Surgical Management of Recurrent Leiomyosarcoma in Heart

Leiomyosarcoma may occur anywhere in the body but rarely occurs in the heart or great vessels. Leiomyosarcoma may be managed by surgical resection with or without chemotherapy or radiotherapy. Owing to the high rate of metastasis and poor prognosis, a definitive treatment modality for leiomyosarcoma has not yet been suggested. This case study reports the surgical management of the recurrent leiomyosarcoma of the heart and the great vessels in a 63-year-old woman.

Comparative Analysis of Thoracotomy and Sternotomy Approaches in Cardiac Reoperation

BACKGROUND: Reoperation of cardiac surgery via median sternotomy can be associated with significant complications. Thoracotomy is expected to reduce the risk of reoperation and to enhance the surgical outcomes. We retrospectively analyzed two operative approaches (thoracotomy vs. sternotomy) in cardiac reoperation. MATERIALS AND METHODS: From September 2007 to December 2010, 35 patients who required reoperation of the mitral valvular disease following previous median sternotomy were included. Average age of patients was 45.8+/-15.4 years (range, 14 to 76 years) and male-to-female was 23:12. Interval period between primary operation and reoperation was 135.8+/-105.6 months (range, 3.3 to 384.9 months). RESULTS: Comparative analysis was done dividing the patient group into two groups that are thoracotomy group (22 patients) and sternotomy group (13 patients). Thoracotomy group was significantly lower in operative time (415.2+/-90.3 vs. 497.5+/-148.0, p<0.05), bleeding control time (108.0+/-29.5 vs. 146.4+/-66.8, p<0.05) and chest tube drainage (287.5+/-211.5 mL vs. 557.3+/-365.5 mL, p<0.05) compared to sternotomy group. CONCLUSION: The thoracotomy approach is superior to sternotomy in some variables, and it is considered as a valid alternative to repeat median sternotomy in patients who underwent a previous median sternotomy.

Short-term Outcomes of Aortic Wrapping for Mild to Moderate Ascending Aorta Dilatation in Patients Undergoing Cardiac Surgery

BACKGROUND: The adequate management of mild to moderate dilatation of the ascending aorta during cardiac operations remains controversial. In this study, we present the short-term outcomes of 90 patients undergoing ascending aortic wrapping with a Dacron graft during other cardiac operations. MATERIALS AND METHODS: From March 2008 to January 2011, 90 consecutive patients underwent treatment for ascending aortic aneurysm using the external wrapping technique during the concomitant procedure. The study group consisted of 49 male and 41 female patients with a mean age of 58.7+/-13 years. The primary cardiac surgical procedures were coronary artery bypass grafting (CABG) in 3, aortic valve replacement in 2, and aortic valvuloplasty in 85 patients (isolated in 62 and combined with CABG or mitral valvuloplasty in 23). The ascending aorta diameter was measured using a computed tomography scan within 4 weeks after surgery, and was compared with the preoperative value. RESULTS: The diameters of the ascending aorta wrapped with the Dacron graft were significantly reduced within a month after surgery from 46.4+/-4.3 mm to 33.0+/-3.5 mm (p<0.05). There was no early mortality or major surgical complication. During the mean follow-up period of 15.4+/-5.2 months, there was only one late death caused by septic multiorgan failure. CONCLUSION: Dacron wrapping of the ascending aorta offers excellent results with very low mortality and morbidity, and it can be regarded as a safe and effective method for the treatment of moderately dilated ascending aorta in selected patients.

Heart Transplantation in Pediatric Patients: Twelve-Year Experience of the Asan Medical Center

Heart transplantation is a standard treatment for end-stage heart disease. Pediatric heart transplantation, however, is not frequently performed due to the shortage of pediatric heart donors. This is the first report of pediatric heart transplantation in Korea. Our retrospective study included 37 patients younger than 18 yr of age who underwent heart transplantation at Asan Medical Center between August 1997 and April 2009. Preoperative diagnosis was either cardiomyopathy (n = 29, 78.3%) or congenital heart disease (n = 8, 22.7%). Mean follow up period was 56.9 +/- 44.6 months. There were no early death, but 7 late deaths (7/37, 18.9%) due to rejection after 11, 15, 41 months (n = 3), infection after 5, 8, 10 months (n = 3), suspicious ventricular arrhythmia after 50 months (n = 1). There was no significant risk factor for survival. There were 25 rejections (25/37, 67.6%); less than grade II occurred in 17 patients (17/25, 68%) and more than grade II occurred in 8 patients (8/25, 32%). Actuarial 1, 5, and 10 yr survival was 88.6%, 76.8%, and 76.8%. Our midterm survival of pediatric heart transplantation showed excellent results. We hope this result could be an encouraging message to do more pediatric heart transplantation in Korean society.

Surgical Correction of Cor Triatriatum Associated with Pulmonary Artery Thrombosis in an Adult

We herein present a case of a successful correction of cor triatriatum associated with thrombotic pulmonary hypertension diagnosed in an adult female patient. We confirmed diagnosis using transthoracic and transesophageal echocardiography in addition to cardiac computed tomography and magnetic resonance imaging. Surgical repair comprised excision of the fibromuscular membranous septum in the left atrium, patch closure of an atrial septal defect, and reconstruction of the pulmonary arteries with a vascular graft. Cor triatriatum complicated pulmonary thrombotic hypertension with atrial septal defect is amenable to surgical correction with satisfactory results.

Short-term Mechanical Circulatory Support with a Centrifugal Pump: Results of Peripheral Extracorporeal Membrane Oxygenator According to Clinical Situation

BACKGROUND: A peripheral extracorporeal membrane oxygenator (p-ECMO) has been developed to support patients who are dying due to a serious cardiopulmonary condition. This analysis was planned to define the clinical situation in which the patient benefits most from a p-ECMO. MATERIAL AND METHODS: Between June 2007 and Aug 2009, a total of 41 adult patients used the p-ECMO. There were 23 males and 18 females (mean age 54.4+/-15.1 years). All patients had very unstable vital signs with hypoxia and complex cardiac problems. We divided the patients into 4 groups. In the first group, a p-ECMO was used as a bridge to cardiac operation. In the second group, patients did not have the opportunity to undergo any cardiac procedures; nevertheless, they were treated with a p-ECMO. In the third group, patients mostly had difficulty in weaning from CPB (cardiopulmonary bypass) after cardiac operation. The fourth group suffered from many complications, such as pneumonia, bleeding, infections, and LV dysfunction with underlying cardiac problems. All cannulations were performed by the Seldinger technique or cutting down the femoral vessel. A long venous cannula of DLP(R) (Medtronic Inc, Minneapolis, MN) or RMI(R) (Edwards Lifesciences LLC, Irvine, CA) was used together with a 17~21 Fr arterial cannula and a 21 Fr venous cannula. As a bypass pump, a Capiox emergency bypass system (EBS(R); Terumo, Tokyo, Japan) was used. We attempted to maintain a flow rate of 2.4~3.0 L/min/m2 and an activated clotting time (ACT) of around 180 seconds. RESULTS: Nine patients survived by the use of the p-ECMO. Ten patients were weaned from a p-ECMO but they did not survive, and the remainder had no chance to be weaned from the p-ECMO. The best clinical situation to apply the p-ECMO was to use it as a bridge to cardiac operation and for weaning from CPB after cardiac operation. CONCLUSION: Various clinical results were derived by p-ECMO according to the clinical situation. For the best results, early adoption of the p-ECMO for anatomical correction appears important.

Linear Fat Deposition in the Middle Layer of the Left Ventricular Myocardium: Computed Tomographic Findings

We report here a case of streaky fat deposition in the middle layer of the left ventricular myocardium, without any underlying etiology, and this was seen on computed tomography coronary angiography. This report suggests that left ventricular middle layer fat deposition should be investigated in order to determine its etiology, the pathogenesis and the prognosis.

Myocardial Bridging of the Left Anterior Descending Coronary Artery: Depiction Rate and Morphologic Features by Dual-Source CT Coronary Angiography

OBJECTIVE: To evaluate the depiction rate and morphologic features of myocardial bridging (MB) of the left anterior descending coronary artery (LAD) using dual-source CT (DSCT). MATERIALS AND METHODS: CT scans from a total of 1,353 patients who underwent DSCT were reviewed retrospectively for LAD-MB. Seventy-eight patients were excluded due to poor image quality or poor enhancement of the coronary artery. The length and depth of the MB were analyzed and classified as superficial or deep with respect to the depth ( 1 mm) of the LAD tunneled segment. Superficial MB was subdivided into complete or incomplete types according to full or partial encasement of the myocardium. RESULTS: Of the 1,275 patients included in this study, 557 cases of MB were found from 536 patients (42%). Superficial MB was observed in 368 of 557 (66%) cases, and deep MB was seen in 189 of 557 (34%) cases. Superficial MB showed 2 types: complete (128 of 368, 35%) and incomplete (240 of 368, 65%). The mean length of a tunneled segment for superficial MB was 16.4 +/- 8.6 mm. The mean length and depth of a tunneled segment for deep MB were 27.6 +/- 12.8 mm and 3.0 +/- 1.4 mm, respectively. The incidence of atherosclerotic plaques in a 2-cm-long segment proximal to MB was 16%. CONCLUSION: The depiction rate of LAD-MB using DSCT in a large series of patients was 42%, with two-thirds of MB segments being the superficial type.

CABG for Treating Unstable Angina with Multivessel Coronary Artery Aneurysms: A case report / 대한흉부외과학회지

Coronary artery aneurysm is an uncommon disease. The optimal medical or surgical treatment for this disease remains obscure. The causes of coronary artery aneurysms include atherosclerosis, Kawasaki disease, infectious vascular disease, connective tissue disorder and congenital malformation. A 50 year old man visit our institution for chest pain that had started 3 days previously. After coronary angiography, multiple coronary aneurysms were diagnosed and successful surgical intervention was performed.

Recent Early Operative Outcomes of Comprehensive Aortic Root & Valve Reconstruction (CARVAR) Procedure / 대한흉부외과학회지

BACKGROUND: A Comprehensive Aortic Root and Valve Reconstruction (CARVAR) procedure is comprised of aortic root wall reconstruction and corrections of the leaflets for treating various aortic valve diseases. We evaluated our recent early clinical experience with the CARVAR procedure. MATERIAL AND METHOD: From October 2007 to September 2008, 114 cases (66 males) of CARVAR procedures were performed. The mean patient age was 53 years (range: 14~84). The patients were divided into 4 groups: 1) the AAR group: aortic regurgitation with aortic root wall deformity such as annulo-aortic ectasia or ascending aortic aneurysm (n=18), 2) the IAR group: isolated AR with leaflet abnormality (n=42), 3) the IAS group: isolated aortic stenosis (n=51) and 4) the PAVR group: previous aortic valve replacement (n=3). Sinotubular junction (STJ) reduction was done in all the patients, leaflet correction was done in 10 of the AAR group patients and in all the patients of the other groups, annulus reduction was done in 14 of the AAR group patients and in 6 of the IAR group patients. Aortic dissection was excluded from this analysis. RESULT: There was no mortality or follow-up death. The diameter of the aortic sinus decreased from 54.6+/-8.4 mm to 38.3+/-3.8 mm in the AAR group, the mean AR grade decreased from 3.2 to 0.2 in the IAR group, the mean aortic valve pressure gradient decreased from 47.1+/-24.4 mmHg to 15.1+/-11.7 mmHg in the IAS group and the mean AR grade decreased to 0 in the PAVR group. Balloon type coronary perfusion cannula-related coronary ostial stenosis developed in 4 patients and this was treated with OPCAB in three patients and with PTCA in one patient. Two patients developed postoperative infectious endocarditis. All the patients were discharged and followed up in a stable condition. CONCLUSION: The CARVAR procedure showed excellent short term results, but a good further follow up result is required to apply this procedure to most kinds of aortic valve diseases.

Three-dimensional Transesophageal Echocardiography for Mitral Valve Repair Surgery: A case report / 대한마취과학회지

Although several reports have showed the application of 3-dimensional (3D) echocardiography, it is hard to find a report regarding the intraoperative use of real time 3D transesophageal echocardiography (TEE) in mitral valve repair surgery. In the present case, real time 3D TEE the one from the one TEE probe position as well as their rotated and cropped images showed detailed spatial images enough for immediate assessment of the mitral valve deformity and the characteristics of mitral regurgitation flow. Under cardiopulmonary bypass (CPB) employing moderate hypothermia, the prolapsed mital leaflet was excised, the ruptured cord was repaired and an annuloplasty ring was inserted to reinforce the mitral valve and to close up the defect. The 2D and 3D TEE images after CPB showed effective repair providing complete closure of the mitral leaflets and absence of residual regurgitation flow. Considering that the conventional 2D TEE requires examiner's ability to gather the various 2D TEE images and experience essential for intergrating the 2D images for full understanding of spatial structure of valvular deformity and dysfunction, 3D TEE's ability for making a comprehensive spatial image from a limited number of 2D images seems to have an additional clinical efficacy in intraoperative TEE monitoring for cardiac value surgery.

Recent Advancement in Heart and Lung Transplantation

Heart transplantation remains the definitive surgical solution for Stage D heart failure. There have been impressive developments in lung transplantation also. This review is focused on the recent advancements in the field of heart and lung transplantation and the current status of thoracic organ transplantation in Korea. Future directions of thoracic organ transplantation are discussed.

Postoperative Outcomes of Patients with Severe Aortic Regurgitation and Decreased Left Ventricular Ejection Fraction

BACKGROUND AND OBJECTIVES: The postoperative outcomes of patients with severe aortic regurgitation (AR) and a low ejection fraction (EF) were elucidated. SUBJECTS AND METHODS: The study group consisted of 201 consecutive patients that underwent corrective surgery for isolated AR. The clinical data of patients with a preoperative EF or =50% (n=142, group II) were compared. The clinical follow-up duration was 3.2+/-2.4 years. RESULTS: There was no operative mortality for patients in both groups. Group I patients showed significant improvement of the EF after surgery, from 41+/-6% to 53+/-12% (p<0.001) and the EF (53+/-12 vs 56+/-1%, p=0.09) at follow-up was not significantly different between patients in the two groups. The 5-year survival rate was 70.5+/-8.9% for group I patients and 88.0+/-3.5% for group II patients (p=0.06). The cumulative incidence of congestive heart failure at 5 years was significantly higher in group I patients (32.1+/-9.7% vs 8.5+/-3.1%, p=0.003). Independent determinants of development of congestive heart failure in group I patients were age [hazards ratio (HR)=1.1, 95% confidence interval (CI)=1.02-1.16, p=0.01] and EF (HR=0.82, 95% CI=0.69-0.97, p=0.02). The best cut-off value of the preoperative EF in predicting the development of congestive heart failure was 41.5%, with a sensitivity and specificity of 90.9% and 68.9%, respectively. CONCLUSION: A relatively high 5-year survival rate without operative mortality is anticipated in patients with reduced a preoperative left ventricular ejection fraction (LVEF) and the incidence of congestive heart failure was higher when compared to patients with a normal preoperative LVEF, which could be predicted by the level of the preoperative LVEF.

Mid to Long Term Outcomes of Surgical Treatment for Isolated Coarctation of Aorta / 대한흉부외과학회지

BACKGROUND: The surgical repair of an isolated coarctation of the aorta, without complex cardiac anomalies, has improved, with very good results. However, despite the success of surgical repair, many long-term complications, such as hypertension, re-coarctation and an aortic aneurysm, still exist. MATERIAL AND METHOD: Between 1991 and 2006, 50 patients diagnosed with an isolated coarctation of the aorta were reviewed retrospectively. The incidence of re-coarctation and hypertension were compared with respect to age and surgical methods. RESULT: There were no early & late mortality, or post operative aortic aneurysms. Hypertension developed in 11 patients (22%). A greater number of patients in the child/adult group had hypertension (52.4%) than in the neonate/infant group (0%). With respect to the surgical methods, the patients in the graft interposition group suffered more hypertension (88.9%) than those in the EEEA (extended end to end anastomosis) group (5.3%). Post operative re-coarctation developed in 2 out of the 29 patients (6.9%) in the neonate/infant group and 2 out of the 21 patients (9.5%) in the child/adult group, but without any statistical difference. There were no statistical differences between the operative type-related groups. CONCLUSION: Even though the surgical outcomes have greatly improved, an isolated coarctation of the aorta still has many long-term problems, such as hypertension and re-coarctation. An isolated coarctation is accepted as a systemic vascular dysfunction, and often progresses to other cardiovascular diseases. Therefore, patients with a coarctation of the aorta have to be carefully followed-up, and aggressive management must be given when required.

B-type Natriuretic Peptide (BNP) as a Predictive Marker after Heart Transplantation / 대한흉부외과학회지

BACKGROUND: B-type natriuretic peptide (BNP) is a cardiac hormone that is primarily synthesized by the ventricular cardiac myocytes. Increased plasma BNP levels have been observed in patients suffering with congestive heart failure, ventricular hypertrophy and myocaridits and also during heart transplantation rejection. We investigated the serum BNP level as a predictive marker for rejection after heart transplantation. MATERIAL AND METHOD: To test the usefulness of measuring the BNP level in cardiac transplant patients, consecutive blood samplings for BNP, right ventricular endomyocardial biopsies, hemodynamic measurements and transthoracic echocardiogram were all done in 10 such patients between January 2004 and August 2005 at the Department of Thoracic and Cardiovascular Surgery in Asan Medical Center. Two groups were identified with using the median value: the low BNP group (n=28, BNP: 290 pg/mL). We retrospectively analyzed rejection, the ejection fraction, tricuspid regurgitation, left ventricular hypertrophy, the pulmonary capillary wedge pressure and the right atrial pressure between the 2 groups. RESULT: There were no differences in age, gender, rejection, the ejection fraction, tricuspid regurgitation, left ventricular hypertrophy and the right atrial pressure between the 2 groups (p>0.05). However, a higher pulmonary capillary wedge pressure and a higher mean pulmonary atrial pressure were observed in the high BNP group (p12 mmHg) with a sensitivity of 83.3% and a specificity of 91.1% (AUC: 0.900+/-0.045, p<0.001). CONCLUSION: The BNP level after heart transplantation does not show any significant correlation with rejection, yet it might be a predictive marker of ventricular diastolic dysfunction.

Combined Heart and Kidney Transplantation in Patient with Postpartum Cardiomyopathy and Renal Failure / 대한흉부외과학회지

Heart and kidney transplantation has made great progress in the modern era. Coupled with the growing successes in individual solid organ transplantation, there has also been an increase in the number of multiple organ transplants, such as heart-kidney transplantation. This trend has been in part due to a better understanding of immunobiology, advances in surgical technique and postoperative care, and an often-common pathologic association between dual-organ failure. This pathologic course is representative for end-stage heart failure leading to secondary renal dysfunction or failure, or for end-stage renal failure as a cause for (uremic) cardiomyopathy. However, refractory cardiac failure has long been considered a contraindication to kidney transplantation. Additionally, cardiac transplantation has been denied for patients with end-stage renal disease. Over recent years, combined heart-kidney transplantation has been offered to select patients who were once denied transplantation. We report the first experience of combined heart-kidney transplantation with one year follow-up results.

Off-pump Reoperative Coronary Artery Bypass by Thoracotomy and Laparotomy : A case report / 대한흉부외과학회지

The incidence of reoperative coronary artery bypass grafting (CABG) has increased because of the rise in the number of patients who have undergone initial CABG. In addition, recent technological advances have resulted in widespread application of off pump coronary artery bypass (OPCAB). We report a case of redo OPCAB through thoracotomy and small laparotomy in 76-year-old man with recurrent unstable angina.

Score System for Operative Risk Evaluation in Coronary Artery Bypass Surgery / 대한흉부외과학회지

BACKGROUND: The purpose of this study is to assess a score system for operative risk evaluation of CABG. MATERIAL AND METHOD: From January 2001 to September 2005, retrospective study for various perioperative factors of 2993 cases was done. RESULT: The early operative mortality was 2.4% and the beta coefficients of 7 core variables related to it (preoperative LV dysfuction, preoperative renal failure, MI within 1 week, reoperation, combined surgery, preoperative atrial fibrillation, preoperative IABP) were adjusted to score system. ROC curve and Hosmer and Lemeshow goodness of fit test was done. CONCLUSION: This score system was effective in assessing operative risk of CABG. But It is necessary to gather larger volume of case and perform multicenter study.

The Efficacy and Safety of an Immunosuppressive Regimen Including the Use of Mycophenolate Mofetil and an Interleukin-2 Monoclonal Antibody in Heart Transplant Patients

BACKGROUND AND OBJECTIVES: An immunosuppressive regimen including the use of mycophenolate mofetil (MMF) and an interleukin-2 monoclonal antibody (IL2mAb) has shown promise to prevent acute rejection after heart transplantation. There has been a lack of report on the evaluation of the efficacy and safety of this regimen in patients receiving heart transplants in Korea. SUBJECTS AND METHODS: From November 1992 to December 2003, 111 consecutive patients who had received heart transplants in our institute were classified into two groups: patients who received the immunosuppressive regimen with MMF and an IL2mAb (group A, n=51) and patients who did not receive the regimen (group B, n=60). We compared the clinical outcomes of patients in each group including the survival rate and the occurrence of acute rejection and infection at 24 months post transplantation. RESULTS: Both drugs were tolearated in all patients except in 5 patients who complained of gastrointestinal side effects due to MMF. Despite a longer ischemic time (137.4+/-54.6 vs. 92.3+/-25.8 hours, p<0.05) and a lower serum level of cyclosporine (212.3+/-66.8 vs. 259.1+/-62.1 ng/mL, p<0.05), the rate of treatment for acute rejection was lower in group A than in group B (16% vs. 53%, p<0.05). In addition, the median time to the first treatment for acute rejection was almost twice as long for group A as for group B (91 vs. 43 days, p<0.05). The 2-year survival rate and the incidence of major infection requiring hospitalization in both groups were 94% vs. 88% and 26% vs. 21%, respectively, which were not statistically different. CONCLUSION: An immunosuppressive regimen including the use of MMF and an IL2mAb is efficacious and safe as a prophylaxis against acute rejection without the increased risk of major infection in patients who have received heart transplants in Korea.

Novel Technique of Aortic Valve Repair

BACKGROUND AND OBJECTIVES: The purpose of this study was to assess the results of a newly developed aortic valve repair technique. SUBJECTS AND METHODS: Between December 1997 and April 2005, 75 aortic valvuloplasties were performed using a new technique that addressed the 3 main components of the aortic root; annulus, sinotubular junction and leaflet. An internal synthetic strip and ring were implanted along the fibrous annulus to reduce the annulus and sinotubular junction, and additional leaflets were implanted for leaflet correction. Based on the primary pathology, there were 35, 22 and 18 cases of isolated aortic regurgitation, aortic regurgitation due to ascending aortic aneurysm and aortic regurgitation due to annuloaortic ectasia, respectively. RESULTS: The average age of the subjects was 46.4+/-16 years; there were 51 and 24 males and females, respectively. There was no operative mortality, with a 2-year freedom from reoperation rate of 97%. Follow up echocardiograms showed significant improvements in the grade of aortic regurgitation, from a preoperative mean of 3.1+/-1.2 to 1.08+/-0.7 immediate postoperatively, to 1.15+/-0.6 at the final follow up. CONCLUSION: The results of the current study showed this technique to be effective in the treatment of aortic regurgitation of various causes. Although long-term results are pending, it is our contention that this aortic valve repair technique will be a reliable method in the future.