Department of Thoracic & Cardiovascular Surgery, Pusan Paik Hospital, College of Medicine, Inje University. MATERIAL AND METHOD: Among the total of 2,000 cases of OHS, 1532 cases were congenital heart disease (CHD) and 468 cases were acquired heart disease (AHD). The age distribution was 9 days (4.0kg) to 68 years in CHD and 11 to 66 years in AHD. In 1532 cases of CHD, there were 1403 acyanotic cases and 129 cyanotic cases. RESULT: The CHD cases consisted of 940 ventricular septal defects (61.4%), 324 atrial septal defects (21.1%), 112 tetralogy of Fallot (7.3%), 46 pulmonary stenosis (3%), 38 endocardial cushion defects (2.5%), 15 valsalva sinus ruptures (1%), 4 transposition of great arteries (0.3%), 4 double outlet right ventricles (0.3%), and etc. Corrective operations were applied for congenital heart disease with a result of 3.1% hospital mortality. Of 468 AHD, 381 cases were valvular heart diseases, 48 ischemic heart diseases, 12 cardiac tumors, 8 annuloaortic ectasias, 16 dissecting aortic aneurysms and etc. In the 381 valvular heart diseases, there were 226 single valve replacements (36 aortic valve replacements (AVR), 188 mitral valve replacements (MVR), and 2 tricuspid valve replacements (TVR), among these were 71 cases of double valve replacements (AVR & MVR), 54 cases of MVR with tricuspid valve annuloplasty (TVA), and 18 cases of AVR, MVR with TVA. The total implanted prosthetic valves were 466. In MVR, 123 St. Jude Medical valves, 90 Carpentier-Edwards valves, 65 CarboMedics valves, 42 Sorin valves and 16 other valves were used. In AVR, 68 St. Jude Medical valves, 36 CarboMedics valves, 14 Carpentier-Edwards valves and 9 other valves were used. Coronary Artery Bypass Surgery (CABG) were performed in 48 cases. The patterns of bypass graft were 14 patients of single vessel graft, 21 patients of two vessels graft, 10 patients of three vessels graft and 3 patients of four vessels graft. CONCLUSION: The hospital operation mortality rate of congenital acyanotic, cyanotic and acquired heart diseases were 2.0%, 15.5%, and 5.1% respectively. The overall mortality rate was 3.6% (72/2,000).

Beneficial Effects of High-Dose Transamine on Hematologic Aspects in Cardiopulmonary Bypass / 대한흉부외과학회지

BACKGROUND: The purpose of this study was to independently evaluate the beneficial effects of a high dose of transamine administrated prior to CPB on the postoperative hematologic aspect and bleeding. MATERIALS AND METHODS: This study included randomly selected groups of 40 adult patients undergoing OHS with CPB. All patients were divided into 2 groups: transamine group (T-group, n=20) and placebo group (P-group, n=20). The T-group received a high-dose of transamine (10 g) before and during CPB. The P-group received normal saline at the same times and served as a control group. RESULTS: The results of comparative studies between the 2 groups in the same hematologic variables were summarized as follows. (1) During CPB, the fibrinogen concentrations and platelet counts were significantly lower in the P-group than in the T-group (p<0.01). (2) During CPB, production of D-dimer occurred in 18 patients (90%) in the P-group and did not occur in the T-group (0%) (p<0.0001). (3) At CPB-off, the % concentration of fibrinogen (70.2+/-3.9%) and the % platelet counts (72.4+/-4.5%) of the T-group were significantly higher than those (54.5+/-3.8%, 64.3+/-2.9%) of the P-group (p<0.01). (4) Postoperative values of PT (14.0+/-0.03 sec.) and aPTT (27.6+/-0.1 sec.) of the T-group were significantly lower than those (16.0+/-0.02sec., 30.1+/-0.1sec.) of the P-group (p<0.05). (5) Postoperative bleeding and requirement of whole blood and other blood products were significantly less in the T-group than in the P-group (p <0.05). (6) There were no significant hypercoagulability signs such as cerebral em bolism, myocardial infarction, pulmonary embolism, or any other neurological prob lems in either group. CONCLUSIONS: We concluded that a high dose of transamine administered prior to CPB prevents the activation of fibri nolytic system and has beneficial effects of reducing the postoperative bleeding t endency without apparent hypercoagulability signs.