General anesthesia versus sedation with dexmedetomidine for thoracic endovascular aortic repair in 38 patients in multicenter experiences: A retrospective study

BACKGROUND: Endovascular stent graft placement is a useful treatment option in lesions of the thoracic aorta. The aim of this study was to assess the possibility of sedation with dexmedetomidine compared with general anesthesia in patients undergoing thoracic endovascular aortic repair (TEVAR) in a multi-center clinical trial. METHODS: Data from 38 patients with thoracic aorta lesions treated by TEVAR between April 2010 and November 2013 were retrospectively collected at two hospitals. General anesthesia or sedation with dexmedetomidine was determined according to the hospital. Demographics, anesthetic recordings, and complications were reviewed. RESULTS: Stent graft placement was technically successful in all patients. There were no events during the anesthetic period. A total of 38 patients underwent TEVAR; 29 patients received general anesthesia, and 9 received sedation. Dexmedetomidine sedation (loading dose: 0.5-1.0 microg/kg for 10 min, maintenance: 0.2-0.8 microg/kg/h) was successfully performed without anesthesia-related complications or mortality. During the procedure, mean arterial pressure, heart rate, and saturation of peripheral oxygen were not statistically different between general anesthesia and dexmedetomidine sedation. CONCLUSIONS: In our study, TEVAR under sedation with dexmedetomidine was shown to be a feasible procedure that was well tolerated without specific complications.

Rhabdomyolysis Induced by Microembolism with Intra-Aortic Balloon Pump (IABP) Use in a Patient after Coronary Artery Bypass Graft (CABG) - A Case Report - / 대한구급학회지

A fifty seven-year-old man visited the outpatient department with chest pain and claudication. Coronary angiogram showed coronary artery diseases (3-vessel diseases) and CABG was planned. However, lower extremity angiogram showed stenosis of both common iliac arteries and stent implantation of both iliac arteries were done before CABG. He underwent CABG and IABP was inserted for weaning from cardiopulmonary bypass. After CABG, ischemic change on ends of feet was noted with red-brown colored urine and hyperkalemia. Blood myoglobin level was over 3,000 ng/ml. Microembolism of his lower body was revealed by multiple uptakes on the whole body bone scan study. After management by massive hydration and alkalization of urine with sodium bicarbonate, he was recovered without renal replacement therapy and discharged in good condition.

Right Ventricle Exclusion in Severe Neonatal Ebstein's Anomaly / 대한흉부외과학회지

A one-day-old baby was transferred for cyanosis and heart murmur. Echocardiographic evaluation revealed that he had severe neonatal Ebstein's anomaly (Carpentier type C), pulmonary atresia, and pulmonary circulation via patent ductus arteriosus. Because the wall of the atrialized right ventricle was very thin, showed decreased contractility, and the small right ventricle showed pulmonary atresia, we decided that a two-ventricular repair was impossible. When the patient was one-month-old, he underwent right atrium reduction-plasty, a right ventricular exclusion procedure (including atrialized right ventricle resection and functional right ventricle plication), and right modified Blalock-Taussig shunt. He was discharged without specific problems. He received a bidirectional cavopulmonary shunt successfully at 4 months later.

Successful Resection of a Giant Left Ventricular Pseudoaneurysm Developed Later after Mitral Valve Replacement

We present a case of successful surgical resection of a giant left ventricular (LV) pseudoaneurysm that developed 5 yr after mitral valve replacement (MVR). A 59-yr-old female was admitted with exertional chest pain radiating to left arm and back. 64-slice multidetector computed tomography (MDCT) revealed significant stenosis on the ostium of the first diagonal branch of the left anterior descending coronary artery and also a huge pseudoaneurysm compressing the right atrium and the inferior vena cava. She underwent resection of the pseudoaneurysm, and the pseudoaneurysm tunnel was repaired from the inside of LV cavity by removing the previously inserted prosthetic valve, followed by redo MVR together with coronary arterial bypass grafting (CABG) for a single-vessel disease. At the 6-month follow-up, the patient continued to do well without any complications.

Surgical Treatment of a Right Common Carotid Artery Aneurysm / 대한흉부외과학회지

A 38-year old man was admitted to our hospital due to a 5x6 cm sized pulsating mass in the right neck. He suffered from intermittent neck pain and hoarseness for two months due to the rapidly growing mass. The radiological examinations revealed an aneurysm of the right common carotid artery near the bifurcation, and it was compressing the internal and external carotid arteries. Endarterectomy of the right internal carotid artery, aneurysmectomy of the right common carotid artery and graft interposition were done, while the cerebral circulation was maintained by an internal shunt. Intraoperative injury to the nerve tissue around the aneurysm was avoided. He was discharged on the postoperative 7th day without any complications.

Surgical Venous Thrombectomy for Chronic May-Thurner Sysndrome: 2 cases report / 대한흉부외과학회지

May-Thurner syndrome is a deep vein thrombosis of the ilio-femoral vein due to compression of the left common iliac vein by the overlying right common iliac artery. Although, catheter directed thrombectomy (CDT) and thrombolysis with stent insertion has become the standard treatment method for acute or subacute May-Thurner syndrome, because of technical feasibility and lower recurrence rate, however, sometimes this methods make fatal complications. Furthermore, there are few reports on optimal treatment strategies for patients in a chronic state of May-Thurner syndrome,. We now present two cases of chronic (>1 month since onset of symptoms) May-Thurner syndrome treated by surgical thrombectomy and femoral arteriovenous shunt with simultaneous stent insertion after failed endovascular treatment. This technique may provide a significant benefit for patients who are not suitable for conventional endovascular treatment.

Hybrid Procedure for Muscular Ventricular Septal Defects: 2 case reports / 대한흉부외과학회지

Although surgical closure is the standard approach for a muscular ventricular septal defect, the procedure may be complicated by poor visualization and the need for incision on the ventricle. Another approach is catheter-based intervention. However, it also has limitations. A hybrid procedure, the intraoperative combined use of an interventional device may reduce the procedure's invasiveness. We successfully managed two cases of muscular ventricular septal defect with a hybrid procedure. We report here on these 2 cases along with a review of the literature.

Closure of Atrial Septal Defects through a Video-assisted Mini-thoracotomy / 대한흉부외과학회지

BACKGROUND: Minimally invasive surgery is currently popular, but this has been applied very sparingly to cardiac surgery because of some limitations. Our study evaluated the safety and efficacy of atrial septal defect (ASD) closure through a video-assisted mini-thoracotomy. MATERIAL AND METHOD: Fifteen patients were analyzed. Their mean age was 31+/-6 years. The mean ASD size was 24+/-5 mm and there were 3 cases of significant tricuspid regurgitation. The working window was made through the right 4th intercostal space via a 4~5 cm inframammary skin incision. CPB was conducted with performing peripheral cannulation. After cardioplegic arrest, the ASDs were closed with a patch (n=11) or direct sutures (n=4), and the procedures were assisted by using a thoracoscope. There were 3 cases of tricuspid repair and 1 case of mitral valve repair. The mean CPB time and aortic occlusion time were 160+/-47 and 70+/-26 minutes, respectively. RESULT: There was no mortality, but there were 3 minor complications (one pneumothorax, one wound dehiscence and one arrhythmia). The mean hospital stay was 5.9+/-1.8 days. The mean follow-up duration was 10.7+/-6.4 months. The follow-up echocardiogram noted no residual ASD or significant tricuspid regurgitation. Three patients suffered from pain or numbness. CONCLUSION: This study showed satisfactory clinical and cosmetic results. Although the operative time is still too long, more experience and specialized equipment would make this technique a good option for treating ASD.

One Stage Total Repair of the Aortic Arch Anomaly using the Regional Perfusion / 대한흉부외과학회지

BACKGROUND: Deep hypothermic circulatory arrest during repair of aortic arch anomalies may induce neurological complications or myocardial injury. So we surveyed if the regional cerebral and myocardial perfusion might eliminate those potential side effects. MATERIAL AND METHOD: From March 2000 to December 2004, 62 neonates or infants with aortic arch anomaly underwent one stage biventricular repair using the regional perfusion technique by single surgeon. Preoperative diagnosis of the arch anomaly consisted of coarctation (n=46), interruption of the aorta (n=12), hypoplastic left heart syndrome (n=2) and truncus areteriosus (n=2). Combined anomalies were ventricular septal defect (n=51), TAPVR (n=1), PAPVR (n=1) and atrioventricular septal defect (n=2). Arterial cannula was inserted at the innominate artery. RESULT: The mean regional perfusion time of brain was 28+/-10 min. Operative mortality rates was 0 (0/62). Late death was 1 (1/62) during 11+/-7 months of follow-up. Neurologic complications consisted of transient chorea in 1 case. There was no reoperation associated with arch anolamy. Pulmonary complication associated with arch repair occurred in 1 case which was managed by aortopexy. CONCLUSION: One-stage arch repair using the regional prefusion is safe and effective in minimizing the neurologic and myocardial complications.

Congenital Left Main Coronary Artery Atresia / 대한흉부외과학회지

Left main coronary artery atresia is a very rare congenital coronary anomaly with blind end of left main trunk. The clinical symptoms as syncope, failure to thrive, and myocardial infarction are presented and surgical treatments are required in most cases. We report a case of a 14-months-old girl with left main coronary artery atresia and excellent surgical result of 1 year follow-up after coronary artery bypass with left internal thoracic artery.

The Recent Outcomes after Repair of Tetralogy of Fallot Associated with Pulmonary Atresia and Major Aortopulmonary Collateral Arteries / 대한흉부외과학회지

BACKGROUND: Tetralogy of Fallot (TOF) with pulmonary atresia and major aortopulmonary collateral arteries (MAPCAs) is complex lesion with marked heterogeneity of pulmonary blood supply and arborization anomalies. Patients with TOF with PA and MAPCAs have traditionally required multiple staged unifocalization of pulmonary blood supply before undergoing complete repair. In this report, we describe recent change of strategy and the results in our institution. MATERIAL AND METHOD: We established surgical stratagies: early correction, central mediastinal approach, initial RV-PA conduit interposition, and aggressive intervention. Between July 1998 and August 2004, 23 patients were surgically treated at our institution. We divided them into 3 groups by initial operation method; group I: one stage total correction, group II: RV-PA conduit and unifocalization, group III: RV-PA conduit interposition only. RESULT: Mean ages at initial operation in each group were 13.9+/-16.0 months (group I), 10.4+/-15.6 months (group II), and 7.9+/-7.7 months (group III). True pulmonary arteries were not present in 1 patient and the pulmonary arteries were confluent in 22 patients. The balloon angioplasty was done in average 1.3 times (range: 1~6). There were 4 early deaths relating initial operation, and 1 late death due to incracranial hemorrhage after definitive repair. The operative mortalities of initial procedures in each group were 25.0% (1/4: group I), 20.0% (2/10: group II), and 12.2% (1/9: group III). The causes of operative mortality were hypoxia (2), low cardiac output (1) and sudden cardiac arrest (1). Definitive repair rates in each group were 75% (3/4) in group I, 20% (2/10, fenestration: 2) in group II, and 55.6% (5/9, fenestration: 1) in group III. CONCLUSION: In patients of TOF with PA and MAPCAs, RV-PA connection as a initial procedure could be performed with relatively low risk, and high rate of definitive repair can be obtained in the help of balloon pulmonary angioplasty. One stage RV-PA connection and unifocalization appeared to be successful in selected patients.

Aortopulmonary Window / 대한흉부외과학회지

BACKGROUND: Aortopulmonary window (APW) is a very rare congenital heart anomaly, often associated with other cardiac anomalies. It causes a significant systemic to pulmonary artery shunt, which requires early surgical correction. Accurate diagnosis and surgical correction will bring good outcomes. The purpose of this study was to describe our 20-year experience of aortopulmonary window. MATERIAL AND METHOD: Between March 1985 and January 2005, 16 patients with APW underwent surgical repair. Mean age at operation was 157.8+/-245.3 (15.0~994.0) days and mean weight was 4.8+/-2.5 (1.7~10.7) kg. Patent ductus arteriosus (8), atrial septal defect (7), interrupted aortic arch (5), ventricular septal defect (4), patent foramen ovale (3), tricuspid valve regurgitation (3), mitral valve regurgitation (2), aortic valve regurgitation (1), coarctation of aorta (1), left superior vena cavae (1), and dextrocardia (1) were associated. Repair methods included 1) division of the APW with primary closure or patch closure of aorta and pulmonary artery primary closure or patch closure (11) and 2) intra-arterial patch closure (3). 3) Division of the window and descending aorta to APW anastomosis (2) in the patients with interrupted aortic arch or coarctation. RESULT: There was one death. The patient had 2.5 cm long severe tracheal stenosis from carina with tracheal bronchus supplying right upper lobe. The patient died at 5th post operative day due to massive tracheal bleeding. Patients with complex aortopulmonary window had longer intensive care unit and hospital stay and showed more morbidities and higher reoperation rates. 5 patients had reoperations due to left pulmonary artery stenosis (4), right pulmonary artery stenosis (2), and main pulmonary artery stenosis (1). The mean follow-up period was 6.8+/-5.6 (57.0 days~16.7 years)years and all patients belonged to NYHA class I. CONCLUSION: With early and prompt correction of APW, excellent surgical outcome can be expected. However, optimal surgical method needs to be established to decrease the rate of stenosis of pulmonary arteries.

Risk Factor Analysis and Surgical Indications for Pulmonary Artery Banding / 대한흉부외과학회지

BACKGROUND: Pulmonary artery banding (PAB) is an initial palliative procedure for a diverse group of patients with congenital cardiac anomalies and unrestricted pulmonary blood flow. We proved the usefulness of PAB through retrospective investigation of the surgical indication and risk analysis retrospectively. MATERIAL AND METHOD: One hundred and fifty four consecutive patients (99 males and 55 females) who underwent PAB between January 1986 and December 2003 were included. We analysed the risk factors for early mortality and actuarial survival rate. Mean age was 2.5+/-12.8 (0.2~92.7) months and mean weight was 4.5+/-2.7 (0.9~18.0) kg. Preoperative diagnosis included functional single ventricle (88, 57.1%), double outlet right ventricle (22, 14.2%), transposition of the great arteries (26, 16.8%), and atrioventricular septal defect (11, 7.1%). Coarctation of the aorta or interrupted aortic arch (32, 20.7%), subaortic stenosis (13, 8.4%) and total anomalous pulmonary venous connection (13, 8.4%) were associated. RESULT: The overall early mortality was 22.1% (34 of 154). The recent series from 1996 include patients with lower age (3.8+/-15.9 vs. 1.5+/-12.7, p=0.01) and lower body weight (4.8+/-3.1 vs. 4.0+/-2.7, p=0.02). The early mortality was lower in the recent group (17.5%; 16/75) than the earlier group (28.5%; 18/45). Aortic arch anomaly (p=0.004), subaortic stenosis (p=0.004), operation for subaortic stenosis (p=0.007), and cardiopulmonary bypass (p=0.007) were proven to be risk factors for early death in univariate analysis, while time of surgery (<1996) (p=0.026) was the only significant risk factor in multivariate analysis. The mean time interval from PAB to the second-stage operation was 12.8+/-10.9 months. Among 96 patients who survived PAB, 40 patients completed Fontan operation, 21 patients underwent bidirectional cavopulmonary shunt, and 35 patients underwent biventricular repair including 25 arterial switch operations. Median follow-up was 40.1+/-48.9 months. Overall survival rates at 1 year, 5 years and 10 years were 81.2% 65.0%, and 63.5% respectively. CONCLUSION: Although it improved in recent series, early mortality was still high despite the advances in perioperative management. As for conventional indications, early primary repair may be more beneficial. However, PA banding still has a role in the initial palliative step in selective groups.

Mitigation of Calcification of Heterograft Tissue / 대한흉부외과학회지

BACKGROUND: With the development of cardiac surgical technique, we need more prosthetic materials for repairing the intra- and extracardiac defects. Although bovine pericardial bioprosthesis treated with glutaraldehyde (GA) solution is one of the most popular materials, it has a drawback of later calcific degeneration. The purpose of this study is to investigate the effectiveness of several materials and methods in reducing the calcific degeneration of bovine pericardium. MATERIAL AND METHOD: Forty square-shaped pieces of bovine pericardia were fixed in 0.625% GA solution with 4 g/L MgCl2.6H2O as a control group (group 1). Other 40 pieces pre-treated with 1% SDS (group 2) and 40 pieces post-treated with 8% glutamate (group 3) and 2% chitosan (group 4) were also fixed in the same GA solution. Other 40 pieces pre-treated with 1% SDS and post-treated with 8% glutamate and 40 pieces post-treated with 2% chitosan were also fixed in the same GA solution (group 5, 6). The pericardial pieces were implanted into the belly of 40 Fisher 344 rats subdermally and were extracted 1 month, 2 months, 3 months, and 6 months after the implantation. With an atomic absorption spectrophotometry, we measured the calcium amount deposited and examined the tissue with microscope. RESULT: The calcium deposition in 1 month was less in group 2, 5, 6 than that in group 1 (p<0.05). It was most prominent in group 5 (p<0.01). This finding continued in 2 month. In 3 month, the calcium deposition was less in group 3 and 4 as well as group 2, 5, and 6 than in group 1. In 6 month, the calcium deposition in group 2, 3, 4, 5, and 6 was less than that in group 1 and the difference was more than that of 1, 2, and 6 month. The microscopic calcium deposition was also less in group 2 and 5. Calcium deposition developed in the whole layer of pericardium, beginning with the surrounding the collagen fiber and progressing inwardly. CONCLUSION: Pre-treatment with SDS, post-treatment with glutamate or chitosan, and SDS pre-treatment and post-treatment with glutamate or chitosan were effective in reducing the calcium deposition in bovine pericardium. Moreover, the combined method of SDS pre-treatment and glutamate post-treatment was more effective than other methods.

Factors Influencing on Early Patency Rate of Autogenous Arteriovenous Fistula for Hemodialysis / 대한흉부외과학회지

BACKGROUND: It is very important for hemodialysis in patients with end stage renal disease to obtain vascular access that resists repeated punctures and maintains adequate blood flow. This study was designed to indentify factors that may influence early patency rate of autogenous arteriovenous fistula. MATERIAL AND METHOD: 49 cases in 47 patients who underwent radiocephalic fistula formation in our hospital from June 2002 through May 2003 were reviewed and analyzed. RESULT: The early patency rate was 79.6%. Age, sex, hypertension, and diabetes mellitus were not significant factors for patency. Body mass index and duration of hypertension and diabetes did not influence the early results either. Cephalic vein diameter measured preoperatively and blood flow at radiocephalic fistula were significantly positive correlative factors. Groups with the vein diameter less than 2.7 mm, or with the blood flow less than 100 mL/min had significantly lower early patency rate than the other groups. CONCLUSION: To improve early patency rate of radiocephalic fistula, large sized cephalic vein should be selected and if the intraoperative flow at radiocephalic fistula is less than 100 mL/min, another arteriovenous fistula formation should be considered.

A Giant Bronchial Artery Aneurysm in Brochiectatic Patient: One case report / 대한흉부외과학회지

Bronchial artery aneurysm is a rare but life-threatening disease when it ruptures, and it requires prompt treatment to prevent from catastrophic ruptures.A 78-year-old woman was referred to our hospital to evaluate mediastinal massfound on chest computed tomography. We did a selective bronchial artery angiography and diagnosed as bronchial artery aneurysm. Aneurysmectomy with division of afferent and efferent arteries was performed through standard thoracotomy without cardiopulmonary bypass. The patient recovered uneventfully and was discharged on postoperative 8th day without any complications.

Primary Giant Cell Tumor of Rib-Unusual Location / 대한흉부외과학회지

Giant cell tumor rarely occurs in ribs. Usually it is located in the posterior arc. We reported a very rare case of primary giant cell tumor of rib in the anterior arc with review of literatures.

Efficacy of Intra-Aortic Balloon Pump in Postcardiotomy Cardiogenic Shock / 대한흉부외과학회지

BACKGROUND: Intra-aortic balloon pump (IABP)is well known for its hemodynamic benefit but still has its own complications.Proper use of IABP is the best way t o obt ai n maximum benefit with low complication rate. MATERIALS AND METHOD: Twenty one(men 10,female 11) patients were included in this study among the 100 consecutive adult cardiac surgery patients in our hospital.Eighteen(85.7%)were ischemic heart disease patients.They all received IABP therapy due to postcardiotomy cardiogenic shock according to the well-known indications.Their preoperative conditions,intraoperative factors including hemodynamics, postoperative conditions and IABP-related complications were analyzed. RESULT: Nineteen patients(90.5%)were successfully weaned from IABP.There were 2 patients of operative death and the mortality rate was 9.5%.Duration of IABP use was 40.7+/-24.3 hours.There were 2 cases(9.5%)of IABP-related vascular complications that required surgical intervention. CONCLUSION: We concluded that IABP could be used effectively and safely for postcardiotomy cardiogenic shock patients with low complication rate.