• Journal of Chest Surgery
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• v.37 no.1
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• pp.27-34
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• 2004

Background: Infective endocarditis shows higher operative morbidity and mortality rates than other cardiac diseases. The vast majority of studies on infective endocarditis have been made on aortic endocarditis, with little attention having been paid to infective endocarditis on the mitral valve. This study attempts to investigate the clinical aspects and operative results of infective endocarditis on the mitral valve. Meterial and Method: The subjects of this study consist of 23 patients who underwent operations for infective endocariditis on the mitral valve from June 1995 to May 2003. Among them, 2 patients suffered from prosthetic valvular endocarditis and the other 21 from native valvular endocarditis. The subjects were evenly distributed age-wise with an average age of 44.8$\pm$15.7 (11∼66) years. Emergency operations were performed on seventeen patients (73.9%) due to large vegetation or instable hemodynamic status. In preoperative examinations, twelve patients exhibited congestive heart failure, four patients renal failure, two patients spleen and renal infarction, and two patients temporary neurological defects, while one patient had a brain abscess. Based on the NYHA functional classification, seven patients were determined to be at Grade II, 9 patients at Grade III, and 6 patients at Grade IV. Vegetations were detected in 20 patients while mitral regurgitation was dominant in 19 patients with 4 patients showing up as mitral stenosis dominant on the preoperative echocardiogram. Blood cultures for causative organisms were performed on all patients, and positive results were obtained from ten patients, with five cases of Streptococcus viridance, two cases of methicillin-sensitive Staphylococcus aureus, and one case each of Corynebacteriurn, Haemophillis, and Gernella. Operations were decided according to the AA/AHA guidelines (1988). The mean follow-up period was 27.6 $\pm$23.3 (1 ∼ 97) months. Result: Mitral valve replacements were performed on 43 patients, with mechanical valves being used on 9 patients and tissue valves on the other 4. Several kinds of mitral valve repair or mitral valvuloplasty were carried out on the remaining 10 patients. Associated procedures included six aortic valve replacements, two tricuspid annuloplasty, one modified Maze operation, and one direct closure of a ventricular septal defect. Postoperative complications included two cases of bleeding and one case each of mediastinitis, low cardiac output syndrome, and pneumonia. There were no cases of early deaths, or death within 30 days following the operation. No patient died in the hospital or experienced valve related complications. One patient, however, underwent mitral valvuloplasty 3 months after the operation. Another patient died from intra-cranial hemorrhage in the 31st month after the operation. Therefore, the valve-related death rate was 4.3%, and the valve-related complication rate 8.6% on mid-term follow-up. 1, 3-, and 5-year valve- related event free rates were 90.8%, 79.5%, and 79.5%, respectively, while 1, follow-up. 1, 3-, and 5-year valve- related event free rates were 90.8%, 79.5%, and 79.5%, respectively, while 1, 3-, and 5-year survival rates were 100%, 88.8%, and 88.8%, respectively. Conclusion: The findings suggest that a complete removal of infected tissues is essential in the operative treatment of infectious endocarditis of the mitral valve. It is also suggested that when infected tissues are completely removed, neither type of material nor method of operation has a significant effect on the operation result. The postoperative results also suggest the need for a close follow-up observation of the patients suspected of having brain damage, which is caused by preoperative blood contamination or emboli from vegetation, for a possible cerebral vascular injury such as mycotic aneurysm.

• Journal of Chest Surgery
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• v.32 no.11
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• pp.1031-1035
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• 1999

Background: ATS mechanical valve is a recently introduced pyrolytic carbon bileaflet prosthesis. This report is to evaluate the results of hemodynamic and anticoagulant therapy after ATS valve replacement. Material and Method: From May 1995 to October 1998, 53 patients received 65 ATS prosthesis; 38 Mitral(27-33 mm), 27 Aortic(19-25 mm). 2 CABGs and 5 Tricuspid annuloplasty were taken concomitantly. The follow up period was 769 patient-months(mean 16.2$\pm$10.0), varied from 1 month to 39 months with 92.5% follow up rate. All patients were evaluated with Doppler echocardiography, 7-14 days after operation. Result: NYHA functional class was improved significantly, from 2.6$\pm$0.8 preoperatively to 1.3$\pm$0.4 postoperatively. The average value of peak and mean transvalvular pressure gradients were 25.7$\pm$13.5 mmHg, 12.7$\pm$8.3 mmHg in aortic position. In the mitral position, the average values of peak and mean transvalvular pressure gradient and valve area were 5.9$\pm$2.5 mmHg, 3.1$\pm$0.8 mmHg and 2.9$\pm$0.5 $\textrm{cm}^2$, respectively. In the anticoagulant therapy, mean INR was 2.5$\pm$0.6 in mitral valve replacement and 1.9$\pm$0.5 in aortic valve replacement. There was no anticoagulant related complication. During that period, there were 3 hospital death(5.9%) and 1 late death(1.9%). Conclusion: The early clinical results of the ATS heart valve replacement is quite satisfactory, and low target INR reginmen is safe. And long term follow of hemodynamic characteristics is also necessary.

• Journal of Chest Surgery
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• v.32 no.3
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• pp.255-261
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• 1999

Background: Atrial fibrillation is one of the most prevalent of all arrhythmias and in up to 79% of the patients with mitral valve disease. This study examined whether the atrial fibrillation that occur in patients with mitral valve operation could be eliminated by a concommitant maze operation without cryoablation. Material and Method: From May 1997 to April 1998, 14 patients with atrial fibrillation associated with mitral valve disease underwent Maze III operation without cryoablation. Preoperatively there were 6 men and 8 women with an average age of 46.2${\pm}$10.7 years. Eleven patients had mitral stenosis, and three had mitral insufficiency. The associated heart diseases were aortic valve disease in 4, tricuspid valve regurgitation in 1 and ASD in 2. Using transthoracic echocardiography, the mean left atrial diameters was 54.7${\pm}$5.3 mm and thrombi were found in the left atrium of 2 patients. Postoperatively the ratio between the peak speed of the early filling wave and that of the atrial contraction wave (A/E ratio) was determined from transmitral flow measurement. Operations were mitral valve replacement in 13 including 4 aortic valve replacements, 1 DeVega annuloplasty and 2 ASD closures. Maze III operation was performed in 1 patient. Result: Five patients (38%) had recurred atrial fibrillation, which was reversed with flecainide or amiodarone at the average time of postoperative 38.8${\pm}$23.5 days. Postoperative complications were postoperative transient junctional rhythm in 6, transient atrial fibrillation in 5, reoperation for bleeding in 3, postpericardiotomy syndrome(1), unilateral vocal cord palsy(1), postoperative psychosis(1), and myocardial infarction(1). Postoperatively A/E ratio was 0.43${\pm}$0.22 and A wave found in 9(64%) patients. 3 to 14 months postoperatively (average follow- up, 8.1 months), all of patients had normal sinus rhythm and 9(64%) patients had left atrial contraction and 11(79%) patients were not on a regimen of antiarrhythmic medication. Conclusion: We conclude that Maze III operation without cryoablation is an effective surgical treatment in atrial fibrillation associated with the mitral valve disease.

• Journal of Chest Surgery
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• v.9 no.2
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• pp.207-214
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• 1976

Operations for cardiac valvular disease has been progressed in various ways. Since 1949 when Lord Russel operated mitral stenosis by closed technique at Johns Hopkins Hospital then much progress has been achieved and that nowadays severely diseased cardiac valve has been replaced by prosthetic valve, which is almost ideal in hemodynamic aspect, but still it has many problems such as thromboembolism, destruction of red blood cell, pressure gradient, and disturbance of left ventricular function, so in case of delicate situations, valve replacement should be decided carefully. Besides prosthetic valve, there are some kinds of reconstructive procedures and these have been resulted in better prognosis than prosthetic valve replacement in selected cases. So, authors have reviewed 61 Cases of cardiac patients who have been operated reconstructive valvular surgery by cardiopulmonary bypass, at Yonsei University, from Jan. 1963 to Mar. 1976. Out of 61 cases, 9 patients were replaced by prosthetic valve and rest of the patients were operated upon in various reconstructive procedures such as commissurotomy, valvotomy, valvuloplasty, and annuloplasty. Twenty cases of congenital heart diseases with valvular lesion, which had been operated for valvular lesion were also included in this statistics. Out of 9 cases of prosthetic valvular replacement five cases of prosthetic valvular replacement was done combined with other reconstructive procedures after attempted valvuloplasty. Comparative prognosis of both procedures are somewhat variable by reporters, average 19% of mortality after reconstructive surgery and 38% of mortality after prosthetic valve replacement in long term results. Most common cause of death in postoperative period was low output syndrome in both cases. It seems that good preoperative evaluation and proper reconstructive surgery will afford good prognosis in selected cardiac valvular diseased patient.

• Journal of Chest Surgery
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• v.41 no.3
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• pp.320-328
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• 2008

Background: Numerous surgical devices for mitral repair have been used in the past with good results. In this study we describe a simple annuloplasty technique with using a new device ($Mitracon^{(R)}$). The aim of this study was to assess its efficacy and surgical results with using $Mitracon^{(R)}$. Material and Method: From May 2003 to October 2005, 46 patients (21 women and 25 men (mean age of $51.4{\pm}17.8$ years) with mitral regurgitation from various causes were treated with either the $Mitracon^{(R)}$ (the $Mitracon^{(R)}$ group) or the Capentier Edward rigid ring (the CE group). The median follow-up duration was 18.9 months. Result: The mean grade of mitral regurgitation before and immediately after surgery in the $Mitracon^{(R)}$ group and the CE group decreased from $3.2{\pm}0.8$ to $0.6{\pm}0.7$ and $3.4{\pm}0.7$ to $0.3{\pm}0.5$, respectively. There were no significant changes in the ejection fraction either between the two groups or before and immediately after surgery. No deaths were seen in either group. Early postoperative echocardiography of all 46 patients showed only trivial mitral regurgitation or none at all. Echocardiography at a median of 18.9 months also showed no progression in mitral regurgitation. The mean grade of mitral regurgitation in the $Mitracon^{(R)}$ group at this time point decreased from $3.2{\pm}0.8$ to $0.8{\pm}0.7$ (p<0.05). The CE group also showed a similar degree of decrease from $3.4{\pm}0.7$ to $0.3{\pm}0.6$ (p<0.05). The mitral valve area in the $Mitracon^{(R)}$ group at 1 year follow-up was $3.3{\pm}0.9cm^2$. The mitral valve area in the CE group was $2.7{\pm}0.6cm^2$. The mean mitral pressure gradient in the $Mitracon^{(R)}$ group at 1 year follow-up was $3.1{\pm}1.3$ mmHg. The mean pressure gradient in the CE group was $4.5{\pm}2.1$ mmHg, although any statistical significant difference for this between the groups was not reached. Conclusion: The present study showed the described technique to be safe and effective in the intermediate term. Because long term results are unavailable, a more extensive prospective randomized multicenter trial may be warranted to determine whether this procedure should be generally applied for repair of mitral valve disease.

• Journal of Chest Surgery
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• v.18 no.1
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• pp.13-18
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• 1985

Cortriatriatum is rare congenital heart disease characterized by the presence of a fibromuscular diaphragm that subdivides the left atrium into a proximal or "accessory" and a distal or "true" left atrial chamber. A 15 year old girl with cortriatriatum underwent surgical correction at the department of Thoracic and Cardiovascular Surgery, Soonchunhyang College in November, 1984. This case was preoperatively diagnosed as a single atrium with functional tricuspid regurgitation But on operation, we found that there were transverse septum in the left atrium through large ASD, low chamber receives the pulmonary veins, and the upper chamber gives rise to the left atrial appendage and leads to the mitral valve. And the anomalous membrane has no fenestrations. We excised completely the anomalous septum, reconstructed atrial septal defect with dacron patch and performed the tricuspid annuloplasty with DeVega method. Postoperative course was uneventful during follow up, during follow up.

• Journal of Chest Surgery
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• v.40 no.8
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• pp.536-545
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• 2007

Background: Compared to adult patients, mitral regurgitation in pediatric patients is uncommon and it shows a wide spectrum of morphologic abnormalities. We retrospectively evaluated the midterm results of mitral valve repair in pediatric patients. Material and Method: Between December 1993 and August 2006, mitral valve repair was performed in 35 patients who were aged less than 18 years, The mean age was $5.3{\pm}5.3$ years and the mean body weight was $20,0{\pm}16.3\;kg$. 18 patients had associated cardiac anomalies. The most common pathologic finding was leaflet prolapse (n=17). The most common method of repair was the double orifice technique (n=15). Result: There was no early mortality. Eight patients underwent reoperation (24.2%), and five of them required mitral valve replacement. Among the four ring annuloplasty cases, two have developed mitral stenosis. Four out of the 14 double orifice cases required reoperation. One case of early mortality and one case of late mortality occurred in the reoperation cases. The 5-year survival rate and the freedom from reoperation rate were $93.3{\pm}4.6%$ and $76.1{\pm}8.2%$, respectively. The 5-year freedom from mitral valve replacement rate was $83.6{\pm}6.7%$. There was no significant risk factor for reoperation. Conclusion: The midterm results of mitral valve repair are very acceptable in pediatric patients compared to the adult cases, although the reoperation rate is slightly higher.

• Journal of Chest Surgery
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• v.46 no.2
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• pp.93-97
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• 2013

Background: Minimally invasive cardiac surgery has emerged as an alternative to conventional open surgery. This report reviews our experience with atrial septal defect using the da VinciTM surgical robot system. Materials and Methods: This retrospective study included 50 consecutive patients who underwent atrial septal defect repair using the da VinciTM surgical robot system between October 2007 and May 2011. Among these, 13 patients (26%) were approached through a totally endoscopic approach and the others by mini-thoracotomy. Nineteen patients had concomitant procedures including tricuspid annuloplasty (n=10), mitral valvuloplasty (n=9), and maze procedure (n=4). The mean follow-up duration was $16.9{\pm}10.4$ months. Results: No remnant interatrial shunt was detected by intraoperative or postoperative echocardiography. The atrial septal defects were mainly repaired by Gore-Tex patch closure (80%). There was no operative mortality or serious surgical complications. The aortic cross clamping time and cardiopulmonary bypass time were $74.1{\pm}32.2$ and $157.6{\pm}49.7$ minutes, respectively. The postoperative hospital stay was $5.5{\pm}3.3$ days. Conclusion: The atrial septal defect repair with concomitant procedures like mitral valve repair or tricuspid valve repair using the da VinciTM system is a feasible method. In addition, in selected patients, complete port access can be helpful for better cosmetic results and less musculoskeletal injury.

• Journal of Chest Surgery
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• v.13 no.1
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• pp.77-81
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• 1980

We present one case of 26-year-old male having saddle block combined with mitral valvular disease [NYHA Class IV] with auricular fibrillation. The most common cause of emboli is atrial fibrillation. The clinical manifestations of saddle emboli are relatively slow due to development of collateral circulation and large size of lumen of the aorta. The 5month duration of saddle emboli in this case led to severe atrophic changes, coldness, peripheral cyanosis on the both lower extremities, and flexion deformity on the knee and ankle joint of the left lower extremity. We planned staged operation for the saddle block and for mitral stenoinsufficiency and tricuspid insufficiency, because of poor general condition of the patient. The thromboembolectomy of aortic bifurcation was performed through the transabdominal approach without trial of Fogarthy catheter embolectomy, because of expectation of the secondary inflammatory changes of the vessel wall and thrombi which was 3 cm X 1 cm X 0.5 cm in size with irregular surfaced solid in consistency. 1 month later, after thromboembolectomy, mitral valve replacement and tricuspid annuloplasty were performed, with successful early operative result. During operation organized thrombi [1 cm X 0.5 cm] in the left auricle was removed. We wonder if simple management using Fogarthy catheter might be possible to remove the thromboemboli instead of thromboembolectomy by aortotomy in this case.

• Journal of Chest Surgery
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• v.32 no.4
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• pp.373-378
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• 1999

Background: Minimally invasive technique for various cardiac surgeries has become widely accepted since it has been proven to have distinct advantages for the patients. We describe here the results of our experiences of minimal incision in cardiac surgery. Material and Method: From February 1997 to November 1998, we successfully performed 31 cases of minimally invasive cardiac surgery. Male and female ratio was 17:14, and the patients age ranged from 1 to 75 years. A left parasternal incision was used in 9 patients with single vessel coronary heart disease. A direct coronary bypass grafting was done under the condition of the beating heart without cardiopulmonary bypass support(MIDCAB). Among these, one was a case of a reoperation 1 week after the first operation due to a kinked mammary artery graft. A right parasternal incision was used in one case of a redo mitral valve replacement. Mini-sternotomy was used in the remaining 21 patients. The procedures were mitral valve replacement and tricuspid annuloplasty in 6 patients, mitral valve replacement 5, double valve replacement 2, aortic valve replacement 1, removal of left atrial myxoma 1, closure of atrial septal defect 2, repair of ventricular septal defect 2, and primary closure of r ght ventricular stab wound 1. The initial 5 cases underwent a T-shaped mini-sternotomy, however, we adopted an arrow-shaped ministernotomy in the remaining cases because it provided better exposure of the aortic root and stability of the sternum after a sternal wiring. Result: The operation time, the cardiopulmonary bypass time, the aorta cross-clamping time, the mechanical ventilation time, the amount of chest tube drainage until POD#1, the chest tube indwelling time, and the duration of intensive care unit staying were in an acceptable range. There were two surgical mortalities. One was due to a rupture of the aorta cannulation site after double valve replacement on POD#1 in the mini-sternotomy case, and the other was due to a sudden ventricular arrhythmia after MIDCAB on POD#2 in the parasternal incision case. Postoperative complications were observed in 2 cases in which a cerebral embolism developed on POD#2 after a mini-sternotomy in mitral valve replacement and wound hematoma developed after a right parasternal incision in a single coronary bypass grafting. Neither mortality nor complication was directly related to the incision technique itself. Conclusion: Minimally invasive surgery using parasternal or mini-sternotomy incision can be used in cardiac surgeries since it is as safe as the standard full sternotomy incisions.