Early Transcatheter Aortic Valve Failure Accompanied with Leaflet Perforation

No abstract available.

Electrocautery-Ignited Surgical Field Fire Caused by a High Oxygen Level during Tracheostomy

Tracheostomy is a relatively common surgical procedure that is performed easily in an operating room or intensive care unit. Open tracheostomy is needed in patients requiring prolonged ventilation when percutaneous tracheostomy is inappropriate. Sometimes, it is difficult to achieve bleeding control in the peritracheal soft tissue, and in such cases, we usually use diathermy. However, the possibility of an electrocautery-ignited surgical field fire can be overlooked during the procedure. This case report serves as a reminder that the risk of a surgical field fire during tracheostomy is real, particularly in patients requiring high-oxygen therapy.

High Glucose Induces Connective Tissue Growth Factor Expression and Extracellular Matrix Accumulation in Rat Aorta Vascular Smooth Muscle Cells Via Extracellular Signal-Regulated Kinase 1/2

Connective tissue growth factor (CTGF) is a potent pro-fibrotic factor, which is implicated in fibrosis through extracellular matrix (ECM) induction in diabetic cardiovascular complications. It is an important downstream mediator in the fibrotic action of transforming growth factor beta (TGFbeta) and is potentially induced by hyperglycemia in human vascular smooth muscle cells (VSMCs). Therefore, the goal of this study is to identify the signaling pathways of CTGF effects on ECM accumulation and cell proliferation in VSMCs under hyperglycemia. We found that high glucose stimulated the levels of CTGF mRNA and protein and followed by VSMC proliferation and ECM components accumulation such as collagen type 1, collagen type 3 and fibronectin. By depleting endogenous CTGF we showed that CTGF is indispensable for the cell proliferation and ECM components accumulation in high glucose-stimulated VSMCs. In addition, pretreatment with the MEK1/2 specific inhibitors, PD98059 or U0126 potently inhibited the CTGF production and ECM components accumulation in high glucose-stimulated VSMCs. Furthermore, knockdown with ERK1/2 MAPK siRNA resulted in significantly down regulated of CTGF production, ECM components accumulation and cell proliferation in high glucose-stimulated VSMCs. Finally, ERK1/2 signaling regulated Egr-1 protein expression and treatment with recombinant CTGF reversed the Egr-1 expression in high glucose-induced VSMCs. It is conceivable that ERK1/2 MAPK signaling pathway plays an important role in regulating CTGF expression and suggests that blockade of CTGF through ERK1/2 MAPK signaling may be beneficial for therapeutic target of diabetic cardiovascular complication such as atherosclerosis.

Insulin Like Growth Factor Binding Protein-5 Regulates Excessive Vascular Smooth Muscle Cell Proliferation in Spontaneously Hypertensive Rats via ERK 1/2 Phosphorylation

Insulin-like growth factor binding proteins (IGFBPs) are important components of insulin growth factor (IGF) signaling pathways. One of the binding proteins, IGFBP-5, enhances the actions of IGF-1, which include the enhanced proliferation of smooth muscle cells. In the present study, we examined the expression and the biological effects of IGFBP-5 in vascular smooth muscle cells (VSMCs) from spontaneously hypertensive rats (SHR) and Wistar Kyoto rats (WKY). The levels of IGFBP-5 mRNA and protein were found to be higher in the VSMC from SHR than in those from WKY. Treatment with recombinant IGFBP-5-stimulated VSMC proliferation in WKY to the levels observed in SHR. In the VSMCs of WKY, incubation with angiotensin (Ang) II or IGF-1 dose dependently increased IGFBP-5 protein levels. Transfection with IGFBP-5 siRNA reduced VSMC proliferation in SHR to the levels exhibited in WKY. In addition, recombinant IGFBP-5 significantly up-regulated ERK1/2 phosphorylation in the VSMCs of WKY as much as those of SHR. Concurrent treatment with the MEK1/2 inhibitors, PD98059 or U0126 completely inhibited recombinant IGFBP-5-induced VSMC proliferation in WKY, while concurrent treatment with the phosphatidylinositol-3 kinase inhibitor, LY294002, had no effect. Furthermore, knockdown with IGFBP-5 siRNA inhibited ERK1/2 phosphorylation in VSMC of SHR. These results suggest that IGFBP-5 plays a role in the regulation of VSMC proliferation via ERK1/2 MAPK signaling in hypertensive rats.

Acute Type II Aortic Dissection with Severe Aortic Regurgitation and Chronic Descending Aortic Dissection in Pregnant Patient with Marfan Syndrome

Aortic dilatation and dissection are severe complications during pregnancy that can be fatal to both the mother and the fetus. The risks of these complications are especially high in pregnant patients with Marfan syndrome; however, incidents of descending aortic dissection are very rare. This case report involves a successful Bentall procedure for and recovery from a rare aortic dissection in a pregnant Marfan patient who developed acute type II aortic dissection with severe aortic regurgitation and chronic descending aortic dissection immediately after Cesarean section. Regular follow-up will be needed to monitor the descending aortic dissection.

Simultaneous Aortic and Tricuspid Valve Endocarditis due to Complication of Sinus of Valsalva Rupture

We experienced a case of ruptured aneurysm of the sinus of Valsalva, and this resulted in simultaneous aortic and tricuspid valve endocarditis through a shunt. The echocardiography showed a ruptured sinus of Valsalva aneurysm to the right atrium with a shunt. The aortic non-coronary cusp was fibro-thickened with vegetation. Vegetations of the septal leaflet and the anterior leaflet of the tricuspid valve were also found. The blood culture grew Enterococcus garllinarum. We replaced both tricuspid and aortic valve with successful surgical result.

Aneurysm of Sinus of Valsalva Dissecting Into the Interventricular Septum After Aortic Valve Replacement: Diagnosis by Echocardiography and Magnetic Resonance Imaging and Treatment With Surgical Sealant

Aneurysm of the sinus of Valsalva that causes dissection of the interventricular septum is an extremely rare entity. In this report we describe a case of aneurysm of the sinus of Valsalva dissecting into the interventricular septum, from the base to mid septum, after aortic valve replacement. After the diagnosis was made by transthoracic echocardiography and magnetic resonance imaging, the patient was successfully treated with surgical sealant-mediated occlusion of the aneurysmal sac and cardiac resynchronization therapy used for the first time.

Multiple Time Aortic Valve Replacement

No abstract available.

Regression of Left Ventricular Mass after Aortic Valve Replacement in Isolated Aortic Regurgitation / 대한흉부외과학회지

BACKGROUND: The aim of our study was to assess the extent of regression of left ventricular mass after aortic valve replacement in isolated aortic regurgitation. MATERIAL AND METHOD: Retrospective analysis of echocardiographic data was collected preoperative and postoperative 1 year. There were 20 patients (12 males, 8 females, mean age 55.8+/-11.8 years, mean body surface area 1.64+/-0.19 m2) with aortic regurgitation from 2002 through 2007. We studied the change of left ventricular ejection fraction, ventricular septum and left ventricular posterior wall thickness, and left vemtricular muscle index (LVMI). The control group was age matched with normal echocardiographic study results. Patients with combined surgery or infective endocarditis were excluded. RESULT: Seven cases of tissue valves and thirteen cases of mechanical valve were used. The valve sizes were 21 mm (3 cases), 23 mm (13 cases) and 25 mm (4 cases). The postoperative (125.5+/-42 g/m2) LVMI has decreased than preoperative LVMI (212.3+/-80 g/m2, p=0.000) but higher than that of control group (80.5+/-15.9 g/m2, p=0.000). Postoperative septal wall (systolic/diastolic: 13.5+/-3.4 mm/17.1+/-4.1 mm) and left ventricular posterior wall (systolic/diastolic: 12.9+/-3.4 mm/16.7+/-3.4 mm) thickness were slightly decreased after the valve replacement but was not significantly different than preoperative levels. And postoperative interventricular septal wall and left ventricular posterior wall thickness (systolic/diastolic: 8.6+/-1.4 mm/12.1+/-1.7 mm, systolic/diastolic: 8.4+/-1.4/13.2+/-1.9) were higher than that of the control group (p<0.001). CONCLUSION: The significant regression of LVMI after aortic valve replacement developed at postoperative one year but the level was higher than control group. The main cause of decreased LVMI is decreased in left ventricular dimension.

Analysis of Risk Factors and Effect of Vancomycin for Sternal Infection after Coronary Artery Bypass Graft / 대한흉부외과학회지

BACKGROUND: Sternal wound infection (SWI) is an important complication after cardiac surgery. The aim of this study was to investigate the predictors affecting sternal wound infection and preventive factors including short term Vancomycin therapy in patients who underwent coronary artery bypass grafting (CABG). MATERIAL AND METHOD: A retrospective study was done using data collected from January 2001 through December 2007. This included 219 patients who had isolated CABG. The definition of SWI was documentation from a microbiological study and a requirement for simple closure or other surgical revision. RESULT: The overall incidence of SWI was 7.8% (n=17). The causative organisms were methicillin resistant Staphylococcus aureus (MRSA, n=13), methicillin resistant Staphylococcus epidermidis (n=2), Pseudomonas aeruginosa (n=1), and Candida albicans (n=1). Ten cases had deep sternal wound infection with mediastinitis; 7 cases had a superficial wound infection. Infection-related mortality was low (1/17; 6%). Diabetes mellitus (p=0.006) and smoking history (p=0.020) were factors that predicted high risk. Short term use of vancomycin decreased the incidence of MRSA-associated SWI (p=0.009). For treatment, curettage and rewiring or flap were needed in most cases (88%, n=14). CONCLUSION: Patients who had diabetes mellitus and a smoking history need careful management. Short term use of vancomycin is effective for prevention of SWI with MRSA.

Native Coronary Artery and Grafted Artery Spasm Just after Coronary Artery Bypass Grafting: A Case Report

Native coronary artery spasm after coronary artery bypass grafting (CABG) is scarce. It frequently causes disastrous circulatory collapse. We report a 72-yr-old male, who experienced native coronary artery spasm and grafted artery spasm following CABG, which was successfully treated with coronary angiography and intracoronary injection of nitroglycerine.

Heme Oxygenase-1 Induced by Aprotinin Inhibits Vascular Smooth Muscle Cell Proliferation Through Cell Cycle Arrest in Hypertensive Rats

Spontaneous hypertensive rats (SHR) are an established model of genetic hypertension. Vascular smooth muscle cells (VSMC) from SHR proliferate faster than those of control rats (Wistar-Kyoto rats; WKY). We tested the hypothesis that induction of heme oxygenase (HO)-1 induced by aprotinin inhibits VSMC proliferation through cell cycle arrest in hypertensive rats. Aprotinin treatment inhibited VSMC proliferation in SHR more than in normotensive rats. These inhibitory effects were associated with cell cycle arrest in the G1 phase. Tin protoporphyrin IX (SnPPIX) reversed the anti-proliferative effect of aprotinin in VSMC from SHR. The level of cyclin D was higher in VSMC of SHR than those of WKY. Aprotinin treatment downregulated the cell cycle regulator, cyclin D, but upregulated the cyclin-dependent kinase inhibitor, p21, in VSMC of SHR. Aprotinin induced HO-1 in VSMC of SHR, but not in those of control rats. Furthermore, aprotinin-induced HO-1 inhibited VSMC proliferation of SHR. Consistently, VSMC proliferation in SHR was significantly inhibited by transfection with the HO-1 gene. These results indicate that induction of HO-1 by aprotinin inhibits VSMC proliferation through cell cycle arrest in hypertensive rats.

Aprotinin Inhibits Vascular Smooth Muscle Cell Inflammation and Proliferation via Induction of HO-1

Aprotinin is used clinically in cardiopulmonary bypass surgery to reduce transfusion requirements and the inflammatory response. The mechanism of action for the anti-inflammatory effects of aprotinin is still unclear. We examined our hypothesis whether inhibitory effects of aprotinin on cytokine-induced inducible nitric oxide synthase (iNOS) expression (IL-1beta plus TNF-alpha), reactive oxygen species (ROS) generation, and vascular smooth muscle cell (VSMC) proliferation were due to HO-1 induction in rat VSMCs. Aprotinin induced HO-1 protein expression in a dose-dependent manner, which was potentiated during inflammatory condition. Aprotinin reduced cytokine mixture (CM)-induced iNOS expression in a dose dependent manner. Furthermore, aprotinin reduced CM-induced ROS generation, cell proliferation, and phosphorylation of JNK but not of P38 and ERK1/2 kinases. Aprotinin effects were reversed by pre-treatment with the HO-1 inhibitor, tin protoporphyrin IX (SnPPIX). HO-1 is therefore closely involved in inflammatory-stimulated VSMC proliferation through the regulation of ROS generation and JNK phosphorylation. Our results suggest a new molecular basis for aprotinin anti-inflammatory properties.

The Effects of Moxifloxacin in Endotoxin-induced Acute Lung Injury / 대한흉부외과학회지

BACKGROUND: The pathophysiology of acute respiratory distress syndrome with sepsis is acute lung injury (ALI) that's' caused by endotoxin (LPS). We evaluate effects of moxifloxacin on LPS-induced ALI in a rat model. MATERIAL AND METHOD: The rats were divided into 3 groups as the control group (C), the LPS insult group (L), and the LPS+moxifloxacin treated group (L-M). ALI was induced by endotracheal instillation of E.coli LPS, then moxifloxacin was given in 30 minutes. Five hours later, we checked the lung weight/body weight ratio(the L/BW ratio), the protein & neutrophils in the bronchoalveolar lavage fluid (BALF), the myeloperoxidase (MPO) activity & the malondialdehyde (MDA) content, the expressions of cytosolic and secretory phospholipase A2 (c, sPLA2), and the morphology of the lung with using a light microscope. RESULT: The L/BW ratio, the protein content and the neutrophil count in the BALF, and the MPO activity and the MDA content in lung were significantly increased in group L compared to group C, and these factors were markedly decreased in group L-M compare to group L. The cPLA2 expression and the sPLA2 expression were increased in group L and the cPLA2 expression was decreased in group L-M. Yet the sPLA2 expression was not changed in group L-M. Morphologically, many inflammatory findings were observed in group L, but not in group L-M. CONCLUSION: Many of the inflammatory changes of ALI that were caused by LPS insult were ameliorated by moxifloxacin treatment.

Evaluation of Curriculums of Medical Schools for Fostering Various Basic Qualities of Medical Professionalism / 한국의학교육

PURPOSE: Today, the social requirement of medicine emphasizes the importance of medical professionalism. This forces medical educators to introduce new contents and methods into the curriculum. This study aims to offer ideas for developing the curriculum through clarifying priorities on the basic qualities of medical professionalism and evaluating the current curriculums in medical schools in South Korea. METHODS: In April 2005, 46 respondents majoring in basic medical sciences, clinical medicine, and medical humanities/social sciences completed a structured questionnaire. The questionnaire consisted of 3 categories related to: 1) the basic qualities of medical professionalism/general education courses, 2) the process of developing the qualities of humanities and social sciences in medical education, and 3) the appropriate allocation of credits for each subject to premedical and medical courses. The analysis consisted of frequency, chi-square, and multiple responses using Korean Ed, SPSS 14.0 for Windows. RESULTS: The most important basic quality is basic medical knowledge. The credits for the general education are sufficient but it's contribution is lacking (44.44%). The most lacking element in the general education courses is socio-cultural comprehension (45.65%). The knowledge of humanities and social sciences is very important in developing the basic qualities (56.52%). The important learning experiences related to these is the introspection into human beings (32.16%). Credits for medical humanities classes in premedical and medical course are noticeably insufficient (45.65, 54.35%, respectively). The appropriate program of informal curriculum for fostering the qualities is meeting with various medical specialists (44.44%, 47.83%, respectively). There is almost no difference among the major groups under (p<.05.) CONCLUSION: To assist medical students to be equipped with the basic qualities of medical professionalism, the realm of medical humanities should be made mandatory; and the general education courses need to be reformed, especially in the premedical curriculum. In particular, continuous cooperation between faculties in medicine, liberal arts, and/or social sciences need to exist with the conglomeration of these into fewer medical humanities majors in Korea.

Extraanatomic Bypass Graft was Performed in Adult Coarctation / 대한흉부외과학회지

We performed three cases of extraanatomic bypass graft for treating adult coarctation. Two cases of left subclavian artery to descending aorta bypass graft were done via left thoracotomy for treating 2 patients who had extensive aortic occlusive disease. One case of ascending aorta to descending aorta bypass graft and aortic valve replacement was done via median sternotomy for a patient who had combined arch hypoplasia and aortic valve regurgitation. One patient was reoperated on for aneurysm rupture of an anastomosis site four months after the first operation and two patients have had no specific problems during and after their operations.

The Role of B-type Natriuretic Peptide in Predicting Postoperative Complications and Outcomes in Patients Undergoing Coronary Artery Bypass Graft / 대한흉부외과학회지

BACKGROUND: Circulating levels of brain natriuretic peptide (BNP) provide prognostic information for patients with heart failure. The aim of our study was to investigate whether preoperative and postoperative BNP levels could predict postoperative complications and outcomes in patients after coronary artery bypass graft (CABG). MATERIAL AND METHOD: Data was collected prospectively on 30 patients (M/F=19/11, age 60.0+/-9.6 years) undergoing conventional CABG during a 1-year period beginning on January 1, 2005. Patients underwent off-pump CABG, and combined surgery was excluded. The BNP assay was performed preoperatively, immediate postoperatively at the intensive care unit (ICU), and 1, 3, 5, and 7days postoperatively. RESULT: Preoperative BNP levels significantly correlated with preoperative echocardiographic ejection fraction and an ICU stay of 5 days or more (r=-0.4, p=0.028; r=0.39, p=0.031, respectively). A preoperative BNP cut-off value above 263 pg/mL demonstrated high specificity (90.5%) for predicting postoperative complications using the receiver operating characteristics curves. Preoperative and postoperative (7 days) BNP levels were different depending on the abscence (mean BNP=99+/-23 pg/mL vs. 296+/-74 pg/mL, p 263 pg/mL predict postoperative complications in patients receivingCABG.

Plasma Levels of Brain Natriuretic Peptide Predict Postoperative Atrial Fibrillation in Patients Undergoing Heart Surgery / 대한흉부외과학회지

BACKGROUND: The brain natriuretic peptide (BNP) level has been reported in some studies to be associated with the occurrence of atrial fibrillation (AF). The aim of this study is to evaluate the potential usefulness of the BNP level as a predictor of the occurrence of postoperative (postop) AF and to assess the relationship of the BNP level with the onset of AF and the restoration of sinus rhythm. MATERIAL AND METHOD: From January 1, 2005 to February 28, 2006, 82 patients without a history of atrial arrhythmia that had undergone cardiac surgery were enrolled in the study. Blood samples for plasma BNP were drawn daily for all these patients from the preoperative (preop) day to the 7th postop day. The patient records were reviewed and postop EKGs were checked daily for AF until the time of discharge. RESULT: Patients were divided into two groups based on development of postop AF. Postoperative AF developed in 26 patients (31.7%). There was no significant statistical difference in age, sex distribution, preop left ventricle ejection fraction, hypertension, left ventricular hypertrophy, or the use of beta blockers between the non-postop AF and postop AF group. More patients in the AF group had undergone valve surgery (39.3% versus 76.9%, p=0.002). The preop left atrium size was significantly larger in the AF patients (43.8+/-10.3 mm versus 49.8+/-11.5 mm, p=0.029). The preop plasma BNP levels were higher in the postop AF patients (144.1+/-20.8 pg/mL versus 267.5+/-68 pg/mL, p=0.034). In the postop AF group, the plasma BNP level was the highest on the 3rd postop day. Postop AF developed in most patients by the 3rd postop day; restored sinus rhythm developed by the 7th postop day. CONCLUSION: Elevated plasma BNP levels may lead to the occurrence of postop AF in patients undergoing cardiac surgery. Patients who have a high risk of postop AF should be considered for aggressive prophylactic antiarrhythmic therapy.

Extracorporeal Life Support with a Twin-pulse Life Support (T-PLS) System / 대한흉부외과학회지

A mechanical circulatory support system is a life-saving option for treating acute severe respiratory failure or cardiac failure. There are currently a few types of assist devices and the Twin-Pulse Life Support (T-PLS) system is a kind of pulsatile pump. We report here on three patients with severe life threatening cardiopulmonary dysfunction who had the T-PLS system used as an assist device. The indications for applying the T-PLS system were continuing respiratory or cardiac failure in spite of maximal ventilatory and inotropic support. There were two patients with acute respiratory failure due to infection and one patient with cardiac failure due to acute myocarditis. One respiratory failure patient and one cardiac failure patient survived after applying the T-PLS system for 3 days and 5 days, respectively. The T-PLS system is useful as an assist device and it should be considered before multi-organ failure occurs.

Spinal Cord Infarction following Off-pump Coronary Artery Bypass Surgery / 대한흉부외과학회지

A 62-year-old woman with ischemic heart disease, hypertension and hypercholesterolemia had developed spinal cord infarction after off-pump coronary artery bypass (OPCAB). The incidence of postoperative neurological complications is well known to be less in OPCAB than that of conventional coronary bypass surgery. Furthermore, spinal cord infarction is an uncommon clinical event after coronary bypass surgery. Here we report a case of spinal cord infarction following OPCAB, discuss possible mechanism of spinal cord infarction with relate literatures.