• Journal of Chest Surgery
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• v.38 no.10 s.255
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• pp.675-679
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• 2005

Background: Clinical reports on replacement of all three (AV + MV + TV) valves are rare. Material and Method: From January 1992 to December 2003, 38 patients received triple valve replacement (aortic, mitral, tricuspid) at Yonsei Cardiovascular Center. Mean age of patients was $49.5\pm10.7 (28\~69)$ years, and 24 patients $(63.1\%)$ were female. Rheumatic valve disease was the most common cause of operation (n=37). Preoperative New York Heart Association functional class were II in 4, III in 24 and IV in 10. Fifteen patients (group 1) received triple valve replacement at their first operation. Twenty three patients (group 2) received one or more operations before tricuspid valve replacement (TVR). Seven patients received tricuspid valve annuloplasty at first operation and received TVR later. Result: Six patients died at hospital after operation $(15.8\%)$ and all these patients were in group 2. All patients in group I survived and were discharged. Three patients $(9.4\%)$ died during follow up periods. Most of the survivors had improved functional class (I in 22, II in 8, III in 1, IV in 1). During follow up period, there were 4 valve related complications. The 10-year survival rate was $68.8\%$ and survival rate for free from valve related event at 10 years was $85.5\%$. Conclusion: After triple valve replacement, most patients showed improvement of symptoms. And during follow up period, valve related complications and survival were acceptable. Therefore, if indicated, triple valve replacement is recommended before the patients' conditions get worse.

• Journal of Chest Surgery
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• v.33 no.11
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• pp.881-885
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• 2000

배경: 승모판막 질환에 동반된 심방세동의 경우 그 기간이 길면 승모판막 질환을 수술하여도 동성 율동으로 전환될 가능성이 매우 적다. 본 연구는 승모판막 질환에 동반된 심방세동에 대한 변형 Maze 수술후 장기 결과와 심방세도의 재발에 미치는 요인을 조사 하고자 하였다. 대상 및 방법: 1990년부터 1996년까지 승모판막 질환과 동반된 심방세동으로 외과적 요법을 시행받은 35명의 환자를 대상으로 하였다. 심방세동의 평균 유병기간은 평균 7.7$\pm$4.5년이었고 수술은 승모판막 대치술 34례(재수술 3례)와 승모판막 성형술 1례를 시행하였고 승모판 질환 수술 외에 동반 수술로는 삼첨판륜 성형술 4례, 삼첨판막 대치술 3례 였다. 심 방세동에 대한 수술은 좌측 폐정맥 부위는 격리하지 않는 변형 Maze 수술을 시행하였다. 수술 후 동성 율동으로 회복여부, 심방세동의 재발에 미치는 요인과 장기 결과를 분석하였다. 결과: 수술 직후 2례를 제외한 33례(93.9%)에서 동성율동으로 돌아왔으나 수술 후 퇴원 전에 12례에서 심방세동이 재발되었다. 수술환자중 1례에서 수술 후 3일에 동성 정지에 따른 심정지가 발생하여 소생되었으나 뇌손상으로 수술 후 15일에 사망하였다. 심방세동이 재발된 경우 수술 후 약 2개월에서 6개월 사이에 항부정맥 약물(mquinidine)과 전기적 제세동으로 치료하여 12례중 10례에서 동성 율동으로 돌아온 환자는 항부정맥 약물을 모두 중단하 였으며, 수술 후 3년에서 9년(평균 71.1$\pm$17.5개월) 추적 관찰 중 9례에서 심방세동이 재발되어 장기간 동성 율동이 유지된 환자는 34명중 25명으로 73.5%이었다. 승모판 질환이 있던 환자에서 수술 후 심방세동의 재발에 미치는 요인들을 조사한 결과 수술전 심방세동의 기간(동성율동 유지군 : 재발군=6.3년 : 10.3년, P=0.008)과 수술 전 단순 흉부 X선상 심흉비율(0.58 : 0.72, p=0.009)은 통계학적으로 유의하게 나타났으나 심초음파 검사상 좌심방의 직경(57.2mm : 77.4mm, p=0.106)은 통계학적 유의성이 없었다. 결론: 심방세동이 있는 환자에서 동반 질환 수술시 병행하여 수술한다면 정상 동성 율동으로 회복될 기회를 증가시킬 수 있는 유용한 수술법으로 생각된다. 그러나 수술후 재발률을 감소시키기 위하여 적절한 술기의 변형에 대한 연구와 약물요법의 병행을 고려하여야 할 것으로 사료된다.

• Journal of Chest Surgery
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• v.35 no.5
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• pp.350-355
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• 2002

Background: Most of pulmonary regurgitation with or without stenosis appears to be well tolerated early after the repair of pulmonary outflow tract. However, it may result in symptomatic right ventricular dilatation, dysfunction and arrhythmias over a long period of time. We studied the early outcome of pulmonary valve replacement with tissue valves for patients with the above clinical features. Material and Method: Sixteen consecutive patients who underwent pulmonary valve replacement from September 1999 to February 2002 were reviewed(9 males and 7 females). The initial diagnoses included tetralogy of Fallot(n=11), and other congenital heart anomalies with pulmonary outflow obstruction(n=5). Carpentier-Edwards PERIMOUNT Pericardial Bioprostheses and Hancock porcine valves were used. The posterior two thirds of the bioprosthetic rim was placed on the native pulmonary valve annulus and the anterior one third was covered with a bovine pericardial patch. Preoperative pulmonary regurgitation was greater than moderate degree in 13 patients. Three patients had severe pulmonary stenosis. Tricuspid regurgitation was present in 12 patients. Result: Follow-up was complete with a mean duration of 15.8 $\pm$ 8.5months. There was no operative mortality. Cardiothoracic ratio was decreased from 66.0 $\pm$ 6.5% to 57.6 $\pm$ 4.5%(n=16, p=0.001). All patients remained in NYHA class I at the most recent follow-up (n=16, p=0.016). Pulmonary regurgitation was mild or absent in all patients. Tricuspid regurgitation was less than trivial in all patients. Conclusion: In this study we demonstrated that early pulmonary valve replacement for the residual pulmonary regurgitation with or without right ventricular dysfunction was a reasonal option. This technique led to reduce the heart size, decrease pulmonary regurgitation and tricuspid regurgitation as well as to improve the patients'functional status. However, a long term outcome should be cautiously investigated.

• Journal of Chest Surgery
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• v.40 no.10
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• pp.659-666
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• 2007

Background: Preserving the subvalvular apparatus after mitral valve replacement (MVR) results in better ventricular function and a better outcome. In conjunction, mitral valve repair (MVr) is associated with a better outcome, yet little is known about the hemodynamics and outcomes between patients undergoing MVr and MVR with chordal preservation. We prospectively evaluated the hemodynamic changes and outcomes of patients undergoing MVr and MVR with chordal preservation. Material and Method: Fifty-four patients with mitral regurgitation (MR) who under-went MVR with chordal preservation (n=21) or MVr (n=33) were studied. The patients' characteristics, the intra-and postoperative hemodynamics and the use of cardiac medications, the postoperative outcome and the complications were recorded during the hospital stay. All the patients were followed up for at least 6 months post-operatively for determining their morbidity and mortality. Result: The patients' characteristics were similar between the groups, except for the presence of atrial fibrillation and congestive heart failure which was more frequent in the MVR group. Also, the preoperative left ventricular ejection fraction was lower in the MVR group than in the MVr group ($64{\pm}9%$ versus $69{\pm}5%$, respectively, p=0.043). There were no significant differences of the hemodynamics between the groups. The use of inotropic drugs and pacemakers during the 12hrs postoperatively was more common in the MVR group than in the MVr group (48% versus 24%, p=0.025 and 52% versus 24%, p=0.035, respectively). The other postoperative outcomes were similar in both groups for at least the 6 months follow-up period. Conclusion: MVR with chordal preservation was comparable with regard to the hemodynamics and clinical outcomes, supporting the beneficial effect of preserving the subvalvular apparatus after MVR.

• Journal of Chest Surgery
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• v.30 no.7
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• pp.656-662
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• 1997

Aortic valvuloplasty has recently gained attention as an attractive alternative procedure for aortic valvular disease. Between March 1995 to August 1996, 14 patients with pure aortic regurgitation(AR) underwent aortic alvuloplasty using leaflet extension with glutaraldehydepreserved autologous pericardium. There were 11 males and 3 females, and the mean age was 34.8 $\pm$ 15.3 years. Preoperative echocardiography and cardiac catheterization revealed that the degree of AR was mean 3.4$\pm$0.65, and more than moderate degree of mitral regurgitation(MR) were detected in 4 patients. In 12 patients, 3 leaflets were extended and in another 2 patients only one deformed leaflet was extended. Concomitant mitral valvuloplasty (MVP) was performed in 4 patients. The competency of the aortic valve after completion of repair was evaluated by the transesophageal echocardiography in operating theater, and there was no aortic and mitral stenosis or regurgitation. In an early postoperative echocardiography, trivial AR was detected in 3 patients and mild MR in 1 patient. The end-systolic and end-diastolic dimensions of the left ventricle were decreased significantly(p<0.05) as compared with those of preoperative values. T ere was no mortality and no significant postoperative complication encountered. Late complication developed in 2 patients during the follow-up period(mean 7.9$\pm$ 5.9 months). One patient underwent AVR on postoperative 7th month due to endocarditis, and the another patient with Behcet's disease underwent Ross operation at postoperative 4th month. In conclusion, AVP of leaflet extension technique offers an excellent early clinical result and represents a good alterna!ivy surgical treatment for the pure AR especially in young age group, although long-term follow-up is necessary to determine the durability of glutaraldehyde-preserved autologous pericardium as a valve leaflet.

• Journal of Chest Surgery
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• v.37 no.6
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• pp.492-498
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• 2004

Background: In this study, we investigated the risk factors for the development or progression of aortic regurgitation(AR) in patients with type I ventricular septal defect (VSD) to determine the optimal surgical timing and strategy. Material and Method: Three-hundred and ten patients with type I VSD with or without AR were included. The mean of age was 73.7$\pm$114.7 (1-737) months. One hundred and eighty six patients (60%) had no AR, 83 (27%) had mild AR, 25 (8%) had moderate AR and 16 (5%) had severe AR. Aortic valve was repaired in 5 patients and replaced in 11 patients with closure of VSD in the first operation. Four patients required redo aortic valve repair and 11 patients required redo aortic valve replacement. Age at operation, association with aortic valve prolapse, Qp/Qs, systolic pulmonary arterial pressure, VSD size and systolic pulmonary artery to aortic pressure ratio(s[PAP/AP］) were included as risk factors analysis for the development of AR. The long-term result of aortic valve repair and aortic valve replacement were compared. Result: Older age at operation, association with aortic valve prolapse, high Qp/Qs, and s[PAP/AP] were identified as risk factors for the development of AR (p<0.05, Table 2). The older the patient at the time of operation, the higher the severity of preoperative AR and the incidence of postoperative AR (p<0.05, Table 1, Fig. 1). For the older patients at operation, aortic valve repair had higher occurrence of AR compared to those who had aortic valve replacement (p<0.05, Fig. 2). Conclusion: From the result of this study, we can concluded that early primary repair is recommended to decrease the progression of AR. Aortic valve repair is not always a satisfactory option to correct the aortic valve pathology, which may suggest that aortic valve replacement should be considered when indicated.

• Journal of Chest Surgery
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• v.39 no.12 s.269
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• pp.891-899
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• 2006

Background: This study is to evaluate the safety of ATS valve by examining the clinical results of ten-years experience. Material and Method: From July 1995 to March 2005, we reviewed 305 patients with ATS valve implantation. Mean age was $49.8{\pm}11.7$ years and 140(45.6%) males were included. Etiologies were rheumatic diseases in 207 cases(67.4%), degenerative changes in 57 cases(18.6%), valve dysfunction in 23 cases(7.5%) and infective endocarditis in 14 cases(4.6%). AVR was performed in 72 patients(23.5%), MVR in 156 patients (50.8%), DVR(AVR+MVR) in 63 patients(20.5%) and TVR in 16 patients(5.2%). Result: There were 9 operative mortalities(2.9%). Follow up period was $56.5{\pm}34.0(0{\sim}115)$ months and 96.4% patients were followed up with 9 late deaths. Five and ten years survival rates were $94.9{\pm}1.3%,\;91.2{\pm}2.3%$ using Kaplan-Meier's methods. Valve related event free survival rates in 5 and 10 years were $90.8{\pm}2.0%$ and $86.9{\pm}3.2%$. There were 16 anticoagulation-related hemorrhages, 6 thromboembolisms, 3 prosthetic valve endocarditis and 1 paravalvular leakage. NYHA class improved after operation(p<0.05). Postoperative echocardiography showed significant decrease in LA size, LVEDD and IVESD(p<0.01). Patients with 19 and 21 mm valve showed significantly higher transvalvular pressure gradient in aortic position(p<0.001, p<0.001). Conclusion: ATS valve showed good hemodynamic results with few valve related complications and thus can be used with acceptable risk.

• Journal of Chest Surgery
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• v.25 no.8
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• pp.826-831
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• 1992

Ebstein`s anomaly is characterized by a downward displacement of a malformed tricuspid valve, The ideal surgical management of Ebstein`s anomaly is not yet established. Recently we experience one case of Ebstein`s anomaly, which was treated sussessfully by partial artificial annulus formation, and tricuspid valve replacement with St. Jude Medical valve. We have achieved excellent results with mechanical valve replacement and partial artificial annulus formation using wessex pericardial patch. On follow up for 4 years, the patient is well and in functional class I.

• Journal of Chest Surgery
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• v.14 no.3
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• pp.280-284
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• 1981

• Journal of Chest Surgery
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• v.41 no.4
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• pp.430-438
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• 2008

Background: All the patients with mechanical valves require warfarin therapy in order to prevent them from developing thromboembolic complications. According to the ACC/AHA practice guidelines, after AVR with bileaflet mechanical prostheses in patients with no risk factors, warfarin is indicated to achieve an INR of 2.0 to 3.0. After MVR with any mechanical valve, warfarin is indicated to achieve an INR of 2.5 to 3.5. But in our clinical experience, bleeding complications (epistaxis, hematuria, uterine bleeding, intracerebral hemorrhage etc.) frequently developed in patients who maintained their INR within this value. So, we retrospectively reviewed the patients with bileaflet mechanical heart valve prosthesis and we determined the optimal anticoagulation value. Material and Method: From January 1984 to February 2007, 311 patients have been followed up at a national medical center. We classified the AVR patients (n=60) into three groups as follows: an INR from 1.5 to 2.0 in Group I, an INR from 2.0 to 2.5 in Group II and an INR from 2.5 to 3.0 in Group III. We classified the MVR (n=171) and DVR (n=80) patients into four groups as follows: an INR from 1.5 to 2.0 in Group I, an INR from 2.0 to 2.5 in Group II, an INR from 2.5 to 3.0 in Group III and an INR from 3.0 to 3.5 in Group III. We compared the groups for their thromboembolic and bleeding complications by means of the Kaplan Meier method. Result: In the AVR patients, 2 thromboembolic complications and 4 bleeding complications occurred and the log rank test failed to identify any statistical significance between the groups for thethromboembolic complication rate, but groups I and II had lower bleeding complication rates than did group III. Thirteen thromboembolic complication and 15 bleeding complication occurred in the MVR and DVR patients, and the log rank test also failed to identify statistical significance between the groups for the thromboembolic complication rate, but groups I and II had lower bleeding complication rates that did groups III and IV. Conclusion: The thromboembolic complication rate was not statistically different between groups I and II and groups III and IV, but the bleeding complication rates of groups I and II were lower than those of groups III and IV. So this outcome encouraged us to continue using our low intensive anticoagulation regime, that is, an INR of 1.5 to 2.5.