• Journal of Chest Surgery
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• v.31 no.11
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• pp.1043-1048
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• 1998

Background: As coronary arterial disease is increasing, we evaluated the patients who underwent CABG(Coronary Artery Bypass Grafting) and thus report the early results and risk factors related to mortality and morbidity. Materials and methods: Between July 1996 and February 1998, 42 patients underwent CABG. We analyzed age, sex, preoperative ejection fraction, Canadian heart classification, prevalence factors of CAD(Coronary Artery Disease), angiographic findings, graft vessel numbers, IMA(Internal Mallary Artery) use, ECC* (extracorporeal circulation) time and morbidity. We also evaluated the mortality rate and the causes of death. Results: Complication was developed at 17cases. The average age of the complication group was 61±11.9 years and that of the noncomplication group was 51±10.5 years(p=0.004). ECC time was 198±42.5(min) in the complication group and 158±47.4(min) in the noncomplication group(p=0.008). The other factors had no correlation to the morbidity, statistically. The average follow up duration was 12.5 months and all the patients were alive except for the 2 expired cases. The mortality rate was 4.7%, among which one patient who underwent CABG with aortic valve replacement died due to multiorgan failure and the other died due to sepsis with pneumonia and wound infection. Conclusions: We conclude that the risk factors related to morbidity were age and ECC time, and that there were no correlations between other factors and morbidity.

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

• The Korean Society of Law and Medicine
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• v.18 no.2
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• pp.163-194
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• 2017

Coronary artery disease has increased in Korea as the country enters the aged society. It is well known that the incidence of coronary artery disease is related to aging, hypertension, diabetes, hyperlipidemia, and dietary habit. For effective treatment of significant coronary stenosis, close coordination between cardiac surgery and cardiology team is essential. Especially cardiologists' decision whether to do the stent placement or CABG is very important because the cardiologists usually start to consult the patients for their treatment. Recently, non-surgical interventions(that is stent placement) in cardiology field have dramatically increased as the national insurance system removed the limitation of the number of stents deployed. However, accidents are often caused by inappropriate use of stents, especially in patients with triple coronary disease or left main disease with heavy coronary calcifications. Another aspect of stent placement is to cope with an emergency case in the event of coronary rupture or pericardial tamponade during coronary interventions without cardiac surgeons. In the past two years, the Korea Consumer Agency (Consumer Dispute Coordination Committee) analyzed eight cases of medical dispute settlement. Only two hospitals were manned with both cardiologists and cardiac surgeons. Seven patients died of procedures of stenting and five patients died on the day of the procedure. Among the 8 cases, 5 cases showed 3 vessel disease and the rest of the cases had either severe calcification, complete occlusion or poor coronary antomies for stenting According to a 2017 national data registry of coronary stenting, less than 3 drug-eluting stents were implanted in 98% of all patients. In 2015, the number of stent procedures was 38,922, and approximately in 800 (2%) cases, more than four stents were used per patient. We emphasize that it is necessary to seriously consider the cost-benefit analysis between stent and CABG. The patient has the right to choose the right procedure by asking the liability of 'instruction explanation obligation'. He should be well informed of the pros and cons of both procedures to avoid overuse of stent. It can be solved by intimate discussion of individual cases with the cardiac surgeon and the patient. Unilateral dialogue with the patient, forceful restriction on the number of stenting, lack of surgeon's backup in difficult cases should all be avoided. It is also necessary to solve the problem not only at the hospital level, such as multidisciplinary integrated medical care, but also a nationwide solution such as expanding cardiac surgeons as essential personnel to public officials.

• Investigative Magnetic Resonance Imaging
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• v.7 no.1
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• pp.22-30
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• 2003

Purpose : The efficacy of magnetic resonance imaging for evaluating coronary artery disease has been reported. In this study, we evaluated the usefulness of breath-hold segmented K-space cine MR imaging for evaluating the patency of coronary artery bypass grafts (CABG). Materials and Method s : Thirty eight patients with a total of 92 CABGs (36 internal thoracic arteries and 56 saphenous vein grafts) were evaluated using segmented K-space cardiac-gated fast gradient echo sequence (2D-FASTCARD) MR imaging. MR magnitude images were evaluated from the hard copies by two independent observers. A graft was defined as patent if it was seen as a bright small round area on at least two consecutive images throughout the cardiac cycle at a position consistent with the expected location for that graft. Results : MR images were obtained successfully for 23 patients (61%). The sagittal planes were most helpful in visualizing the cross-section of sapheneous vein bypass graft to left circumflex artery branch, whereas the transverse planes were used for identification of internal mammary artery grafts to left anterior descending coronary artery or its branch and identification of saphenous vein grafts to right coronary artery. Forty five grafts were visible using this MR technique, while the grafts were not visible on seven saphenous vein grafts and two internal mammary artery grafts. In two patients showing symptoms of myocardial ischemia, one or two bypass grafts were not visible. Imaging, perpendicular plane to a CABG was important to visualize the flow inside the CABG with maximum sensitivity. Conclusion : Evaluation of patency of the bypass graft was clinically feasible by 2D-FASTCARD MR imaging, whereas any invisible bypass grafts should be further studied by contrast-enhanced MR angiography or by conventional angiography for confirmation of abnormalities.

• Journal of Chest Surgery
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• v.39 no.1 s.258
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• pp.48-55
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• 2006

Background: The benefits of preoperative use of aspirin and plavix in coronary patients have been well documented. Due to their bleeding tendency, there have been many discussions about when to stop the antiplatelet agent before operation. We evaluated the effects of preoperative continuous use of aspirin and plavix in OPCAB patients. Material and Method: 123 patients underwent OPCAB from March, 2004 to Feb., 2005. We divided them into two groups; those who had continuous administration of aspirin and plavix during the preoperative period (n=45, 36.6$\%$) and those who discontinued them at least one day before the operation (n=78, 63.4$\%$). We then compared the platelet count, hemoglobin/hematocrit level, graft patency, postoperative bleeding and related complications, and operation time between the two groups. The patients were also divided into long-term users ($\geq$ 1 month) and short-term users (< 1 month), with the aforementioned factors equally compared. Result: There was no statistical difference between the two groups regarding postoperative bleeding, related complications, graft patency, operation time and mortality. Continuous users showed significantly low platelet levels on immediate post operation (p=0.02), postoperative day (POD) $\sharp$1 (p=0.002) and POD $\sharp$2 (p=0.021), respectively. But there was no difference on POD $\sharp$7. Long-term users showed statistically significant difference in pre- and postoperative platelet count, but none in postoperative bleeding and related complications. Conclusion: Continuous use of aspirin and plavix did not increase postoperative bleeding or related complications. Also graft patency and mortality had no statistical differences in continuous users. We think that there is no need to stop aspirin and plavix before OPCAB.

• Journal of Chest Surgery
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• v.30 no.1
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• pp.27-33
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• 1997

Retrograde myocardial protection is widely accepted in CABG operation because of the limitations of the antegrade method in the coronary arterial stenosis lesions. We analyzed 76 c ses of retrograde myocardial protection among 96 cases of CABG operation performed between April 1994 and August 1995, There were 48 males and 25 females, and the mean age was 58.2 $\pm$ 8.3 years. 53 patients (70%) were operated for unstable angina, 14 (18%) for stable angina, 6 (8%) for post-infarct angina, 1 (1%) for acute myocardial infarction, and 2()%) for failed PTCA. Preoperative coronary angiography revealed 3-vessel disease in 42 cases, 2-vessel disease in 11, 1-vessel disease in 10, and left main disease in 13 cases. We used SVG(63 cases), LIMA(69 cases), RIMA(11 cases), radial artery(6 cases), and gastroepiploic artery(1 case) for the grafts. Mean anastomosis was 3.2 $\pm$ 1.1. We protected the myocardium with antegrade induction and retrograde maintenance in all the cases except a case of retrograde induction and maintenance. During the aortic cross-clamping, blood cardioplegia was administered intermittently in 19 cases, and continuously in 57 In 39 cases, we used retrograde ardioplegia and antegrade perfusion of RCA graft simultaneously. We had no operative motality. Perioperative complications were arrhythmia in 15 cases, perioperatve myocardial infarction in 10, low cardiac output syndrome In 8, transient neurologic problem in 7, transient psychiatric problem in 6, ARF in 3, bleeding in 2, pneumonia in 2, wound infection in 1, and duodenal ulcer perforation in 1 . In this report, we experienced 76 cases of CABG operation with retrograde myocardial protection under the acceptable operative risk without operative mortality.

• Journal of Chest Surgery
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• v.41 no.1
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• pp.55-60
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• 2008

Background: Circulating levels of brain natriuretic peptide (BNP) provide prognostic information for patients with heart failure. The aim of our study was to investigate whether preoperative and postoperative BNP levels could predict postoperative complications and outcomes in patients after coronary artery bypass graft (CABG). Material and Method: Data was collected prospectively on 30 patients (M/F=19/11, age $60.0{\pm}9.6$ years) undergoing conventional CABG during a 1-year period beginning on January 1, 2005. Patients underwent off-pump CABG, and combined surgery was excluded. The BNP assay was performed preoperatively, immediate postoperatively at the intensive care unit (ICU), and 1, 3, 5, and 7days postoperatively. Result: Preoperative BNP levels significantly correlated with preoperative echocardiographic ejection fraction and an ICU stay of 5 days or more (r=-0.4, p=0.028; r=0.39, p=0.031, respectively). A preoperative BNP cut-off value above 263 pg/mL demonstrated high specificity (90.5%) for predicting postoperative complications using the receiver operating characteristics curves. Preoperative and postoperative (7 days) BNP levels were different depending on the abscence (mean BNP=$99{\pm}23\;pg/mL$ vs. $296{\pm}74\;pg/mL$, p<0.05) and presence (mean BNP=$212{\pm}29\;pg/mL$ vs. $408{\pm}23\;pg/mL$, p<0.01). Conclusion: Preoperative BNP levels >263 pg/mL predict postoperative complications in patients receiving CABG.

• Journal of Chest Surgery
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• v.30 no.11
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• pp.1077-1082
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• 1997

To assess the early results, risk factors and optimal timing for coronary artery bypass graft surgery(CABG) after an acute myocardial infarction(AMI), we reviewed our 19 patients who underwent CABG within 30 days after AMI, between June 1994 and October 1996. This study excluded 1 patient whose diagnosis was AMI with ventricular septal rupture. 14 of the patients were male and 5 were female. Their ages ranged from 41 to 77 years(mean age, 60.6$\pm$ 10.4 years), and the amount of time between AMI and CABG ranged from 8 hours to 24 days(mean time, 10.6$\pm$6.4 days). There were 11 anteroseptal infarctions and 8 inferior wall infarctions. 11 patients had trsnsmural infarctions and 8 had subendocardial infarctions. Indications of operations were p imary revascularization and postinfarction angina. Three patients required preoperative intra-aortic balloon pump(IABP) support, and 4 additional patients required IABP to be separated from cardiopulmonary bypass. An average of 3.6 $\pm$ 0.6 vessels per patient were bypassed. The early mortality rate for these 19 patients was 5.3% and late mortality rate was 5.5%, 1-year and 2-year actuarial survival rates were 89.5% Univariate analysis of mortality showed that an ejection fraction less than 30% and intraopretative IABP supports were associated with risk factors(p value=0.018 and 0.015 respectively). Age, sex, time to CABG, emergency operations, types and locations of infarctions were not significant. Although our studies have weak p.oints in that there was only a small number of patients and the lack of long-term results, we could conclude that early myocardial revascularization is relatively safe after AMI for those individuals with an ejection fraction greater than 30%.

• Journal of Chest Surgery
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• v.32 no.9
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• pp.790-798
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• 1999

Background: As the early outcome after coronary artery bypass grafting(CABG) has been stabilized, neurologic complication has now become one of the most important morbidity. The aim of this study was to find out the risk factors associated with the neurologic complications after CABG. Material and Method: In 351 patients who underwent CABG, the incidence and features of neurologic complications, with associated perioperative risk factors, were retrospectively reviewed. Neurologic complication was defined as a new cerebral infarction confirmed by postoperative neurologic examination and radiologic studies, or delayed recovery of consciousness and orientation for more than 24 hours after the operation. Result: Neurologic complications occurred in 18 patients(5.1%), of these nine(2.6%) were diagnosed as having new cerebral infarctions(stroke). Stroke was manifested as motor paralysis in four patients, mental retardation or orientation abnormality in four, and brain death in one. Statistical analysis revealed the following variables as significant risk factors for neurologic complications by both univariate and multivariate analyses: cardiopulmonary bypass longer than 180 minutes, atheroma of the ascending aorta, carotid artery stenosis detected by Duplex sonography, and past history of cerebrovascular accident or transient ischemic attack. Age over 65 years, aortic calcification detected by simple X-ray, and intraoperative myocardial infarction were significant risk factors by univariate analysis only. Neither the severity of carotid artery stenosis nor technical modifications such as cannulation of the aortic arch or single clamp technique, which were expected to affect the inciden e of neurologic complications, had significant relationship with the incidence. Conclusion: This study confirmed the strong association between neurologic complications after CABG and atherosclerosis of the arterial system. Therefore, to minimize the incidence of neurologic complications, systematic evaluation focused on atherosclerotic lesions of the arterial system followed by adequate alteration of operative strategy is needed.

• Nuclear Medicine and Molecular Imaging
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• v.42 no.4
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• pp.285-291
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• 2008

Purpose: Although automatic quantification software of myocardial perfusion SPECT provides highly objective and reproducible quantitative measurements, there is still some limitation in the direct use of quantitative measurements. In this study we derived parameters using normal variation of perfusion measurements, and tried to test the usefulness of these parameters. Materials and Methods: In order to calculate normal variation of perfusion measurements on myocardial perfusion SPECT, 55 patients (M:F = 28:27) of low-likelihood for coronary artery disease were enrolled and $^{201}TI$ rest/$^{99m}Tc$-MIBI stress SPECT studies were performed. Using 20-segment model, mean (m) and standard deviation (SD) of perfusion were calculated in each segment. As a myocardial viability assessment group, another 48 patients with known coronary artery disease, who underwent coronary artery bypass graft surgery (CABG) were enrolled. $^{201}TI$ rest/$^{99m}Tc$-MIBI stress / $^{201}TI$ 24-hr delayed SPECT was performed before CABG and SPECT was followed up 3 months after CABG. From the preoperative 24-hr delayed SPECT, $Q_{delay}$ (perfusion measurement), ${\Delta}_{delay}$ ($Q_{delay}$ - m) and $Z_{delay}$ (($Q_{delay}$ - m)/SD) were defined and diagnostic performances of them for myocardial viability were evaluated using area under curve (AUC) on receiver operating characteristic (ROC) curve analysis. Results: Segmental perfusion measurements showed considerable normal variations among segments. In men, the lowest segmental perfusion measurement was $51.8{\pm}6.5$ and the highest segmental perfusion was $87.0{\pm}5.9$, and they are $58.7{\pm}8.1$ and $87.3{\pm}6.0$, respectively in women. In the viability assessment $Q_{delay}$ showed AUC of 0.633, while those for ${\Delta}_{delay}$ and $Z_{delay}$ were 0.735 and 0.716, respectively. The AUCs of ${\Delta}_{delay}$ and $Z_{delay}$ were significantly higher than that of $Q_{delay}$ (p = 0.001 and 0.018, respectively). The diagnostic performance of ${\Delta}_{delay}$, which showed highest AUC, was 85% of sensitivity and 53% of specificity at the optimal cutoff of -24.7. Conclusion: On automatic quantification of myocardial perfusion SPECT, the normal variation of perfusion measurements were considerable among segments. In the viability assessment, the parameters considering normal variation showed better diagnostic performance than the direct perfusion measurement. This study suggests that consideration of normal variation is important in the analysis of measurements on quantitative myocardial perfusion SPECT.