Rapid Regrowth of Left Atrial Myxoid Fibrosarcoma Considered to be Myxoma after Surgical Resection / 대한내과학회지

Malignant primary cardiac tumors are rare with the most common type among them being sarcomas. However, a myxoid sarcoma in the heart is very rare and differentiating it from from cardiac myxoma is often difficult. Here, we report a case of rapid regrowth of a left atrial tumor after surgical resection that was finally diagnosed as cardiac myxoid fibrosarcoma. An 82-year-old man, who underwent resection of a cardiac tumor 3 months ago, presented with severe dyspnea and peripheral edema. He was diagnosed with a mitral valve obstruction due to the regrowth of a huge left atrial tumor. The patient had a second resection and the resected tumor was finally diagnosed as myxoid fibrosarcoma.

Acupuncture Induced Necrotizing Aortitis with Infected Pseudoaneurysm Formation

Necrotizing aortitis is a rare and life-threatening complication of local or generalized bacterial infections and most commonly affects the abdominal aorta. We described a case of a 79-year-old man with an acupuncture-induced bacterial aortitis associated with pseudoaneurysm formation causing near rupture. The patient underwent emergent explolapartomy, resection of the infected aorta, wide debridement of surrounding infected tissues, and extra-anatomic axillary to bifemoral graft bypass. The microbiologic examination revealed Escherichia coli and methicillin resistant Staphylococcus aureus (MRSA). Necrotizing aortitis is very serious and fatal disease, careful history taking as well as rapid diagnosis and urgent treatment are of critical importance.

First Experience of Cardiac Surgery using da Vinci(TM) Surgical System in Korea / 대한흉부외과학회지

da Vinci(TM) Surgical System is an advanced mode of minimal invasive surgery, using 3-dimensional imaging system and robotic arms which can mimic the dexterity of the human hand. Thus, various operations can be performed with minimal incision and limited surgical field and the merits of minimal invasive surgery can be maximized by using it. We report our first experience of robotic open heart surgery using the da Vinci(TM) Surgical System for repairing atrial septal defect.

Total Arterial Off-Pump Coronary Revascularization with Multiple Y Arterial Composite Grafts / 대한흉부외과학회지

BACKGROUND: Complete arterial off-pump coronary artery bypass grafting (OPCAB) by sequential anastomoses with one or two arterial grafts provides favorable outcomes. However, problems of insufficient graft length, hypoperfusion, kinking of graft, and unfavorable course of graft may be encountered. To solve these problems, we have used different technique with multiple arterial Y composite graft to allow end-to-side rather than sequential anastomoses and evaluated the results of this method. MATERIAL AND METHOD: Between February 2003 and October 2004, 71 patients underwent total arterial OPCAB using multiple arterial Y composite grafts with left internal mammary artery (LIMA), radial artery (RA), and right internal mammary artery (RIMA). We divided RA into multiple segments by number of distal target site after measuring of individual proper length and constructed arterial composite graft. One of segments was sutured end-to-side to LIMA and other segment was sutured end-to-side to the previously constructed radial graft. Postoperative graft patency was evaluated in 61 patients by multi-slice computed tomography. RESULT: An average of 2.5+/-0.6 arteries and 3.7+/-0.7 distal anastomoses per patient were done. There was no perioperative myocardial infarction, clinical hypoperfusion syndromes, and operative mortality. Postoperative mean CK-MB level was 17.4+/-29.7 IU/L. Overall graft patency was 99.1% (214/216)(LIMA: 100%, RA: 98.4%, RIMA: 100%). CONCLUSION: This technique allows total arterial OPCAB without technical problems and provides excellent early clinical results and graft patency. We believe that this technique is more convenient in the obtuse marginal area compared to sequential technique, and helpful in patients who require complex arterial grafting.

Off Pump Total Arterial Myocardial Revascularization / 대한흉부외과학회지

BACKGROUND: Arterial conduits using in coronary artery bypass grafting (CABG) have been known a great long term patency rates, and improved short and long term clinical outcomes. It has been reported that Off pump CABG has better clinical results than CABG using cardiopulmonary bypass. To evaluate the advantage of arterial conduits over venous conduits and to avoid the adverse effects of cardiopulmonary bypass, we performed total arterial Off pump CABG. MATERIALS AND METHOD: From January 2001 to October 2004, Off pump CABG using only arterial conduits was performed on 325 patients with a mean age of 59.3+/-11.9 years (36~83). Mean ejection fraction was 55.4+/-14.0% (15~86). Angiography showed left main disease or triple-vessel disease in 81.9% of the patients. Indications of using arterial conduits was stenosis > or =50% of left anterior descending artery, stenosis > or =80% of branches of left circumflex artery, and stenosis > or =90% of right coronary artery and its branches. Multi-slice computed tomography was performed on 194 patients to evaluate the short term patency rates. RESULT: A total of 928 distal anastomoses were performed and the average anastomoses per a patient were 2.86+/-0.78. There was 1 operative mortality. Postoperative complications were mediastinitis in 6 patients (1.8%), renal failure in 4 patients (1.2%), perioperative myocardial infarction in 3 patients (0.9%), reoperation for bleeding in 3 patients (0.9%). There was no postoperative stroke. Patency rate of arterial conduits was 99.3% (581/585). There were 4 stenoses or competitive flows in 2 radial arteries and 2 right internal mammary arteries. CONCLUSION: Total arterial Off pump CABG appears to be safe, showing a low surgical mortality and morbidity and excellent short term patency rates of arterial conduits.

Spontaneous Recovery of Renal Function after Off-pump Coronary Artery Bypass Grafting in Chronic Renal Failure Patients / 대한흉부외과학회지

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) has shown better outcome in chronic renal failure (CRF) patients by avoiding the effects of cardiopulmonary bypass. We evaluated renal function after OPCAB in CRF patients. MATERIAL AND METHOD: 656 patients underwent OPCAB between January, 2001 and December, 2004. Data were collected in 26 CRF patients (Cr>1.7 mg/dL). Preoperative/postoperative creatinine (Cr) levels, creatinine clearance and postoperative data were evaluated. We divided the patients into group 1 (Cr or =3 mg/dL). RESULT: Three patients started dialysis after surgery. Preoperative mean creatinine level (4.19+/-3.4 mg/dL) was elevated to 4.36+/-2.7 mg/dL at the third postoperative day and decreased below preoperative level at the fifth postoperative day. In group 1 (mean Cr level=1.87+/-0.25 mg/dL), Cr level reached its peak level of 2.19+/-0.52 mg/dL at the fourth postoperative day (p=0.017), with subsequent decrease. Patients without pre- or postoperative dialysis (n=15) showed peak Cr elevation on postoperative day four (p=0.017) and subsequent decrease (p=0.01). Postoperative creatinine clearance showed reverse correlation with creatinine level. CONCLUSION: Creatinine level was elevated at third/fourth postoperative day, but decreased 5 days after surgery. Thus, if urgent dialysis is not indicated, postoperative renal replacement therapy in CRF patients may be better to be considered after four days observation.

The Clinical Outcomes of Off-Pump Coronary Artery Bypass Grafting in the Octogenarians / 대한흉부외과학회지

BACKGROUND: With the increasing age of the population, coronary artery bypass grafting in the elderly patients is becoming common. Off-pump coronary artery bypass grafting (OPCAB) has been proven to be less morbidity and to facilitate early recovery. The elderly patients may have benefits by avoiding the adverse effects of the cardiopulmonary bypass. The purpose of this study is to evaluate our results of OPCAB in elderly patients. MATERIAL AND METHOD: A retrospective chart review was carried out for 12 patients aged over 80 years who underwent isolated OPCAB from January 2001 and March 2004. Data were collected risk factors for disease, extent of coronary disease, and in-hospital outcomes. Postoperative graft patency was evaluated in 9 patients by multi-slice computed tomography. RESULT: Eleven patients had triple vessel disease or left main disease. Four patients were suffered from preoperative CVA, and 4 patients had chronic obstructive pulmonary disease. Two patients had myocardial infarction (MI), among them 1 patient was suffered from pulmonary edema after preoperative MI. There was no perioperative death, perioperative MI, and no ventricular arrhythmia. Also there was no perioperative stroke and renal failure. But there was one deep sternal infection who recovered by treating of muscle flap. Atrial fibrillation was newly developed in 1 patient, but was well controlled by medication. Mean intubation time was 15.9+/-4.4 (8~20 hrs) hrs and mean ICU stay was 2.9+/-0.8 (2~4 days) days. Mean hospital day was 21.6+/-14.3 (13~56 days) days. Postoperative mean CK-MB was 11.3+/-14.1 ng/mL. Early postoperative graft patency rate was 100% (24/24). Follow-up was completed in all patients. In this time, there was no patients with angina or death. CONCLUSION: The results of this study suggest that OPCAB reduces morbidity and favors hospital outcomes. Therefore, OPCAB is safe, reasonable and might be preferable operative strategy in elderly patients.

Long-term Result after Repair of Sinus Valsalva Aneurysm Rupture / 대한흉부외과학회지

BACKGROUND: Sinus valsalva aneurysm (SVA) is a rare disease, and it is frequently accompanied by ventricular septal defect and aortic valve regurgitaion. For treatment of SVA, several surgical mordalities were applied, but there was no report on the long-term result after surgical repair in Korea. We reviewed our 28 years of experiences and analyzed the long-term results after treatment of sinus valsalva aneurysm with or without rupture. MATERIAL AND METHOD: Between March 1974 and February 2002, 81 patients were operated under the impression of sinus valvsalva aneurysm or sinus valsalva aneurym rupture. Retrospectively we reviewed the patients' record. Mean age of patients was 29.2+/-11.5 and there were 49 males. Accompanyng diseases were as follows: VSD in 50, PDA in 2, Behcet's disease in 2, TOF in 1, RVOTO in 1, AAE in 1. Seventy-seven (95%) patients had sinus valsalva rupture and in 14 patients, subacute bacterial endocarditis was accompanied. Degree of aortic valve regurgitation was as follows: grade I: 8, II: 10, III: 9, IV: 4. Most common rupture site was right coronary sinus (66 patients, 81%) and most common communication site was right ventricle (53 patients). In repair of sinus valsalva rupture, patch was used in 37 patients, and direct suture was done in 38 patients. RESULT: There was one surgical death (1.2%). Follow up was done in 78 patients (97.5%), mean follow up period was 123.3+/-80.9 (3~330 months). During the follow up period, 3 patients died (3.8%). One patient died of heart failure, another patient died of arrhythmia and the other one died of unknown cause. In two patients, complete atrio-ventricular block was developed during follow up period, and there was no operation related event or complication. Kaplan-Meier survival analysis revealed 92.5+/-3.5% survival at 15 and 27 years and it seems to be satisfactory. CONCLUSION: Long-term surgical results and survival is satisfactory after repair of sinus valsalva aneurysm with or without rupture.

Risk Factors for Recurrence in Completely Resected pT1/2N1 Non-small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Complete surgical resection is the most effective treatment for pT1/2N1 non-small cell lung cancer, however 5 year survival rate of these patients is about 40% and the major cause of death is recurrent disease. We intended to clarify the risk factors of recurrence in completely resected pT1/2N1 non-small cell lung cancer. MATERIAL NAD METHOD: From Jan. 1990 to Jul. 2003, total of 117 patients were operated for pT1/2N1 non-small cell lung cancer. The risk of recurrence according to patients characteristics, histopathologic findings, type of resection, pattern of lymph node metastasis, postoperative adjuvant treatment were evaluated retrospectively. RESULT: Mean age of patients was 59.3 years. There were 14 patients with T1N1 and 103 patients with T2N1 disease. Median follow-up time was 27.5 months and overall 5 year survival rate was 41.3%. 5 year freedom-from recurrence rate was 54.1%. Recurrence was observed in 44 (37.6%) patients and distant recurrence developed in 40 patients. 5 year survival rate of patients with recurence was 3.3%, which was significantly lower than patients without recurrence (61.3%, p=0.000). In multi-variate analysis of risk factors for freedom-from recurrence rate, multi-station N1 (hazard ratio=1.997, p=0.047) was a poor prognostic factor. CONCLUSION: Multi-station N1 is the risk factor for recurrence in completely resected pT1/2N1 non-small cell lung cancer.

A Case of Normal Delivery of a Fetus with Prenatally Diagnosed 47,XYY,inv(9)(p11;q13) / 대한주산의학회잡지

A 35-year-old multigravida woman received triple marker screening tests in 16weeks 2days of gestation. MSAFP and MShCG values were increased, whereas MSuE3 value was decreased. So we performed amniocentesis for karyotyping and confirmed male fetus with 47,XYY,inv(9)(p11:q13). A neonatal survey showed the incidence of XYY male to be approximately 1:1000, the majority of cases are phenotypically normal. XYY males are taller than normal and show delayed mental development. A pericenteric inversion of chromosome 9 that extends from p11 to q13 is considered a normal chromosome variant, but the carrier is at high risk to produce abnormal offspring. As she did not want to terminate her pregnancy, she delivered vaginally in 39weeks 6days of gestation. As a result of physical examination, the neonate showed a normal phenotype. We report it with brief review.

Two cases of cervical pregnancy associated with multiple risk factors in elderly gravida / 대한산부인과학회잡지

Cervical pregnancy is a rare life-threatening form of ectopic pregnancy. The exact etiology of cervical pregnancy is not known, but several contributing factors have been considered. Probably a combination of factors leads to cervical pregnancy. The first case was required hysterectomy. The second case was successfully treated with a unique combination of precurettage cerclage, suction curettage and postcurettage balloon tamponade. Conservative treatment has evolved in recent years, with a considerable reduction in the number of hysterectomies. We present two cases of cervical pregnancy associated with multiple risk factors in elderly gravida, with brief reviews.

A case of cystic lymphangioma of the broad ligaments / 대한산부인과학회잡지

Cystic lymphangioma of the broad ligament is very rare benign cystic lesion. They rarely present in adult life. We present the case of a 37-year-old female with a history of chronic recurrent left lower abdominal dull pain over a period of several months. Clinical presentation of these tumors varies greatly from an asymptomatic mass to serious complications. The therapy of choice is a complete excision, unless vital structures were involved. Once excised, the prognosis is excellent. Our patient had complete excision of her lesion with a good outcome.

Comparisons between Classic Shunt and Non-Invasive Shunt in One-Lung Ventilated and Hemodiluted Dogs / 대한마취과학회지

BACKGROUND: As the clinical application of non-invasive shunt estimation to operation under one-lung ventilation has not been reported, this study was carried out to evaluate the validity and accuracy of the non-invasive shunt estimations in one-lung ventilation with hemodilution. METHODS: Following general anesthesia with enflurane 0.5 1 vol.% and 100% oxygen in ten Mongrel dogs (B.W. around 16 kg), tracheostomy and insertion of left-side endobronchial tube and one-lung ventilation were performed. Acute normovolemic hemodilution was produced by sequential hemodilution with hydroxyethyl starch. The intrapulmonary shunt (QS/QT) was calculated by the classic shunt equation, by the oxygen contents-based estimated shunt equation, and by oxygen tension-based estimations such as alveolar to arterial oxygen difference (P(A-a)O2), respiratory index (RI, P(A-a)O2/PaO2), arterial oxygen tension to alveolar oxygen ratio (PaO2/PAO2), and PaO2 to FiO2 ratio. To assess the quantitative accuracy of the estimated shunt, the data were divided arbitrarily into two groups on the basis of the mean arteriovenous oxygen content difference (C(a-v)O2) being 3.6 ml/dl or greater (group 1) and less than 3.6 ml/dl (group 2). Relationships to QS/QT were analyzed by simple linear regression. RESULTS: In 104 measurements, the correlation between QS/QT and non-invasive shunt were poor (r = 0.66 - 0.76). However, in group 1 (n = 45), the correlation between QS/QT and the estimated shunt were very good (r = 0.93) and good for P(A-a)O2 (r = 0.83), RI (r = 0.87), PaO2/PAO2 (r = - 0.84), and PaO2/FiO2 (r = - 0.85). In group 2 (n = 58), the correlation between QS/QT and non-invasive shunt were worse than in group 1. Group 2 had lower hematocrit (20.6% vs 26.7 %, P < 0.001), higher cardiac output, and lower pulmonary and systemic vascular resistance than group 1 (P < 0.05). The difference between the estimated shunt and the classic shunt in group 1 remained constant when the classic shunt was increased further. However, the difference in group 2 was enhanced by the increment of the classic shunt. CONCLUSIONS: We conclude that even if the non-invasive shunt estimation might be affected by hemoglobin and cardiac output, it is a viable method in mild hemodiluted patients with good cardiovascular reserve.

Tracheal Puncture and Endotracheal Tube Cuff Perforation as a Complication of the Subclavian Vein Catheterization: A case report / 대한마취과학회지

Subclavian venous catheterization is common technique for a variety of purposes, but this procedure is associated with complications that include damage to the lung, pleura, thoracic duct, nerve and subclavian artery. We recently encountered a case of the tracheal puncture and endotracheal cuff perforation during the subclavian catheterization in a 67-year-old female who was scheduled for tracheal reconstruction. Tidal volume was escaping from around the endotracheal tube during the subclavian catheterization, however, repeated inflation of the cuff failed to maintain the necessary cuff pressure to seal the trachea. After the operation, by using the fiberoptic bronchoscope and injecting dye into the cuff, we confirmed the site of tracheal puncture and endotracheal cuff perforation which caused by the introducer needle of the central venous kit. We suggest that tracheal puncture and endotracheal cuff perforation be added to the list of complication of subclavian catheterization. This complication should be suspected whenever the cuff pressure cannot be maintained during or after an subclavian catheterization.