• Journal of Chest Surgery
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• v.40 no.6 s.275
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• pp.407-413
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• 2007

Background: The brain natriuretic peptide (BNP) level has been reported in some studies to be associated with the occurrence of atrial fbrillation (AF). The aim of this study is to evaluate the potential usefulness of the BNP level as a predictor of the occurrence of postoperative (postop) AF and to assess the relationship of the BNP level with the onset of AF and the restoration of sinus rhythm. Material and Method: From January 1, 2005 to February 28, 2006, 82 patients without a history of atrial arrhythmia that had undergone cardiac surgery were enrolled in the study. Blood samples for plasma BNP were drawn daily for all these patients from the preoperative (preop) day to the 7th postop day. The patient records were reviewed and postop EKGs were checked daily for AF until the time of discharge. Result: Patients were divided into two groups based on development of postop AF. Postoperative AF developed in 26 patients (31.7%). There was no significant statistical difference in age, sex distribution, preop left ventricle ejection fraction, hypertension, left ventricular hypertrophy, or the use of beta blockers between the non-postop AF and postop AF group. More patients in the AF group had undergone valve surgery (39.3% versus 76.9%, p=0.002). The preop left atrium size was significantly larger in the AF patients ($43.8{\pm}10.3 mm$ versus $49.8{\pm}11.5 mm$, p=0.029). The preop plasma BNP levels were higher in the postop AF patients ($144.1{\pm}20.8 pg/mL$ versus $267.5{\pm}68 pg/mL$, p=0.034). In the postop AF group, the plasma BNP level was the highest on the 3rd postop day. Postop AF developed in most patients by the 3rd postop day; restored sinus rhythm developed by the 7th postop day. Conclusion: Elevated plasma BNP levels may lead to the occurrence of postop AF in patients undergoing cardiac surgery. Patients who have a high risk of postop AF should be considered for aggressive prophylactic antiarrhythmic therapy.

• Journal of Chest Surgery
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• v.42 no.1
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• pp.14-21
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• 2009

Background: Postoperative atrial fibrillation (AF) is a common complication after coronary artery bypass graft (CABG) surgery. Although postoperative AF is regarded as benign, transient and self-limited, it has been associated with increased morbidity, thromboembolic events and an increased duration and cost of hospitalization. Material and Method: From January 1994 to December 2007, 190 patients that had isolated CABG surgery were divided into two groups. Group 1 (n=139) involved those who had postoperative atrial fibrillation, and group 2 (n=51) did not have any such events. We reviewed the medical records retrospectively including the incidence of postoperative AF, patient characteristics, surgery related factors and the outcome of the patients with postoperative AF. Result: The frequency of postoperative AF was 26.8%, the conversion rate to regular sinus rhythm before discharge was 82.4%; 82.4% of the AF developed within the first three postoperative days. Although the postoperative AF group was significantly older and had a prolonged postoperative Intensive care unit (ICU) stay, there was no difference in the aortic crossclamp time or duration of hospitalization. No spontaneous defibrillation at declamping, and longer duration of cardiopulmonary bypass were significantly related to the development of postoperative AF. However, postoperative treatment with a beta blocker was associated with a decreased incidence of postoperative AF. The multivariate analysis showed that age and ICU stay were significantly associated with the development of POAF. Spontaneous defibrillation and postoperative beta blocker treatment were significantly associated with a decreased frequency of POAF. Conclusion: AF after CABG surgery is a common complication associated with increased morbidity and a longer ICU stay. Therefore, various strategies aimed at reducing AF, and its complications, such as postoperative treatment with a beta blocker should be considered.

• Journal of Chest Surgery
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• v.36 no.5
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• pp.329-334
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• 2003

Backgound: Cryoablation and radiofrequency ablation have been used to treat the atrial fibrillation. Some reports insisted that the microwave ablation Is a better method for a deep and extensive lesion. Material and Method: From December 2001 to July 2002, we peformed 8 microwave ablations in patients who needed mitral valve surgery (7 MVR, 1 MVR+AVR). There were 3 men and 5 women, and their mean age was 43.4$\pm$8.3 years and mean follow up period was 5.6$\pm$2.4 months respectively. The microwave was applied on endocardium or epicardium by Lynx (Afx, inc.) using a power of 45 watts for 25 seconds. We studied the left atrial dimension, the left atrial function and the sinus conversion with echocardiography and electro-cardiography at three times; 1) before the operation, 2) immediately after the operation, and 3) 6 months after the operation. Result: There was no complication and no mortality. The mean aortic clamping time was 104.6$\pm$25.0 minutes, and the mean total bypass time was 130.5$\pm$28.7 minutes. The rate of sinus conversion was 75%, A wave across the mitral valve was a mean of 77.0$\pm$24.8 cm/sec, and the AVE was a mean of 0.46$\pm$0.17 at 5.6 months postoperatively Conclusion: There was no difference in the early result of microwave ablation compared to other methods. The microwave ablation was an acceptable method due to its convenient application especially in beating heart.

• Proceedings of the KTCVS Conference
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• 1998.10a
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• pp.163-163
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• 1998

• Journal of Chest Surgery
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• v.30 no.3
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• pp.287-292
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• 1997

.Itrial fibrillation is one of the most common cardiac arrhythmias requiring treatment. About 60% of patients with mitral valvular disease have atrial fibrillation and one third of patients with atrial fibrillation may have the past history of thromboembolic events. Between April 1994 and June 1995, 20 patients with organic heart diseases combined with atrial fibrillation underwent open heart surgery including Cox-maze 111 procedure. There were 6 men and 14 women with an average age of 48 years (range, 31 to 66 years). Nineteen patients had valvular heart diseases and 1 ventricular septal defEct (VSD). Mean duration of atrial fibrillation was 36 months (:42 months) (range, 1 to 132 months). T e past medical history of thromboembolic events was positive in 7 patients (35%) and left atrial thrombus was detected in 9 patients (45%). The concomitant procedures were mitral valve replacement (MVR) and aortic valve replacement (AVR) in 5 patients, MVR in 4, MVd and tricuspid annuloplasty(TAP) in 4, mitral valvuloplasty(Mln) in 3, Mln and Tln in 1, MIW and coronary artery bypass surgery in 1, AVR in 1, and patch closure of VSD in 1. Mean aortic cross-clamping time was 175 minutes (range, 116 to 270 minutes). Atrial fibrillation recurred in 16 patients (80%) during the early postoperative period, but, recurrent atrial fibrillation was converted to regular rhythm at postoperative forty-first day in average. There was no early or late death in this series of 20 patients and postoperative complications were inappropriate tachycardia in 5 patients (25%), low cardiac output syndrome in 3 (15%), aggravated hemiplegic in 1, and acute renal failure in 1. Mean follow-up interval of patient was 16.5 months (range, 10.5 to 24 months) and all patients are currently in regular rhythm. Seventeen patients (85%) are in sinus rhythm and 3 (15%) in junctional rhythm. Right atrial contraction was detected in 95% of patients and left atrial contraction in 63% on postoperative transthoracic echocardiogram. The surgical treatment of atrial fibrillation concomitant with open heart surgery is warranted in the recent clinical setting of improved myocardial protection technique, considering the untoward side-effects of atrial fibrillation.

• Journal of Chest Surgery
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• v.32 no.3
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• pp.255-261
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• 1999

Background: Atrial fibrillation is one of the most prevalent of all arrhythmias and in up to 79% of the patients with mitral valve disease. This study examined whether the atrial fibrillation that occur in patients with mitral valve operation could be eliminated by a concommitant maze operation without cryoablation. Material and Method: From May 1997 to April 1998, 14 patients with atrial fibrillation associated with mitral valve disease underwent Maze III operation without cryoablation. Preoperatively there were 6 men and 8 women with an average age of 46.2${\pm}$10.7 years. Eleven patients had mitral stenosis, and three had mitral insufficiency. The associated heart diseases were aortic valve disease in 4, tricuspid valve regurgitation in 1 and ASD in 2. Using transthoracic echocardiography, the mean left atrial diameters was 54.7${\pm}$5.3 mm and thrombi were found in the left atrium of 2 patients. Postoperatively the ratio between the peak speed of the early filling wave and that of the atrial contraction wave (A/E ratio) was determined from transmitral flow measurement. Operations were mitral valve replacement in 13 including 4 aortic valve replacements, 1 DeVega annuloplasty and 2 ASD closures. Maze III operation was performed in 1 patient. Result: Five patients (38%) had recurred atrial fibrillation, which was reversed with flecainide or amiodarone at the average time of postoperative 38.8${\pm}$23.5 days. Postoperative complications were postoperative transient junctional rhythm in 6, transient atrial fibrillation in 5, reoperation for bleeding in 3, postpericardiotomy syndrome(1), unilateral vocal cord palsy(1), postoperative psychosis(1), and myocardial infarction(1). Postoperatively A/E ratio was 0.43${\pm}$0.22 and A wave found in 9(64%) patients. 3 to 14 months postoperatively (average follow- up, 8.1 months), all of patients had normal sinus rhythm and 9(64%) patients had left atrial contraction and 11(79%) patients were not on a regimen of antiarrhythmic medication. Conclusion: We conclude that Maze III operation without cryoablation is an effective surgical treatment in atrial fibrillation associated with the mitral valve disease.

• Journal of Chest Surgery
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• v.31 no.10
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• pp.939-944
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• 1998

Background: The sugical results of the Cox-Maze procedure (CMP) for lone atrial fibrillation(AF) have proven to be exellent. However, those for AF associated with mitral valve(MV) disease have been reported to be a little inferior. Materials and methods: To assess the efficacy and safety of the CMP as a combined procedure with MV operation, we studied retrospectively our experiences. Between April 1994 and October 1997, we experienced 70 (23 males, 47 females) cases of CMP concomitantly with MV operation. Results: The etiologies of MV disease were rheumatic in 67 and degenerative in 3 cases. The mean duration of AF before sugery was 66$\pm$70 months. Fifteen patients had the past medical history of thromboembolic complications, and left atrial thrombi were identified at operation in 24 patients. Twelve cases were reoperations. Aortic cross clamp (ACC) time was mean 151$\pm$44 minutes, and cardiopulmonary bypass (CPB) time was mean 246$\pm$65 minutes. Concomitant procedures were mitral valve replacement (MVR) in 19, MVR and aortic valve replacement (AVR) in 14, MVR and tricupid annuloplasty (TAP) in 8, MVR with AV repair in 3, MV repair in 11, MVR and coronary artery bypass grafting (CABG) in 2, MVR and AVR and CABG in 1, redo-MVR in 10, redo-MVR and redo-AVR in 2 patients. The rate of hospital mortality was 1.4%(1/70). Perioperative recurrence of AF was seen in 44(62.9%), and atrial tachyarrhythmias in 10(14.3%), low cardiac output syndrome in 4(5.7%), postoperative bleeding that required mediastinal exploration in 4(5.7%) patients. Other complications were acute renal failure in 2, aggravation of preoperative hemiplegia in 1, and transient delirium in 1 patient. We followed up all the survivors for 16.4 months(3-44months) on an average. Sinus rhythm has been restored in 65(94.2%) patients. AF has been controlled by operation alone in 73.9% and operation plus medication in 20.3%. Two patients needed permanent pacemaker implantation; one with sick sinus syndrome, and the other with tachycardia- bradycardia syndrome. Only two patients remained in AF. We followed up our patients with transthoracic echocardiography to assess the atrial contractilities and other cardiac functions. Right atrial contractility could be demonstrated in 92% and left atrial contractility in 53%.We compared our non-redo cases with redo cases. Although the duration of AF was significantly longer in redo cases, there was no differences in ACC time, CPB time, postoperative bleeding amount and sinus conversion rate. Conclusions: In conclusion, the CMP concomitant with MV operation demonstrated a high sinus conversion rate under the acceptable operative risk even in case of reoperation.

• Journal of Chest Surgery
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• v.38 no.11 s.256
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• pp.739-745
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• 2005

Background: The Maze procedure considered the most effective method of treatment for atrial fibrillation. However, the sinus conversion rates decreased due to several factors, especially enlarged left atrium. The purpose of this study was to investigate the effects of Maze procedure with aen atrial volume reduction plasty on rheumatic mitral valve disease, Material and Method: From December of 200f to July of 2004, 45 patients received mitral valve and Maze operation. The patients were placed in either group f or group 2, based on the left atrial volume reduction plasty. The presence and onset of sinus rhythm and the incidence of trans mitral A waves were monitored during the postoperative 7 days and throughout the follow up period of 3 and 6 months. Mean follow up periods were 15.8 10.1 months in group 1 and $6.1\pm2.7$ months in group 2. Result: The sinus onset were $9.88\pm12.2$ days in group 1, and $1\pm3.6$ days in group 2 (p<0.01). The sinus conversion rates in the group 1 and 2 were $65\%,\;75\%$ (p=0.07) in the postoperative 7 days, $70.5\%,\;100\%$ (p<0.01) at postoperative 3 months, and $93\%,\;100\%$ (p<0.01) at postoperative 6 months, respectively. The wave detection rates in the postoperative 7days were $31.2\%\;and\;63.6\%$, and continued to improve over time to $83.3\%\;and\;100\%$ by 6months, respectively. Conclusion: The results suggest that Maze procedure with left atrial volume reduction plasty is effective for inducing sinus rhythm and for restoring left atrial contractile function after concomitant rheumatic mitral valve surgery. However further follow up of this patients for long time is necessary.

• Journal of Chest Surgery
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• v.33 no.11
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• pp.863-868
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• 2000

배경: Cox-Maze III (CM-III) 술식은 복잡한 심방 절개로 인한 긴 수술시간 때문에 다른 개심 수술과 병행하여 시행하기 어려운 단점이 있다. 대상 및 방법: 저자들은 CM-III 술직을 다음과 같이 변형하여 시행하고 그 임상성적을 분석하였다. \circled1 좌심방이를 절제하는 대신 좌심방이를 외부에서 결찰하고, \circled2 폐정맥 분리 절개선과 좌심방이 사이에 냉동절제술을 시행하며, \circled3 우심방이를 절제하는 대신에 우심방 외측 절개선을 우심방이까지 연장하고, \circled4 후종 우심방 절개 하부에서 우심방 외측을 지나 삼첨판막륜으로 향하는 T-자 절개선을 생략하였다. 저자들이 시행한 변형 술식의 용이성과 효율성을 평가하기 위하여, 우리나라에서도 빈도가 높은 류마치스성 승모판막 질환에서, 전통적인 Cox-III 술식(그룹 I)의 임상결과와, 변형된 CM-III 술식(그룹 II)의 임상결과를 비교하였다. 결과: 그룹 I(n=18)에서 동반된 수술은 승모판막 치환술 10례, 승모판막 성형술3례, 승모판막 치환술과 삼첨판막륜 성형술3례, 승모판막 재치환술 2례 등이었다. 그룹II(n=23)에서 동반된 수술은 승모판막 치환술 7례, 승모판막 성형술 5례, 승모판막 치환술과 삼첨판막륜 성형술 1례, 승모판막 재치환술 10례 등이었다. 그룹 I과 그룹 II에서 평균 대동맥 차단 시간(ACC)은 각각 135$\pm$29분과 104$\pm$18 분, 심패바이패스(CPB) 시간은 각각 240$\pm$33분과 185$\pm$42분이었다. 그룹 I과 그룹 II의 평균 추적 관찰 기간은 각각 47$\pm$14 개월과 29$\pm$4 개월이었다. 그룹 I에서는 16례(88.9%)에서 정상 동율동으로 회복되었고 1례에서 심방세동이 남아 있었으며, 다른 1례는 서맥증후군(sick sinus syndrome)으로 인공 심박조율기를 삽입하였다. 그룹 II에서는 21례(91.3%)에서 정상 동율동으로 회복되었고 2례는 심방세동이 지속되었다. 그룹 I에서 정상동율동으로 회복된 16례는 100%(16/16)에서 우심방의 수축을 심장 초음파검사에서 확인할 수 있었으며, 좌심방의 수축은 75%(12/16)에서 확인할 수 있었다. 그룹 II에서는 정상 동율동으로 회복된 21례 중 100%(21/21)에서 우심방의 수축을 확인할 수 있었으며, 좌심방의 수축은 76.2%(16/21)에서 확인할 수 있었다. 결론: 변형 CM-III 술식은 전통 CM-III 술식에 비하여 ACC time(p<0.005)과 CPB time(p<0.001)을 의미있게 줄이면서도 필적할 만 한 정상 동율동 전환율과 심방 수축력의 회복을 보여주었다.

• Proceedings of the KTCVS Conference
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• 1995.10a
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• pp.58-58
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• 1995