• Journal of Chest Surgery
• /
• v.48 no.4
• /
• pp.258-264
• /
• 2015

Background: This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures. Methods: Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated. Results: Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of $63{\pm}4.54$ years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, $10.24{\pm}13.62days$). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was $11.69{\pm}6.516days$. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism. Conclusion: Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time.

• Journal of Chest Surgery
• /
• v.38 no.5 s.250
• /
• pp.357-365
• /
• 2005

Background: Patients with mitral regurgitation (MR) in the setting of coronary artery disease have a dismal long-term prognosis whether treated medically or surgically. Moreover, the optimal management of moderate ischemic MR at the time of coronary artery bypass grafting (CABG) remains the subjects of controversy. Thus, the present retrospective study was undertaken to determine whether mitral valve surgery for moderate ischemic MR at the time of CABG would be preferable to CABG alone in terms of clinical outcome. Material and Method: Between January 1997 and December 2003, 34 patients with moderate (Gr 3/4) ischemic MR underwent CABG alone (Group I, n=23) or CABG plus mitral valve surgery (Group II, n=11). Operative mortality, long-term survival and echocardiographic parameters were used to evaluate the efficacy of mitral valve surgery in patients with moderate ischemic MR. The mean follow-up durations of each group were $69.3\pm4.3$ months and $53.1\pm4.9$ months respectively. Result: There was no hospital mortality in both groups. There was one case of late mortality in Group I. The mean number of bypass graft was similar ($3.8\pm1.2\;vs\;3.7\pm1.3$ respectively). Cardiopulmonary bypass time was longer in group II (p=0.014). In group II, all of the patients received mitral annuloplasty using ring. On immediate postoperative echo-cardiogram, mitral regurgitation was reduced more in group II (p=0.002). Echocardiogram performed at last follow-up state showed no difference except the grade of MR between the two groups. Actuarial survival of both groups at 5 years was similar ($95.5\%\;vs\;100\%$, p=0.48). Conclusion: This study shows that in selected patients with moderate ischemic MR, CABG without mitral valve surgery might be sufficient. However, patients with low EF and NYHA functional class pre-operatively had tendency of significant residual MR, so mitral valve surgery should be necessary in these patients, and moreover, MR severity and left ventricle volume decreased more in mitral valve surgery group. Therefore, more large-scale studies are necessary to determine these effects on the ventricular function and long-term survival.

• Journal of Chest Surgery
• /
• v.56 no.3
• /
• pp.224-227
• /
• 2023

Median sternotomy is a standard surgical technique used for left ventricular assist device (LVAD) implantation. However, if sternotomy has a prohibitive surgical risk, LVAD implantation can be performed through only left thoracotomy. We managed a patient with end-stage heart failure who had recently undergone coronary artery bypass grafting (CABG) elsewhere. The patient also had a deep sternal wound infection and bacteremia. Because of refractory cardiogenic shock, we performed extracorporeal membrane oxygenation (ECMO). After multiple mediastinal washouts and omental flap placement, ECMO was converted to extracorporeal LVAD (from the left ventricular apex to the descending aorta) through a left thoracotomy. The extracorporeal LVAD was maintained for 18 days and replaced by the HeartMate 3 LVAD. The patient was discharged in good condition 115 days after CABG.

• Journal of Chest Surgery
• /
• v.38 no.9 s.254
• /
• pp.601-608
• /
• 2005

Background: To maximize the histological advantage and minimize the physiological disadvantage, we have been using the skeletonized gastroepiploic artey (GEA) as a free graft for total arterial revascularization. The aims of the current study was to assess the efficacy of the skeletonized GEA as a composite or extended graft for total arterial revascularization. Material and Method: Between January 2000 and Feburary 2005, 133 patients (43 female, mean age=61.8 yrs) undergoing coronary artery bypass grafting (CABG) with a skeletonized GEA as free graft (22 extended, 107 composite and 4 others) were enrolled in this study. Coronary angiograms were performed in the immediate (median 44 days, n=86), early (median 366 days, n=56) and midterm (median 984 days, n=29) postoperative periods. Result: There were 3 ($2.2\%$) early and 4 ($3.3\%$) late cardiac-related deaths. The mean number of distal anastomoses per patient was 3.34 for total graft and 1.92 for GEA graft. The immediate, early, and midterm GEA patency were 157/159 ($98.7\%$), 106/142 ($94.6\%$), and 53/56 ($94.6\%$), respectively. During follow-up, four patients required percutaneous intracoronary intervention because of GEA and target coronary artery stenosis or competitive flow. Conclusion: These data demonstrate satisfactory clinical and angiographic results in the skeletonized GEA as free graft for total arterial revascularizatioh. Although we need a careful longer follow-up, the skeletonized GEA as a free graft will be a valuable option 'to be' for CABG.

• Journal of Chest Surgery
• /
• v.39 no.10 s.267
• /
• pp.754-758
• /
• 2006

Background: Surgical role for acute coronary syndrome has been reduced in recent years due to development of drug eluting stent. We evaluated the surgical results of acute coronary syndrome in our hospital. Material and Method: Between January 2001 and August 2005, 416 patients underwent coronary artery bypass grafting (CABG) under diagnosis of non-ST-elevation acute coronary syndrome (NSTE ACS). Mean age was $61.8{\pm}9.0$ years and 276 (66.3%) patients were male. 324 (77.9%) patients had triple vessel disease and 92 (22.1%) had left main disease at angiographic study. 236 (56.7%) patients had hypertension and 174 (41.8%) had diabetes mellitus. Conventional on-pump CABG was performed in 194 patients (46.6%) and off-pump CABG in 222 (53.4%). Total arterial revascularization with no touch technique was done in 97 patients (23.3%). The number of total distal anastomosis was 1,306 and the number per patient was $3.21{\pm}1.71$. Result: Surgical mortality rate was 1.0% (4 patients) and postoperative complication rate was 15.6% (65 patients). Graft patency was checked at mean $3.7{\pm}7.6$ months (from 1 to 37 months) postoperatively with multi-directional computed tomography in 152 patients. Left internal mammary artery was patent in 95.3%, right internal mammary artery in 98.1%, radial artery in 92.2% and saphenous vein in 89.0%. Conclusion: The surgical treatment of NSTE ACS showed relatively low mortality rate and good graft patency rate. Further study is needed to compare the long term results with drug eluting stent.

• Journal of Chest Surgery
• /
• v.38 no.10 s.255
• /
• pp.680-684
• /
• 2005

Background: With the increasing age of the population, coronary artery bypass grafting in the elderly patients is becoming common. Off-pump coronary artery bypass grafting (OPCAB) has been proven to be less morbidity and to facilitate early recovery. The elderly patients may have benefits by avoiding the adverse effects of the cardiopulmonary bypass. The purpose of this study is to evaluate our results of OPCAB in elderly patients. Material and Method: A retrospective chart review was carried out for 12 patients aged over 80 years who underwent isolated OPCAB from January 2001 and March 2004. Data were collected risk factors for disease, extent of coronary disease, and in-hospital outcomes. Postoperative graft patiency was evaluated in 9 patients by multi-slice computed tomography. Result: Eleven patients had triple vessel disease or left main disease. Four patients were suffered from preoperative CVA, and 4 patients had chronic obstructive pulmonary disease. Two patients had myocardial infarction (MI), among them 1 patient was suffered from pulmonary edema after preoperative MI. There was no perioperative death, perioperative MI, and no ventricular arrhythmia. Also there was no perioperative stroke and renal failure. But there was one deep sternal infection who recovered by treating of muscle flap. Atrial fibrillation was newly developed in 1 patient, but was well controlled by medication. Mean intubation time was $15.9\pm4.4(8\~20hrs)$ hrs and mean ICU stay was $2.9\pm0.8(2\~4 days)$ days. Mean hospital day was $21.6\pm14.3(13\~56 days)$ days. Postoperative mean CK-MS was $11.3\pm14.1\;ng/mL$. Early postoperative graft patency rate was $100\%(24/24)$. Follow-up was completed in all patients. In this time, there was no patients with angina or death. Conclusion: The results of this study suggest that OPCAB reduces morbidity and favors hospital outcomes. Therefore, OPCAB is safe, reasonable and might be preferable operative strategy in elderly patients.

• Journal of Chest Surgery
• /
• v.41 no.2
• /
• pp.210-215
• /
• 2008

Background: Drug-eluting stents are contributing to the exponential growth of percutaneous coronary intervention, and even in the patients with left main coronary artery disease, owing to the decreased restenosis rate. Our study aimed at comparing the one-year results after coronary artery bypass grafting versus percutaneous coronary intervention with drug-eluting stents in patients with left main coronary artery disease. Material and Method: Those patients who underwent coronary bypass surgery or stenting at our hospital under the diagnosis of left main coronary artery disease were divided in two groups. The variables for comparison were the preoperative disease severity, the length of the hospital stay, the early mortality and the cumulative incidence of mortality, myocardial infarction and repeated revascularization. Result: There were 101 cases in the surgery group and 78 cases in the stent group. Age, gender, the risk factors, the left ventricular ejection fraction and the proportion of acute coronary syndrome showed no significant differences between the two groups. The surgery group showed a more severe condition according to the Euroscore, a greater incidence of urgency, a longer hospital stay and a greater incidence of multi-vessel disease. The early mortality and one-year cumulative mortality were not different between the groups. The Euroscore-matched comparison for the surgery group (41 patients) and the stent group (78 patients) showed no significant differences in the Euroscore, age, gender, risk factors and the proportion of acute coronary syndrome. The surgery group in the Euroscore-matched comparison showed more multi-vessel disease and a longer hospital stay. The surgery group showed lower early mortality and lower one-year cumulative mortality, but this was statistically insignificant (0% vs 2.6%, respectively, p=0.55; 0% vs 6.6%, respectively, p=0.30). The rates of repeated revascularization and major adverse events (death or myocardial infarct) were lower in the CABG group, but this was not statistically significant (13.3% vs 6.3%, respectively, p=0.48; 10.0% vs 0%, respectively, p=0.09). Conclusion: Percutaneous coronary intervention using drug-eluting stents in low-risk patients with left main coronary artery disease resulted in a shortened length of the hospital stay, as compared with that of the CABG group of patients. However, the patients who underwent percutaneous coronary intervention using drug-eluting stents showed a tendency for an increased rate of repeated revascularization and higher one-year cumulative mortality. Further studies with large populations and longer follow-up will be necessary to reaffirm our findings.

• Journal of Chest Surgery
• /
• v.37 no.1
• /
• pp.56-63
• /
• 2004

Background: Patch angioplasty is an alternative surgical procedure to coronary artery bypass grafting (CABG) for left main coronary ostial stenosis. The purpose of this study is to evaluate the outcome of patch angioplasty by analyzing the short-term and long-term results. Material and Method: Twenty nine patients who had undergone patch angioplasty due to left main coronary ostial stenosis between July 1991 and May 2003 were enrolled in the study. The mean age of the patients was 53.1 $\pm$12.5 years. There were 8 males and 21 females, and there were 12 female patients who had no risk factor for atherosclerosis. Twenty six (89.7%) patients showed isolated coronary ostial stenosis without any distal coronary lesion. Result: Anterior approach was used in 28 patients and superior approach was used in one patient. Transsection of the main pulmonary artery was used in one patient. Concomitant CABG was performed in 4 patients because of left anterior descending artery lesions in 3 patients and unstable postoperative hemodynamic status in one patient. Hospital mortality had occurred in one patient (3.4%) and late mortality also in one patient, therefore the overall 5 year survival rate was 91.2$\pm$6.1%. Seventeen coronary angiographies were done in 13 patients (44.8%) postoperatively. Two distal patch stenoses, 1 proximal patch stenosis, and 1 new right coronary ostial lesion were identified and 3 percutaneous interventions and 1 CABG were performed during the follow-up period. The overall 5 year freedom from reintervention rate was 82.4 $\pm$ 8.5%. Aortic regurgitation less than grade 1 had developed postoperatively in 4 patients and one patient showed progression of preexisting aortic regurgitation from grade II to III. Conclusion: Patch angioplasty in left main coronary ostial lesion showed acceptable short-term and long-term results in this study. However, restenosis at the patch anastomosis site and aortic regurgitation should be carefully investigated during the follow-up period.

• Journal of Chest Surgery
• /
• v.41 no.2
• /
• pp.202-209
• /
• 2008

Background: The introduction of Drug Eluting Stents (DES) decreased the number of patients referred for coronary artery bypass grafting (CABG). The impact of DES on CABG (Step 1) was studied and compared with the 1-year outcome after CABG with DES (Step 2). Material and Method: Surgical results for patients who underwent off-pump CABG (OPCAB) before the introduction of DES(n=298) were compared with those who underwent OPCAB after the introduction of DES (n=288) (Step 1). Postoperative 30-day and 1-year results were also compared between the patients who underwent percutaneous coronary intervention (PCI) using DES (n=220) and those who underwent OPCAB (n=255) (Step 2). Result: Since the introduction of DES, the ratio of CABG versus PCI decreased. In the CABG group, the number of high risk patients such as elderly patients (age 62 vs. 64, p=0.023), those with chronic renal failure (4% vs. 9%, p=0.021), calcification of the ascending aorta (9% vs. 15%, p=0.043), or frequency of urgent or emergent operations (12% vs. 22%, p=0.002) increased. However, there were no differences in the cardiac death and graft patency rates between the two groups (step 1). During the one-year follow up period, the rate of target vessel revascularization (12.3% vs. 2.4%, p<0.001) and major adverse cardiac events (MACE: death, myocardial infarct, TVR) were higher in the DES than the CABG group (13.6% vs 4.3%) (stage 2). Conclusion: Introduction of DES decreased the number of patients referred for surgery, and increased the comorbidity in patients who underwent CABG. DES increased the rate of target vessel revascularization, and the occurrence of MACE during the 1-year follow-up. However, there was no difference in the incidence of myocardial infarction and cardiac death between the two groups.

• Journal of Chest Surgery
• /
• v.35 no.5
• /
• pp.365-368
• /
• 2002

Background: Coronary artery bypass grafting(CABG) imposes large amount of medical costs, which are greatly affected by the surgical approach, quality of perioperative care and associated co-morbidities. Recently, off-pump CABG(OPCAB) has been introduced and performed with increasing frequency. To evaluate the efficacy of OPCAB in view of financial impact, we analyzed the costs and medical resources of OPCAB and compared with conventional CABG. Material and Method: From January 1998 to July 1999, 184 patients underwent CABG operation; 111 patients with OPCAB(group I) and 73 patients with conventional CABG(group II). We prospectively collected clinical data including risk factors and retrospectively reviewed the hospital resources. Result: Preoperative parameters including risk factors, postoperative mortality, morbidity and length of hospital stay were not different between the two groups, Duration of stay in the intensive care unit(ICU) (51.3 vs 128.3 hours, p<0.01) and ventilator, support time(14.9 vs 56.2 hours, p<0.01) were significantly shorter in the OPCAB group. Total hospital coats were 17,220,000 add 21,250,000(Korean Won) in group I and II, respectively(p<0.01). There were significant differences in operation fee, costs for operative materials, transfusion and diagnostic radiology between two groups. In group I, all the resources except diagnostic radiology were significantly decreased compared with group II. Conclusion: OPCAB has a beneficial effect on hospital charge and resource utilization. Shorter duration of the ICU stay and ventilatory support time may reduce the total hospital costs.