• Journal of Chest Surgery
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• v.30 no.2
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• pp.172-178
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• 1997

We present a etrospective analysis of arterial embolectomies performed at the Inje University Seoul Paik Hospital. During the period of March 1987 Feburary 1996 twenty-six patients underwent embolectomies, eighteen patients were male and eight patients were female, mean age of patients was 56.8 years. Rest pain was the chief complaint in 24 patients, the remaining two patients complained of long term history of claudication after recovery of acute symtoms. But only 10 patients had sensBrylmotor symtoms. Heart was the most common source of embolization and frequent predisposing factor of embolism was ischemic heart disease in 8 cases and valvular heart disease in 11 cases. The sites of embolization were upper extremities artery in 6 cases, saddle embolism in 2 cases, lower extremities artery in 18 cases and the most common site of embolism was femoral artery in 1 1 cases. Preoperative angiography was taken in the diagnosis and planning of the embolectomy in 1) patients while in the other patient p eoperative angiography was not taken. Only two cases were operated within the golden period of 6 hours and other cases were operated in more than 6 hours after embolization. In all patients, the Fogarty embolectomy catheter was used without bypass surgery via bachial ateriotomy in the embolism of upper extremities artery, bilateral groin approaches in the saddle embolism and transfemoral approach in the embolism of lower extremities artery. However 3 patients were re-operated via transpopliteal approach in the distal poplitiotibial embolism. Eighteen patients received perioperative anticoagulation therapy by heparin or fraxiparine and wafarin was used in 17 patients at the time of discharge and the indication of anticogulation was patients of valvular heat disease andfor atrial fibrillation, peripheral artery atherosclerosis and recurrent embolism. Postoperative results of the embolectomy were as follows: fouteen pateints had excellent results, five cases had symtom improvement after re-operation, B. K. amputation in 1 case who had severe atherosclerosis of lower extremities, recurrent embolism in 1 case and death in 2 cases the cause of death were acute renal failure and cerebral artery embolism, respectively. The complications of the embolectomy were reperfusion syndrome, pseudoaneurysm and intimal dissection in one case each. Conclusively the problems of embolism is delayed diagnosis and increasing number of old aged patient who had suffered from ischemic heart diease. Preoperative angiography was not always needed for embol ectomy. Selective anticoagulation therapy can decrease incidence of re-embolism. In the distal poplitiotibial embolism, embolectomy of tibial artery was difficult.

• Journal of Chest Surgery
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• v.39 no.8 s.265
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• pp.611-618
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• 2006

Background: There have been controversies whether mitral valvular surgery is necessary in the patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting. The purpose of this study is to evaluate the long term clinical results of patients with moderate ischemic mitral regurgitation. Material and Method: Between January 1992 and February 2005, 44 patients with moderate ischemic mitral regurgitation underwent coronary artery bypass grafting. Concomitant mitral valvular procedure was performed in 20 patients (group 1) and isolated coronary artery bypass grafting was performed in 24 patients (group 2). There were no significant difference between groups except cardiopulmonary bypass time (p<0.01). Postoperative follow up duration was $30.1{\pm}29.6$ months and last follow up echocardiographic examination was performed at $21.2{\pm}28.0$ months. Result: There was no difference in operative mortality between groups (group 1 vs group 2, 15.0% vs 8.3%, p=0.493). Grade of mitral regurgitation ${(0.81{\pm}0.91\;vs\;1.50{\pm}0.05,\;p=0.046)}$ and reduction in regurgitation grade ${(1.75{\pm}0.93\;vs\;0.70{\pm}1.26,\;p=0.009)}$ were different between two groups. But there were no significant differences in left ventricular ejection fraction ${(34.1{\pm}11.4%\;vs\;41.6{\pm}12.9%)}$, left ventricular end systolic volume ${(118.2{\pm}63.9\;ml%\;vs\;85.6{\pm}281\;ml)}$, New York Heart Association functional class ${(2.1{\pm}0.2\;vs\;2.4{\pm}1.2)}$ and 5 year survival rate ${(85{\pm}8%\;vs\;82{\pm}8%)}$. There was no risk factor for operative mortality and the only risk factor for late death was preoperative atrial fibrillation (p=0.042). There was no significant correlation between mitral valvular surgery and late death. Conclusion: Concomitant mitral valvular procedure in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting had no significant positive effect on survival and ventricular function compared with isolated coronary artery bypass grafting. Prospective randomized study may be needed to evaluate the necessity of concomitant mitral procedure and to find more effective method for the improvement of ventricular function.

• Journal of Chest Surgery
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• v.42 no.2
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• pp.193-200
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• 2009

Background: The long-term administration of oral anticoagulant to the patients with a mechanical heart valve prosthesis is mandatory. However, the appropriate intensity of oral anticoagulant therapy to prevent thromboembolic or hemorrhagic complications is still controversial. We tried to apply low intensity anticoagulant therapy for which the International Normalized Ratios ranged between 1.5 and 2.5, and we analyzed the anticoagulation-related long term outcomes. Material and Method: From January 1992 to December 2002, 144 patients who underwent a single cardiac valve replacement were included in the study, and their ages ranged from 15 to 72 years (mean age: $47.4{\pm}15.1$): there were 49 aortic valve replacements (AVR) and 95 mitral valve replacements (AVR). The patients were followed up monthly or bi-monthly at the outpatient clinic with clinical examinations and measuring the prothrombin time to adjust the International Normalized Ratios (INRs) within the low-intensity target range between 1.5 and 2.5. Result: The follow-up period was 835.3 patient-years (mean: $5.9{\pm}3.5$) and the INRs of 7,706 measurements were available for evaluation. The mean INRs of the aortic and the mitral valve replacement groups were significantly different (p<0.01). All the patients' INRs were within the target range in 61.9% of the measurements. The mean INRs $(2.16{\pm}0.23)$ of the patients with atrial fibrillation, which was found in 30.3% of the patients, were definitely higher than those $(2.03{\pm}0.27)$ measured in the patients with regular rhythm (p<0.01). Thromboembolic episodes occurred in 9 patients with an incidence of 1.08%/patient-year. Major bleeding occurred in 2 patients (MVR) with an incidence of 0.24%/patient-year. The patients who displayed better compliance showed a lower incidence of complications (p=0.000). Conclusion: The anticoagulation therapy with a low-intensity target range after MVR or AVR seems to be effective and feasible, and increasing the patients’ compliance should be done for achieving more effective anticoagulation therapy.

• Journal of Chest Surgery
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• v.42 no.4
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• pp.456-463
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• 2009

Background: Although the reports on re-operative coronary revascularization (redo-CABG) have increased, there are only limited reports on redo-CABG using arterial grafts. The aim of this study was to analyze the safety and feasibility of using various arterial grafts for redo-CABG. Material and Method: A consecutive series of patients who underwent 33 redo-CABGs from March 2001 to July 2008 were retrospectively reviewed. We performed conventional CABG in 17 patients, on-pump beating CABG in 7, off-pump CABG in 7 and minimally invasive direct coronary artery bypass in 2. The grafted that were used included 34 internal thoracic arteries (ITA), 14 radial arteries, 14 right gastroepiploic arteries and others. Arterial composite grafts were constructed in 26 patients. Of these, a previously patent in-situ left ITA was re-used as the in-flow of a composite graft in 10 patients. Result: No hospital deaths or major wound problems occurred. The post-operative complications included 2 myocardial infarctions (6%), 1 intra-aortic balloon pump insertion (3%), 5 cases of atrial fibrillation (15.1 %) and 3 neurologic complications (9.1%). The meanfollow-up duration was 31.1$\pm$22.7 months and the 3 year survival rate was 86.4%. There were 4 late deaths (2 cardiac deaths) and no recurrent angina during the follow-up period. Conclusion: Redo-CABG with using various arterial grafts is currently a safe, feasible procedure, but further investigation and long term follow-up are needed.

• Journal of Chest Surgery
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• v.38 no.11 s.256
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• pp.733-738
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• 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
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• v.40 no.5 s.274
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• pp.351-355
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• 2007

Background: Postinfarction ventricular septal rupture is associated with mortality as high as $85\sim90%$, if it is treated medically. This report documents our experience with postinfarction ventricular septal rupture that was treated surgically, Material and Method: We retrospectively reviewed the medical records of 11 patients who were operated on due to postinfarction ventricular septal rupture between August 1996 and August 2006. There were 4 men and 7 women, with a mean age of $70{\pm}11$ years (age range: $50\sim84$ years). The location of the rupture was anterior in 7 cases and posterior in 4 cases. The interval between the onset of acute myocardial infarction and the occurrence of the ventricular septal rupture was $2.0{\pm}1.3$ days (range: $1\sim5$ days). Operation was performed at an average of $2.4{\pm}2.7$ days (range: $0\sim8$ days) after the diagnosis of septal rupture. Preoperative intraaortic balloon pump therapy was performed in 10 patients. Result: The infarct exclusion technique was used in all cases. Coronary artery bypass grafting was done in 8 cases, with the mean number of distal anastomosis being $1.0{\pm}0.8$. There was one operative death. In 2 patients, reoperation was performed due to a residual septal defect. The postoperative morbidities were transient atrial fibrillation (n=7), paroxysmal supraventricular tachycardia (n=1), low cardiac output syndrome (n=3), bleeding reoperation (n=2), delayed sternal closure (n=2), acute renal failure (n=2), pneumonia (n=1), intraaortic balloon pump-related thromboembolism (n=1), and transient delirium (n=2). Nine patients have been followed up for a mean of $38{\pm}40$ months except for one follow-up loss. There have been 3 late deaths. At the latest follow-up, all 6 survivors were in a good functional class. Conclusion: We demonstrated satisfactory operative and midterm results with our strategy of preoperative intraaortic balloon pump therapy, early repair of septal rupture by infarct exclusion and combined coronary revascularization.

• Journal of Chest Surgery
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• v.43 no.5
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• pp.475-481
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• 2010

Background: We evaluated mid-term results of mitral annuloplasty using a flexible band and a completely rigid ring for mitral valve repair in patients with degenerative mitral regurgitation (MR). Material and Method: From January 2004 to September 2008, 71 patients (M:F=36:35, $55{\pm}13$ years) underwent mitral valve repair with mitral annuloplasty for degenerative MR. Ring annuloplasty was done using a Cosgrove-Edwards flexible band (Group I, n=43) or a Carpentier-Edwards classic ring (Group II, n=28). There were no differences in preoperative characteristics of the participants. Average duration of follow-up was 36 months (range: 2~69 mos). Result: There was no in-hospital mortality. Postoperative morbidity, which included atrial fibrillation (n=7) and low cardiac output syndrome (n=5) in groups I and II were similar. There was one late death in group II. The proportion exhibiting freedom from recurrent mitral regurgitation ($\geq$moderate) at 4 years in Groups I and II were, respectively, 94.5 and 91.8%, (p=0.695). Left ventricular ejection fraction decreased in the early postoperative period ($7{\pm}2$ days) and recovered by last follow-up ($25{\pm}16$ mos; p=0.002). The pattern was similar in groups I and II (p=0.905). Re-operation was performed in 3 patients (1 in Group I and 2 in Group II, p=0.316). Four-year event-free survival (free of adverse valve-related events) was 95.2% for Group I and 92.6% for Group II; this difference was not significant, p=0.646). Conclusion: The type of technique used in mitral annuloplasty to repair the mitral valve repair after degenerative MR did not affect mid-term clinical and functional results.

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