• Journal of Chest Surgery
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• v.30 no.7
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• pp.670-676
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• 1997

The structural failure of the glutaraldehyde-treated xenograft valves has been the primary concern about the limited durability as predicted from the begimling of clinical use, and long-term follow-up has shown a significant incidence of primary tissue failure(PTF) from both biological and mechanical reasons. Twenty-seven patients with the low-profile lonescu-Shiley valves explanted from mitral position for PTF(Group III) were studied on the patient characteristics and valve pathology, and the results were compared with the matched observations of the Haycock(Group I) and of the standard-profile lonesiu-Shiley valves(Group II). Patients were aged 16 to 56 years(mean, 38.0$\pm$ 11.0 years), and the size of the failed mitral bioprosthesis was 30.8$\pm$ 1.3 mm. The hemodynamic consequences were stenosis in 29.6%, insufficiency in 44.4%, mixed steno-insufficiency in 14.8%, together with normal function for the rest of patients of prophylactic re-replacement. Pathology revealed calcification with or without tissue damage in 63.0% and tissue damage with or without calcification in 58.l%, in contrast with the observations of predominant tissue damage(76.8%) over calcification in Group I and of calcification(76.1%) over tissue damage in group II. Although dystrophic calcification has long and repeatedly dealt with patient's young age as a determinant of valve durability, such a characteristic evidence was not reached even in patients with calcified valves. Moreover, the prolonged explantation p riods from the studied on the previous report suggested strongly yet possibly evolving destructive processes among the valves in the remaining patients, and awaits further follow-up. In conclusion, PTF of the xenograft valves seems to result from more complicated biologic and metabolic reasons as well as more complex mecharical factors than the reported, and newer generation prostheses, with tissue preservation with glutaraldehyde, do not likely to provide decisive improvement in the occurrence of structural failurebioprostheses is generally limited to the highly aged.

• Journal of Chest Surgery
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• v.32 no.6
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• pp.495-503
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• 1999

Background: We tested the technical feasibility of fetal cardiac bypass and collected baseline data on the fetal hemodynamics and placental functions related to the cardiopulmonary bypass in the fetal lamb model. Material and Method: Eleven fetuses at 120 to 150 days of gestation were subjected to bypass via trans-sternal approach with a 12 G pulmonary arterial cannula and 14 to 18 F venous cannula for 30 minutes. All ewes received general anesthesia with ketamine. In all the fetuses, no anesthetic agents were used except muscle relaxant. Eight served as a group in which placenta was excluded from the extracorporeal circulation by clamping the umbilical cord during the bypass(the oxygenator group) and in the remaining three, the placenta worked as the only source of oxygen supply(the placenta group). Observations were made every 10 minute during a 30-minute bypass and 30-minute post bypass period. No prostaglandin inhibitors were used both in ewes and in fetuses. Result: Weights of the fetuses ranged from 1.9 to 5.2 kg. In the oxygenator group, means of arterial pressure, PaO2, atrial pressure, heart rate, and bypass flow rate ranged 69.8 to 82.6 mmHg, 201.7 to 220.9 mmHg, 4.1 to 4.3 mmHg, 169 to 182/min, and 140.3 to 164.0 ml/kg/min, respectively during bypass, but rapid deterioration of the fetal cardiac functions and the placental gas exchange was observed after the cessation of bypass. In the placenta group, means of arterial pressure decreased from 44.7 to 14.4 mmHg and means of PaCO2 increased from 61.9 to 129.6 mmHg during bypass. Flow rate was suboptimal(74.3 to 97.0 ml/kg/min) during bypass. All hearts fibrillated immediately after the discontinuation of bypass. Conclusion: In this study, the technical feasibility of fetal cardiopulmonary bypass was confirmed in the fetal lamb model. However, further studies with modifications of the bypass including an addition of prostaglandin inhibitor, an application of the total spinal anesthesia on the fetus, a creation of more concise bypass circuit, and a use of active pump are mandatory to improve the outcome.

• Journal of Chest Surgery
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• v.37 no.4
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• pp.313-321
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• 2004

Excellent clinical results of the arterial switch operation and the limited availablity of the intraventricular rerouting has recently made an arterial switch operation to become the therapeutic method of choice for the repair of double-outlet right ventricle (DORV) with subpulmonary ventricular septal defect (VSD). The early and midterm outcomes of arterial switch operation for this anomaly were evaluated. Material and Method: Between August 1994 and July 2002, 13 patients underwent an arterial switch operation for the correction of double-outlet right ventricle with subpulmonary VSD at Dong-A university hospital.. The 50% rule was used to define DORV. Median age and mean body weight were 27 days (range, 3-120 days) and 3.8$\pm$0.7kg (range, 2.92-5.3kg) respectively. Aortic arch anomalies were associated in 6 cases (46.2%), which were all repaired through one-stage operation. The relationship of the great arteries were side-by-side in 8 cases (61.5%) and anteroposterior in 5 (38.5%). Coronary artery patterns were 1 LCx-2R in 6 cases, retropulmonary left coronary artery (LCA) in 6, and intramural LCA in 1 respectively. The enlargement of VSD was required in 1 patient and the patch enlargement of right ventricular outflow tract was performed in another one patient. The Lecompte maneuver was used in all but 3 patients with a side by side relationship of the great arteries. Result: Overall postoperative hospital mortality was 23.1 % (3/13). All operative deaths were occurred in the patients with aortic arch anomalies. There was one late death related to the postoperative complication of the central nerve system during the mean follow-up of 41.3$\pm$30.7 months. Pulmonary valvar stenosis (＞30mmHg of pressure gradient) developed in 1 patient (10%) and left pulmonary artery stenosis in 2 (20%), among them, one required reoperation 52 months after repair. There was an asymptomatic patient with moderate aortic regurgitation. 5-year survival rate including operative deaths was 68.3%. Conclusion: Although the operative mortality is high in the patients with aortic arch anomaly, the arterial switch operation for DORV with supbpulmonary VSD can be performed with low operative mortality and low reoperation rate in the patients Without arch anomaly. The arterial switch operation can be considered a good option for this complex anomaly.

• Journal of Chest Surgery
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• v.37 no.7
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• pp.547-552
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• 2004

Recently, autologous bone marrow cell transplantation (CTx) for angiogenesis and myogenesis in ischemic myocardium has been extensively investigated to improve heart functions. This study was designed to evaluate the effects of CTx with off-pump coronary artery bypass grafting (OPCAB) in patients who were not feasible for complete revascularization. Material and Method: Four male patients underwent CTx and OPCAB simultaneously. Bone marrow was aspirated from iliac bone. Mean 1.5 ${\times}$ 10$^{9}$ mononuclear cells including mean 6.7 ${\times}$ 10$^{6}$ CD34 + cells and 3.7 ${\times}$ 10$^{6}$ AC133 + cells were obtained and concentrated with 10 cc. These cells were transplanted into non-graftable ischemic myocardium after OPCAB. The heart function of all patients were evaluated using the MIBI scan, echocardiogram and MRI preoperatively. The effects of CTx was evaluated using MIBI scan and echocardiogram at 1 month postoperatively. Result: An average of 2 grafts were bypassed to left anterior descending artery territory. Other territories were transplanted with isolated mononuclear cell. All patients had uncomplicated postoperative course. After 1 month follow up, there were improvement in symptom, ejection fraction (from 49% to 55%) on echocardiogram and myocardial perfusion on MIBI scan in all patients. Conclusion: These preliminary data showed improvement of heart function and myocardial perfusion and also showed the feasibility and safety of combined therapy with OPCAB and CTx in ischemic myocardium. However, the effectiveness of CTx alone cannot be readily assessed. Further randomized, controlled studies are required to evaluate the effectiveness of CTx alone.

• Journal of Chest Surgery
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• v.34 no.12
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• pp.901-908
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• 2001

Background : Coronary artery bypass graft(CABG) in patients with advanced left ventricular dysfunction has often been regarded as having high mortality rate, despite the great improvement in operative result of CABG. With recent advances in surgical technique and myocardial protection, surgical revascularization improved the symptom and long-term survival of these high risk patients more than the medical conservative treatment. Material and Methold : Clinical data of 31(4.1％) patients with preoperative ejection fraction less than 30% among 864 CABGs performed between January 1995 and March 1999 were retrospectively analyzed and pre- and postoperative changes of the ejection fraction on echocardiography were analyzed. There were 26 men and 5 women. The mean age was 60.7 years(range 41 to 72 years). History of myocardial infarction(30 cases, 98％) was the most common preoperative risk factor. There were seven irreversible myocardial infarction on thallium scan. Most patients had triple vessel diseases(26 cases, 84％) and first degree of Rentrop classification(16 cases, 52％) on coronary angiography. The mean number of distal anastomosis during CABG was per patient was 4.9${\pm}$0.8 sites in each patient. In addition to long saphenous veins, the internal mammary artery was used in 20 patients. Total bypass time was 244.7${\pm}$3.7 minutes(range, 117 to 567 minutes), and mean aortic cross-clamp time was 77.9 ${\pm}$ 1.6 minutes(range, 30 to 178 minutes). There were five other reparative procedures such as two left ventricular aneurysrmectomy, two mitral repair, and one aortic valve replacement. There were twelve postoperative complications such as three cardiac arrhythmia, two bleeding(re-operation), one delayed sternal closure, eleven usage of intra-aortic balloon counterpulsation for low cardiac output. Two patients died, postoperative mortality was 6.5% . Twenty-nine patients were relieved of chest pain and left ventricular ejection fraction after operation was significantly higher(38.5${\pm}$11.6%, p 0.001) as compared with preoperative left ventricular ejection fraction(25.3${\pm}$2.3%). The follow up period of out patient was 25. 3 months. Conclusion: In patients with coronary artery disease and advanced left ventricular dysfunction, coronary artery bypass grafting can be performed relatively safely with improvement in left ventricular function, but it will be necessary to study long term results.

• Journal of Chest Surgery
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• v.34 no.6
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• pp.447-453
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• 2001

Background: Although pulmonary resection is the standard approach for the management of pulmonary metastases from soft tissue sarcoma, most of them are unresectable and chemotherapy remains the only option. The effectiveness of the cytotoxic drugs may be limited by the toxicities that occur before the therapeutic dose is reached. The regional administration of doxorubicin using pulmonary arterial perfusion in a rodent model can produce 10 to 25 times higher concentrations in the lung than systemic administration with minimal systemic toxicities. However, it is unclear whether a high concentration of doxorubicin has beneficial effects for killing cancer cells. Material and Method: We studied this to evaluate the dose-dependent cytotoxic and apoptotic effects of doxorubicin on methylcholanthrene-induced rat fibrosarcoma(MCA) cells. This study examined the cytotoxicity and apoptosis-related gene expressions(Fas, FasL, Bax, caspase 1, caspase 2, caspase 8, Bcl-2, Bcl-xL, Bcl-xS) in MCA cells after 24 hours exposure to various concentrations of doxorubicin such as 1, 5, 10, 50, and 100 $\mu$M. Result: Dose-dependent cytotoxicity was observed after 24 hours exposure to doxorubicin. However, peak apoptosis after 24 hours exposure was observed at 5 $\mu$M of doxorubicin. Above 5 $\mu$M, apoptotic activity was decreased with dose-increment. All mRNA levels of apoptosis-related genes after 24 hours exposure were up-regulated above the control level at 1 $\mu$M of doxorubicin and then decreased by doxorubicin dose-increment except caspase 8, which showed higher levels than the control level at 5 $\mu$M. Apoptosis-related protein levels were highest at 1 $\mu$M of doxorubicin and then decreased by doxorubicin dose-increment. However, Bax and Bcl-xL proteins steadily showed higher levels than the control throughout the different concentrations of doxorubicin. Conclusion: These results suggest that apoptosis is the main cytotoxic mechanism in low concentrations of doxorubicin in MCA cells and apoptosis-related genes, such as Bax, caspase 8, and Bcl-xL, are involved. At high concentrations, doxorubicin still can kill MCA cells, even when apoptosis is inhibited, and have its propriety for achieving much cytotoxicity against MCA cells.

• Journal of Chest Surgery
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• v.36 no.6
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• pp.411-417
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• 2003

Esophageal cancer is an aggressive disease with a poor prognosis. Recently, neoadjuvant therapy been used in an attempt to increase the long term survival but has not been shown as a clear advantage. We reviewed the recurrence and survival after complete resection of esophageal cancer without neoadjuvant therapy. Material and Method: From December 1994 to December 2001, 182 consecutive patients who underwent intrathoracic esophagectomy, transthoracic esophagogastrostomy and two-field lymph node dissection for esophageal canter without neoadjuvant therapy were studied retrospectively. Result: There were 167 men and 15 women. The median age was 65 years (range, 40 to 90 years). The tumor was located in the upper third part of the esophagus in 7 patients (3.8%), middle third in 86 (47.3%), and lower third in 89 (48.9%). The postsurgical stage were as follows: stage 0 in 2 patients (1.1%), stage I in 32 (17.6%), stageIIA in 47 (25.8%), stage IIB in 25 (13.7%), stage III in 54 (29.7%), stage IVA in 10 (5.5%), and stage IVB in 12 (6.6%). The in-hospital mortality rate was 3.8% (7 patients) and complications occurred in 65 patients (35%), Follow-up was complete in 95.6%. The recurrence occurred in 56 patients (30.8%) and the overall 5-year disease free rate was 55%. The overall 5-year survival rate was 57%; it was 80% for patients in stage I, 65% in stage IIA, 58% in stage IIB, 48% in stage III, and 40% in stage IVB. The overall 5-year survival rate of patients with postoperative adjuvant therapy was 59% compared to 34% in patients without postoperative adjuvant therapy (p<0.05). Conclusion: The most effective therapy for esophageal cancer may be complete resection. More aggressive surgical therapy and adjuvant therapy may improve the long-term survival, even for advanced stage esophageal cancer.

• Journal of Chest Surgery
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• v.29 no.9
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• pp.983-988
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• 1996

Aneurysm of the sinus of Valsalva is fairly rare. Between 1987 and 1994, we operated on a total of 12 cases of aneurysm of the sinus of Valsalva at the Inje University Seoul Paik Hospital. This represents 0.7% of all cardiac operation under cardiopulmonary bypass. There were eight male and four female patients aged from 8 to 38 years(mean, 19.2 years). 8 of 12 patients had ruptured aneurysms. The origin of aneurysm of the sinus of Valsalva was the right coronary sinus in 10(83. 3%), and the noncoronary sinus in 2(16.6%). In ruptured aneurysm, the origin was the right oronary sinus in 6, and the noncoronary sinus in 2. The aneurysms originating from the right coronary sinus ruptured into the right ventricle in 5, and into both the right atrium and right ventricle in 1. The aneurysms originating from the noncoronary sinus ruptured into the right ventricle in 1, and into the right atrium in 1. Associated congenital cardiac defects included ventricular septal defect in 10(83.3%) patients 39 cases of these were associated with the aneurysms of the right coronary sinus), aortic regurgi- tation in 3 (all of these had an additional ventricular septal defect), mitral regurgitation in 1, and double chambered right ventricle in 1. No hospital deaths occurred, although one late death occurred as a result of endocarditis 15 months after the first operation. The mean follow-up period was 29 months, range from 4 to 60 months. Eleven patients except one late death were in New York Heart Association class 1. Due to the low mortality risk o( an operation for aneur sm of the sinus of Valsalva, a ruptured aneurysm of the sinus of Valsalva should be corrected surgically when the diagnosis is mane, and unruptured aneurysm of the sinus of Valsava with complication should also be operated. In most cases the aorta was opened to examine the morphology of the aneurysm and the aortic cusps, and an associated aortic valve defect should be corrected simultaneously.

• Journal of Chest Surgery
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• v.36 no.3
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• pp.157-163
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• 2003

Traditionally, patients with stage IIIB non small cell lung cancer (NSCLC) have been con-sidered Inoperable due to the short-term survival rate of this disease. However, some recent papers have reported good surgical treatment results for T4 lesions in stage IIIB NSCLC. This study reports the results of stage IIIB NSCLC patients who underwent surgical treatment at our institute. Material and Method: This study includes 109 patients who were diagnosed with pathological stage IIIA lung cancer and 59 patients who were diagnosed with pathological stage IIIB at our institute between 1994 to December 2001. Patients who underwent neo-adjuvant chemotherapy and radiation therapy were excluded from this study. According to the TNM classification, 13 patients from stage IIIA were classified into T3N1, 12 into T1N2, 73 into T2N2 and 11 into T3N2. Stage IIIB patients consisted of 26 patients with T4N0, 18 with T4Nl, 14 with T4N2, and 1 with T4N3. Result: The 30-day mortality for stage IIIA and IIIB were 4.58% and 5.08% respectively. The overall survival rate at the 1st, 2nd, 3rd, and 5th year were 69.1%, 53.7%, 41.6%, and 30.7% respectively in stage IIIA and 68.8%, 55.6%, 42.9%, and 35.9% respectively in stage IIIB. Patients with satellite nodules in the same lobe & no Iymph node involvement had a survival rate of 53.9% in 3 years compared with 15.2% in patients with satellite nodules in the same lobe with Iymph node involvement. Conclusion: Surgical treatment is recommended for selected stage IIIB NSCLC patients (pathological N0 stage & completely resectable patients), particularly for patients with satellite nodules in the same lobe & no lymph node involvement.

• Journal of Chest Surgery
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• v.37 no.9
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• pp.727-734
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• 2004

The Lecompte procedure for transposition of the great arteries has an advantage because it obviates the need for an extracardiac conduit for the reconstruction of the pulmonary outflow tract. We evaluated the effectiveness and the application of the Lecompte procedure. Material and Method: A retrospective review was conducted of the records of 46 patients who underwent the Lecompte procedure during the past 15 years. Mean age at operation was 29.2$\pm$20.3 (range: 3∼83) months. The diagnoses involved anomalies of the ventriculoarterial connection with ventricular septal defect and pulmonary outflow tract obstruction, such as transposition of the great arteries, double-outlet right ventricle, and double-outlet left ventricle. Result: Early mortality was 4.4% (2 of 46 patients) and late mortality was 6.8% (3 of 44). The mean follow-up was 11.2$\pm$6.9 years. Eighteen patients (43.9% of survivors, n=41) had pulmonary stenosis (pressure gradient above 30 mmHg), the main reason for which was a calcified monocusp valve (n=15, 83.3%). Seventeen of 46 patients (37.0%) underwent reoperation: 15 for pulmonary stenosis, 5 for residual ventricular septal defect, 4 for left ventricular outflow tract obstruction, 3 for pulmonary insufficiency, and 4 for other causes. The cumulative survival rates were 91.3$\pm$4.2%, and 87.0$\pm$5.8% at 10 and 15 years, respectively. The actuarial probabilities of freedom from reoperation for pulmonary stenosis were 90.6$\pm$4.5%, 73.9$\pm$7.3%, and 54.0$\pm$10.4% at 5, 10, and 15 years, respectively. Conclusion: The Lecompte procedure is an effective treatment modality. Repair in early age is possible with acceptable morbidity and mortality, but recurrent right ventricular outflow tract obstruction caused by degeneration of the monocusp valve is a problem that needs resolution.