• 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.37 no.9
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• pp.768-773
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• 2004

Failure of mitral valve repair sometimes may be ascribed to severe or progressive alteration of the subvalvar apparatus. The aim of this study was to evaluate the effects of new chordae formation on mitral repair. Material and Method: From March 1997 to february 1999, 26 patients underwent mitral valve repairs with new chordae formation, we compared the symptoms and echocardiographic findings checked at preoperative state, and intraoperative period, discharge, and their last OPD visit. There were 45 male, and 11 female patients, and their mean age was 51.2$\pm$43.4 years. Etiology of the lesions was degenerative (18), rheumatic (6), infective (1) and ischemic (1). Chordal lesions were caused by rupture (18), elongation (6), and a combination of two causes (2). Associated lesions included atrial septal defect (2), tricuspid insufficiency (7), aortic insufficiency(4), and a combination of previous two factors (2). The number of mean artificial chordae was 3.6$\pm$1.6. Annuloplasty was per-formed in all cases. The CPB time was 182,1$\pm$63.7 minutes and the ACC time was 133.1$\pm$45.6 minutes. Aver-age follow up period was 49.2$\pm$7.1 months. Result: There was no early death. Early reoperation was performed in bud patients, one patient received mitral valve replacement because of an abnormality of annuloplasty and ano-ther received pericardiostomy due to postoperative pericardial effusion. During the follow up of 49.2$\pm$7.1 moths, there was no late mortality. Postoperative NYHA functional class checked at last OPD visit was class I in 22 patients (88%), class II in 2 (8%), and class III in 1 (4%). Regarding the late echocardiogram MR was absent in 20 patients (78%), 1 in 4 (15%), and II in 1 (4%). The postrepair mitral valve area was 2.2$\pm$0.35 $\textrm{cm}^2$ Conclusion: This study suggests that mitral valve repair using new chordae formation provides good early and mid term survivals and functional improvement. We think that the artificial chorda formation with polytetrafluoroethylene suture might be safe and effective technique for mitral valve repair.

• Journal of Chest Surgery
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• v.37 no.8
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• pp.652-659
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• 2004

Background: In this study, we retrospectively analyzed the outcomes of aortic valvuloplasty in pediatric age. Material and Method: Between January 1993 and March 2004, 35 patients underwent aortic valvuloplasty for aortic stenosis (AS) or aortic regurgitation (AR). The mean age was 81.1$\pm$61.5 (1∼223) months. The mean follow up was 50.8$\pm$30.2 (3∼121) months. Nine patients had AS, 21 had AR, and 6 had AS and AR. Valve morphology was tricuspid in 24 patients, bicuspid in 9, quadricuspid in 1, and unicuspid in 1. The mean peak pressure gradients of AS were 72.0$\pm$33.0 mmHg, and the mean grades of AR were 3.1$\pm$0.9. Result: There was one late mortality without early mortality. After operation, AS improved with mean peak pressure gradients of 23.5$\pm$21.0 mmHg (p < 0.05), and AR improved with mean grades of 1.9$\pm$0.8 (p < 0.05). At mean follow up of 35.0$\pm$23.0 months, AS maintained with mean peak pressure gradients of 31.5$\pm$24.0 mmHg, but AR progressed with mean grades of 2.8$\pm$1.3 (p < 0.05). Reoperation was required in 6 patients 38.3$\pm$21.8 months after the original operation. The actuarial figures for freedom from reoperation at 2, 5 and 8 years were 96.9$\pm$3.1%, 79.5$\pm$5.5%, and 56.8$\pm$11.4%, respectively. Age at operation, presence of AS, preoperative severity of AS or AR, and morphology of aortic valve were not significant risk factors for reoperation, and improvement of AS or AR. Conclusion: Aortic valvuloplasty showed good immediate postoperative valve function. Aortic valvuloplasty offers children many years with tolerable valve function and allows to postpone aortic valve replacement or Ross procedure in pediatric patients.

• 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.36 no.10
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• pp.780-783
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• 2003

Pacemaker lead-related infective endocarditis is an uncommon, but serious complication. We report a case of a 45-year-old man who had symptom of intermittent high fever and rupture of sinus Valsalva that developed after a redo aortic valve replacement and transvenous permanent pacemaker implantation. Positive blood cultures of streptococcus viridans and transesophageal echocardiography showing a large mobile vegetation on pacemaker lead and tricuspid valve lead to the diagnosis of pacemaker lead-related infective endocarditis. Initial antibiotic therapy followed by surgical extraction of the pacemaker lead and wide debridement of infective tissues including multiple vegetations was required. Postoperative antibiotic therapy was continued for 4 weeks. The postoperative course has been uneventful. The patient is totally asymptomatic and is doing well up to now.

• Journal of Chest Surgery
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• v.31 no.7
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• pp.679-683
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• 1998

From June 1995 to May 1997, we have implanted 52 Sorin Bicarbon mechanical valves in 41 patients. They were 16 men and 25 women, and their mean age was 47.4${\pm}$14.8(range; 18∼74 y.o.). 35(27 mm∼31 mm) were in mitral position, 15(19 mm∼25 mm) in aortic position, and 2(31 mm) in tricuspid position. 3 CABGs and a tumor excision were taken concomittantly. 35 patients were primary operation, and 6 were re-do operations. By intraoperative transesophageal doppler echocardiography, transvalvular peak/mean pressure gradient was 6.1${\pm}$2.7/2.4${\pm}$1.4 mmHg in mitral position and 27.6/10.7 mmHg in aortic position. The effective valve opening area in mitral position was 3.2${\pm}$0.6 cm2. Follow-up was total 508.6 patient-months, and mean follw-up was 12.7${\pm}$9.2 months. NYHA class was improved from 2.6${\pm}$0.6 to 1.2${\pm}$0.3 in average postoperatively. During that period, there was no operative death. 2 late non-valve related deaths were occurred. One was died of COPD, and the other was possible acute myocardial infarction. Among 7 postoperative complications, one valve related complication(minimal paravalvular leakage) was noticed. In conclusion, Sorin Bicarbon mechanical valve is believed one of the safe choice in clinical settings. It showed excellent hemodynamic and mechanical functions, and very low postoperative valve related complications in short term clinical experience.

• 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.

• Journal of Chest Surgery
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• v.36 no.9
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• pp.646-650
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• 2003

Many surgical techniques for ischemic mitral regurgitation (IMR) have been used with their excellent results and advantages. Here, we report our simple posterior annuloplasty techniques using vascular graft strip with their early results. Material and Method: Twenty two patients (13 male) underwent the operations for IMR (excluding the papillary muscle rupture) from December 2001 to January 2003. Preoperative risk factors were low ejection fraction (<35％, n=9), hypertension (n=13), diabetes (n=9), and renal failure (Cr>2.5, n=4). The wide dissection beneath the both vena cavae and interatrial groove after bicaval cannulation enabled the easy exposure of mitral valve even in the small left atrium. After eight or nine interrupted sutures in posterior annulus for anchoring the 6 mm width vascular graft strip, symmetric (n=8) or asymmetric (n=14) annuloplasty were done. Combined surgeries were CABG (n=21), Dor procedures (n=3), tricuspid valve annuloplasty (n=1), Maze operation (n=1), and aorto-right subclavian artery bypass (n=1). Result: Except for one surgical mortality, all the patients were doing well and the mean grade of regurgitation was decreased from 2.95 to 0.88, however the ejection fraction had not changed significantly just before discharge. Post-operative valve function evaluated before discharge revealed no residual regurgitation in 8 (including 1 patient with mild stenosis due to over reduction), minimal in 11, mild in 2, and mild to moderate regurgitation in 1. One patient who had ischemic cardiomyopathy and renal failure died of the arrhythmia during the hemodialysis. Conclusion: These observations suggest that the annuloplasty with vascular graft strip could be a safe and cost effective techniques for ischemic mitral regurgitation. However, the long term evaluation for the mitral valve function should be defined for the final conclusion.

• Journal of Chest Surgery
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• v.30 no.7
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• pp.663-669
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• 1997

This is a report on the clinical outcome and hemodynamic profile of the ATSwcardiac valve prosthesis, which is a recently introduced pyrolytic carbon bileaflet prosthesis. We retrospectively reviewed the early outcome of 100 consecutive patients who underwent isolated cardiac valve replacement with the ATS(w prosthesis from October 1994 through June 1996 at our hospital. All patients were evaluated with Doppler echocardiography before discharge from the hospital. The mean age of the patients was 48.6 years(range: 2 to 74). A tota of 124 prosthesis were implanted; 71 mitral, 46 aortic, and 7 tricuspid. The two most frequently used sizes were 27 mm(40.8%) and 29 mm(35.2%) in the mitral position, and 23 mm(30.4%) and 21 mm(28.3%) in the aortic position. There was no early or late death. The total follow-up period was 950 patient-months with 99% follow-up rate. Serious late morbidity occurred in three patients; reoperation in two patients for late rupture of Sinus of Valsava in one and for endocarditis with prosthetic dehiscence in the other, and intracranial hemorrhage due to hypertension in one patient. There has been no thromboembolic complication or structural valval deterioration. In the mitral position, the average values of peak and mean transprosthetic pressure gradients and valve area calculated from pressure half time were 6.9$\pm$2.8 mmHg, 2.6$\pm$ 1.5 mmHg, and 2.7 $\pm$0.8 cm2 respectively. In the aortic position, the peak and mean pressure gradients'were 26.4 $\pm$ 15.9 mmHg and 14.2 $\pm$ 7.9 mmHg. For the mitra prostheses larger than 25-mm size, there was no significant difference among prosthetic sizes in terms of transprosthetic gradients, whereas there was a significant negative correlation between the prosthesis size and the transprosthetic gradients for the aortic valves. The peak and mean Pressere pradients were 52.2 $\pm$ 17.6 tmHg and 26.9$\pm$ 7.4 mmHg across the 19-mm aortic Prostheses, and 27.1 $\pm$ 11.9 mmHg and 13.3$\pm$6.6 mmHg across the 21-mm size. Above results can lead to the conclusion that the early clinical outcome of the ATS valve prosthesis is quite satisfactory, And the hemodynamic characteristics are comparable, if not better, with other bileaflet prostheses.

• Journal of Chest Surgery
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• v.35 no.3
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• pp.209-216
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• 2002

Background: Valvular heart disease is still the most common health problem in Korea. By the end of the year 1999, there has been 94,586 cases of open heart surgery since the first case in 1958. Among them, 36,247 cases were acquired heart diseases and 20,704 of those had valvular heart disease. But there was no database system and every surgeon and physician had great difficulties in analysing and utilizing those tremendous medical resources. Therefore, we developed a valve registry database program and utilize it for risk factor analysis and so on. Material and Method: Personal computer-based multiuser database program was created using Microsoft AccessTM. That consisted of relational database structure with fine-tuned compact field variables and server-client architecture. Simple graphic user interface showed easy-to-use accessability and comprehensibility. User-oriented modular structure enabled easier modification through native AccessTM functions. Infinite application of query function aided users to extract, summarize, analyse and report the study result promptly. Result: About three-thousand cases of valve replacement procedure were performed in our hospital from 1968 to 1999. Total number of prosthesis replaced was 3,700. The numbers of cases for mitral, aortic and tricuspid valve replacement were 1600, 584, 76, respectively. Among them, 700 patients received prosthesis in more than two positions. Bioprosthesis or mechanical prosthesis were used in 1,280 and 1,500 patients respectively Redo valve replacements were performed in 460 patients totally and 40 patients annually Conclusion: Database program for registry of valvular heart disease was successfully developed and used in personal computer-based multiuser environment. This revealed promising results and perspectives in database management and utilization system.