Clinical study of 62 cases of anomalous left coronary artery from the pulmonary artery / 临床儿科杂志

Objective To explore the clinical manifestation, treatment and prognosis of anomalous left coronary artery from the pulmonary artery (ALCAPA). Method The clinical data of patients with ALCAPA from January 2011 to September 2016 were retrospectively analyzed. All the patients were divided into infant group (<12 months) and child group (≥12 months). Results In the 62 patients (38 infants and 24 children) with ALCAPA, the median ΔLVDD (actually measured LVDD – the normal upper limit of LVDD in this age group) of infant group and child group was 13.6 (8.4～17.5) mm and 8.5 (3.3～13.7) mm respectively. The mean LVEF of the infant group was 40.6±2.4 ％, lower than that of the children group (59.0±2.9) ％, and the difference was statistically significant (P<0.01). Sixty children were treated with surgery. The mean cardiopulmonary bypass duration of infant group (137.1±8.4 min) was longer than that of the children group (105.9±6.6 min), and the difference was statistically significant (P=0.010). The median mechanical ventilation time after operation in infant group (6 d, 3～7 d), was longer than that in the children group (2 d, 1～4 d), and the difference was statistically significant (P<0.01). The median follow-up time of 60 patients was 38 months. Six patients died within 1 month after surgery (5 cases in the infant group and 1 in the children group), and there were no deaths more than 1 month after surgery. In 22 cases, the flow rate of pulmonary valve increased rapidly within 1 week after operation (>1.8 m/s). Conclusion ALCAPA is easily misdiagnosed as dilated cardiomyopathy. The clinical manifestations of infants were more severe than those of children. The mortality was high within 1 month after surgery, and the long-term prognosis was better.

Aneurisma de la arteria coronaria derecha: Revisión de la literatura y reporte de casos / Aneurysm of the right coronary artery: Literature review and cases report

El aneurisma de la arteria coronaria derecha es una entidad rara, que se presenta principalmente en mujeres. Las causas más frecuentes de muerte por aneurisma son en su orden: ruptura, trombosis, isquemia. La enfermedad aterosclerótica es la causa más frecuente de aneurisma espontáneo. La mayoría de los pacientes son asintomáticos, y presentan soplo continuo o moderada cardiomegalia, y plétora en la radiografía de tórax. En etapas avanzadas produce cardiopatía isquémica. Para su diagnóstico es necesario un juicio clínico adecuado y exámenes de rutina para enfermedad coronaria. Se exponen dos casos tratados en la Fundación Clìnica A. Shaio, con base en los cuales se analiza el diagnóstico, las complicaciones y el tratamiento realizado.

The aneurysm of the right coronary artery is a rare entity, which occurs primarily in women. The most frequent causes of death in these aneurysms are in its order: rupture, thrombosis and ischemia. Atherosclerotic disease is the most frequent cause of spontaneous aneurysm. Most patients are asymptomatic and have a continuous murmur or moderate cardiomegaly and plethora on chest X-ray. In advanced stages it causes ischemic heart disease. Its diagnosis requires an adequate clinical judgment and routine tests for coronary artery disease.

Minimally Invasive Coronary Artery Bypass Grafting / 대한흉부외과학회지

Minimally invasive coronary artery bypass grafting without using cardiopulmonary bypass (CPB) is a recently accepted modality of myocardial revascularization prcedures which is particularly suitable to the patients with lesions in the left anterior descending (LAD) and the right coronary arteries. Of the consecutive 35 patients of coronary artery bypass grafting performed at Sejong General Hospital from March to August 1996, six patients underwent minimally invasive coronary artery bypass grafting without CPB. All had stenotic lesions of the LAD more than 90%. Bypass grafting of the LAD was approached through midline sternotomy in one, through ministernotomy in two, and through limited left anterior thoracotomy in three patients, respectively. The internal mammary arteries were prepared without the use of thoracoscope. The mobilized mammary arteries were connected directly to the LAD in 5 patients, and the anastomosis required interposition of a segment of the radial artery in the remaining one. The diagonal branch was revascularized with the saphenous vein graft at the same time in one patient. No blood transfusion was necessary in 2 patients, and average blood required during surgery was 800ml in 4 patients. All patients were extubated from 4 to 14 hours (mean 9 hours) after operation. Early postoperative coronary angiography in 5 patients between 7 and 10 days after surgery has proved full patency of the grafts. With these limited clinical experiences, the clinical results demonstrated that minimally invasive coronary artery bypass grafting without CPB is an useful procedure especially in patients with isolated lesion in the proximal LAD.

Cytokines Production and Ultrafiltration in Patients Undergoing Cardiopulmonary Bypass during Coronary Artery Surgery / 대한마취과학회지

BACKGROUND: An increase in total body water and the systemic inflammatory response occurs during cardiopulmonary bypass (CPB) which has resulted in the release of inflammatory mediators, including tumor necrosis factor-alpha (TNFalpha), interleukin-1beta, interleukin-6,and interleukin-8. These substances were suggested to be responsible for postoperative organ dysfunction and morbidity. Conventional ultrafiltration (cUF) and modified ultrafiltration (mUF) were used in cardiac operations to reduce volume overload and total body water. The purpose of this study was to estimate the value of these techniques in removing inflammatory mediators during CPB. METHODS: Serial plasma samples were taken before CPB,after 1 hour of CPB, just before cUF, after cUF, after mUF and 24 hrs after bypass. Cytokines were detected using highly specific double-ligand enzyme-linked immunosorbent assays. The data were analyzed using the repeated measurement ANOVA. RESULTS: TNFalpha, interleukin-1beta, interleukin-6, and interleukin-8 were increased during CPB and peaked just before cUF. After cUF, all four cytokines had been significantly decreased. After mUF,interleukin-6 and interleukin-8 had significantly been decreased, but TNFalpha and interleukin-1beta did not change significantly. After 24 hours of CPB , TNFalpha and interleukin-8 returned to preCPB values, but interleukin-1beta and interleukin-6 did not. CONCLUSIONS: We conclude that ultrafiltration has the potential to remove cytokines from the circulation. The ultrafiltration technique may be a useful technique in the management of patients undergoing bypass, particularly in patients at high risk of accumulating fluids and inflammatory reactions.

Complete Myocardial Revascularization Utilizing Parallel Sequential Anastomoses / 대한흉부외과학회지

We evaluated the feasibility and safety of this method by reviewing the early outcome of the patients who underwent coronary artery bypass grafting(CABG) utilizing parallel sequential anastomoses with saphenous vein grafts, comparing with the outcome of the patients revascularized with grafts having only single distal anastomosis. During the one-year period of 1995, a total of 79 patients underwent isolated CABG, among whom 39 patients with sequential vein grafts(sequential group) and 40 patients without sequential grafts(non-sequential group). There was no difference between the two groups in terms of preoperative status, except in the extent of the coronary disease; 87.2% of the sequential group and 45.0% of the non-sequential group had left main and/or triple vessel involvement. 318 distal coronary anastomoses were done; 198 for the sequential group(5.1/patient) and 120 for the non-sequential group(3.0/patient). In the sequential group, the mean durations of cardiopulmonary bypass and aortic clamp per one distal anastomosis were 33.5 and 21.1 minutes, respectively. In the non-sequential group, these were 41.8 and 22.7 minutes. There were two operative deaths, both in the non-sequential group. There was no difference in the incidence of postoperative complications including myocardial infarction. During the follow-up period(2 to 15 months), 8 patients(3 in the sequential and 5 in the non- sequential group) complained of residual or recurrent angina. Comparison of preoperative and postoperative 201Thallium myocardial perfusion scans in 30 patients showed improved or normal perfusion reserve in 83.3% of segments bypassed with sequential grafts and 82.5% of segments bypassed with non-sequential graft(s). These results show that, utilizing parallel sequential anastomoses with saphenous vein grafts, we could achieve satisfactory short-term clinical results in patients with extensive coronary stenoses. So, we conclude that this technique is a safe, technically feasible strategy for CABG, which can achieve the aim of complete myocardial revascularization with a limited length of graft. These results show that, utilizing parallel sequential anastomoses with saphenous vein grafts, we could achieve satisfactory short-term clinical results in patients with extensive coronary stenoses. So, we conclude that this technique is a safe, technically feasible strategy for CABG, which can achieve the aim of complete myocardial revascularization with a limited length of graft.

Intraoperative Measurement and Analysis of Coronary Artery Bypass Graft Flow / 대한흉부외과학회지

This study aimed to determine factors that influence blood flow through coronary bypass grafts and to analyze relationship between the graft flow and postoperative outcome. Blood flow through 146 bypass grafts(GBF) was measured with transit-time ultrasound flowmeter during coronary artery bypass grafting operations in 50 patients. Single and multiple regression analyses were done for relationships between the GBF and four variables: internal diameter of recipient coronary artery, myocardial value of bypassed branch(es), type of graft, and finding of preoperative myocardial perfusion scan. The relationship between GBF and postoperative scan finding was also analyzed. 1. The mean GBF was significantly higher in sequential grafts than in single vein grafts or in internal thoracic artery grafts(61.5 vs. 46.9 and 42.5 ml/min). 2. Myocardial value and recipient artery diameter were found to be the factors determining GBF. There was no correlation between GBF and presence of perfusion defect in the preoperative scan. 3. Myocardial value was found to be more important than recipient artery diameter in determinintg GBF. 4. Reversible perfusion defects were more frequently found in the areas supplied by grafts with low GBF. But this fact had only mild statistical significance. These results suggest that blood flow through a bypass graft is more determined by the size of its supplying myocardium than by the size of recipient artery. So, we can expect effective improvement in myocardial flow reserve after grafting of small(1~1.5mm) coronary arteries, if they supply substantial area of myocardium.