• Journal of Chest Surgery
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• v.38 no.5 s.250
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• pp.335-348
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• 2005

Background: This retrospective review examines the preoperative condition, postoperative course, mortality and cause of death for the patients who underwent modified Blalock-Taussig shunt for complex congenital heart defects in early infancy. Material and Method: Fifty eight patients underwent modified Blalock-Taussig shunts from January 2000 to November 2003. The mean age at operation was $23.1\pm16.2$ days ($5\~81\;days$), and the mean body weight was $3.4\pm0.7\;kg\;(2.1\~4.3\;kg)$. Indications for surgery were pulmonary atresia with ventricular septal defect in 12 cases, pulmonary atresia with intact ventricular septum in 17, single ventricle (SV) in 18, and hypoplastic left heart syndrome (HLHS) in 11. Total anomalous pulmonary venous return (TAPVR) was associated with SV in 4 cases. Result: There were 11 ($19.0\%$) early, and 5 ($10.6\%$) late deaths. Causes of early death included low cardiac output in 9, arrhythmia in 1, and multiorgan failure in 1. Late deaths resulted from pneumonia in 2, hypoxia in 1, and sepsis in 1. Risk factors influencing mortality were preoperative pulmonary hypertension, metabolic acidosis, use of cardiopulmonary bypass, HLHS and TAPVR. Twenty four patients ($41.4\%$) had hemodynamic instability during the 48 postoperative-hours. Six patients underwent shunt revision for occlusion, and 1 shunt division for pulmonary overflow. Conclusion: Modified Blalock-Taussig shunt for complex congenital heart defects in early infancy had satisfactory results except in high risk groups. Many patients had early postoperative hemodynamic instability, which means that continuous close observation and management are mandatory in this period. Aggressive management may appear warranted based on understanding of hemodynamic changes for high risk groups.

• Tuberculosis and Respiratory Diseases
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• v.40 no.5
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• pp.501-508
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• 1993

Background: Sleep apnea syndrome is a common disorder which is estimated to affect about 1~4% of adult male population. And if untreated, sleep apnea can cause significant sequelae, such as hypertension, nocturnal cardiac arrhythmia, daytime hypersomnolence, and cognitive impairment. Various kinds of treatment for obstructive sleep apnea (OSA) have been developed. Among them nasal CPAP, first introduced by Sullivan et al in 1981, has received widespread interest and acclaim as a treatment of OSA, and is currently recommended as first-line treatment for OSA. We evaluated the effect of nasal CPAP in OSA and the side effects of nasal CPAP hindering patients from using nasal CPAP. Methods: We performed sleep studies in 20 OSA patients at 2 consecutive nights; baseline night at first day and CPAP night at second day. We compared apnea index, lowest oxygen concentration during apnea, maximal apnea time, and total apnea duration per total sleep time before and after CPAP. We also evaluated the side effects of CPAP with inquiry to the patients. Results: 1) Apnea index was significantly decreased after CPAP in 17 out of 20 OSA patients (85%) and increased in 3 patients (15%). 2) Average apnea index was significantly decreased after CPAP ($34.1{\pm}18.9/h{\rightarrow}15.4{\pm}10.3/h$, p<0.01). 3) Total apnea duration per total sleep time was also significantly decreased after CPAP ($28.5{\pm}16.0%{\rightarrow}11.9{\pm}9.3%$, p<0.05). 4) The lowest oxygen satuation and maximal apnea time were not significantly changed after CPAP. 5) The most frequent side effect of nasal CPAP was mask discomfort (80%), and the next was drying of nasal passages (65%). Conclusion: Nasal CPAP is an effective treatment for OSA. Futher studies should be concentrated on long term follow up of nasal CPAP for its therapeutic effects and the study of methods to enhance patients' compliance.

• Journal of Chest Surgery
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• v.38 no.7 s.252
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• pp.476-482
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• 2005

Recently, coronary artery obstructive disease and coronary artery bypass graft surgery have increased, and the operative result has been improved. We reviewed 154 cases of coronary artery bypass graft surgery from Jan. 1985 to Jun. 2004. Material and Method: We reviewed 148 patients, 154 cases of coronary artery bypass surgery from Jan. 1985 to Jun. 2004. This investigation is designed to illustrate the preoperative diagnosis, severity of disease, operative method, the kind of used bypass graft used, number of distal anasomosis, associated surgery, and postoperative morbidity and mortality. Result: There were 84 males, 64 females and the average age was $58.9\pm8.3$ years old. Preoperative clinical diagnosis were unstable angina in 97 cases $(63.0\%)$, stable angina in 31 cases $(20.1\%)$, acute myocardial infarction in 12 cases $(7.8\%)$ and postinfartion angina in 14 cases $(9.1\%)$. Preoperative angiographic diagnosis were three-vessel disease in 68 $(44.2\%)$, two-vessel disease in 39 $(25.3\%)$, one-vessel disease in 35$(22.7\%)$, and left main disease in 12$(7.8\%)$ cases. There were 78 cases of on-pump coronary artery bypass graft surgery and 76 cases of off-pump coronary artery bypass graft surgery. The total distal anastomoses number was 319, mean number of anastomoses was $2.06\pm0.96$. There were 10 concomitant procedures. Postoperative intra-aortic balloon pump was used in 21$(13.6\%)$ cases, but only 4 cases were used at off-pump coronary artery bypass surgery. Total early mortality was $7.8\%$. The mortality was decreased as $4.5\%$ from Jan. 2001 to Jun. 2004. Post operative complication was perioperative yocardial infarction in 9cases$(5.8\%)$, low cardiac output syndrome in 17 cases$(11\%)$, and arrhythmia in 30 cases$(19.5\%)$ cases. Conclusion: Since 1985, The result of coronary artery bypass graft surgery has been improved because of more refined technique, use of off-pump coronary artery bypass surgery, use of internal thoracic artery and radial artery as bypass graft. We should study the long-term follow up more for better operative results.

• 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.29 no.6
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• pp.599-605
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• 1996

A total of 249 patients undergoing isolated coronary revascularization were studied for the occurrence of postoperative atrial fibrillation(AF). Possible associations of this arrhythmia with various preoperative, intraoperative and postoperative factors were studied by univariate and multivariate analysis. The overall incidence of postoperative AF was 15%, with the median time occurence of 48 hours(mean time : 59.1 $\pm$ 56.9 hours) after arrival to the intensive care unit. Cardiac index decreased significantly after occurence of AF(p=0.001). There were no in-hospital complications in those patients with AF. Univariate studies indicated preoperative ejection fract on(EF), triglyceride level, postoperative peak CKMB isoenzpme and atrial pacing to be the dominant factor promoting postoperative AF, with an increasing prevalence in lower EF(p=0.025), triglyceride(p=0.006) and peak CKMB isoenzyme(p=0.002), and in patients with atrial pacing(p=0.001). Hospital stay(p=0.001) and late mortality(p=0.003) were significantly increased in patients with postoperative AF Multivariate analysis showed that body weight and postoperative atrial pacing to be the dominant factor promoting postoperative AF, with an increasing prevalence in over- weight patients(p=0.011) and patients with atrial pacing(p=0.001). Both univariate and multivariate analy- sis showed that the age was not a significant factor but tended to promote postoperative AF respectively (p=0.053, 0.064). After 30.1 $\pm$ 11.4 months gfollow-up, those patients with AF had sinus rhythm. We think that we must try to prevent postoperative AF after ccoronary artery bypass grafting because of its deleterio s hemodynamic effect, prolonged hospital stay, and increased late mortality.

• Journal of Chest Surgery
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• v.38 no.2 s.247
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• pp.123-131
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• 2005

Background: The number of elderly patients undergoing coronary artery bypass grafting (CABG) is increasing. Elderly patients are at increased risk for a variety of perioperative complications and mortality. We identified determinants of operative complications and mortality in elderly patients undergoing CABG. Material and Method: Between January 1995 and July 2003, 91 patients older than 75 years underwent isolated CABG at Asan Medical Center. There were 67 men and 24 women with mean age of $77.0\pm2.4$ years. Thirty clinical or hemodynamic variables hypothesized as predictors of operative mortality were evaluated. Result: CABG was performed under emergency conditions in 5 patients. The internal thoracic artery was used in 85 patients and 10 patients received both internal thoracic arteries. The mean number of distal anastomosis was 3.7 per patient. Operative mortality was $3.3\%$. Twenty-two patients had at least one major postoperative complication. Low cardiac output syndrome was the most common complication, followed by reoperation for bleeding, pulmonary dysfunction, perioperative myocardial infarction, stroke, acute renal failure, ventricular arrhythmia, upper gastrointestinal bleeding, infection, and delayed sternal closure. None were the predictors of mortality. Renal failure, peripheral vascular disease, emergency operation, recent myocardial infarction, congestive heart failure, New York Heart Association (HYHA) class III or IV, Canadian Cardiovascular Society (CCS) angina scale III or IV, and low left ventricle ejection fraction below $40\%$ were univariate predictors of overall complications. Actuarial probability of survival was $94.9\%,\;89.8\%,\;and\;83.5\%$ at postoperative 1, 3 and 5 years respectively. During the follow-up period $93.3\%$ of patients were in NYHA class I, or II and $91.1\%$ were free from angina. Conclusion: Although operative complication is increased, CABG can be performed with an acceptable operative mortality and excellent late results in patients older than 75 years.

• Journal of Chest Surgery
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• v.29 no.12
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• pp.1323-1328
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• 1996

The obstructive diseases involving the left main coronary artery(LMCA) are serious. Surgical treatment is generally regarded as much more effective than medical therapy in terms of long-term survival and relief of symptoms. This study represents an attempt to present an analysis of early surgical results in 21 cases conducted at Chonnam University Hospital between October 1992 And August 1995. The subject. 12 males and 9 female, ranged in age from 25 to 67 years with a mean age of 49.3${\pm}$12.5 years. As for indications for operation, unstable angina was reported on 66.7% of the subjects, while stable angina and acute myocardial infarction in 4 and 3 cases, respectively. There were also 2 cases of Takayasu's aortitis and 1 case of failed percutaneous translumlnal coronary angioplasty(PTCA). Eleven subjects had isolated LMCA diseases compared to 10 subjects with associated LMCA diseases. Of the patients with ass;3ciated LMCA diseases, 4 subjects had single coronary artery disease, 3 had double coronary artery disease, remaining 3 suffered from triple coronary artery disease. As for the group with isolated LMCA disease, ostidl angioplasty llsing autopericardium was conducted with 5 subjects. The remaining subjects with the isolated diseases and all of the patients with associated LMCA disease underwent aortocoronary bypass grafts. The left internal mammary artery was used in all patients and the average number of anastomoses was 3.13 ${\pm}$0.93. One subject died of low cardiac output syndrome at the second postoperative day. There were 5 instances of postoperative complication including reoperation for bleeding in two patients, wound infection in two, and arrhythmia in one. Follow-up coronary angiogram were conducted with eights patients, including five patients who underwent ostial angioplasty. In these cases, the patients showed surf. ficient enlargement of the left coronary ostium and the grafted vessels kept their patency. In our experience, surgical treatment of the LMCA diseases has not shown a higher rAte of operative mortAlity or morbidity than other obstructive coronary artery diseases. To patients with ostial stenosis, which is frequently observed among young female, angioplasly utilizing autopericardium seems to be a desirable choice considering the cosmetic effect, chances of reoperation and hemodynamic characteristics.

• Journal of Chest Surgery
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• v.42 no.6
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• pp.710-718
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• 2009

Background: The Cox maze procedure has been used as a standard surgical treatment for atrial fibrillation for about 20 years. Recently, the creators have used a bipolar radiofrequency electrode (Cox maze IV procedure) instead of the incision and suture (cut-sew) technique to make atrial ablation lesions for persistent atrial fibrillation. We investigated clinical outcomes for the Cox maze procedure with a bipolar radiofrequency electrode and cryoablator in patients with persistent atrial fibrillation, and compared results with clinical outcomes of the cut-sew procedure. Material and Method: Between April 2005 and July 2007, 40 patients with persistent atrial fibrillation underwent Cox maze IV procedure with a bipolar radiofrequency electrode and cryoablator (bipolar radiofrequency group). Surgical outcomes were compared with those of 35 patients who had the cut-sew technique for the Cox maze III procedure. All patients had concomitant cardiac surgery. Postoperatively, the patients were followed up every 1 to 2 months. Result: At 6 months postoperatively, the conversion rate to regular sinus rhythm was not significantly different between the two groups: 95.0% for the bipolar radiofrequency ablation group; 97.1% for the cut-sew technique (p=1.0). At the end of the follow-up period, the conversion rate to regular sinus rhythm was also not significantly different (92.5% vs. 91.6%, p=1.0). In multivariate analysis using a Cox-regression model, the postoperative atrial dimension was an independent determinant of sinus conversion in the bipolar radiofrequency ablation group (hazard ratio 31, p=0.005). In the Cox-regression model for both groups, atrial fibrillation at 6 months postoperatively (hazard ratio 92.24, p=0.003) and the postoperative left atrial dimension (hazard ratio 16.05, p=0.019) were independent risk factors of continuance or recurrence of atrial fibrillation after Cox maze procedures. Aortic cross-clamp time and cardiopulmonary bypass time were significantly shorter in the radiofrequency group than in the cut-sew group. Conclusion: In the Cox maze procedure for patients with persistent atrial fibrillation, the use of bipolar radiofrequency ablation and a cryoablator is as good as the cut-sew technique for conversion to sinus rhythm. The postoperative left atrial dimension is an independent determinant of postoperative continuance and recurrence of atrial fibrillation.

• Journal of Chest Surgery
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• v.41 no.3
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• pp.329-334
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• 2008

Background: Percutaneous cardiopulmonary support. (PCPS) has the potential to rescue patients in cardiogenic shock who might otherwise die. PCPS has been a therapeutic option in a variety of the clinical settings such as for patients with myocardial Infarction, high-risk coronary intervention and postcardiotomy cardiogenic shock, and the PCPS device is easy to install. We report our early experience with PCPS as a life saving procedure in cardiogenic shock patients due to acute myocardial infarction. Material and Method: From January 2005 to December 2006, eight patients in cardiogenic shock with acute myocardial infarction underwent PCPS using the CAPIOX emergency bypass system($EBS^{(R)}$, Terumo, Tokyo, Japan). Uptake cannulae were inserted deep into the femoral vein up to the right atrium and return cannulae were inserted into the femoral artery with Seldinger techniques using 20 and 16-French cannulae, respectively. Simultaneously, autopriming was performed at the $EBS^{(R)}$ circuit. The $EBS^{(R)}$ flow rate was maintained between $2.5{\sim}3.0L/min/m^2$ and anticoagulation was performed using intravenous heparin with an ACT level above 200 seconds. Result: The mean age of patients was $61.1{\pm}14.2$ years (range, 39 to 77 years). Three patients were under control of the $EBS^{(R)}$ before percutaneous coronary intervention (PCI), three patients were under control of the $EBS^{(R)}$ during PCI, one patient was under control of the $EBS^{(R)}$ after PCI, and one patient was under control of the $EBS^{(R)}$ after coronary bypass surgery. The mean support time was $47.5{\pm}27.9$ hours (range, 8 to 76 hours). Five patients (62.5%) could be weaned from the $EBS^{(R)}$ after $53.6{\pm}27.2$ hours. (range, 12 to 68 hours) of support. All of the patients who could successfully be weaned from support were discharged from the hospital. There were three complications: one case of gastrointestinal bleeding and two cases of acute renal failure. Two of the three mortality cases were under cardiac arrest before $EBS^{(R)}$ support, and one patient had an intractable ventricular arrhythmia during the support. All of the discharged patients are still surviving at $16.8{\pm}3.1$ months (range, 12 to 20 months) of follow-up. Conclusion: The use of $EBS^{(R)}$ for cardiogenic shock caused by an acute myocardial infarction could rescue patients who might otherwise have died. Successfully recovered patients after $EBS^{(R)}$ treatment have survived without severe complications. More experience and additional clinical investigations are necessary to elucidate the proper installation timing and management protocol of the $EBS^{(R)}$ in the future.

• Journal of Chest Surgery
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• v.35 no.9
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• pp.643-652
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• 2002

As the prevalence of coronay artery disease is increasing, the surgical treatment has been universalized and operative outcome has been improved. We analyzed the short and mid-term results of 292 CABGs performed in Kangdong Sacred Heart Hospital. Material and Method: From June 1994 to December 2001, 292 patients underwent coronary artery bypass grafting. There were 173 men and 119 women and their ages ranged from 39 to 84 years with a mean of $61.8{\pm}9.1$ years. We analyzed the preoperative risk factors, operative procedures and operative outcome. In addition, we analyzed the recurrence of symptoms, long-term mortality and complications via out-patient follow-up for discharged patients. Result: Preoperative clinical diagnoses were unstable angina in 137(46.9%), stable angina in 34(11.6%), acute myocardial infarction in 40(13.7%), non-Q myocardial infarction in 25(8.6%), postinfarction angina in 22(7.5%), cardiogenic shock in 30(10.3%) and PTCA failure in 4(1.4%) patients. Preoperative angiographic diagnoses were three-vessel disease in 157(53.8%), two-vessel disease in 35 (12.0%), one-vessel disease in 11(3.8%) and left main disease in 89(30.5%) patients. We used saphenous veins in 630, internal thoracic arteries in 257, radial arteries in 50, and right gastoepiploic arteries in 2 distal anastomoses. The mean number of distal anastomoses per patient was $3.2{\pm}1.0$ There were 18 concomitant procedures ; valve replacement in 8(2.7%), left main coronary artery angioplasty in 6(2.1%), patch closure of postinfarction ventricular septal defect(PMI-VSD) in 2(0.7%), replacement of ascending aorta in 1(0.3%) and coronary endarterectomy in 1(0.3%) patient. The mean ACC time was $96.6{\pm}35.3 $ minutes and the mean CPB time was $179.2{\pm}94.6$ minutes. Total early mortality was 8.6%, but it was 3.1% in elective operations. The most common cause of early mortality was low cardiac output syndrome in 6(2.1%) patients. The stastistically significant risk factors for early mortality were hypertension, old age($\geq$ 70 years), poor LV function(EF＜40%), congestive heart failure, preoperative intraaortic balloon pump, emergency operation and chronic renal failure. The most common complication was arrhythmia in 52(17.8%) patients. The mean follow-up period was $39.0{\pm}27.0$ months. Most patients were free of symptoms during follow-up. Fourteen patients(5.8 %) had recurrent symptoms and 7 patients(2.9%) died during follow-up period. Follow-up coronary angiography was performed in 13 patients with recurrent symptoms and they were managed by surgical and medical treatment according to the coronary angiographic result. Conclusion: The operative and late results of CABG in our hospital, was acceptable. However, There should be more refinement in operative technique and postoperative management to improve the results.