• 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.37 no.9
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• pp.755-761
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• 2004

We evaluated the efficacy of Dor procedure in patients with ischemic left ventricular dysfunction. Material and Method: Between April 1998 and December 2002, 45 patients underwent the Dor procedure con-comitant with coronary artery bypass grafting (CABG). Left ventricular ejection fraction (LVEF) and left ventricular end-diastolic/end-systolic volumes (LVEDV/LVESV) were measured by echocardiography, myocardial SPECT, and cardiac catheterization and angiography performed at the sequence of preoperative, early postoperative, and one year postoperative stage. Result: Cardiopulmonary bypass and aortic clamp times were mean 141$\pm$64, 69$\pm$24 minutes, respectively. Intraaortic balloon pump (IABP) therapy was required in 19 patients (42%; 7 preoperatively, 9 intraoperatively, 3 postoperatively). Operative mortality rate was 2.2% (1/45). Postoperative morbidities were low cardiac output syndrome (12), atrial fibrillation (5), acute renal failure (4), and postoperative bleeding (4). Functional class (NYHA) was improved from classes 2.8 to 1.1 (p < 0,01). When we compared between the preoperative and early postoperative values, LVEF was improved from 32$\pm$9% to 52$\pm$11% (p<0.01). The asynergy portion decreased from 57$\pm$12% to 22$\pm$9%, and LVEDV/LVESV indexes improved from 125$\pm$39 mL/$m^2$, 85$\pm$30 mL/$m^2$ to 66$\pm$23 mL/$m^2$, 32$\pm$16 mL/$m^2$ (p<0.01). Although these changes in volumes were relatively preserved at postoperative one year, the left ventricular volumes showed a tendency to increase. Conclusion: After the Dor procedure for ischemic left ventricular dysfunction, LVEF improvement and left ventricular volume reduction were maintained till postoperative one year. The tendency for left ventricular volume to increase at postoperative one year suggested the requirement of strict medical management.

• Journal of Chest Surgery
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• v.31 no.10
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• pp.952-963
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• 1998

Background: Cardiopulmonary bypass(CPB)-induced hemostatic defects may result increased possibility of excessive hemorrhage and additional multiple transfusion reactions or reoperation. Particularly, fibrinolytic activation and decreased platelet count and function by CPB were proposed as a predictor of hemorrhage during postoperative periods in several reports. Materials and methods: Present study, which was conducted in 20 adult patients undergoing CPB, was prospectively designed to examine the hematologic changes, including fibrinolytic activation during and after CPB and to clarify the relationships between these changes and the magnitude of the postoperative nonsurgical blood loss. The serial blood samples for measurment of hematologic parameters were taken during operation and postoperative periods. Blood loss was respectively counted via thoracic catheter drainage at postoperative 3, 6, 12, 24, 48 hours and total period. Results: The results were obtained as follows:Platelet count rapidly declined following CPB(p<0.01), which its decreasing rate was an inverse proportion to total bypass time(TBT, r=0.55, p=0.01), And platelet count in postoperative 7th day was barely near to its control value. Fibrinogen degradating product(FDP) and D-dimer level significantly increased during CPB(p<0.0001, p<0.0001, respectively), and both of fibrinogen and plasminogen concentration correlatively decreased during CPB(r=0.57, p<0.01), implying activation of fibrinolytic system. Postoperative bleeding time (BT), postoperative activated partial thromboplastin time(aPTT) and postoperative prothrombin time (PT) were significantly prolonged as compare with each control value (p=0.05, p<0.0001, p<0.0001, respectively). Total blood loss was positively correlated with patient's age, aortic clamping time (ACT) and TBT, while there was negative correlation between platelet count and blood loss at pre-CPB, CPB-off and the 1st postoperative day, and in some periods. Postoperative aPTT and postoperative PTwere positively related to postoperative 6 hr and 48 hr blood loss(r=0.53, p=0.02; r=0.43, p=0.05) but not to total blood loss, whereas there was no relationship between postoperative BT and blood loss at any period. Conclusions: These observations suggest that CPB results various hematologic changes, including fibrinolytic activation and severe reduction in platelet count. Diverse factors such as age, platelet count, ACT, TBT and postoperative aPTT and PT may magnify the postoperative bleeding. This study will be a basic reference in understanding CPB-induced hemostatic injuries and in decreasing the postoperative hemorrhage

• Journal of Chest Surgery
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• v.39 no.7 s.264
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• pp.534-543
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• 2006

Background: There are a lot of debates regarding the optimal timing of operation of acute myocardial infarction (AMI). Off pump coronary artery bypass grafting (OPCAB) has benefits by avoiding the adverse effects of the cardio-pulmonary bypass, but its efficacy in AMI has not been confirmed yet. The purpose of this study is to evaluate retrospectively early and mid-term results of OPCAB in patients with AMI according to transmurality and timing of operation. Material and Method: Data were collected in 126 AMI patients who underwent OPCAB between January 2002 and July 2005, Mean age of patients were 61.2 years. Male was 92 (73.0%) and female was 34 (27.2%). 106 patients (85.7%) had 3 vessel coronary artery disease or left main disease. Urgent or emergent operations were performed in 25 patients (19.8%). 72 patients (57.1%) had non-transmural myocardial infarction (group 1) and 52 patients (42.9%) had transmural myocardial infarction (group 2). The incidence of cardiogenic shock and insertion of intra-aortic balloon pump (IABP) was higher in group 2. The time between occurrence of AMI and operation was divided in 4 subgroups (<1 day, $1{\sim}3\;days,\;4{\sim}7\;days$, >8 days). OPCAB was performed a mean of $5.3{\pm}7.1$ days after AMI in total, which was $4.2{\pm}5.9$ days in group 1, and $6,6{\pm}8.3$ days in group 2. Result: Mean distal an-astomoses were 3.21 and postoperative IABP was inserted in 3 patients. There was 1 perioperative death in group 1 due to low cardiac output syndrome, but no perioperative new MI occurred in this study. There was no difference in postoperative major complication between two groups and according to the timing of operation. Mean follow-up time was 21.3 months ($4{\sim}42$ months). The 42 months actuarial survival rate was $94.9{\pm}2.4%$, which was $91.4{\pm}4.7%$ in group 1 and $98.0{\pm}2.0%$ in group 2 (p=0.26). The 42 months freedom rate from cardiac death was $97.6{\pm}1.4%$ which was $97.0{\pm}2.0%$ in group 1 and $98.0{\pm}2.0%$ in group 2 (p=0.74). The 42 months freedom rate from cardiac event was $95.4{\pm}2.0%$ which was $94.8{\pm}2.9%$ in group 1 and $95.9{\pm}2.9%$ in group 2 (p=0.89). Conclusion: OPCAB in AMI not only reduces morbidity but also favors hospital outcomes irrespective of timing of operation. The transmurality of myocardial infarction did not affect the surgical and midterm outcomes of OPCAB. Therefore, there may be no need to delay the surgical off-pump revascularization of the patients with AMI if surgical revascularization is indicated.

• Journal of Chest Surgery
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• v.38 no.10 s.255
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• pp.685-692
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• 2005

Background: Wall motion abnormalities may be a significant predictor for long-term survival after coronary bypass surgery (CABG). The aim of this study is to see whether post-infarction wall motion abnormality of left ventricle affect on the long-term survival after CABG. Material and Method: One-hundred and thirty-three patients (male/female, 92/41) undergoing CABG more than 9 years ago were included in this study. Fifty-six patients (M/F, 42/14; mean age, $59.2\pm9.2$ years) with LV wall motion abnormalities were compared to 77 patients (M/F, 50/27; mean age, $58.0\pm7.6$ years) without the wall motion abnormalities. Most patients (112/133, $84.2\%$) had undergone on-pump CABG with the in-situ left internal thoracic artery and free grafts of saphenous vein, in which the proximal and distal anastomoses were done for the single aortic cross-clamping period. Result: Ejection fraction of left ventricle was lower in the group with LV wall motion abnormalities (mean ejection fraction, $48.7\pm13.2\%$) compared to the group without wall motion abnormalities (mean ejection fraction, $57.1\pm10.1\%$)(p=0.0001). Risk­unadjusted survivals after CABG in the group without wall motion abnormalities were $85.7\pm4.0\%,\;76.2\pm4.9\%,\;and\;57.2\pm10.3\%$ at 5, 10, and 13 years, respectively, and in the group with wall motion abnormalities were $80.4\pm5.3\%,\;58.7\pm7.3\%,\;and\;51.9\pm7.9\%$ at 5, 10, and 13 years, respectively (p=0.1). In univariate analysis, predictable factors of long-term survival in the patients with LV wall motion abnormalities were LV ejection fraction and post operative outpatient treatment. In multivariate analysis, predictable factor of long-term survival in the patients with the wall motion abnormalities was postoperative outpatient treatment, and that in those without the wall motion abnormalities was female. Conclusion: Although there was no significant survival difference after CABG between the group with LV wall motion abnormalities and that without wall motion abnormalities, the survival in the group with wall motion abnormalities seems to be more decreased. For the patients with LV wall motion abnormalities after myocardial infarction, the post-CABG outpatient treatment is suggested to be an important factor for the long-term survival.

• Journal of Chest Surgery
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• v.31 no.5
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• pp.466-471
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• 1998

Purpose: The safety and efficacy of minimally invasive techniques in congenital heart surgery were tested in this study. Materal and method: Between July 1997 and November 1997, a total of 46 children were underwent minimally invasive cardiac operations at Seoul National University Children's Hospital. Age and body weight of the patients averaged 34.6${\pm}$41.8 (Range: 1∼148) months and 14.5${\pm}$9.9(Range: 3.0∼40.0) kg, respectively. Twenty eight patients were male. Preoperative surgical indications included 15 atrial septal defects, 25 ventricular septal defects, 1 foreign body in aorta, 3 partial atrioventricular septal defects, 1 total anomalous pulmonary venous connection(cardiac type), and 1 tetralogy of Fallot. After creating a small lower midline skin incision starting as down as possible from the sternal notch, a vertical midline sternotomy extended from xyphoid process to the level of the second intercostal space, where one of the T-, J-, I- or inverted C-shaped lower lying mini-sternotomy was completed with a creation of unilateral right or bilateral trap door sternal opening. A conventional direct aortic and bicaval cannulation was routine. Result: A mean length of skin incision was 6.1${\pm}$1.0(range: 4.0∼9.0) cm. A mean distance between the suprasternal notch and the upper most point of the skin incision was 4.0${\pm}$1.1 (range: 2.0∼7.0) cm. Mean cardiopulmonary bypass time, aortic cross-clamp time, and the operation time were 62.9${\pm}$20.0(range: 28∼147), 29.8${\pm}$12.8(range: 11∼79), and 161.1${\pm}$34.5 (range: 100-250) minutes. A mean total amount of postoperative blood transfusion was 71.0${\pm}$68.1 (range: 0∼267) cc. All patients were extubated mean 11.3${\pm}$13.8(range: 1∼73) hours after operation. A mean total amount of analgesics used was 0.8${\pm}$1.8(range: 0∼9) mg of morphine. The mean duration of stay in intensive care unit and hospital stay were 35.0${\pm}$32.2 (range: 10∼194) hours and 6.2${\pm}$2.0(range: 3∼11) days. There were no wound complications and hospital deaths. Conclusion: This short-term experience disclosed that the minimally invasive technique can be feasibly applied in a selected group of congenital heart disease as well as is cosmetically more attractive approach.

• Journal of Chest Surgery
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• v.32 no.4
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• pp.353-357
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• 1999

Background: Mitral valve replacement(MVR) with chordal preservation in patients with mitral vlavular disease has been proven to be beneficial for left ventricular function and for reduction of postoperative complication. Material and Method: From January 1995 to July 1996, the early postoperative results of mitral valve replacement were compared between 20 patients who underwent chordae resection(classic MVR group) and 10 patients who underwent chordae preservation(preservation MVR group) in the Department of Thoracic and Cardiovascular Surgery, Chunbuk National University Hospital. Result: There was no significant difference between the two groups in age, sex, NYHA functional class, cardiothoracic ratio, echocardiographic finding, cardiopulmonary bypass time and aortic cross clamping time. The difference between preoperative and postoperative cardiothoracic ratio after 3 months was not statistically significant. At echocardiographic left ventricular evaluation, ejection fraction and fractional shortening decreased slightly in the preservation group then preoperative value (p=0.47, p=0.12), however, decreased significantly in the classic MVR group(p=0.03, p=0.04), and were statistically significant between the two groups(p=0.03, p=0.02). Conclusion: We conclude that MVR with chorda preservation seems to have a beneficial effect on postoperative left ventricular performance in mitral valve disease than the classic MVR.

• 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.

• Journal of Chest Surgery
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• v.36 no.1
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• pp.1-6
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• 2003

Currently, atrial septal defect repair has been considered low risk operation duo to the development of open heart surgery Not only the operation itself, but also the cosmetic aspect is now focused. Though many methods exist as minimally invasive cardiac surgery in atrial septal defect repair, some surgeons advocate that right anterolateral thoracotomy is better than the others in the cosmetic aspect and we compared right anterolateral thoracotomy with median sternotomy. Material and Method: From January 1999 to August 2002, 43 patient underwent atrial septal defect repair by one operator, including 15 patients through right anterolateral thoracotomy(group A) and 15 patients through median sternotomy(group B) in Hanyang university Hospital. The data were randomized and operation outcomes were analyzed between these two groups. Result: The mean weight of group A was 38.77$\pm$15.57kg and 38.21$\pm$21.82kg in group B. In group A, mean operation (OP) time was 197.6$\pm$61.40min, mean cardiopulmonary bypass(CPB) time was 48.66$\pm$13.02min and mean fibrillation time or aortic cross clamp(ACC) time was 30$\pm$11.64min. In group B, mean OP time was 212.33$\pm$31.95min, mean CPB time was 55$\pm$12.10min, and mean fibrillation or ACC time was 29.33$\pm$9.04min. There was no significant differences in these two groups. In group A, mean mechanical ventilation time was 3.78$\pm$0.78 hours, mean postoperative ICU stay was 1.2$\pm$0.47 days and mean postoperative hospital stay was 10.20 41.08 days. In group B, mean mechanical ventilation time was 5.95$\pm$3.73 hours, mean post operative ICU stay was 1.41$\pm$0.61 days, and mean postoperative hospital stay was 12.20$\pm$3.55 days. There was no any significant difference in two groups. Group A had significantly lower mean thoracic and pleuropericardial drainage than group B (175.33$\pm$90.54cc vs 352.33$\pm$239.43cc, p<0.05). Complication was seen in one case in group B, transient 2nd degree A-V block. Conclusion: Right anterolateral thoracotomy was better than median sternotomy not only in cosmetic aspect but also in postoperative thoracic and pleuropericardial drainage, using the same instrument(p.0.05). But, right anterolateral thoracotomy was more technically difficult due to narrow operative field and we should be careful of aortic cannulation.

• Journal of Chest Surgery
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• v.29 no.9
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• pp.983-988
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• 1996

Aneurysm of the sinus of Valsalva is fairly rare. Between 1987 and 1994, we operated on a total of 12 cases of aneurysm of the sinus of Valsalva at the Inje University Seoul Paik Hospital. This represents 0.7% of all cardiac operation under cardiopulmonary bypass. There were eight male and four female patients aged from 8 to 38 years(mean, 19.2 years). 8 of 12 patients had ruptured aneurysms. The origin of aneurysm of the sinus of Valsalva was the right coronary sinus in 10(83. 3%), and the noncoronary sinus in 2(16.6%). In ruptured aneurysm, the origin was the right oronary sinus in 6, and the noncoronary sinus in 2. The aneurysms originating from the right coronary sinus ruptured into the right ventricle in 5, and into both the right atrium and right ventricle in 1. The aneurysms originating from the noncoronary sinus ruptured into the right ventricle in 1, and into the right atrium in 1. Associated congenital cardiac defects included ventricular septal defect in 10(83.3%) patients 39 cases of these were associated with the aneurysms of the right coronary sinus), aortic regurgi- tation in 3 (all of these had an additional ventricular septal defect), mitral regurgitation in 1, and double chambered right ventricle in 1. No hospital deaths occurred, although one late death occurred as a result of endocarditis 15 months after the first operation. The mean follow-up period was 29 months, range from 4 to 60 months. Eleven patients except one late death were in New York Heart Association class 1. Due to the low mortality risk o( an operation for aneur sm of the sinus of Valsalva, a ruptured aneurysm of the sinus of Valsalva should be corrected surgically when the diagnosis is mane, and unruptured aneurysm of the sinus of Valsava with complication should also be operated. In most cases the aorta was opened to examine the morphology of the aneurysm and the aortic cusps, and an associated aortic valve defect should be corrected simultaneously.