• Journal of Chest Surgery
• /
• v.35 no.12
• /
• pp.862-870
• /
• 2002

The surgical results of the patients with single ventricle(SV) associated with total anomalous pulmonary venous connection(TAPVC) has been reported with high mortality and morbidity due to their morphologic and hemodynamic complexity. A retrospective review was undertaken to report the outcome of the first-stage palliative surgery in our institution and to determine the factors influencing early death. Material and Method: Between January 1987 and June 2002, 39 patients with SV and TAPVC underwent surgical intervention with or without TAPVC repair. Age at operation ranged from 1day to 10.7months (median age, 2.4month), and 29 patients were male. Preoperative diagnosis included 20 right-dominant SV, 15 SV with endocardial cushion defect, 3 left-dominant SV, and 1 tricuspid atresia. The pulmonary venous connection was supracardiac in 22, cardiac in 5, infracardiac in 11, and mixed in 1, Obstructed TAPVC was present in 11. First-stage palliative surgery was performed in 37. Repair of TAPVC, either alone or in association with other procedures, was performed during the initial operation in 31. Univariate and multivariate analyses were performed to analyze the risk factors influencing the operative death. Result: A mean follow-up period of survivors was 34.3 $\pm$ 43.0(0.53 ~ 146.2)months. Overall early operative mortality was 43.6%(17/39). The causes were low cardiac output in 8, failure of weaning from cardiopulmonary bypass in 3, sepsis in 2, pulmonary hypertensive crisis in 1, pulmonary edema in 1, pneumonia in 1, and postoperative arrhythmia in 1. Risk factors influencing early death in univariate analysis were body weight, surgical intervention in neonate, obstructive TAPVC, preoperative conditions including metabolic acidosis, and need for inotropic support, TAPVC repair in initial operation, operative time, and cardiopulmonary bypass(CPB) time. In multivariable analysis, body weight, age at initial operation, surgical intervention in neonate, preoperative conditions including metabolic acidosis, need for inotropic support and CPB time were the risk factors. Conclusion: In this study, we demonstrated that the patients with SV and TAPVC had high perioperative mortality. Preoperative poor condition, young age, the length of operative and CPB time, the presence of obstructive TAPVC had been proven to be the risk factors. This fact suggests that the avoidance of unnecessarily additional procedures may improve the surgical outcomes of the first-stage palliative surgery. However further observation and collection of the data is mandatory to determine the ideal surgical strategy.

• Journal of Chest Surgery
• /
• v.31 no.10
• /
• pp.964-972
• /
• 1998

Background: The purpose of this study was to independently evaluate the beneficial effects of a high dose of transamine administrated prior to CPB on the postoperative hematologic aspect and bleeding. Materials and methods: This study included randomly selected groups of 40 adult patients undergoing OHS with CPB. All patients were divided into 2 groups: transamine group (T-group, n=20) and placebo group(P-group, n=20). The T-group received a high-dose of transamine(10 g) before and during CPB. The P-group received normal saline at the same times and served as a control group. Results: The results of comparative studies between the 2 groups in the same hematologic variables were summarized as follows. \circled1 During CPB, the fibrinogen concentrations and platelet counts were significantly lower in the P-group than in the T-group(p<0.01). \circled2 During CPB, production of D-dimer occurred in 18 patients(90%) in the P-group and did not occur in the T-group(0%) (p<0.0001). \circled3 At CPB-off, the % concentration of fibrinogen(70.2$\pm$3.9%) and the % platelet counts(72.4$\pm$4.5%) of the T-group were significantly higher than those(54.5$\pm$3.8%, 64.3$\pm$2.9%) of the P-group(p<0.01). \circled4 Postoperative values of PT(14.0$\pm$0.03 sec.) and aPTT (27.6$\pm$0.1 sec.) of the T-group were significantly lower than those(16.0$\pm$0.02sec., 30.1$\pm$0.1sec.) of the P-group(p<0.05). \circled5 Postoperative bleeding and requirement of whole blood and other blood products were significantly less in the T-group than in the P-group(p <0.05). \circled6 There were no significant hypercoagulability signs such as cerebral em bolism, myocardial infarction, pulmonary embolism, or any other neurological prob lems in either group. Conclusions: We concluded that a high dose of transamine administered prior to CPB prevents the activation of fibri nolytic system and has beneficial effects of reducing the postoperative bleeding t endency without apparent hypercoagulability signs.

• Journal of Chest Surgery
• /
• v.38 no.1 s.246
• /
• pp.29-37
• /
• 2005

This study was prospectively designed to determine the physiologic effects of normothermic CPB and to compare its influences with hypothermic CPB. Material and Method: Thirty-six adult patients scheduled for el­ective cardiac surgery were randomly assigned to moderate hypothermic (hypothermic group nasopharyngeal tem­perature $26\~28^{\circ}C,\;n=18)$ ornormothermic (normothermic group, nasopharyngeal temperature > $35.5^{\circ}C\;n=18)$ CPB. Arterial blood samples were taken before CPB (Pre-CPB), 10 minutes after the start of CPB (CPB-10), and imme­diately after CPB stop (CPB-off) for determining total leukocyte counts, neuron-specific enolase (NSE), interleukin-6 (IL-6), endothelin-1 (ET-1), cortisol, troponin I (TNI), aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine, blood urea nitrogen (BUN), and the pulmonary index $(Pi,\;PaO_{2}/FiO_{2}),$Other parameters such as urine output, mechanical ventilating period, ICU-staying period, postoperative complications and hospitalized days were also evaluated. Result: Total leukocyte counts, increased rate in NSE, in IL-6 and in cortisol at CPB-10 and CPB-off were significantly higher in normothermic group than in hyphothermic group. Urine output during CPB was lower in normothermic group than in hyphothermic group. The duration of mechanical ventilation, ICU-stay, and hospitalization were longer in normothermic group than in hyphothermic group. Conclusion: These findings sug­gested that normothermic CPB caused higher inflammatory and stress responses than hypothermic CPB during car­diac surgery using cold crystalloid cardioplegia. However, further studies with large number of cases should be carried out to validate this hypothesis.

• Journal of Chest Surgery
• /
• v.39 no.5 s.262
• /
• pp.366-375
• /
• 2006

Background: Hypomagnesemia is a common complication after cardiac surgery with cardiopulmonary bypass. The purpose of this study was to assess the clinical beneficial effect of administration of magnesium sulfate in cardiac surgery. Material and Method: Thirty five patients scheduled for elective cardiac surgery were randomly assigned to magnesium group (n=20) which received magnesium sulfate in priming solution (1 g) and cardioplegic solution (1 g) or control group (n=15) which did not receive it. Arterial blood samples were drawn for measuring $Mg^{++}$ and electrolytes contents, blood gas analysis, CBC, total protein, albumin, blood urea nitrogen (BUN), creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, tumor necrosis factor-${\alpha}$ $(TNF-{\alpha})$, interleukin-6 (IL-6), interleukin-10 (IL-10), creatine phosphokinase (CpK), creatine kinase-MB (CK-MB), lactate dehydrogenase(LDH), troponin-1 (TNI), prothrombin time (PT) and activated pratial thromboplastin time level (aPTT). Venous blood samples were drawn before and after the operation for measuring activated clotting time level (ACT). Result: $Mg^{++}$ levels in magensium group were higher than those of control group at intraoperative and post-operative periods (p<0.05). dysrhythmias were lower in magnesium group (8 cases out of 17 patients, 46.4%) than in control group (10 cases out of 10, 100%, p=0.050). Conclusion: These results showed that administration of low dose magnesium sulfate during cardiac surgery prevented hypomagnesemia and lowered incidence of dysrhythmia.

• Journal of Chest Surgery
• /
• v.39 no.12 s.269
• /
• pp.913-919
• /
• 2006

Background: Vasodilatory shock has been implicated in life-threatening complications after open heart surgery, where the systemic inflammatory reaction is attributed to the cardiopulmonary bypass(CPB). The secretion of arginine vasopressin(AVP) has been found to be defective in a variety of vasodilatory shock states and administration of AVP markedly improves vasomotor tone and blood pressure. So we reviewed our experience of AVP therapy in patients with vasodilatory shock following heart surgery using CPB. Material and Method: From January 2004 to July 2006, we reviewed the records of patients who received AVP therapy for vasodilatory shock following heart surgery using CPB. Vasodilatory shock was defined as a mean arterial pressure lower(MAP) than 70 mmHg, a cardiac index greater than 2.5 $L/min/m^2$, peripheral vascular resistance lower than 800 $dyn/s/cm^5$, and vasopressor requirements. The hemodynamic responses of patients who received AVP therapy for vasodilatory shock after cardiac surgery were analyzed retrospectively. Result: One hundred ninety nine open cardiac surgery patients were consecutively included in this study. Twenty two patients(11.1%) met criteria for vasodilatory shock. Despite the administration of high dose catecholamine vasopressor, all patients were hypotensive with a mean arterial pressure less than 70 mmHg. AVP therapy increased MAP from $53.3{\pm}7.4\;to\;82.0{\pm}12.0$ mmHg at 1 hour (p<0.001) and decreased other vasopressor requirements from $25{\pm}7\;to\;18{\pm}6$ at 1 hour(p<0.001) and individually maintained it for 12 hours. Conclusion: Our date suggest that AVP may be a safe and an effective vasopressor in patients with vasodilatory shock. In patients exhibiting vasodilatory shock after heart surgery, replacement of AVP increases blood pressure and reduces catecholamine vasopressor requirements.

• Journal of Chest Surgery
• /
• v.32 no.2
• /
• pp.130-137
• /
• 1999

Background: In cardiac surgery, hypothermia is associated with a number of major disadvantage, including its detrimental effects on enzymatic function, energy generation and cellular integrity. Warm cardioplegia with normothermic cardiopulmonary bypass cause three times more incidence of permanent neurologic deficits than the cold crystalloid cardioplegia with hypothermic cardiopulmonary bypass. Interruptions or inadequate distribution of warm cardioplegia may induce anaerobic metabolism and warm ischemic injury. To avoid these problems, tepid blood cardioplegia was recently introduced. Material and Method: To evaluate whether continuous tepid blood cardioplegia is beneficial in clinical practice during valvular surgery, we studied two groups of patients matched by numbers and clinical characteristics. Warm group(37$^{\circ}C$) consisted of 18 patients who underwent valvular surgery with continuous warm blood cardioplegia. Tepid group(32$^{\circ}C$) consisted of 17 patients who underwent valvular surgery with continuous tepid blood cardioplegia. Result: Heartbeat in 100% of the patients receiving continuous warm blood cardioplegia and 88.2% of the patients receiving continuous tepid blood cardioplegia converted to normal sinus rhythm spontaneously after removal of the aortic cross clamp. There were no differences between these two groups in CPB time, ACC time, the amount of crystalloid cardioplegia used and peak level of potassium. During the operation, the total amount of urine output was more in the warm group than the tepid group(2372${\pm}$243 ml versus 1535${\pm}$130 ml, p<0.01). There were no differences between the two groups in troponin T level measured 1hr and 12hrs after the operation. Conclusion: Continuous tepid blood cardioplegia is as safe and effective as continuous warm blood cardioplegia undergoing cardiac valve surgery in myocardial protection.

• Clinical and Experimental Pediatrics
• /
• v.50 no.5
• /
• pp.476-483
• /
• 2007

Purpose : The objective of this study was to assess ventricular function by tissue Doppler imaging (TDI) in children with congenital heart disease (CHD) who have been undergoing open heart surgery (OHS) using cardiopulmonary bypass. We tried to compare the parameters of tissue Doppler imaging before and after OHS in patients with congenital heart disease. Methods : This study was conducted on 32 patients with CHD after OHS from January 2005 to December 2005 at Kyungpook National University hospital. Patients who underwent 2-D echocardiography before and after their OHS. All patients were divided into three groups, left ventricular volume overloading group (group 1), and right ventricular volume overloading group (group 2), and right ventricular pressure overloading group (group 3). The TDIs were examined before and 1 to 3 months after OHS. Peak early diastolic (E), and peak late diastolic (A) velocity of transmitral flow were measured by pulsed wave Doppler examination. Peak systolic (Sm), peak early diastolic (Em), and peak late diastolic (Am) velocity in apical 4-chamber and 2-chamber views were measured by TDI. The author calculated E/Em ratio. Results : The patients were 14 boys and 18 girls and the average age of patients was 2 years and 3 months. The congenital heart diseases which have to get OHS were ventricular septal defect (13 cases), atrial septal defect (7), atrioventricular septal defect (3), isolated pulmonary stenosis (2) and tetralogy of Fallot (7). There were significant decrease of Sm, Em, Am measured on tricuspid annulus and E/Em measured on mitral annulus in apical 4 chamber view (P<0.05). Conclusion : This study showed significant decrease of Sm, Em, Am measured on tricuspid annulus and E/Em measured on mitral annulus in apical 4 chamber view after OHS. These changes might be due to the effects of cardiopulmonary bypass in OHS and/or hemodynamic changes after correction of congenital heart disease. To clarify these changes, further study on more patients is needed.

• Journal of Chest Surgery
• /
• v.34 no.9
• /
• pp.653-661
• /
• 2001

Background: Retrograde cerebral perfusion(RCP) is one of the methods used for brain protection during aortic arch surgery. The author previously published the data, however, for the safety of it, there still remains many controversies. The author performed RCP and checked various parameters to clarify the possibility of early detection of cerebral injury. Material and Method: The author used pigs(Landrace species) weighing 25 to 30kg and performed RCP for 120 minutes. After weaning of cardiopulmonary bypass, we observed pigs for another 120 minutes. Rectal temperature, jugular venous oxygen saturation, central venous pressure were continuously monitored, and the hemodynamic values, histological changes, and serum levels of neuron-specific enolose(NSE) and S100$\beta$ protein were checked. Central venous pressure during RCP was maintained in the range of 20 to 25 mmHg. Result: Flow rates(ml/min) during RCP were 224.3$\pm$87.5(20min), 227.1$\pm$111.0(40min), 221.4$\pm$119.5(60min), 230.0$\pm$136.5(80min), 234.3$\pm$146.1(100min), and 184.3$\pm$50.5(120min). Serum levels of NSE did not increase after retrograde cerebral perfusion. Serum levels of S100$\beta$ protein(ng/ml) were 0.12$\pm$0.07(induction of anesthesia), 0.12$\pm$0.07(soon after CPB), 0.19$\pm$0.12(20min after CPB), 0.25$\pm$0.06(RCP 20min), 0.29$\pm$0.08(RCP 40min), 0.41$\pm$0.05(60min), 0.49$\pm$0.03(RCP 80min), 0.51$\pm$0.10(RCP 100min), 0.46$\pm$0.11(RCP 120min), 0.52$\pm$0.15(CPBoff 60min), 0.62$\pm$0.15(60min after rewarming), 0.76$\pm$0.17(CPBoff 30min), 0.81$\pm$0.20(CPBoff 60min), 0.84$\pm$0.23(CPBoff 90min) and 0.94$\pm$0.33(CPBoff 120min). The levels of S100$\beta$ after RCP were significantly higher than thosebefore RCP(p<0.05). The author could observe the mitochondrial swellings using transmission electron microscopy in neocortex, basal ganglia and hippocampus(CA1 region). Conclusion: The author observed the increase of serum S100$\beta$ after 120 minutes of RCP. The correlation between its level and brain injury is still unclear. The results should be reevaluated with longterm survival model also considering the confounding factors like cardiopulmonary bypass.

• Journal of Chest Surgery
• /
• v.32 no.4
• /
• pp.358-363
• /
• 1999

Background: Recently, many cardiac centers have been using aprotinin to reduce operative bleeding in cardiac operations using cardiopulmonary bypass. A variety of reports have confirmed the effectiveness of the drug in cardiac operations. In addition to the operations which could be considered to cause severe operative bleeding such as redo operation, long cardiopulmonary bypass operation and etc, the use of aprotinin is increasing in the field of primary cardiac operations. Varying doses of regimen have been introduced since the first report by Royston et al, and also various opinions on the effectiveness and safeness of the each regimen have been reported. We reviewed our own experience of the full dose aprotinin regimen(Hammersmith regimen) retrospectively. Material and Method: From October 1994 to February 1998, 40 cases of cardiac operative patients were randomized into two groups: aprotinin group(20 patients) which received a full dose aprotinin regimen and control group(20 patients) which did not receive aprotinin. To evaluate the degree of bleeding decrease, we analysed and compared the amount of postoperative 6 hours and 24 hours bleeding in the each group. To confirm the renal dysfunction, we measured the postoperative creatinine level. Result: In the amount of postoperative 6 hours bleeding, a statistically significant bleeding decrease was demonstrated in the aprotinin group compared to the control group(aprotinin group: 186${\pm}$40cc, control group:409${\pm}$69cc, P=0.010). Similar result was observed in the postoperative 24 hours(aprotinin group:317${\pm}$53cc, control group: 671${\pm}$133cc, P=0.024). Conclusion: We concluded that full dose regimen of aprotinin can remarkably reduce postoperative bleeding in cardiac operations without significant renal dysfunctions.

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