• Journal of Chest Surgery
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• v.32 no.3
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• pp.237-248
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• 1999

Background: The late results of repair of tetralogy of Fallot(TOF) are favorable in most patients. Some portion of the patients with tetralogy, however, require reoperation for residual lesions or result in late death. The outcome of patients after tetralogy repair performed during the past 13 years was studied, with an emphasis on postrepair survival and problems including reoperations. Material and Method: A retrospective review of clinical, echocardiographic and catheterization data was performed in 569 of 775 patients with TOF who underwent corrective repair between 1983 and 1995 at Sejong General Hospital, Buchon, Korea. Result: Of 28(4.9%) early deaths(defined as 30 days postrepair), 12 deaths(42.9%) were <1 year of age, with an operative mortality of 15.4%. The surviving 541 patients(age 2.8 months to 43.4 years, median 23 months) have been followed up from 1 month to 12.6 years(median 35 months) postoperatively. Most patients were in good functional class and had normal right ventricular(RV) function. Postrepair results were compared between the transatrial-transpulmonary approach and the conventional right ventriculotomy. The former technique provided a lesser incidence of significant pulmonary regurgitation(P<0.001) and alesser degree of RV dysfunction(P<0.05) compared with those in the latter. There were 10(1.8%) late deaths during the follow-up period and 6 of the deaths were directly related to reoperation or ventricular dysfunction. The 10-year actuarial survival rate was 96.7%. There were 44 reoperations(8.1%) in 39 patients(7.2%), with an operative mortality of 10.3%. The main indications or reoperation included residual ventricular septal defect(VSD) (n=6), pulmonary stenosis(PS) (n=11), VSD with PS(n=17), pulmonary regurgitation(n=7), and tricuspid regurgitation(n=2). The 5- and 10-year freedom from reoperation were 89.4% and 76.1%, respectively. Conclusion: Although the majority of patients with repaired TOF are clinically well, with a high rate of survival, approximately 7% of patients have residual lesions that require surgical therapy. Therefore, the timely and meticulous corrective repair is mandatory to avoid reoperation, and continued close surveillance is also needed for the early detection of residual problems.

• Journal of Chest Surgery
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• v.32 no.3
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• pp.215-223
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• 1999

Background: The replacement of the narrowed long-segment trachea with various prosthetic materials or tissue grafts remains a difficult and unsolved surgical problem. Homologous cryopreserved tracheal transplantation has been considered to treat the irreversibly-damaged organs, such as in the lung or heart transplantation and also to overcome the limited supply of donor organs. We examined the morphological changes and the immunosuppressive effects of the cryopreserved trachea after the heterotopic transplantation in the rats. Material and Method: Sixty tracheal segments harvested from 30 donor Wistar rats were heterotopically implanted into the peritoneal cavity of 20 recipient Wistar rats and 40 Sprague Dawley rats. The 60 recipient rats were divided into 6 groups(10 rats/ group). In groups I, II, and III, 30 tracheal segments were implanted immediately after the harvesting and in groups IV, V, and VI, the segments were implanted 28 days after the cryopreservation. Groups I and IV were Wistar syngeneic controls. Groups II and V were Sprague Dawley recipients receiving no immunosuppression and Groups III and VI, were Sprague Dawley recipients receiving immunosuppressive agents. At 28 days all rats were sacrificed and the tracheal segments were evaluated grossly and histologically. Result: Immunosuppression of the tracheal segments had a significant influence on the changes of the tracheal lumen and tracheal epithelial cells, irrespective of the cryopreservation of the trachea(p<0.001). In groups III and VI receiving immunosuppressive agents, the tracheal lumen was patent and the normal epithelial cells were observed, however in the other groups not receiving the immunosuppressive agents, there were almost luminal obliteration by the proliferation of the fibrous tissues and a loss of the epithelial cells, the findings were similar to those in the case of obliterative bronchiolitis after a lung and a heart-lung transplantation. Conclusion: With the appropriate immunosuppressive agents, the lumen and the respiratory epithelium of the transplanted tracheal segment were well preserved, even after the cryopreservation of the tracheal segment, which shows the possibility of the long-term preservation and homologous transplantation of the trachea. But fibroproliferative obliteration of the tracheal lumen and the loss of the normal respiratory epithelial cells, characteristic findings of obliterative bronchiolitis, were observed in the groups without the immunosuppression. This experiment using the rat trachea may be useful in studying the pathogenesis, treatment, and prevention of obliterative bronchiolitis after a lung and a heart-lung transplantation.

• Journal of Chest Surgery
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• v.32 no.3
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• pp.249-254
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• 1999

Background: Recovery of the left atrial contractile function after the Cox-Maze procedure is related to the size of the left atrium. We have postulated that if too wide area of the atrium were isolated electrically, then the atrial contractile function would be impaired postoperatively. We have modified the Cox-Maze procedure to dissect each pair of the pulmonary veins separately instead of the conventional pulmonary vein encircling incision, and compared the atrial contractile function after each procedure. Material and Method: From February 1995 to October 1997, 55 cases of the Cox-Maze procedure were performed in mitral valvular heart disease. We excluded the cases that did not covert to sinus rhythm. The patient groups were divided according to the interpulmonary vein distance(IPVD) and the procedure performed. Group I was IPVD under 6.5 cm(n=30), group II was IPVD over 6.5cm and the conventional Cox-Maze III procedure was performed(n=16), and group III was IPVD over 6.5cm and the modified Cox-Maze procedure was performed(n=9). Result: Atrial contractile function was evaluated by the echocardiography follow-up between 6 months to 12 months. The right atrial contractile function recovered gradually, the recovery rate after long-term follow-up was 90% in group I, 81% in group II, and 100% in group III(p>0/05). In the left atrium the recovery rate was 63% in group I, 31% in group II(p=0.03), and 66% in group III(p>0.05). Conclusion: The modified Cox-Maze procedure may have beneficial effects on the recovery of the left atrial contractile function, however, there are no statistically significant values. Therefore, further evaluation of this procedure is 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.32 no.9
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• pp.781-789
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• 1999

Background: Pulmonary artery banding(PAB) accompanies some risks in the aspect of band complications and mortality in the second-stage operation. To assess these risks of the second-stage operation after PAB, we reviewed the surgical results of the second-stage operation in the pediatric patients who had undergone PAB in infancy. Material and Method: From May 1988 to June 1997, a total of 29 patients with preliminary PAB underwent open heart surgery. Ages ranged from 2 to 45 months(mean 20.6$\pm$9.0 months). Preoperative congestive heart failure conditions were improved after PAB(elective operation group) in 27 patients, but early second-stage procedures were required in the remaining 2 patients due to sustaining congestive heart failure(early operation group). Preoperative surgical indications included 2 double outlet right ventricles(DORV group) and 27 ventricular septal defects as the main cardiac anomaly(VSD group). Result: The mean time interval from PAB to the second-stage operation was 15.5$\pm$8.7 months(range 5 days to 45 months). One patient in the DORV group underwent intraventricular tunnel repair and modified Glenn procedure in the other. In the VSD group, the VSD was closed with a Dacron patch in all patients. Concomitant procedures included a right ventricular infundibulectomy in 4 patients and a valvectomy of the dysplastic pulmonary valve in 1 patient. At the second-stage operations, pulmonary angioplasty was required due to the stenotic banding sites in 18 patients. One patient underwent complete ligation of the main pulmonary artery with the modified Glenn procedure. The mortality at the second-stage operation was 17.2%(5 patients). Causes of death were 4 low cardiac output, and 1 autoimmune hemolytic anemia. Diagnosis with DORV and the early operative group were the risk factors for operative death in this series. There was 1 late death. Conclusion: This study revealed the second-stage operation for pulmonary artery debanding and closure of VSD in children was complicated by the correction of the acquired lesions with a significantly high incidence of morbidity and early postoperative deaths. Primary repair is recommended for isolated VSD, if possible.

• Journal of Chest Surgery
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• v.29 no.12
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• pp.1329-1336
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• 1996

From January, 1994 to January. 1996, mitral valve replacement was performed in 27 patients. Among these, 17 patients underwent mitral valve replacement(MVR) with preservation of the annulo-papillary continuity(PAPCMVR) (-Group I), and 10 patients underwent conventional methods of excision of all the chordae(Group II). The operative technique for PAPCM VR consists of the division of the anterior leaflet into anterior and posterior segments, shifting and reattachment of the divided segments to the mitral ring of the respective commissural areas. This retrospective study has been designed to evalute the postoperative left ventricular function in the two groups. In the group 1, LVEF(Left Vnetricular Ejection Fraction : %) was 52 $\pm$ 3 preoperatively And 50$\pm$3 postoperatively, LVESI Vent icular End Systolic Volume Index/mL/m2) wIns 59 :6 and 51 $\pm$ 7, LVEDI Ventricular End Diastolic Volume Index/mL/m2) was 124$\pm$ 11 and 91 :8. In the group II, LVEF was 56$\pm$1 and 47:), LVESVI 62$\pm$12 and 61$\pm$15, LVEDVI 133$\pm$27 and 104$\pm$17. : the variation of the LVEF in these two group was statistically different(p(0.05). A comparison of left ventricular function data between Group I(n: 17) and Group II(n: 10) revealed better results in echocardiographic LVEF(p<0.05), LVEDVI(p<0.01) in the former group. The mean functional class(UYHA) was 2.6 preoperative and improved to 1.0 postoperatively In group 1, and 2.8 and to 1.0 in group II. We conclude that maintenance of continuity between the mitral annulus and papillary muscles is expected to have a beneficial effect on postoperative left ventricular performance.

• Journal of Chest Surgery
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• v.29 no.12
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• pp.1306-1315
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• 1996

This study reviewed the changes of hemodynamlcs and centrAl pulmonary artery dimension in 54 patients who underwent bidirectional cavopulmonary shunt(BCPS) between February 1992 and December 1995 at Seoul National University Childrell's Hospital. Ag and body weight of patients averaged 36.8 $\pm$ 37.7 months and 8.0$\pm$3.0 kg, respectively Eightynine percent of patients had more than 2 violations of the risk factors for Fontan operation, resulting overall hospital mortality of 16.6%(9154). Serial hemodynamic and anglographic examinations before and mean 16.3 $\pm$ 14.3 months iirter BCPS were compared. The arterial oxygen saturation improved from a preoperative value of 71 9: 10.1 % to 79.H $\pm$ 8. 5% (n:4), p<0.05). The values of arterial oxygen saturation were lower as the age of the patients with BCPS in place was older(n=22, R'=0.341, p=0.004). A mean pulmonary artery pressure and pulmonary vascular resistance reduced from 31 $\pm$17 to 1).5$\pm$3.SmmHg(n=22, p<0.05) and from ).2$\pm$2.1 to 2.3$\pm$2.7 unit (n=7. p>0.05), respectively. Follow-up study showed a significant Increase of absolute values of ipsilateral pulmoanry artery (n: 14, p<0.05), but no change of contralateral pulmonary artreries (n: 14. p=not significant(HSI). However, there w re significant decreases in diameters of both ipsilateral and contralateral pulmonary arteries standardized by patients' body surface areas(16.8% decrease, n: 14, p< 0. 05 for ipsilatreal, 25.1%, n=14, p<0.05 for contralateral). Pulmonary artery indices for cross sectional areas of both pulmonary arterises decreased 9.3 $\pm$ 13.8% with showing a trend of more decrease as the follow-up duration was longer, We conclude that the bidirectional cavopulmonary shunt provide an excellent.

• Journal of Chest Surgery
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• v.29 no.12
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• pp.1316-1322
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• 1996

From May 1977 to December 1994, 1.060 cases of open heart surge y for congenital heart disease were performed under cardiopulmonary bypass in Chonnam University Hospital They were divided into two groups; group A(677 cases, from May 1977 lo December 1989), group B(38B cases, from January 1990 to December 1994), to be compared and analized. Of the 1, 060 cases, there were 889 acyanotic (83.9%) and 171 cyanotic(16.1%). The operative mortality was 7.8% in group A and 5.7% in group B (total : 6.6%). The operative mortality for group A was 25% in cyanotic disease and 3.7% in acyanotic disease, respectively in group B, it was 23.8%, 3.2%. There were 19 patients (3.8%) and 78 patients(20.4%) with body weight under 10kg in group A and group B respectively. The operative mortality for these patients were 31.6% in A group and 16.1% in B group. In result, increasing trend in congenital heart disease in patients under 10 kg of body weight has been noted, whereas mortality has decreased. The operative mortality of tetralogy of Fallot has decreased in group B t an group A. These results suggest that the operative result have improved in recent years.

• Journal of Chest Surgery
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• v.29 no.12
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• pp.1323-1328
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• 1996

The obstructive diseases involving the left main coronary artery(LMCA) are serious. Surgical treatment is generally regarded as much more effective than medical therapy in terms of long-term survival and relief of symptoms. This study represents an attempt to present an analysis of early surgical results in 21 cases conducted at Chonnam University Hospital between October 1992 And August 1995. The subject. 12 males and 9 female, ranged in age from 25 to 67 years with a mean age of 49.3${\pm}$12.5 years. As for indications for operation, unstable angina was reported on 66.7% of the subjects, while stable angina and acute myocardial infarction in 4 and 3 cases, respectively. There were also 2 cases of Takayasu's aortitis and 1 case of failed percutaneous translumlnal coronary angioplasty(PTCA). Eleven subjects had isolated LMCA diseases compared to 10 subjects with associated LMCA diseases. Of the patients with ass;3ciated LMCA diseases, 4 subjects had single coronary artery disease, 3 had double coronary artery disease, remaining 3 suffered from triple coronary artery disease. As for the group with isolated LMCA disease, ostidl angioplasty llsing autopericardium was conducted with 5 subjects. The remaining subjects with the isolated diseases and all of the patients with associated LMCA disease underwent aortocoronary bypass grafts. The left internal mammary artery was used in all patients and the average number of anastomoses was 3.13 ${\pm}$0.93. One subject died of low cardiac output syndrome at the second postoperative day. There were 5 instances of postoperative complication including reoperation for bleeding in two patients, wound infection in two, and arrhythmia in one. Follow-up coronary angiogram were conducted with eights patients, including five patients who underwent ostial angioplasty. In these cases, the patients showed surf. ficient enlargement of the left coronary ostium and the grafted vessels kept their patency. In our experience, surgical treatment of the LMCA diseases has not shown a higher rAte of operative mortAlity or morbidity than other obstructive coronary artery diseases. To patients with ostial stenosis, which is frequently observed among young female, angioplasly utilizing autopericardium seems to be a desirable choice considering the cosmetic effect, chances of reoperation and hemodynamic characteristics.

• Journal of Chest Surgery
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• v.37 no.5
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• pp.391-400
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• 2004

Xenotransplantation in discordant species results in immediate and irreversible hyperacute rejection due to natural antibodies, IgM. With this, antibody depletion is one option to reduce hyperacute rejection, we investigated the effect of PCPP (postcentrifugal plasmapheresis) on the depletion of natural antibodies and the effect of antibody titer on xenograft survival. Material and Method: Outbred swines (n=4) weighing 10∼20 kg were used as donors and mongrel dogs (n=4) weighing 25∼30 kg were used as recipients. Recipient canines underwent plasmapheresis (COBE TPE Laboratories, Lakewood. CO, USA). Pre-transplantation PCPP was peformed on day －2 and day 0. There were three groups (Group 0: no PCPP, Group 1: 1 pla sma-volume (PV) at day －2 and 2 PV at day 0, Group 2: 2 PV at day －2 and 2 PV at day 0). A swine heart was heterotopically transplanted into a recipient's abdominal infrarenal aorta and inferior vena cava. Mean percent depletion of total IgM and IgG in plasma of the recipients was calculated. Serum albumin, electrolyte, complement activity and coagulation factors were measured. Histopathologic examination of heart specimens was performed. Result: Mean percent depletion of IgM and IgG were 95.7$\pm$1.2%, 80.5$\pm$2.4% in the group 2 at the end of PCPP. The percent depletion of serum albumin concentration was decreased from 2.8 to 1.4 g/㎗ in the group 1 and 3.0 to 1.5 g/㎗ in the group 2. Complement hemolytic activity was decreased in group 1 and 2, but returned to normal level within 24 hours. Complement hemolytic activity was reduced to 10% of pre-PCPP level in group 2. Serum fibrinogen decreased to 20% or less and was recovered within 24 hours in group 2. Antithrombin III decreased but less than fibrinogen. PT and aPTT were sometimes but not always prolonged during plasmapheresis. After plasmapheresis, PT and aPTT were prolonged beyond the measurable level. D-dimer was not found during PCPP, but appeared and maintained from 10 minutes after trasplantation. Graft Survival time was 5 min in group 0, and it was 90$\pm$0 min in the group 2. Histopathologic changes were more typically characterized by edema, hemorrhages, thrombosis in all groups at the end of experiment. Conclusion: PCPP effectively removed immuoglobulins and reduced the titer of natural antibodies, as a result, significantly prololonged swine heart xenograft survival.