• Journal of Chest Surgery
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• v.32 no.10
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• pp.874-882
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• 1999

배경: 체외순환 후의 부종현상 및 이에 따른 여러 장치의 기능 저하를 방지하기 위하여, 최근에 체외 순환 이탈 후 환자의 혈액을 짧은 시간에 관류하여 여과해 주는 변형 초여과법의 사용이 늘고 있다. 이에 대한 긍정적인 임상결과들의 보고도 있으나, 다른 한편 체외 순환 후 염증반응을 포함한 폐손상의 기전에 혈구 성분의 영향이 보고되고 있는 바, 변형 초여과법의 효과, 특히 폐 조직에 대한 영향을 밝혀 보고자 하였다. 대상 및 방법: 몸무게 15에서 22 Kg(평균 16.5$\pm$0.5)의 16 쌍의 잡견을 이용한 정소성 심장이식, 실험에서, 통상적인 인공심폐기 작동군과 인공심폐기 작동 후 변형 초여과 관류를 시행한 군으로 무작위 구분하였다. 변형초여과법은 체외순환 정지 후에 대동맥관에서 나온 혈류를 Roller pump를 거쳐 Amicon Diafilter 초여과 관에 150 mL/m 정도의 속도로 10~15 분 정도 관류시켜 정맥관을 통하여 우심방에 직접 주입하였다. 혈액 채취 및 폐생검은 심폐기 시작 전과 정지 직후, 그리고 변형초여과 시행 군은 초여과 완료 직후에, 대조군은 심폐기 정지 10~15분 후에 각각 시행하였다. 혈류역학 측정요소는 동맥압, 우심방압, 좌심방압 등이었으며, 혈액 검사 항목은 동맥혈 가스분석, 혈색소 농도, 헤마토크릿, 백혈구 수, 혈소판 수, 혈중 단백 성분, 알부민 성분 등이었다. 폐 생검 조직으로는 냉동 건조법을 이용한 수분 함유량을 측정하였고, 광학 및 전자현미경으로 관찰을 하였다. 결과: 변형 초여과 군에서 혈중 혈색소 농도는 수술전 10.3$\pm$1.7 mg/dL, 심폐기 정지 직후 6.3$\pm$1.7 mg/dL, 초여과 직후는 8.3$\pm$2.8 mg/dL의 변화를(p=0.0078, 0.0117), 혈중 총 단백질의 농도 변화는 4.3$\pm$0.9, 3.1$\pm$1.5, 4.1$\pm$1.6 mg/dL, 혈중 알부민의 농도는 1.9$\pm$0.5, 1.4$\pm$0.7, 1.8$\pm$0.8 mg/dL로서, 각각 초여과법의 시행 전후에 유의한 증가를 가져왔고(p=0.0280, 0.0277), 폐조직의 수분 함유량의 변화는 수술전 75.1$\pm$8.6%, 심폐기 정지 직후 82.8$\pm$6.0%, 초여과 직후 77.88%를 보인 반면, 대조군에서는 각각 74.7$\pm$4.9, 82.1$\pm$5.9, 82.3$\pm$5.1%의 변화를 보였다. 미세 구조의 관찰에서, 폐포의 내포세피의 융합 기저막층과 미토콘드리아에서의 부종은 변형 초여과 후에 급격히 감소하였으나, 미토콘드리아내 크리스티의 파괴성 변화와 막성 파괴 성향이 초여과 후에 심화되게 관찰되었고, 세포질 내 소체의 팽창과 공포화 현상도 심폐기 가동 후 발생하여 초여과 후에 더 심화되게 관찰되었다. 세포질 내 소체의 팽창과 공포화 현상도 심폐기 가동 후 발생하여 초여과 후에 더 심화되게 관찰되었다. 폐조직 내의 백혈구는 심폐기 작동 후에 그 수에 있어서 증가하였으며 백혈구의 괴변, 탈과립 정도도 심폐기 작동 후 및 초여과 후에 증가한 소견을 보였다. 결론: 변형 초여과법은 인공 심폐기 후의 혈색소 농도 및 혈중 단백질 농도의 복원에 효과가 있었으며 변형 초여과 관류후 폐의 미세 조직내에서 부종의 급격한 감소 등을 관찰할 수 있었다.

• Journal of Chest Surgery
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• v.36 no.9
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• pp.659-665
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• 2003

The aim of this study was to evaluate the early and midterm results of off-pump total arterial revascularization using the skeletonized right gastroepiploic artery (RGEA) as a third arterial conduit. Material and Method: We prospectively analyzed 103 patients who underwent off-pump total arterial revascularization using bilateral internal thoracic arteries (ITAS) and RGEA. The RGEA was used as in situ graft in 88 patients, composite graft in 10 patients, and free graft in 5 patients. Postoperative coronary angiographies were performed before discharge in 100 patients, and at postoperative one year in 88 patients. Result: The RGEA showed a significantly higher free flow (130$\pm$95 ml/min) than that of right ITA(113$\pm$57 ml/min) or left ITA (107$\pm$55 ml/min), which was measured before anastomosis (p < 0.05). The total number of distal anastomoses was 3.8$\pm$0.7. The number of distal anastomoses per bilateral ITAs was 2.8$\pm$0.7 and the number of distal anastomosis per RGEA was 1.0. There were two morialities including one operative mortality. The late mortality was not related to cardiac events. Early postoperative morbidities were atrial fibrillation in 15 patients, bleeding reoperation in 4 patients, mediastinitis in 1 patients, perioperative myocardial infarction in 2 patient, and transient ARF in 3 patients. Postoperative coronary angiographies showed the early patency rate of 98.6％ (272/276) for ITAs and 97.0％ (97/100) for RGEA, respectively (p=ns), and the one-year patency rate of 95.9％ (234/244) for ITAs and 88.6％ (78/88) for RGEA, respectively (p=0.07). Flow competition between the RGEA and NCA (native coronary artery) was seen in 5 of the 100 patients (5.0％) immediate postoperatively and 7 of the 88 patients (8.0％) 1 year after surgery. Since July, 2000, we measured transit time flow intraoperatively and could reduce flow competition significantly Conclusion: The skeletonized RGEA demonstrated excellent early and midterm patency rates and could be used as a third arterial graft following the bilateral ITAs.

• Journal of Chest Surgery
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• v.39 no.8 s.265
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• pp.598-603
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• 2006

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 $66{\pm}6$ 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.

• Journal of Chest Surgery
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• v.38 no.12 s.257
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• pp.821-827
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• 2005

Background: Hemodilution after priming of the cardiopulmonary bypass is known to increase the possibility of bleeding and homologous transfusion in adult cardiac surgery. We investigated the effects of retrograde autologous priming (RAP) to see whether it would decrease postoperative bleeding and homologous transfusion. Material and Method: We retrospectively reviewed 34 patients wpho underwent RAP and 46 patients who did not. Retrograde autologous priming consisted of arterial lire drainage, venous reservoir and oxygenator drainage and venous line drainage. We compared the amount of priming solution and RAP volume, perioperative hematocrit, postoperative bleeding and transfusion requirements in the two groups. Resuit: Mean withdrawal volume in RAP group was 613.5$\pm$160.6 mL and initial priming volume was 1381.9$\pm$37.2 mL. Hemoatocrits ($\%$) in RAP and control groups were 25.0$\pm$3.7 vs 20.9$\pm$3.6 (5 minutes after CPB), 25.9$\pm$3.7 vs 22.5$\pm$3.6 (30 minutes after CPB), 25.9$\pm$3.4 vs 23.8$\pm$2.8 (60 minutes after CPB), 31.9$\pm$3.9 vs 31.5$\pm$4.5 (postoperative 1 hour), 32.4$\pm$4.4 vs 32.1$\pm$4.5 (postoperative 6 hours), 33.4$\pm$5.0 vs 31.7$\pm$5.1 (postoperative 1 day)[repeated measures ANOVA, p < 0.05]. Chest tube drainages (mL) in the two groups were 357.2$\pm$177.1 vs 411.7$\pm$279.5 (postoperative 6 hours), 599.4$\pm$145.6 vs 678.8$\pm$256.4 (postoperative 24 hours)[t-test, p < 0.05]. Homologous transfusion was performed in 7 out of 34 patients in RAP group (20.6$\%$), and 16 out of 46 (34.8$\%$) in control group (p < 0.05). Conclusion: This study suggests that the effects of reducing the priming volume during cardiopulmonary bypass may result in lesser bleeding and homologous transfusion. Retrograde autologous priming would be used to reduce postoperative bleeding and chance of transfusion after adult cardiac surgery.

• Journal of Chest Surgery
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• v.35 no.5
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• pp.375-380
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• 2002

Background: Sternal infection after open heart surgery is a serious complication associated with high rate of mortality. We reviewed the effect of improved operating room and intensive care unit un the sternal infection by analyzing the incidence and condition of that around the movement of operating room and intensive care unit in July 1997. Material and method: We reviewed a total of 453 patients. Group I contains 237 patients who underwent open heart surgery between January 1997 and December 1978 before we moved the intensive care unit and of operating room, and Group II contains 216 patients who underwent open heart surgery between January 2000 and July 2001 after we moved. We only included adult patients over age 15 who underwent cardiopulmonary bypass through median sternotomy and excluded the mortality cases except sternal infections in this study. Result: Sternal infection developed in 18 patients(8.0%) in Group I, and in only 1 patient(0.49%) in Group II. Emergency operation, cardiopulmonary bypass time, operation tilde, transfusion, tracheostomy, and reoperation are significantly associated with sternal infection among the known risk factors. The logistic regression analysis containing those six factors revealed that the movement of intensive care unit and operating roots is effective on the decreasing sternal infection(p=0.029, 95% confidence interval 0.011 ∼ 0.788). Conclusion: Although there have been studies on manly risk factors associated with the sternal infection after open heart surgery, we think that the improvement of operting room and intensive care unit is a method for decreasing the incidence of sternal infection.

• Journal of Chest Surgery
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• v.39 no.8 s.265
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• pp.643-647
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• 2006

Congenital tracheomalacia associated esophageal atresia is a rare foregut anomaly. We report a case of 40-day old male infant with tracheomalacia who has undergone repair of esophageal atresia at his age of 1 day. The patient had progressive dyspnea and stridor after repair of esophageal atresia. His 3-dimensional chest computed tomography showed severe stenosis at the middle of trachea. We underwent resection and end-to-end anastomosis under cardiopulmonary bypass. Histologic examination revealed esophageal tissues indicating congenital origin as well as no cartilage.

• Journal of Chest Surgery
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• v.34 no.9
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• pp.653-661
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• 2001

Background: Retrograde cerebral perfusion(RCP) is one of the methods used for brain protection during aortic arch surgery. The author previously published the data, however, for the safety of it, there still remains many controversies. The author performed RCP and checked various parameters to clarify the possibility of early detection of cerebral injury. Material and Method: The author used pigs(Landrace species) weighing 25 to 30kg and performed RCP for 120 minutes. After weaning of cardiopulmonary bypass, we observed pigs for another 120 minutes. Rectal temperature, jugular venous oxygen saturation, central venous pressure were continuously monitored, and the hemodynamic values, histological changes, and serum levels of neuron-specific enolose(NSE) and S100$\beta$ protein were checked. Central venous pressure during RCP was maintained in the range of 20 to 25 mmHg. Result: Flow rates(ml/min) during RCP were 224.3$\pm$87.5(20min), 227.1$\pm$111.0(40min), 221.4$\pm$119.5(60min), 230.0$\pm$136.5(80min), 234.3$\pm$146.1(100min), and 184.3$\pm$50.5(120min). Serum levels of NSE did not increase after retrograde cerebral perfusion. Serum levels of S100$\beta$ protein(ng/ml) were 0.12$\pm$0.07(induction of anesthesia), 0.12$\pm$0.07(soon after CPB), 0.19$\pm$0.12(20min after CPB), 0.25$\pm$0.06(RCP 20min), 0.29$\pm$0.08(RCP 40min), 0.41$\pm$0.05(60min), 0.49$\pm$0.03(RCP 80min), 0.51$\pm$0.10(RCP 100min), 0.46$\pm$0.11(RCP 120min), 0.52$\pm$0.15(CPBoff 60min), 0.62$\pm$0.15(60min after rewarming), 0.76$\pm$0.17(CPBoff 30min), 0.81$\pm$0.20(CPBoff 60min), 0.84$\pm$0.23(CPBoff 90min) and 0.94$\pm$0.33(CPBoff 120min). The levels of S100$\beta$ after RCP were significantly higher than thosebefore RCP(p<0.05). The author could observe the mitochondrial swellings using transmission electron microscopy in neocortex, basal ganglia and hippocampus(CA1 region). Conclusion: The author observed the increase of serum S100$\beta$ after 120 minutes of RCP. The correlation between its level and brain injury is still unclear. The results should be reevaluated with longterm survival model also considering the confounding factors like cardiopulmonary bypass.

• Journal of Chest Surgery
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• v.36 no.8
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• pp.576-582
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• 2003

During the Off-Pump Coronary Arterial Bypass surgery (OPCAB), the manipulation of the heart can depress cardiac contractility and cause hemodynamic instability. In this study, hemodynamic parameters were measured during operation and the laboratory and clinical data were investigated to evaluate their effects on postoperative outcome. Material and Method: From March 2001 to August 2002, 50 consecutive patients who underwent OPCAB were included in this study. During the same period, total number of CABG was 71 The blood pressure, pulmonary artery pressure, mixed venous oxygen saturation, and cardiac index were measured before manipulation, after application of stabilizer, and at the end of anastomosis. Postoperatively, we measured the cardiac enzymes such as CK-MB, troponin 1 and checked the amount of inotropes required, chest tube drainage, the amount of transfusion, duration of ventilator support, and duration of ICU stay. Result: The number of mean distal anastomoses was 2.8$\pm$0.9 per patient. On elevation and stabilization of the heart, systolic blood pressure was depressed and pulmonary artery pressure was elevated significantly, but during each anastomosis no significant changes were detected. The peak level of cardiac markers was 29.2$\pm$46.7 for CK-MB, 0.69$\pm$0.86 for troponin 1 on postoperative day f. Among the intraoperative hemodynamic parameters, the ischemic change of EKG and bolus injection of inotropes significantly affected the posteroperative cardiac enzymes. But, no difference other than the level of cardiac enzymes between the two groups with or without the ischemic change of EKG and bolus injection of inotropes was noticed. Conclusion: The significant hemodynamic changes occurred when the heart was elevated and stabilized, however during anastomoses there were no significant changes. Serum cardiac enzymes rose significantly in the group that showed the ischemic charge of EKG or needed the bolus injection of inotropes for maintaining hemodynamic stability intraoperatively, but it did not affect the postoperative outcome. In conclusion, the ischemic change of EKG and the need for bolus injection of intropes during operation may be very indicative for probable ischemia.

• Journal of Chest Surgery
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• v.41 no.2
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• pp.202-209
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• 2008

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.

• Journal of Chest Surgery
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• v.36 no.7
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• pp.531-534
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• 2003

A 43-year-old woman who had had an invasive mole 5 years previously required emergent pulmonary embolectomy under cardiopulmonary bypass. Curative resection was impossible because the tumor invaded the right main pulmonary artery and left lower pulmonary artery. The pathologic diagnosis made by the tumor emboli specimens was choriocarcinoma. The patient received post-operative chemotherapy over a 6-month period and had complete remission. Although rare, choriocarcinoma should be considered in the differential diagnosis of fertile women presented with pulmonary embolism.