• Journal of Chest Surgery
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• v.38 no.4 s.249
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• pp.284-290
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• 2005

We evaluated the early and mid-term results for repair of Ebstein's anomaly. Material and Method: Between January 1989 and June 2004, 29 patients underwent repair of Ebstein's anomaly. The median age was 11.4 years (4 days-50 years). Tricuspid insufficiency equal to or greater than grade 3 was present in 21 $(72.4\%)$ patients. Surgical techniques included tricuspid valve repair with vertical plication of the atrialized ventricle (n=14), Carpentier's technique (n=7), tricuspid valve replacement (n=4), systemic-to-pulmonary arterial shunt (n=2), tricuspid valve repair (n=1), and Fontan operation (n=1). Bi-directional cavopulmonary shunt (BCPS) was required in 5 patients. Among the 2 neonates, one patient underwent successful biventricular repair, and the other patient underwent systemic-to-pulmonary arterial shunt. Follow-up was possible in 21 patients $(75\%)$, and the average follow-up was 37.6 months (3 months-11.3 years). Result: There were $1(3.4\%)$ early and 1 late deaths. Reoperation was required in 4 patients. Two patients underwent tricuspid valve re-replacement, and the other 2 tricuspid valve repair. At recent follow-up, only 2 patients showed tricuspid insufficiency equal to or greater than grade 3, and most patients showed clinical improvement. Excluding the patients who underwent tricuspid valve replacement, the actuarial rate of freedom from reoperation at 1 and 5 years were $94.7\%\;and\;79.0\%$, respectively. Conclusion: Tricuspid valve repair was possible in most patients with good mid-term outcome. Most patients showed clinical and hemodynamic improvement. Indications for the BCPS should be clarified.

• Journal of Chest Surgery
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• v.31 no.6
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• pp.560-566
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• 1998

Background: Bovine pericardial bioprosthesis treated with glutaraldehyde (GA) is one of the most popular prosthetic materials, but late calcific degeneration after implantation is a problem that remains unsolved. For the purpose of mitigating the calcific degeneration, we added MgCl2 into the 0.625% GA solution to compete with calcium for binding to the free aldehyde from GA and pretreated with the surfactants like sodium dodecyl sulfate (SDS) and Triton X-100 before GA fixation for preventing the phospholipid infiltration into the pericardial tissue, the first step of the calcific degeneration. Material and Method: 40 square-shaped pieces of bovine pericardia were fixed in 0.625% GA solution with 4g/L MgCl2 6H2O as a control group (group 1). 40 pieces pretreated with 1% SDS were also fixed in the same GA solution (group 2) and other 40 pieces pretreated with 1% Triton X-100 were prepared with the same method (group 3). After 1 month of fixation these were implanted into the belly of 40 Sprague-Dawley subdermally and extracted 1 month, 2 months, 3 months and 6 months after implantation. With atomic absorption spectrophotometry we measured the deposited calcium amount. Result: 1 month after implantation we could not find any differences between the three groups, but by the 2nd month calcium deposition was 0.921$\pm$0.121 mg/g in group 1, 0.481$\pm$0.037 mg/g in group 2 and 1.369$\pm$0.200 mg/g in group 3. By the 3rd month it was 0.786$\pm$0.080 mg/g in group 1, 0.584$\pm$0.054 mg/g in group 2 and 1.139$\pm$0.188 mg/g in group 3, and on the 6th month 1.623$\pm$0.601 mg/g in group 1,0.501$\pm$0.043 mg/g in group 2 and 1.625$\pm$0.382 mg/g in group 3, with statistical significance in group 2(p<0.05). Conclusion: Pretreatment with SDS showed meaningful calcium mitigation effects on subcutaneously implanted bovine pericardium in the rat models but the neutral type surfactant, Triton X-100, had no positive mitigation effect in this experiment.

• Journal of Chest Surgery
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• v.34 no.11
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• pp.848-853
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• 2001

Background: Sternal infection or dehiscence after cardiac surgery through median sternotomy is rare. If suitable treatment is not performed for the complication, however, the mortality is high. For 12 patients with sternal dehiscence or infection, we performed wide excision of the infected and necrotic tissue and covered with muscle flap(s) to obliterate the mediastinal dead space. Material and method: Sternal infection or dehiscence occurred in 13 of patients who underwent cardiac surgery One patient, who died of cerebral infarction before the sternal complication was treated, was excluded in this study. The sternal wound complication occurred in 6 of patients with valve replacement and 6 of patients with coronary bypass surgery, respectively. Since 1991, 9 patients underwent definite surgical debridement and muscle transposition as soon as fever was controlled with closed irrigation and drainage. The necrotic tissue and bone was widely excised and the sternal dead space was eradicated with the single flap or the combined flaps of right pectoralis flap(turnover flap), left pectoralis flap(turnover flap or rotation-advancement flap), and right rectus muscle flap. Result : There was no mortality in 12 patients with coverage of muscle flap(s) for sternal infection or dehiscence The mean interval between the diagnosis of sternal complication and the myoplasty was 6.6$\pm$3.9 days. In 4 patients, one pectoralis muscle flap was used, and in 8 patients both pectoralis muscle flaps were used. For each 1 patient and 2 patients in each group, right rectus muscle flap was added. For the last 3 patients, a single pectoralis flap was used to eradicate the mediastinal dead space and the longer placement of the mediastinal drain catheter was needed. One patient, who had suffered from necrosis of left pectoralis flap(rotation-advancement flap) with subsequent chest wall abscess after coverage of both pectoralis flaps, was managed with reoperation using right rectum flap. Conclusion : Sternal dehiscence or infection after cardiac operation can be readily managed with wide excision of necrotic infected tissue(including bone) and muscle flap coverage after short-term irrigation of sternal wound. The sternal(mediastinal) dead space may be completely eradicated with right pectoralis major muscle flap alone.

• Journal of Chest Surgery
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• v.36 no.3
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• pp.142-149
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• 2003

To know the feasibility of the coronary artery bypass graft (CABG) for multivessel coronary artery disease with purely bilateral internal thoracic arteries (ITAs), we analyzed the short-term clinical results and the coronary angiography of the patients. Material and Method: From March 2001 to June 2002, four hundred and five patients underwent CABG. Purely bilateral ITAs were used in 159 patients (39.3%). We analyzed these patients retrospectively The mean age of these patients was $61.2{\pm}8.5$ (range: 30 ~80) years and there were 123 male patients. The preoperative risk factors were as follows: diabetes in 54 patients (34.0%), history of acute myocardiac infarction within 4 weeks in 29 (18.2%), and emergency operation in 6 (3.8%). Off-pump CABG was carried out in 128 patients (80.5%). Associated procedures were mitral valvuloplasty (5), aortic valve replacement (3), Dor procedure (1), and so on. Result: The mean number of distal anastomoses was $3.1{\pm}0.9$ (range: 2~6), the mean duration of hospital stay was $8.4{\pm}4.5$ days. There was one (0.6%) operative death. Except for one early death, no other patients suffered from low cardiac output. The other postoperative complications were occurred as follows: reoperation due to bleeding in 3 patients, perioperative myocardiac infarction in 1, transient cardiac arrest in 2, transient cognitive dysfunction in 7, and transient ischemic attack in 1, and deep sternal wound infection in 1 patient. Recently, early postoperative angiography was performed in 19 patients who had triple vessel disease. The total number of distal anastomosis was 78 (mean $4.1{\pm}0.8$/patient). All distal anastomosis sites were patent, but competition flow was observed at the bypass sites where the native coronary artery stenosis was not significant. Conclusion: The CABG with purely bilateral ITAs for triple vessel disease was performed safely. The early patency rate was relatively good in small number of patients. However the long-term patency rate and the functional study to evaluate the sites where competition flow was observed should be followed.

• Journal of Chest Surgery
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• v.38 no.4 s.249
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• pp.271-276
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• 2005

We analysed differences in operative methods and postoperative outcome according to the severity of preoperative cyanosis in adult ToF (Tetralogy of Fallot) patients. Material and Method: From August 1989 to June 2001, thirty three adult patients, 18 females and 15 males, underwent total correction for ToF. Their age ranged from 15 years to 54 years (median: 34). Patients were divided into 2 groups by preoperative $SaO_2$ (arterial oxygen saturation): group I$(n=cyanotic,\;SaO_2\;\geq94\%)$ and group II $(acyanotic,\; SaO_2\geq95%)$. Preoperative median hemoglobin level was higher in group I compared to group II (17.5 g/dl vs 15 g/dl). Postoperative follow-up duration ranged from 1 to 94 months (670 patient-month, median: 14 months), and 63 two-dimensional echocardiographic examinations were done during this period. Result: There were no early or late mortality. With regard to RVOT (right ventricular outflow tract) reconstruction, trans-annular patch and RV-PA extracardiac conduit were used in 7 and 3 patients respectively, and all of them belonged to group I. In group I, cardiopulmonary bypass time, aortic cross-clamping time, ICU day, hospital day were significantly longer than in group II, and postoperative inotropic support was significantly greater than in group II. There was no ventricular arrhythmia in both groups, and one patient in group I suffered from atrial arrhythmia, which was resolved spontaneously after tricuspid and pulmonary valve replacement. During follow-up periods, functional class, residual RVOT stenosis and pulmonary regurgitation, tricuspid regurgitation, occurrence of ventricular and atrial arrhythmias were comparable between two groups. Conclusion: In adult ToF patients with severe preoperative cyanosis, more aggressive RVOT reconstruction and careful postoperative care are mandatory. However intermediate-term outcome of this group of patients is comparable to the patients with minimal or no preoperative cyanosis.

• Journal of Chest Surgery
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• v.35 no.4
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• pp.261-266
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• 2002

In an attempt to avoid the adverse effects of the cardiopulmonary bypass, off pump coronary artery bypass grafting(Off pump CABG) that has recently been rediscovered and refined. We compared the preoperative risk factors and in-hospital outcomes of patients done Off pump with those done On pump CABG. Material na Method: One hundred seventy eight patients was underwent CABG between January 2001 and July 2001 12 patients whom underwent associated valvular or left ventricular volume reduction surgery were excluded in this study Data were collected for 52 Off pump CABG and 114 On pump CABG for patient and disease risk factors, extent of coronary disease, and in-hospital outcomes. Result: Off pump CABG and On pump CABG groups did not show any differences in their patient and disease risk factors, and extent of coronary disease. Off pump CABG group had significantly lower mean operation time(234 $\pm$ 37 min vs 290 $\pm$ 48 min, p<0.001), lower mean CK-MB level(10.1 $\pm$ 13.5 IU/L vs 33.1 $\pm$ 18.2 IU/L, p<0.001) and mean ventilation time(14.8 $\pm$ 3.5 hours vs 16.2 $\pm$ 4.9 hours, p=0.048) than On pump CABG groups. On pump CABG group had significantly more distal grafts(3.4 $\pm$ 0.9 vs 2.6 $\pm$ 0.8, p<0.001) than Off pump CABG groups. There were no operative mortality in two groups. Off pump) CABG and On pump CABG groups did not show any differences in their postoperative complications and outcomes including perioperative myocardial infarction, stroke, respiratory failure, renal failure, reoperation, the amount of bleeding, the need of intraaortic balloon pump, the need of inotropics, and the stay of intensive care unit and hospital. Two patients were converted to On pump CABG. Conclusion: This study showed that patients having Off pump CABG are not exposed to a greater risks of adverse outcomes and also provided evidence that patients having Off pump CABG have significantly lower operation time, CK-MB, ventilation time and less distal grafts. Although there may be potential benefits to Off pump CABG, further studies must be directed to determine those patients who would benefit from Off pump CABG.

• Journal of Chest Surgery
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• v.30 no.9
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• pp.869-875
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• 1997

Perimembranous ventri ular septal defects(PMVSDS) are the most common type of ventricular septal defects(VSDs) and consist morphologically of deficiency of the membranous septum and variable portions of the adjacent muscular septum. Repair of VSD has begun via a right ventriculotomy. Even with this exposure, however, it mght lead to ventricular dysfunction. Transatrial exposure of VSDs is luiown to a versatile approach to PMVSDS and even malaligunent defects can be repaired by this method. Although transatrial exposure can be improved by taking down'the atrioventricular valve at the annulus, surgeons have been hesitant to do so because of concern for valvular competence. Therefore, this study was undertaken to clarity the effects of transamlular approach of tricuspid valve (TATV) at operation of PMVSD. During last 5 years, twenty eight cases from 96 patients of PMVSD were closed by TATV and follow up study was done from 3 months to 33 months and results were obtained as follows. 1. Age at operation was fr m 4 months to 38 years and most patients(17, 62%) were above 5 years. 2. Preoperative pulmonary-systemic flow ratio(QPIQS) was ranged from 1 to 2.8 and 22 patients(79%) were less than 2. 3. Peak systolic pulmonary artery pressure was below 30mmHg in 8, 30-50mmHg in 17, above 50mmHg in 3 patients and 25 patients(89%) were less than 50mmHg. 4. Preoperative tricuspid regurgitation(TR) is none in 12, trivial in 6, mild in 3, moderate in 5, severe in 2 patients but postoperative TR was none in 18, trivial in 6, mild in 4 patients, so TR in most patients had decreased or not. 5. Indications for operation were based on the presence of a significant shunt. However, in patients with small shunts, indications for operation were included additional factors, tricuspid valve pouch, RVOT obstruction(right ventricular outflow tract obstruction), subacute bacterial endocarditis and associated anomalies. 6. There were no hospital deaths and residual shunts in postoperative echocardiography. Therefore TATV is especially a good method in PMVSn where patients have trcuspid valve pouch. And it is a safe and effective technique that improves exposure for PMVSD repair and does not adversely affect tricuspid valvular competence.

• Journal of Chest Surgery
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• v.31 no.11
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• pp.1043-1048
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• 1998

Background: As coronary arterial disease is increasing, we evaluated the patients who underwent CABG(Coronary Artery Bypass Grafting) and thus report the early results and risk factors related to mortality and morbidity. Materials and methods: Between July 1996 and February 1998, 42 patients underwent CABG. We analyzed age, sex, preoperative ejection fraction, Canadian heart classification, prevalence factors of CAD(Coronary Artery Disease), angiographic findings, graft vessel numbers, IMA(Internal Mallary Artery) use, ECC* (extracorporeal circulation) time and morbidity. We also evaluated the mortality rate and the causes of death. Results: Complication was developed at 17cases. The average age of the complication group was 61±11.9 years and that of the noncomplication group was 51±10.5 years(p=0.004). ECC time was 198±42.5(min) in the complication group and 158±47.4(min) in the noncomplication group(p=0.008). The other factors had no correlation to the morbidity, statistically. The average follow up duration was 12.5 months and all the patients were alive except for the 2 expired cases. The mortality rate was 4.7%, among which one patient who underwent CABG with aortic valve replacement died due to multiorgan failure and the other died due to sepsis with pneumonia and wound infection. Conclusions: We conclude that the risk factors related to morbidity were age and ECC time, and that there were no correlations between other factors and morbidity.

• Journal of Chest Surgery
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• v.31 no.11
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• pp.1023-1030
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• 1998

Background: Calcific degeneration limits durabilities of the bioprosthetic tissues implanted in the human body. The direct coupling sulphonated polyethyleneoxide(PEO-SO3) to the bioprosthetic tissues after glutaraldehyde(GA) fixation and the removal of residual aldehyde groups from the tissues can augment the effect of calcification-resistance. Materials and methods: To study the anti-calcification effect by PEO-SO3 modification and the removal of the residual aldehyde groups of tissues, surface modified bovine pericardia(BP-PEO-SO3) were preserved in aseptic saline to wash out GA(saline group) and 0.65% GA solution(GA group). And then above two groups and PERIGUARD (Bio-vascular. Co.) (product group) were evaluated with respects to calcium contents and microscopic findings using in vivo implantation models at carotid and femoral artery and peritoneum of 8 adult dogs. Results: In the tissues retrieved from carotid artery, calcium content was significantly decreased in saline group than in other two groups(saline; 2.89±0.31 vs. GA; 6.14±1.08 vs. product; 22.82±5.00 mg/g of dried tissue; p<0.05). In the tissues retrieved from femoral artery and peritoneum, calcium amount was also decreased in saline group than in other two groups, but not reached the significant difference between groups. On the other hand, the pathologic findings of pericardial tissues showed marked destructuction in GA group compared to the other two groups. Conclusions: In this study, covalently PEO-SO3 bound to bovine pericardium decreased calcifications and the anti-calcification effect of BP-PEO-SO3 could be augmented by the washing out the residual aldehyde groups using saline after GA fixation. Conclusively, the PEO-SO3 modified bovine pericardium is highly resistant to calcification and can be useful for the development of calcification-resistant cardiovascular patches and valves.

• Journal of Chest Surgery
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• v.30 no.3
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• pp.275-281
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• 1997

The radial artery as a graft for myocardial revascularization was introduced by Carpentier in the early 1970s. Mid-term results were unfortunately discoura ing, and the clinical experience with this graft was interrupted. At the end of the 1980s, these authors reproposed the same arterial conduit with more satisfying results, because of improved technique and pharmacological management of the graft. Between October 1994 and July 1995, 36 patients underwent myocardial revascularization with a radial artery graft in Seiong General Hospital. Left internal mammary artery was concomitantly used as a pedicled Vift in 34 patients. Fifteen patients (42%) had a complete arterial waft revascularization. A total of 12) distal anastomoses were performed (average 3.4 per patient), including 36 left internal mammary artery wafts (two sequential in 2 patients), and 23 saphenous vein grafts. The remaining 64 distal anastomoses were perFormed with radial artery grafts (mean 1.8 per patient). The radial arteries were anastomosed to the circumflex (n=38), diagonal (n= 18), right coronary(n=G), and left anterior descending coronary artery(n=2). The percent ge of radial artery graft anastomoses (64) to the total anastomoses(123) was 52%. The radial artery was used as a single graft in 10 patients, as a sequential graft in 25 patients, and two grafts in 1 patient. Twenty patients underwent associated procedures coronary endarterectomy (14), coronary artery patch angioplasty (4), mitral valve repair (1), and repair of ventricular septal rupture (1). One patient died of low cardiac output syndrome and the others had no perioperative myocardial infarction. There are no ischemic and functional complications in the arm or hand aftcr removal of the radial artery. Only 1 patient required reexploration of the am, for the hematoma evacuation, and 2 patients complained transient thumb dysesthesia of the side of the havested arm. This dysesthesia improved within one month. Postoperative angiovaphic controls were obtained in 11 patients(31%) postoperative 79 to 210 days (mean 126 days). The patency rate were as follows : left internal mammary artery (100%), saphcnous vein (100%), and radial artery(95%). We concluded that the radial artery is useful alternative graft, but long term clinical and angiographic studies are required to derterminc whether wider application is warranted.