Modified Surgical Intervention for Extensive Mitral Valve Endocarditis and Posterior Mitral Annular Calcification

The concomitant presence of posterior mitral annular calcification and infectious mitral valve lesions poses a technical challenge with considerable perioperative risk when using previously proposed techniques for mitral valve surgery. Herein, we report a case of the use of a modified surgical technique to successfully treat a patient with mitral infective endocarditis complicated by a subendocardial abscess and extensive posterior mitral annular calcification.

Nodular Fasciitis of the Chest in a Young Woman

Nodular fasciitis is a benign reactive proliferation that usually involves the deep fascia. Although it is relatively common in the adult population, it is often misdiagnosed as sarcoma due to its rapid growth and pathological features. It rarely presents as a chest wall tumor in young patients. Here, we report a case of nodular fasciitis involving the chest wall of an 18-year-old woman and its surgical management. This case underscores the need to consider nodular fasciitis in the differential diagnosis of chest wall tumors in young patients.

Neurologic Outcomes of Preoperative Acute Silent Cerebral Infarction in Patients with Cardiac Surgery

BACKGROUND: Acute cerebral infarction is a major risk factor for postoperative neurologic complications in cardiac surgery. However, the outcomes associated with acute silent cerebral infarction (ASCI) have not been not well established. Few studies have reported the postoperative outcomes of these patients in light of preoperative Diffusion-weighted magnetic resonance imaging (DWI). We studied the postoperative neurologic outcomes of patients with preoperative ASCI detected by DWI. METHODS: We retrospectively studied 32 patients with preoperative ASCI detected by DWI. None of the patients had preoperative neurologic symptoms. The mean age at operation was 68.8+/-9.5 years. Five patients had previous histories of stroke. Four patients had been diagnosed with infective endocarditis. Single cerebral infarct lesions were detected in 16 patients, double lesions in 13, and multiple lesions (>5) in three. The median size of the infarct lesions was 4 mm (range, 2 to 25 mm). The operations of three of the 32 patients were delayed pending follow-up DWI studies. RESULTS: There were two in-hospital mortalities. Neurologic complications also occurred in two patients. One patient developed extensive cerebral infarction unrelated to preoperative infarct lesions. One patient showed sustained delirium over one week but recovered completely without any neurologic deficits. In two patients, postoperative DWI confirmed that no significant changes had occurred in the lesions. CONCLUSION: Patients with preoperative ASCI showed excellent postoperative neurologic outcomes. Preoperative ASCI was not a risk factor for postoperative neurologic deterioration.

Acute Thrombotic Occlusion of Left Internal Jugular Vein Compressed by Bypass Graft for Thoracic Endovascular Aortic Repair Debranching Procedure

Thoracic endovascular aortic repair has become a widespread alternative treatment option for thoracic aortic aneurysm. The debranching of arch vessels may be required to provide an acceptable landing zone for an endovascular stent graft. We report a case where the bypass graft used in the thoracic endovascular aortic repair procedure compressed the left internal jugular vein, causing acute thrombotic occlusion.

Assessment of Left Ventricular Function after Mitral Valvular Replacement Using Multidetector Row Computed Tomography: Initial Experience

PURPOSE: To assess the usefulness of cardiac MDCT for the evaluation of cardiac function and morphology of mitral valve replacement (MVR) with or without subvalvular preservation. MATERIALS AND METHODS: Sixteen patients with (n = 10) or without (n = 6) subvalvular sparing and control subjects (n = 6) were evaluated using 16-slice MDCT (Sensation 16, Siemens, Erlangen, Germany). Images of MDCT were reconstructed for the evaluation of cardiac morphology and ventricular function. Patients were compared with respect to variables such as ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), and the diastolic-systolic left ventricular area ratio on a short-axis view at apical, mid-ventricular, and basal levels. RESULTS: The average values for cardiac function variables for control subjects and after MVR (with subvalvular preservation versus without subvalvular preservation) were, respectively, 54 +/- 8%, 54 +/- 7% and 44 +/- 6 %, for EF; 91 +/- 28 ml, 108 +/- 35 ml and 99 +/- 33 ml for EDV; 43 +/- 19 ml, 52 +/- 24 ml and, 56 +/- 21 ml for ESV. The area ratio was 2.56, 2.75, 2.09 at the apex; 2.20, 2.17, 1.56 at the mid-ventricular level; 1.90, 1.87, 1.76 at the basal level, respectively. Mid ventricular contraction for patients following subvalvular resection was significantly decreased (p < 0.05). CONCLUSION: MDCT is a useful diagnostic modality for functional and morphologic evaluation of MVR.

Catastrophic Primary Antiphospholipid Syndrome

Catastrophic antiphospholipid syndrome (CAPLS) was diagnosed in a 64-year-old male who was admitted to our hospital with dyspnea. The clinical and radiological examinations showed pulmonary thromboembolism, and so thromboembolectomy was performed. Abdominal distention rapidly developed several days later, and the abdominal computed tomography (CT) abdominal scan revealed thrombus within the superior mesenteric artery with small bowel and gall bladder distension. Cholecystectomy and jejunoileostomy were performed, and gall bladder necrosis and small bowel infarction were confirmed. The anticardiolipin antibody was positive. Anticoagulant agents and steroids were administered, but the patient expired 4 weeks after surgery due to acute respiratory distress syndrome (ARDS). We report here on a case of catastrophic APLS with manifestations of pulmonary thromboembolism, rapidly progressing GB necrosis and bowel infarction.

Catastrophic Primary Antiphospholipid Syndrome

Catastrophic antiphospholipid syndrome (CAPLS) was diagnosed in a 64-year-old male who was admitted to our hospital with dyspnea. The clinical and radiological examinations showed pulmonary thromboembolism, and so thromboembolectomy was performed. Abdominal distention rapidly developed several days later, and the abdominal computed tomography (CT) abdominal scan revealed thrombus within the superior mesenteric artery with small bowel and gall bladder distension. Cholecystectomy and jejunoileostomy were performed, and gall bladder necrosis and small bowel infarction were confirmed. The anticardiolipin antibody was positive. Anticoagulant agents and steroids were administered, but the patient expired 4 weeks after surgery due to acute respiratory distress syndrome (ARDS). We report here on a case of catastrophic APLS with manifestations of pulmonary thromboembolism, rapidly progressing GB necrosis and bowel infarction.

Availability of the Skeletonized Gastroepiploic Artery as a Free Graft for Coronary Artery Bypass Grafting / 대한흉부외과학회지

BACKGROUND: To maximize the histological advantage and minimize the physiological disadvantage, we have been using the skeletonized gastroepiploic artey (GEA) as a free graft for total arterial revascularization. The aims of the current study was to assess the efficacy of the skeletonized GEA as a composite or extended graft for total arterial revascularization. MATERIAL AND METHOD: Between January 2000 and Feburary 2005, 133 patients (43 female, mean age=61.8 yrs) undergoing coronary artery bypass grafting (CABG) with a skeletonized GEA as free graft (22 extended, 107 composite and 4 others) were enrolled in this study. Coronary angiograms were performed in the immediate (median 14 days, n=86), early (median 366 days, n=56) and midterm (median 984 days, n=29) postoperative periods. RESULT: There were 3 (2.2%) early and 4 (3.3%) late cardiac-related deaths. The mean number of distal anastomoses per patient was 3.34 for total graft and 1.92 for GEA graft. The immediate, early, and midterm GEA patency were 157/159 (98.7%), 106/112 (94.6%), and 53/56 (94.6%), respectively. During follow-up, four patients required percutaneous intracoronary intervention because of GEA and target coronary artery stenosis or competitive flow. CONCLUSION: These data demonstrate satisfactory clinical and angiographic results in the skeletonized GEA as free graft for total arterial revascularization. Although we need a careful longer follow-up, the skeletonized GEA as a free graft will be a valuable option 'to be' for CABG.

Heart Failure by a Calcific Pericardial Ring: A case report / 대한흉부외과학회지

Calcific constrictive pericarditis is considered to be a nonspecific response to chronic inflammation. This disease has become rare, because the cause of it is usually tuberculosis, which has the tendency to decrease. Other possible causes of it include radiation, rheumatoid disorders, sarcoidosis, and trauma. Whatever the etiology, it can lead to cardiac tamponade by reducing cardiac diastolic filling. We report, herein, the case of a patient with heart failure by a calcific pericardial ring.

Effect of Left Atrial Volume Reduction with Maze Operation on Sinus Conversion and Recovery of Left Atrial Transport Function / 대한흉부외과학회지

BACKGROUND: The Maze procedure considered the most effective method of treatment for atrial fibrillation. However, the sinus conversion rates decreased due to several factors, especially enlarged left atrium. The purpose of this study was to investigate the effects of Maze procedure with left atrial volume reduction plasty on rheumatic mitral valve disease. MATERIAL AND METHOD: From December of 2001 to July of 2004, 45 patients received mitral valve and Maze operation. The patients were placed in either group 1 or group 2, based on the left atrial volume reduction plasty. The presence and onset of sinus rhythm and the incidence of trans mitral A waves were monitored during the postoperative 7 days and throughout the follow up period of 3 and 6 months. Mean follow up periods were 15.8 10.1 months in group 1 and 6.1+/-2.7 months in group 2. RESULT: The sinus onset were 9.88+/-12.2 days in group 1, and 1+/-3.6 days in group 2 (p<0.01). The sinus conversion rates in the group 1 and 2 were 65%, 75% (p=0.07) in the postoperative 7 days, 70.5%, 100% (p<0.01) at postoperative 3 months, and 93%, 100% (p<0.01) at postoperative 6 months, respectively. The wave detection rates in the postoperative 7 days were 31.2% and 63.6%, and continued to improve over time to 83.3% and 100% by 6months, respectively. CONCLUSION: The results suggest that Maze procedure with left atrial volume reduction plasty is effective for inducing sinus rhythm and for restoring left atrial contractile function after concomitant rheumatic mitral valve surgery. However further follow up of this patients for long time is necessary.

Coronary Arteriovenous Fistula Complicated with Dilated Pulmonary Sinus Confirmed by Multidetector-row CT

Congenital coronary arteriovenous fistula (CAVF) is a rare condition which is characterized by abnormal communication of the coronary artery with the right ventricle, right atrium, left atrium, left ventricle or pulmonary artery. In this paper, we report a case of a 68-year-old woman complaining of resting chest pain for one week. Initially, after performing a coronary arteriogram, the case was diagnosed as a CAVF combined with a pulmonary artery aneurysm. However, a multidetector-row CT (MDCT) was also performed, and the structure initially diagnosed as a pulmonary artery aneurysm was identified as a dilated pulmonary sinus. Subsequently, the patient was treated successfully with a simple ligation.

Aortic Dissection Presenting with Secondary Pulmonary Hypertension Caused by Compression of the Pulmonary Artery by Dissecting Hematoma: A Case Report

The rupture of an acute dissection of the ascending aorta into the space surrounding the pulmonary artery is an uncommon occurrence. No previous cases of transient pulmonary hypertension caused by a hematoma surrounding the pulmonary artery have been documented in the literature. Herein, we report a case of acute aortic dissection presenting as secondary pulmonary hypertension.

Chondroblastoma of the Rib : Case Report

Chondroblastoma is an uncommon, benign, cartilaginous neoplasm originating in an epiphysis or apophysis of a long tubular bone. The rib is an unusual site for chondroblastoma. The authors describe a case of chondroblastoma of the rib and present a brief review of the literature.

Clinical outcome in elderly patients older than 70 years with acute myocardial infarction after use of platelet glycoprotein IIb/IIIa receptor blocker during percutaneous coronary intervention : Comparison with those younger than 70 years / 대한내과학회지

BACKGROUND: This study was designed to evaluate the safety and clinical benefits of a glycoprotein IIb/IIIa receptor inhibitor, ReoPro(R) in the elderly patients with acute myocardial infarction (AMI) (>or=70 years of age) undergoing percutaneous coronary intervention (PCI). METHODS: AMI patients who underwent PCI with use of ReoPro(R) at Chonnam National University Hospital from Jan 2000 to Jan 2002 were divided into two groups: Group I (>or=70 years of age: 74 +/- 2.4 years, n=28) and Group II (<70 years of age: 56 +/- 8.0 years, n=122). Early and long-term clinical outcomes after PCI were analyzed in a retrospective fashion. RESULTS: As for risk factors and angiographic profiles, there were no differences between the two groups. Stenting was performed in 18 patients (64%) in group I and in 78 patients (63%) in group II. The incidence of gastrointestinal bleeding was 3 patients in group I and no patient in group II (p=0.005). At one-month evaluation, three cardiac deaths developed in group I, but no cardiac death in group II (p=0.005). During a period of 25 +/- 10.4 months of clinical follow-up, three cardiac deaths (11%) occurred in group I and 3 (2%) in group II, four AMIs (3%) in group II, and one stroke (0.8%) in group II. Target lesion revascularization (TLR) was performed in two patients (7%) in group I and in 24 patients (19%) in group II. No differences were found in the incidences of these variables between the two groups. CONCLUSION: ReoPro(R) in elderly patients with AMI undergoing PCI entailed higher bleeding complications and early mortality. However, it has comparable clinical effect in elderly patients to younger patients during long-term clinical follow-up.

Adrenal Crisis after Off-pump Coronary Artery Bypass Surgery / 대한흉부외과학회지

Addisonian crisis, also commonly referred to as adrenal crisis, occurs when the cortisol produced by the adrenal gland is insufficient to meet the body's needs. Pituitary apoplexy usually occurs as hemorrhagic and ischemic necrosis in the presence of a pre-existing pituitary adenoma, and is a rare sequela of cardiovascular surgery. Most pituitary apoplexy that happens in cardiovascular surgery has been known to be related to harmful effects of the cardiopulmonary bypass. The case presented herein illustrates occult pituitary apoplexy that occurred after off-pump coronary artery bypass grafting. In this patient, the initial signs of addisonian crisis was similar to those of septic shock, and were overlooked. However, once recognized, they were reduced dramatically with standard stress-dose cortisone.

Early and Mid-term Results of Operation for Infective Endocarditis on Mitral Valve / 대한흉부외과학회지

BACKGROUND: Infective endocarditis shows higher operative morbidity and mortality rates than other cardiac diseases. The vast majority of studies on infective endocarditis have been made on aortic endocarditis, with little attention having been paid to infective endocarditis on the mitral valve. This study attempts to investigate the clinical aspects and operative results of infective endocarditis on the mitral valve. METERIAL AND METHOD: The subjects of this study consist of 23 patients who underwent operations for infective endocariditis on the mitral valve from June 1995 to May 2003. Among them, 2 patients suffered from prosthetic valvular endocarditis and the other 21 from native valvular endocarditis. The subjects were evenly distributed age-wise with an average age of 44.8+/-15.7 (11~66) years. Emergency operations were performed on seventeen patients (73.9%) due to large vegetation or instable hemodynamic status. In preoperative examinations, twelve patients exhibited congestive heart failure, four patients renal failure, two patients spleen and renal infarction, and two patients temporary neurological defects, while one patient had a brain abscess. Based on the NYHA functional classification, seven patients were determined to be at Grade II, 9 patients at Grade III, and 6 patients at Grade IV. Vegetations were detected in 20 patients while mitral regurgitation was dominant in 19 patients with 4 patients showing up as mitral stenosis dominant on the preoperative echocardiogram. Blood cultures for causative organisms were performed on all patients, and positive results were obtained from ten patients, with five cases of Streptococcus viridance, two cases of methicillin-sensitive Staphylococcus aureus, and one case each of Corynebacterium, Haemophillis, and Gernella. Operations were decided according to the AA/AHA guidelines (1988). The mean follow-up period was 27.6+/-23.3 (1~97) months. RESULT: Mitral valve replacements were performed on 13 patients, with mechanical valves being used on 9 patients and tissue valves on the other 4. Several kinds of mitral valve repair or mitral valvuloplasty were carried out on the remaining 10 patients. Associated procedures included six aortic valve replacements, two tricuspid annuloplasty, one modified Maze operation, and one direct closure of a ventricular septal defect. Postoperative complications included two cases of bleeding and one case each of mediastinitis, low cardiac output syndrome, and pneumonia. There were no cases of early deaths, or death within 30 days following the operation. No patient died in the hospital or experienced valve related complications. One patient, however, underwent mitral valvuloplasty 3 months after the operation. Another patient died from intra-cranial hemorrhage in the 31st month after the operation. Therefore, the valve-related death rate was 4.3%, and the valve-related complication rate 8.6% on mid-term follow-up. 1, 3-, and 5-year valve- related event free rates were 90.8%, 79.5%, and 79.5%, respectively, while 1, follow-up. 1, 3-, and 5-year valve- related event free rates were 90.8%, 79.5%, and 79.5%, respectively, while 1, 3-, and 5-year survival rates were 100%, 88.8%, and 88.8%, respectively. CONCLUSION: The findings suggest that a complete removal of infected tissues is essential in the operative treatment of infectious endocarditis of the mitral valve. It is also suggested that when infected tissues are completely removed, neither type of material nor method of operation has a significant effect on the operation result. The postoperative results also suggest the need for a close follow-up observation of the patients suspected of having brain damage, which is caused by preoperative blood contamination or emboli from vegetation, for a possible cerebral vascular injury such as mycotic aneurysm.

Total Arterial Revascularization Using Y-composite Graft for Isolated Left Main Coronary Artery Disease / 대한흉부외과학회지

BACKGROUND: For the treatment of isolated left main coronary artery disease, twelve arterial revascularizations with Y-composite grafts using left internal thoracic artery and radial artery or right gastroepiploic artery were performed. This study was performed to investigate whether Y-composite graft can satisfy the blood flow required to make myocardium act properly or not. Borderline stenotic lesions on the left main coronary artery, which are very prone to remodel the bypassed vessels due to competitive flows, were also considered. MATERIAL AND METHOD: Among 247 patients who underwent coronary artery bypass grafting from March 2000 to April 2003, 12 patients (4.7%) who had received total arterial revascularizations for the isolated left main coronary artery disease were studied retrospectively. RESULT: Left anterior descending arteries were bypassed with left internal thoracic artery by off-pump technique in all patients, however, 2 cases of left obtuse marginal branches were bypassed under on-pump beating heart. Except for one patient, who did not have an obtuse marginal branch more than 1 mm in diameter, 11 patients had gone through complete arterial revascularizaions by use of the Y shape arterial graft. Among five patients who had less than 75% stenosis, one patient showed string sign on left internal thoracic artery grafted to left anterior descending artery. However, two grafts to obtuse marginal branches were completely obstructed and one showed slender sign. There were no graft-dominant flow in patients with stenotic lesion less than 75%. On the contrary to the result of patients with stenotic lesions less than 75%, all the patients with stenotic lesions more than 90% showed graft-dominant blood flow. CONCLUSION: In conclusion, it is assumed that, when stenotic lesions are over 90%, coronary artery bypass grafting with an Y shape arterial graft could possibly give enough help to the obstructed coronary arteries in blood supplying to myocardium, which needs massive quantity of blood to act well. However, when patients have borderline stenoses, through scrupulous examinations, more prudent and flexible decisions are required in choosing the treatment methods, such as, direct anastomosis of vein or artery to aorta, or adding supplementary treatment methods like percutaneous coronary intervention, rather than choosing a fixed treatment methods.

MR Imaging of Congenital Heart Disease

MRI is useful for demonstrating the anatomy of various congenital cardiac lesions and plays an important role in the diagnosis of congenital cardiac lesions. Its large field of view and unlimited imaging planes enable the depiction of complex lesions, the complicated three-dimensional relations of the cardiac chambers and anomalies of the central pulmonary arteries, the systemic and pulmonary veins, and aorta. We describe the normal MR anatomy and MR imaging findings of a variety of congenital pathologies of the heart, in order to provide a better understanding and facilitate the interpretation of the MR features of various congenital heart diseases.

Early Clinical Experience in Aortic Valve Replacement Using On-X(R) Prosthetic Heart Valve / 대한흉부외과학회지

BACKGROUND: Since the first implanted in September 1997, the use of On-X prosthetic heart valve has been increasing around in the world. This study was designed to assess the feasibility, safety, and the postoperative hemodynamics with this new valve in clinical setting. MATERIAL AND METHOD: The current study was carried out on 52 patients undergoing aortic valve replacement with this prosthesis between April 1999 to August 2002 at Chonnam National University Hospital to evaluate the surgical results. 52% of the patients were male and the average age at implant was 50+/-13 years. The study followed the guidelines of the AATS/STS. Preoperatively, 32 (61.5%) patients were in NYHA functional class III or IV and 2 patients had previous aortic valve surgery. Concomitant cardiac surgery was performed in 71.1%. The implanted valve sizes were 19 mm in 13 patients, 21 mm in 26, 23 mm in 10 and 25 mm in 3, respectively. Mean follow-up was 16.6+/-10.5 months (1~39 months). Echocardiographic assessment was performed pre- and immediate postoperatively, as well as 3, 6, 12 months after surgery, evaluating pressure loss and regression of left ventricular hypertrophy. RESULT: Mean cardiopulmonary bypass time was 191+/-94.7 minutes with an aortic cross-clamp time of 142+/-51.7 minutes. There was no early and late mortality. Freedom from adverse events at 1 year in the study were as follows: thromboembolism, 95.6+/-6%; bleeding events, 90.2+/-4%; paravalvular leakage 92.3+/-4%; and overall valve-related morbidity at 1 year was 76.6+/-3%. There were no cases of valve thrombosis, prosthetic valve endocarditis and structural or non-structural failure. Left ventricular function at 12 months after surgery (EF=62.7+/-9.8%) revealed a statistically significant improvement compared to preoperative investigation (EF=55.8+/-15.9%, p=0.006). Left ventricular mass index was 247.3+/-122.3 g/m2 on preoperative echocardiographic study, but regressed to 155.5+/-58.2 g/m2 at postoperative 1 year (p=0.002). Over the follow-up period a further decrease of peak transvalvular gradients was observed in all patients: 62.5+/-38.0 mmHg on preoperative assessment, 18.2+/-6.8 mmHg at immediate postoperative period (p<0.0001), 7.6+/-5.09 mmHg (p<0.0001) at 6 month, 18.0+/-10.8 mmHg (p<0.0001) at 1 year. CONCLUSION: The On-X prosthetic heart valve performs satisfactorily in the first 1 year period. Clinical outcome by examining NYHA functional classification revealed especially good results. Effective regression of left ventricular hypertrophy and statistically significant decrease of transvalvular gradient were observed over the first year, but longer-term follow-up of this patient group is needed to establish the expected rates for late valve-related events as well as the long-term clinical efficacy of this valve.

Pneumomediastinum by Blunt Chest Trauma (The Macklin Effect) / 대한흉부외과학회지

Pneumomediastinum, also referred to as mediastinal emphysema or Hamman's syndrome, is defined as the presence of air or gas within the fascial planes of the mediastinum. Superior extension of air into the cervicofacial subcutaneous space via communications between the mediastinum and cervical fascial planes or spaces occurs occasionally. Pneumomediastinum frequently results from blunt tracheobronchial lesions and esophageal injuries. However, in most cases, the origin of pneumomediastnum remains unclear. In some cases, it is attributed to the Macklin effect. We report a case of patient with pneumomediastinum, that presented with Mackin effect on chest computed tomographic scan.