Application of the New Surgical Technique for Orthotopic Heart Transplantation in Dogs / 대한흉부외과학회지

BACKGROUND: Conventional cardiac transplantation with each atrial anastomosis designed by Shumway and associates has been used widely in cardiac transplantation because of its simplicity and efficiency. There have been many reports about the postoperative atrioventricular value regurgitation resulting from the alteration in atrial geometry after cardiac transplantation by Shumway's technique. New surgical technique of direct anastomosis of superior vena cava, inferior vena cava, right pulmonary vein and left pulmonary vein was introduced to overcome the those problems. We performed this study to test the feasibility of this new surgical technique prior to application to clinical practice. MATERIAL AND METHOD: Conventional cardiac transplantation was performed on 12 mongrel dogs(Group I) and cardiac transplantation with new surgical mthod of direct anastomosis of SVC, IVC, left and right pulmonary veins was performed on 11 mongrel dogs(Group II). After weaning from cardiopulmonary bypass, we compared the postoperative rhythm, hemodynamic data, and echocardiographic findings between two groups. RESULT: The cardiopulmonary bypass time and graft ischemic time were 119.0+/-4.4 minutes, 162.0+/-4.5 minutes respectively in group I, and 140.0+/-7.1 minutes, 180.5+/-5.4 minutes respectively in group II. The cardiopulmonary time and graft ischemic time in group II were longer than those of group I (p<0.05). There were 3 cases of failure to weaning from cardipulmonary bypass onein group I and two in group II, and this difference was not significant statistically. Sinus rhythm was regained postoperatively in 58% (group I) and 82%(group II), without statistical significant between 2 groups. Postoperative echolcardiography showed 2 cases of tricuspid value regurgitation and 1 case of mitral regurgitation in group I, and no regurgitation of atrioventricular value in group II. CONCLUSIONS: Although these was no statistically significant difference between 2 groups, there was tendency of less arrhythmia and less atrioventricular valvular regurgitation in group II. We suggested that the new surgical technique could be a useful strategy in heart transplantation, especially in the case of size mismatching between donor and recipient.

Effect of Aprotinin on Changes in Plasma Thromboxane B2 and Endothelin-1 Concentratin after Extracorporeal Circulation / 대한흉부외과학회지

BACKGROUND: Thromboxane A2 and endothelin-1 are the potent vasoconstrictors affecting pulmonary pathophysiology in response to whole body inflammatin following CPB. Aprotinin, as an antiiflammatory agent, may decrease the release of such vasoactive substance from pulmonary tissues, preventing pulmonary hypertension after cardiopulmonary bypass. MATERIAL AND METHOD: Ten mongrel dogs(Bwt. ac. 20kg) were subjected to cardioupulmonary bypass for 2 hours and postbypass pulmonary vascular resistance(0, 1, 2, 3 hours) were compared with prebypass level. The dogs were divided into 2 groups; control group(n-5) and aprotinin group(n=5). In the aprotinin group, aprotinin was administered as follows; 50,000 KIU/kg mixed in pump priming solution, 50,000 KIU/kg prebypass intravenous infusion over 30 minutes, 10,000 KIU/kg/hour postbypass continuous infusion. Prebypass and postbypass 0, 1, 2, 3 hour pulmonary vascular resistance were measured. At prebypass and postbypass 0, 90, 180 minutes, blood samples were obtained from pulmonary arterial and left atrial catherers for the assay of plasma thromboxane B2 a stable metabolite of thromboxane A2, and endothelin-1 concentrations. RESULT: The ratios of pustbypass over prebypass pulmonary vascular at postbypass 0, 1, 2, 3 hours were 1.28+/-0.20, 1.82+/-0.23, 1.90+/-0.19, 2.14+/-0.18 in control group, 1.58+/-0.18, 1.73+/-0.01, 1.66+/-0.10, 1.50+/-0.08 in aprotinin group ; the ratios gradually increased in control group while decreased or fluctuated after postbypass 1 hour in aprotinin group. There was statistically significant difference between control group and aprotinin group at postbypass 3 hours(P=0.014). Pulmonary arterial plasma concentration of thromboxane B2(pg/ml) at prebypass, postbypass 0, 90, 180 minutes were 346.4+/-61.9, 529.3+/-197.6, 578.3+/-255.8, 493.3+/-171.3 in control group, 323.8+/-118.0, 422.6+/-75.6, 412.3+/-59.9, 394.5+/-154.0 in aprotinin group. Left atrial concentrations were 339.3+/-89.2, 667.0+/-65.7, 731.2+/-192.7, 607.5+/-165.9 in control group, 330.0+/-111.2, 468.4+/-190.3, 425.4+/-193.6, 4.7.3+/-142.8 in aprotinin group. These results showed decrement of pulmonary thromboxane A2 generation in aprotinin group. Pulmonary arterial concentrations of endothelin-1(fmol/ml) at the same time sequence were 7.84+/-0.31, 13.2+/-0.51, 15.0+/-1.22, 16.3+/-1.73 in control group, 7.76+/-0.12, 15.3+/-0.71, 22.6+/-6.62, 14.9+/-1.11 in aprotinin group. Left atrial concentrations were 7.61+/-17.2, 57.1+/-28.4, 18.9+/-18.2, 31.5+/-20.5 in control group, 5.61+/-7.61, 37.0+/-26.2, 28.6+/-21.7, 37.8+/-30.6 in aprotinin group. These results showed that aprotinin had no effect on plasma endothelin-1 concentration after cardiopulmonary bypass. CONCLUSIONS: Administration of aprotinin during cardiopulmonary bypass could attenuate the increase in pulmonary vascular resistance after bypass. Inhibition of pulmonary thromboxane A2 generation was thought to be one of the mechanism of this effect. Aprotinin had no effect on postbypass endothelin-1 concentration.

Modified Ultrafiltration in Pediatric Open Heart Surgery / 대한흉부외과학회지

BACKGROUND: This study has proven the effect of modified ultrafiltration(MUF) performed after the cessation of cardiopulmonary bypass in pediatric patients who underwent open heart surgery. MATERIAL AND METHOD: From Jan. to Dec. 1997, modified ultrafiltration was performed after cardiopulmonary bypass in 50 infants with cyanotic heart disease and the results were compared to the control group of 50 patients with cyanotic heart disease in whom modified ultrafiltration was not used. Changes of hematocrit, central venous pressure, systolic and diastolic pressure, heart rate and body weight were compared. RESULT: Age and body weight were not different(p=0.38, p=0.46). Disease categories were similar. Average filtering volume was 60.0+/-29.2cc/kg for 7.0+/-2.4minutes of filtration. Mean hematocrit after filtration(MUF=36.1%, control=26.4%, p=0.001) was higher in the MUF group. Systolic (p=0.0001) and diastolic blood pressure(p=0.0001) were observed to increase more and the central venous pressure(p=0.02) and the heart rate(p=0.02) were lower after filtration in the MUF group. CONCLUSION: This study demonstrated that modified ultrafiltration after cardiopulmonary bypass was a technically feasible option to improve the post-surgical course through the effective hemoconcentration, hemodynamic improvements, and body water control.

Clinical Analysis of 500 Cases of Coronary Artery Bypass Grafting / 대한흉부외과학회지

BACKGROUND: We analyzed five hundred patients who underwent either isolated or concomitant coronary artery bypass grafting(CABG) between November 1981 and June 1997. MATERIAL AND METHOD: There were 330 males and 170 females with a mean age of 57.4+/-8.9 years. To evaluate the preoperative status, we performed electrocardiograghy, echocardiography, MIBI scan, Duplex sonogram, common blood test including CK and LDH and coronary angiography. RESULT: Preoperative clinical diagnoses were unstable angina in 282 (56.4%), stable angina in 141 (28.2%), postinfarction angina in 58 (11.6%), acute myocardial infarction in 8 (1.6%), variant angina in 7 (1.4%) and failed percutaneous transluminal coronary angioplasty in 4 (0.8%) patients. Preoperative angiographic diagnoses were three-vessel disease in 263 (52.6%), two-vessel disease in 93 (18.6%), one-vessel disease in 71 (14.2%), left main disease in 68 (13.6%), and others in 5 (1.0%) patients. Patients had various risk factors for coronary disease, and the frequency of the risk factors such as hypertension, diabetes and smoking showed increasing tendency year by year. We used saphenous vein grafts in 1143, internal thoracic artery grafts in 442, radial artery graft in 17, and gastroepiploic artery graft in 1 anastomosis. The mean number of grafts was 3.2+/-1.2 per patient. Concomitant operations were prosthetic valve replacement or valvuloplasty in 31, coronary endarterectomy and angioplasty in 27, left main coronary angioplasty in 13, carotid endarterectomy in 5, and neurologic problems, bleeding, and perioperative myocardial infarction. The mean follow-up period was 25+/-23 months and there were 5 cases of reoperation. CONCLUSION: We hope that the surgical results would improve with the accumulation of experience, application of new myocardial protection technique, and timely intervention of mechanical assisted devices.

Tetralogy of Fallot Associated with Pulmonary Atresia and Major Aortopulmonary Collateral Arteries: Comparison between the different surgical approaches / 대한흉부외과학회지

BACKGROUND: Patients with tetralogy of Fallot(TOF), pulmonary atresia(PA) and major aortopulmonary collateral arteries(MAPCAs) have been managed by heterogenous surgical strategies. We have taken 5 different surgical approaches to this lesion. In this study, relative advantages and disadvantages of each strategy were discussed by analyzing our surgical results. MATERIAL AND METHOD: Between January 1986 and June 1998, 50 patients aged 1 to 177(39+/-31) months at a various morphologic spectrum of this lesion were treated at our institution. The groups, which were classified according to the initial approaches, consisted of one-stage unifocalization(A-1, n=9), staged unifocalization(A-2, n=11), right ventricle to pulmonary artery connection(RV-PA)(B-1, n=11), one-stage RV-PA plus unifocalization (B-2, n=11), and one-stage definitive repair(C, n=8). Morphologic charateristics, operative mortalities, and probabilities of definitive repair were compared between the groups and the causes of death, complications and the follow-up results were described. RESULT: Mean ages at the first operation were 57+/-18(A-1), 42+/-48(A-2), 18+/-14(B-1), 52+/-55(B-2), and 32+/-34(C) months (p0.05). Nineteen patients had more than 1 dependent MAPCAs. True pulmonary arteries were not present 13 patients and they were confluent in 29. A total of 101 operations were performed. Operative mortalities of initial procedures were 33%(3/9, A-1), 18%(2/11, A-2), 0%(0/11, B-1), 36%(5/11, B-2) and 13%(1/8, C) (p<0.05). Percentages of the definitive repair among the patients of each group were 22%(2/9, A-1), 18%(2/11, A-2). 45%(5/11, B-1), 27%(4/11, B-2), and 100%(8/8, C)(p<0.05). Hypoxic respiratory and cardiac failure(6), hypoxic encephalopathy(2) and sepsis(4) were the major causes of death. Phrenic nerve palsy occured in 5 patients. Thirty-one patients among the survivals have been followed up for a mean duration of 74+/-42(3-145) months. One and five year actuarial survival rates were 73% and 73 %. CONCLUSION: In conclusion, Right ventricle to pulmonary artery connection used in patients with TOF/PA/MAPCA as an inital procedure appeared to be highly successful in enhancing the chance of satisfactory definitive repair without the significant surgical risks. One-stage total repair at an ealier age group could be performed safely with the resonable outcomes. Unifocalization approach, whether it was performed in a single stage or in the multiple stages, resulted in the high operative mortality and the lowest chance of definitive repair, however more tailored selection of the patients and the long follow-up is mandatory to prove the usefulness of this approach.

Risk Factors Analysis and Results of the Arterial Switch Operation for Transposition of the Great Arteries with Intact Ventricular Septum / 대한흉부외과학회지

BACKGROUND: To evaluate the risk factor and long-term result of arterial switch operation , a retrospective study was done. MATERIAL AND METHOD: A retrospective analysis was done to evaluate the early and long-term results on 58 patients who underwent an arterial switch operation(ASO) for transposition of the great arteries(TGA) with intact ventricular septum, between January 1988 and December 1996. Beforesurgery, 36 patients(62.1%) underwent balloon atrial septostomy, 32 patients(51.7%) received PGE1 infusion, and preparatory banding of pulmonary artery was performed on 6 patients(mean LV/RV pressure ratio 0.53+/-0.11). RESULT: The age at operation ranged from 1 to 137 days(mean 24+/-26 days) and the weights ranged from 1.8 to 6.8 kg (mean 3.5+/-0.8 kg). There were 14 early deaths(24.1%), but of the last 24 patients operated on since 1994, there were only 2 early deaths(8.3%). In the risk factor analysis, the date of operation was the only risk factor for early death(p-value <0.01). Eight of the 14 early deaths were due to acute myocardial failure(mainly inadequate coronary blood flow). The length of follow-up ranged from 2 months to 8 years, average of 36+/-27 months. The follow-up included sequential noninvasive evaluations and 21 catheterizations and angiographic studies performed 5 to 32 months postoperatively with particular attention to the great vessel and coronary anastomosis, ventricular function, valvular competence, and cardiac rhythm. There were 5 late deaths(11.4%), one of thesedeaths was related to the late coronary problems, two to aspiration, one to uncontrolled chronic mediastinitis, and one to progressive aortic insufficiency and heart failure. The most frequent postoperative hemodynamic abnormality was supravalvular stenosis and the degree of pulmonary or aortic obstruction had slowly progressed in some cases, however there were no children who had to undergo a reoperation for supravalvular pulmonary or aortic stenosis. Aortic regurgitation was identified in 9 patients, which was mild in 7 and moderate in 2 and had progressed in some cases. Two patients who had an unremarkable perioperative course were identified as having coronary artery obstructions. The other late survivors were in good condition, were in sinus rhythm, and had normal LV functions. Actuarial survival rate at 8 years was 68.8%. CONCLUSION: We concluded that anatomic correction will be established as the optimal approach to the TGA with intact ventricular septum, though further long-term evaluations are needed.

Operative Treatment of Congenitally Corrected Transposition of the Great Arteries ( CCTGA ) / 대한흉부외과학회지

BACKGROUND: Sixty five cases with congenitally corrected transposition of the great arteries (CCTGA) indicated for biventricular repair were operated on between 1984 and september 1998. Comparison between the results of the conventional(classic) connection(LV-PA) and the anatomic repair was done. MATERIAL AND METHOD: Retrospective review was carried out based on the medical records of the patients. Operative procedures, complications and the long-term results accoding to the combining anomalies were analysed. RESULT: Mean age was 5.5+/-4.8 years(range, 2 months to 18years). Thirty nine were male and 26 were female. Situs solitus {S,L,L} was in 53 and situs inversus{I,D,D} in 12. There was no left ventricular outflow tract obstruction(LVOTO) in 13(20%) cases. The LVOTO was resulted from pulmonary stenosis(PS) in 26(40%)patients and from pulmonary atresia(PA) in 26(40%) patients. Twenty-five(38.5%) patients had tricuspid valve regurgitation(TR) greater than the mild degree that was present preoperatively. Twenty two patients previously underwent 24 systemic- pulmonary shunts previously. In the 13 patients without LVOTO, 7 simple closure of VSD or ASD, 3 tricuspid valve replacements(TVR), and 3 anatomic corrections(3 double switch operations: 1 Senning+ Rastelli, 1 Senning+REV-type, and 1 Senning+Arterial switch opera tion) were performed. As to the 26 patients with CCTGA+VSD or ASD+LVOTO(PS), 24 classic repairs and 2 double switch operations(1 Senning+Rastelli, 1 Mustard+REV-type) were done. In the 26 cases with CCTGA+VSD+LVOTO(PA), 19 classic repairs(18 Rastelli, 1 REV-type), and 7 double switch operations(7 Senning+Rastelli) were done. The degree of tricuspid regurgitation increased during the follow-up periods from 1.3+/-1.4 to 2.2+/-1.0 in the classic repair group(p<0.05), but not in the double switch group. Two patients had complete AV block preoperatively, and additional 7(10.8%) had newly developed complete AV block after the operation. Other complications were recurrent LVOTO(10), thromboembolism(4), persistent chest tube drainage over 2 weeks(4), chylothorax(3), bleeding(3), acute renal failure(2), and mediastinitis(2). Mean follow-up was 54+/-49 months(0-177 months). Thirteen patients died after the operation(operative mortality rate: 20.0%(13/65)), and there were 3 additional deaths during the follow up period(overall mortality: 24.6%(16/65)). The operative mortality in patients underwent anatomic repair was 33.3%(4/12). The actuarial survival rates at 1, 5, and 10 years were 75.0+/-5.6%, 75.0+/-5.6%, and 69.2+/-7.6%. Common causes of death were low cardiac output syndrome(8) and heart failure from TR(5). CONCLUSION: Although our study could not demonstrate the superiority of each classic or anatomic repair, we found that the anatomic repair has a merit of preventing the deterioration of tricuspid valve regurgitations. Meticulous selection of the patients and longer follow-up terms are mandatory to establish the selective advantages of both strategies.

A Case Report of Heart-Lung Transplantation / 대한흉부외과학회지

We report a case of heart-lung transplantation in a 32 year-old female with Eisenmenger syndrome secondary to patent ductus arteriosus. She has been suffered from congestive heart failure since June 1996 and repeatedly treated at Intensive Care Unit with intravenous inotropic support since July 1997. Preoperative echocardiography showed a patent ductus arteriosus with right to left shunt, severe regurgitation of tricuspid valve and estimated right ventricular systolic pressure of 100mmHg. The brain-dead donor was an 18 year-old male with head trauma from traffic accident 3 days ago. Heart-lung block procurement was performed at another general hospital and was transported to the Seoul National University Hospital by ambulance. Total ischemic time of the transplanted heart and lung were 249 minutes and 270 minutes, respectively. The immunosuppressive therapy was commenced preoperatively with cyclosporine and azathioprine. Corticosteroid was not used until postoperative 3 weeks in order to avoid infection and delayed healing at the tracheal anastomotic site. The patient was discharged at 31st postoperative day, and has been regularly followed up at outpatient clinic without specific complication. The follow-up bronchoscopy, performed 2 weeks and 4 months after surgery, revealed no evidence of cellular rejection.

Lecompte Procedure in Complex Congenital Heart Diseases / 대한흉부외과학회지

BACKGROUND: This study is to evaluate the effectiveness and application of Lecompte procedure as a treatment for various complex cardiac anomalies with pulmonary outflow tract obstruction. Methods: Between July 1988 and December 1997, 44 patients underwent Lecompte procedure in Seoul National University Children's Hospital. The male to female ratio was 24 to 20 and the mean age was 29.2 months (range, 3 to 83). Of these patients, 28 (63.6%) had transposition of great arteries with ventricular septal defect and pulmonary stenosis (or pulmonary atresia), 14 (31.8%) had double outlet right ventricle with pulmonary stenosis (or pulmonary atresia), and so on. The principles of the technique are 1) extension of the ventricular septal defect or conal resection, 2) construction of a intracardiac tunnel connecting the left ventricle to the aorta, and 3) direct connection, without a prosthetic conduit, of the pulmonary trunk to the right ventricle. RESULTS: There were 3 in-hospital deaths and their causes were sustained hypoxia, myocardial failure, and sepsis, respectively. There was 1 late death due to sepsis. Reoperations were performed in 6 patients who had pulmonary outflow tract obstructions (4 cases), residual muscular ventricular septal defect (1 case), and recurrent septic vegetation (1 case). The cumulative survival rates by the Kaplan-Meier method were 92.7%, 92.7%, and 92.7% at 1, 2, and over 4 years. The reoperation free survival rates were 92.7%, 92.7%, and 70.2% at 1, 3, and over 5 years. Among the risk factors for the operative death, aortic cross clamping time had statistical significance (p0.05). CONCLUSIONS: Our review suggests that Lecompte procedure is an effective treatment modality for various complex cardiac anomalies with pulmonary outflow tract obstruction. Repair in early age is possible and the rates of mortality and morbidity are also acceptable.

Postoperative Arrhythmias after Open Heart Surgery in Adults / 대한흉부외과학회지

BACKGROUND: We prospectively investigated types, incidences, and risk factors for arrhythmias after open heart surgery in adults. MATERIALS AND METHODS: From June 1994 to May 1995, we performed 302 cases of adult cardiac surgery at our department. This study group consisted of 150 men and 152 women, with a mean age of 43.9+/-28.0 (range 16 to 75)years. We included all the patients irrespective of their operative types or disease entities. RESULTS: The overall incidence of arrhythmias after open heart surgery in adults was 58.3%. The incidence of postoperative arrhythmias for redo-valvular heart surgery was 77.8%, and those for simple valvular procedure, coronary artery bypass surgery, aortic surgery, and congenital heart disease were 70.8%, 45.3%, 40.0%, and 29.5%, respectively. Eight out of twelve risk factors showed statistical significance for the development of postoperative arrhythmias. They were preoperative history of arrhythmias, antiarrhythmic drug medication, previous cardiac surgery, larger left ventricular end-diastolic, end-systolic dimension, left atrial dimension on preoperative echocardiogram, longer cardiopulmonary bypass time and aortic cross clamping time. Univariated analyses for age and types of cardioplegic solution did not show statistical significance. CONCLUSIONS: Prospective study on postoperative arrhythmias occurrence, treatment and prevention of is warrauted to draw more clear conclusion.

Surgical treatment of Supravalvular Aortic Stenosis / 대한흉부외과학회지

BACKGROUND: Supravalvular aortic stenosis is a rare form of congenital cardiac anomaly involving ascending aorta distal to coronary orifice. MATERIALS AND METHODS: We operated 12 cases of supravalvular aortic stenosis between July 1986 and March 1997. Age ranged from 4 to 17 (mean 10.2) years and 11 of them were male. Nine patients had clinical features of Williams syndrome. We experienced two types of supravalvular aortic stenosis, including 10 hour glass type and 2 diffuse type. RESULTS: Preoperative transaortic pressure gradient ranged from 40 to 180 (mean 92) mmHg by cardiac catheterization. Pulmonary stenosis was associated in 5 and 2 of them required angioplasty. Operative techniques included 6 standard aortoplasty with elliptical patch, 4 extended aortoplasty with inverted Y shaped patch, and 2 modified Brom's repair. There were no operative deaths. Postoperative echocardiographic evaluation was done at a mean interval of 12 months. Grade I or II aortic regurgitation was found in 3 cases. Postoperative cardiac catheterization revealed a mean transaortic pressure gradient of 26 (range 0 to 75) mmHg. A mean pressure drop was 78 (range 30 to 114) mmHg. All patients were followed up for a mean of 40 (range 1 to 67) months with uneventful clinical course. CONCLUSIONS: Our data proved the low mortality and excellent hemodynamic improvement after surgical relief of supravalvular aortic stenosis in children.

Minimally invasive cardiac surgery with the partial mini-sternotomy in children / 대한흉부외과학회지

Purpose: The safety and efficacy of minimally invasive techniques in congenital heart surgery were tested in this study. Materal and method: Between July 1997 and November 1997, a total of 46 children were underwent minimally invasive cardiac operations at Seoul National University Children's Hospital. Age and body weight of the patients averaged 34.6+/-41.8 (Range: 1~148) months and 14.5+/-9.9 (Range: 3.0~40.0) kg, respectively. Twenty eight patients were male. Preoperative surgical indications included 15 atrial septal defects, 25 ventricular septal defects, 1 foreign body in aorta, 3 partial atrioventricular septal defects, 1 total anomalous pulmonary venous connection (cardiac type), and 1 tetralogy of Fallot. After creating a small lower midline skin incision starting as down as possible from the sternal notch, a vertical midline sternotomy extended from xyphoid process to the level of the second intercostal space, where one of the T-, J-, I-or inverted C-shaped lower lying mini-sternotomy was completed with a creation of unilateral right or bilateral trap door sternal opening. A conventional direct aortic and bicaval cannulation was routine. RESULT: A mean length of skin incision was 6.1+/-1.0 (range: 4.0~9.0) cm. A mean distance between the suprasternal notch and the upper most point of the skin incision was 4.0+/-1.1 (range: 2.0~7.0) cm. Mean cardiopulmonary bypass time, aortic cross-clamp time, and the operation time were 62.9+/-20.0 (range: 28~147), 29.8+/-12.8 (range: 11~79), and 161.1+/-34.5 (range: 100-250) minutes. A mean total amount of postoperative blood transfusion was 71.0+/-68.1 (range: 0~267) cc. All patients were extubated mean 11.3+/-13.8 (range: 1~73) hours after operation. A mean total amount of analgesics used was 0.8+/-1.8 (range: 0~9) mg of morphine. The mean duration of stay in intensive care unit and hospital stay were 35.0+/-32.2 (range: 10~194) hours and 6.2+/-2.0 (range: 3~11) days. There were no wound complications and hospital deaths. CONCLUSION: This short-term experience disclosed that the minimally invasive technique can be feasibly applied in a selected group of congenital heart disease as well as is cosmetically more attractive approach.

Mid-term results of IntracardiacLateral Tunnel Fontan Procedure in the Treatment of Patients with a Functional Single Ventricle / 대한흉부외과학회지

We reviewed the surgical results of intracardiac lateral tunnel Fontan procedure for the repair of functional single ventricles. Between 1990 and 1996, 104 patients underwent total cavopulmonary anastomosis. Patients' age and body weight averaged 35.9 (range 10 to 173) months and 12.8 (range 6.5 to 37.8) kg. Preoperative diagnoses included 18 tricuspid atresias and 53 double inlet ventricles with univentricular atrioventricular connection and 33 other complex lesions. Previous palliative operations were performed in 50 of these patients, including 37 systemic to pulmonary artery shunts, 13 pulmonary artery bandings, 15 surgical atrial septectomies, 2 arterial switch procedures, 2 resections of subaortic conus, 2 repairs of total anomalous pulmonary venous connection and 1 Damus-Stansel-Kaye procedure. In 19 patients bidirectional cavopulmonary shunt operation was performed before the Fontan procedure and in 1 patient a Kawashima procedure was required. Preoperative hemodynamics revealed a mean pulmonary artery pressure of 14.6 (range 5 to 28) mmHg, a mean pulmonary vascular resistance of 2.2 (range 0.4 to 6.9) wood-unit, a mean pulmonary to systemic flow ratio of 0.9 (range 0.3 to 3.0), a mean ventricular end-diastolic pressure of 9.0 (range 3.0 to 21.0) mmHg, and a mean arterial oxygen saturation of 76.0 (range 45.6 to 88.0)%. The operative procedure consisted of a longitudinal right atriotomy 2cm lateral to the terminal crest up to the right atrial auricle, followed by the creation of a lateral tunnel connecting the orifices of either the superior caval vein or the right atrial auricle to the inferior caval vein, using a Gore-Tex vascular graft with or without a fenestration. Concomitant procedures at the time of Fontan procedure included 22 pulmonary artery angioplasties, 21 atrial septectomies, 4 atrioventricular valve replacements or repairs, 4 corrections of anomalous pulmonary venous connection, and 3 permanent pacemaker implantations. In 31, a fenestration was created, and in 1 an adjustable communication was made in the lateral tunnel pathway. One lateral tunnel conversion was performed in a patient with recurrent intractable tachyarrhythmia 4 years after the initial atriopulmonary connection. Post-extubation hemodynamic data revealed a mean pulmonary artery pressure of 12.7 (range 8 to 21) mmHg, a mean ventricular end-diastolic pressure of 7.6 (range 4 to 12) mmHg, and a mean room-air arterial oxygen saturation of 89.9 (range 68 to 100) %. The follow-up duration was, on average, 27 (range 1 to 85) months. Post-Fontan complications included 11 prolonged pleural effusions, 8 arrhythmias, 9 chylothoraces, 5 of damage to the central nervous system, 5 infectious complications, and 4 of acute renal failure. Seven early (6.7%) and 5 late (4.8%) deaths occured. These results proved that the lateral tunnel Fontan procedure provided excellent hemodynamic improvements with acceptable mortality and morbidity for hearts with various types of functional single ventricle.

Influence of Anatomy, Associated Anomalies, Age, and Surgical Methods on the Surgical Results of Aortic Coarctation / 대한흉부외과학회지

One hundred forty-four patients underwent operation for coarctation of the aorta at Seoul National University Children's Hospital between June 1986 and Decembsr 1995. Age ranged 0.1 to 191 months. Of these 78.5%(113) were infants. We classified the patients in terms of the anatomic location of coarctatiln and the associatCd anomalies(I[40]= primary coarctation, II[74]=isthmic hypoplasia, lII[30]=tubular hypoplasia involving transverse arch, A[63]=with ventricular septal defect, B[28]=with other major cardiac defects). Subcalvian flap coarctoplasty(60), resection and anastomosis(44), extended aortoplasty(26), and onlay patch(14) were used as surgical methods. Overall operative mortality was 16.0(23/144)%. The hospital mortality was significantly higher in patheints with type III, subtype B, younger age(under 3 months), extended aortoplasty(p<0.01). However, one-stage total repair in patients with subtype A or B were not found to be a predictor of hospital death. Restenosis had occured in 18 patients among 121 survivals(14.9%). The mean follow-up period was 29.1+/-28.8(0~129.2) months. Preoperative, immediate postoperative(within 3 months after operation) and postoperative(later than 6 months after operation) echocardiographic data on the dimensions of ascending aorta(AA), transverse arch(TA), an4 aortic isthmus(Al) were available in 77 patients(I=20, II=42, III= 15). Preoperative and postoperative aortic isthmus(All) and tra sverse arch indices(TAI), defined as TA/AA and AI/AA respectively, were compared. Immediate postoperative All in type I, II and TAI in type III were significantly smaller in stenotic than non-stenotic group suggesting incomplete relieves of stenotic segment Younger age, subclavian coarctoplasty in patient under 3 months of age were round to be the risk factors for restenosis in this series. In conclusion, We found that aortic arch index and transverse arch index can be a useful tool to figure out the anatomic and clinical characteristics of the patients with aortic coarctation, and that anatomy, associated anomalies, age, and surgical methods may influence the surgical outcome of the coarctation repair.

Palliative Surgery for Tetralogy of Fallot: Report of 43 Cases

Forty three cases of the Tetralogy of Fallot for whom palliative surgical treatment was performed at the Department of Thoracic Surgery from January 1962 to October 1971 were reviewed in this study. 1. Sex ratio of the observed patients was 1.9:1, showing relating relatively high incidence on the male patients. 2. The age distribution in the series ranged from 2 to 24 years of age. and 31 patients were under 10 years of age. 3. On the electrocardiogram right ventricular hypertrophy pattern was observed in all of the patients and right axis deviation patern was observed in all except two cases which had dextrocardia and situs inversus visceralis. 4. The so-called "Pentalogy of Fallot" associated with atrial septal defect was observable in 7 cases and one of the pentalogy case had persistent left superior vena cava. Dextrocardia with situs inversus visceralis was observed in two cases. 5. Procedures employed in this series were as follows; Glenn operation in 13 cases, Bakulev operation in 1 cases, Blalock operation in 16 cases, Brock operation in 3 cases, Waterston's operation in 10 cases. 6. The operative mortality was 18.6% (8 cases).;i.e., 2 cases after Glenn operation, 2 cases after Brock operation, 1 case after Blalock operation, and 3 cases during or following Waterston's operation.