The Clinical Outcomes of Marginal Donor Hearts: A Single Center Experience

Background and Objectives@#Although the shortage of donor is a common problem worldwide, a significant portion of unutilized hearts are classified as marginal donor (MD) hearts. However, research on the correlation between the MD and the prognosis of heart transplantation (HTx) is lacking. This study was conducted to investigate the clinical impact of MD in HTx. @*Methods@#Consecutive 73 HTxs during 2014 and 2021 in a tertiary hospital were analyzed.MD was defined as follows; a donor age >55 years, left ventricular ejection fraction 240 minutes, or significant cardiac structural problems. Preoperative characteristics and postoperative hemodynamic data, primary graft dysfunction (PGD), and the survival rate were analyzed. Risk stratification by Index for Mortality Prediction after Cardiac Transplantation (IMPACT) score was performed to examine the outcomes according to the recipient state. Each group was sub-divided into 2 risk groups according to the IMPACT score (low <10 vs. high ≥10). @*Results@#A total of 32 (43.8%) patients received an organ from MDs. Extracorporeal membrane oxygenation was more frequent in the non-MD group (34.4% vs. 70.7, p=0.007) There was no significant difference in PGD, 30-day mortality and long-term survival between groups. In the subgroup analysis, early outcomes did not differ between low- and high-risk groups. However, the long-term survival was better in the low-risk group (p=0.01). @*Conclusions@#The outcomes of MD group were not significantly different from non-MD group. Particularly, in low-risk recipient, the MD group showed excellent early and longterm outcomes. These results suggest the usability of selected MD hearts without increasing adverse events.

A Case of Endocarditis on Mitral Annular Calcification

no abstract available.

Effects of Preoperative Autologous Blood Donation in Patients Undergoing Minimally Invasive Cardiac Surgery

BACKGROUND@#Preoperative autologous blood donation (PABD) is a conservation strategy for reducing allogenic blood transfusion (ABT) during minimally invasive cardiac surgery (MICS). We aimed to evaluate the effects of PABD on the frequency of ABT and clinical outcomes in patients undergoing MICS.@*METHODS@#We enrolled 113 patients (47.8±13.1 years, 50 men) undergoing MICS without preoperative anemia (hemoglobin >11 g/dL) between 2014 and 2017. Of these patients, 69 (the PABD group) donated autologous blood preoperatively and were compared to the non-PABD group (n=44). We analyzed the frequency of perioperative ABT and clinical outcomes.@*RESULTS@#Baseline characteristics did not significantly differ between groups, although preoperative hemoglobin levels were lower in the PABD group. All operations were performed using a minimally invasive approach. Patients’ surgical profiles were similar. There were no cases of mortality or significant differences in early postoperative outcomes. During the early postoperative period, hemoglobin levels were higher in the PABD group. No significant difference was found in the frequency of ABT.@*CONCLUSION@#Although the PABD group had higher postoperative hemoglobin levels, there was no clear clinical benefit in the early postoperative period, despite a great deal of effort and additional cost. Additional PABD in the setting of strict policies for blood conservation was ineffective in reducing ABT for young and relatively healthy patients who underwent MICS.

Effects of Preoperative Autologous Blood Donation in Patients Undergoing Minimally Invasive Cardiac Surgery / 대한흉부외과학회지

BACKGROUND: Preoperative autologous blood donation (PABD) is a conservation strategy for reducing allogenic blood transfusion (ABT) during minimally invasive cardiac surgery (MICS). We aimed to evaluate the effects of PABD on the frequency of ABT and clinical outcomes in patients undergoing MICS.METHODS: We enrolled 113 patients (47.8±13.1 years, 50 men) undergoing MICS without preoperative anemia (hemoglobin >11 g/dL) between 2014 and 2017. Of these patients, 69 (the PABD group) donated autologous blood preoperatively and were compared to the non-PABD group (n=44). We analyzed the frequency of perioperative ABT and clinical outcomes.RESULTS: Baseline characteristics did not significantly differ between groups, although preoperative hemoglobin levels were lower in the PABD group. All operations were performed using a minimally invasive approach. Patients’ surgical profiles were similar. There were no cases of mortality or significant differences in early postoperative outcomes. During the early postoperative period, hemoglobin levels were higher in the PABD group. No significant difference was found in the frequency of ABT.CONCLUSION: Although the PABD group had higher postoperative hemoglobin levels, there was no clear clinical benefit in the early postoperative period, despite a great deal of effort and additional cost. Additional PABD in the setting of strict policies for blood conservation was ineffective in reducing ABT for young and relatively healthy patients who underwent MICS.

Minimally Invasive Mitral Valve Repair in a Woman with Marfan Syndrome and Type B Dissection

We report the case of a patient with mitral regurgitation complicated by type B dissection and Marfan syndrome (MFS) who was managed successfully with minimally invasive mitral valve repair. Without type A aortic dissection or aortic root dilation, MFS patients may develop mitral valve regurgitation, as in this case, and need valve surgery to improve their symptoms and long-term survival. However, it is not clear that a full sternotomy and prophylactic aortic surgery are necessary. Although retrograde perfusion to the dissected aorta is controversial, our approach minimizes the risk of future anticipated aortic surgery in MFS patients.

Minimally Invasive Mitral Valve Repair in a Woman with Marfan Syndrome and Type B Dissection / 대한흉부외과학회지

We report the case of a patient with mitral regurgitation complicated by type B dissection and Marfan syndrome (MFS) who was managed successfully with minimally invasive mitral valve repair. Without type A aortic dissection or aortic root dilation, MFS patients may develop mitral valve regurgitation, as in this case, and need valve surgery to improve their symptoms and long-term survival. However, it is not clear that a full sternotomy and prophylactic aortic surgery are necessary. Although retrograde perfusion to the dissected aorta is controversial, our approach minimizes the risk of future anticipated aortic surgery in MFS patients.

Erratum: Diagnostic Performance of Intravascular Ultrasound-Derived Minimal Lumen Area to Predict Functionally Significant Non-Left Main Coronary Artery Disease: a Meta-Analysis

In the article, the weighted overall mean MLA cut-off value has been miscalculated. Tha authors deeply apologize for any inconvenience it may have caused.

Single-Suture Neochorda-Folding Plasty for Mitral Regurgitation

The single-suture neochorda-folding plasty technique is a modification of existing mitral valve repair techniques. In the authors' experience, its simplicity, reliability, and versatility make it a useful technique for mitral valve repair, especially when a minimally invasive approach is used.

Diagnostic Performance of Intravascular Ultrasound-Derived Minimal Lumen Area to Predict Functionally Significant Non-Left Main Coronary Artery Disease: a Meta-Analysis

BACKGROUND AND OBJECTIVES: Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention frequently results in unnecessary stenting due to the low positive predictive value of IVUS-derived minimal lumen area (MLA) for identification of functionally significant coronary stenosis. We appraised the diagnostic accuracy of IVUS-derived MLA compared with the fractional flow reserve (FFR) to assess intermediate coronary stenosis. SUBJECTS AND METHODS: We searched MEDLINE and Cochrane databases for studies using IVUS and FFR methods to establish the best MLA cut-off values to predict significant non-left main coronary artery stenosis. Summary estimates were obtained using a random-effects model. RESULTS: The 17 studies used in our analysis enrolled 3920 patients with 4267 lesions. The weighted overall mean MLA cut-off value was 2.58 mm². The pooled MLA sensitivity that predicted functionally significant coronary stenosis was 0.75 (confidence interval [CI]: 0.72 to 0.77) and the specificity was 0.66 (CI: 0.64 to 0.68). The positive likelihood ratio (LR) was 2.33 (CI: 2.06 to 2.63) and LR (-) was 0.33 (CI: 0.26 to 0.42). The pooled diagnostic odds ratio (DOR) was 7.53 (CI: 5.26 to 10.76) and the area under the summary receiver operating characteristic curve for all the trials was 0.782 with a Q point of 0.720. Meta-regression analysis demonstrated that an FFR cut-off point of 0.75 was associated with a four times higher diagnostic accuracy compared to that of 0.80 (relative DOR: 3.92; 95% CI: 1.25 to 12.34). CONCLUSION: IVUS-derived MLA has limited diagnostic accuracy and needs careful interpretation to correlate with functionally significant non-left main coronary artery stenosis.

Present and Future of ECMO in ICU / 대한구급학회지

Extracorporeal Membrane Oxygenation (ECMO) is a variation of cardiopulmonary bypass that temporarily supports tissue oxygenation in patients with life threatening respiratory or cardiac failure. As the ECLS technique becomes safer and simpler following technology advances, and as complications and survival have improved, indication of ECLS has widened. In 2009, a multicentre randomized controlled trial of conventional ventilator support versus extracorporeal life support for severe adult respiratory failure in 180 patients was published (the conventional ventilation or ECMO for severe adult respiratory failure (CESAR) trial). Of patients allocated to ECMO support, 63% survived for six months without disability compared to 47% allocated to conventional ventilation care. This represented the first positive randomized clinical trial on adult ECMO application in acute respiratory distress syndrome patients. In this review, we report on the common terminologies used with ECMO, the practical running mode of ECMO, indications of ECMO application in intensive care unit settings and results of recent clinical trials. In addition, management during ECMO support and common complications of ECMO is outlined. Finally, evolving technologies involved with the progress of ECMO are summarized.

On-Pump versus Off-pump Myocardial Revascularization in Patients with Renal Insufficiency: Early and Mid-term Results

BACKGROUND: Myocardial revascularization in patients with renal insufficiency is challenging to the cardiac surgeon, irrespective of utilizing extracorporeal circulation. This study aimed to compare the number of bypass grafts and the mid-term results and to evaluate independent survival predictors in patients with renal insufficiency undergoing on-pump or off-pump myocardial revascularization. MATERIALS AND METHODS: We retrospectively analyzed the data of 103 patients with renal insufficiency, who had isolated myocardial revascularization between January 1999 and January 2009. The patients were divided into two groups, the on-pump group and the off-pump group. RESULTS: The off-pump group received a significantly greater number of distal arterial grafts than the on-pump group. However, the mean number of total grafts, the degree of complete revascularization, and survival rate of the patients were not significantly different between the two groups. Multivariate analysis showed the independent predictors for reduced mid-term survival were the number of total grafts and postoperative periodic renal replacement therapy. Off-pump myocardial revascularization does not decrease the number of bypass grafts or influence on the mid-term results for patients with renal insufficiency, compared to on-pump myocardial revascularization. CONCLUSION: Myocardial revascularization with a large number of total grafts has a beneficial effect on survival in patients with renal insufficiency, irrespective of utilizing extracorporeal bypass.

The Laparoscopic Repair of a Morgagni Hernia in a Child

A 12-year-old female presented with the abnormal findings on the chest PA. The chest CT revealed a retrosternal defect of the diaphragm and a fatty opacity in the pleural cavity, resulting in a diagnosis of Morgagni hernia. It was decided to undergo a laparoscopic surgery. The retrosternal defect of the diaphragm measuring 3.5 cm in diameter was found, through which a portion of the greater omentum and the fatty tissue connected with the falciform ligament were herniated into the pleural cavity. The greater omentum was pushed back into the peritoneal cavity and the fatty tissue connected with falciform ligament was excised. The mediastinal pleura was plicated and the defect of the diaphragm was repaired primarily. Immediately after the operation, the patient developed a right pneumothorax for which a chest tube was inserted. She was discharged at the post-operative third day without any further complications.

Bronchospasm during Minimally Invasive Cardiac Surgery in a Patient with a Mosaic Attenuation Pattern on Lung Computed Tomography: A Case Report / 대한구급학회지

Severe bronchospasm during cardiac surgery is an uncommon, but serious problem. A 52-year-old woman with a mosaic attenuation pattern on the whole lung field was scheduled for repair of an atrial septal defect under minimally invasive cardiac surgery. Bronchospasm developed intraoperatively, but the underlying ventilatory impairment, poor performance of one-lung ventilation and initiation of cardiopulmonary bypass delayed diagnosing and treating the bronchospasm. The bronchospasm induced severe pulmonary edema that required postoperative ventilatory care.

Surgical Outcomes and Post-Operative Changes in Patients with Significant Aortic Stenosis and Severe Left Ventricle Dysfunction

Little is known regarding long-term survival and changes in systolic function following surgery after the occurrence of a severe left ventricular (LV) dysfunction in patients with severe aortic stenosis. Inclusion criteria were an aortic valve area less than 1 cm2 and an LV ejection fraction (EF) less than 35%. Between January 1990 and July 2007, 41 (male: 30) patients were identified. The pre-operative mean EF and mean aortic valve area were 26.7+/-6.1% and 0.54+/-0.2 cm2, respectively. Concomitant coronary artery bypass surgery was performed in 8 patients (19.6%). Immediate post-operative echocardiogram showed to be much improved in LV EF (27.2+/-5.5 vs. 37.4+/-11.3, P<0.001), LV mass index (244.2+/-75.3 vs. 217.5+/-71.6, P=0.006), and diastolic LV internal diameter (62.5+/-9.3 vs. 55.8+/-9.6, P<0.001). Post-operative LV changes were mostly complete by 6 months, and were maintained thereafter. There was one in-hospital mortality (2.4%) and 12 late deaths including one patient diagnosed with malignancy in whom LV function was normal. Multivariate analysis showed pre-operative atrial fibrillation and NYHA FC IV to be significant risk factors for cardiac-related death. Aortic valve replacement in patients with significant aortic stenosis and severe LV dysfunction showed acceptable surgical outcomes. Moreover, LV function improved significantly in many patients.

Minimally Invasive Cardiac Surgery

Traditional cardiac surgery has been performed via a "big" median sternotomy incision by significant complexity and invasiveness. The traditional big incision has presented with many problem, and at the same time, has given opportunity to make the procedures less invasive. During the past decade, improvement in endoscopic equipments and operative techniques has resulted in development of minimal invasive cardiac operations using small incisions with or without robotics. A number of cardiac procedures are currently performed by minimal invasive approaches and for many surgeons a minimal invasive cardiac surgery has become a standard practice. Herein, we reviewed the minimal invasive cardiac surgery in the aortic valve, mitral valve, tricuspid valve, atrial septal defect, and coronary artery disease.

Blood Protein Adsorption and Platelet Activation on an Ultra-hydrophilic Substrate / 대한흉부외과학회지

BACKGROUND: We evaluate the efficacy of ultra-hydrophilic coated bypass circuits in comparison with uncoated bypass circuits in a porcine cardiopulmonary bypass model. MATERIAL AND METHOD: Normothermic cardiopulmonary bypass was performed in 10 anesthetized pigs via the left atrium and ascending aorta with a centrifugal biopump. Ultra-hydrophilic coated bypass circuits were used in 5 pigs (the study group) and uncoated bypass circuits were used for the control group. Platelet counts and platelet aggregation tests were performed. The thrombin-antithrombin (TAT) complex level and total protein level were evaluated. RESULT: There were no significant changes in the platelet counts and aggregation ability of both groups. The TAT complex levels were not different between the two groups. The total protein level was significantly lower in the control group after cessation of cardiopulmonary bypass. CONCLUSION: The clinical effects of ultra-hydrophilic coating circuits were not remarkable, in terms of reducing inflammatory reaction and protection of platelet function. However, the effect of protection for blood protein adsorption might be acceptable.

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.

Clinical Analysis of the Acute Respiratory Distress Syndrome after Thoracotomy / 대한흉부외과학회지

BACKGROUND: The cause and clinical course of the postoperative ARDS is, as of yet, not very well understood. The current study is a review of our experience on patients with ARDS after thoracotomy. MATERIAL AND METHOD: Between Jan. 1996 to Aug. 2001, a retrospective analysis was conducted on 32 post-thoracotomy ARDS patients among 4018 patients receiving thoracotomy inclusive of thoracoscopic surgery. RESULT: The incidence of ARDS after pneumonectomy cases was 5.3%(13/245), 1.3% after lobectomy(9/ 710), and 4.4% after esophageal surgery(10/226). Of the 32 ARDS patients, 31 had malignant disease. The remaining 1 patient had aspergillosis. In the majority, the cause of ARDS was unknown. The average onset was on the 7.4th postoperative day. In 10 cases, the initial lesion was in the right lower lung field(31.2%), in the left lower lung field in 9(28.1%), and in both lower lung fields in 12(37.5%) cases. In all, the initial lesion was in the lower lung fields in 96.9% of the cases(31/32). There was a significant relationship between the development of ARDS and intraoperative I/O balance. The overall mortality rate was 65.6%(21/32). In the earlier period of the study(1996-Jun, 1998) the mortality rate was 100%, but in the latter period(July, 1998-Aug, 2001) it was significantly reduced to 47.6%. CONCLUSION: The current data showed a higher incidence of postoperative ARDS in patients with malignant disease and in those receiving extensive lymph node dissection with either lobectomy or pneumonectomy, and also in patients receiving esophageal surgery. In addition, introperative fluid overload was also associated with an increased incidence of ARDS. Treatment outcome could be improved with prone positioning and NO gas inhalation