A Case of an Infected Pseudoaneurysm with Complications Due to A Non-Typhoidal Salmonella Species / 대한내과학회지

Non-typhoidal Salmonella infections, which rarely present with multiple complications, are predominantly seen in immunocompromised patients. In particular, non-typhoidal Salmonella infections presenting with more than two complications are extremely rare. Here, we report a case of an infected pseudoaneurysm in the aortic arch caused by a non-typhoidal Salmonella species complicated by pleural empyema, pericarditis, pericardial empyema, and mediastinitis. To our knowledge, this is the first such case report in Korea.

Surgical Experience of Ascending Aorta and Aortic Valve Replacement in Patient with Calcified Aorta

BACKGROUND: The conventional method of aortic cross-clamping is very difficult and increases the risk of cerebral infarct due to embolism of the calcified aorta in these patients. Accordingly, we analyzed our experience with 11 cases of ascending aorta and aortic valve replacement with hypothermic circulatory arrest. MATERIALS AND METHODS: From January 2002 to December 2009, 11 patients had ascending aorta and aortic valve replacement with hypothermic arrest at our hospital. We performed a retrospective study. RESULTS: There were 5 males and 6 females, with a mean age of 68 years (range, 44 to 82 years). Eight patients had aortic stenosis, and 3 patients had aortic regurgitation. An aortic cannula was inserted into the right axillary artery in 3 patients and ascending aorta in 6 patients. Two patients with aortic regurgitation had a remote access perfusion catheter inserted though the right femoral artery. The mean cardiopulmonary bypass time was 180 minutes (range, 110 to 306 minutes) and mean hypothermic circulatory arrest time was 30 minutes (range, 20 to 48 minutes). The mean rectal temperature during hypothermic circulatory arrest was 21degrees C (range, 19degrees C to 23degrees C). No patient had any new onset of cerebral infarct or cardiovascular accident after surgery. There was no hospital mortality. Early complications occurred in 1 patient who needed reoperation due to postoperative bleeding. Late complications occurred in 1 patient who underwent a Bentall operation due to prosthetic valve endocarditis. The mean follow-up duration was 32 months (range, 1 month to 8 years) and 1 patient died suddenly due to unknown causes after 5 years. CONCLUSION: Patients with a calcified aorta can be safely treated with a technique based on aorta and aortic valve replacement under hypothermic circulatory arrest.

Mass Reduction and Functional Improvement of the Left Ventricle after Aortic Valve Replacement for Degenerative Aortic Stenosis

BACKGROUND: Left ventricular (LV) hypertrophy caused by aortic valve stenosis (AS) leads to cardiovascular morbidity and mortality. We sought to determine whether aortic valve replacement (AVR) decreases LV mass and improves LV function. MATERIALS AND METHODS: Retrospective review for 358 consecutive patients, who underwent aortic valve replacement for degenerative AS between January 1995 and December 2008, was performed. There were 230 men and 128 women, and their age at operation was 63.2+/-10 years (30~85 years). RESULTS: There was no in-hospital mortality, and mean follow-up duration after discharge was 48.9 months (2~167 months). Immediate postoperative echocardiography revealed that LV mass index and mean gradient across the aortic valve decreased significantly (p7) (p=0.045) were risk factors for late death. CONCLUSION: After AVR for degenerative AS, reduction of left ventricular mass and improvement of left ventricular function continue late after operation.

Intracardiac Metastasis of Testicular Embryonal CarcinomaThat Presented with a Right Ventricular Mass / 대한흉부외과학회지

Metastases to the heart are rarely diagnosed before the patient dies. A 26-year-old man was admitted with multiple metastasis of a testicular embryonal carcinoma and he was found to have intracardiac metastasis. Echocardiography showed that he had a mass rising from the interventricular septum and it was floating through the right ventricular outflow tract. The histology of the mass we removed from the right ventricle was consistent with testicular embryonal carcinoma. The patient made a smooth recovery after surgical intervention and chemotherapy. We believe this is the first reported case of testicular embryonal carcinoma that metastasized to the heart and that was successfully removed via surgery in Korea.

Sequential Bilateral Lung Transplantation with Extracorporeal Membrane Oxygenation (ECMO) Support: A case report / 대한흉부외과학회지

Artificial lung support may be necessary in various conditions during the performance of bilateral lung transplantation, and cardiopulmonary bypass (CPB) has usually been used. Yet using the conventional CPB techniques may increase risk of bleeding and early allograft dysfunction due to the large dosages of heparin and the complement activation. Extracorporeal membrane oxygenation (ECMO) is able to support gas exchange and maintain the hemodynamics without administering high-dose heparin for anticoagulation. We performed sequential bilateral lung transplantation with ECMO support. ECMO is a valuable tool when performing lung transplantation and it has the potential to replace CPB.

Redo CABG Using Various Arterial Grafts / 대한흉부외과학회지

BACKGROUND: Although the reports on re-operative coronary revascularization (redo-CABG) have increased, there are only limited reports on redo-CABG using arterial grafts. The aim of this study was to analyze the safety and feasibility of using various arterial grafts for redo-CABG. MATERIAL AND METHOD: A consecutive series of patients who underwent 33 redo-CABGs from March 2001 to July 2008 were retrospectively reviewed. We performed conventional CABG in 17 patients, on-pump beating CABG in 7, off-pump CABG in 7 and minimally invasive direct coronary artery bypass in 2. The grafted that were used included 34 internal thoracic arteries (ITA), 14 radial arteries, 14 right gastroepiploic arteries and others. Arterial composite grafts were constructed in 26 patients. Of these, a previously patent in-situ left ITA was re-used as the in-flow of a composite graft in 10 patients. RESULT: No hospital deaths or major wound problems occurred. The post-operative complications included 2 myocardial infarctions (6%), 1 intra-aortic balloon pump insertion (3%), 5 cases of atrial fibrillation (15.1%) and 3 neurologic complications (9.1%). The mean follow-up duration was 31.1+/-22.7 months and the 3 year survival rate was 86.4%. There were 4 late deaths (2 cardiac deaths) and no recurrent angina during the follow-up period. CONCLUSION: Redo-CABG with using various arterial grafts is currently a safe, feasible procedure, but further investigation and long term follow-up are needed.

Pulmonary Embolectomy for Treatment of Pulmonary Embolism / 대한흉부외과학회지

BACKGROUND: The treatment of acute pulmonary embolism is difficult, and it can be lethal when cardiogenic shock is involved with major pulmonary embolism. In the past, pulmonary embolectomy was considered as the last choice for patients with pulmonary embolism. Accordingly, we analyzed our experience with seven cases of pulmonary embolectomy as an alternative option for the early treatment of pulmonary embolism. MATERIAL AND METHOD: A retrospective analysis of medical charts of all patients who underwent pulmonary embolectomy at our hospital over the past eight years was performed. The patients were observed during their hospital stay and followed until their last visit to the outpatient department. RESULT: Among 7 patients (4 men and 3 women), 4 had massive pulmonary embolism, and 3 had submassive pulmonary embolism. An extracorporeal membrane oxygenator was inserted in 3 patients before surgery. There was no mortality, and postoperative echocardiography showed no pulmonary hypertension in 6 patients. CONCLUSION: Pulmonary embolectomy can be performed with minimal mortality. We think that the use of an extracorporeal membrane oxygenator in patients with cardiogenic shock before surgery improves survival.

Changes in Polytetrafluoroethylene and Dacron GraftDiameters after Arterial Bypass Surgery

PURPOSE: We compared postoperative diameter changes between polytetrafluoroethylene (PTFE) and Dacron grafts after aortic reconstruction and femoropopliteal bypass. METHOD: We analyzed 173 PTFE grafts and 73 Dacron grafts (165 aortic grafts, 81 peripheral grafts). The mean follow-up period was 28.4 months. RESULT: The mean diameter change in the Dacron grafts (6.6+/-3.0 SD mm) was larger than that in the PTFE grafts (3.7+/-1.8 SD mm). There was a statistically significant difference in the diameter change of PTFE and Dacron aortic grafts (p<0.001). The diameter changes in PTFE peripheral grafts were not significant (p=0.065). There was a significant linear correlation between diameter changes in the Dacron aortic grafts and follow-up duration (correlation coefficient=0.238, p=0.043). Diameter changes in the PTFE grafts showed no linear correlation with follow-up duration, irrespective of grafting range (aortic grafting correlation coefficient=0.048, p=0.646; peripheral grafting correlation coefficient=0.011, p=0.925). CONCLUSION: This study suggests that PTFE has superior durability compared to Dacron, and the change in graft diameter should be taken into consideration when the diameter of the graft needed for aortic reconstruction is selected.

Heart Transplantation in a 78-year-old Patient / 대한흉부외과학회지

Advanced age is known to be a risk factor for early mortality after heart transplantation and is considered to be a relative contraindication. However, recent studies have shown that there are no significant differences in early and midterm survival rates between older and younger recipients. With rising life expectancy and improvements in medical support, the demand for heart transplantation in elderly patients continues to grow. We present a successful case of heart transplantation in a 78-year-old patient.

Surgical Approach of Concomitant Coronary and Carotid Artery Disease

PURPOSE: A definite guideline for the surgical approach to patients suffering with combined coronary and carotid artery disease remains controversial. The aim of this study was to compare the cardiovascular and neurologic complications between the staged approach and the synchronous approach. METHODS: This study reviewed the outcomes following each procedure in 17 cases from 1995 to 2004; 8 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group I), 6 patients underwent CEA followed by CABG (group II) and the remaining 3 patients underwent CABG followed by CEA (group III). RESULTS: In group I, the mean percentage of internal carotid artery stenosis was 77.9%. Preoperatively, 3 patients had neurologic symptoms, and all the cases had triple vessel disease. Off-pump CABG (OPCABG) was performed for 4 cases. In group II, the mean percentage of internal carotid artery stenosis at the time of CEA was 78.7%; all cases had triple vessel disease and/or left mainstem coronary artery disease and 4 cases had neurologic symptoms. OPCABG was performed for 1 case. In group III, the mean percentage of internal carotid artery stenosis at the time of CABG was 76.7%. One patient had neurologic symptoms;all cases had triple vessel disease. OPCABG was performed for 2 cases. Neurologic complication occurred in 1 patient of group III. CONCLUSION: Because the data was reviewed retrospectively, there were limitations for understanding the reasons for the staged or synchronous approach. However, we obtained the result that the synchronous approach resulted in fewer perioperative neurologic complications and this might be a good operative strategy, while OPCABG allowed the use of the synchronous approach.

Mid-term Follow-Up Results of Cryopreserved Valved Conduit in RVOT Reconstruction / 대한흉부외과학회지

BACKGROUND: Since Ross and Sormeville first reported the use of aortic homograft valve for correction of pulmonary atresia in 1966, homograft valves are widely used in the repair of congenital anomalies as conduits between the pulmonary ventricle and pulmonary arteries. On the basis of these results, we have used it actively. In this report, we describe our experience with the use of cryopreserved valved homograft conduits for infants and children requiring right ventricle to pulmonary artery connection in various congenital cardiac anomalies. MATERIAL AND METHOD: Between January,1996 and December 2001, 27 infants or children with a median age of 16 months(range 9days to 18years) underwent repair of RVOTO using homograft valved conduit by two surgeons. We studied 22 patients who have been followed up at least more than one year. The diagnosis at operation included pulmonary atresia with ventricular septal defect (n=13), truncus arteriosus (n=3), TGA or corrected TGA with RVOTO (n=6). Homograft valved conduits varied in size from 15 to 26 mm (mean, 183.82 mm). The follow-up period ranged from 12 to 80.4 months (median, 48.4 months). RESULT: There was no re-operation due to graft failure itself. However, early progressive pulmonary homograft valve insufficiency developed in one patient, that was caused by dilatation secondary to the presence of residual distal pulmonary artery stenosis and hypoplasia after repair of pulmonary atresia with ventricular septal defect. This patient was required reoperation (conduit replacement). During follow-up period, there were significant pulmonary stenosis in one, and pulmonary regurgitation more than moderate degree in 3. And there were mild calcifications at distal anastomotic site in 2 patients. All the calcified homografts were aortic in origin. CONCLUSION: We observed that cryopreserved homograft conduits used in infant and children functioned satisfactorily in the pulmonic position at mid-term follow-up. To enhance the homograft function, ongoing investigation is required to re-establish the optimal strategy for the harvest, preservation and the use of it.

Surgical Rrepair of Ebsteins Anomaly with Ventricular Septal Defect in the Infant / 대한흉부외과학회지

Ebsteins anomaly is a rare congenital cardiac malformation that is the downward displacement of the septal and posterior leaflets of the tricuspid valve into the ventricular apex, resulting in the formation of an atrialized portion of the right ventricle. In most patients, symptoms such as cyanosis and progressive heart failure occur during the adolescence or young adulthood. The associated anomalies include ventricular septal defect, transposition of the great arteries, and malformation of the mitral valve. An 8-months-old male with Ebsteins anomaly, ventricular septal defect, and duplication of the mitral valve orifice successfully underwent operation with VSD patch closure. Postoperatively, cardiac size was significantly reduced and tricuspid regurgitation was trivial in echocardiography. He has been doing well without any cardiac medication during the 18 months follow up after operation.

Short-Term Results of Early Surgery for Active Infective Endocarditis / 대한흉부외과학회지

BACKGROUND: Although there is a controversy on the optimal timing for active infective endocarditis(IE), recently good results of early surgical intervention have been published. Herein, we analyzed the results of surgery for active IE according to the duration of preoperative antibiotic treatment. MATERIAL AND METHOD: Retrospectively, we analyzed 51 patients who underwent operation for active IE at the department of thoracic and cardiovascular surgery of Samsung medical center from Mar. 1995 to Oct. 2001. Male to female ratio was 39:12, mean age of the patients was 44.5+/-17.8 years(range : 13~74). Infected valves were mitral valve in 17(33.3%), aortic valve in 15(29.4%), mitral and aortic valve in 12(23.5), and tricuspid valve in 5(9.8%) cases. Among them, prosthetic valve endocarditis was present in 10(19.6%) cases. Infecting organism was Staphylococcus in 19 (37.3%), Streptococcus in 17(33.3%), Enterococcus in 3(5.9%), fungus in 3(5.9%), and other bacteria in 5(9.8%) cases. Organism was not isolated in 6(11.8%) cases, and two organisms were isolated in 4(7.8%) cases. Dividing these patients into two groups according to the duration of preoperative antibiotic treatment(A: less than 7 days, B: more than 8 days), we compared the surgical results between the two groups. RESULT: There were 16 cases in group A and 35 in group B. Annular reconstruction was performed in 10(62.5%) cases in group A and 10(28.6%) cases in group B, which has statistically significance(p<0.05). There was one early death in group B. Forty nine patients(96.1%) except two were followed up with mean follow-up duration of 28.7+/-23.6 months. Endocarditis was recurred in one in group A, and two in group B. Three late deaths occurred in group B. Recurrence rate and survival were not statistically different between the two groups. CONCLUSION: Early surgery for active IE showed good results as the result of that which was performed after prolonged antibiotic treatment; therefore, we believe that early surgery for active IE could effectively eradicate the infection.

Surgical Experience of Reconstruction of the Annular and the Intervalvular Fibrous Skeleton for Active Infective Endocarditis

BACKGROUND AND OBJECTIVES: The treatment for active infective endocarditis (IE) with a paravalvular abscess results in a high morbidity and mortality. Recently, some good results with a reconstruction of the annulus or fibrous skeleton in active IE have been published. However, there are few papers on this subject reported in Korea. SUBJECTS AND METHODS: The hospital records of 29 patients who had undergone surgery for active IE with a paravalvular abscess from Mar. 1995 to Jun. 2002 were retrospectively reviewed. The mean age was 43.8 +/-16.9 (range : 13-69) years. The NYHA functional class was either III or IV in 11 cases (37.9%) and prosthetic valve endocarditis was present in 8 cases (27.6%). The mean duration of preoperative antibiotic treatment was 13.3+/-11.9 days. RESULTS: The aortic annulus was reconstructed in 7 patients, an aortic annulus+the aorto-mitral continuity was done in 8 cases, an aortic annulus+mitral annulus+aorto-mitral continuity was done in 1 case, and a mitral annulus was done in 13 cases. There was one (3.4%) early death due to a non-cardiac cause. The postoperative complications were as follows : additional surgery due to bleeding in 3 cases (10.3%), mediastinitis in 1 case (3.4%), a complete atrioventricular block in 1 case (3.4%), and a cerebral hemorrhage in 2 cases (6.9%) who had had a history of cerebral embolism. All patients (100%) were followed up with a mean follow-up duration of 22.0+/-19.2 months. There was 1 late death (3.6%) and 2 additional procedures including one recurrence. CONCLUSION: Reconstruction of the annulus and intervalvular fibrous skeleton in these patients showed a relatively low morbidity and mortality, and recurrence rate. Therefore, it is recommended that these patients be treated aggressively.

Long Term Results of Bronchial Sleeve Resection for Primary Lung Cancer / 대한흉부외과학회지

BACKGROUND: Bronchial sleeve resection for centrally located primary lung cancer is a lung- parenchyma-sparing operation in patients whose predicted postoperative lung function is expected to diminished markedly. Because of its potential bronchial anastomotic complications, it is considered to be an alternative to pneumonectomy. However, since sleeve lobectomy yielded survival results equal to at least those of pneumonectomy, as well as better functional results, it became and accepted standard procedure for patients with lung cancer who have anatomically suitable tumors, regardless of lung function. In this study, from analyzing of occurrence rate of postoperative complication and survival rate, we wish to investigate the validity of sleeve resection for primary lung cancer. MATERIAL AND METHOD: From January 1989 to December 1998, 45 bronchial sleeve resections were carried out in the Department of Thoracic Surgery of Seoul National University Hospital. We included 40 men and 5 women, whose ages ranged from 23 to 72 years with mean age of 57 years. Histologic type was squamous cell carcinoma in 35 patients, adenocarcinoma in 7, and adenosquamous cell carcinoma in 1 patients. Right upper lobectomy was performed in 24 patients, left upper lobectomy in 11, left lower lobectomy in 3, right lower lobectomy in 1, right middle lobecomy and right lower lobectomy in 3, right upper lobectomy and right middle lobecomy in 2, and left pneumonectomy in 1 patient. Postoperative stage was Ib in 11, IIa in 3, IIb in 16, IIIa in 13, and IIIb in 2 patients. RESULT: Postoperative complications were as follows; atelectasis in 9, persistent air leakage for more than 7 days was in 7 patients, prolonged pleural effusion for more than 2 weeks in 7, pneumonia in 2, chylothorax in 1, and disruption of anastomosis in 1. Hospital mortality was in 3 patients. During follow-up period, bronchial stricture at anastomotic site were found in 7 patients under bronchoscopy. Average follow-up duration of survivals(n=42) was 35.5+/-29 months. All of stage I patients were survived, and 3 year survival rate of stage II and III patients were 63%, 21%, respectively. According to N stage, all of N0 patients were survived and 3 year survival rates of N1 and N2 were 63% and 28% respectively. CONCLUSION: We suggest that this sleeve resection, which is technically demanding, should be considered in patients with centrally located lung cancer, because this lung-saving operation is safer than pneumonectomy and is equally curative.

One-year Graft Patency after Coronary Artery Bypass Surgery / 대한흉부외과학회지

Between July 1994 and August 1995, 78 patients underwent coronary artery bypass graft at Seoul National University Hospital. Coronary angiogram was performed one year after coronary artery bypass graft in 49 patients(62.8%) for evaluation of the graft patency and analysis of the risk factors for graft occlusion. The patency rates of both the internal mammary artery and the radial artery grafts were 100%, although three internal mammary artery grafts(5.0%) were narrowed(string sign). And that of the saphenous vein grafts were 85.2%. Multivariate analysis for the preoperative, operative, and postoperative factors was done between the widely patent and the narrowed internal mammary artery graft groups, and between the patent and the occluded saphenous vein graft groups by the general linear models procedure. Patient's age(>or=60 years), postoperative intraaortic balloon pump insertion, bleeding, and acute renal failure were found to be the significant risk factors for internal mammary artery graft narrowing, and coronary artery size(<1.5 mm) was the significant risk factor for the saphenous vein graft occlusion (p<0.05). This study confirms that the arterial graft is superior to the vein graft at one-year patency rate, and suggests the risk factors for graft occlusion during the first postoperative year. Knowledge of this study may provide a basis for estimating the risk factors for graft occlusion, and thereby modifying surgical strategy and postoperative surveillance.