• Journal of Chest Surgery
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• v.54 no.5
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• pp.383-388
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• 2021

Background: Achieving external access to and manual occlusion of the left atrial appendage (LAA) during minimally invasive mitral valve surgery (MIMVS) through a small right thoracotomy is difficult. Occlusion of the LAA using an epicardial closure device seems quite useful compared to other surgical techniques. Methods: Fourteen patients with atrial fibrillation underwent MIMVS with concomitant surgical occlusion of the LAA using double-layered endocardial closure stitches (n=6, endocardial suture group) or the AtriClip Pro closure device (n=8, AtriClip group) at our institution. The primary safety endpoint was any device-related adverse event, and the primary efficacy endpoint was successful complete occlusion of blood flow into the LAA as assessed by transthoracic echocardiography at hospital discharge. The primary efficacy endpoint for stroke reduction was the occurrence of ischemic or hemorrhagic neurologic events. Results: All patients underwent LAA occlusion as scheduled. The cardiopulmonary bypass and aortic cross-clamp times in the endocardial suture group and the AtriClip group were 202±39 and 128±41 minutes, and 213±53 and 136±44 minutes, respectively (p=0.68, p=0.73). No patients in either group experienced any device-related serious adverse events, incomplete LAA occlusion, early postoperative stroke, or neurologic complication. Conclusion: Epicardial LAA occlusion using the AtriClip Pro during MIMVS in patients with mitral valve disease and atrial fibrillation is a simple, safe, and effective adjunctive procedure.

• Journal of Chest Surgery
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• v.56 no.6
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• pp.374-386
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• 2023

Background: The heightened morbidity and mortality associated with repeat cardiac surgery are well documented. Redo median sternotomy (MS) and minimally invasive valve surgery are options for patients with prior cardiac surgery who require mitral valve surgery (MVS). We conducted a systematic review and meta-analysis comparing the outcomes of redo MS and minimally invasive MVS (MIMVS) in this population. Methods: We searched PubMed, EMBASE, and Scopus for studies comparing outcomes of redo MS and MIMVS for MVS. To calculate risk ratios (RRs) for binary outcomes and weighted mean differences (MDs) for continuous data, we employed a random-effects model. Results: We included 12 retrospective observational studies, comprising 4157 participants (675 for MIMVS; 3482 for redo MS). Reductions in mortality (RR, 0.54; 95% confidence interval [CI], 0.37-0.80), length of hospital stay (MD, -4.23; 95% CI, -5.77 to -2.68), length of intensive care unit (ICU) stay (MD, -2.02; 95% CI, -3.17 to -0.88), and new-onset acute kidney injury (AKI) risk (odds ratio, 0.34; 95% CI, 0.19 to 0.61) were statistically significant and favored MIMVS (p<0.05). No significant differences were observed in aortic cross-clamp time, cardiopulmonary bypass time, or risk of perioperative stroke, new-onset atrial fibrillation, surgical site infection, or reoperation for bleeding (p>0.05). Conclusion: The current literature, which primarily consists of retrospective comparisons, underscores certain benefits of MIMVS over redo MS. These include decreased mortality, shorter hospital and ICU stays, and reduced AKI risk. Given the lack of high-quality evidence, prospective randomized control trials with adequate power are necessary to investigate long-term outcomes.

• Journal of Chest Surgery
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• v.35 no.7
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• pp.517-522
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• 2002

Background: Congenital heart surgery may lead to myocardial swelling and hemodynamic instability. Delayed sternal closure may be beneficial in this setting. The purpose of this study was to assess mortality and mediastinal infection rate associated with delayed sternal closure after congenital heart surgery and to evaluate the risk factors which affect mortality and mediastinal infection rate. Material and Method: We retrospectively reviewed 40 patients who underwent delayed sternal closure after repair of congenital heart disease at Yonsei Cardiovascular Hospital, from January 1994 to May 2001. In these patients, we assessed the mortality and mediastinal infection rate, and evaluated their risk factors including operation time, bypass time, aortic cross clamp time, duration to sternal closure and postoperative artificial ventilation time. Mediastinal infection was defined to have positive culture in mediastinum. Result: Hemodynamic instability was the most common indication for delayed sternal closure(n=36) and other indications included postoperative bleeding(n=2) and conduit compression(n=2). The median age at operation was $14.4{\pm}33.4$months old(range, 2days-12years). The patients with postoperative bleeding and conduit compression were much older than the others. The sternum was left open for $4.5{\pm}3.4$ days(range, 1-20days). Overall mortality was 25%(10/40) and mediastinal infection occured in 24.3%(9/37) (3 patients were excluded in mediastinal infection for early death). In risk factor analyses, only aortic cross clamp time had statistical significance for mortality in univariate analyses. However, multivariate analyses revealed that there were no significant predictors for risk of mortality and mediastinal infection. Conclusion: Delayed sternal closure after repair of congenital cardiac disease had relatively high mortality and mediastinal infection rate. But, in patients with hemodynamic instability, postoperative bleeding and conduit compression after repair of congenital cardiac disease, delayed sternal closure may be an effective life saving method.

• Journal of Chest Surgery
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• v.39 no.2 s.259
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• pp.99-105
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• 2006

Background: Interrupted aortic arch is a rare congenital heart anomaly which still shows high surgical mortality. In this study, we investigated the causes of and the risk factors for mortality to improve the surgical outcomes for this difficult disease entity. Material and Method: From 1984 to 2004, 42 patients diagnosed as IAA were reviewed retrospectively. Age, body weight at operation, preoperative diagnosis, preoperative PGE1 requirement, type of interrupted aortic arch, degree of left ventricular outflow stenosis, CPB time, and ACC time were the possible risk factors for mortality. Result: There were .14 hospital deaths. Preoperative use of PGE1, need for circulartory assist and aortic cross clamp time proved to be positive risk factors for mortality on univariate analysis. Preoperative left ventricular outflow stenosis was considered a risk factor for mortality but it did not show statistical significance (p-value=0.61). Causes of death included hypoxia due to pulmonary banding, left ventricular outtract stenosis, infection, mitral valve regurgitation, long cardiopulmonary bypass time and failure of coronary transfer failure in TGA patients. Conclusion: In this study, we demonstrated that surgical mortality is still high due to the risk factors including preoperative status and long operative time. However preoperative subaortic dimension was not related statistically to operative death statistically. Adequate preoperative management and short operation time are mandatory for better survival outcome.

• Journal of Chest Surgery
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• v.24 no.7
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• pp.674-684
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• 1991

The surgical treatment of tetralogy of Fallot [TOF] was initiated by Blalock and Taussig in 1945 with the establishment of the subclavian artery to pulmonary artery anastomosis. In an imaginative and daring effort, in 1954, Lillehei and collaborators [1955] using controlled cross-circulation, carried out the first intracardiac repair of TOF by closing the ventricular septal defect [VSD] and relieving the pulmonary stenosis under direct vision. Nowadays, total correction is the ideal operation for treatment of TOF and is accomplished with extracorporeal circulation. And the results of surgery for TOF have steadily improved over the years, thanks to important contributions of many surgeons. Nevertheless because of its protean physiologic and anatomic presentation, TOF continues to offer challenges to cardiologist and cardiac surgeons. Thirty two cases of TOF have undergone total corrective surgery using extracorporeal circulation in the Department of Thoracic & Cardiovascular Surgery, Pusan Paik Hospital, Inje University, from Oct. 1985 to Feb. 1990. Clinical considerations were applied to these cases and the results were obtained as follows. 1. The heart lung machine used for extracorporeal circulation was SarnsO 7000, 5-head roller pump, and the number and type of oxygenators were 10 of bubble type and 22 of membrane type. The mean bypass time was 148.9 minutes and the mean aortic cross clamp time was 123.8 minutes. The GIK [glucose-insulin-potassium] solution was used as cardioplegic solution for myocardial protection during operation. 2. 20 cases were male and 12 were female, the mean age was 8 years old and the mean body weight was 25Kg. 3. The preoperative symptoms were cyanosis [29 cases], squatting [27 cases] and etc. The mean values of preoperative Hb., Hct., and SaO2 were 16.5 gm /dl, 50.3%, and 78.5%. 4. Combined anomalies were noticed in 16 cases [50%]. Among them 10 cases were PFO and 6 cases were ASD. 5. The degree of aorta overriding were 25% in 5 cases, 25 ~ 50% in 22 cases and above 50% in 5 cases. The dPA/Ao [ratio of diameter of pulmonary artery trunk to ascending aorta] were below 25% in 5 cases, 25 ~ 50% in 10 cases, 50 ~ 70% in 6 cases and above 75% in 11 cases. 6. The types of RVOT [right ventricular outflow tract] stenosis were valvular and infundibular in 14 cases [43.6%], diffuse hypoplastic type in 12 cases [37.5%], infundibular in 5 cases, and valvular and supravalvular in 1 case. 7. One stage radical corrective surgery was applied to the all cases. In widening of the RVOT, 3 types of patches were used: MVOP [monocusp ventricular outflow patch, Polystan BioprosthesesO] in 3 cases, knitted Dacron vessel patches in 2 cases, and double layer with bovine pericardium and woven Dacron prosthesis in 26 cases. 8. Postoperative complications were occurred in 15 cases. Among them, low output syndrome were occurred in 10 cases [31.3%] and 2 of them were expired postoperatively.

• Journal of Chest Surgery
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• v.36 no.9
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• pp.651-658
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• 2003

Since the first implanted in September 1997, the use of On-X prosthetic heart valve has been increasing around in the world. This study was designed to assess the feasibility, safety, and the postoperative hemodynamics with this new valve in clinical setting. Material and Method: The current study was carried out on 52 patients undergoing aortic valve replacement with this prosthesis between April 1999 to August 2002 at Chonnam National University Hospital to evaluate the surgical results. 52％ of the patients were male and the average age at implant was 50$\pm$13 years. The study followed the guidelines of the AATS/STS. Preoperatively, 32(61.5％) patients were in NYHA functional class III or IV and 2 patients had previous aortic valve surgery. Concomitant cardiac surgery was performed in 71.1％. The implanted valve sizes were 19 mm in 13 patients, 21 mm in 26, 23 mm in 10 and 25 mm in 3, respectively. Mean follow-up was 16.6$\pm$10.5 months (1∼39 months). Echocardiographic assessment was performed pre- and immediate postoperatively, as well as 3, 6, 12 months after surgery, evaluating pressure loss and regression of left ventricular hypertrophy. Result: Mean cardiopulmonary bypass time was 191$\pm$94.7 minutes with an aortic cross-clamp time of 142$\pm$51.7 minutes. There was no early and late mortality, Freedom from adverse events at 1 year in the study were as follows: thromboembolism, 95.6$\pm$6％; bleeding events, 90.2$\pm$4％; paravalvular leakage 92.3$\pm$4％; and overall valve-related morbidity at 1 year was 76.6$\pm$3％. There were no cases of valve thrombosis, prosthetic valve endocarditis and structural or non-structural failure. Left ventricular function at 12 months after surgery (EF=62.7$\pm$9.8％) revealed a statistically significant improvement compared to preoperative investigation (EF=55.8$\pm$15.9％, p=0.006). Left ventricular mass index was 247.3$\pm$122.3 g/$m^2$ on preoperative echocardiographic study, but regressed to 155.5$\pm$58.2 g/$m^2$ at postoperative 1 year (p=0.002). Over the follow-up period a further decrease of peak transvalvular gradients was observed in all patients: 62.5$\pm$38.0 mmHg on preoperative assessment, 18.2$\pm$6.8 mmHg at immediate postoperative period (p < 0.0001), 7.6$\pm$5.09 mmHg (p<0.0001) at 6 month, 18.0$\pm$10.8 mmHg (p<0.0001) at 1 year. Conclusion: The On-X prosthetic heart valve performs satisfactorily in the first 1 year period. Clinical outcome by examining NYHA functional classification revealed especially good results. Effective regression of left ventricular hypertrophy and statistically significant decrease of transvalvular gradient were observed over the first year, but longer-term follow-up of this patient group is needed to establish the expected rates for late valve-related events as well as the long-term clinical efficacy of this valve.

• Journal of Chest Surgery
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• v.34 no.12
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• pp.901-908
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• 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
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• v.29 no.11
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• pp.1218-1222
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• 1996

The reported incidence of postcardiotomy cardiogenic shock not responding to conventional therapy is still 0.1 to 0.8%. For this group of patients, more aggressive form of circulatory support must be employed. Centrifugal pumps are a ventricular assist device most commonly used on this purpose, due to low cost and easy availability. Currently, however, clinical experience of centrifugal pumps as a ventricular assist device is rarely reported in Korea. From January 1992 to January 1996, 2986 patients underwent cardiac operations on cardiopulmonary bypass at Seoul National University Hospital. Refractory postcardiotomy cardiac failure requring ventricular support with a Biomedicus centrifugal pump developed in ten of these patients. There were eight men and two women, ranged in age from nine years to 77 years with a mean of 50$\pm$20 years. The primary surgical procedures consisted of isolated coronary revascularization in four patients, combined coronary revascularization and aortic valve replacement in two, aortic dissection repair in two, pulmonary embolectomy in one, and heart transplantation in one. Of the ten patients, five had left ventricular assistance, one had right ventricular assistance, and four had biventricular assistance. Duration of ventricular assistance ranged from 24 to 175 hours, with a mean of 76$\pm$51 hours. Seven patients were weaned from ventricular assistance, and four of them discharged. The causes of death for nonsurvivors were progressive cardiac failure in two patients and multiorgan failure, intractable ventricular fibrillation, irreversible brain injury, and mechanical problem, respectively, in the other four. Survival was not predicted by time on cardiopulmonary bypass, aortic cross-clamp time, or duration of ventricular support. Major complications included bleeding(7), renal failure(6), infection(3) and neurologic complication(2). These results indicate that a centrifugal pump can provide reasonably satisfactory short-term circulatory support.

• Journal of Chest Surgery
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• v.36 no.7
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• pp.463-471
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• 2003

The long-term results of combined mitral valve repair and aortic valve replacement (AVR) have not been well evaluated. This study was performed to investigate the early and long-term results of mitral valve repair with AVR. Material and Method: We retrospectively reviewed 45 patients who underwent mitral valve repair and AVR between September 1990 and April 2002. The average age was 47 years: 28 were men and 17 women. Twelve patients had atrial fibrillation and three had a previous cardiac operation. The mitral valve disease consisted of pure insufficiency (MR) in 34 patients, mitral stenosis (MS) in 3, and mixed lesion in 8. Mitral valve disease was due to rheumatic origin in 24 patients, degenerative in 11, annular dilatation in 8, and ischemia or endocarditis in 2. The functional anatomy of mitral valve was annular dilatation in 31 patients, chordal elongation in 19, leaflet thickening in 19, commissural fusion in 13, chordal fusion in 10, chordal rupture in 6, and so on. Aortic prostheses used included mechanical valve in 32 patients, tissue valve in 12, and pulmonary autograft in one. The techniques of mitral valve repair included annuloplasty in 32 patients and various valvuloplasty of 54 techniques in 29 patients. Total cardiopulmonary bypass and aortic cross clamp time were 204$\pm$62 minute and 153$\pm$57 minutes, respectively. Result: Early death was in one patient due to low output syndrome (2.2%). After follow up of 57$\pm$37 months, late death was in one patient and the actuarial survival at 10 years was 96$\pm$4%. Recurrent MR developed grade II or III in 11 patients and moderate MS in 3. Three patients required reoperation for valve-related complications. The actuarial freedom from recurrent MR, MS, and reoperation were 64$\pm$11%, 86$\pm$8%, and 89$\pm$7% respectively. Conclusion: Combined mitral valve repair with AVR offers good early and long-term survival, and adequate techniques and selection of indication of mitral valve repair, especially in rheumatic disease, are prerequisites for better long-term results.

• Journal of Chest Surgery
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• v.41 no.4
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• pp.423-429
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• 2008

Background: The interest in robotic cardiac surgery has recently grown but there has not been much clinical research reported on this. The aim of this study is to examine our initial experience, since August 2007, with robotic cardiac surgery using the da $Vince^{TM}$ surgical system and to evaluate the feasibility and safety of it. Material and Method: Between August and December 2007, a total of 20 patients underwent robotic cardiac surgery using the da Vinci surgical system. For mitral valve repair (n=11), tricuspid valve repair (n=1), and ASD repair (n=1), cannulation, antegrade cardioplegia and transthoracic aortic cross-clamping were conducted for the right femoral vessels and the right internal jugular vein. For minimally invasive direct CABG (MIDCAB) (n=7), the internal thoracic artery (ITA) was harvested with the da Vinci surgical system. Result: The mean age of the patients was 50.1 (range: $26{\sim}78$) years. Three concomitant Maze procedures and one tricuspid annuloplasty were combined with mitral valve repair. The mean cardiopulmonary bypass time was $208.0{\pm}61.3$ minutes and the aortic cross clamp time was $158.8{\pm}40.6$ minutes. No patients showed more than mild mitral regurgitation after repair and the median hospital stay was 4 days. The robotic-harvested ITA was used for either left ITA (n=6) or bilateral ITA (n=1). The mean harvest time was $43.2{\pm}12.0$ minutes. The harvested ITA showed good flow and it was anastomosed under direct vision after left anterolateral thoracotomy. The patency of all the grafts was 100% (18/18) in MIDCAB. Conclusion: Robotic cardiac surgery using the da Vinci surgical system was variously adapted to areas such as mitral and tricuspid valve repair, ASD repair and ITA harvest for MIDCAB. The early results of the robotic cardiac surgery showed its safety and feasibility. With this primary report, we anticipate that clinical applications and further studies on robotic cardiac surgery using the da Vinci surgical system will be actively conducted in Korea.