Clinical Application of 3 Dimensional Reconstruction of CT from Fish Bone Foreign Body Model / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: This study aimed to gather three-dimensional data to detect fish bones as an esophageal foreign body model and to assess the possibility that this method could be applied for cases of real fish bone foreign body (FBFB). MATERIALS AND METHOD: Fish bones from two species were collected and sizes were measured. Pork meat loaf was placed flat into a plastic box containing plaster cast and bones were laid over the meat layer. Another layer of meat was placed on the bones, then another layer of plaster cast, and the final layer of meat were placed. The meat-bone sandwich was regarded as a fish bone foreign body model of esophagus. The model was imaged using computed tomography (CT) scan and the CT data were reconstructed three-dimensionally making multi-planar reconstruction, maximal intensity projection, and volume rendering images. We tried to find tools to detect the shape and lying position of the FBFB model. The above tools were applied to 3 FBFB cases to verify effectiveness of the tools. RESULTS: Multi-planar reconstruction, maximal intensity projection, and volume rendering images were reconstructed easily. After single or more processing, all of the bones could be detected. The shape and lying positions could be detected using tools made from FBFB models. CONCLUSION: Reconstructed images of CT data readily enabled the detection of fish bone in the esophageal model and real cases.

Application of Three-dimensional Reconstruction in Esophageal Foreign Bodies

This study was conducted to investigate the clinical application of three-dimensional (3D) reconstructed computed tomography (CT) images in detecting and gaining information on esophageal foreign bodies (FBs). Two patients with esophageal FBs were enrolled for analysis. In both cases, 3D reconstructed images were compared with the FB that was removed according to the object shape, size, location, and orientation in the esophagus. The results indicate the usefulness of conversion of CT data to 3D images to help in diagnosis and treatment. Use of 3D images prior to treatment allows for rapid prototyping and surgery simulation.

Right Coronary Artery to Left Ventricular Fistula with a Giant Right Coronary Artery Aneurysm: A case report / 대한흉부외과학회지

A right coronary artery to left ventricular fistula with a giant right coronary artery aneurysm is a very rare condition. This requires surgical treatment because of the possibility of rupture of aneurysm, heart failure and infective endocarditis. A 47 years old male patient with dyspnea on exertion for 3 months was diagnosed as having a right coronary artery to left ventricular fistula with a giant right coronary artery aneurysm according to the CT and coronary artery angiography. We resected the aneurysm and performed a coronary artery bypass graft.

Time-related Histopathologic Changes of Fresh Frozen Vascular Xenograft in Pig-to-goat Model / 대한흉부외과학회지

BACKGROUND: As determined from the recent investigations of discordant cardiac xenotransplantation, hyperacute rejection occurs mainly at the endothelial cells in donor microvascular systems, but this does not occur at cardiac valve leaflets or at medium-to-large caliber vessels. On the basis of this background, this study was performed to look into the biocompatibility for transplantation of a middle or large diameter xenogenic blood vessel by conducting xenogenic arterial transplantation with the carotid artery in a pig-to-goat model. MATERIAL AND METHOD: The experimental group was composed of 10 pairs of pig-to-goat combinations. They were divided into each period of 1 week, and 1, 3, 6 and 12 months. Four carotid artery grafts obtained through collection of the bilateral carotid arteries from two pigs were preserved at -70degrees C without other treatment, and then they were transplanted into the bilateral carotid arteries of two goats. Doppler ultrasonography was done on a periodic basis after transplantation to evaluate the patency of the grafted blood vessel. At the ends of a predetermined period, the grafts were explanted from the goats and they underwent gross examination. Hematoxylin-eosin and Masson's trichrome staining were conducted. In addition, in order to examine the immunological rejection of the grafted xenogenic blood vessel, immunohistochemical staining was conducted with T-lymphocyte indicator and von Willebrand factor. RESULT: Two goats at the each one-week period and the one-year period died during the experimental period because of a reason unrelated to the experimental procedure, and the remaining 8 goats survived until the end of each experiment period. On Doppler ultrasonography, unilateral carotid artery occlusion was found in a goat, whose period was specified as 3 months, among the 8 survived goats. However, the vascular patency was maintained well and there was no graft that formed aneurysms in the other goats. On gross examination, the region of vascular anastomosis was preserved well, and calcification of the grafted blood vessel was not shown. Histologically, the endothelial cells of the graft disappeared one week after transplantation, and then there was progressive spread of the recipients' endothelial cells from the anastomotic site. The reendothelialization occurred over the whole graft at one month after transplantation. The neointimal thickening and adventitial inflammation became severe by 3 months after transplantation, but this lessened at 6 months and 12 months, respectively. The rate of CD3 positive cells was very low among the infiltrated inflammatory cells. CONCLUSION: The fresh-frozen xenogenic artery kept its patency without being greatly influenced by xenogenic immune reaction.

The Change of Arterial Blood Gas during Endoscopic Saphenous Vein Harvesting for Coronary Artery Bypass Grafting / 대한마취과학회지

BACKGROUND: Endoscopic surgical procedure has recently been applied to not only intraabdominal or intrathoracic surgery but also saphenous vein harvesting, because it is less invasive and more cosmetically advantageous. Carbon dioxide insufflation during an endoscopic saphenous vein harvesting may cause an adverse effects on arterial blood gas and hemodynamic variables. This study was conducted to evaluate the safety of carbon dioxide insufflation during endoscopic saphenous vein harvesting. METHODS: Patients in ASA physical status III or IV, scheduled for an endoscopic saphenous vein harvesting (n=30) were gathered for the evaluation. Until the end of the procedure, controlled mechanical ventilation (tidal volume: 10 ml/kg, respiratory rate: 10 rates/min) and ventilator mode was fixed in this tidal volume and respiratory rate. Arterial blood gas analysis, end-tidal carbon dioxide, blood pressure and heart rate were measured before and at 10, 20, 30, 40 minutes after carbon dioxide insufflation. RESULTS: Preinsufflation values of PaCO2 (partial pressure of arterial carbon dioxide) and PETCO2 (partial pressure of end-tidal carbon dioxide) were 33.4 +/- 3.6 mmHg and 24.1 +/- 4.1 mmHg, respectively. PaCO2 was significantly increased at 30 and 40 minutes after carbon dioxide insufflation (40.1 +/- 7.4 mmHg and 41.4 +/- 8.6 mmHg). PETCO2 was significantly increased at 20, 30 and 40 minutes after carbon dioxide insufflation(27.6 +/- 5.5 mmHg, 28.9 +/- 7.0 mmHg and 29.6 +/- 7.8 mmHg). But, the magnitude of difference between PaCO2 and PETCO2 was not significantly different. CONCLUSIONS: During endoscopic saphenous vein harvesting, PaCO2 was significantly increased compared with preinsufflation values. Careful monitoring of PaCO2 is mandatory during the procedure.

Changes of Coagulability after Off-pump CABG: Comparison with On-pump CABG / 대한흉부외과학회지

BACKGROUND: Hemostatic function is regarded to be preserved after an off-pump coronary artery bypass grafting (CABG), compared to conventional CABG, and the preserved hemostatic function may increase thrombotic occlusion of the graft. We studied the changes of hemostatic variables in patients undergoing off-pump CABG, and compared to those of on-pump CABG. MATERIAL AND METHOD: We studied the changes of coagulation function in 11 patients who underwent off-pump CABG (group I), and compared them with those of 11 patients who underwent on-pump CABG and Dor procedure (group II). Coagulation status was evaluated by thromboelastography and blood coagulation test preoperatively, postoperative 1st day, 2nd day, 3rd day, and 5th day, respectively. RESULT: Among the variables measured by thromboelastography (such as r time, k time, alpha angle, and MA value) and blood coagulation test (such as factor VII, protein S, protein C, antithrombin III, activated protein C resistance test, plasminogen, D-dimer, prothrombin time, activated partial thromboplastin time, platelet count, hemoglobin, and fibrinogen), there were significant differences in the MA value, alpha angle, and platelet counts between the two groups. MA values were 140+/-72% and 153+/-98% in group I, and 87+/-27% and 78+/-28% in group II, at postoperative 3rd and 5th days, respectively (p<0.05). alpha angle was 122+/-92% in group I and 69+/-23% in group II at postoperative 3rd day (p=0.09). Platelet count was 63+/-55% in group I and 33+/-13% in group II at postoperative 3rd day (p<0.05). CONCLUSION: Patients who underwent off-pump CABG showed increased coagulability during postoperative periods, compared to those who underwent on-pump CABG. Our data suggest that aggressive perioperative anticoagulation therapy is warranted in patients undergoing off-pump CABG.

Nuss Operation with Simultaneous Intracardiac Repair: A case report / 대한흉부외과학회지

There are still some controversies regarding one stage repair of pectus deformity with congenital heart disease due to probable complications after extensive resection of deformed cartilages. We performed Nuss operation with simultaneous intracardiac repair in 8 year old patient with pectus excavatum and partial atrioventricular septal defect. The result of operation was satisfactory without prolongation of operation time, bleeding or instability of chest wall.

Successful Treatment of Left Atrial Auricular Abscess

Mural endocarditis causing myocardial abscess without valvular involvement is very rare. We report an unusual case of left atrial auricular abscess which was successfully treated by surgical resection, treatment with antibiotics, and mediastinal irrigation. A 9-yr-old female patient with previous history of urinary tract infection was admitted because of persistent fever. Echocardiography and magnetic resonance imaging revealed massive pericardial effusion and a mass lesion at the left upper cardiac border. Pericardiocentesis isolated Staphylococcus aureus on culture. The patient underwent mass removal under cardiopulmonary bypass. The mass was located in the left atrial auricle with fibropurulent abscess formation inside. Postoperative mediastinal irrigation was performed using povidone iodine solution. Pathological examination of the mass showed organized thrombi with chronic fibrosing mural endocarditis.

Relationship of Hemodynamic Changes during Off-Pump Coronary Bypass Grafting and Their Effects on Postoperative Outcome / 대한흉부외과학회지

BACKGROUND: During the Off-Pump Coronary Arterial Bypass surgery (OPCAB), the manipulation of the heart can depress cardiac contractility and cause hemodynamic instability. In this study, hemodynamic parameters were measured during operation and the laboratory and clinical data were investigated to evaluate their effects on postoperative outcome. MATERIAL AND METHOD: From March 2001 to August 2002, 50 consecutive patients who underwent OPCAB were included in this study. During the same period, total number of CABG was 71. The blood pressure, pulmonary artery pressure, mixed venous oxygen saturation, and cardiac index were measured before manipulation, after application of stabilizer, and at the end of anastomosis. Postoperatively, we measured the cardiac enzymes such as CK-MB, troponin I and checked the amount of inotropes required, chest tube drainage, the amount of transfusion, duration of ventilator support, and duration of ICU stay. RESULT: The number of mean distal anastomoses was 2.8+/-0.9 per patient. On elevation and stabilization of the heart, systolic blood pressure was depressed and pulmonary artery pressure was elevated significantly, but during each anastomosis no significant changes were detected. The peak level of cardiac markers was 29.2+/-46.7 for CK-MB, 0.69+/-0.86 for troponin I on postoperative day 1. Among the intraoperative hemodynamic parameters, the ischemic change of EKG and bolus injection of inotropes significantly affected the posteroperative cardiac enzymes. But, no difference other than the level of cardiac enzymes between the two groups with or without the ischemic change of EKG and bolus injection of inotropes was noticed. CONCLUSION: The significant hemodynamic changes occurred when the heart was elevated and stabilized, however during anastomoses there were no significant changes. Serum cardiac enzymes rose significantly in the group that showed the ischemic change of EKG or needed the bolus injection of inotropes for maintaining hemodynamic stability intraoperatively, but it did not affect the postoperative outcome. In conclusion, the ischemic change of EKG and the need for bolus injection of intropes during operation may be very indicative for probable ischemia.

Aortic Valvuloplasty Using Triangular Resection Technique / 대한흉부외과학회지

BACKGROUND: With an increasing awareness of the limitations of both mechanical prostheses and bioprostheses, aortic valvuloplasty has gained attention as an alternative procedure for aortic valve disease. MATERIAL AND METHOD: Eight consecutive patients underwent aortic valvuloplasty caused by leaflet prolapse between June 1999 to June 2000. Mean age of the patients was 18.4+/- 12.6 year. Four paitents(50%) were male. Six patients had tricuspid valves and ventricular septal defect and two patients had bicuspid valves. The extent of aortic insufficiency was 3.5+/- 0.5 by preoperative Doppler echocardiography. The technique involved triangular resection of the free edge of the prolapsed leaflet, annular plication at the commissure, and resection of a raphe when present in bicuspid valves. RESULT: There was no in-hospital mortality or morbidity. Mean follow-up was complete at 11.9+/- 3.6months. There was no late mortality or morbidity. The amount of the severity of aortic insufficiency, as assessed by echocardiography preoperatively, postoperatively and at late follow-up was 3.5+/- 0.5, 0.6+/- 0.5 and 0.8+/- 0.6, respectively(p value = 0.01). There was one patient with grade 2/4 aortic insufficiency and in the other patients, grade 1/2 or trivial aortic insufficiency were detected with late echocardiograms. CONCLUSION: Triangular resection in the patients with aortic leaflet prolapse offers a good early clinical result, but long-term follow-up is necessary.

Thoracodorsal Artery as an Alternative in Complete Arterial Coronary Revascularization: 3 Cases / 대한흉부외과학회지

It is now widely accepted that the complete arterial coronary revascularization has better short and long term results compared to coronary bypass surgery using arterial graft mixed with vein graft mainly due to its superior patency rate. However, sometimes the internal thoracic artery and other conventionally used grafts might be unavailable or it may require caution in using bilateral internal thoracic artery especially in diabetic patient because of the possible risk of the mediastinitis or other associated morbidities. Moreover, there could also be a shortage for arterial graft in case of coronary reoperation. We report our first three cases using thoracodorsal artery(TDA) as an alternative graft in complete arterial coronary revascularization.

Pulmonary Valve Replacement with Tissue Valves After Pulmonary Outflow Tract Repair in Children / 대한흉부외과학회지

BACKGROUND: Most of pulmonary regurgitation with or without stenosis appears to be well tolerated early after the repair of pulmonary outflow tract. However, it may result in symptomatic right ventricular dilatation, dysfunction and arrhythmias over a long period of time. We studied the early outcome of pulmonary valve replacement with tissue valves for patients with the above clinical features. MATERIAL AND METHOD: Sixteen consecutive patients who underwent pulmonary valve replacement from September 1999 to February 2002 were reviewed(9 males and 7 females). The initial diagnoses included tetralogy of Fallot(n=11), and other congenital heart anomalies with pulmonary outflow obstruction(n=5). Carpentier-Edwards PERIMOUNT Pericardial Bioprostheses and Hancock porcine valves were used. The posterior two thirds of the bioprosthetic rim was placed on the native pulmonary valve annulus and the anterior one third was covered with a bovine pericardial patch. Preoperative pulmonary regurgitation was greater than moderate degree in 13 patients. Three patients had severe pulmonary stenosis. Tricuspid regurgitation was present in 12 patients. RESULT: Follow-up was complete with a mean duration of 15.8+/-8.5months. There was no operative mortality. Cardiothoracic ratio was decreased from 66.0+/-6.5% to 57.6+/-4.5% (n=16, p=0.001). All patients remained in NYHA class I at the most recent follow-up (n=16, p=0.016). Pulmonary regurgitation was mild or absent in all patients. Tricuspid regurgitation was less than trivial in all patients. CONCLUSION: In this study we demonstrated that early pulmonary valve replacement for the residual pulmonary regurgitation with or without right ventricular dysfunction was a reasonal option. This technique led to reduce the heart size, decrease pulmonary regurgitation and tricuspid regurgitation as well as to improve the patients' functional status. However, a long term outcome should be cautiously investigated.

Clinical Application of Stent-graft in Thoracic Aortic Diseases / 대한흉부외과학회지

BACKGROUND: Endovascular stent-graft insertion in aortic diseases is now generally accepted as an attractive alternative treatment modality. We reviewed our clinical experiences of endovascular stent-graft insertion in thoracic aorta. MATERIAL AND METHOD: Since 1995, we performed 8 cases of endovascular stent-graft insertion. Preoperative diagnoses were aortic aneurysms in 4, traumatic aortic ruptures in 3, and ruptured aortic pseudoaneurysm in 1. All procedures were performed in angiography room with the guidance of fluoroscopy. The stent-graft device is a custom-made 0.35 mm thickness Z-shaped stainless steel wires, intertwined with each other using polypropylene suture ligation. It is covered with expanded Dacron vascular graft. RESULT: All procedures were performed successfully. Follow-up studies revealed 2 minimal perigraft leakages. There was no significant leakage or graft migration. 2 patients expired due to multiple organ failure and fungal sepsis. Other survivors(6) are doing well. CONCLUSION: Endovascular stent-graft insertion is relatively safe and effective treatment modality in the management of various types of aortic diseases. It may be an effective alternative in aortic diseases of great surgical risk.

Expression of NF-kappaB and Cytokines in Chronic Rejection of Transplanted Murine Heart

The heart transplantation-associated accelerated graft arteriosclerosis (AGAS) is one of the major causes of cardiac allograft failure. We investigated the early time-course of expresssion patterns of cytokines, transcription factor, and its inhibitor in the intraabdominally transplanted mice hearts that differed only in the D locus of class I histocompatibility antigen. The allograft hearts were harvested at 1-3, 5, 7, 14, 28, and 42 days after the transplantation, and the expressions of NF-kappaB/I-kappaB and cytokines (TNF-alpha , INF-gamma) were examined in these specimens. The expressions of TNF-alpha and INF-gamma were observed on day 1, peaking on day 5 and 7, respectively. Activated NF-kappaB (p65) expression was present on the cytoplasm and perinuclear area in the endothelial cells of coronary arteries on day 1. The peak of translocation of NF-B from cytoplasm to nucleus appeared on day 5 in the endothelial cells, myocytes, and leukocytes within the vessels, and remained elevated until day 42. The I-kappaB expression gradually increased from day 1 until day 5, but a remarkable decrease was detected on day 7. Our data suggest that the increased expressions of NF-kappaB/I-kappaB and cytokines (TNF-alpha, INF-gamma) play an important role in inducing immune responses in the donor allograft heart and hence the blockage of the expressions might be mandatory to avoid a potential graft failure.

Modified Extracardiac Fontan Procedure in a Univentricular Heart with Separate Hepatic and Inferior Vena Caval Drainage / 대한흉부외과학회지

In a patient with single ventricle associated with complex systemic and/or pulmonary venous drainage, intraatrial Fontan procedure is sometimes technically difficult due to the complex spatial relationship between their orifices in the atrium. We report a case of the modified extracardiac conduit Fontan procedure in a patient with a single ventricle in which the inferior vena cava and the hepatic vein drained separately into the atrium and the intraatrial orifice of the hepatic vein was abut to the orifice of the left lower pulmonary vein.

Central Nervous System Complications of Coronary Artery Bypass Grafting - Comparison Between Off - Pump CABG and Conventional CABG / 대한흉부외과학회지

BACKGROUND: Central nervous system complication after coronary artery bypass grafting (CABG) is one of the major prognostic determinants and the use of the cardiopulmonary bypass(CPB) may increase the incidence of this devastating complication. In this study, the outcomes after off-pump CABG were studied and compared with those following the conventional CABG using CPB. MATERIAL AND METHOD: Among the consecutive isolated CABG's performed in SNUH during Feb. 1995 and Jun. 1999, 338 coronary artery bypass grafting were divided into two groups. 223 patients underwent CABG using the CPB(Group I), and 115 patients underwent CABG without CPB(OPCAB)(Group II). All patients enrolled in this study received extensive preoperative examinations including thorough neurologic examination before and after surgery, transcranial doppler study, carotid duplex ultrasonography, and magnetic resonance angiography if necessary. Central nervous system(CNS) complications were defined as stroke, seizure, metabolic or hypoxic encephalopathy and transient delirium after surgery. RESULT: There were 61 cases(27.3%) who developed postoperative CNS complication in Group I, whereas 8 cases(7.0%) of CNS complications developed postoperatively in group II(p<0.05). Statistically significant predictors of postoperative CNS complications in group I were age and the use of cardiac assist devices perioperatively. CONCLUSION: This study suggested that omitting the use of CPB in CABG resulted in significant decrease of the postoperative CNS complications. OPCAB should be more widely applied especially to the elderly who have preexisting cerebrovascular disease.

Modification of the Cox-Maze III Procedure / 대한흉부외과학회지

BACKGROUND: The extended operative time needed for surgery in complicated atrial incision may preclude application of the Cox-Maze III procedure(CM-III) as a concomitant operation with standard open heart surgery. MATERIALS AND METHOD: We have modified the CM-III by : (1) obliterating the left atrial(LA) appendage instead of excising it, (2) cryoablating the bridge between the LA appendage and margin of pulmonary vein encircling incision, (3) extending the lateral incision of right atrium(RA) onto the RA appendage without excising the RA appendage, and (4) omitting the T-incision of the RA from the lower portion of posterior longitudinal right atriotomy. To assess the simplicity and efficiency of our modifications, we compared the clinical results of the conventional CM-III(group I) with those of the modified CM-III(group II) performed in patients with rheumatic mitral valve(MV) disease. RESULT: In group I(n=18), the combined procedures were mitral valve replacement(MVR) in 10, MV repair in 3, MVR and tricuspid annuloplasty(TAP) in 3, and redo-MVR in 2 patients. In group II(n=23), the combined procedures were MVR in 7, MV repair in 5, MVR and TAP in 1, and redo-MVR in 10 patients. Mean aortic cross clamp(ACC) times were 135 +/-29 minutes and 104 +/-18 minutes, and cardiopulmonary bypass(CPB) times were 240 +/-33 minutes and 185 +/-42 minutes in group I and group II, respectively. All patients were followed for a mean duration of 47 +/-14 and 29 +/-4 months after the operation in group I and group II, respectively. In group I, sinus rhythm was restored in 16 patients(88.9 %). One patient remained in AF and another patient needed pacemaker implantation due to sick sinus syndrome. In group II, sinus rhythm was restored in 21 patients(91.3 %) and AF in 2 patients. In group I, RA contractility was demonstrated in 100% of patients(16/ 16) and LA contractility in 75%(12/ 16) in the latest follow-up echocardiography. In group II, RA contractility was demonstrated in 100 % of patients(21/22) and LA contractility in 76.2% (16/21). CONCLUSION: Our modified CM-III showed comparable sinus conversion rates and incidence of atrial contractility restoration with significantly shorter ACC time(p<0.005) and CPB time(p<0.001) than the conventional CM-III.

Intracardiac Foreign Body: A Sewing Needle in Right Ventricle of Unknown Etiology / 대한흉부외과학회지

A 34 year-old woman was hospitalized with anterior chest pain and indigestion. Chest radiograph and computed tomogram revealed a sewing needle in the cardiac cavity. She had no histories of surgical intervention, drug abuse, or acupuncture. We removed the needle from the right ventricle under cardiopulmonary bypass.

Combined Percutaneous Transluminal Coronary Angioplasty and Minimally Invasive Coronary Arterial Bypass Grafting ( Hybrid CABG ) / 대한흉부외과학회지

Percutaneous coronary intervention including intracoronary stenting is currently an accepted treatment modality in the treatment of coronary artery disease and is widely performed to treat the patient with multivessel disease with decreased morbidities and less cost compared with conventional coronary rtery bypass grafting(CABG), Repeated interventions due to restenosis even after successful angioplasty are the major disadvantage of the angioplsty especially when the lesion is located inthe left anterior descending artery(LAD) Recently CABG through left anterior small thoracotomy using the left internal thoracic artery to revascularize the LAD territory without cardiopulmonary bypass so called Minimally Invasive Direct Coronary Artery Bypass(MIDCAB) was intrduced and performed with comparable early outcomes. In this regard the integrated approach with percutaneous coronary intervention and minimally invasive direct coronary artery bypass surgery so called 'Hybrid CABG' was suggested to be an effective treatment in suitable patients with multivessel coronary artery disease. We report three cases of Hybrid CABG.