• Journal of Korean Neurosurgical Society
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• 제66권3호
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• pp.289-297
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• 2023

Technological advances in neonatology led to the improvement of the survival rate in preterm babies with very low birth weights. However, intraventricular hemorrhage (IVH) has been one of the major complications of prematurity. IVH is relevant to neurodevelopmental disorders, such as cerebral palsy, language and cognitive impairments, and neurosensory and psychiatric problems, especially when combined with brain parenchymal injuries. Additionally, severe IVH requiring shunt insertion is associated with a higher risk of adverse neurodevelopmental outcomes. Multidisciplinary and longitudinal rehabilitation should be provided for these children based on the patients' life cycles. During the infantile period, it is essential to detect high-risk infants based on neuromotor examinations and provide early intervention as soon as possible. As babies grow up, close monitoring of language and cognitive development is needed. Moreover, providing continuous rehabilitation with task-specific and intensive repetitive training could improve functional outcomes in children with mild-to-moderate disabilities. After school age, maintaining the level of physical activity and managing complications are also needed.

• Journal of Korean Neurosurgical Society
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• 제66권3호
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• pp.298-307
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• 2023

Remarkable advances in neonatal care have significantly improved the survival of extremely low birth weight infants in recent years. However, intraventricular hemorrhage (IVH) continues to be a major complication in preterm infants, leading to a high incidence of cerebral palsy and cognitive impairment. IVH is primarily caused by disruption of the fragile vascular network of the subependymal germinal matrix, and subsequent ventricular dilatation adversely affects the developing infant brain. Based on recent research, periventricular white matter injury is caused not only by ischemia and morphological distortion due to ventricular dilatation but also by free iron and inflammatory cytokines derived from hematoma and its lysates. The current guidelines for the treatment of posthemorrhagic hydrocephalus (PHH) in preterm infants do not provide strong recommendations, but initiating treatment intervention based on ultrasound measurement values before the appearance of clinical symptoms of PHH has been proposed. Moreover, in the past decade, therapeutic interventions that actively remove hematomas and lysates have been introduced. The era is moving beyond cerebrospinal fluid shunt toward therapeutic goals aimed at improving neurodevelopmental outcomes.

• Journal of Chest Surgery
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• 제19권1호
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• pp.50-57
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• 1986

Sixty-nine patients with various types of cyanotic congenital heart disease underwent systemic-pulmonary artery shunts with a microporous polytetrafluoroethylene [PTFE] prosthesis between 1979 and 1985. Their ages ranged from 2 months to 39 years [mean$\pm$SD: 5.2$\pm$7.4, median: 3.3 years]. Diagnosis included the following: Tetralogy of Fallot, 45: Double outlet right or left ventricle, 11: Single ventricle, .5: Transposition of great vessels, 4: Tricuspid atresia, 3 and Pulmonary atresia with intact ventricular septum, 1. Forty-eight patients had subclavian-pulmonary artery anastomosis, 12 patients aorta-right pulmonary artery anastomosis, 6 patients aorta-main pulmonary artery anastomosis, and 3 patients descending aorta-pulmonary artery anastomosis. The PTEE graft of 3 mm in diameter was used in 1, 4 mm in 29, 5 mm in 35 and 6 mm in 4 patients. Ten patients were died within 30 days after operation [mortality rate: 14.5%]. Among them, 6 patients were operated in urgency due to cardiac arrest or severe anoxic spell after cardiac catheterization, and so surgical mortality of elective operation is 9.5%. The 59 survivors showed improvement of the arterial oxygen saturation [65.4% - 9.8%] and hemoglobin [18.8 gm/dl - 16.0 gm/dl] values [V<0.01]. The follow up period ranged from 1 month to 67 months, [752 patient-months] and during this periods there were 4 late shunt failures after 3 months postoperatively with 4 mm graft, and 2 with 5 mm graft. The over-all patency rate of 4 mm PTFE was 85.9$\pm$9.2% [SEM] in 12 months and 40.9$\pm$22.5% in 24 months. The over-all patency rate of 5 mm PTFE was 87.5$\pm$9.6% in 12 months and 58.3$\pm$24.6% in 36 months. The lowest systolic pressure in death group was 64.9$\pm$15.0 mmHg and in survival group, 86.4$\pm$12.1 mmHg [P<0.001]. We think that the PTFE graft is useful in palliative shunt operation, but the effectiveness of the 4 mm PTFE graft may be limited. The blood pressure also may play an important role in patency of Prosthesis.

• Journal of Chest Surgery
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• 제20권3호
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• pp.536-543
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• 1987

The Fontan procedure was physiological correction which was initially applied to tricuspid atresia. We had used the modified Fontan operation in 8 cases at National Medical Center, Seoul, from Aug. 1984 to Oct. 1986. Age range was 20 months to 15 years [mean: 9 years] and male: female ratio was 5:3. 5 patients had tricuspid atresia [lb: 2 cases, Ic: 1 case, lib: 1 case, & llc: 1 case], 2 Patients had univentricular heart of left ventricular type, and one patient had transposition of great arteries with complete endocardial cushion defect. The operative principle was direct anastomosis between right atrium and pulmonary artery, whether main pulmonary artery or right pulmonary artery without any conduits. Postoperatively all patients needed high central venous pressure for adequate hemodynamic status in both survival [20-24 CmH2O] and mortality groups [20-24 CmH2O]. The fatal complications were as follows: empyema with bronchopleural fistula [1 case], bleeding tendency & brain damage [1 case], low cardiac output syndrome & acute renal failure [2 cases], and right to left shunt of unknown origin [1 case]. There were 5 hospital deaths; 3 of 5 tricuspid atresia patients, 1 of 2 univentricular heart patients, and 1 of 1 transposition of great arteries with complete endocar4ial cushion defect patient. The overall mortality was 62.5%. 3 survivors were nearly compatible with Choussat & Fontan criteria. Thus appropriate patient selection and experienced surgical technique were required for good results.

• Journal of Chest Surgery
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• 제20권2호
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• pp.404-410
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• 1987

An 18-day-old male neonate with hypoplastic left heart syndrome underwent surgical intervention by modification of the Norwood procedure on September 23, 1986. Hypoplastic left heart syndrome is a serious congenital cardiac anomaly that has a fatal outlook if left untreated. Included in this anomaly are [1] aortic valve atresia, and hypoplasia of the ascending aorta and aortic arch, [1] mitral valve atresia or hypoplasia, and [3] diminutive or absent left ventricle. Patent ductus arteriosus is essential for any survival, and there is usually a patent foramen ovale. Coarctation of the aorta is frequently associated with the lesion.z With a limited period of cardiopulmonary bypass, deep hypothermia, and circulatory arrest, the ductus arteriosus was excised. The main pulmonary artery was divided immediately below its branches, and the distal stump of the divided pulmonary artery was closed with a pericardial patch. The aortic arch was incised, and a 1 5mm tubular Dacron prosthesis was inserted between the main pulmonary artery and the aortic arch. A 4mm shunt of polytetrafluoroethylene graft was established between the new ascending aorta and the right pulmonary artery to provide controlled pulmonary blood flow. Following rewarming, the heart started to beat regularly, but the patient could not be weaned from cardiopulmonary bypass. At autopsy, the patient was found to have hypoplasia of the aortic tract complex with mitral atresia and aortic atresia. A secundum atrial septal defect was noted. Right atrial and ventricular hypertrophy was present, and the left ventricle was entirely absent. Although unsuccessful in this case report, continuing experience with hypoplastic left heart syndrome will lead to an improvement in result.

• Journal of Chest Surgery
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• 제22권1호
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• pp.25-31
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• 1989

Forty-five patients, aged 16 months to 15.5 years mean 69 months, with a wide variety of cardiac malformations underwent the modified Fontan operation between Sep. 1986 to Aug. 1988. Nineteen patients had previously undergone palliative operations mainly modified B-T shunt. Twenty patients had a mean pulmonary artery pressure greater than 15 mmHg, with nine operative deaths. Thirteen patients had anomalies of systemic venous connection and seven patients had anomalies of pulmonary venous connection. There were eighteen patients under the age 4 years and fifteen of them survived [83.3%]. Eighteen patients had a pulmonary vascular resistance [PVR] more than 2.5U/m, and nine died [50%] whereas two of twenty-three with a PVR less than 2.5U/m died[8.6%]. PVR and anomalies of pulmonary venous connection had a significant influence on survival, but age and anomalies of systemic venous connection did not. Amount of pleural effusion drained postoperatively and PVR had positive linear correlation. Pulmonary artery pressure was not an independent predictor of outcome and pulmonary artery pressure alone should not contraindicate a Fontan procedure if PVR is low. In general, the Fontan operation should be done at a younger age less than 4 year to avoid ventricular dysfunction due to long-standing exposure to hypoxia.

• Journal of Chest Surgery
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• 제38권6호
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• pp.403-409
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• 2005

온전한 심실중격을 가진 폐동맥 폐쇄증은 병변의 다양성으로 인하여 여러 가지의 외과적 술식이 요구되는 질환이다. 본 연구에서는 온전한 심실중격을 가진 폐동맥 폐쇄증으로 수술을 받은 환자들을 대상으로 수술 방법에 따른 결과 및 장기 성적에 대하여 알아보고자 하였다. 대상 및 방법: 1992년 1월부터 2004년 6월 사이에 외과적 치료를 받았던 총 38명의 환자들을 대상으로 하였다. 평균 연령은 18일$(2\~382일)$이었으며, 삼첨판막륜 크기의 평균 Z값은 $-3.1(-5.6\~0.8)$이었다. 우심실-관상동맥루를 동반한 환자는 13명$(36\%)$이었으며, 우심실의존 관상동맥순환을 보인 환자는 4명$(11\%)$이었다. 평균 추적기간은 55개월(3개월-12.2년)이었다. 결과: 24명의 환자들에서 우심실 감압술이 시행되었고, 14명의 환자들에서는 체폐동맥 단락술만이 시행되었다. 우심실 감압술을 시행받은 환자들의 평균 삼첨판막륜 Z-값은 $-2.2\pm1.1$로 체폐동맥 단락술만 시행받은 환자들의 평균 Z값 $-4.8\pm0.6$보다 컸다(p=0.000). 5명$(13\%)$의 조기 사망과 1명의 만기 사망이 발생하였다. 조기 사망은 우심실 감압술을 시행받은 환자들 중 3명$(13\%)$, 체페동맥 단락술만 시행받은 환자들 중에서 2명$(14\%)$이 발생하였다(p=1.0). 양심실 교정을 받은 환자가 12명$(32\%)$, 단심실 교정을 받은 환자가 8명$(21\%)$, 부분양심실 교정을 받은 환자가 4명$(11\%)$, 최종 교정을 기다리고 있는 환자가 9명$(24\%)$이었다. Kaplan-Meier방법으로 산출한 5년 및 8년 생존율은 $83.2\%$이었다. 결론: 대부분의 사망은 초기 수술 후에 발생하였으며, 양심실 혹은 단심실 교정을 의도한 군간에 사망률의 차이는 없었다. 전체적인 장기 생존율은 비교적 양호하였다. 환자 각각의 삼첨판막륜 및 우심실 크기, 그리고 관상동맥 이상 유무를 정확히 평가하여 적절한 수술 방법을 적용하면 조기 사망률의 개선을 기대할 수 있으리라 생각한다.

• Journal of Chest Surgery
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• 제30권3호
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• pp.263-269
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• 1997

1987년 4월부터 1996년 5월까지 복잡 선천성 심기형을 가진 13명의 환자에서 Norwood술식을적용 하였다. 진단별 분포로는 좌심형성부전증후군이 7례이었고, 상행대동맥과 대동맥궁의 형성부전이 있으 면서 심실중격결손증 및 대동맥하 협착증을 동반한 승모판 협착증, 심실중격결손증, 대동맥축착 및 대 동맥하 헙착증을 동반한 승모판 폐쇄증, 심실중격결손증 및 대동맥하 협착증을 동반한 대동맥궁 단절, 대혈관전위를 동반한 삼첨판 폐쇄증이 각각 1례씩 있었으며 이중입구부 좌심실이 2례 있었다 수술 당 시 나이는 3일에서 8.7개월 (평균 60.5 $\pm$ 71.6일, 중앙값 i9일)이었다. 수술 사망율( <30일)은 46% (6명) 이었으며 만기 사망율은 15% (2명)였다. 모든 수술사망은 술후 24시간 이내에 발생하였으며 체외순환으 로부터 이탈에 실패한 경우가 5례, 술후 갑작스런 혈역학적 불안정으로 사망한 경우가 1례 있었고, 만기 사망은모두 흡인성 폐렴에 의한 것이었다. 5명의 장기 생존자에 대한추후술식으로는2명의 환자에서 Norwood술식 후 각각 12, 17개월에 변형 Fontan수술을 하였으며 1명에서 4.5개월 후에 완전 대정맥폐동맥 단락술을 시행하였고 수술 사망은 없었다. 나머지 2명의 환자에서는 Fontan 술식전의 중간단계 로 양방향성 상대정맥-폐동맥 단락술을 각각 3, 5.5개휠 후에 시행하였으며 수술사망이 1례 있었다. 수 술 사망 및 만기 사망을 포함한 모든 환자에서 1년 생존율은 30.8%였다. 결론적으로 본원에서 경험한 Norwood 술식의 사망율이 다른 주요 심장기 형의 사망율과 비교하여 높지만 이에 대한 경험이 축적되면서 더 좋은 성적을 기대할 수 있을 것으로 생각된다.

• Journal of Chest Surgery
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• 제46권6호
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• pp.433-438
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• 2013

Background: Surgical repair of post-infarct ventricular septal defect (VSD) is considered one of the most challenging procedures having high surgical mortality. This study aimed to evaluate the outcomes of the surgical repair of post-infarct VSD. Methods: From May 1991 to July 2012, 34 patients (mean age, $67.1{\pm}7.9$ years) underwent surgical repair of post-infarct VSD. A retrospective review of clinical and surgical data was performed. Results: VSD repair involved the infarct exclusion technique using a patch in all patients. For coronary revascularization, 12 patients (35.3%) underwent concomitant coronary artery bypass graft, 3 patients (8.8%) underwent preoperative percutaneous coronary intervention, and 9 patients (26.5%) underwent both of these procedures. The early mortality rate was 20.6%. Six patients (17.6%) required reoperation due to residual shunt or newly developed VSD. During follow-up (median, 4.8 years; range, 0 to 18.4 years), late death occurred in nine patients. Overall, the 5-year and 10-year survival rates were $54.4%{\pm}8.8%$ and $44.3%{\pm}8.9%$, respectively. According to a Cox regression analysis, preoperative cardiogenic shock (p=0.069) and prolonged cardiopulmonary bypass time (p=0.008) were independent predictors of mortality. Conclusion: The early surgical outcome of post-infarct VSD was acceptable considering the high-risk nature of the disease. The long-term outcome, however, was still dismal, necessitating comprehensive optimal management through close follow-up.

• Journal of Trauma and Injury
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• 제32권4호
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• pp.202-209
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• 2019

Purpose: Cranioplasty (CP) is often required for survival after decompressive craniectomy. Several materials, including autologous bone and various artificial materials, have been introduced for CP, but it remains unclear which material is best for CP. This study aimed to explore differences in complications between patients who underwent CP using an autologous bone flap versus a three-dimensional (3D) titanium mesh and to identify significant risk factors for post-CP complications. Methods: In total, 44 patients were enrolled in this study and divided into two groups (autologous bone vs. 3D titanium mesh). In both groups, various post-CP complications were evaluated. Through a comparative analysis, we aimed to identify differences in complications between the two groups and, using binary logistic analysis, to determine significant factors associated with complications after CP. Results: In the autologous bone flap group, there were three cases of surgical infection (3/24, 12.5%) and 11 cases of bone flap resorption (BFR) (11/24, 45.83%). In the 3D titanium mesh group, there was only one case of surgical infection (1/20, 5%) and 11 cases of various complications, including mainly cosmetic issues (11/20, 55%). A subgroup risk factor analysis of CP with an autologous bone flap showed no risk factors that predicted BFR with statistical significance, although a marginal association was found between larger bone flaps and BFR (odds ratio [OR]=1.037, p=0.090). In patients treated with a 3D titanium mesh, multivariate analysis revealed that only the existence of a ventriculo-peritoneal shunt system was strongly associated with overall post-CP complications (OR=18.66, p=0.021). Conclusions: Depending on which material was used, different complications could occur, and the rate of complications was relatively high in both groups. Hence, the material selected for CP should be selected based on individual patients' conditions.