• Journal of Chest Surgery
• /
• v.38 no.3 s.248
• /
• pp.181-190
• /
• 2005

The results of biventricular repair for double outlet right ventricle have been improved in recent series. We studied the surgical and long term results for total correction of double outlet right ventricle by the type of ventricular septal defect. Material and Method: Between November 1979 and December 2003, 126 patients had biventricular repair for double outlet right ventricle. The mean age was 1.8 years (range 1$\~$44) and 86 patients ($68.3\%$) were male. We classified and studied this disease by the type of VSD. Result: The locations of VSD were subaortic in 79 ($62.7\%$), subpulmonary in 17 ($13.5\%$), doubly committed in 16 ($12.7\%$) and noncommitted in 14 ($11.1\%$). 28 patients had palliative operation before total correction and the mean interval to total correction was 41.0$\pm$45.1 months. The methods of total correction were intraventricular baffling in 37 ($29.4\%$), intraventricular baffling with patch enlargement of right ventricular outflow tract in 49 ($38.9\%$), intraventricular baffling with Rastelli procedure in 15 ($11.9\%$), arterial switch operation in 8 ($6.3\%$) and REV procedure in 4 ($3.2\%$), etc. Hospital mortality rate was $10.3\%$ (13 patients) and 25 reoperations were performed in 24 patients ($19.0\%$). The risk factors for hospital mortality and reoperation were cardiopulmonary bypass time (p=0.020) and previous palliative operation (p=0.013), respectively. Follow up was possible in 98 patients and mean follow up period was 118.9$\pm$70.7 months. The percent survival and survival for freedom from reoperation at 15 years were $82.5\%$ and $66.7\%$, respectively. The survival rate was significantly lower (p=0.003) in transposition of great artery type and remote type than in simple ventricular septal defect type and tetralogy of Fallot type, but there was no statistical differences in survival rate for freedom from reoperation. Conclusion: It is thought to be that acceptible surgical and long term results can be obtained with application of appropriate methods of repair for double outlet right ventricle.

• Journal of Chest Surgery
• /
• v.41 no.5
• /
• pp.591-597
• /
• 2008

Background: Pulmonary endarterectomy is widely accepted as a treatment for chronic thromboembolic pulmonary hypertension. Based on our experiences, we sought to find ways to reduce perioperative complications and to improve surgical outcomes in patients undergoing pulmonary endarterectomy. Material and Method: This study was designed as a retrospective analysis of 20 patients with pulmonary hypertension who underwent pulmonary endarterectomy between January 1998 and March 2008. All patients presented with chronic dyspnea. Deep vein thrombosis (DVT) was the major cause of chronic pulmonary thromboembolism (55%). Seventeen patients (85%) underwent inferior vena cava (IVC) filter placement. Thirteen patients underwent surgery under total circulatory arrest, while the others underwent surgery while on low flow cardiopulmonary bypass. Concomitant tricuspid annuloplasty was done in 6 patients (66%) whose tricuspid regurgitation was as severe as grade IV/IV. The mean follow-up duration was $45{\pm}32$ months. Result: Using of University of California, San Diego (UCSD), thromboembolism classification, 4 patients (20%) were type 1, 8 patients (40%) were type II, and 8 patients (40%) were type III. Right ventricular systolic pressure was reduced significantly from $77{\pm}29$ mmHg to $37{\pm}19$ mmHg after pulmonary endarterectomy (p<0.001). The degree of tricuspid regurgitation and the NYHA functional class were all improved postoperatively. Reperfusion edema occurred in 7 cases (35%). The incidence of reperfusion edema was higher in the UCSD type III group than in the other group (25% vs 50%, p=0.25) and the length of postoperative intensive care unit stay was longer in type III group ($5{\pm}2$ days vs $9{\pm}7$ days, p=0.07). The early mortality rate was 10%, and the late mortality rate was 15% (n=3); one death was due to progression of underlying non-Hodgkin's lymphoma, and the other deaths were related to recurrent thromboembolism and persistent pulmonary hypertension, respectively. Conclusion: Pulmonary endarterectomy, as a curative surgical method for treating chronic thromboernbolic pulmonary hypertension, should be performed aggressively in patients diagnosed with chronic thromboembolic pulmonary hypertension, and an effort should be made to reduce the frequency of perioperative complications and to improve surgical outcomes.

• Journal of Chest Surgery
• /
• v.30 no.7
• /
• pp.647-655
• /
• 1997

We evaluated the feasibility and safety of this method by reviewing the early outcome of the patients who underwent coronary artery bypass grafting(CABG) utili ing parallel sequential anastomoses with saphenous vein grafts, comparing with the outcome of the patients revascularized with grafts having only single distal anastomosis. During the one-year period of 1995, a total of 79 patients underwent isolated CABG, among whom 39 patients with sequential vein grafts(sequential group) and 40 patients without sequential grafts(non-sequential group). There was no difference between the two groups in terms of preoperative status, except in the extent of the coronary disease; 87.2% of the sequential group and 45.0% of the non-sequential group had left main andlor triple vessel involvement. 318 distal coronary anastomoses were done; 198 for the sequential group(5.1/patient) and 120 for the non-sequential group(3.0/patient). In the sequential group, the mean durations of cardiopulmonary bypass and aortic clamp per one distal anastomosis were 33.5 and 21.1 minutes, respectively. In the non-sequential group, these were 41.8 and 22.7 minutes. There were two operative deaths, both in the non-sequential group. There was no difference in the incidence of postoperative complications including myocardial infarction. During the follow-up period(2 to 15 months), 8 patients(3 in the sequential and 5 in the nonsequential group) complained of residual or recurrent angina. Comparison of preoperative and postoperative ."'Thallium myocardial perfusion scans in 30 patients showed improved or normal perfusion reserve in 83.3% of segments bypassed with sequential grafts and 82.5% of segments bypassed with non-sequential graft(5), These results show that, utilizing parallel sequential anastomoses with saphenous vein grafts, we could achieve satisfactory short-term clinical results in patients with extensive coronary stenoses. So, we conclude that this technique is a safe, technically feasible strategy for CABG, which can achieve the aim of complete myocardial revascularization with a limited length of graft.raft.

• Journal of Chest Surgery
• /
• v.37 no.4
• /
• pp.322-327
• /
• 2004

Coronary artery bypass grafting on the beating heart is no longer a new methods for any cardiac surgeon. We evaluated the application of the off-pump coronary artery bypass procedure relative to safety and efficiency as measured by postoperative complication and operative mortality. Material and Method: We used our retrospective database to compare the patients having off-pump coronary surgery (n=100) with those having on-pump coronary surgery (n=100) between June, 1999 and August, 2002. Patients whom underwent associated valvular or aortic aneurysmal operation were excluded. Result: Neither groups showed any differences in the patient's risk factors and extent of coronary disease. Off-pump CABG group did not have significantly less mean operation time (295$\pm$73 min vs 323$\pm$83 min, p=ns) and mean hospital day (15.34$\pm$6.02 day vs 13.80$\pm$4.95 day, p=ns). However, off-pump CABG group had significantly shorter mean ventilation time (17.3$\pm$11.27 hour vs 24.98$\pm$16.1 hour, p＜0.05). No patients were converted to on-pump CABG in off-pump CABG. Intraoperative hemodynamic instability in off-pump CABG were 6 cases, of whom 2 cases were in lateral wall approach and 4 cases in right coronary anastomosis. Postoperative mortality was 1 case in off-pump CABG and 2 cases in on-pump CABG. Intra-aortic ballon pump (IABP) was applied in 1 case with off-pump CABG and in 2 cases with on-pump CABG. No patients presented postoperative cerebral infarction ＆ stroke in off-pump CABG but 2 patients in on-pump CABG. Postoperative arrhythmia presented in 4 cases with off-pump CABG and in 6 cases with on-pump CABG. Acute renal failure (ARF) was complicated in 3 cases with off-pump CABG and in 2 cases with on-pump CABG. Conclusion: This study documented the immediate safety and efficiency of the off-pump CABG procedure.

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

• Journal of Chest Surgery
• /
• v.39 no.6 s.263
• /
• pp.440-448
• /
• 2006

Background: Surgery of descending thoracic or thoracoabdominal aorta has the potential risk of causing neurological injury including spinal cord damage. This study was designed to find out the risk factors leading to spinal cord and brain damage after surgery of descending thoracic and thoracoabdominal aorta. Material and Method: Between October 1995 and July 2005, thirty three patients with descending thoracic or thoracoabdominal aortic disease underwent resection and graft replacement of the involved aortic segments. We reviewed these patients retrospectively. There were 23 descending thoracic aortic diseases and 10 thoracoabdominal aortic diseases. As an etiology, there were 23 aortic dissections and 10 aortic aneurysms. Preoperative and perioperative variables were analyzed univariately and multivariately to identify risk factors of neurological injury. Result: Paraplegia occurred in 2 (6.1%) patients and permanent in one. There were 7 brain damages (21%), among them, 4 were permanent damages. As risk factors of spinal cord damage, Crawford type II III(p=0.011) and intercostal artery anastomosis (p=0.040) were statistically significant. Cardiopulmonary bypass time more than 200 minutes (p=0.023), left atrial vent catheter insertion (p=0.005) were statistically significant as risk factors of brain damage. Left heart partial bypass (LHPB) was statistically significant as a protecting factor of brain (p=0.032). Conclusion: The incidence of brain damage was higher than that of spinal cord damage after surgery of descending thoracic and thoracoabdominal aorta. There was no brain damage in LHPB group. LHPB was advantageous in protecting brain from postoperative brain injury. Adjunctive procedures to protect spinal cord is needed and vigilant attention should be paid in patients with Crawford type II III and patients who have patent intercostal arteries.

• Journal of Chest Surgery
• /
• v.39 no.2 s.259
• /
• pp.99-105
• /
• 2006

Background: Interrupted aortic arch is a rare congenital heart anomaly which still shows high surgical mortality. In this study, we investigated the causes of and the risk factors for mortality to improve the surgical outcomes for this difficult disease entity. Material and Method: From 1984 to 2004, 42 patients diagnosed as IAA were reviewed retrospectively. Age, body weight at operation, preoperative diagnosis, preoperative PGE1 requirement, type of interrupted aortic arch, degree of left ventricular outflow stenosis, CPB time, and ACC time were the possible risk factors for mortality. Result: There were .14 hospital deaths. Preoperative use of PGE1, need for circulartory assist and aortic cross clamp time proved to be positive risk factors for mortality on univariate analysis. Preoperative left ventricular outflow stenosis was considered a risk factor for mortality but it did not show statistical significance (p-value=0.61). Causes of death included hypoxia due to pulmonary banding, left ventricular outtract stenosis, infection, mitral valve regurgitation, long cardiopulmonary bypass time and failure of coronary transfer failure in TGA patients. Conclusion: In this study, we demonstrated that surgical mortality is still high due to the risk factors including preoperative status and long operative time. However preoperative subaortic dimension was not related statistically to operative death statistically. Adequate preoperative management and short operation time are mandatory for better survival outcome.

• Journal of Chest Surgery
• /
• v.36 no.8
• /
• pp.566-575
• /
• 2003

We reviewed our 18-year surgical experience of biventricular repair for double-outlet right ventricle. Material and Method: One hundred twelve consecutive patients (80 males and 32 females) who underwent biventricular repair for double-outlet right ventricle between May 1986 and September 2002 were included. We assessed risk factors for early mortality and reoperation. Reoperation-free survival rate and actual survival rate were analysed. Result: Most common type of ventricular septal defect was subaortic (n=58, 52%) and non-committed type was second most common (n=32, 29%). Four different surgical methods were used: intraventricular baffle repair (n=71 , 63%): right ventricle to pulmonary ariery conduit interposition or REV with left ventricle to aorta baffle repair (n=24, 21 .4%): arierial switch operation with left ventricle to pulmonary artery baffle (n=14, 12.5%): Senning atrial switch operation with left ventricle to pulmonary artery baffle (n=3, 2.7%). Thirty four patients(30%) underwent palliative procedures before definite repair. Twenty three patients (21%) required reoperations. There were 12 (10.7%) early deaths and 4 late deaths. Age younger than 3 months at repair (p=0.003), cardiopulmonary bypass and aortic cross clamp time (p=0.015, p=0.067), type of operation (arterial switch operation) (p <0.001) and type of ventricular septal defect (subpulmonic type) (p=0.002) were revealed as risk factors for early death in univariate analysis, while age under 3 months was the only significant risk factor in multivariate analysis. Patients younger than 1 year of age (p=0.02), pulmonary artery angioplasty at definitive repair (p=0.024), type of ventricular septal defect (non-committed) (p=0.001), type of operation (right ventricle to pulmonary artery conduit interposition and REV operation) (p=0.028, p=0.017) were risk factors for reoperation in univariate analysis but there was no significant risk factor in multivariate analysis. Follow-up was available on 91 survivals with a mean duration of 110.8$\pm$56.4 (2~201) months. 5, 10 and 15 year survival rates were 86.5%, 85% and 85% and reoperation free survival were 85%, 71.5%, 70%. Conclusion: Age under 3 months at repair, subpulmonic ventricular septal defect and arterial switch operation were significant risk factors for early mortality. Patients with non-committed ventricular septal defect and who underwent conduit interposition or REV operation were risk factors for reoperation. With careful attention to chose best timing and surgical approach depending on morphologic characteristics, biventricular repair for double outlet right ventricle can be achieved with good long-term outcome.

• Journal of Chest Surgery
• /
• v.31 no.5
• /
• pp.466-471
• /
• 1998

Purpose: The safety and efficacy of minimally invasive techniques in congenital heart surgery were tested in this study. Materal and method: Between July 1997 and November 1997, a total of 46 children were underwent minimally invasive cardiac operations at Seoul National University Children's Hospital. Age and body weight of the patients averaged 34.6${\pm}$41.8 (Range: 1∼148) months and 14.5${\pm}$9.9(Range: 3.0∼40.0) kg, respectively. Twenty eight patients were male. Preoperative surgical indications included 15 atrial septal defects, 25 ventricular septal defects, 1 foreign body in aorta, 3 partial atrioventricular septal defects, 1 total anomalous pulmonary venous connection(cardiac type), and 1 tetralogy of Fallot. After creating a small lower midline skin incision starting as down as possible from the sternal notch, a vertical midline sternotomy extended from xyphoid process to the level of the second intercostal space, where one of the T-, J-, I- or inverted C-shaped lower lying mini-sternotomy was completed with a creation of unilateral right or bilateral trap door sternal opening. A conventional direct aortic and bicaval cannulation was routine. Result: A mean length of skin incision was 6.1${\pm}$1.0(range: 4.0∼9.0) cm. A mean distance between the suprasternal notch and the upper most point of the skin incision was 4.0${\pm}$1.1 (range: 2.0∼7.0) cm. Mean cardiopulmonary bypass time, aortic cross-clamp time, and the operation time were 62.9${\pm}$20.0(range: 28∼147), 29.8${\pm}$12.8(range: 11∼79), and 161.1${\pm}$34.5 (range: 100-250) minutes. A mean total amount of postoperative blood transfusion was 71.0${\pm}$68.1 (range: 0∼267) cc. All patients were extubated mean 11.3${\pm}$13.8(range: 1∼73) hours after operation. A mean total amount of analgesics used was 0.8${\pm}$1.8(range: 0∼9) mg of morphine. The mean duration of stay in intensive care unit and hospital stay were 35.0${\pm}$32.2 (range: 10∼194) hours and 6.2${\pm}$2.0(range: 3∼11) days. There were no wound complications and hospital deaths. Conclusion: This short-term experience disclosed that the minimally invasive technique can be feasibly applied in a selected group of congenital heart disease as well as is cosmetically more attractive approach.

• Journal of Chest Surgery
• /
• v.34 no.10
• /
• pp.787-791
• /
• 2001

Coronary artery aneurysm is a rare disorder. It is defined as abnormal dilatation of coronary artery with diameter exceeding 1.5 times the adjacent normal segments. The incidence of coronary aneurysm is 2.6% in Caucasians and 0.25% in Asians. Over half of the former were associated with atherosclerotic coronary artery disease. However, 70 percents of the latter were nonobstructive coronary artery aneurysms. Coronary artery fistula is a rare disorder. It has been identified in only 0.2% of routine cardiac angiographic studies conducted over a 10-year period. The clinical spectrums are various, asymtomatic, asymptomatic murmur, dyspnea on exertion, fatigue, and congestive heart failure. The right coronary artery (56%) and left coronary artery(36%) are mainly involved in the origin site of congenital coronary artery fistula. The draining site of fistula are right ventricle(39%), right atrium(33%), and pulmonary artery(20%) and so on. This 54 years-old woman had intermittent chest tightness and an abnormal mediastinal shadow on chest roentgenogram and chest C-T examination, which was diagnosed as a mediastinal mass such as teratoma. We performed the operation under left anterolateral thoracotomy for mass excision. However, we knew the mass had the pulsating arterial blood flow through a fine needle puncture of the mass and that it was attached to the left ventricle. We believed the excision of mass on beating heart would be very dangerous. Therefore, we closed the wound without excising the mass. After several days, we performed an echocardiography and coronary angiography, We knew it was cardiac tumor. Incidentally, the patient had a tortuous coronary fistula from the right coronary artery to pulmonary trunk. Using cardiopulmonary bypass with moderate systemic hypothermia, the mass was resected and the fistula was clipped with surgical clips. Pathology of the specimen was a giant coronary arterial aneurysm.