Effects of Combined Antiplatelets on Bleeding in Off-Pump Coronary-Artery Bypass Surgery / 영남의대학술지

BACKGROUND: Antiplatelet agent administration is critical in managing coronary-artery disease, but there is a concern regarding operation-related bleeding and an increase in blood transfusion in such, especially when delivering combined antiplatelet agents. This study was conducted to evaluate the effect of the administration of antiplatelet agents on off-pump coronary-artery bypass surgery (OPCAB). METHODS: From March 2003 to December 2009, 49 patients who had undergone OPCAB were collected retrospectively. The patients were divided into three groups according to the administration of antiplatelet agents before the OPCAB operation: 21 patients were given an aspirin agent (group 1), 19 patients were given combined agents (aspirin+clopidogrel) (group 2), and nine patients were not given any antiplatelet agent (group 3). The three groups' perioperative hematologic and coagulation profiles, including their platelet counts, hemoglobin levels, hematocrit, prothrombin times, and aPTTs (activated partial thromboplastin times), and their postoperative bleeding, related complications, transfusion requirements, and operation times, were compared. RESULTS: The operation time in group 2 was 4.3 hours, longer than those in the two other groups, and urgent operation was significantly most frequent in group 2 (63%). The amount of blood loss and the number of patients who received blood transfusion were not different in the three groups. The perioperative hemoglobin level, hematocrit, platelet count, prothrombin time, and aPTT were also not significantly different among the three groups. CONCLUSION: The continuous administration of antiplatelet agents to the patients in this study did not increase their postoperative bleeding or operation-related complications. Therefore, OPCAB may well be considered even if combined antiplatelet agents are being administered.

Effects of Preoperative Combined Antiplatelet Agents on the Postoperative Bleeding that Occurs during Off-pump Coronary Artery Bypass Surgery / 대한흉부외과학회지

BACKGROUND: It is well known that preoperative administration of combined antiplatelet agents can have an impact on the postoperative bleeding, the requirement for transfusion and the need for reexploration during on-pump coronary artery bypass surgery. Yet its effects have not been well evaluated in the case of off-pump coronary artery bypass surgery. MATERIAL AND METHOD: We performed a retrospective study of nineteen patients who underwent OPCAB from March 2003 to December 2004. All the patients had taken antiplatelet agents until 12 hours before operation. The patients were divided into two groups as an aspirin group and a combined (aspirin+clopidogrel) group. The perioperative platelet count, the hemoglobin level, the hematocrit, the prothrombin time and the aPTT were compared between both groups. The amount of postoperative bleeding, the transfusion requirement and the need for re-exploration to control bleeding were also compared between both groups. RESULT: There was no difference of operation time and the intraoperative ACT between the aspirin group and the combined group. The amount of blood loss through the chest tube for 24 hours was not different between the aspirin group (697+/-271 mL) and the combined group (944+/-432 mL). The number of patients who received blood transfusion was also not different between both groups. There was no patient who required reexploration for bleeding control in both groups. The perioperative hemoglobin level and hematocrit were also not different between both groups, but the postoperative hemoglobin level and hematocrit were decreased significantly in the group. CONCLUSION: The preoperative combined antiplatelet (aspirin+clopidogrel) therapy group was not different from the aspirin group for the amount of postoperative bleeding, the amount of blood transfusion and the need for reexploration during off-pump coronary artery bypass grafting. This subject needs further evaluation because of small population in our study.

Descending Necrotizing Mediastinitis Caused by Yeast: A case report / 대한흉부외과학회지

Descending nectorizing mediastinitis (DNM) represents a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce the high morbidity mortality associated with this disease. Intr.avenous broad-spectrum antibiotic therapy alone is not efficient without adequate surgical drainage of the cervical and mediastinal collections, extensive debridement and excision of necrotic tissue, and wide mediastino-pleural irrigation. A 38-year-old man admitted via emergency room with painful left neck swelling and uncontrolled high fever. Chest computed tomogram showed left paratracheal abscess descending into the superior and anterior mediastinum. Transcervical mediastinal drainage was performed with 26 Fr. chest tube and left paratracheal drainage was performed with Penrose drain in urgency. Culture and sensitivity test grew Yeast. The drains removed via gradually shortening on day 39 after surgery.

The Early Results of CABG with Bilateral Internal Thoracic Artery / 대한흉부외과학회지

BACKGROUND: It has been known that internal thoracic artery grafting has a better patency rate compare to other graft conduits in coronary revascularization. Better patency rates can be expected in more coronary arteries with the use of bilateral internal thoracic artery. However, there were some debates on the complications after the use of bilateral internal thoracic artery. The purpose of our study was to reveal the results of bilateral internal thoracic artery. MATERIAL AND METHOD: The 26 coronary artery bypass operations with bilateral internal thoracic artery were performed from July 2001 to May 2002. We compared the results of 8 diabetic patients to those of 18 non-diabetic patients. We compared the results of BITA (bilateral internal thoracic artery) group to those of SITA (single internal thoracic artery) group that were 20 patients and performed during same period. RESULT: There was no mortality. There was one wound complication in the diabetic group and one in the non-diabetic group. There were no significant differences in operation time, duration of mechanical ventilation, amount of bleeding, infusing duration of cardiotonics, and complication between two groups. There were no significant differences in results between the BITA group and the SITA group. CONCLUSION: There were no significant differences in early results between the BITA group and the SITA group, and there were no significant differences in results between the diabetic group and the non-diabetic group. We think coronary artery bypass grafting with the use of bilateral internal thoracic artery is considered in diabetic patients.

Treatment of Atrial Fibrillation with Microwave / 대한흉부외과학회지

BACKGROUND: Cryoablation and radiofrequency ablation have been used to treat the atrial fibrillation. Some reports insisted that the microwave ablation is a better method for a deep and extensive lesion. MATERIAL AND METHOD: From December 2001 to July 2002, we performed 8 microwave ablations in patients who needed mitral valve surgery (7 MVR, 1 MVR+AVR). There were 3 men and 5 women, and their mean age was 43.4+/-8.3 years and mean follow up period was 5.6+/-2.4 months respectively. The microwave was applied on endocardium or epicardium by LynxR (Afx, inc.) using a power of 45 watts for 25 seconds. We studied the left atrial dimension, the left atrial function and the sinus conversion with echocardiography and electrocardiography at three times; 1) before the operation, 2) immediately after the operation, and 3) 6 months after the operation. RESULT: There was no complication and no mortality. The mean aortic clamping time was 104.6+/-25.0 minutes, and the mean total bypass time was 130.5+/-28.7 minutes. The rate of sinus conversion was 75%, A wave across the mitral valve was a mean of 77.0+/-24.8 cm/sec, and the A/E was a mean of 0.46+/-0.17 at 5.6 months postoperatively. CONCLUSION: There was no difference in the early result of microwave ablation compared to other methods. The microwave ablation was an acceptable method due to its convenient application especially in beating heart.

Iatrogenic Large Esophageal perforation caused by Sengstaken-Blackmore Tube / 대한흉부외과학회지

This patient was an 53-year-old man who had undergone Sengstaken-Blackmore tube insertion for esophageal varix bleeding. Two days after Sengstaken-Blackmore tube insertion, he developed severe left hemothorax and was transferred to our hospital. The esophagoscopic findings revealed a large perforation lengthening 8-cm in the intrathoracic esophagus. A left thoracotomy was performed 33 days after the injury due to repeated varix bleedings and poor conditions. An 8-cm longitudinal perforation of the intrathoracic esophagus with gross suppurative empyema was found. Primary repair and esophageal exclusion was performed 2cm proximal and distal to the perforation, using rows of nonabsorbable staplers (TA stapler 60x4.8) and large bore thoracostomy tubes were placed for local drainage. Six days after intrathoracic esophageal exclusion, an esophagogram revealed a leakage at just above the proximal stapling site. A cervical esophageal exclusion was performed using the same method. One hundred thirty seven days after exclusion operation for the intra-thoracic esophageal perforation, the patient was able to eat per orally without any secondary esophageal reconstructive surgery.

Multiple Pulmonary Nodules in A Patient with Sinusitis, Proteinuria and Hematuria / 결핵

A 49-year old man who had been treated for five months at a private clinic due to chronic paranasal sinusitis was admitted to our hospital because of recently aggravated nasal stuffiness, headache, and cough. The X-ray film of paranasal sinuses and facial CT scan showed marked mucosal thickening of the nasal cavity and paranasal sinuses. The plain chest film and chest CT scan showed multiple, variable sized, pulmonary nodules in both lungs. The level of c-ANCA was elevated and urinalysis revealed proteinuria and hematuria. Percutaneous lung and kidney biopsies were performed for confirmative diagnosis. Histologic examination of the lung nodule demonstrated extensive necrosis and poorly-formed granulomatous inflammation. The histologic finding of the kidney showed focal necrotizing glomerulonephritis. A diagnosis of Wegener's granulomatosis involving the paranasal sinuses, lung and kidney was made, and treatment was successfully performed with cyclophosphamide and prednisone.

Risk Factors of Redo-valve Replacement / 대한흉부외과학회지

BACKGROUND: The results of reoperative valve replacement can be improved if appropriate analysis for the risk of reoperation was achieved. The purpose of our study was to analyze the results of reoperations for failure of bioprosthesis, and to define the risk factors in high-risk populations for reoperative procedures. MATERIAL AND METHOD: The series of 46 consecutive patients who had undergone first reoperative replacement for failed bioprosthesis between 1993 and 2001 were reviewed retrospectively. Mean age was 42+/-12 years, mean body surface area was 1.52+/-0.15 m2. The reoperative procedure comprised of 36 MVR, 8 DVR, and 2 AVR. The first operation comprised of 2 DVR, 1 AVR, and 43 MVR. Factors which were choose to assess a predictor of results in reoperative valve replacement were sex, old age(>60 years), early age at first operation(15years), poor NYHA functional class(>3), LV dysfunction(LVEF8hours), endocarditis, combined procedures, and renal insufficiency. RESULT: Overall mortality was 4.3%(2 cases). The risk factors that influenced postoperative complications and unexpected postoperative results were lower ejection fraction(p=0.012), older age(p=0.045), endocarditis(p=0.023), long operation time above 8 hours(p=0.027). There was no statistically significant factor influencing hospital mortality. CONCLUSION: No factor influenced the mortality. Better results could be achieved if reoperation was performed carefully in poor left ventricular function, old aged patient, and with endocarditis. Effort to shorten the operation time would be helpful on postoperative results.

The Clinical Effects of Normocapnia and Hypercapnia on Cerebral Oxygen Metabolism in Cardiopulmonary Bypass / 대한흉부외과학회지

BACKGROUND: Substantial alterations in cerebral blood flow(CBF) are known to occur during cardiopulmonary bypass(CPB). Many investigators have speculated that these changes may be responsible for both minor and major cerebral damages after CPB. More recently, these changes in CBF have been observed to be intimately related to the arterial carbon dioxide tension(PaCO2) maintained during CPB. The present study was prospectively designed to investigate the clinical effects of normocapnic and hypercapnic CPB on the cerebral oxygen metabolism in cardiac surgery. MATERIAL AND METHOD: Thirty-six adult patients scheduled for elective cardiac surgery were randomized to either normocapnic group (PaCO2 35~40 mmHg, n=18) or hypercapnic group(PaCO2 45~55 mmHg, n=18) with moderately hypothermic nonpulsatile CPB(nasopharyngeal temperature of 29~30degrees C). In each patient, middle cerebral artery blood flow velocity(VMCA), cerebral arteriovenous oxygen content difference (C(a-v)O2), cerebral oxygen extraction(COE), cerebral metabolic rate for oxygen(CMRO2), cerebral oxygen transport(TEO2), TEO2/CMRO2 ratio, cerebral desaturation(internal jugular bulb blood oxygen saturation

Aorto-Esophageal Fistula Complicated by Esophageal Metalic Stent: A case report / 대한흉부외과학회지

Aortoesophageal fistula induced by endoesophageal stent is rare;however,it is usually a fatal disorder,with few survivors reported.We report a case of a 32-year old female with aortoesophaeal fistula after insertion of the esophageal stent in esophageal lye stricture who was successfully diagnosed with endoscopy and treated in a two-stage operation.In the first stage,we performed esophagectomy,primary repair of the fistula site in the descending thoracic aorta,and feeding gastrostomy.After the patient recovered well postoperatively,a retrosternal interposition of the right colon and cervical esophago-colo-grastostomy were performed,to re-establish the gastrointestinal tract.

Waffle Procedure in Chronic Constrictive Epicarditis Patient with Pericardial Effusion: A Case Report / 대한흉부외과학회지

The purpose of this presentation is to demonstrate a good results of a second operation, the Waffle procedure, in a patient who did not improve following pericardiectomy. Incomplete parietal pericardiectomy, myocardial fiber atrophy, and unexpected restrictive cardiomyopathy can be considered when the patient's symptom does not improve after pericardiectomy is carried out. Constrictive epicarditis is always ruled out. In our case, the patient having constrictive pericarditis combined with pericardial effusion received a pericardiectomy. However, hemodynamics and symptoms of the patient following the operation did not improve. However, we experienced a good result following a second operation, the Waffle procedure.

Multiple Rhabomyomas in left Ventricular Outflow Tract Combined with Tuberous Sclerosis: A Case Report / 대한흉부외과학회지

Cardiac rhabdomyoma is a rare type of benign tumor affecting the heart. There are a few previous reports of intracardiac rhabdomyomas causing ventricular arrythmia. We describe a 1-year-old female tuberous sclerosis patient who was presented with a ventricular tachycardia. Diagnostic echocardiography revealed two masses in the left ventricular outflow tract originating from the ventricular septum. The masses were surgically resected through aortotomy using cardiopulmonary bypass and the masses appeared benign. The pathology was that of a cardiac rhabdomyomas. Postoperative course was uneventful and the ventricular tachycardia was controlled.

The Clinical Effects of Leukocyte-Depleting Filter on Cardiopulmonary Bypass / 대한흉부외과학회지

BACKGROUND: It has been recognized that systemic inflammatory reaction and oxygen free radical formed by activated leukocyte in the procedure of cardiopulmonary bypass(CPB) frequently produce postoperative cardiac and pulmonary dysfunction. The purpose of this study was to evaluate the efficacy of leukocyte-depleting filters in the cardiopulmonary bypass circuit for patients undergoing open heart surgery(OHS). MATERIAL AND METHOD: The study involved 15 patients who underwent OHS with a Leukoguard-6 leukocyte filter placed in the arterial limbs of the bypass circuit(filter group, n=15) and 15 patients who did not have the filter(control group, n=15). We analyzed the differences between the groups in intraoperative changes of peripheral blood leukocyte and platelet counts, pre- and postbypass changes of malondialdehyde(MDA), troponin-T(TnT), 5'-nucleotidase(5'-NT) in coronary sinus blood, spontaneous recovery rate of heart beat after CPB, pre-and postoperative cardiac index(CI) and pulmonary vascular resistance(PVR), and the amounts of postoperative bleeding and sternal wound complication. RESULT: During CPB, total leukocyte count of the filter group(9,567 +/- 842/mm3) was significantly less than that of the control group(13,573 +/- 1,167/mm3) (p<0.01), but there was no significant difference in platelet count between the groups. Postoperative levels of MDA(3.78 +/- 0.32 micromole/L vs 5.86 +/- 0.65 micromole/L, p<0.01), TnT(0.40 +/- 0.04 ng/mL vs 0.59 +/- 0.08 ng/mL, p<0.05) and 5'-NT(3.88 +/- 0.61 U/L vs 5.80 +/- 0.90 U/L, p<0.05) were all significantly lower in the filter group than the control group. Postoperative CI was higher in the filter group than the control group(3.26 +/- 0.18 L/m2/min vs 2.75 +/- 0.17 L/m2/min, p=0.05). PVR of the filter group was lower than that of the control group(65.87 +/- 7.59 dyne/sec/cm5 vs 110.80 +/- 12.22 dyne/sec/cm5, p<0.01). Spontaneous recovery rate of heart beat in the filter group was higher than that in the control group(12 patients vs 8 patients, p<0.05). Postoperative wound infection occurred in one case in the filter group and 4 case in the control group(p<0.05). Postoperative 24 hour blood loss of the filter group was more than that of the control group (614 +/- 107 mL vs 380 +/- 71 mL, p=0.05). CONCLUSION: These data suggest that the leukocyte-depleting filter has beneficial effects on postoperative cardiac and pulmonary functions with diminution of reperfusion injury. However, bleeding tendency at early postoperative period is higher in the filter group than the control group and thus the further studies seem to be necessary at this point.

Early Results of the Nuss Procedure / 대한흉부외과학회지

BACKGROUND: Minimally invasive surgery of pectus excavatum by Dr. Nuss is a new technique that allows the repair of this deformity without any cartilage resection or sternal osteotomy. We describe the early experiences with Nuss procedure. MATERIAL AND METHOD: From December 1999 to January 2001, twenty patients with pectus excavatum underwent repair by Nuss procedure. There were 14 males and 6 females whose mean age was 10.1 +/- 7.7 years, ranging from 1 to 33 years. Most patients(N=19) were below 20 years, except 33 years old female patient(N=1). RESULT: The severity of depression was assessed by computed tomography(CT). CT index was mean 4.9 +/- 5.7(ranged from 3.3 to 8). The average operating time was 85.8 +/- 23.7 minutes. The used metal bars were ranged in length from 8 inches to 16 inches(average 11.8 +/- 14.4 inches). Early postoperative complications were pneumothorax in three patients, paralytic ileus in one, and postoperative chest pain requiring analgesics in all patients. Epidural analgesia was used in one adult patient for control of postoperative pain. In our experiences, there were no serious complications posteoperatively. CONCLUSION: There were good early results with the Nuss procedure that we performed for repairing of pectus excavatum. However, we believe the procedure needs to be observed for the long term results for it to be broadly accepted.

Comparison of Inflammatory Response and Myocardial injury Between Normoxic and Hyperoxic Condition during / 대한흉부외과학회지

BACKGROUND: Hyperoxemic cardiopulmonary bypass (CPB) has been recognized as a safe technique and is widely used in cardiac surgery. However, hyperoxemic CPB may produce higher toxic oxygen species and cause more severe oxidative stress and ischemia/reperfusion injury than normoxemic CPB. This study was undertaken to compare inflammatory responses and myocardial injury between normoxemic and hyperoxemic CPB and to examine the beneficial effect of normoxemic CPB. MATERIAL AND METHOD: Thirty adult patients scheduled for elective cardiac surgery were randomly divided into normoxic group (n=15), who received normoxemic CPB (about PaO2 120 mmHg), and hyperoxic group (n=15), who received hyperoxemic CPB (about PaO2 400 mmHg). Myeloperoxidase (MPO), malondialdehyde (MDA), adenosine monophosphate (AMP), and troponin-T (TnT) concentrations in coronary sinus blood were determined at pre- and post-CPB. Total leukocyte and neutrophil counts in arterial blood were measured at the before, during, and after CPB. Lactate concentration in mixed venous blood was analyzed during CPB, and cardiac index (CI) and pulmonary vascular resistance (PVR) were evaluated pre- and post-CPB. All of the parameters were compared between the groups. RESULT: Normoxic group at post-CPB had lower MDA (4.79+/-0.7 vs 5.86+/-0.65 micromol/L, p=0.04) and MPO levels (5.38+/-1.01 vs 8.73+/-0.90 ng/mL, p=0.02), decreased total leukocyte counts (10,484+/-836 vs 13,572+/-1167/mm3, p=0.04) and higher AMP concentrations(1.23+/-0.07 vs 1.00+/-0.04 nmol/L, p=0.05), as well as a reduction in PVR (90.37+/-16.36 vs 118.12+/-12.21 dyne/sec/cm5, p=0.04) compared to hyperoxic group. There were no significant differences between the two groups with regard to TnT, lactate concentrations, and CI. CONCLUSION: Normoxic CPB provides less myocardial and lung damage related to oxygen free radicals and low inflammatory responses compared to hyperoxic CPB at post-CPB. Therefore, these results suggest that normoxemic CPB is a safe and salutary technique that could be applied in all cardiac surgery.

Angiosarcoma in Right Atrium / 대한흉부외과학회지

Primary cardiac tumors are rare, and primary malignant cardiac tumors are even rarer. Of these, angiosarcoma was uncommon. Surgical resection of the tumor was very difficult because symptoms were nonspecific and did not become present until the tumor had advanced. A 15-year-old male patient was diagnosed with primary cardiac angiosarcoma by microscopic examination under surgery and underwent resection of the tumor, which compressed and obstructed the right atrium. He was discharged from the hospital after 15 days without any problems.

Relationship Between Interleukin-6 Production and Inflammatory Response during Cardiopulmonary Bypass / 대한흉부외과학회지

BACKGROUND: With open heart surgery(OHS), it has been recognized that many postoperative complications and postperfusion syndrome are associated with the activations of complements and leulocytes. Recently, some investigators also demonstrated that interlukin-6(IL-6) linked highly with postperfusion syndrome. The puropose of this study was to investigate the sequential changes of the IL-6 and to clarify each IL-6 relationship to the complements(C3, C4) and inflammatory response following cardiopulmonary bypass(CPB). MATERIAL AND METHOD: To determine serum levels of IL-6, complements, leukocytes, and biochemistric markers of liver and renal function, blood samples were taken from th radial artery in 30 adult patients undergoing OHS with CPB. RESULT: Serum IL-6 levels incrased significantly at 10 minutes after CPB-on(CPB-10) in comparison with the control levels and reached the peak at CPB-off(p<0.05). Serum complement levels declined rapidly at CPB-10 and remained at the lower levels during CPB(p<0.01). Sequential changes of IL-6 levels had positive correlations with the changes of total leukocytes and neutrophil fractions(p<0.05), but had negative correlations with lymphocyte fractions(p<0.05). Changes of C3 related postively to monocyte fractions(p<0.05). Postoperative levels of total protein and albumin, decreased significantly in comparison with the control levels(p<0.01), while the postoperative levels of AST(aspartate transaminase) and bilirubin increased (p<0.01). At CPB-off, IL-6 levels had negative correlations with total protein and albumin levels(r=-0.60, -0.47 respectively, p<0.05), whereas C3 levels had positive correlations with albumin levels(r=0.40, p<0.05). IL-6 levels, as well as neutrophil fractions, had positive correlations with aortic clamp time(ACT) and total bypass time(TBT) (IL-6; r=0.82, 0.79 respectively, neutrophil fractions; r=0.50, 0.56 respectively, p<0.05), wheres lymphocyte frations and albumin levels had negative correlations whith ACT and TBT(lymphocyte fractions; r=-0.52, -0.58 respectively, albumin; r=-0.58, -0.55 respectively, p<0.05). CONCLUSIONS: These data showed that elevated production of serum IL-6 during CPB may play a pivotal role in systemic inflammatory responses and prologed CPB period may be assosiated with more sever postperfusion syndromes.

Early and Midterm Results of Cabrol Technique in the Aortic Root Replacement / 대한흉부외과학회지

BACKGROUND: The purpose of this study was to analyze the early and midterm results of Cabrol technique to assist in making future decisions on a more adequate technique for repairing aortic root diseases. MATERIAL AND METHOD: From August 1993 to July 1999, we performed Cabrol technique in 18 patients ; 12 annuloaortic ectasia, 6 Stanford type A aortic dissection. Male and female ratio was 11;7, mean age was 46.9+/-12.3 years and mean follow up period was 22.5+/-21.5 months. We analysed the factors influencing postoperative complications and early mortality. The factors were old age(>60 years), high NYHA(>III), preoporative concomitant disease, urgency of operation, concomitant procedure, long pump preoperative concomitant disease, urgency of operation, concomitant procedure, long pump time(>200 minute), and hospital stay time (>30 days). RESULT: Operative mortality was 11.1%, late mortality was 11.1%, and overall mortality was 22.2%. The causes of operative death were a heart failure and an arrhythmia. The causes of late death were an acute myocardial infarction and an unknown etiology. Postoperative complications were bleeding, wound infection, toxic hepatitis, acute renal failure, and cerebral infarction. The factors influencing postoperative complications were hihg MYHA Fc(>III) (p=0.044), concomitant disease (p=0.044), long pump time(>200 minute)(p=0.015), and concomitant procedure(p=0.004). There were no significant factors influencing early mortality. CONCLUSION: The lower postoperative bleeding rate and no complication related to tension of anastomosis after Cabrol technique warrant its consideration in patients requiring aortic root replacement, especially without feasible mobilization of coronary arteries. However, to confirm the graft thrombosis, a more detailed study including periodic angiography will be required.

Midterm results of aortic root enlargement with AVR in patients with narrow aortic root and AS / 대한흉부외과학회지

BACKGROUND: For AVR using conventional prosthetic valves in adult patients with a narrow aortic root, aortic root enlargement is necessary to reduce postoperative pressure gradient across the aortic valve (deltaP). An evaluation of early and mid-term results of aortic root enlargement with AVR and echocardiographic follow up of deltaP and left ventricular function was performed. METHOD: From Aug. 1991 to Feb. 1998, eighteen patients aged 17 to 59 years(mean, 38+/-12 years) underwent Manouguian procedure with AVR. Aortic annular circumstance was enlarged 10.0mm to 18.0mm(mean, 12.6+/-6.3mm). Eight patients(44.0%) had NYHA class III status before operation, and seven cases of them underwent concomitant MVR. Valve pathology was ASr in 6 cases, AS in 4 cases, nd ASr+MSr in 8 cases. Replaced valve size was 21mm in 8 cases and 23 mm in 10 cases, and St. Jude Medical mechanical valve was used in 10 cases and Carbomedics in 8 cases. RESULT: Follow-up duration was 6 to 57 months (mean, 26+/-18 months), and total follow-up was 287 patient-year. There were one hospital death and one late death, therefore, actuarial survival rate was 85.7% at 56 months. Peak deltaP wad decreased significantly at postoperative mid-term period as 13+/-5mmHg, compared with thepreoperative one (42+/-8mmHg) (p<0.01). LVM(gm/m(2)) was also diminished as 35.8%(115+/-36gm/m(2))at postoperative mid-term period, compared with preoperative one (179+/-56gm/m(2))(p<0.05). CONCLUSIONS: There were no specific complications related to the procedure. And we could have adequate enlargement of aortic annulus to suitable prosthetic valve that have no effect of patient-prosthese mismatch.

Arch-First Technique in Aortic Arch Aneurysm / 대한흉부외과학회지

To minimize the period of brain ischemia and the potential for neurologic damage during aortic arch replacement, we used the arch-first technique. First case was a 28-year-old female with extensive aneurysm involving ascending, arch and descending thoracic aorta. Exposure was obtained via a bilateral via a bilateral thoracotomy (clamshell incision) in the anterior 4th right and 3rd left intercostal space with oblique sternotomy. To prepare for arch perfusion, the side-arm graft(10mm) was anastomosed to the aortic graft, opposite the site of the planned anastomosis to the arch vessels. After completing the arch anastomosis under total circulatory arrest(37min) and retrograde cerebral perfusion(12min), aortic graft was clamped on either side and the arch was perfused via side-arm graft for 36min. When distal aortic anastomosis was finished, distal clamp of aortic graft was released and arch vessels were perfused via common femoral artery, and the proximal aortic anastomosis was accomplished. The patient was discharged with no event. Second case was a 48-year-old male with extensive aneurysm involving ascending, arch, and aortic regurgitaiton(grade III/IV). This case was also done using the clamshell incision. Aortic valve replacement was done by valved-conduit(Vascutek 30mm), both coronary artery anastomosis using Cabrol's procedure. Last operation procedure was the same as the 1st case.