• Journal of Chest Surgery
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• v.54 no.6
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• pp.551-553
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• 2021

Although it is attractive, a limitation of aortic valve (AV) replacement (AVR) through a mini-thoracotomy approach (mini-AVR) is the limited exposure of the AV. Here, we present a simple exposure technique named "suspending commissural sutures" for a more efficient mini-AVR. The technique involves making 3 half-depth stitches with 1-0 silk at each of the commissures, which are anchored to each corresponding pericardial surface. These stitches are tightened up so that the aortic root is axially expanded and is pulled upward. The technique of suspending commissural stitches seems to offer reasonable exposure of the AV in mini-AVR, and shows excellent early surgical outcomes.

• Journal of Chest Surgery
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• v.26 no.12
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• pp.909-914
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• 1993

Complete and optimal visualization of the mitral apparatus is a prerequisite for accurate repair or replacement of the mitral valve. A vertical left atriotomy just posterior to the interatrial groove is the most commonly used approach. However,exposure can be difficult under certain circumstances,such as small left atrium or reoperation. Other approaches have been advocated to deal with this difficult situations. We used an extended transseptal approach in 10 patients and good clinical results and excellent educational effects were obtained. The extended transseptal approach combines two semicircular atrial incisions circumscribing the tricuspid and mitral annuli anteriorly and superiorly,allowing exposure of the mitral valve by deflecting the ventricular side using stay sutures. The right atrium is opened anteriorly along the atrioventricular sulcus. The atrial septum is incised vertically through the fossa ovalis. Right atrial and septal incisions are joined at the superior end of the interatrial septum and extended across the dome of the left atrium to the left atrial appendage. The mitral valve was replaced in all 10 patients. Four of 10 patients had other simultaneous valve procedure: one had aortic valve replacement: 2 underwent tricuspid annuloplasty: 1 had aortic valve replacement and tricuspid annuloplasty. There was no hospital death and complication. Among the 5 patients who had atrial fibrillation preoperatively,4 had atrial fibrillation postoperatively,1 converted to sinus rhythm. The five patients who were in normal sinus rhythm preoperatively remained in sinus rhythm after replacement. A review of our results with this approach confirms the efficacy and safty of this method. So we recommanded this approach for routine mitral valve procedure,especially difficult situations,such as a small left atrium or the redo operation.

• Journal of Chest Surgery
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• v.28 no.1
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• pp.65-68
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• 1995

Pectus excavatum occasionally occurs in patients who have underlying cardiac disease, especially Marfan syndrome. This report describes a patient with pectus excavatum who had ascending aortic aneurysm with aortic regurgitation and anterior leaflet prolapse of mitral valve. This patient underwent replacement of aortic valve and ascending aorta with 25 mm SJM valved conduit graft[Bentall operation with Cabrol shunt , and mitral valve replacement with SJM 31 mm, the pectus excavatum was corrected at the time of completion of the intracardiac operation with the modified sternal turnover. This procedure offered excellent operative exposure for the inracardiac operation with prevention of low cardiac output after operation due to depressed sternum and maintained chest wall stability resulting good cosmetic chest wall appearance. This patient recovered and discharged in good postoperative result with minimal temporary peroneal nerve palsy in his left leg.

• Journal of Cardiovascular Imaging
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• v.31 no.2
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• pp.108-115
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• 2023

BACKGROUND: Minimizing contrast dose and radiation exposure while maintaining image quality during computed tomography angiography (CTA) for transcatheter aortic valve replacement (TAVR) is desirable, but not well established. This systematic review compares image quality for low contrast and low kV CTA versus conventional CTA in patients with aortic stenosis undergoing TAVR planning. METHODS: We performed a systematic literature review to identify clinical studies comparing imaging strategies for patients with aortic stenosis undergoing TAVR planning. The primary outcomes of image quality as assessed by the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were reported as random effects mean difference with 95% confidence interval (CI). RESULTS: We included 6 studies reporting on 353 patients. There was no difference in cardiac SNR (mean difference, -1.42; 95% CI, -5.71 to 2.88; p = 0.52), cardiac CNR (mean difference, -3.83; 95% CI, -9.98 to 2.32; p = 0.22), aortic SNR (mean difference, -0.23; 95% CI, -7.83 to 7.37; p = 0.95), aortic CNR (mean difference, -3.95; 95% CI, -12.03 to 4.13; p = 0.34), and ileofemoral SNR (mean difference, -6.09; 95% CI, -13.80 to 1.62; p = 0.12) between the low dose and conventional protocols. There was a difference in ileofemoral CNR between the low dose and conventional protocols with a mean difference of -9.26 (95% CI, -15.06 to -3.46; p = 0.002). Overall, subjective image quality was similar between the 2 protocols. CONCLUSIONS: This systematic review suggests that low contrast and low kV CTA for TAVR planning provides similar image quality to conventional CTA.

• Journal of Veterinary Clinics
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• v.35 no.1
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• pp.10-12
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• 2018

Mitral regurgitation is the most frequent cause of cardiac disability and death in dogs. A wide range of medical and surgical treatments have been used for mitral regurgitation. Surgical treatments for complete correction of mitral regurgitation include valve repair and valve replacement, which have the advantages of eliminating or correcting the primary cause. Surgical treatments approach the mitral valve via right- or left-side thoracotomy. Aortic root exposure is needed for cardiopulmonary bypass. To compare right-side and left-side approaches, 10 dog cadavers were used in this study. Subsequently, the left-side surgical approach was used in vivo and in conjunction with cardiopulmonary bypass and cardioplegic arrest. Based on the results, and considering ease of access to the aortic root, valve incision site, and visualization of the surgical field, a left-side approach is recommended.

• Journal of Chest Surgery
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• v.28 no.6
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• pp.579-582
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• 1995

The extended transseptal approach to the mitral valve replacement has been used for 30 patients. There were 19 women and 11 men. Twenty five patients had rheumatic heart disease, 4 had degenerative valve ,and 1 had valve prolapse. Fifteen of 30 patients had other associated procedure; 10 had aortic valve replacement; 5 had tricuspid annuloplasty. There were no postoperative complications associated with the approaches, ie, no bleeding, no sinus node dysfuction, and no atrioventricular conduction disturbance. Despite division of the sinus node artery, preoperative atrial rhythms[3 sinus rhythms and 27 atrial fibrillations were not changed during postoperative period. The extended transseptal approach provides good mitral valve exposure without inherent complications, and is superior to that of standard approach, so we use it routinely for mitral valve procedure.

• Journal of Chest Surgery
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• v.33 no.8
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• pp.676-680
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• 2000

To minimize the period of brain ischemia and the potential for neurologic damage during aortic arch replacement, we used the arch-first technique. First case was a 28-year-old female with extensive aneurysm involving ascending, arch and descending thoracic aorta. Exposure was obtained via a bilateral via a bilateral thoracotomy (clamshell incision) in the anterior 4th right and 3rd left intercostal space with oblique sternotomy. To prepare for arch perfusion, the side-arm graft(10mm) was anastomosed to the aortic graft, opposite the site of the planned anastomosis to the arch vessels. After completing the arch anastomosis under total circulatory arrest(37min) and retrograde cerebral perfusion(12min), aortic graft was clamped on either side and the arch was perfused via side-arm graft for 36min. When distal aortic anastomosis was finished, distal clamp of aortic graft was released and arch vessels were perfused via common femoral artery, and the proximal aortic anastomosis was accomplished. The patient was discharged with no event. Second case was a 48-year-old male with extensive aneurysm involving ascending, arch, and aortic regurgitaiton(grade III/IV). This case was also done using the clamshell incision. Aortic valve replacement was done by valved-conduit(Vascutek 30mm), both coronary artery anastomosis using Cabrol's procedure. Last operation procedure was the same as the 1st case.

• Journal of Chest Surgery
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• v.31 no.11
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• pp.1037-1042
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• 1998

Background: Among the various techniques for the adequate exposure of the mitral valve, the extended transseptal approach is the essential prerequisite for accurate repair or replacement of the mitral apparatus. But the efficacy and safty of the extended transseptal approach has not determined in Korea yet. Materials and methods: Retrospective data of 80 consecutive patients, operated from September 1992 to July 1997 were reviewed. Seventy- eight patients underwent mitral valve replacement and 2 patients underwent excision of left atrial myxoma. Thirty-eight of 78 patients had other concomitant procedures such as aortic valve replacement(n=22), tricuspid annulopasty(n=14), coronary artery bypass graft(n=1) and closure of ventricular septal defect(n=1). Mean follow up was 23.3±15.0 months and total follow up was 1792 patient-months. Results: The hospital mortality rate was 3.8%(3 patients). Two deaths were due to low cardiac output and one due to postoperative bleeding of coagulopathy. Among the 46 patients who had atrial fibrillation preoperatively, 45 had atrial fibrillation postoperatively and 1 converted to sinus rhythm. All 34 patients who were in normal sinus rhythm preoperatively remained in sinus rhythm after the operation. Mean aortic cross clamping time was 62 minutes for isolated mitral procedure and 90 minutes for concomitant procedures. There were no specific complications related to this approach. Conclusions: We suggest that the extended transseptal approach is an easy and good method for mitral valve surgery, especially in patients with small sized left atrium.

• Journal of Chest Surgery
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• v.35 no.7
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• pp.556-559
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• 2002

The presense of pectus excavatum in Marfan's syndrome may complicate cardiac operation by making midline sternotomy technically more difficult and limiting the operative exposure of the heart. We operated on a 33 year old male patient with Marfan's syndrome and severe pectus excavatum who had severe mitral regurgitation and moderate aortic regurgitation with 52mm aortic root dilation. The operative field was adequately exposed through a midline sternal incision with two sternal retactors. The patient underwent Bentall operation and mitral valve replacement. The repair of pectus excavatum was performed after completion of CPB and the administration of protamin. Permanent internal stabilization achieved by overlapping of the ends of lower ribs and reinforced with sternal closure wire.

• Journal of Chest Surgery
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• v.41 no.6
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• pp.679-686
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• 2008

Background: Cellular remnants in the bioprosthetic heart valve are known to be related to a host's immunologic response and they can form the nidus for calcification. The extracellular matrix of the decellularized valve tissue can also be used as a biological scaffold for cell attachment, endothelialization and tissue reconstitution. Thus, decellularization is the most important part in making a bioprosthetic valve and biological caffold. Many protocols and agents have been suggested for decellularization, yet there ave been few reports about the effect of a treatment with hypotonic solution prior to chemical or enzymatic treatment. This study investigated the effect of a treatment with hypotonic solution and the appropriate environments such as temperature, the treatment duration and the concentration of sodium dodecylsulfate (SDS) for achieving proper decellularization. Material and Method: Porcine aortic valves were decellularized with odium dodecylsulfate at various concentrations (0.25%, 0.5%), time durations (6, 12, 24 hours) and temperatures ($4^{\circ}C$, $20^{\circ}C$)(Group B). Same the number of porcine aortic valves (group A) was treated with hypotonic solution prior to SDS treatment at the same conditions. The duration of exposure to the hypotonic solution was 4, 7 and 14 hours and he temperature was $4^{\circ}C$ and $20^{\circ}C$, respectively. The degree of decellularization was analyzed by performing hematoxylin and eosin staining. Result: There were no differences in the degree of decellularization between the two concentrations (0.25% 0.5%) of SDS. Twenty four hours treatment with SDS revealed the best decellularization effect for both roups A and B at the temperature of $4^{\circ}C$, but there was no differences between the roups at $20^{\circ}C$. Treatment with hypotonic solution (group A) showed a better ecellularization effect at all the matched conditions. Fourteen hours treatment at $4^{\circ}C$ ith ypotonic solution prior to 80S treatment revealed the best decellularization effect. The treatment with hypotonic solution at $20^{\circ}C$ revealed a good decellularization effect, but his showed significant extracellular matrix destruction. Conclusion: The exposure of porcine heart valves to hypotonic solution prior to SDS treatment is highly effective for achieving decellularization. Osmotic treatment with hypotonic solution should be considered or achieving decellularization of porcine aortic valves. Further study should be carried out to see whether the treatment with hypotonic solution could reduce the exposure duration and concentration of chemical detergents, and also to evaluate how the structure of the extracellular matrix of the porcine valve is affected by the exposure to hypotonic solution.