• Clinical and Experimental Pediatrics
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• v.50 no.6
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• pp.588-591
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• 2007

Left ventricular thrombus is mainly caused by anterior myocardial infarction or severe cardiac wall dysfunction of the apex, and is rarely caused by a complication of acute myocarditis. A 12-year-old female who developed symptoms of motor dysphasia and incomplete hemiparesis of the right side was admitted to the hospital. The brain MRI taken on the day of her admission showed acute cerebral infarction in the left basal ganglia and the frontoparietal lobe. The echocardiogram showed a movable thrombus, which was $19{\times}28mm$ sized and located in the apex of the left ventricle. So in order to prevent further thromboembolic event we performed open cardiac surgery via the atrium and removed the thrombus of the left ventricle. After the removal of the thrombus her symptoms improved and she was discharged from the hospital. Thrombus formation in acute viral myocarditis are considered to be related with endocardial injury and blood flow stasis. Treatment with anticoagulants in left ventricular thrombosis may not be effective and may even cause a major thromboembolism. When the thrombus is laminar and fixed, one should consider anticoagulant therapy. But if the thrombus is pedunculated and movable, which means that there are higher possibilities of major embolism or there may be already one, one should consider surgical removal. We report a 12-year-old girl who required surgical removal of a left ventricular thrombus caused by acute viral myocarditis.

• Clinical and Experimental Pediatrics
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• v.48 no.3
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• pp.321-326
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• 2005

Kawasaki disease is an acute systemic vasculitis of unknown origin. Giant coronary aneurysm is one of the most serious complications, although peripheral artery vasculitis can produce life-threatening events. Myocardial ischemia and infarction can be caused by coronary artery stenosis, aneurysm, and stagnation of blood flow in coronary arteries which triggers thromboembolism. Atypical presentation in young infants often interferes with prompt diagnosis and timely treatment, resulting in poor outcomes. We describe a 3-month-old infant with multiple giant coronary aneurysms with flow stagnation, stenosis and large mural thrombus due to Kawasaki disease. He presented with a prolonged course of severe coronary involvement in spite of all measures to reduce coronary complications. Finally, surgical intervention was tried because of the worsening coronary artery abnormalities. The patient died of acute cardiorespiratory failure shortly after weaning from cardiopulmonary bypass.

• Journal of Korean Neurosurgical Society
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• v.30 no.6
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• pp.805-812
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• 2001

Objectives : The goal of the surgical management of large and giant aneurysm is complete extirpation of the aneurysms with preservation or reconstruction of the parent artery. To improve the surgical management results of those aneurysms in the future, we review our experience and discuss technical maneuvers and strategies used to avoid potential complications of those aneurysm surgery. Material and Methods : During the past 12 years, thirty six cases of large and giant aneurysms(diameter>19mm) were managed by surgery. The clinical characteristics, treatment methods, surgical complications and outcome of those cases were analyzed and, based on the review of the literatures, the preventive methods of surgical complication related to the clipping of those aneurysms were discussed. Results : The locations of those aneurysms were anterior circulation in 34 cases and posterior circulation in 2 cases. The most frequent site of aneurysmal location was a paraclinoidal region of the anterior circulation. The aneurysms were managed surgically by direct clipping of aneurysmal neck in 31 cases, aneurysmal trapping followed by extracranial-intracranial bypass in 2 cases, proximal clipping of parent artery, aneurysmorrhaphy, and excision of aneurysm followed by end to end anastomosis of parent artery in each one case. Surgical complications occurred in 13 cases. A parent vessel occlusion by thrombus formation and parent vessel stenosis after clipping of aneurysm were the main complications. We obtained good outcome in 27, fair 5, poor 1 and dead in 3 case(s). Conclusion : We conclude that selection of suitable management method for each case, high quality of surgical technique and prevention of complication during operation are important key points for the successful treatment of large and giant aneurysm. The heparinization prior to application of temporary clip on parent vessels, aneurysmal decompression during dissection and clipping of aneurysm, complete closing of the aneurysmal neck and avoiding the narrowing of parent vessel after clipping of aneurysm were the main technical maneuvers used to avoid complications of those aneurysm surgery.

• Korean Journal of Clinical Pharmacy
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• v.23 no.2
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• pp.151-157
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• 2013

Purpose: Warfarin is the most widely used anticoagulant drug for preventing cardiovascular diseases after ischemic stroke and thromboembolism related to atrial fibrillation, artificial heart valves, deep vein thrombosis, and pulmonary embolism. Warfarin is commonly used in combination with other drugs such as diuretics in order to treat the comorbidity. Although several warfarin-diuretics interactions have been reported, the results are conflicting. Therefore, the initial aim of this study was to identify the effects of diuretics on the warfarin response in patients with atrial fibrillation. Methods: One hundred forty six patients with atrial fibrillation who were on anticoagulation therapy with warfarin and maintained INR levels of 2-3 for three consecutive times were followed up, retrospectively. Stable warfarin doses and INR per stable warfarin dose were compared according to age, gender, comorbidity, and concurrent medication. The stable warfarin dose was defined as the maintenance dose of warfarin of the measured patient whose INR was within the target INR range more than 3 times consecutively. Results: The differences of stable warfarin doses in patients with ($3.22{\pm}1.21$ mg/day) and without ($3.58{\pm}1.14$ mg/day) diuretics were marginally significant (P=0.069). On the other hand, stable warfarin doses were $2.97{\pm}1.10$ mg/day in patients with thiazide (n=36) and $3.58{\pm}1.14$ mg/day in patients without diuretics (n=82), which was statistically significant (p=0.009). INR values per stable warfarin dose in patients with diuretics and thiazide were $0.84{\pm}0.31$ and $0.90{\pm}0.34$, respectively, which were statistically different from those without diuretics ($0.72{\pm}0.21$, P=0.010 and P=0.006, respectively). Age, gender, and concurrent use of thiazide diuretics were found to have significant influence on the warfarin response from multivariate analysis. Conclusion: Our study showed that the concurrent use of thiazide diuretics could increase the response of warfarin in patient with atrial fibrillation. Therefore, clinicians should be aware that warfarin dose needs to be adjusted when it is used with thiazide diuretics concomitantly.

• Korean Journal of Clinical Pharmacy
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• v.27 no.1
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• pp.15-21
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• 2017

Objective: The perioperative management of antithrombotic therapy is often challenging and it requires a fine balance between the risk of hemorrhage and thrombosis. We aimed to evaluate the antithrombotic management for moderate to high risk patients in real world setting. Methods: Among the patients who were consulted to the neurologist for the evaluation of perioperative risk from 2010 to 2012, patients undergoing moderate to high risk surgery and taking antithrombotics within 30 days were identified. We analyzed the timing of discontinuation and reinitiation of antithrombotic drugs before or after surgery as well as the status of bridging therapy. In addition, the conformity with the guideline suggested by American College of Chest Physicians was assessed. The rate of thromboembolic event and major hemorrhage were also investigated. Results: A total of 329 patients were included. The concordance rate of warfarin stop and restart time with guideline was 23.4% and 10.3%, respectively. Continuing aspirin in patients undergoing coronary artery bypass surgery or non-cardiac surgery in patients with high risk for cardiovascular events were 59.2% and 2.6%, respectively. Bridging therapy was adopted in 92.9% and 81.2% in patients who had received anticoagulant before surgery and who were at high and low risk thromboembolism, respectively. In entire cohorts, 30-day incidence of major bleeding and thromboembolic event were 31.9% and 3.0%. Co-morbid renal disease were shown as independent predictor for major bleeding (adjusted OR 2.65. 95% CI 1.33-5.28). Conclusion: The concordance rate with guideline regarding perioperative antithrombotic use was low and bridging therapy was prevalent in patients undergoing moderate to high risk surgery.

• Journal of Chest Surgery
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• v.31 no.6
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• pp.591-597
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• 1998

Background: The aim of the current study was to analyze the early and intermediate-term performance of aortic valve replacement. Material and Method: Between January 1986 and January 1996, records of 61 consecutive patients who had received aortic valve replacement were reviewed. 38 were male and 23 were female patients, ranging from 10 to 71 years of age(mean: 40.5${\pm}$11.2). Results: The early death rate was 4.9%(3/61). A thorough follow-up rate of 93.1% was accomplished in these 58 patients who left the hospital(mean: 51.5${\pm}$32.0 patient-months) under the assistance of the same operator. Three of these patients who left the hospital died. The late death rate was 5.2%(3/58). Five patients experienced anticoagulant-related hemorrhage(all were minor). Three patients had thromboembolic episodes. There was no clinical evidence of hemolysis and structural failure of valves used. Of those patients who survived, the NYHA functional class improved significantly. Linearized rate were 1.58%/patient-year and 2.0%/patient-year respectively for thromboembolism and anticoagulant-related hemorrhage. The 10 year actuarial survival rate was 83.6%. Conclusion: This early and intermediate-term follow-up suggests that the mechanical valve is a reliable and durable prosthesis with good hemodynamic function and low rate of prosthesis-related complication.

• Journal of Chest Surgery
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• v.31 no.11
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• pp.1031-1036
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• 1998

Background: Medtronic-Hall mechanical valve is a world widely using prosthesis. But, in Korea, the clinical result from Medtronic-Hall valve replacement is not frequenthy available. Materials and methods: From March 1986 to May 1990, 50 patients underwent valve replacement surgery with Medtronic-Hall valve at Pusan National University Hospital. Seventeen were male and thirty three were female and ra nging in age from 16 to 70 years of age(mean=35 years). Results: The causes of valvular lesion were rheumatic in 43 patients, bicuspid aortic valve in 3 patients, degenerative lesion in three patients and bacterial endocarditis in one patient. The operative procedures were mitral valve replacement(MVR) in 38, aortic valve replacement(AVR) in 5 and double valve replacement(DVR) in 7. The most commonly used valve size was 21mm in AVR, 29mm in MVR. Concomitant surgical procedures were performed in 15 patients; left atrial thrombectomy in 9, left atrial auricle obliteration in 6 and tricuspid annuloplasty in 5(Kay: 2, DeVega: 3). New York Heart Association functional class was mostly Class Ⅲ or Ⅳ(91.5%) preoperatively and ClassⅠor Ⅱ(87.2%) after operation. The findings of postoperative echocardiogram of LAD, LVESD, LVEDD were reduced compared with preoperative period and ejection fraction was increased compared with preoperative period. Postoperative complications were massive bleeding in three, low cardiac output syndrome in two, thromboembolism in one and fulminant hepatitis in one patient. There were three hospital deaths and their causes were low cardiac output syndrome in two and rupture of left ventricle in one patient. The 5 year survival rate was 93.65±0.71% and 10 year actuarial survival rate was 88.27±6.42%. Conclusions: Medtronic-Hall mechanical valve has low valve related complication rate. It's durability and hemodynamic performance is comparable to other mechanical valves.

• Tuberculosis and Respiratory Diseases
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• v.47 no.1
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• pp.103-110
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• 1999

A thromboembolic event in patients later given a diagnosis of cancer is the result rather than the cause of the cancer. The risk of hidden cancer is significantly higher for patients with recurrent idiopathic thromboembolism compared to those with secondary deep vein thrombosis. Microemboli from hepatic or adrenal metastases and large-sized emboli from the great veins invaded by the tumor are the sources of tumor embolization The intraarterial tumor emboli less likely invade the arterial wall. Thrombus formation and organization may be capable of destroying tumor cells within pulmorlary blood vessels. Therefore, all tumor emboli are not true metastases. The treatment of deep vein thrombosis and pulmonary embolism in patients with cancer consists of anticoagulation with heparin and warfarin, venacaval filters, appropriate anti-neoplastic agents, and surgical methods(embolectomy, thromboendarterectomy). However, considerable literatures suggest that oral anticoagulant such as warfarin is ineffective in the treatment of those. We report a case of primary unknown squamous cell carcinoma incidentally found in the thrombus after pulmonary embolectomy.

• Korean Journal of Clinical Pharmacy
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• v.20 no.2
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• pp.159-164
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• 2010

Radiofrequency ablation (RA) is being used to manage atrial fibrillation (AF) with patients failed at the $1^{st}$-line anti-arrhythmic medications. Patients undergoing this procedure are at increased risk of thromboembolism after ablation, and anticoagulation management surrounding the ablation remains controversial. Although no conclusive recommendations can be made, published guidelines and data support therapeutic anticoagulation with warfarin. The purpose of this study was to analyze effectiveness of current therapy and to find factors fluctuate International Normalized Ratio (INR) values in patients undergone RA followed by anticoagulation service (ACS). Retrospective review was conducted utilizing database in a hospital. Among 110 patients under warfarin around ablation between January 2006 to September 2007, 54 patients were selected and allocated into 2 groups: Group A included 47 who discontinued warfarin after ablation, while 7 in B continued the medication. Information on demographics, amount and length of warfarin dosing, INR values and measuring frequencies, and the causing factors on INR fluctuation were abstracted. Differences were analyzed using chi-squared test, Fisher's Exact test, and unpaired Student t-test. Mean amount of warfarin before and after surgery was 4.0 mg, 4.1 mg in Group A and was 5.1 mg, 4.6 mg in Group B, respectively. Average duration of warfarin doing before ablation was 73.7 days in Group A, 129.9 days in B with no significant difference (p = 0.312). The duration time of warfarin on groups after ablation lasted several months. The number of checking INRs was 4.1 and 7.6, respectively. Inter-individual variability of INR fluctuations were $2.1{\pm}0.6$ in Group A and $2.2{\pm}0.7$ in B which were not significantly different (p = 0.062). 164 cases of decreased INR were: 'omission in taking medication, stressfulness and headache, 'increased intake of high vitamin K foods', 'lifestyle change of increased physical activities', and 'increase of food-intakes'. To the contrary, 36 cases of increased INR were: 'reduce of food-intake', 'use of non-prescription drugs', 'reduction in physical activities', and 'excessive restriction on food-intake', consecutively. In conclusion, the study validated therapeutic outcomes of RA patients who we treated with standard guideline and demonstrated 9 factors of INR fluctuations in the patient. A well-trained, pharmacist-monitored anticoagulation service could reduce the risk of adverse effects and prevent complications in patients with AF around RA operation.

• Journal of Chest Surgery
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• v.46 no.2
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• pp.104-110
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• 2013

Background: We reviewed the long-term outcomes of aortic root replacement at Asan Medical Center and investigated the predictors affecting mortality. Materials and Methods: A retrospective analysis was performed on 225 consecutive adult patients undergoing aortic root replacement with mechanical conduits (n=169), porcine aortic root prosthesis (n=23), or aortic homografts (n=33) from January 1992 to September 2009. The median follow-up duration was 6.1 years (range, 0 to 18.0 years). Results: The porcine root group was older than the other groups (freestyle $55.9{\pm}14.3$ years vs. mechanical $46.3{\pm}14.6$ years, homograft $48.1{\pm}14.7$ years; p=0.02). The mechanical group had the highest incidence of the Marfan syndrome (mechanical 22%, freestyle 4%, homograft 3%; p=0.01). Surgery performed for infective endocarditis was more frequent in the homograft group (mechanical 10%, freestyle 10%, homograft 40%; p<0.001). The overall 30-day mortality was 5.3% (12/225). Actuarial survival rates in the mechanical, porcine root, and homograft groups were 79.4%, 81.5%, and 83.5% at 5 years and 67%, 61.9%, and 61.1% at 10 years, respectively (p=0.73). By multivariate analysis, preoperative diabetes mellitus, older age, and longer cardiopulmonary bypass time were independent predictors of mortality. Incidence of postoperative complications, including infective endocarditis and thromboembolism were comparable in all of the groups. Conclusion: Aortic root replacement can be safely performed with different types of prostheses as the outcome was not affected by the choice of prosthesis. Further studies are required to assess the long-term durability of biological prostheses.