Changes of the Structural and Biomechanical Properties of the Bovine Pericardium after the Removal of alpha-Gal Epitopes by Decellularization and alpha-Galactosidase Treatment

BACKGROUND: Bovine pericardium is one of the most widely used materials in bioprosthetic heart valves. Immunologic responses have been implicated as potential causes of limited durability of xenogenic valves. This study aimed to determine the effectiveness of decellularization and alpha-galactosidase (alpha-gal) to remove major xenoreactive antigens from xenogenic tissues. MATERIALS AND METHODS: Recombinant Bacteroides thetaiotaomicron (B. thetaiotaomicron) alpha-gal or decellularization, or both were used to remove alpha-gal from bovine pericardium. It was confirmed by alpha-gal-bovine serum albumin-based enzyme-linked immunosorbent assay (ELISA), high-performance anion exchange chromatography, flow cytometry, 3,3'-diaminobenzidine-staining, and lectin-based ELISA. The mechanical properties of bovine pericardium after decellularization or alpha-gal treatment were investigated by tests of tensile-strength, permeability, and compliance. Collagen fiber rearrangement was also evaluated by a 20,000x transmission electron microscope (TEM). RESULTS: Recombinant B. thetaiotaomicron alpha-gal could effectively remove alpha-gal from bovine pericardium B. thetaiotaomicron (0.1 U/mL, pH 7.2) while recombinant human alpha-gal removed it recombinant human alpha-gal (10 U/mL, pH 5.0). There was no difference in the mechanical properties of fresh and recombinant alpha-gal-treated bovine pericardium. Furthermore, the TEM findings demonstrated that recombinant alpha-gal made no difference in the arrangement of collagen fiber bundles with decellularization. CONCLUSION: Recombinant B. thetaiotaomicron alpha-gal effectively removed alpha-gal from bovine pericardium with a small amount under physiological conditions compared to human recombinant alpha-gal, which may alleviate the harmful xenoreactive immunologic responses of alpha-gal. Recombinant alpha-gal treatment had no adverse effects on the mechanical properties of bovine pericardium.

Surgical Treatment of Patients with Abdominal Aortic Aneurysm / 대한흉부외과학회지

BACKGROUND: Open surgical repair of abdominal aortic aneurysms was initiated by Dubost in 1952. Despite the rapid expansion of percutaneous endovascular repair, open surgical repair is still recognized for curative intent. We retrospectively analyzed surgical outcome, complications, and mortality-related factors for patients with abdominal aortic aneurysms over a 6 year period. MATERIAL AND METHOD: We analyzed 18 patients who underwent surgery for abdominal aortic aneurysms between March 2002 and March 2008. The indications for surgery were rupture, a maximal aortic diameter >60 mm, medically intractable hypertension, or pain. RESULT: The mean age was 66.6+/-9.3 years (range, 49~81 years). Twelve patients (66.7%) were males and 6 patients were females. Extension of the aneurysm superior to the renal artery existed in 6 patients (33.3%), and extension to the iliac artery existed in 13 patients (72.2%). Five patients (27.8%) had ruptured aortic aneurysms. The mean maximal diameter of the aorta was 72.2+/-12.9 mm (range, 58~109 mm). Surgery was performed by a midline laparotomy, and 6 patients underwent emergency surgery. The mean total ischemic time from aorta clamping to revascularization was 82+/-42 minutes (range, 35~180 minutes). The mortality rate was 16.7%; the mortality rate for patients with ruptured aneurysms was 60%, and the mortality rate for patients with unruptured aneurysms was 0%. The postoperative complications included one each of renal failure, femoral artery and vein occlusion, and wound infection. The patients who were discharged had a long-term survival of 34+/-26 months (range, 4~90 months). Rupture and emergency surgery had a statistically significant mortality-related factor (p<0.05). CONCLUSION: Emergency surgery for ruptured aortic aneurysms continues to have a high mortality, but unruptured cases are repaired with relative safety. Successfully operated patients had long-term survival. Even though endovascular aortic repair is the trend for abdominal aortic aneurysms, aggressive application should be determined with care. Experience and systemic support of each center is important in the treatment plan

Clinical Analysis of Disease Recurrence for the Patients with Secondary Spontaneous Pneumothorax / 대한흉부외과학회지

BACKGROUND: Secondary spontaneous pneumothorax is caused by various underlying lung diseases, and this is despite that primary spontaneous pneumothorax is caused by rupture of subpleural blebs. The treatment algorithm for secondary pneumothorax is different from that for primary pneumothorax. We studied the recurrence rate, the characteristics of recurrence and the treatment outcomes of the patients with secondary spontaneous pneumothorax. MATERIAL AND METHOD: Between March 2005 to March 2007, 85 patients were treated for their first episodes of secondary spontaneous pneumothorax. We analyzed the characteristics and factors for recurrence of secondary spontaneous pneumothorax by conducting a retrospective review of the medical records. RESULT: The most common underlying lung disease was pulmonary tuberculosis (49.4%), and the second was chronic obstructive lung disease (27.6%). The recurrence rate was 47.1% (40/85). The second and third recurrence rates were 10.9% and 3.5%, respectively. The mean follow up period was 21.1+/-6.7 months (range: 0~36 month). For the recurrence cases, 70.5% of them occurred within a year after the first episode. The success rates according to the treatment modalities were thoracostomy 47.6%, chemical pleurodesis 74.4%, bleb resection 71% and Heimlich valve application 50%. Chemical pleurodesis through the chest tube was the most effective method of treatment. The factor that was most predictive of recurrence was 'an air-leak of 7 days or more' at the first episode. (p=0.002) CONCLUSION: The patients who have a prolonged air-leak at the first episode of pneumothorax tend to have a higher incidence of recurrence. Further studies with more patients are necessary to determine the standard treatment protocol for secondary spontaneous pneumothorax.

Treatment of Malperfusion Caused by Acute Aortic Dissection / 대한흉부외과학회지

Malperfusion of a major organ with aortic dissection has various clinical features according to the involved aortic branch. The morbidity and mortality rate can increase without suspicion especially during the intraoperative and postoperative period. Surgical outcomes and prognosis are influenced by early detection and active treatment, and expeditious diagnostic and therapeutic measures are mandatory for successful treatment. The authors report four successful cases of acute aortic dissection with malperfusion of various organs, such as the brain, kidney, and the lower extremities.

Prevalence and clinical significance of the positive antinuclear antibody in children with idiopathic thrombocytopenic purpura / 소아과

PURPOSE: An association between idiopathic thrombocytopenic purpura (ITP) and systemic lupus erythematosus (SLE) has been recognized for decades because thrombocytopenia is the first manifestation in some patients with SLE. However, the risk of later development of SLE in childhood ITP is currently unknown. We retrospectively evaluated the incidence and clinical significance of the positive antinuclear antibody (ANA) in children with acute ITP. METHODS: This study was retrospectively performed to review the clinical and laboratory characteristics in 77 children diagnosed to have acute ITP and admitted to the Pusan National University Hospital between January 2003 and December 2006. Patients tested positive for ANA were regularly followed-up for at least 12 months for symptoms indicative of SLE. RESULTS: Seventy-seven children were included in the study; 38 males (49.4%) and 39 females (50.5%), the mean age was 4.5 years. Sixteen (20.8%) ITP patients had a positive ANA, with a median titer of 1:320. The mean age of the patients with positive ANA was 9.3 years, which is much older than 3.3 years for patients with negative ANA (P<0.05). The positive ANA group was predominantly female (81.3%) compared to the negative ANA group (P<0.05). There was no statistically significant difference in mean platelet counts between both groups. No statistically significant difference was found in ANA positivity and progression to chronic ITP or SLE. After the median follow-up of 32 months, SLE was diagnosed only in one ITP patient with positive ANA. CONCLUSION: Our data demonstrated that ANA positivity is often found in children with acute ITP. Large-scale studies should be considered to determine the significance of ANA positivity in childhood ITP for the later development of SLE.

Development of Porcine Pericardial Heterograft for Clinical Application(Tensile Strength-thickness) / 대한흉부외과학회지

BACKGROUND: Bioprosthetic devices for treating cardiovascular diseases and defects may provide alternatives to autologous and homograft tissue. We evaluated the mechanical and physical conditions of a porcine pericardial bioprosthesis treated with Glutaraldehyde (GA), Ethanol, or Sodium dodecylsulfate (SDS) before implantation. MATERIAL AND METHOD: 1) Thirty square-shaped pieces of porcine pericardium were fixed in 0.625%, 1.5% or 3% GA solution. 2) The tensile strength and thickness of these and other bioprosthesis, including fresh porcine pericardium, fresh human pericardium, and commercially produced heterografts, were measured. 3) The tensile strength and thickness of the six treated groups (GA-Ethanol, Ethanol-GA, SDS only, SDS-GA, Ethanol-SDS-GA and SDS-Ethanol-GA) were measured. RESULT: 1) Porcine pericardium fixed in 0.625% GA the thinnest and had the lowest tensile strength, with thickness and tensile strength increasing with the concentration of GA solution. The relationship between tensile strength and thickness of porcine pericardium increased at thicknesses greater than 0.1 mm (correlation-coefficient 0.514, 0<0.001). 2) There were no differences in tensile strength or thickness between commercially-produced heterografts. 3) Treatment of GA, ethanol, or SDS minimally influenced thickness and tensile strength of porcine pericardium, except for SDS alone. CONCLUSION: Porcine pericardial bioprosthesis greater than 0.1 mm thick provide better handling and advantageous tensile strength. GA fixation did not cause physical or mechanical damage during anticalcification or decellularization treatment, but combining SDS-ethanol pre-treatment and GA fixation provided the best tensile strength and thickness.

Descending Aorto-bronchial Fistula after Ascending Aorta Graft Interposition for Type I Acute Aortic Dissection / 대한흉부외과학회지

A 59-year old female patient was admitted due to massive hemoptysis. 6-months previously, we performed ascending aorta graft interposition for terating Debakey type 1 acute aortic dissection. Chest CT scan showed the fistula between the descending thoracic aorta and the left lower lobe. We performed descending thoracic aorta graft interposition under cardiopulmonary bypass. She recovered well without any postoperative problems. Distal aorto-bronchial fistula after a previous aortic operation is very rare. We report here the good results of treating aorto-bronchial fistula because we recognized this lesion early and performed an early operation.

Surgical Treatment for Renovascular Hypertension and Iliac Artery Occlusion / 대한흉부외과학회지

A 48-year old male patient visited our hospital with uncontrolled hypertension and pain of the left leg. CT angiography shows atherosclerotic occlusion of both renal artery orifices and the left common iliac artery. Despite of medical treatment for 2 months, the clinical condition of the patient worsened. We performed the surgical revascularization with both renal arteries and aorto-left femoral artery bypass with using an 8 mm artificial vascular graft. He lived well without hypertension with using only angiotensin receptor blocker and an anticoagulant for 10 postoperative months. Using surgical revascularization for renovascular hypertension has decreased due to the development of intervention technology and medication, but this surgery is indicated in cases of renovascular hypertension with extensive atherosclerotic lesions. We report here on a case of surgical revacularization for medically intractable atherosclerotic renovascular hypertension together with left common iliac artery occlusion.

Surgical Treatment for Common Iliac Arteriovenous Fistula after Lumbar Laminectomy / 대한흉부외과학회지

A 40 year-old male patient admitted for dyspnea and edema of the lower extremities. A pulsatile abdominal mass with a bruit was palpable in the right lower quadrant. Four months previously, he had underwent left partial laminectomy (L4~5) and discectomy at the L4 level due to disc protrusion. Computed tomography showed an ilio-iliac AV fistula with pseudoaneurysm at the L5 level. Because massive bleeding occurred when the aneurysm was entered, we closed the aneurysm and performed resection and suture of the aorta and both iliac arteries very near the aneurysm. After exclusion of the arterial side, we performed reduction angioplasty at the aneurysm and aorto-biiliac reconstruction with an artificial graft. Twenty-four months after operation, he is doing well and hasn't had any complications on the follow-up.

Snuffbox Arteriovenous Fistula Formation for Hemodialysis / 대한흉부외과학회지

BACKGROUND: The arteriovenous fistula (AVF), which maintains satisfactory blood flow, is necessary to the patients of end-stage renal disease for the long term hemodialysis. We performed the snuffbox fistula as the first operation for hemodialysis vascular access. This study was performed to investigate the patency rates, complications, risk factors for occlusion of the AVF, and the types of reoperations. MATERIAL AND METHOD: We performed 146 snuffbox fistulas from Jun. 1994 to Dec. 2001. The records of the patients except six patients who were lost from follow up were analyzed retrospectively. Mean age and male:female ratio were 52+/-15 years (range, 17~79 years) and 80:60 respectively. Diabetes mellitus and hypertension were combined in 47 patients and 101 respectively. Preoperative levels of creatinine and potassium were 9.09+/-3.68 mg/dL (range, 2.55~20.09 mg/dL) and 4.7+/-0.9 mmol/L (range, 2.3~8.1 mmol/L). One hundred thirteen cases of the snuffbox fistulas were done at left side hand and the others at right hand. RESULT: Mean follow up period of the patients was 41.8+/-31.0 months (range, 0.2~108.8 months). During the follow up period, 35 occlusions of AVF occurred and these AVFs were patent for 9.8+/-10.1 months (range, 0.1~40.4 months). The patency rates of 1 month, and 1, 2, 3, 5 years were known as 92.8, 80.2, 73.8, 71.3, 69.6% respectively. Right sided snuffbox fistulas (p-value=0.045) and old age (p-value=0.048) were revealed as significant risk factors for occlusion of AVF. The postoperative complications consisted of occlusions of AVF caused by intimal hyperplasia of vein in 24, thrombosis in nine, stenosis of anastomosis site in three, and venous hypertensions in two. After the first operation 37 patients underwent 86 reoperations. CONCLUSION: The snuffbox fistulas showed acceptable patency rates and low complication rates. The snuffbox fistulas as the first operation for AVF formation can be a good option for the patients with end-stage renal disease.

Rapidly Progressed Primary Choriocarcinoma of the Lung / 대한흉부외과학회지

A 69-year-old man was admitted due to blood-tinged sputum. The preoperative examination revealed 5x2.8cm sized nodular mass on left upper lobe of the lung. The patient underwent left upper lobectomy and radical lymph node dissection under impression of lung cancer. Postoperative pathologic examination revealed as primary choriocarcinoma of the lung. The patient expired at postoperative 58 days despite meticulous postoperative care. We planned on immediate adjuvant chemotherapy but was delayed due to postoperative pneumonia and the choriocarcinoma progressed rapidly. Primary choriocarcinoma is an extremely rare clinical entity in lung cancer with no established therapeutic guidelines available. We report a case of the primary pulmonary choriocarcinoma which was diagnosed postoperatively.

Fibrocalcific Embolism of Right Coronary Artery Combined with Aortic Valvular Stenosis / 대한흉부외과학회지

The main cause of ischemic heart disease combined with aortic valve disease is the systemic atherosclerotic process. Coronary artery embolism by a particle from the calcified aortic valvular tissue is very rare. A 73-year-old female patient was admitted due to chest tightness of recent onset. Two dimensional echocardiogram showed severe calcific aortic valve stenosis. Preoperative coronary angiogram exhibited a stenotic lesion at the distal right coronary artery, which seemed to be embolic in origin. The coronary embolus was removed through the coronary arteriotomy and then the arteriotomy site was repaired by onlay patch angioplasty technique. Aortic valve was replaced by a bioprosthetic valve. The embolus was reported as a fibrocalcified particle of diseased valve.

Aortobronchial Fistula After Chest Trauma / 대한흉부외과학회지

Few patients with traumatic aortic laceration remain undiagnosed and survive long enough to develop a chronic aneurysm. Such aneurysms are frequently asymptomatic: alternatively, they may manifest chest pain, dysphagia, bronchial irritation, or sudden death. A case of aortobronchial fistula secondary to a chronic post-traumatic aneurysm of the aortic isthmus is presented. Hemoptysis was the main sign. The affected segment of the thoracic aorta was repaired with a Hemashield patch and a left upper lobectomy was performed.

Primary Repair of Boerhaave's Syndrome / 대한흉부외과학회지

Boerhaave's syndrome has the worst prognosis of the esophageal perforation, despite the advancement in the treatment of esophageal perforation due to the development of ICU care and antibiotics. There were controversies in the treatment of esophageal perforation when diagnosed after 24hrs. From 1995 to 2000, we performed a buttressed primary repair and mediastinal drainage in 6 Boerhaave's syndrome patients among 13 esophageal perforation patients. Two patients died(33%). They died because of pneumonia, ARDS and sepsis on 38th, 39th post-operative day respectively. Two patients had leak at the site of repair which was treated completely with conservative treatment. We report on the result of a buttressed primary repair and mediastinal drainage for 6 Boerhavve's syndrome patients.

Interrelationship between the Fingerprint and Sasang Constitutional Types / 체질인류학회지

In oriental medicine, classification of the Sasang constitutional types (Tae-Yang, Tae-Eum, So-Yang, and So-Eum) is important for the treatment. To classify the Sasang constitutional types, the old methods such as pulse palpation are not objective; the recent methods such as immunohematology are expensive, painful, and time consuming. To overcome this problem, a body measurement, one of the anthropological methods, has been developed. The purpose of this study was to define whether the fingerprint, other one of the anthropological methods, is helpful to classify the Sasang constitutional types. Thus, we looked for the interrelationship between the fingerprint and Sasang constitutional types. Before analyzing the fingerprint, two kinds of questionnaires for classifying the Sasang constitutional types were surveyed on 760 Koreans (465 males, 295 females). As there was no Tae-Yang individual, we only could find the fingerprint characteristics of Tae-Eum(288 persons), So-Yang (193 persons), and So-Eum(279 persons) individuals. In the fingerprints of Tae-Eum individual, the arch types were more frequent, and the loop types were less frequent. These characteristics were prominent in female, right, second, and fifth fingers. In those of So-Yang individual, the arch types were less frequent, and the whorl types were more frequent. These characteristics were prominent in male, female, left, first, second, third, and fifth fingers. In those of So-Yang individual, fingerprint ridge count was greater in fourth finger. In those of So-Eum individual, loop types were more frequent, and whorl types were less frequent. These characteristics were prominent in male, right, left, first, third, and fifth fingers. In those of So-Eum individual, fingerprint ridge count was lesser. These characteristics were prominent in male, fourth, and fifth fingers. The fingerprint seems to be helpful to classify the Sasang constitutional types.

Morphology of Fingerprints in Koreans / 체질인류학회지

Fingerprints have been used for personal identification, for revealing physical anthropological characteristics, and for diagnosing genetic disorders. Morphology of fingerprints has been analyzed in various tribes. However, in Korean, the analytical methods of fingerprints and the numbers of subjects were not sufficient to find standard values for Korean fingerprints. In this study, fingerprints of 3216 Koreans (2095 males and 1121 females) were analyzed using the various methods and compared with those of other tribes to contribute in revealing physical anthropological characteristics of Korean and also in diagnosing genetic disorders of Korean. The results were as follows. 1. The incidence of ulnar loop type, whorl type, radial loop type, and arch type was 50.4%, 42.9%, 3.8%, and 2.9%, respectively. Data from the comparison of the incidences of fingerprint types in Korean with those in various tribes lead us to conclude that Korean belongs to the Asians and becomes closer to the Whites and Blacks in which loop type is frequent and whorl type is not frequent. 2. Fingerprint type seems to be related to the strength of finger since whorl type was frequent in male and in right hand, and arch type was frequent in female and in left hand. In addition, loop of fingerprint appears to have the tendency to open to the side bearing more physical contact since radial loop type was frequent in second finger, and ulnar loop type was frequent in fifth finger. 3. Among the subtypes of fingerprint, morphologically simple types were common. Among the subtypes of arch types, simple arch type with the same number of radial dermal ridges as ulnar ones was the most common. Among the subtypes of loop types, ulnar loop type without concentric circles or spirals was the most common. Among the subtypes of whorl types, concentric whorl type without loops was the most common. 4. Finger ridge counts were 16.9, 13.9, 11.9, 11.3, and 11.2 in first, fourth, third, second, and fifth finger, respectively; and were greater in male than in female. Finger ridge counts are greater in fingers which shows whorl type. However, there would be other factors to determine finger ridge counts; for examples, the size and behavioral habit of finger.

The Role of Intra-Aortic Balloon Pump in Coronary Artery Bypass Surgery / 대한흉부외과학회지

In the era of coronary artery bypass grafting, the intraaortic balloon pump(IABP) is more widely used and its indication has been expanded. We performed retrospective clinical analysis on the patients who have received IABP pre and/or postoperatively during the course of CABG. From January 1981 to June 1995, total 322 patients have received CABG at the Seoul National University Hospital and among them 50 patients(15.5%) were supported by IABP during the course of the operation. The mean age at the time of the operation was 57.2 years(39-75 years) and the male to female ratio was 33:17. The preoperative diagnosis was unstable angina in 33(66%), stable angina in 7(14%) and postinfarct angina in 8 patients(16%). As for the indications of the IABP, there were 13 cases(26%) with left main disease, 13(26%) with class IV angina, 12(24%) with difficulty in CPB weaning, 6(12%) with postinfarct angina and 3(6%) with severe LV dysfunction. In the remaining 3 cases, one patient was operated on after PTCA failure in emergency basis, another was a patient with AMI, and the other was one who had postoperative low cardiac output syndrome. All IABPs were introduced via femoral artery and among them 45 cases(90%) percutaneously. The mean postoperative assist time was 22.3 hours(0.5-168 hours) and IABP could be removed within 48 hours in most of them(44/50). The operative mortality was 6.1%(3 cases) and postoperative morbidity was only one with lower extremity ischemia. The more general application of the IABP during the course of the CABG ,especially in patients with high preoperative risk factors or difficulty in CPB weaning is a good measure of protecting and recovering myocardial function with minimal risk.