Development of Models for Regional Cardiac Surgery Centers

BACKGROUND: This study aimed to develop the models for regional cardiac surgery centers, which take regional characteristics into consideration, as a policy measure that could alleviate the concentration of cardiac surgery in the metropolitan area and enhance the accessibility for patients who reside in the regions. METHODS: To develop the models and set standards for the necessary personnel and facilities for the initial management plan, we held workshops, debates, and conference meetings with various experts. RESULTS: After partitioning the plan into two parts (the operational autonomy and the functional comprehensiveness), three models were developed: the ‘independent regional cardiac surgery center’ model, the ‘satellite cardiac surgery center within hospitals’ model, and the ‘extended cardiac surgery department within hospitals’ model. Proposals on personnel and facility management for each of the models were also presented. A regional cardiac surgery center model that could be applied to each treatment area was proposed, which was developed based on the anticipated demand for cardiac surgery. The independent model or the satellite model was proposed for Chungcheong, Jeolla, North Gyeongsang, and South Gyeongsang area, where more than 500 cardiac surgeries are performed annually. The extended model was proposed as most effective for the Gangwon and Jeju area, where more than 200 cardiac surgeries are performed annually. CONCLUSION: The operation of regional cardiac surgery centers with high caliber professionals and quality resources such as optimal equipment and facility size, should enhance regional healthcare accessibility and the quality of cardiac surgery in South Korea.

Public Perception of the Concentration of Cardiac and Cerebrovascular Surgery to Metropolitan Hospitals

BACKGROUND: This study investigates the perception of the general public regarding the concentration to metropolitan, hospitals of cardiac and cerebrovascular surgeries, and the perceived public need for government policies to resolve this issue. METHODS: A total of 800 participants were recruited for our telephone interview survey. Quota sampling was performed, adjusting for age and sex, to select by various geographic regions. Sampling with random digit dialing was performed; we called the randomly generated telephone numbers and made three attempts for non-responders before moving on to a different telephone number. RESULTS: Our sample population was 818 participants, 401 men (49.0%) and 417 women (51.0%). Our data showed that 85.5% of participants thought that cardiac surgery and neurosurgery patients are concentrated in large hospitals in Seoul. The principle reason for regional patients to want to receive surgery at major hospitals in Seoul was because of poor medical standards associated with regional hospitals (87.7%). We found that a vast majority of participants (97.5%) felt that government policies are needed to even out the clustering of cardiac surgery and neurosurgery patients, and that this clustering may be alleviated if policies that can specifically enhance the quality and the capacity of regional hospitals to carry out surgeries are adopted (98.3%). CONCLUSION: Government policy making must reflect public desiderata, and we suggest that these public health needs may be partially resolved through government-designated cardiac and neurosurgery specialist hospitals in regional areas.

Thoracic and Cardiovascular Surgeons’ Perception of the Concentration of Cardiovascular Operations in Seoul Metropolitan Area’s Hospitals

BACKGROUND: The purpose of this study is to evaluate the concentration of cardiovascular surgical procedures in a metropolitan area and investigate the perception of specialists regarding governmental policies to resolve this imbalance. METHODS: From March to May 2015, surveys were distributed to members of the Thoracic and Cardiovascular Surgery Association. The final pool of research subjects consisted of 75 respondents. Subjects were queried regarding the concentration of cardiovascular operations in metropolitan areas, alternatives to the imbalance, and governmental policies to resolve the inequalities. RESULTS: Survey participants responded that South Korea needs governmental policies to alleviate the concentration of cardiovascular surgery patients in large metropolitan hospitals. Participants agreed that the freedom to choose medical institutions and improved accessibility to metropolitan hospitals due to advanced transportation systems were some of the causes for the concentration. A majority (98.7%) of respondents thought establishing thoracic and cardiovascular surgery centers in provinces was an appropriate solution to alleviate the concentration. Thoracic and cardiovascular surgery specialists were ranked as the number one group on which to focus development. CONCLUSION: Developing and carrying out policies to establish thoracic and cardiovascular surgery centers in provinces will alleviate the regional imbalance in available heart surgery services and an overall improvement in cardiovascular disease treatment in South Korea.

Trends in Percutaneous Coronary Intervention and Coronary Artery Bypass Surgery in Korea

BACKGROUND: Coronary angioplasty has been replacing coronary artery bypass grafting (CABG) because of the relative advantage in terms of recovery time and noninvasiveness of the procedure. Compared to other Organization for Economic Cooperation and Development (OECD) countries, Korea has experienced a rapid increase in coronary angioplasty volumes. METHODS: We analyzed changes in procedure volumes of CABG and of percutaneous coronary intervention (PCI) from three sources: the OECD Health Data, the National Health Insurance Service (NHIS) surgery statistics, and the National Health Insurance claims data. RESULTS: We found the ratio of procedure volume of PCI to that of CABG per 100,000 population was 19.12 in 2014, which was more than triple the OECD average of 5.92 for the same year. According to data from NHIS statistics, this ratio was an increase from 11.4 to 19.3 between 2006 and 2013. CONCLUSION: We found that Korea has a higher ratio of total procedure volumes of PCI with respect to CABG and also a more rapid increase of volumes of PCI than other countries. Prospective studies are required to determine whether this increase in absolute volumes of PCI is a natural response to a real medical need or representative of medical overuse.

Hospital Arrival Rate within Golden Time and Factors Influencing Prehospital Delays among Patients with Acute Myocardial Infarction

PURPOSE: This research was done to identify the hospital arrival rate and factors related to prehospital delay in arriving at an emergency medical center within the golden time after symptom onset in patients with acute myocardial infarction (AMI). METHODS: Data used in the research was from the National Emergency Department Information System of the National Emergency Medical Center which reported that in 2014, 9,611 patients went to emergency medical centers for acute myocardial infarction. Prehospital time is the time from onset to arrival at an emergency medical center and is analyzed by subdividing arrival and delay based on golden time of 2 hour. RESULTS: After onset of acute myocardial infarction, arrival rate to emergency medical centers within the golden time was 44.0%(4,233), and factors related to prehospital delay were gender, age, region of residence, symptoms, path to hospital visit, and method of transportation. CONCLUSION: Results of this study show that in 2014 more than half of AMI patients arrive at emergency medical centers after the golden time for proper treatment of AMI. In order to reduce prehospital delay, new policy that reflects factors influencing prehospital delay should be developed. Especially, public campaigns and education to provide information on AMI initial symptoms and to enhance utilizing EMS to get to the emergency medical center driectly should be implemented for patients and/or caregivers.

Interleukin-6 (-636 C/G) Gene Polymorphism in Korean Children With Kawasaki Disease

BACKGROUND AND OBJECTIVES: Kawasaki disease (KD) is a multi-systemic vasculitis with coronary artery involvement. Serum interleukin (IL)-6 levels during acute phase showed a significant correlation with the duration of fever in patients with KD who were not treated with intravenous immunoglobulin (IVIG), suggesting that the regulation of IL-6 expression in KD patients may differ from that in normal children. However, there are controversies surrounding the association between IL-6 (-636 C/G) gene polymorphism and development of KD. SUBJECTS AND METHODS: One hundred and nine children with KD and 191 children with congenital heart disease were included in this study. Echocardiography was performed to examine cardiac involvement in patients with KD. Genotyping of the IL-6 (-636 C/G) gene polymorphism was performed using the single-base extension method, and serum IL-6 concentrations were estimated using the sandwich enzyme immunoassay method. RESULTS: Neutrophil, platelet count, liver function test, total protein and albumin concentrations were significantly different in the KD group and the serum IL-6 concentration was significantly higher in the KD group than the control group. There was no difference between the patients with coronary arterial dilatation (CAD) and those without CAD in the IL-6 (-636 C/G) polymorphism. The serum albumin concentration was significantly lower in patients with KD who had the -636 C/G or GG genotype compared with the control group. The serum IL-6 concentration was significantly higher in patients with KD who had the -636 C/G or GG genotype. CONCLUSION: There was no association between the IL-6 (-636 C/G) gene polymorphism and development of coronary arterial lesions in KD. Further multicenter studies are required to establish the relationship between the IL-6 (-636 C/G) gene polymorphism and development of KD.

Mycoplasma pneumoniae infection in patients with Kawasaki disease / 소아과

PURPOSE: Kawasaki disease (KD) is the main cause of acquired heart disease in children. In addition to cardiovascular involvement, many complications have been recognized in KD. However, respiratory complications have been rarely reported. We investigated the differences in clinical characteristics, laboratory findings, radiography findings, and echocardiography findings of Mycoplasma pneumoniae infection and other types of pneumonia in KD patients. METHODS: Among 358 patients with KD, 54 developed concurrent pneumonia. Among the 54 patients, 12 (22.2%) with high titers of anti-M. pneumoniae antibody (AMA) (>1:640) were grouped in the M. pneumoniae group and 42 were included in the control group. Serum AMA was measured in each patient. Clinical laboratory findings and total duration of fever were analyzed. RESULTS: The duration of fever, serum hemoglobin, white blood cell count, platelet count, erythrocyte sedimentation rate, C-reactive protein level, albumin level, and the incidence of coronary arterial lesions showed no statistical difference in the 2 groups. Neutrophil count was significantly higher in the M. pneumoniae group than in the control group. Among various radiography findings observed in pneumonia, consolidation and pleural effusion were more frequent in the M. pneumoniae group than in the control group. On the other hand, parahilar peribronchial opacification, diffuse interstitial lesion, and normal findings prevailed in the control group. CONCLUSION: KD patients can have concurrent infections, especially pulmonary symptoms. The cause of KD is likely to be associated with M. pneumoniae infection. Thus, immediate treatment of M. pneumoniae infection in KD patients is very important.

Left ventricular dysfunction measured by tissue Doppler imaging and strain rate imaging in hypertensive adolescents / 소아과

PURPOSE: Left ventricular (LV) hypertrophy and impaired diastolic function may occur early in systemic hypertension. Diastolic dysfunction is associated with increased cardiovascular risk. Tissue Doppler imaging (TDI)-derived tissue velocity and strain rate are new parameters for assessing diastolic dysfunction. The aim of this study is to determine whether TDI and strain rate imaging (SRI) would improve the ability to recognize early impaired diastolic and systolic functions compared with conventional echocardiography in hypertensive adolescents. METHODS: We included 38 hypertensive patients with systolic blood pressure above 140 mmHg or diastolic blood pressure above 90 mmHg. Ejection fraction and myocardial performance index (MPI) were estimated by conventional echocardiography. Peak systolic myocardial velocity, early diastolic myocardial velocity (Em), and peak late diastolic myocardial velocity (Am) were obtained by using TDI and SRI. RESULTS: In the hypertensive group, interventricular septal thickness was significantly increased on M-mode echocardiography. Em/Am was significantly decreased at the mitral valve annulus. Among hypertensive subjects, the E strain rate at basal, mid, and apex was significantly decreased. Systolic strain was significantly decreased at the septum in the hypertensive group. CONCLUSION: Strain rate might be a useful new parameter for the quantification of both regional and global LV functions and could be used in long-term follow up in hypertensive patients. Early identification by SRI of subjects at risk for hypertensive and ventricular dysfunction may help to stratify risk and guide therapy. Further studies, including serial assessment of LV structure and function in a larger number of adolescents with hypertension, is necessary.

Carotid Intima-Media Thickness and Pulse Wave Velocity After Recovery From Kawasaki Disease

BACKGROUND AND OBJECTIVES: Kawasaki disease (KD) is an acute inflammatory process affecting the arterial walls that results in panvasculitis. Recent studies have shown that even after resolution of the disease, endothelial dysfunction persists and may progress to atherosclerosis. The pulse wave velocity (PWV) and the ankle-brachial index (ABI) are simple and non-invasive methods for evaluating the degree of atherosclerosis, and are known as the predictors of cardiovascular disease in adults. Carotid intima-media thickness (cIMT) is also known as a predictor of cardiovascular disease. We conducted this study to determine the change in arterial stiffness by measuring the PWV, ABI, and cIMT in children who have recovered from KD. SUBJECTS AND METHODS: Twenty-five patients with KD and coronary aneurysm were recruited. They all recovered from KD and were normal for more than 8 years. Fifty-five healthy children were evaluated as the control group. Their height, weight, body mass index, and blood pressure (systolic, diastolic, and the mean) were measured. The PWV, ABI, ejection time (ET), and pre-ejection period (PEP) were measured by ultrasonography. The cIMT was measured by ultrasonography. RESULTS: The left brachial ankle PWV was significantly higher in the KD group (1020.6+/-146.5 cm/sec) than the control group (984.0+/-96.5 cm/sec). The ABI did not differ between the two groups. There was no difference in PEP/ET and cIMT. CONCLUSION: The PWV in children who recovered from KD was higher than the control group. Long-term follow up is necessary in children after recovery from KD even if there is no abnormality in echocardiography.

Intestinal pseudo-obstruction as the initial presentation of systemic lupus erythematosus in a 13-year-old girl / 소아과

Intestinal pseudo-obstruction (IPO) is a rare and poorly understood manifestation of systemic lupus erythematosus (SLE), especially in children. The characteristic clinical feature of IPO is obstruction without an identifiable obstructive lesion. The authors a 13-year-old girl whose first symptom of SLE was IPO. The patient presented with a 3-day history of nausea, bilious vomiting, abdominal distention, and no bowel movement. Simple abdominal radiographs revealed mild dilatation with partial air-fluid levels in the small intestine. Abdominal CT and methylcellulose small bowel studies showed massive ascites, engorgement of the small mesenteric vessels, pleural effusion, and diffuse bowel wall thickening of the gastric antrum, duodenum. and jejunum. The delayed passage of contrast for 15 days after the methylcellulose small bowel studies was suggestive of decreased bowel motility. Laboratory findings were positive for ANA, anti-double-stranded DNA, anti-Smith and lymphopenia. After 10-day treatment with high-dose corticosteroids, the symptoms improved. IPO associated with SLE should be considered in the differential diagnosis for patients presenting with symptoms of intestinal obstruction. Early recognition of IPO in SLE and appropriate therapy are important for prevention of complications and unnecessary surgery. This case raises awareness among pediatricians that although rare, IPO can be the presenting symptom of SLE in children.