Hybrid Coronary Artery Revascularization for Takayasu Arteritis with Major Visceral Collateral Circulation from the Left Internal Thoracic Artery

Coronary arterial involvement in Takayasu arteritis (TA) is not uncommon. Herein, we describe a case of TA with celiac trunk and superior mesenteric artery occlusion combined with coronary artery disease. Bilateral huge internal thoracic arteries (ITAs) and the inferior mesenteric artery provided the major visceral collateral circulation. After percutaneous intervention to the right coronary artery, off-pump coronary artery bypass grafting for the left coronary territory was done using a right ITA graft and its large side branch because of its relatively minor contribution to the visceral collateral circulation.

Results of Protocol-based Perioperative Management in Off-Pump Coronary Artery Bypass Grafting for Patients with Non-dialysis-dependent Chronic Kidney Disease

BACKGROUND: Recent studies have demonstrated the benefits of off-pump coronary bypass grafting over the on-pump technique in patients with chronic kidney disease (CKD). To further reduce the risk of acute kidney injury and the need for renal replacement therapy, even in patients undergoing off-pump coronary artery bypass grafting, we adopted protocol-based perioperative management for patients with CKD. METHODS: From December 2012 to March 2015, 265 patients underwent isolated off-pump coronary artery bypass grafting. To analyze renal function in a stable condition, we excluded 12 dialysis-dependent end stage renal failure and 10 emergency or urgent cases. Among the remaining 243 patients, 208 patients had normal kidney function (normal group), and 35 patients had CKD (CKD group). Minimizing contrast exposure, ensuring adequate hydration, using strict drug dosage adjustment, and optimizing hemodynamic status were key elements of the protocol for the CKD group. RESULTS: The risk of acute kidney injury was about ×3 higher in the CKD group than in the normal group (p=0.01). Estimated glomerular filtration rates and serum creatinine levels deteriorated until the third postoperative day in the CKD group. However, by adopting protocol-based perioperative management, this transient renal dysfunction recovered to preoperative levels by the fifth postoperative day without requiring renal replacement therapy in all cases. CONCLUSION: Off-pump coronary bypass surgery combined with this protocol-based perioperative management strategy in patients with non-dialysis-dependent CKD could mostly be performed without renal replacement therapy.

Off-pump Coronary Artery Bypass Surgery Versus Drug Eluting Stent for Multi-vessel Coronary Artery Disease / 대한흉부외과학회지

BACKGROUND: The introduction of Drug Eluting Stents (DES) decreased the number of patients referred for coronary artery bypass grafting (CABG). The impact of DES on CABG (Step 1) was studied and compared with the 1-year outcome after CABG with DES (Step 2). MATERIAL AND METHOD: Surgical results for patients who underwent off-pump CABG (OPCAB) before the introduction of DES(n=298) were compared with those who underwent OPCAB after the introduction of DES (n=288) (Step 1). Postoperative 30-day and 1-year results were also compared between the patients who underwent percutaneous coronary intervention (PCI) using DES (n=220) and those who underwent OPCAB (n=255) (Step 2). RESULT: Since the introduction of DES, the ratio of CABG versus PCI decreased. In the CABG group, the number of high risk patients such as elderly patients (age 62 vs. 64, p=0.023), those with chronic renal failure (4% vs. 9%, p=0.021), calcification of the ascending aorta (9% vs. 15%, p=0.043), or frequency of urgent or emergent operations (12% vs. 22%, p=0.002) increased. However, there were no differences in the cardiac death and graft patency rates between the two groups (step 1). During the one-year follow up period, the rate of target vessel revascularization (12.3% vs. 2.4%, p<0.001) and major adverse cardiac events (MACE: death, myocardial infarct, TVR) were higher in the DES than the CABG group (13.6% vs 4.3%) (stage 2). CONCLUSION: Introduction of DES decreased the number of patients referred for surgery, and increased the comorbidity in patients who underwent CABG. DES increased the rate of target vessel revascularization, and the occurrence of MACE during the 1-year follow-up. However, there was no difference in the incidence of myocardial infarction and cardiac death between the two groups.

Post-Infarction Ventricular Septal Rupture: 10 Years of Experience / 대한흉부외과학회지

BACKGROUND: Postinfarction ventricular septal rupture is associated with mortality as high as 85~90%, if it is treated medically. This report documents our experience with postinfarction ventricular septal rupture that was treated surgically. MATERIAL AND METHOD: We retrospectively reviewed the medical records of 11 patients who were operated on due to postinfarction ventricular septal rupture between August 1996 and August 2006. There were 4 men and 7 women, with a mean age of 70+/-11 years (age range: 50~84 years). The location of the rupture was anterior in 7 cases and posterior in 4 cases. The interval between the onset of acute myocardial infarction and the occurrence of the ventricular septal rupture was 2.0+/-1.3 days (range: 1~5 days). Operation was performed at an average of 2.4+/-2.7 days (range: 0~8 days) after the diagnosis of septal rupture. Preoperative intraaortic balloon pump therapy was performed in 10 patients. RESULT: The infarct exclusion technique was used in all cases. Coronary artery bypass grafting was done in 8 cases, with the mean number of distal anastomosis being 1.0+/-0.8. There was one operative death. In 2 patients, reoperation was performed due to a residual septal defect. The postoperative morbidities were transient atrial fibrillation (n=7), paroxysmal supraventricular tachycardia (n=1), low cardiac output syndrome (n=3), bleeding reoperation (n=2), delayed sternal closure (n=2), acute renal failure (n=2), pneumonia (n=1), intraaortic balloon pump-related thromboembolism (n=1), and transient delirium (n=2). Nine patients have been followed up for a mean of 38+/-40 months except for one follow-up loss. There have been 3 late deaths. At the latest follow-up, all 6 survivors were in a good functional class. CONCLUSION: We demonstrated satisfactory operative and midterm results with our strategy of preoperative intraaortic balloon pump therapy, early repair of septal rupture by infarct exclusion and combined coronary revascularization.

Epicardial Repair of Acute Atrioventricular Groove Disruption Complicating Mitral Valve Replacement: A case report / 대한흉부외과학회지

A left ventricular rupture might be one of the most disastrous complications after a mitral valve replacement. An acute atrioventricular groove rupture (type I) was detected in a 54-year-old female diagnosed with a mitral stenosis combined with severe tricuspid regurgitation. She had a prior medical history of an open mitral commissurotomy in Japan at 30 years ago. The surgical findings suggested that the previous procedure was not a simple commissurotomy but a commissurotomy combined with a posteromedial annuloplasty procedure. After a successful mitral valve replacement and a measured (De Vega type) tricuspid annuloplasty, the weaning from a cardiopulmonary bypass was uneventful. However, copious intraoperative bleeding from the posterior wall was detected and the cardiopulmonary bypass was restarted. Exposure of the posterior wall of the left ventricle showed bleeding from the atrioventricular groove 3 cm lateral to the left atrial auricle. Under the impression of a Type I left ventricular rupture, epicardial repair (primary repair of the Teflon felt pledgetted suture, continuous sealing suture using auto-pericardial patch and application of fibrin-sealant) was attempted. Successful local control was made and the patient recovered uneventfully. The patient was discharged at 14 postoperative days without complications. We report this successful epicardial repair of an acute type I left ventricular rupture after mitral valve replacement.

Ruptured Penetrating Atherosclerotic Ulcer Involving the Aortic Arch: A case report / 대한흉부외과학회지

Penetrating atherosclerotic ulcer involving the aortic arch has rarely been reported on in the literature. Acute rupture of a penetrating atherosclerotic ulcer involving the distal arch and the proximal descending thoracic aorta was found in a 78-year-old male, and he originally presented with acute-onset shoulder pain and hoarseness. Patch repair of the perforated arch and the proximal descending thoracic aorta was successfully done under total circulatory arrest.

Awake OPCAB: Initial Experience / 대한흉부외과학회지

BACKGROUND: High thoracic epidural anesthesia allows awake coronary artery bypass grafting, avoiding the drawbacks of mechanical ventilation and general anesthesia. Materian and Method: From April, 2005 to September, 2005, 12 patients were underwent awake coronary artery bypass grafting using high thoracic epidural anesthesia. There were 1 female and 11 male patients, with a mean age of 66+/-6 years. Off pump coronary artery bypass grafting was performed through a median sternotomy using arterial grafts. RESULT: There were no mortality. Pneumothorax was developed during surgery in 8 patients. Five patients required secondary intubation because of pneumothorax (n=3), bowel herniation (n=1), and hemothorax after chest tube insertion (n=1). Postoperative coronary angiography was performed before discharge in all patients and all the grafts were patent. CONCLUSION: Our intial experience demonstrated the feasibility of awake off-pump coronary artery bypass grafting. Further study is required to define the indications, advantages and limitations of this strategy.

Awake OPCAB: Initial Experience / 대한흉부외과학회지

BACKGROUND: High thoracic epidural anesthesia allows awake coronary artery bypass grafting, avoiding the drawbacks of mechanical ventilation and general anesthesia. Materian and Method: From April, 2005 to September, 2005, 12 patients were underwent awake coronary artery bypass grafting using high thoracic epidural anesthesia. There were 1 female and 11 male patients, with a mean age of 66+/-6 years. Off pump coronary artery bypass grafting was performed through a median sternotomy using arterial grafts. RESULT: There were no mortality. Pneumothorax was developed during surgery in 8 patients. Five patients required secondary intubation because of pneumothorax (n=3), bowel herniation (n=1), and hemothorax after chest tube insertion (n=1). Postoperative coronary angiography was performed before discharge in all patients and all the grafts were patent. CONCLUSION: Our intial experience demonstrated the feasibility of awake off-pump coronary artery bypass grafting. Further study is required to define the indications, advantages and limitations of this strategy.

Aortic Valve Papillary Fibroelastoma Triggering Chest Pain: A case report / 대한흉부외과학회지

Papillary fibroelastoma is the second most common benign cardiac tumor, usually involving the cardiac valve. Papillary fibroelastoma attached at the right coronary cusp of the aortic valve was found in a 51-year-old woman, who was presented with chest pain and dyspnea. During the operation, the tumor mass was excised without causing damage on the aortic valve leaflet.

Extraanatomic Ascending-to-Descending Aorta Bypass Graft for Atypical Coarctation: A case report / 대한흉부외과학회지

Under median sternotomy and left thoracotomy, extra-anatomic aorta bypass between ascending aorta and descending thoracic aorta without cardiopulmonary bypass support has been done effectively and easily without complications for a selected case of atypical coarctation associated with hypoplasia of aortic arch. It should be considered as an alternative operative technique for complex aortic arch reconstruction.

Hybrid Off-pump Coronary Artery Bypass Combined with Percutaneous Coronary Intervention: Indications and Early Results / 대한흉부외과학회지

BACKGROUND: The possibility of incomplete revascularization and development of flow competition after revascularization of the borderline lesion made the hybrid strategy as an option for complete revascularization. MATERIAL AND METHOD: From January 1998 to July 2004, 25 (3.2%) patients underwent hybrid revascularization among 782 total OPCAB procedures. Clinical results and angiographic patencies were evalulated. Percutaneous coronary intervention (PCI) was performed before CABG in 8 patients and after CABG in 17 patients. RESULT: The causes of PCIs before CABG were to achieve complete revascularization with minimally invasive surgery (n=7) and emergent PCI for culprit lesion (n=1). The indications of PCIs after CABG were high possibility of flow competition in the borderline lesion of right coronary artery territory (n=8), diffuse atheromatous lesion preventing anastomosis of graft (n=5), severe calcified ascending aorta with no more arterial graft available (n=3), and intramyocardial coronary lesion (n=1). Mean number of distal anastomoses was 2.3+/-1.0. Mean number of lesions treated by PCI was 1.2+/-0.4. There was no operative or procedure-related mortality. PCI-related complication was periprocedural myocardial infarction in one patient, and complications related to CABG were transient atrial fibrillation (n=5), perioperative myocardial infarction (n=1), and transient renal dysfunction (n=1). Early postoperative coronary angiography (1.8+/-1.6 days) revealed 100% patency rate of grafts (57/57). The stenosis occurred in one patient performed PCI before CABG, which was successfully treated with re-ballooning. During midterm follow-up (mean; 25+/-26 months), 1 patient died of congestive heart failure. All survivors (n=24) accomplished follow-up coronary angiographics, which showed all grafts (56/57) were patent except one string sign. In-stent restenosis was developed in 2 patients who received bare metal stents. CONCLUSION: In selected patients, complete revascularization was achieved with low risk by taking the hybrid strategy.

Morphologic Follow-Up of the Anastomotic Sites Using One-year and Five-year Angiography after Coronary Artery Bypass Grafting / 대한흉부외과학회지

BACKGROUND: We analysed the characteristics of anastomotic sites after coronary artery bypass grafting (CABG) using coronary angiographies (CAGs) performed at one and five years postoperatively in the same patient population. MATERIAL AND METHOD: Among the 219 patients who underwent isolated CABGs between January 1995 and December 1997, follow-up coronary angiograms were performed in 149 (75.3%) patients at one year and in 115 (58.1%) patients at five years postoperatively. FitzGibbon grading system was used to evaluate the anastomotic sites. RESULT: The patency rates of arterial grafts at one- and five-year were 96.5% (192/199) and 93.1% (134/144), which were higher than those of saphenous vein grafts (SVGs) (82.9% (224/270) and 77.5% (141/182), respectively) (p=0.01). Although there were significant decreases in the patency rates between one- and five-year CAGs of both arterial and venous grafts, the proportion of FitzGibbon grade B among the SVGs was increased from 5.2% (one-year) to 8.2% (five-year), suggesting the progression of vein graft disease (p<0.01). CONCLUSION: The patency rate of the arterial graft was higher than that of SVG in both one- and five-year CAGs. The attrition rate of saphenous vein graft was higher than arterial grafts.

Endoventricular Circular Patch Plasty (Dor Procedure) for Ischemic Left Ventricular Dysfunction / 대한흉부외과학회지

Background: We evaluated the efficacy of Dor procedure in patients with ischemic left ventricular dysfunction. Material and Method: Between April 1998 and December 2002, 45 patients underwent the Dor procedure concomitant with coronary artery bypass grafting (CABG). Left ventricular ejection fraction (LVEF) and left ventricular end-diastolic/end-systolic volumes (LVEDV/LVESV) were measured by echocardiography, myocardial SPECT, and cardiac catheterization and angiography performed at the sequence of preoperative, early postoperative, and one year postoperative stage. Result: Cardiopulmonary bypass and aortic clamp times were mean 141+/-64, 69+/-24 minutes, respectively. Intraaortic balloon pump (IABP) therapy was required in 19 patients (42%; 7 preoperatively, 9 intraoperatively, 3 postoperatively). Operative mortality rate was 2.2% (1/45). Postoperative morbidities were low cardiac output syndrome (12), atrial fibrillation (5), acute renal failure (4), and postoperative bleeding (4). Functional class (NYHA) was improved from classes 2.8 to 1.1 (p<0.01). When we compared between the preoperative and early postoperative values, LVEF was improved from 32+/-9% to 52+/-11% (p<0.01). The asynergy portion decreased from 57+/-12% to 22+/-9%, and LVEDV/LVESV indexes improved from 125+/-39 mL/m2, 85+/-30mL/m2 to 66+/-23 mL/m2, 32+/-16 mL/m2 (p<0.01). Although these changes in volumes were relatively preserved at postoperative one year, the left ventricular volumes showed a tendency to increase. Conclusion: After the Dor procedure for ischemic left ventricular dysfunction, LVEF improvement and left ventricular volume reduction were maintained till postoperative one year. The tendency for left ventricular volume to increase at postoperative one year suggested the requirement of strict medical management.

Mid-term Results of the Congenital Bicuspid Aortic Valve Repair / 대한흉부외과학회지

BACKGROUND: Despite the excellent early results after the repair of congenital bicuspid aortic valve (BAV) disease, the mid-term durability of the repaired valve has still controversies. MATERIAL AND METHOD: To evaluate the mid-term results of BAV repair, retrospective review of medical records and echocardiographic data were done. Between 1994 and 2003, twenty-two patients underwent reparative procedure for either regurgitant or stenotic congenital bicuspid aortic valve (BAV). RESULT: Mean age was 41+/-14 years with male predominance (Male=17, Female=5). The pathophysiologies of the BAV were regurgitation-dominant in 20 (91%) and stenosis-dominant in 2 (9%) cases. Various repair techniques were used for raphe, prolapsed leaflet, thickened leaflet, and commissures; 1) release of raphe in 19 (86%), 2) wedge resection and primary repair in 11 (50%), pericardial patch reinforcement after plication of the leaflet in 6 (27%), and plication of the leaflet in 3 (14%), 3) slicing of thickened leaflet was used in 12 (55%) cases, 4) commissuroplasty in 8 (36%), and commissurotomy in 6 (27%) cases. There was no in-hospital mortality. During the mean follow-up of 38+/-17 months, one patient underwent aortic valve replacement after developing acute severe regurgitation from dehiscence of the suture on postoperative 2 months. New York Heart Association functional class was improved from 1.9+/-0.6 to 1.2+/-0.5 (p<0.01). Left ventricular end-systolic and diastolic dimension (LVESD/LVEDD) were also improved from 45+/-9 and 67+/-10 to 37+/-10 and 56+/-10, respectively (p<0.01). The grade of aortic regurgitation (AR) was improved from preoperative (3.1+/-1.2) to post-bypass (0.9+/-0.7). However, the grade at last follow-up (1.7+/-1.1) was deteriorated during the follow-up period (p<0.01). Freedom from grade III and more AR at one, three, and four year were 89.7%, 89.7%, and 39.9% respectively. CONCLUSION: Midterm clinical result of the BAV repair was favorable. But, the durability of the repaired valve was not satisfactory.

Unusual Presentations of Takayasu's Arteritis: Report of two cases

Takayasu's arteritis is occlusive disease of aorta, its main branches, and pulmonary artery. Its clinical manifestations are quite variable, but comes from mainly stenotic or aneurysmal change of the vascular wall. We experienced two cases of unusual presentations of Takayasu's arteritis, one with thorcoabdominal aortic aneurysm (Crawford type III) and the other with atypical coarctation of descending aorta. Surgical procedures were graft replacement of thoracoabdominal aortic aneurysm with implantation of inferior mesenteric artery supplying almost all abdominal vicera to the graft, and graft bypass of the coarctation. They survived postoperatively with improved clinical symptoms.