Clinical Analysis for the Correlation of Intra-abdominal Organ Injury in the Patients with Rib Fracture

BACKGROUND: Although it is rare for the fracture itself to become a life threatening injury in patients suffering from rib fracture, the lives of these patients are occasionally threatened by other associated injuries. Especially, early discovery of patients with rib fracture and intra-abdominal organ injury is extremely important to the prognosis. This study analyzed the link between rib fracture and intra-abdominal injury to achieve improved treatment. MATERIALS AND METHODS: Among trauma patients that had visited the hospital emergency room from January 2007 to December 2009, a retrospective study was conducted on 453 patients suffering from rib fracture due to blunt trauma. Rib fracture was classified according to location (left, right, and bilateral), and according to level (upper rib fracture [1-2nd rib], middle rib fracture [3-8th rib], and lower rib fracture [9-12th rib]). The researched data was statistically compared and analyzed to investigate the correlation between the location, level, and number of rib fracture and intra-abdominal organ injury. RESULTS: Motor vehicle injury was found to be the most common mechanism of injury with 208 cases (46%). Associated injuries accompanied with rib fracture were generated in 276 cases (61%). Intra-abdominal organ injury was discovered in 97 cases (21%). Liver injury was the most common intra-abdominal injury associated with rib fracture with 39 cases (40%), followed by spleen injury, with 23 cases (23%). Intra-abdominal injury according to level of rib fracture was presented as upper rib fracture in 11 cases (11%), middle rib fracture in 31 cases (32%), and lower rib fracture in 55 cases (57%), thus verifying that intra-abdominal injuries were commonly accompanied in lower rib fractures (p=0.03). In particular, significant increase of intra-abdominal injury was presented in fractures below the 8th rib (p=0.03). The number of intra-abdominal injuries requiring emergency operations was significantly higher in patients with more than 6 rib fractures (p=0.04). CONCLUSION: Intra-abdominal organ injury is more common in patients with lower rib fracture, especially fractures below the 8th rib. Intra-abdominal organ injuries generated in multiple rib fracture patients with more than 6 fractures significantly higher severity. These cases must be thoroughly inspected and carefully observed as there is possibility of emergency operation.

Removal of Alpha-Gal Epitopes from Porcine Aortic Valve and Pericardium using Recombinant Human Alpha Galactosidase A

It has been reported that the immune response due to alpha-Gal epitopes is an important factor in tissue valve failure. The elimination of the interaction between the natural anti-Gal antibodies and alpha-gal epitopes on the xenografts is a prerequisite to the success of xenografts in humans. Previously, we reported that the green coffee bean alpha-galactosidase could remove all alpha-Gal epitopes from cell surface of porcine aortic valve and pericardial tissue, but it has limitations on cost effectiveness. In this study we wanted to know whether the recently produced recombinant human alpha-galactosidase A has the same effective enzymatic activity as green coffee bean alpha-galactosidase in removing alpha-Gal epitopes from the same tissues. After treating fresh porcine aortic valve and pericardial tissue with recombinant alpha-galactosidase A, each sample was stained with Griffonia simplicifolia type I isolectin B4 indirect immunoperoxidase avidin-biotin technique. We then examined whether the alpha-Gal epitopes were reduced or abolished in each consecutive concentration of recombinant alpha-galactosidase A by comparing the degree of the Griffonia simplicifolia isolectin B4 staining. As a result, the recombinant alpha-galactosidase A could remove cell surface alpha-Gals on porcine aortic valve and pericardial tissue as effectively as green coffee bean alpha-galactosidase.

Percutaneous Cardiopulmonary Support (PCPS) for Patients with Cardiopulmonary Bypass Weaning Failure during Open Heart Surgery / 대한흉부외과학회지

BACKGROUND: Recently, percutaneous cardiopulmonary support (PCPS) has been widely used to rescue patients in cardiogenic shock or cardiac arrest. However, patients with cardiopulmonary bypass (CPB) weaning failure during open heart surgery still have very poor outcomes after PCPS. We investigated clinical results and prognostic factors for patients who underwent PCPS during open heart surgery. MATERIAL AND METHOD: From January 2005 to December 2008, 10 patients with CPB weaning failure during open heart surgery underwent PCPS using the CAPIOX emergency bypass system (EBS(R), Terumo Inc, Tokyo, Japan). We retrospectively reviewed the medical records of those 10 patients. RESULT: The average age of the patients was 60.2+/-16.5 years (range, 19~77 years). The mean supporting time was 48.7+/-64.7 hours (range, 4~210 hours). Of the 10 patients, 6 (60%) were successfully weaned from the PCPS While 5 (50%) were able to be discharged from the hospital. Complications were noted in 5 patients (50%). In univariate analysis, long aortic cross clamp time during surgery, mediastinal bleeding during PCPS and high level of Troponin-I before PCPS were significant risk factors. All of the discharged patients are still surviving 34+/-8.6 months (range, 23~48 months) post-operatively. CONCLUSION: The use of PCPS for CPB weaning failure during open heart surgery can improve the prognosis. More experience and additional clinical studies are necessary to improve survival and decrease complications.

Surgical Treatment of Native Valve Aspergillus Endocarditis and Fungemic Vascular Complications

Systemic infection with Aspergillus is an opportunistic disease that affects mainly immunocompromised hosts, and is associated with a high mortality rate. It typically occurs in patients with several predisposing factors, but Aspergillus endocarditis of native valves is rare and experience in diagnosis and treatment is limited. We report a case of native valve endocarditis caused by Aspergillus. A 35-yr-old male patient who underwent pericardiocentesis four months previously for pericardial effusion of unknown etiology presented with right leg pain and absence of the right femoral artery pulse. Cardiac echocardiography revealed severe mitral insufficiency with large mobile vegetations, and computed tomographic angiography showed embolic occlusion of both common iliac arteries. We performed mitral valve replacement and thromoembolectomy, and Aspergillus was identified as the vegetation. We started intravenous amphotericin B and oral itraconazole, but systemic complications developed including superior mesenteric artery aneurysm and gastrointestinal bleeding. After aggressive management, the patient was discharged 78 days post surgery on oral itraconazole. He was well at 12 months post discharge but died in a traffic accident 13 months after discharge.

Development of Porcine Pericardial Heterograft for Clinical Application(Microscopic Analysis of Various Fixation Methods) / 대한흉부외과학회지

BACKGROUND: Various experimental trials for the development of bioprosthetic devices are actively underway, secondary to the limited supply of autologous and homograft tissue to treat cardiac diseases. In this study, porcine bioprostheses that were treated with glutaraldehyde (GA), ethanol, or sodium dodecylsulfate (SDS) were examined with light microscopy and transmission electron microscopy for mechanical and physical imperfections before implantation. MATERIAL AND METHOD: 1) Porcine pericardium, aortic valve, and pulmonary valve were examined using light microscopy and JEM-100CX II transmission electron microscopy, then compared with human pericardium and commercially produced heterografts. 2) Sections from six treated groups (GA-Ethanol, Ethanol-GA, SDS only, SDS-GA, Ethanol-SDS-GA and SDS-Ethanol-GA) were observed using the same methods. RESULT: 1) Porcine pericardium was composed of a serosal layer, fibrosa, and epicardial connective tissue. Treatment with GA, ethanol, or SDS had little influence on the collagen skeleton of porcine pericardium, except in the case of SDS pre-treatment. There was no alteration in the collagen skeleton of the porcine pericardium compared to commercially produced heterografts. 2) Porcine aortic valve was composed of lamina fibrosa, lamina spongiosa, and lamina ventricularis. Treatment with GA, ethanol, or SDS had little influence on these three layers and the collagen skeleton of porcine aortic valve, except in the case of SDS pre-treatment. There were no alterations in the three layers or the collagen skeleton of porcine aortic valve compared to commercially produced heterografts. CONCLUSION: There was little physical and mechanical damage incurred in porcine bioprosthesis structures during various glutaraldehyde fixation processes combined with anti-calcification or decellularization treatments. However, SDS treatment preceding GA fixation changed the collagen fibers into a slightly condensed form, which degraded during transmission electron micrograph. The optimal methods and conditions for sodium dodecylsulfate (SDS) treatment need to be modified.

Initial Experience of the Emergency Bypass System (EBS(R)) for the Patients with Cardiogenic Shock due to an Acute Myocardial Infarction / 대한흉부외과학회지

BACKGROUND: Percutaneous cardiopulmonary support (PCPS) has the potential to rescue patients in cardiogenic shock who might otherwise die. PCPS has been a therapeutic option in a variety of the clinical settings such as for patients with myocardial infarction, high-risk coronary intervention and postcardiotomy cardiogenic shock, and the PCPS device is easy to install. We report our early experience with PCPS as a life saving procedure in cardiogenic shock patients due to acute myocardial infarction. MATERIAL AND METHOD: From January 2005 to December 2006, eight patients in cardiogenic shock with acute myocardial infarction underwent PCPS using the CAPIOX emergency bypass system (EBS(R), Terumo, Tokyo, Japan). Uptake cannulae were inserted deep into the femoral vein up to the right atrium and return cannulae were inserted into the femoral artery with Seldinger techniques using 20 and 16-French cannulae, respectively. Simultaneously, autopriming was performed at the EBS(R) circuit. The EBS? flow rate was maintained between 2.5~3.0 L/min/m2 and anticoagulation was performed using intravenous heparin with an ACT level above 200 seconds. RESULT: The mean age of patients was 61.1+/-14.2 years (range, 39 to 77 years). Three patients were under control of the EBS? before percutaneous coronary intervention (PCI), three patients were under control of the EBS? during PCI, one patient was under control of the EBS after PCI, and one patient was under control of the EBS(R) after coronary bypass surgery. The mean support time was 47.5+/-27.9 hours (range, 8 to 76 hours). Five patients (62.5%) could be weaned from the EBS(R) after 53.6+/-27.2 hours (range, 12 to 68 hours) of support. All of the patients who could successfully be weaned from support were discharged from the hospital. There were three complications: one case of gastrointestinal bleeding and two cases of acute renal failure. Two of the three mortality cases were under cardiac arrest before EBS(R) support, and one patient had an intractable ventricular arrhythmia during the support. All of the discharged patients are still surviving at 16.8+/-3.1 months (range, 12 to 20 months) of follow-up. CONCLUSION: The use of EBS(R) for cardiogenic shock caused by an acute myocardial infarction could rescue patients who might otherwise have died. Successfully recovered patients after EBS(R) treatment have survived without severe complications. More experience and additional clinical investigations are necessary to elucidate the proper installation timing and management protocol of the EBS? in the future.

Removal of alpha-Gal Epitopes in Aortic Valve and Pericardium ofPig Using Green Coffee Bean alpha-Galactosidase / 대한흉부외과학회지

BACKGROUND: It is currently thought that tissue valve degeneration is related to an animal's immune response, which is mainly due to cell surface alpha-Gal epitopes. Cell surface alpha-Gal epitopes are known to be degraded by the enzyme called green coffee bean alpha-galactosidase. It is also well known that alpha-Gal epitopes are immunologically stained by Griffonia Simplicifolia isolectin type B4. We know that many commercially available tissue valves are made of aortic valves and pericardial tissue of pig. So, we investigated whether alpha-Gal epitopes of the aortic valve and pericardial tissue of a pig can be removed by green coffee bean alpha-galactosidase, and we did so by comparing immunologic staining of the tissues before and after the enzyme treatment. MATERIAL AND METHOD: After treating fresh porcine aortic valve and pericardial tissue with green coffee bean alpha-galactosidase at concentrations of 0.5 unit/mL, 1.0 unit/mL, 2.0 unit/mL, respectively, under the condition of pH 6.5, temperature 4degrees C and 24 hours of incubation, each sample was stained with Griffonia Simplicifolia isolectin type B4 immunofluorescent labeling. We then examined whether the alpha-Gal epitopes were reduced or abolished in each consecutive concentration of green coffee bean alpha-galactosidase by comparing the degree of the Griffonia Simplicifolia isolectin B4 staining in each sample. RESULT: In the pig aortic valve tissue, a 1.0 unit/mL concentration of green coffee bean alpha-galactosidase at pH 6.5, 4degrees C and reaction for 24 hours was enough for complete removal of alpha-Gal epitopes from the cell surface on the immunostaining with Griffonia Simplicifolia isolectin B4. On the other hand, more alpha-Gal epitopes were present in the pig pericardial tissue on Griffonia Simplicifolia isolectin B4 staining before the enzyme treatment, and 1.0 unit/mL of galactosidase was not sufficient for complete removal of alpha-Gal from the tissue. 2.0 units/mL of green coffee bean alpha-galactosidase was needed to completely remove the alpha-Gal epitopes from the pericardial tissue on immunostaining. CONCLUSION: The alpha-Gal epitopes of the pig's aortic valve and pericardial tissue were successfully stained with Griffonia Simplicifolia isolectin B4. We could remove nearly all the alpha-Gal epitopes using green coffee bean alpha-galactosidase at the concentration of 1.0 unit/mL in the aortic valve of pig, and 2.0 unit/mL was need to nearly completely remove all the alpha-Gal epitopes in the pericardial tissue of pig under the condition of pH 6.5, 4degrees C and 24 hours of reaction time. In the near future, removal of alpha-Gal epitopes in the pig's aortic valve and pericardial tissue will become a powerful tool for the improvement of the tissue valve durability. It needs to be determined if alpha-galactosidase treated pig tissue is immune to human anti-Gal antibody or anti-Gal monoclonal antibodies.

Surgical Treatment for Descending Necrotizing Mediastinitis / 대한흉부외과학회지

BACKGROUND: Descending necrotizing mediastinitis (DNM) is a serious disease originating in odontogenic or oropharyngeal infection with high mortality despite adequate antibiotics and aggressive surgery. We analyzed results of treatment for DNM. MATERIAL AND METHOD: We studied 8 cases diagnosed as DNM from 1998 to 2007. All patients received emergent surgical drainage and debridement with broad spectrum antibiotics just after diagnosis. Antibiotics were changed after bacterial susceptibility testing. The surgical approach included 2 cases of cervicotomy, 6 cases of cervicotomy, and a thoracotomy. RESULT: The interval between symptom onset and hospitalization was 4.6+/-1.8 days (1~9 day). DNM originated in 4 cases of odontogenic infection (50%), 2 cases of oropharyngeal infection (25%), and 2 cases of unknown origin (25%). Causative organisms were found in 6 cases; Streptococcus in 4 cases, Staphylococcus in 1 case, and Klebsiella in 1 case. The Endo DNM classification was type I (2 cases), IIA (3 cases), and IIB (3 cases). The incidence of thoracotomy was 75%. The surgical mortality rate was 25% (2/8). The cause of death was multiple organ failure caused by septic shock. All mortality cases received only cervicotomy and aggravated infections after initial drainage. CONCLUSION: Early diagnosis, immediate surgical drainage, and adequate antibiotics, including covered anaerobes, are required. Thoracotomy should be performed with cervicotomy even for localized DNM.

Changes of the Cardiac Function and Circulating Catecholamine Level Under Ventricular Assist Device Installed in Acute Cardiogenic Shock Induced Experimental Animals

PURPOSE: The recent rise in the number of patients visiting emergency rooms with acute cardiogenic shock underscores the need for immediate efforts to develop affordable circulatory assist devices. Recently, a pneumatic pulsatile ventricular assist device (VAD) named DKUH-75, has been developed by the authors. We evaluated the feasibility of the DKUH-75 VAD in pigs placed into an acute cardiogenic shock state following myocardial infarction through a novel coronary artery ligation method involving ischemic preconditioning. METHODS: Acute cardiogenic shock was induced in 5 YorkshirexLandracexDuroc pigs by ligating the left anterior descending coronary artery via the ischemic preconditioning process. Afterward, the DKUH-75 VAD was implanted one hour after the onset of shock. Hemodynamic variables, echocardiographic findings and the level of circulating catecholamine were ascertained one hour after VAD installation. RESULTS: Systolic and mean systemic arterial pressures were increased while pulmonary arterial pressure were decreased one hour after the VAD implantation. LVEDP decreased, and the cardiac index increased significantly. In echocardiographic findings, the left ventricular end systolic dimension decreased after VAD implantation, and the fractional shortening and the ejection fraction increased significantly. The level of circulating catecholamine was increased one hour after the coronary artery ligation and was decreased one hour after VAD implantation, but these trends did not reach a statistical significance. CONCLUSION: The DKUH-75 VAD may help in the recovery of myocardial function, and we postulate that early VAD installation can improve outcome for the cardiogenic shock patients in the emergency room by preventing further development of congestive heart failure. However, further experiments are needed in order to demonstrate the statistical significance of the observed results.

The Feasibility of the DKUH-75 Left Ventricular Assist Device for Acute Cardiogenic Shock in Pigs / 대한흉부외과학회지

BACKGROUND: The recent trend of an increasing number of patients with acute cardiogenic shock or chronic congestive heart failure following myocardial infarction, as well as the considerable number who can not be weaned from cardiopulmonary bypass after open heart surgery, call for immediate efforts to develop affordable ventricular assist devices that are suitable for the Korean physique. Recently, a pneumatic pulsatile ventricular assist device (VAD), named DKUH-75, has been developed by the Department of Biomedical Engineering, in collaboration with the Department of Thoracic and Cardiovascular Surgery of Dankook University College of Medicine. The feasibility of the DKUH-75 VAD was evaluated on the bases of common hemodynamic variables and echocardiographic measurements in pigs, which are subjected to an acute cardiogenic shock state following myocardial infarction, using a novel coronary artery ligation method employing the ischemic preconditioning concept. MATERIAL AND METHOD: Acute cardiogenic shock was induced in 10 Yorkshire Landrace Duroc strain pigs by ligating the left anterior descending coronary artery via an ischemic preconditioning process. The hemodynamic variables were monitored, with epicardial echocardiographic measurements performed before and one hour after the ligation. The DKUH-75 VAD was implanted into 5 pigs one hour after the onset of the shock. The hemodynamic variables and echocardiographic measurements were taken one hour after installation of the VAD. RESULT: The systolic, diastolic and mean systemic arterial pressures were significantly decreased in all the experimental animals one hour after the ligation. The systolic, diastolic and mean pulmonary arterial pressures were increased (Eds note: this completely contradicts the preceding statement? However, if you mean the non-experimental animals this should be stated?). The left ventricular end diastolic pressure (LVEDP) was increased, but the cardiac index decreased. An increase in the left ventricular end systolic dimension and decreases in the fractional shortening and ejection fraction were observed all animals one hour after the coronary artery ligation. In all 5 of the VAD implanted pigs, the systolic and mean systemic arterial pressures were increased, and the pulmonary arterial pressures decreased one hour after the implantation; the LVEDP decreased, but the cardiac index was significantly increased. In the echocardiographic measurements, the left ventricular end systolic dimension decreased after the implantation of the VAD, but the fractional shortening and ejection fraction significantly increased. CONCLUSION: Significant improvements in the hemodynamic variables and echocardiographic measurements were observed in the 5 VAD implanted animals one hour after installation, which had been subjected to an acute cardiogenic shock state by ligation of the coronary artery, indicating that the DKUH-75 VAD could help in the recovery of the myocardial function. This suggests that the DKUH-75 VAD is feasible in the short term in relation to an acute cardiogenic shock state due to myocardial infarction.

Broncholithiasis Caused by Actinomycosis / 대한흉부외과학회지

A 32 year-old man was transferred to our hospital due to blood-tinged sputum for 15 days. He had been treated at a private hospital for recurrent pneumonia. The chest X-ray showed an atelectasis on the right middle lobe. Computed tomography of the chest demonstrated a broncholith on right middle lobar bronchus with lobar atelectasis of the right middle lobe. We tried to remove the broncholith through fiberoptic bronchoscopy, but could not remove it. Therefore, we performed surgical removal of broncholith and the right middle lobectomy. The cause of broncholith was identified as actinomycosis by pathologic examination. The broncholith caused by actinomycosis is rare. We report a rare case of broncholithiasis with recurrent obstructive pneumonia caused by actinomycosis, which was treated by surgical operation.

Establishment of the Heart Failure Model in Swine for the Experiment of the Pneumatic Ventricular Assist Device / 대한흉부외과학회지

BACKGROUND: In order to develop the acute heart failure model for the animal experiment of the pneumatic ventricular assist device, we decided to use young pig whose coronary artery distribution is almost the same as humans and also very cheap in price. The purpose of this study is to develop stable, reproducible acute ischemic heart failure model in swine using coronary artery ligation method. MATERIAL AND METHOD: Five young pigs whose weights are the same as adult humans are under experiment. Each pig was under endotracheal intubation and connected to a mechanical ventilator. Through left lateral thoracotomy, we exposed the heart and induced ischemic heart failure by coronary artery ligation. The ligation began at the distal part of the left anterior descending coronary artery. After 5 minutes of initial ligation we reperfused the artery and then re-ligated. Before and after each ligation-reperfusion procedure we assessed the left ventricular end-diastolic pressure, arterial pressure, and cardiac index. We also measured left ventricular end-diastolic dimension, end-systolic dimension, fractional shortening, ejection fraction using intraoperative epicardial echocardiography. After appropriate heart failure was established with sequential (from distal part of LAD to proximal location) ligation-reperfusion-ligation procedure, we inserted the ventricular assist device and operated. RESULT: We established stable acute ischemic heart failure in 3 of 5 young pigs with this sequential ligation-reperfusion-ligation procedure, and could maintained 50% less ejection fraction before the procedure according to intraoperative epicardial echocardiography. We also observed no ventricular arrhythmia usually associated with simple coronary artery ligation in large animals and no cardiac arrest associated with ventricular arrhythmia or myocardial stunning. In pathologic specimen, we observed scattered ischemic myocardium in all around the ischemic field induced by coronary artery ligation. CONCLUSION: Under the concept of ischemic preconditioning, we developed safe and reproducible acute ischemic heart failure model in swine using sequential coronary artery ligation-reperfusion-ligation method.

Left Ventricular Rhabdomyoma with Tuberous Sclerosis: A Report of one case / 대한흉부외과학회지

The most common primary heart tumor in infants is the rhabdomyoma.It is known that tuberous sclerosis is found in half of the patients with cardiac rhabdomyoma. Because the prognosis of this tumor associated with subaortic stenosis is poor,the surgical intervention is indicated.We report one case of left ventricular rhabdomyoma with tuberous sclerosis.