A Case of Coumadin Ridge Confirmed by Surgery: Comparison Between Cardiac Computed Tomographic Images and Operative Findings

The coumadin ridge, a ridge of atrial tissue separating the left atrial appendage from the left upper pulmonary vein, is considered to be a normal anatomic variant. A prominent coumadin ridge can be easily mistaken for a tumor or thrombus. In the present case, a left atrial mass was noted on echocardiography and cardiac computed tomography (CT) in a 66-year-old female patient with a history of stroke who experienced chest pain. Therefore, we considered performing a surgery to remove the mass to prevent a recurrence of cerebral infarction, and the mass was confirmed to be a coumadin ridge rather than an actual tumor or thrombus. The findings from the subsequent CT image reconstruction were consistent with the operative findings. We present a surgically confirmed case of coumadin ridge that was consistent with the reconstructed CT image.

Psychological Problems of Pneumothorax According to Resilience, Stress, and Post-Traumatic Stress

OBJECTIVE: The aims of the study were to investigate psychological distress in pneumothorax patients. METHODS: A cohort study was performed in 101 patients with spontaneous pneumothorax. They were divided into three groups: (A) under 19 years old, (B) those of an intermediate age, and (C) over 45 years old. General well-being [Psychological Wellbeing Index-Short Form (PWI-SF)], traumatic event [Impact of Event Scale (IES)], and resilience [Life Orientation Test-Revised (LOT-R)] were assessed. RESULTS: There were 35 patients in Group A, 51 in B, and 15 in C. The mean length of hospital stay was five days in all patients. The overall recurrence rate after surgery was 8%. All patients were under severe stress and reported an average PWI-SF score of 39. The IES score was 27, which did not meet the criteria for post-traumatic stress disorder but was higher in Group C than in the other groups (p=0.02). Age and operation were significant factors for a high IES, but age was the only significant factor according to multivariate analysis. CONCLUSION: Pneumothorax patients may be at high risk for severe stress. Moreover, post-traumatic stress was higher in elderly patients. Actions to reduce the psychological problems in these patients are required.

A Single Center Analysis of the Positivity of Hepatitis B Antibody after Neonatal Vaccination Program in Korea

The antibody to hepatitis B surface antigen (anti-HBs) seropositivity rate after 3 doses of hepatitis B virus (HBV) vaccination during infancy period is known to be higher than 90%. However, a considerable number of vaccines do not form protective anti-HBs or chronologic decrease of anti-HBs. We retrospectively collected data of HBV serologic test results in 20,738 individuals from 2000 to 2015. After exclusion criteria were applied, 19,072 individuals were included. We analyzed the anti-HBs seropositivity rate, anti-HBs disappearance rate, anti-HBs positive seroconversion rate after receiving a booster vaccine, and the difference in anti-HBs positivity between the 2 groups; group A (born before 2005, while both recombinant vaccines and plasma-derived vaccines were used) and group B (born after 2005, when only recombinant vaccines were used by national regulation). The anti-HBs seropositivity rate was 55.8%, but there was a significant difference in the rate of seropositivity for anti-HBs between the group A and B (53.0% vs. 78.1%, P < 0.001). There was no significant age-adjusted difference in the mean seropositivity rate between the 2 groups (P = 0.058). In addition, the anti-HBs positivity rate was significantly lower in the group A as compared with the group B during infancy (83.1% vs. 92.1%, P < 0.001). A total of 1,106 anti-HBs-positive subjects underwent serologic tests more than twice. Of these, 217 subjects (19.6%) showed anti-HBs disappearance. After booster vaccinations, 87.4% (83/95) achieved seroconversion from seronegative to seropositive. Our results highlight the importance of lifelong protection against HBV and the possible necessity of booster vaccination after adolescent period.

Primary Pulmonary Amyloidosis with Mediastinal Lymphadenopathy

We report a case of inadvertent hoarseness after surgery for primary pulmonary amyloidosis. A 55-year-old male was transferred to our facility due to a lung mass. Chest computed tomography revealed a solitary pulmonary nodule. Positron emission tomography-computed tomography showed fluorodeoxyglucose uptake in the main mass and in the mediastinal lymph nodes. To confirm the pathology of the mass, wedge resection and thorough lymph node dissection were performed via video-assisted thoracic surgery (VATS). No complications except for hoarseness were observed; hoarseness developed soon after surgery and lasted for 3 months. The main mass was diagnosed as amyloidosis, but this was not found in the lymph nodes. In conclusion, VATS wedge resection for peripheral amyloidosis is a feasible and safe procedure. However, mediastinal lymph node dissection is not recommended unless there is evidence of a clear benefit.

Diaphragmatic Hernia after Transhiatal Esophagectomy for Esophageal Cancer

Diaphragmatic hernia was found in a patient who had undergone transhiatal esophagectomy for early esophageal cancer. Chest X-ray was not helpful, but abdominal or chest computed tomography was useful for accurate diagnosis. Primary repair through thoracotomy was performed and was found to be feasible and effective. However, long-term follow-up is required because hernia recurrence is common.

Acute Aortic Dissection in Pregnancy with the Marfan Syndrome

Acute aortic dissection (AAD) during pregnancy can be fatal to both the pregnant mother and the baby, particularly in patients with the Marfan syndrome. We report a case of the modified Bentall procedure in surgery for AAD in a 31-year-old pregnant woman at 24 weeks of gestation with the Marfan syndrome. The patient recovered well after the operation, but unfortunately, the fetus could not be saved.

Mediastinal Paraganglioma: Complete Resection Using Video-Assisted Thoracoscopic Surgery

Mediastinal paragangliomas are very rare neuroendocrine tumors. Complete resection is the standard treatment of a paraganglioma because of the tumor's potential malignancy and poor response to chemo- or radiotherapy. However, the highly vascular nature of the tumor and its characteristic anatomic location make complete resection difficult. We report a case of an anterior mediastinal paraganglioma, which was incidentally found on a chest computed tomography scan for chronic cough work-up of a 55-year-old woman. Complete resection was accomplished using video-assisted thoracoscopic surgery, and the patient recovered without any complications.

Tuberculous Pericarditis Presenting as Multiple Free Floating Masses in Pericardial Effusion

Pericarditis is a rare manifestation of tuberculosis (Tb) in children. A 14-yr-old Korean boy presented with cardiac tamponade during treatment of pulmonary tuberculosis. He developed worsening anemia and persistent fever in spite of anti-tuberculosis medications. Echocardiography found free floating multiple discoid masses in the pericardial effusion. The masses and exudates were removed by pericardiostomy. The masses were composed of pink, amorphous meshwork of threads admixed with degenerated red blood cells and leukocytes with numerous acid-fast bacilli, which were confirmed as Mycobacterium species by polymerase chain reaction. The persistent fever and anemia were controlled after pericardiostomy. This is the report of a unique manifestation of Tb pericarditis as free floating masses in the effusion with impending tamponade.

A Case of Fatal Mechanical Mitral Valve Leaflet Fracture Embolization: A Case Report / 대한구급학회지

The fracture embolization of a mechanical valve is a very rare but potentially fatal event that can cause acute severe valve regurgitation and subsequent decompensated heart failure. Generally, the mechanical valve is durable and semi-permanent. If this is not the case, bacterial endocarditis can occur. However, leaflet fracture embolizations related to mechanical failure may occur in the specific mechanical valve brands associated with the subjects own structural fragilities. In this case, we dealt with a case of fatal Edward-Duromedics mechanical mitral valve leaflet fracture embolization that had been implanted 20 years ago. The patient presented with severe acute heart failure and shock. Severe transvalvular mitral regurgitation and only one valve leaflet was observed in echocardiography. Although the emergency mitral valve replacement was performed under the diagnosis with valve leaflet fracture embolization, the patient was not resuscitated from systolic pump failure and died.

Perioperative Nutritional Management in Cardiac Surgery / 한양의대학술지

Perioperative nutritional status is an important factor for the prognosis of cardiac surgery. Preoperatively debilitated or cachectic patients (i.e., more than 10% weight loss over 6 months) with decreased albumin level are exceptionally prone to complications, such as infections following surgery. For better support of the perioperative nutritional intake, exact preoperative monitoring of nutritional status and supplement of essential nutritional factors are necessary for cardiac patients. I will describe here the nutritional states assessment and monitoring methods of infants with congenital heart diseases and consider essential nutritional factors in patients with heart disease. For the conditions where enteral nutrition is not possible, postoperative control of blood sugar is important, or special nutritional considerations for heart disease patients is needed. I will discuss the clinical problems related to these conditions and suggest possible methods of improvement for each condition.

Long-term Influence of Mild to Moderate Ischemic Mitral Regurgitation after Off-pump Coronary Artery Bypass Surgery / 대한흉부외과학회지

BACKGROUND: Our objective was to review the long-term prognosis of patients with preoperative mild to moderate ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting. MATERIAL AND METHOD: We prospectively followed 1,000 consecutive and systematic off-pump coronary artery bypass grafting patients who were operated on between September 1996 and March 2004; follow-up was achieved for 97%. Sixty-seven patients (6.7%) had mild to moderate ischemic mitral regurgitation at the time of surgery. Operative mortality, actuarial survival and major adverse cardiac event free survival were compared to assess the effect of ischemic mitral regurgitation. RESULT: Average follow-up was 66+/-22 months. Patients with ischemic mitral regurgitation were older (p<0.001), had lower ejection fractions (p<0.001) and more comorbidities. Significantly more female patients presented with ischemic mitral regurgitation (p=0.002). There was no significant difference in operative mortality and perioperative myocardial infarction in ischemic mitral regurgitation patients (p=0.25). Eight-year survival was decreased in ischemic mitral regurgitation patients (39.6+/-11.8% vs 76.7+/-2.2%, p<0.001). However, after correcting for risk factors, mild to moderate ischemic mitral regurgitation was not found to be a significant independent risk factor for long-term mortality (p=0.42). Major adverse cardiac event free survival at 8 years was significantly lower in ischemic mitral regurgitation patients (53+/-12% vs 77+/-2%, p<0.001). After correction for risk factors, ischemic mitral regurgitation remained a significant independent cause of major adverse cardiac events (HR: 2.31), especially congestive heart failure and recurrent myocardial infarction. CONCLUSION: In our series, patients with preoperative mild to moderate ischemic mitral regurgitation had a higher prevalence of preoperative risk factors than patients without ischemic mitral regurgitation. They had comparable perioperative mortality and morbidity, but, in the long term, were found to be at elevated risk for recurrent cardiac events.

Infection with Mycobacterium Tuberculosis Complicating an Intralobar Pulmonary Sequestration: A case report / 대한흉부외과학회지

Pulmonary sequestration is a relatively rare malformation. Infection with common pyogenes is a frequent complication in this disease. We report here on a case of intralobar sequestration that was infected with Mycobacterium tuberculosis in the absence of any other site of tuberculous infection. A 40-year man presented with a small amount of hemoptysis, and the man had been previously diagnosed with bronchiectasis 3 years ago. Chest computerized tomography revealed bronchiectasis with pneumonia in the left lower lobe and there was a large feeding artery from the thoracic aorta. A lobectomy of the left lower lobe was conducted via thoracotomy and the final pathologic examination confirmed pulmonary tuberculosis limited to the intralobar sequestrated lung. The patient underwent antituberculous chemotherapy from the postoperative 7th day and he was discharged without any adverse event.

A Congenital Cystic Adenomatoid Malformation with Intact Pulmonary Vascularities

Congenital cystic adenomatoid malformation (CCAM) is a rare pulmonary disease. It is thought to represent the abnormal proliferation of immature alveoli and other mesenchymal components secondary to abrupt halting of terminal alveolus formation after 16 weeks of gestation. Radiographic parameters such as size, number, and content are variable. On grayscale ultrasound, anechoic, thin-walled cysts are usually noted in pleural or cardiodiaphragmatic locations. To our knowledge, there has been no report of a CCAM showing normal pulmonary vascularities. We report a case of CCAM with normal pulmonary vascularities found within the hypodense lesions on dynamic chest CT.

The Role of GADD45beta in Acute Myocardial Injury / 대한흉부외과학회지

BACKGROUND: A critical shortage of donor organs has necessitated an investigation of new strategies to increase the availability of additional organs available for human transplantation. We investigated the amount of apoptosis and expression of GADD45beta in two groups, a GADD45beta-transfected group and untransfected group. MATERIAL AND METHOD: The experimental groups consist of a control group (normal H9C2 cell line) and GADD45beta-transfected group. After injury of the each group, we evaluated the expression of GADD45beta and the level of apoptosis in each group. RESULT: There was a significant increase in the expression of GADD45beta in the GADD45beta-transfected group at 1 hour, 2 hours, and 3 hours after stimuli as compared with the control group. The amount of cardiac myoblast cell line apoptosis was significantly lower in the GADD45beta-transfected group as compared with the control group. The concentration of annexin in the GADD45beta-transfected group was significantly lower than that of the control group after cell injury. CONCLUSION: Transfection of a rat myoblast cell line with the GADD45beta gene results in decreased susceptibility to cell injury of human serum.

Differentiation between Morgagni Hernia and Pleuropericardial Fat with Using CT Findings / 대한흉부외과학회지

BACKGROUND: Generally hernia is diagnosed with simple chest or gastrointestinal x-ray. Sometimes CT or MRI can give lots of information for the diagnosis. However, there was no study for the differentiation with using CT findings between Morgagni hernia and pleuropericardial fat. The aim of this study was to evaluate the useful CT findings for differentiating Morgagni hernia from pleuropericardial fat. MATERIAL AND METHOD: We retrospectively analyzed CT scans of eight patients with Morgagni hernia and 20 patients with abundant pleuropericardial fat without peridiaphragmatic lesions. All CT scans were performed with coverage of the whole diaphragm in the inspiration state. We evaluated 1) the presence of the defect of the anterior diaphragm, 2) the interface between the lung and fat, 3) the angle between the chest wall and fat, 4) the continuity between the extrapleural fat and fat, 5) the presence of the vessels within fat, and 6) the presence of a thin line surrounding fat. RESULT: In all cases with Morgagni hernia, the defect of the anterior diaphragm was seen. The interface was well-defined, smooth, and convex to the lung. The angle with the chest wall was acute. The continuity with the extrapleural fat was not seen. In the cases with abundant pleuropericardial fat, the defect of the anterior diaphragm was seen in three (15%). The interface was usually irregular (n=10) and flat (n=17). The angle with the chest wall was variable. The continuity with the extrapleural fat, that was markedly increased in amount, was usually seen (n=16). The thin line surrounding fat was seen in four cases with Morgagni hernia, however, not seen in all cases with pleuropericardial fat. All of the above findings were statistically significant, however, vessels within fat was not significant to differentiate Morgagni hernia (n=8/8) from pleuropericardial fat (n=14/20). CONCLUSION: The useful CT findings of Morgagni hernia were fatty mass with sharp margin, convexity toward lung, acute angle with chest wall, and thin line surrounding hernia. Branching structure within fatty mass representing omental vessels that has been known as a characteristic finding of Morgagni hernia was not useful for differentiating Morgagni hernia from pleuropericardial fat.

Cardiac Arrest Occurred by Tension Pneumothorax during Right Thoracotomy: A case report / 대한마취과학회지

Tension pneumothorax during one-lung ventilation is an insidious, life threatening emergency. Even though early diagnosis and rapid intervention are necessary to prevent mortality, treatment may be difficult because of the clinical diagnosis-mediastinal shift, hypoxemia, hypotension and increased airway pressure may be confusing in the operative setting. We present here the case of a patient who underwent right thoracotomy with one-lung ventilation and the patient developed left tension pneumothorax with resulting cardiac arrest.

A Case of Endobronchial Aspergilloma Presented by Solitary Pulmonary Nodule / 대한흉부외과학회지

A 53 year-old woman visited to our hospital due to increased hemoptysis for 4 days. The chest X-ray showed solitary pulmonary nodule on right upper lobe and computed tomography of chest demonstrated mass on posterior segmental bronchus of right upper lobe. Bronchoscopic examination revealed that this segmental bronchus was completely obstructed by a yellow and brownish mud like mass, which was identified as an aspergilloma by pathologic examination. Patient had undergone bilobectomy because of persistent hemoptysis. Tracheobronchial apergillosis in an immunocompetent person is very rare disease. then, we report this case with review of the Korean literature.

A Case of Endobronchial Aspergilloma Presented by Solitary Pulmonary Nodule / 대한흉부외과학회지

A 53 year-old woman visited to our hospital due to increased hemoptysis for 4 days. The chest X-ray showed solitary pulmonary nodule on right upper lobe and computed tomography of chest demonstrated mass on posterior segmental bronchus of right upper lobe. Bronchoscopic examination revealed that this segmental bronchus was completely obstructed by a yellow and brownish mud like mass, which was identified as an aspergilloma by pathologic examination. Patient had undergone bilobectomy because of persistent hemoptysis. Tracheobronchial apergillosis in an immunocompetent person is very rare disease. then, we report this case with review of the Korean literature.

Development of Multimedia Educational Material in Cardiopulmonary Bypass / 한국의학교육

PURPOSE: Cardiopulmonary bypass (CPB) is one of the most fundamental and important subjects in cardiovascular surgery. Thus, it is insufficient to understand CPB through only traditional education methods as a comprehensive knowledge based on anatomy and physiology of the circulating system and surgical techniques is essential. The aim of this study was to develop a multimedia CPB teaching program for a more rewarding learning experience. METHODS: Among all teaching materials, text and picture-based lectures, movies on surgical procedures, and animations were chosen to be included in the teaching programs. Firstly, we made lecture notes and a powerpoint lecture with narration. Secondly, we made and edited movie files on surgical procedures, and incorporated sound in the movies. Thirdly, we developed animation files including all CPB procedures using flash 5.0. Finally we made a CD ROM and a web page for CPB and other basic surgical techniques. A basic wurgical procedures Self-test was also included. Questionnaires were given to medical students to evaluate the effectiveness and the ease of use of this program. RESULTS: The developed CPB educational program was distributed in a CD-ROM. An internet homepage (http: //surgery.chungbuk.ac.kr) for basic surgical procedures was constructed with the multimedia CPB lecture. The results of the questionnaires were positive, Proving the improved understanding of CPB. CONCLUSION: This multimedia education program on CPB not only can help medical students to easily understand the structures and principles involved in CPB, but also give indirect experience of this surgical procedure.

A Case of Prenatally Detected Congenital Lobar Emphysema

Congenital lobar emphysema (CLE) is an overinflation of infantile pulmonary lobe caused by air trapping within the affected area. This is usually diagnosed on radiological findings postnatally. Most cases present in the neonatal period with signs of acute or chronic respiratory distress. There are only a few reports of CLE in the literature with prenatal sonographic feature documented. The routine use of prenatal sonography has helped to find fetal anomalies, such as fetal lung mass, that pose a challenge to early diagnosis, appropriate counselling, postnatal follow-up, and better outcome. A boy with CLE was detected by prenatal sonogram. He had a uniformly echogenic right lung with mediastinal shift to the left which was suspected type III congenital cystic adenomatoid malformation prenatally. He showed no evidence of respiratory distress at birth, but experienced progressive tachypnea and chest retraction. He had right middle lobectomy on the seventh postnatal day and pathologic diagnosis of CLE had been made. We report this rare case with brief review of literature. This is the first domestic case which was detected prenatally and confirmed pathologically after lobectomy.