• Journal of Chest Surgery
• /
• v.38 no.11 s.256
• /
• pp.733-738
• /
• 2005

Background: The possibility of incomplete revascularization and development of flow competition after revascularization of the borderline lesion made the hybrid strategy as an option for complete revascularization. Material and Method: From January f998 to July 2004, 25 $(3.2\%)$ patients underwent hybrid revascularization among 782 total OPCAB procedures. Clinical results and angiographic patencies were evalulated. Percutaneous coronary intervention (PCI) was peformed before CABG in 8 patients and after CABG in 47 patients. Result: The causes of PCIs before CABG were to achieve complete revascularization with minimally invasive surgery (n=7) and emergent PCI for culprit lesion (n=1). The indications of PCIs after CABG were high possibility of flow competition in the borderline lesion of right coronary artery territory (n=8), diffuse atheromatous lesion preventing anastomosis of graft (n=5), severe calcified ascending aorta with no more arterial grafi available (n=3), and intramyocardial coronary lesion (n=1). Mean number of distal anastomoses was $2.3\pm1.0$. Mean number of lesions treated by PCI was $1.2\pm0.4$. There was no operative or procedure-related mortality. PCI-related complication was periprocedural myocardial infarction in one patient, and complications related to CABG were transient atrial fibrillation (n=5), perioperative myocardial infarction (n=1), and transient renal dysfunction (n=1). Early postoperative coronary angiography $(1.8{pm}1.6days)$ revealed $100\%$ patency rate of grafts (57/57). The stenosis occurred in one patient performed PCI before CABG, which was successfully treated with re-ballooning. During midterm follow-up (mean; $25{\pm}26$ months), 1 patient died of congestive heart failure. All survivors (n=24) accomplished follow-up coronary angiographics, which showed .all grafts (56/57) were patent except one string sign. In-stent restenosis was developed in 2 patients who received bare metal stents. Conclusion: In selected patients, complete revascularization was achieved with low risk by taking the hybrid strategy.

• Journal of Chest Surgery
• /
• v.36 no.8
• /
• pp.559-565
• /
• 2003

By improving the flow pattern in Fontan circuit, total cavopulmonary connection (TCPC) could result in a better outcome than atriopulmonary connection Fontan operation. For the patients with impaired hemodynamics after atriopulmonary Fontan connection, conversion to TCPC can be expected to bring hemodynamic and functional improvement. We studied the results of the revision of the previous Fontan connection to TCPC in patients with failed Fontan circulation. Material and method: From October1979 to June 2002, eight patients who had failed Fontan circulation, underwent revision of previous Fontan operation to TCPC at Yonsei University Hospital. Intracardiac anomalies of the patients were tricuspid atresia (n=4) and other functional single ventricles (n=4). Mean age at TCPC conversion was 14.0$\pm$7.0 years (range, 4.6~26.2 years) and median interval between initial Fontan operation and TCPC was 7.5 years (range, 2.4~14.3 years). All patients had various degree of symptoms and signs of right heart failure. NYHA functional class was 111 or IV in six patients. Paroxysmal atrial fibrillation (n:f), cyanosis (n=2), intraatrial thrombi (n=2), and protein losing enteropathy (PLE) (n=3) were also combined. The previous Fontan operation was revised to extracardiac conduit placement (n=7) and intraatrial lateral tunnel (n=1). Result: There was no operative death. Major morbidities included deep sternal infection (n=1), prolonged pleural effusion over two weeks (n=1), and temporary junctional lachyarrhythrnia (n=1). Postoperative central venous Pressure was lower than the preoperative value (17.9$\pm$3.5 vs. 14.9$\pm$1.0, p=0.049). Follow-up was complete in all patients and extended to 50,1 months (mean, 30.3$\pm$ 12.8 months). There was no late death. All patients were in NYHA class 1 or 11. Paroxysmal supraventricular tachycardia developed in a patient who underwent conversion to intraatrial lateral tunnel procedure, PLE was recurred in two patients among three patients who had had PLE before the convertsion. There was no newly developed PLE. Conclusion: Hemodynamic and functional improvement could be expected for the patients with Fontan circulatory failure after atriopulmonary connection by revision of their previous circulation to TCPC. The conversion could be performed with low risk of morbidity and mortality.

• Journal of Chest Surgery
• /
• v.36 no.5
• /
• pp.335-342
• /
• 2003

Background: The aortic arch replacement in an acute aortic dissection is technically demanding procedure that has a lot of postoperative morbidity and high mortality The authors have applied several techniques of aortic arch replacement to overcome the risks of the procedure. Therefore we analysed the results of these techniques. Material and Method: From March of 1996 to July of 2002, we performed 31 cases of the aortic arch replacement in the Stanford type A acute aortic dissection. There were 12 male and 19 female patient's with 59.6$\pm$9.4 years of mean age. Among them 18 cases were treated with the hemiarch replacement and 13 cases with the total arch replacement. We approached the aortic arch through median sternotomy in all but 3 cases of Clamshell incision and applied the deep hypothermic circulatory arrest with retrograde cerebral perfusion. The associated procedures were 2 Bentall's procedures, an axillobifemoral bypass, a femorofemoral bypass and a carotid artery bypass. Result: The postoperative morbidities were 8 acute renal failures, 3 CNS complications, 2 low cardiac output syndromes, 2 malpefusion syndromes, and 2 deep wound infections. There were 4 cases of early hospital mortality which were from an acute renal failure a postoperative bleeding, a low cardiac output syndrome, and a reperfusion syndrome. There were 3 cases of late hospital mortality which were from an acute renal failure, and 2 multiorgan failures. So the total mortality rate was 22.5%. There were 4 cases of late mortality after the discharge, which were form 2 cases of distal anastomotic rupture and 2 cases of intracranial hemorrhage. Conclusion: The hemiarch replacement has relatively shorter operative time and lower hospital mortality but higher late mortality than the total arch replacement. The total arch replacement needs more technically demanding procedure.

• Journal of Chest Surgery
• /
• v.34 no.12
• /
• pp.901-908
• /
• 2001

Background : Coronary artery bypass graft(CABG) in patients with advanced left ventricular dysfunction has often been regarded as having high mortality rate, despite the great improvement in operative result of CABG. With recent advances in surgical technique and myocardial protection, surgical revascularization improved the symptom and long-term survival of these high risk patients more than the medical conservative treatment. Material and Methold : Clinical data of 31(4.1％) patients with preoperative ejection fraction less than 30% among 864 CABGs performed between January 1995 and March 1999 were retrospectively analyzed and pre- and postoperative changes of the ejection fraction on echocardiography were analyzed. There were 26 men and 5 women. The mean age was 60.7 years(range 41 to 72 years). History of myocardial infarction(30 cases, 98％) was the most common preoperative risk factor. There were seven irreversible myocardial infarction on thallium scan. Most patients had triple vessel diseases(26 cases, 84％) and first degree of Rentrop classification(16 cases, 52％) on coronary angiography. The mean number of distal anastomosis during CABG was per patient was 4.9${\pm}$0.8 sites in each patient. In addition to long saphenous veins, the internal mammary artery was used in 20 patients. Total bypass time was 244.7${\pm}$3.7 minutes(range, 117 to 567 minutes), and mean aortic cross-clamp time was 77.9 ${\pm}$ 1.6 minutes(range, 30 to 178 minutes). There were five other reparative procedures such as two left ventricular aneurysrmectomy, two mitral repair, and one aortic valve replacement. There were twelve postoperative complications such as three cardiac arrhythmia, two bleeding(re-operation), one delayed sternal closure, eleven usage of intra-aortic balloon counterpulsation for low cardiac output. Two patients died, postoperative mortality was 6.5% . Twenty-nine patients were relieved of chest pain and left ventricular ejection fraction after operation was significantly higher(38.5${\pm}$11.6%, p 0.001) as compared with preoperative left ventricular ejection fraction(25.3${\pm}$2.3%). The follow up period of out patient was 25. 3 months. Conclusion: In patients with coronary artery disease and advanced left ventricular dysfunction, coronary artery bypass grafting can be performed relatively safely with improvement in left ventricular function, but it will be necessary to study long term results.

• Journal of Chest Surgery
• /
• v.35 no.3
• /
• pp.188-198
• /
• 2002

Background: Reoperations on the aortic root or the ascending aorta are being performed with increasing frequency and remain a challenging problem. This study was performed to analyze the results of reoperations on the ascending aorta and aortic root. Material and Method: Between May 1995 and April 2001, 30 patients had reoperations on the ascending aorta and aortic root and were reviewed retrospectively. The mean interval between the previous repair and the actual reoperation was 56 months(range 3 to 142 months). Seven patients(23.3%) had two or more previous operations. The indications for reoperations were true aneurysm in 7 patients(23.3%), prosthetic valve endocarditis in 6(20%), false aneurysm in 5(16.7%), paravalvular leak associated with Behcet's disease in 4(13.3%), malfunction of prosthetic aortic valve in 4(13.3%), aortic dissection in 3(10%), and annuloaortic ectasia in 1(3.3%). The principal reoperations performed were aortic root replacement in 17 patients(56.7%), replacement of the ascending aorta in 8(26.7%), aortic and mitral valve replacement with reconstruction of fibrous trigone in 2(6.6%), patch aortoplasty in 2(6.6%), and aortic valve replacement after Bentall operation in 1 (3.3%). The cardiopulmonary bypass was started before sternotomy in 7 patients and the hypothermic circulatory arrest was used in 16(53.3%). The mean time of circulatory arrest, total bypass, and aortic crossclamp were 20$\pm$ 12 minutes, 228$\pm$56 minutes, and 143$\pm$62 minutes, respectively Result: There were three early deaths(10%). The postoperative complications were reoperation for bleeding in 7 patients(23.3%), cardiac complications in 5(16.7%), transient acute renal failure in 2(6.6%), transient focal seizure in 2(6.6%), and the others in 5. The mean follow-up was 22.8 $\pm$20.5 months. There were two late deaths(7.4%). The actuarial survival was 92.6$\pm$5.0% at 6 years. One patient required reoperation for complication of reoperation on the ascending aorta and aortic root(3.7%). The 1- and 6-year actuarial freedom from reoperation was 100% and 83.3$\pm$15.2%, respectively. One patient with Behcet's disease are waiting for reoperation due to false aneurysm, which developed after aortic root replacement with homograft. There were no thromboembolisms or anticoagulant related complications. Conclusions: This study suggests that reoperations on the ascending aorta and aortic root can be performed with acceptable early mortality and morbidity, and adequate surgical strategies according to the pathologi conditions are critical to the prevention of the reoperation.

• Journal of Chest Surgery
• /
• v.41 no.5
• /
• pp.598-604
• /
• 2008

Background: The improvements in endoscopic equipment and surgical robots has encouraged the performance of minimally invasive cardiac operations. Yet only a few Korean studies have compared this procedure with the sternotomy approach. Material and Method: Between December 2005 and July 2007, 48 patients (group A) underwent minimally invasive cardiac surgery with AESOP through a small right thoracotomy. During the same period, 50 patients (group B) underwent conventional surgery. We compared the operative time, the operative results, the post-operative pain and the recovery of both groups. Result: There was no hospital mortality and there were no significant differences in the incidence of operative complications between the two groups. The operative $(292.7{\pm}61.7\;and\;264.0{\pm}47.9min$, respectively; p=0.01) and CPB times ($128.4{\pm}37.6\;and\;101.7{\pm}32.5min$, respectively; <0.01) were longer for group A, whereas there was no difference between the aortic cross clamp times ($82.1{\pm}35.0\;and\;87.8{\pm}113.5min$, respectively; p=0.74) and ventilator times ($18.0{\pm}18.4\;and\;19.7{\pm}9.7$ hr, respectively; p=0.57) between the groups. The stay on the ICU $(53.2{\pm}40.2\;and\;72.8{\pm}42.1hr$, respectively; p=0.02) and the hospitalization time ($9.7{\pm}7.2\;and\;14.8{\pm}11.9days$, respectively; p=0.01) were shorter for group A. The Patients in group B had more transfusions, but the difference was not significant. For the overall operative intervals, which ranged from one to four weeks, the pair score was significantly lower for the patients of group A than for the patients of group B. In terms of the postoperative activities, which were measured by the Duke Activity Scale questionnaire, the functional status score was clearly higher for group A compared to group B. The analysis showed no difference in the severity of either post-repair of mitral ($0.7{\pm}1.0\;and\;0.9{\pm}0.9$, respectively; p=0.60) and tricuspid regurgitation ($1.0{\pm}0.9\;and\;1.1{\pm}1.0$, respectively; p=0.89). In both groups, there were no valve related complications, except for one patient with paravalvular leakage in each group. Conclusion: These results show that compared with the median sternotomy patients, the patients who underwent minimally invasive surgery enjoyed significant postoperative advantages such as less pain, a more rapid return to full activity, improved cosmetics and a reduced hospital stay. The minimally invasive surgery can be done with similar clinical safety compared to the conventional surgery that's done through a median sternotomy.

• Journal of Chest Surgery
• /
• v.32 no.8
• /
• pp.715-721
• /
• 1999

Background:The number of old patients receiving coronary artery bypass grafting(CABG) is increasing. With the more recent advances in operative techniques, the age at which CABG is indicated has also increased. This study evaluated the risk factors associated with the hospital mortality and the morbidity following CABG in elderly patients. Material and Method: Between March 1991 and June 1998, we retrospectively reviewed 45 consecutive patients aged 65 years or older who underwent CABG. We compared the data with the results of 179 patients under the age 65 years operated during the same period. Result: Mean age was 68${\pm}$1.41 years(range 65 to 74 years). Emergency surgery was required in 4, and elective surgery in 41 patients. The mean number of distal anastomosis per patient was 3.62 ${\pm}$0.81 and mean aortic cross-cramp time was 69.84${\pm}$18.5 minutes. Thirty patients had Canadian class III or IV preoperatively, but 43 patients had class I or II postoperatively. The left ventricular ejection fraction increased significantly from 54.23${\pm}$10.62% preoperatively to 58.14${\pm}$9.88% postoperatively(p<0.05). Postoperative complication was pneumonia in 2 patients, acute renal failure in 2 patients, sternal wound infection in 1 patient, and postoperative myocardial infarction in 1 patient. There were two postoperative deaths. The causes of deaths were low output syndrome in one patient, and sepsis due to pneumonia in the other patient. The hospital mortality was higher in the elderly group(4.4 versus 2.86%) but was not statistically significant(p>0.05). Incremental risk factors for hospital deaths in the elderly were emergent operation, preoperative PTCA, postoperative use of IABP and postoperative ARF(p<0.05). The duration of hospital stay after operation was significantly longer for the elderly group than the younger group(19.27${\pm}$12.51 vs 15.55${\pm}$6.99 days; p＜ 0.05). Follow-up was complete for 34 of the hospital survivors and ranged from 1 to 73 months(mean: 23.58${\pm}$19.56 months). There was no late mortality of cardiac origin. Conclusion: Age is an important factor in selecting optimal management for elderly patients with coronary compromise, but age alone should not dictate the choice of therapy. Coronary artery bypass surgery in the elderly is associated with acceptable early mortality and excellent long-term results.

• Journal of Chest Surgery
• /
• v.42 no.1
• /
• pp.28-33
• /
• 2009

Background: Functional tricuspid regurgitation (TR) greater than or equal to a mild grade requires tricuspid valvuloplasty, and tricuspid valvuloplasty with ring annuloplasty has shown good outcomes. We report here on our early experience with the Edwards $MC^3$ annuloplasty system (Edwards LifeSciences, Irvine, CA). Material and Method: From November 2004 to July 2006, 72 patients with tricuspid annular dilatation and TR underwent tricuspid valvuloplasty with using the Edwards $MC^3$ annuloplasty ring. Sixty-eight patients were operated on via median sternotomy and four patients were operated on using robotic assisted minimal invasive thoracotomy. The patient population included 21 males and 51 females and their mean age was $53.9{\pm}12.3$. The mean grade of TR, as assessed by the preoperative echocardiography, was $2.2{\pm}1.0$. The mean NYHA functional class was $3.1{\pm}0.8$. The mean left ventricular ejection fraction was $57.0{\pm}9.9$%. Result: The TR and NYHA functional class, as assessed by postoperative echocardiography, was significantly reduced (mean=$0.4{\pm}0.6$ and $2.0{\pm}0.7$, respectively p<0.001). There was one case of hospital mortality. One patient required permanent pacemaker insertion for third degree atrioventricular block. Conclusion: Our study shows that the Edwards $MC^3$ remodeling ring is easy to implant and it effectively corrects functional TR with excellent clinical and echocardiographic outcomes. Further follow-up and a larger clinical series are required to establish the long-term stability of this repair technique.

• Journal of Chest Surgery
• /
• v.38 no.5 s.250
• /
• pp.366-370
• /
• 2005

Background: In general, cardiac surgery has been performed via median sternotomy. During the past decade, improvements in endoscopic equipment and operative techniques have resulted in development of minimally invasive cardiac operation using small incisions. With the advent of a voice controlled camera-holding robotic arm (AESOP 3000, Automated Endoscope System for Optimal Positioning), cardiac surgery entered the robotic age. Material and Method: Between April 2004 and December 2004, a total of seventy eight patients underwent robotic cardiac surgery, of whom sixty four patients underwent robot-assisted minimally invasive cardiac surgery via 5cm right lateral minithoracotomy using voice controlled robotic arm, femoral vessels cannulation, percutaneous internal jugular cannulation, transthoracic aortic cross clamp. Other fourteen patients underwent MIDCAB via internal mammary artery harvesting using AESOP. Result: Robotic cardiac surgery were mitral valve repair in 37 cases, mitral valve replacement in 10 cases, aortic valve replacement in 1 case, MIDCAB in 14 cases, ASD operation in 9 cases, and isolated Maze procedure in 1 case. In mitral operation, mean CPB time was $165.3\pm43.1$ minutes and mean ACC time was $110.4\pm48.2$ minutes. Median length of hospital stay was 6 days (range 3 to 30) in mitral operation, 4 days (range 2 to 7) in MIDCAB, and 4 days (range 2 to 6) in ASD operation. For complications, 3 patients were required by reoperation for bleeding. There was no hospital mortality. Conclusion: Our experience of robot cardiac surgery suggests that many cardiovascular surgeons will be able to perform minimally invasive cardiac operations through small incisions with robot-assisted video-direction. Well-designed studies and close long-term follow-up will be required to analyze the benefits of robot-assisted operation.

• Journal of Chest Surgery
• /
• v.35 no.11
• /
• pp.779-784
• /
• 2002

Recently, the number of coronary artery bypass surgery(CABG) is increasing according to the increasing incidence of coronary artery disease. However, CABG is not a definite corrective surgery; therefore, in some patients, redo-CABG may be required. We retrospectively reviewed our redo-CABG experiences to help future redo-CABG. Material and Method: From January 1991 to April 2001, 14 cases of redo-CABG were performed in Yonsei Cardiovascular Center(M:F＝12:2) and mean age was 61,7 $\pm$ 7.1(47-72) years. Mean time from 1st. CABG to redo-CABG was 121.9 $\pm$ 50.5(6.1-179.6) months. Thirteen cases were conventional on-pump CABG and one case was off-pump CABG. In two patients, mitral valve re-replacement and mitral valve repair were performed each. All redo-CABG were performed through mid-sternotomy. During redo-CABG, left internal mammary artery and saphenous vein grafts were used in 6 patients, left internal mammary artery and left radial artery grafts were used in 2 patients, left internal mammary artery and gastroepiploic artery were used in one patient and only greater saphenous veins were used in 5 cases(In one case, cephalic vein was also used). The number of mean distal anastomosis was 2.1 $\pm$ 0.9(1-4). Result: There were no operative death and no perioperative myocardial infarctions and cerebrovascular accidents or other heart related complications. Mean follow up duration was 40.1 $\pm$ 38.6(1.1-118.5) months. During follow up period, angina was re-developed in one patient 13 months after operation. Two patients died of end-stage renal failure 14.8 months and 116.3 months after redo-CABG, respectively. During follow up period, coronary angiography was performed in 3 patients, and all grafts were patent. At last follow up, mean Canadian class was 1.3. Kaplan-Meier survival at 9 years was 90.0 $\pm$ 9.5% and event free survival at 9 years was 71.4 $\pm$ 6.9%. Conclusion: After redo-CABG, all patients improved their angina symptom and daily activity. And long-term survival after redo-CABG was excellent. Therefore, if patients have indications for redo-CABG, thenredo-CABG must be strongly recommended and performed.