• Journal of the korean academy of Pediatric Dentistry
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• v.27 no.2
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• pp.208-215
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• 2000

Patient with congenital heart disease are susceptible to infective endocarditis, and bacteremia following dental procedures may lead to infective endocarditis is these patients. Therefore prophylactic antibiotics are recommended for patients with congenital heart disease who are undergoing dental procedures that are associated with infective endocarditis. In 1997 American Heart Association revised guidelines for a prophylaxis against infective endocarditis. The new American Heart Association recommendations for the prevention of infective endocarditis represent a substantial departure from past guidelines. Major change involve the indications for prophylaxis, antibiotic choice and dosing that may reduce bacteremic risk. Previously, antibiotic prophylaxis was suggested for dental procedures associated with any amount of bleeding. Now only those that are associated with significant bleeding are recommended for prophylaxis as dictated by clinical judgement. Recommended antibiotic prophylaxis regimens now consist of a single preprocedural dose, no second dose is recommended. This report presents three cases of dental treatment of patients with congenital heart disease under the most recent American Heart Association recommendations for antibiotic prophylaxis.

• Journal of Chest Surgery
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• v.18 no.4
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• pp.753-758
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• 1985

Hemorrhage is an important complication after operation with cardiopulmonary bypass and sometimes necessitates a further emergency operation. Between July, 1962 and June, 1985, reoperation for hemorrhage was carried out on 81 patients [3.1%] out of a total 2634 patients who had previously undergone cardiopulmonary bypass surgery at the Department of Thoracic and Cardiovascular Surgery, Yonsei University Medical Center. There were 38 males and 43 females, with an average age of 25 years [ranging 6 months to 60 years] and an average body weight of 38 kg [ranging 5 to 77 kg].There were 43 patients of cyanotic heart disease, 32 patients of acquired valvular heart disease, 4 patients of coronary artery occlusive disease, 2 patients of ascending aorta aneurysm and annuloaortic ectasia. The average amount of blood loss in the case of cyanotic heart disease was 71.7140ml/kg, in acyanotic heart disease 45.16.3ml/kg, in acquired heart disease, 56.514.4ml/kg and in coronary artery occlusive disease, 50.618.7ml/kg during first post operative day. But there was no statistical difference [p>0.05]. The mean blood loss below 10 years old was 70.412.1 ml/kg. Those below 10 years old were believed to bleed more than any other group. But there was also no statistical difference [p>0.05]. Indications for reoperation were continued excessive blood loss [74%], cardiac tamponade or hypotension [23%] and radiological evidence of a large hematoma in the thorax and pericardium [2%]. Average bypass time was 2.10.1 hours [ranging 30 minutes to 5 hours]. The interval between operation and reoperation was as follows; less than 12 hours in 49 patients [60%], 12 to 24 hours in 20 patients [25%], 24 to 48 hours in 8 patients [10%], more than 48 hours in 4 patients [5%]. The commonest sites for bleeding were chest wall [36%], heart [34%], aorta [12%], pericardium [6%], thymus [5%] and others [6%]. But no definite source was found in ll patients [31%]. Twenty seven out of 81 patients [31%] had wound problems and 5 patients [6%] were expired. [Mean SEM]. In conclusion, in order to decrease the amount of blood loss after open heart surgery with cardiopulmonary bypass, shortening of bypass time and bleeding control at the wire suture site during chest wall closure were important. If the amount of blood loss was over 45 ml/kg or 8 m/kg/hour, reoperation should be considered as soon as possible. After operating, careful wound dressings were applied to prevent wound problems.

• Journal of Chest Surgery
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• v.25 no.11
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• pp.1346-1353
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• 1992

From Febrary 1984 to July 1992, 138 cases of multiple valve replacements were performed at the Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University. There were 81 females and 57 males, and their ages ranged from 19 to 60 years [mean age, 40.1$\pm$10.9 years]. Thirteen of these patients had undergone previous cardiovascular procedures, with an average of 76.3 months between procedures[range, 3 to 180 months]. Mitral and aortic valve replacement were done in 135 patients, 2 underwent triple valve replacement and 1 underwent mitral and tricuspid valve replacement. Associated procedures were necessary in 20 patients[14.5%]. The operative mortality was 5.8% and the most common cause was low cardiac output. Late follow-up of 83% has been accomplished in 130 early survivors, with a late mortality of 5.9%. The late mortality was due to valve thrombosis in 2 patients, cerebral infarction in 1, heart failure in 1, arrhythmia in 1, and bleeding in l. Of those patients who survived, New York Heart Association functional class improved significantly[from 70% class III and IV before to 88% class I and II after]. Actuarial survival rate including all deaths was 88.8% at 8 years. The follow-up studies revealed that thromboembolism, reoperation and bleeding rate were 1.2%/patient-year, 0.85% /patient-year and 0.57%/patient-year at 8 years postoperatively. We concluded that valve thrombosis, embolism, and anticoagulant-related hemorrhage were the main risk factors of longterm survival of patients.

• Journal of Chest Surgery
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• v.22 no.1
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• pp.1-9
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• 1989

We have performed one case of autotransplantation and 11 cases of orthotopic homotransplantation using Korean mongrel dogs, and have scrutinized the hematologic and hemodynamic results. The mean weight of recipients was 15.42*1.2kg and varied from 14kg to 20kg. During the operation, anesthesia and other technical procedures including cardiopulmonary bypass were similar to the usual methods in human cardiac transplantation. It was found that the hematologic values were similar to those of human beings although there was wide variance. Hemodynamically the mean systolic and diastolic arterial pressures were 165.0* 12.9 mmHg and 100.0 *11.8 mmHg respectively, and the mean heart rate was 155.5*23.5/min. All cases died within 24hrs, and the mean survival in all but 6 cases where operative death occurred was 6.83*8.01 hrs[range 2-21 hrs]. The major causes of deaths were bleedings in 7 cases, failure to protect myocardium during the procedure in 2 cases, pulmonary edema in 1 case and multiorgan failure in 2 cases. From the above results we concluded that the most frequent complication was bleeding, and the cardiopulmonary bypass flow of 50-500ml/kg min was not suitable to the dog in CPB. In further experiment after this study, the technical and the bypass flow was increased. Bleeding was not significant. And the immunosuppresion during operation and postoperative period was tried.

• Journal of Chest Surgery
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• v.28 no.7
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• pp.666-670
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• 1995

A total of and consecutive 87 patients underwent concomitant double mitral and aortic valve replacement with the St. Jude Medical prosthesis between January 1985 and December 1993. They were 44 males and 43 females with the ages ranging from 18 to 59 years[mean$\pm$SD: 40.9$\pm$9.5 years . Fifteen patients[17.2% had a history of previous cardiac valve replacement. There were 2 early deaths[2.3% , and 85 early survivors were followed up for a total of 352.6 patient-years[mean$\pm$SD: 4.1 $\pm$2.6 years . All were anticoagulated with coumadin keeping the target international normalized ratio within the range of 1.5 and 2.5. There was a single late death[late mortality of 0.284%/patient-year . Thromboembolism was the most frequent complication[1.985%/patient-year , and bleeding related to anticoagulation was experienced in one patient [0.284%/patient-year . The incidences of prosthetic valve endocarditis and of paravalvular leak were also low[0.284%/patient-year, respectively . The survival including operative mortality was 96.1%$\pm$2.2% at 10 years. The actuarial probabilities of freedom from thromboembolism and from all events were 77.9%$\pm$11.1% and 72.4%$\pm$10.7%, respectively, at 10 years. There was no structural failure of the prosthesis. Results from a series of clinical studies suggest strongly that the use of lower intensity of anticoagulation therapy lowers the thromboembolic as well as bleeding rates in patients with the ST. Jude Medical prosthesis.

• Journal of Chest Surgery
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• v.32 no.6
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• pp.504-509
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• 1999

Background: Heart transplantation is considerated for a selected certain group of complicated congenital heart disease in neonates because corrective surgery is very difficult and has high mortality. Precise planning of transplantation is necessary to adequately fit the donor heart to the recipient. Material and Method: We have performed 4 neonatal pig heart transplantations to test the technical feasibility. Experiment 1: The transplantation was performed using the same technique as the adult heart transplantation. Experiment 2: The transplantation for hypoplastic left heart syndrome was simulated as we reconstructed the whole aortic arch with donor aorta. Experiment 3: The heart transplantation was done with radical pulmonary artery reconstruction. Experiment 4: The experiment was performed for a long term survival. Result: Preoperative planning was very important for adequate fitting. All animals could be weaned from cardiopulmonary bypass, however, two animals died due to bleeding at pulmonary artery and left atrium. Conclusion: We concluded that the neonatal heart transplantation can be applied in some complicated Further using animal model is mandatory.

• Journal of Chest Surgery
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• v.41 no.4
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• pp.430-438
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• 2008

Background: All the patients with mechanical valves require warfarin therapy in order to prevent them from developing thromboembolic complications. According to the ACC/AHA practice guidelines, after AVR with bileaflet mechanical prostheses in patients with no risk factors, warfarin is indicated to achieve an INR of 2.0 to 3.0. After MVR with any mechanical valve, warfarin is indicated to achieve an INR of 2.5 to 3.5. But in our clinical experience, bleeding complications (epistaxis, hematuria, uterine bleeding, intracerebral hemorrhage etc.) frequently developed in patients who maintained their INR within this value. So, we retrospectively reviewed the patients with bileaflet mechanical heart valve prosthesis and we determined the optimal anticoagulation value. Material and Method: From January 1984 to February 2007, 311 patients have been followed up at a national medical center. We classified the AVR patients (n=60) into three groups as follows: an INR from 1.5 to 2.0 in Group I, an INR from 2.0 to 2.5 in Group II and an INR from 2.5 to 3.0 in Group III. We classified the MVR (n=171) and DVR (n=80) patients into four groups as follows: an INR from 1.5 to 2.0 in Group I, an INR from 2.0 to 2.5 in Group II, an INR from 2.5 to 3.0 in Group III and an INR from 3.0 to 3.5 in Group III. We compared the groups for their thromboembolic and bleeding complications by means of the Kaplan Meier method. Result: In the AVR patients, 2 thromboembolic complications and 4 bleeding complications occurred and the log rank test failed to identify any statistical significance between the groups for thethromboembolic complication rate, but groups I and II had lower bleeding complication rates than did group III. Thirteen thromboembolic complication and 15 bleeding complication occurred in the MVR and DVR patients, and the log rank test also failed to identify statistical significance between the groups for the thromboembolic complication rate, but groups I and II had lower bleeding complication rates that did groups III and IV. Conclusion: The thromboembolic complication rate was not statistically different between groups I and II and groups III and IV, but the bleeding complication rates of groups I and II were lower than those of groups III and IV. So this outcome encouraged us to continue using our low intensive anticoagulation regime, that is, an INR of 1.5 to 2.5.

• Journal of Chest Surgery
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• v.29 no.3
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• pp.303-310
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• 1996

From December of 1994 to April of 1995, we, SHUH Department of Pediatric Thoracic and Cardiovascular Surgery, studied effects of aprotinin. 95 patients were randomly divided into two groups : group I (n=47) with aprotinin and group ll (n=48) without aprotinin. Aprotinin was given as one shot injection to cardiopulmonary bypass perfusion solution with dose of 50,000 KIUikg. Laboratory data such as hemoglobin, hematocrit, BUH, creatinine, fibrinogen, electrolyte concentration, aPTT, PT, and AT R was checked preoperatively, 5 minutes after anesthesia, 5 minutes and 35 minutes after CPB circulation, and 5 minutes, 3 hours, and 24 hours after reperfusion. Also, chest-tube drainage, transfused amount of RBC, platelet concentrate, and fresh frozen plasma within first 24 hours postoperatively were checked and analyzed after transition nn body weight demension. Only RBC transfused postoperatively had statistical significance with P value of less than 0.001. Others had no difference statistical wise. Postoperative side effects of aprotinin was not detected weeks after the surgery and there was no reoperated patient due to postoperative bleeding.

• Journal of Chest Surgery
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• v.19 no.1
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• pp.83-91
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• 1986

The Carpentier-Edwards porcine xenograft valve was used in 21 patients at Seoul National University Hospital during the period between 1977 and 1979. Twenty-four Carpentier-Edwards valves were implanted along with 2 others. Three patients died within 30 days of operation, an operative mortality rate of 14.3%. Eighteen early survivors were followed up for a total 67.5 patient-years [mean, 45.0$\pm$32.0 months]. There were 2 late deaths with a linealized late mortality rate of 2.96%/patient-year; one died from cerebral bleeding [1.48% bleeding/patient-year] and the other from prosthetic valve endocarditis [1, 48% endocarditis/patient-year]. There was no case of thromboembolism. Two patients developed mitral regurgitation [2.96% failure/patient-year]. Symptomatic improvement was excellent. The actuarial survival rate and the probability of freedom from overall valve failure were 75.3$\pm$9.6% and 80.7$\pm$12.9% at 9 years after surgery respectively. During the period from October, 1968, through June, 1985, 1, 190 substitute heart valves were used in a total of 967 patients at Seoul National University Hospital; of which, 90.9% were either porcine aortic or bovine pericardial xenograft valves. For the evaluation of the xenograft tissue valves, the consecutive patients with lonescu-Shiley valve in the mitral, aortic and both positions, Angell-Shiley valve and Carpentier-Edwards valve were recently studied on the clinical ground. They were 531 patients, and 643 xenograft valves were used. The operative mortality rate was 6.97% and a linealized late mortality rate 2.94%/patient-year. A total of 490 early survivors were followed up for 917.6 patient-years [mean, 22.5 months], and 70% of patients completed the follow-up. The linealized incidences of complications were: 2.29% emboli/patient-year, 1.98% bleeding/patient-year, 1.20% endocarditis/patient-year, and 3.49% failure/patient-year. These clinical resutls are fully comparable with those in the major reports. The durability of the glutaraldehydepreserved xenograft heart valves remains as a great concern and a continuing debate, expecially for the group of patients in the pediatric age. The need of more durable material for the improved tissue valves was also discussed.

• Korean Journal of Clinical Pharmacy
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• v.9 no.1
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• pp.27-34
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• 1999

The goal of oral anticoagulation therapy with warfarin is to maintain INR values within the therapeutic range in order to prevent complications such as bleeding and thrombosis. The purposes of this study were to investigate the current level of anticoagulation control using INR values, to investigate the incidences of thromboembolism and bleeding complications, and to compare the effect of low intensity INR regimen with therapeutic range recommended by ACCP (American College of Chest Physician). Two hundred three patients with mechanical heart valve replacement done at Yonsei University Cardiovascular Center between January 1994 and December 1996 were selected and reviewed retrospectively. The target INR ranges of $2.5\sim3.5$ (ACCP standard) and low intensity INR of $2.0\sim3.5$ were used for evaluation. According to ACCP standard, $51.2\%$ of patients and $31.1\%$ of INR values were within the therapeutic range when average INR and cumulative INR were used, respectively. Applying low intensity INR values of $2.0\sim3.5$, the therapeutic control was achieved in $57.4\%\;and\;90.1\%$, using average INR and total INR, respectively. The incidences of major and minor bleedings were $0.5\%\;and\;26.6\%$, respectively. The incidence of thromboembolism was $0.5\%$. There was no significant difference in terms of complication incidences between INR $2.0\sim2.5\;and\;INR\;2.5\sim3.5$ groups. However, INR values at the time of bleeding were generally high. In conclusion, the evaluation of patients with mechanical heart valve replacement showed low level of therapeutic control with warfarin therapy. This is partially explained by the fact that the physicians at Yonsei University Cardiovascular Center were using lower intensity INR values as a goal than recommended INR. Also, in the near future, systematic anticoagulation service should be implemented at various hospitals in Korea so that patients on anticoagulant therapy can be more closely monitored to be within the recommended INR by ACCP.