• Journal of Chest Surgery
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• v.30 no.9
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• pp.869-875
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• 1997

Perimembranous ventri ular septal defects(PMVSDS) are the most common type of ventricular septal defects(VSDs) and consist morphologically of deficiency of the membranous septum and variable portions of the adjacent muscular septum. Repair of VSD has begun via a right ventriculotomy. Even with this exposure, however, it mght lead to ventricular dysfunction. Transatrial exposure of VSDs is luiown to a versatile approach to PMVSDS and even malaligunent defects can be repaired by this method. Although transatrial exposure can be improved by taking down'the atrioventricular valve at the annulus, surgeons have been hesitant to do so because of concern for valvular competence. Therefore, this study was undertaken to clarity the effects of transamlular approach of tricuspid valve (TATV) at operation of PMVSD. During last 5 years, twenty eight cases from 96 patients of PMVSD were closed by TATV and follow up study was done from 3 months to 33 months and results were obtained as follows. 1. Age at operation was fr m 4 months to 38 years and most patients(17, 62%) were above 5 years. 2. Preoperative pulmonary-systemic flow ratio(QPIQS) was ranged from 1 to 2.8 and 22 patients(79%) were less than 2. 3. Peak systolic pulmonary artery pressure was below 30mmHg in 8, 30-50mmHg in 17, above 50mmHg in 3 patients and 25 patients(89%) were less than 50mmHg. 4. Preoperative tricuspid regurgitation(TR) is none in 12, trivial in 6, mild in 3, moderate in 5, severe in 2 patients but postoperative TR was none in 18, trivial in 6, mild in 4 patients, so TR in most patients had decreased or not. 5. Indications for operation were based on the presence of a significant shunt. However, in patients with small shunts, indications for operation were included additional factors, tricuspid valve pouch, RVOT obstruction(right ventricular outflow tract obstruction), subacute bacterial endocarditis and associated anomalies. 6. There were no hospital deaths and residual shunts in postoperative echocardiography. Therefore TATV is especially a good method in PMVSn where patients have trcuspid valve pouch. And it is a safe and effective technique that improves exposure for PMVSD repair and does not adversely affect tricuspid valvular competence.

• Journal of Chest Surgery
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• v.36 no.9
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• pp.633-637
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• 2003

Sometimes temporary tricuspid valve detachment is applied for closure of ventricular septal defect to facilitate good exposure and avoiding ventriculotomy, but most surgeons hesitate to do it in the fear of tricuspid incompetence. Moreover in recent textbooks the technique of temporary tricuspid detachment is only described for exceptional situations and is not further analysed or commented on. Material and Method: Retrospective study was carried out in all 11 patients operated between 1985 to 1994, with preoperative data and postoperative course and recent echocardiographic and electrocardiographic data. Result: On the basis of the area of the color flow jet, tricuspid valvular regurgitation was graded as none in 9 and trivial in 2, and significant electrocardiographic heart block did not developed in any patients. Conclusion: Takedown and attachment of the tricuspid valve is a safe and effective technique that improves exposure for ventricular septal defect, and does not adversely effect tricuspid valve competence and electrocardiography.

• Journal of Chest Surgery
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• v.35 no.6
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• pp.475-478
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• 2002

A 45 year old man was admitted for aggravated dyspnea, abdominal distension and poor oral intake. On Echocardiogram, mitral stenosis(severe), tricuspid regurgitaion(IV), and LA thrombus were diagnosed. We used heparin with continuous infusion for prevention of systemic thrombo embolism. On the 11th day of admission, the patient showed thrombocytopenia and we suspected Heparin-induced thrombocytopenia. Hirudin was used in this case as alternative anticoagulant during cardiopulmonary bypass to prevent serious complication of heparin. The patient was recovered without any complication as postoperative bleeding or systemic thromboembolism.

• Journal of Chest Surgery
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• v.29 no.11
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• pp.1197-1201
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• 1996

From October, 1987 to December, 1995, nine patients underwent total correction of tetralogy of Fallot in adults over 20 years of age. There were 5 male and 4 female patients aged from 22 to 42 years(mean, 29.6 years). Three patients were in New York Heart Association(NYHA) functional class II, and 6 patients in class III. The hemoglobin values ranged from 10.8 to 20.7 gm/㎗ (average, l5.6gm/㎗). The preoperative clinical features were as follows: cyanosis, 8 patients; dyspnea on exertion, 6 patients; clubbing of fingers, 5 patients; frequent upper respiratory infection, 3 patients. At the operation both infundibular and valvular stenosis were present in all patients. Reconstruction of right ventricular outflow tract(RVOT) using Goretex was required in 7 patients, and transannular patching with Goretex in 2 pateints. Left pulmonary angioplasty with pericardium was done in 2 patients. No hospital deaths occurred. Four of 9 patients(44.4%) had postoperative low cardiac output syndrome, and postoperative bleeding in 5. One patient required reoperation due to residual ventricular septal defect and tricuspid regurgitation 3 months after the first operation. The mean follow-up period was 25 months, range 11 to 77 months. All was asymptomatic and in NYHA class I. We suggest that advanced age is not contraindication to surgery in tetralogy of Fallot, and tetralogy of Fallot in adults could be operated on due to low mortality.

• Journal of Chest Surgery
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• v.40 no.7 s.276
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• pp.473-479
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• 2007

Background: The Hetzer procedure for the correction of Ebstein's anomaly has the advantages of technical feasibility and incorporation of the atrialized right ventricle (RV) into the functional RV. Material and Method: We preformed a retrospective review of 11 patients with Ebstein's anomaly and they had undergone a Hetzer procedure between March 2002 and December 2006. Result: The median age at operation was 19.8 years (range: 6 months ${\sim}56$ years). There were 4 males and 7 females. All patients showed severe tricuspid regurgitation (TR) preoperatively, and arterial desaturation (<95%) was present in 3 patients. The original Hetzer technique was employed in 6 patients with the Carpentier type A anomaly. In the remaining 5 patients with the Carpentier type B or C anomalies, valve competence was restored at the level of the displaced tricuspid valve mechanism. Adjunct bidirectional cavo-pulmonary shunt, or one and a half ventricle repair strategy was employed for all the patients. The median follow-up was 8.6 months (range: $0.8{\sim}51.9$ months). There was no early or late death, and the immediate postoperative TR was trivial to mild in 8 patients. The median cardio-thoracic ratios on chest X-ray at the preoperative period and at postoperative 0, 1 and 6 months were 65%, 62%, 55% and 55%, respectively. Conclusion: The original or modified Hetzer procedure for Ebstein's anomaly shows excellent intermediate-term outcomes.

• 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.26 no.3
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• pp.196-203
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• 1993

Fourty-five cases of operation were performed for the correction of tricuspid regurgitation [TR] in Pusan National University Hospital between 1982 and 1991.The mean age of the patients was 32.6 years and female was dominant[M:F=1:2.2].Isolated tricuspid regurgitation was rare and 43 patients underwent concomitant other valvular operation including mitral valve replacement. Functional cause was in 39 cases and organic lesions were found in 6 cases. Operative methods were Kay annuloplasty[29], De Vega annuloplasty[12], and tricuspid valve replacement[4]. Ring annuloplasty was not performed. Operative mortality rate was 11.1%[5/45] and late mortality rate was 6.7%[2/30]. The tricuspid valve surgery itself was not a serious risk factor for hospital death and no heart block nor thrombosis was complicated. By echocardiogram early[within 30 days] and late [mean:4.9years] changes of postoperative TR were evaluated. De Vega annuloplasty seemed to bring better late result than Kay annuloplasty[p<0.05]. In four patients with late severe TR,previously replaced tissue valve degeneration[2], pulmonary hypertension[1] and rheumatic TR[1] were the possible causes. This experience suggests that De Vega annuloplasty can be a reliable method in the majority of patients with moderate-to-severe functional TR.

• Journal of Chest Surgery
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• v.41 no.5
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• pp.568-572
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• 2008

Background: Minimally invasive surgery is currently popular, but this has been applied very sparingly to cardiac surgery because of some limitations. Our study evaluated the safety and efficacy of atrial septal defect (ASD) closure through a video-assisted mini-thoracotomy. Material and Method: Fifteen patients were analyzed. Their mean age was $31{\pm}6$ years. The mean ASD size was $24{\pm}5mm$ and there were 3 cases of significant tricuspid regurgitation. The working window was made through the right 4th intercostal space via a $4{\sim}5cm$ inframammary skin incision, CPB was conducted with performing peripheral cannulation. After cardioplegic arrest, the ASDs were closed with a patch (n=11) or direct sutures (n=4), and the procedures were assisted by using a thoracoscope. There were 3 cases of tricuspid repair and 1 case of mitral valve repair. The mean CPB time and aortic occlusion time were $160{\pm}47\;and\;70{\pm}26 $minutes, respectively. Result: There was no mortality, but there were 3 minor complications (one pneumothorax, one wound dehiscence and one arrhythmia). The mean hospital stay was $5.9{\pm}1.8$ days. The mean follow-up duration was $10.7{\pm}6.4$ months. The follow-up echocardiogram noted no residual ASD or significant tricuspid regurgitation. Three patients suffered from pain or numbness. Conclusion: This study showed satisfactory clinical and cosmetic results. Although the operative time is still too long, more experience and specialized equipment would make this technique a good option for treating ASD.

• Journal of Chest Surgery
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• v.35 no.4
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• pp.303-306
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• 2002

Patients with severe Ebstein's anomaly showing in the neonatal period, represent progressive cardiac enlargement with pulmonary hypoplasia and functional pulmonary atresia with patent ductus alteriosus-dependent pulmonary circulation. Biventricular repair in these patients had been mostly unsuccessful except for Starnes' procedure that converts the anatomy to single ventricle physiology for Fontan procedure. A 4-days old male was admitted with the diagnosis of severe Ebstein's anomaly with anatomic pulmonary atresia and severe cardiac enlargement. He successfully underwent biventricular repair with vertical plication method of atrialized right ventricle, tricupid annuloplasty, transannular right ventricular outflow tract reconstrulltion, atrial septal defect patch closure with fenestration, and right atrial reduction angioplasty Postoperatively, cardiothoracic ratio was significantly reduced and mild tricuspid regurgitation was remnant in echocardiography. The patient is currently 10 months old and is fully active without restrictions.

• Journal of Chest Surgery
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• v.34 no.9
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• pp.680-685
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• 2001

Background: Tricuspid valve replacement is very rarely performed procedure and its long-term result is not yet satisfactory. Moreover, it is not well known whether bioprosthesis or mechanical prosthesis is the best selection for artificial valve. We reviewed 72 cases of tricuspid valve replacements in 71 patients between January 1989 and December 1998, trying to analyze the overall results and risk factors for mortality and morbidity. Material and Method: Average age of the patients at the time of operation was 42$\pm$13 years(range 16 to 65 years) and the sex ratio of male versus female was 32/39. Primary diagnosis consisted of 50 cases of aquired valvular heart disease and 18 cases of congenital heart disease, such as Ebstein’s anomaly. 4 cases had isolated tricuspid valve regurgitation. Implanted valves were 69 mechanical prosthesis and 3 bioprosthesis. Concomitant mitral or aortic valve replacements were performed in 50 cases. One patient received concomittant pulmonary valve replacement. Result: There were 7(9.72%) operative deaths and 7(13.0%) late deaths. Actuarial survival at 10 years was 59.2$\pm$7.2%. Prosthetic tricuspid valve thrombosis occurred 11 times in 5 patients. Reoperation for prosthetic tricuspid valve failure was performed in 1 patient. In this case, examination of the explanted prostheses showed that the tricuspid stenosis was the result of valve thrombosis. Among the 47 survivors, 46 patients(98%) were in functional class I or II. Conclusion: In our ten-year experience of tricuspid valve replacement, mortality and morbidity were satisfactory. Mechanical prosthesis in tricuspid position showed comparable clinical results as bioprosthesis.