• Journal of Chest Surgery
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• v.39 no.6 s.263
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• pp.434-439
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• 2006

Background: Deep hypothermic circulatory arrest during repair of aortic arch anomalies may induce neurological complications or myocardial injury. So we surveyed if the regional cerebral and myocardial perfusion might eliminate those potential side effects. Material and Method: From March 2000 to December 2004, 62 neonates or infants with aortic arch anomaly underwent one stage biventricular repair using the regional perfusion technique by single surgeon. Preoperative diagnosis of the arch anomaly consisted of coarctation (n=46), interruption of the aorta (n=12), hypoplastic left heart syndrome (n=2) and truncus areteriosus (n=2). Combined anomalies were ventricular septal defect (n=51), TAPVR (n=1), PAPVR (n=1) and atrioventricular septal defect (n=2). Arterial cannula was inserted at the innominate artery. Result: The mean regional perfusion time of brain was $28{\pm}10min$. Operative mortality rates was 0 (0/62). Late death was 1 (1/62) during $11{\pm}7$ months of follow-up. Neurologic complications consisted of transient chorea in 1 case. There was no reoperation associated with arch anolamy. Pulmonary complication associated with arch repair occurred in f case which was managed by aortopexy. Conclusion: One-tage rch repair using the regional profusion is safe and effective in minimizing the neurologic and myocardial complications.

• Journal of Chest Surgery
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• v.42 no.5
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• pp.576-587
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• 2009

Background: The up-regulation of the nitric oxide (NO)-cGMP pathway might be involved in the change of vascular reactivity in rats 3 days after they suffer acute myocardial infarction. However, the underlying mechanism for this has not been clarified. Material and Method: Acute myocardial infarction (AMI) was induced by occluding the left anterior descending coronary artery (LAD) for 30 min (Group AMI), whereas the sham-operated control rats were treated similarly without LAD occlusion (Group SHAM), The concentration-response relationships for phenylephrine (PE), KCl, acetylcholine (Ach) and sodium nitroprusside (SNP) were determined in the endothelium intact E(+) and endothelium denuded E(-) thoracic aortic rings from the rats 3 days after AMI or a SHAM operation. The concentration-response relationships of PE in the E(+) rings from the AMI rats were compared with those relationships in the rings pretreated with nitric oxide synthase (NOS) inhibitor $N{\omega}$-nitro-L-arginine methyl ester (L-NAME) or the cyclooxygenase inhibitor indomethacin. The plasma nitrite/nitrate concentrations were checked via a Griess reaction. The cyclic GMP content in the thoracic aortic rings was measured by radioimmunoassay and the endothelial nitric oxide synthase (eNOS) mRNA expression was assessed by real time PCR. Result: The mean infarct size (%) in the rats with AMI was $21.3{\pm}0.62%$. The heart rate and the systolic and diastolic blood pressure were not significantly changed in the AMI rats. The sensitivity of the contractile response to PE and KCl was significantly decreased in both the E(+) and E(-) aortic rings of the AMI group (p<0.05). L-NAME completely reversed these contractile responses whereas indomethacin did not (p<0.05). Moreover, the sensitivity of the relaxation response to Ach was also significantly decreased in the AMI group (p<0.05). The plasma nitrite and nitrate content (p<0.05), the basal cGMP content (p<0.05) and the eNOS mRNA expression (p=0.056) in the AMI rats were increased as compared with the SHAM group. Conclusion: Our findings indicate that the increased eNOS activity and the up-regulation of the NO-cGMP pathway can be attributed to the decreased contractile or relaxation response in the rat thoracic aorta 3 days after AMI.

• Journal of Chest Surgery
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• v.29 no.11
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• pp.1218-1222
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• 1996

The reported incidence of postcardiotomy cardiogenic shock not responding to conventional therapy is still 0.1 to 0.8%. For this group of patients, more aggressive form of circulatory support must be employed. Centrifugal pumps are a ventricular assist device most commonly used on this purpose, due to low cost and easy availability. Currently, however, clinical experience of centrifugal pumps as a ventricular assist device is rarely reported in Korea. From January 1992 to January 1996, 2986 patients underwent cardiac operations on cardiopulmonary bypass at Seoul National University Hospital. Refractory postcardiotomy cardiac failure requring ventricular support with a Biomedicus centrifugal pump developed in ten of these patients. There were eight men and two women, ranged in age from nine years to 77 years with a mean of 50$\pm$20 years. The primary surgical procedures consisted of isolated coronary revascularization in four patients, combined coronary revascularization and aortic valve replacement in two, aortic dissection repair in two, pulmonary embolectomy in one, and heart transplantation in one. Of the ten patients, five had left ventricular assistance, one had right ventricular assistance, and four had biventricular assistance. Duration of ventricular assistance ranged from 24 to 175 hours, with a mean of 76$\pm$51 hours. Seven patients were weaned from ventricular assistance, and four of them discharged. The causes of death for nonsurvivors were progressive cardiac failure in two patients and multiorgan failure, intractable ventricular fibrillation, irreversible brain injury, and mechanical problem, respectively, in the other four. Survival was not predicted by time on cardiopulmonary bypass, aortic cross-clamp time, or duration of ventricular support. Major complications included bleeding(7), renal failure(6), infection(3) and neurologic complication(2). These results indicate that a centrifugal pump can provide reasonably satisfactory short-term circulatory support.

• Journal of Chest Surgery
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• v.39 no.10 s.267
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• pp.739-748
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• 2006

Background: The purpose of this study is to ascertain the neuroprotective effect of cyclosporin A on the 25-min surgical ischemia model in the spinal cords of rabbits with neuropathological correlation and histoimmunochemical analyses, Material and Method: Thirty-two New Zealand white rabbits were randomly divided into four groups: Rabbits were randomly divided into four groups: the control 12 group (n=8), the control 17 group (n=8), the cyclosporin Cs2 group (n=8), and the cyclosporin Cs7 group (n=8). The 12 group underwent a 25-min aortic cross- clamp without intervention and were sacrificed on the 2nd day postoperatively, while the 17 group underwent a 25- min of aortic cross-clamp without intervention and were sacrificed on the 7th day postoperatively. The Cs2 group received cyclosporin A (25 mg/kg) intravenously 15 min after the 25-min cross-clamp and were sacrificed on the End day postoperatively, while the Cs7 group received cyclosporin A (25 mg/kg) intravenously 15 min after the 25-min cross-clamp and were sacrificed on the 7th day postoperatively. The rabbits underwent 25-min surgical aortic cross-clamp. Neurologic functions were evaluated on the 2nd day and 7th postoperative day using Tarlov scoring system. After scoring neurologic function, all rabbits were sacrificed for histopathologic observation. Result: All rabbits survived the experimental procedure. The values of Tarlov score did not show any differences between the control and cyclosporin groups on the 2nd day. The scores of group Cs7 ($2.75{\pm}0.89$) were significantly higher than those of group 17 ($1.25{\pm}1.39$) on the 7th day (p<0,05). On the histologic exanminations, specimens of the spinal cord showed necrosis and apoptosis. The pathologic scores of group Cs7 ($1,0{\pm}0.53$) was less than those of group 17 ($2.13{\pm}1.36$, p<0.05). TUNEL staing showed apoptosis of the specimen in group 12 and Cs2 but there was no stastically significant difference between groups on the score. There were more overexpression of HSP70 and nNOS in cyclosporine group than in control group. Conclusion: We think that cyclosporin A may decrease neuronal cell death with induced upregulation of HSP70 against 25-min ischemia of the spiral cord in the rabbit.

• Journal of Chest Surgery
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• v.30 no.10
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• pp.973-978
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• 1997

We reviewed data of 64 patients who underwent reoperation because of prosthetic valve malfunction from January 1991 to December 1995. The indications for reoperation were prosthetic valve failure(primary tissue failure: 53 patients, 82.8%), prosthetic valve thrombosis(6 patients, 9.4%), paravalvular leak(3 patients, 4.7%), prosthetic valve endocarditis(2 patients, 3.6%). Prosthetic valve failure developed most frequently in mitral portion(40 patients, 75%), prosthetic valve thrombosis also in mitral portion(4 patients, 67%), paravalvular leak significantly in aortic portio (3 patients, 100%). Explant period was longest in prosthetic valve failure(mean 107.4 $\pm$ 24.6 months), shortest in prosthetic valve endocarditis with prosthetic valve thrombosis(1 patient, 1 month). Mean explant period, defined as from first valve replacement operation to redo-valve replacement operatopn, was 109.2$\pm$ 10.7 months in mitral portion, 97.8$\pm$ 10.4 months in aortic portion, 109.5$\pm$ 10.4 months in total. Overall hospital mortality was 9.38%. The most common cause of death was the low cardiac output(4 patients), other causes were bleeding(1 patient), CNS injury(1 patient). Preoperative NYHA class IV(P=0.011), emergency operation(P=0.011), prosthetic valve endocarditis(P=0.001) were the independent risk factors, but age, sex, explant period, ACC time, double valve replacement, valve position, second reoperation did not appear to be significant risk factors. Mean follow up period was 28.8 $\pm$ 17.8 months. Actuarial survival at 3 year was 92.0$\pm$6.2%, 2 year event-free survival w s 84.3$\pm$6.1%. We propose that patients undergoing reoperation because of prosthetic valve failure are carfully controlled and selected in regarding to above mentioned risk factors NYHA class IV, emergency operation, prosthetic valve endocarditis in preoperative state. About other risk factors possible, there is necessary of following study.

• Journal of Chest Surgery
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• v.31 no.2
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• pp.125-133
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• 1998

This study was designed to identify the efficiency of serum troponin-T(s-TnT) level as a diagnostic indicator for the perioperative myocardial damage with open heart surgery(OHS) and to compare with the conventional myocardial enzyme tests such as isoenzyme fraction of creatine kinase(% CK-MB) and isoenzyme ratio of lactate dehydrogenase(LDH1/LDH2 ratio). The study was performed on 30 adult patients who underwent OHS from Jan. 1996 to June 1996 at Inje University Pusan Paik Hospital, and they were divided into two groups accor- ding to aortic clamping time(ACT) duration : group I(ACT＜60 minutes, n=15); group II (ACT＞60 minutes, n=15). S-TnT, % CK-MB, and LDH1/LDH2 ratio were measured in serial blood samples from all subjected patients. The results were obtained as follows. 1. In both groups, s-TnT concentrations increased gradually during OHS and elevated significantly at CPB-10(p＜0.001). The peak level was noticed at POD 1 in group I(1.10 $\pm$0.19 ng/ml), whereas, at CPB-off in group II(1.88$\pm$0.42 ng/ml). The elevated levels remained until POD 7 in both groups. 2. %CK-MB was risen significantly with the initiation of operations(p＜0.001) and the peak levels were noticed at CPB-off in both groups(7.14$\pm$0.86% in group I, 10.69$\pm$1.27% in group II). Thereafter, these levels returned to normal values at POD 3. 3. There were no significant changes in the values of LDH1/LDH2 ratio during and after OHS compared with the control levels(p＞0.05). 4. The serial changes of s-TnT were relatively well correlated with those of changes of % CK-MB(r=0.64, p＜0.05). 5. The serial s-TnT levels were significantly higher in group II than group I from B-ACR to POD 1(p＜0.05), suggesting that duration of aortic clamping time was a major factor concerned with perioperative myocardial injury. In conclusion, measurement of s-TnT is a very useful indicator in assessing the myocardial cell damage and therefore it is expected that serial checking and evaluation of the s-TnT is very available for identification of the perioperative myocardial damage and for postoperative cares in patients with OHS.

• Journal of Chest Surgery
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• v.44 no.2
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• pp.115-122
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• 2011

Background: The intramural coronary artery has been known as a risk factor for early death after an arterial switch operation (ASO). We reviewed the morphological characteristics and evaluated the early and mid-term results of ASO for patients with an intramural coronary artery. Materials and Methods: From March 1994 to September 15th 2010, 158 patients underwent ASO at Dong-A and Pusan National University Hospitals for repair of transposition of the great arteries and double outlet right ventricle. Among these patients, 14 patients (8.9%) had an intramural coronary artery. Mean age at operation was $13.4{\pm}10.2$ days (4 to 39 days) and mean body weight was $3.48{\pm}0.33$ kg (2.88 to 3.88 kg). All patients except one were male. Eight patients had TGA/IVS and 4 patients had an aortic arch anomaly. Two patients (14.3%) had side-by-side great artery relation, of whom one had an intramural right coronary artery and the other had an intramural left anterior descending coronary artery. Twelve patients had anterior-posterior relation, all of whom had an intramural left coronary artery (LCA). The aortocoronary flap technique was used in coronary transfer in 8 patients, of whom one patient required a switch to the individual coronary button technique 2 days after operation because of myocardial ischemia. An individual coronary button implantation technique was adopted in 6, of whom 2 patients required left subclavian artery free graft to LCA during the same operation due to LCA injury during coronary button mobilization and LCA torsion. Results: There was 1 operative death (7.1%), which occurred in the first patient in our series. This patient underwent an aortocoronary flap procedure for coronary transfer combining aortic arch repair. Overall operative mortality for 144 patients without an intramural coronary artery was 13.2% (19/144). There was no statistical difference in operative mortality between the patients with and without an intramural coronary artery (p>0.1). There was no late death. The mean follow-up duration was $52.1{\pm}43.0$ months (0.5 to 132 months). One patient who had a subclavian artery free graft required LCA stenting 6.5 years after surgery for LCA anastomotic site stenosis. No other surviving patient needed any intervention for coronary problems. All patients had normal ventricular function at latest echocardiography and were in NYHA class 1. Conclusion: The arterial switch operation in Transposition of Great Arteries or Double Outlet Right Ventricle patients with intramural coronary can be performed with low mortality; however, there is a high incidence of intraoperative or postoperative coronary problems, which can be managed with conversion to the individual coronary button technique and a bypass procedure using a left subclavian free graft. Both aortocoronary flap and individual coronary button implantation techniques for coronary transfer have excellent mid-term results.

• Journal of Chest Surgery
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• v.31 no.9
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• pp.837-844
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• 1998

Background: Adenosine is secreted by myocardial cells during myocardial ischemia or hypoxia. It has many beneficial effects on arrhythmias, myocardial ischemia, and reperfusion ischemia. Although many investigators have demonstrated that cardioplegia that includes adenosine shows protective effects in myocardial ischemia or reperfusion injury, reports of the optimal dose of adenosine in cardioplegic solutions vary. We reported the results of beneficial effects of single dosage(0.75 mg/Kg/min) adenosine by use of self-made Langendorff system. But it is uncertain that dosage was optimal. The objective of this study is to determine the optimal dose of adenosine in cardioplegic solutions. Material and Method: We used a self-made Langendorff system to evaluate the myocardial protective effect. Isolated rat hearts were subjected to 90 minutes of deep hypothermic arrest(15$^{\circ}C$) with modified St. Thomas' Hospital cardioplegia including adenosine. Myocardial adenosine levels were augmented during ischemia by providing exogenous adenosine in the cardioplegia. Three groups of hearts were studied: (1) group 1 (n=10) : adenosine - 0.5 mg/Kg/min, (2) group 2(n=10): adenosine -0.75 mg/Kg/min, (3) group 3 (n=10) : adenosine -1 mg/Kg/min. Result: Group 3 resulted in a significantly rapid arrest time of the heart beat(p<0.05) but significantly slow recovery time of the heart beat after reperfusion(p<0.05) compared to groups 1 and 2. Group 2 showed a better percentage of recovery(p<0.05) in systolic aortic pressure, aortic overflow volume, coronary flow volume, and cardiac output compared to groups 1 and 3. Group 1 showed a a better percentage of recovery(p<0.05) in the heart rate compared to the others. In biochemical study of drained reperfusates, CPK and lactic acid levels did not show significant differences in all of the groups. Conclusion: We concluded that group 2 [adenosine(0.75 mg/Kg/min) added to cardioplegia] has better recovery effects after reperfusion in myocardial ischemia and is the most appropriate dosage compared to group 1 and 3.

• Journal of Chest Surgery
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• v.13 no.3
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• pp.174-185
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• 1980

It was my great nohour that I can be exposed to such plenty materials of the coronary bypass surgery. Here, I am summarizing the xoronary bypass surgery, clinically. The material is serial 101 patients who underwent coronary bypass surgery between July 17, 1979 to November 30, 1979 in Shadyside Hospital, University of Pittsburgh. 1. Incidence of the Atherosclerosis is frequent in white, male, fiftieth who are living in industrialized country. It has been told the etiologic factor of the atherosclerosis is hereditary, hyperlipidemia, hypertension, smoking, drinking, diabetes, obesity, stress, etc. 2. The main and most frequent complication of the coronary atherosclerosis is angina pectoris. Angina pectoris is the chief cause of coronary bypass surgery and the other causes of coronary bypass surgery are obstruction of the left main coronary artery, unstable angina, papillary muscle disruption or malfunction and ventricular aneurysm complicated by coronary artery disease. 3. The preoperative clinical laboratory examination shows abnormal elevation of plasma lipid in 82 patint, plasma glucose in 40 patient, total CPK-MB in 24 patient stotal LDH in 22 patient out of 101 patient. 4. Abnormal ECG findings in preoperative examine were 29.1% myocardial infarction, 25.8% ischemia and injury, 14.6T conduction defect. 5. Also we had done Echocardiography, Tread Mill Test, Myocardial Scanning, Vectorcardiography and Lung function test to get adjunctive benefit in prediction of prognosis and accurate diagnosis. 6. The frequency of coronary atherosclerosis in main coronary arteries were LAD, RCA and Circumflex in that order. 7. The patients' main complaints which were became as etiologic factor undergoing coronary bypass surgery were angina, dyspnea, diaphoresis, dizziness, nausea and etc. 8. For the coronary bypass surgery, we used cardiopulmonary bypass machine, non-blood, diluting prime, cold cardioplegic solution and moderate cooling for the myocardial protection. 9. We got the grafted veins from Saphenous and Cephalic vein. Reversed and anastomosed between aorta and distal coronary A. using 5-0 and 7-0 prolene continuous suture. Occasionally we used internal mammary A. as an arterial blood source and anastomosed to the distal coronary A. and to side fashion. 10. The average cardiopulmonary bypass time for every graft was 43.9 min. and aortic clamp time was 23 minute. We could Rt. coronary A. bypass surgery only by stand by the cardiopulmonary machine and in the state of pumping heart. 11. Rates by the noumbers of graft were as follow : 21.8% single, 33.7% double, 26.7% triple, 13.9% quadruple, 3% quintuple and 1% was sixtuple graft. 12. combined procedures with coronary bypass surgery were 6% aneurysmectomy, 3% AVR, 1% MVR, 13% pacer implantation and 1% intraaortic ballon setting. 13. We could see the complete abolition of anginal pain after operation in 68% of patient, improvement 25.8%, no change in 3.1%, and there was unknown in 3%. 14. There were 4% immediate postoperative deaths, 13.5% some kinds of heart complication, 51.3% lung complications 33.3% pleural complications as prognosis.

• Korean Journal of Head & Neck Oncology
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• v.22 no.1
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• pp.3-7
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• 2006

Purpose: The nonrecurrent laryngeal nerve(NRLN) is a rare anomaly that is associated with the developmentally aberrant subclavian artery. Although rare on the right side and exceptional on the left, an aberrant nonrecurrent pathway for RLN represents a major surgical risk. Three course variations of right NRLN can be distinguished: descending(type I) , horizontal(type II), ascending(type III). This study is performed to characterize the variations of NRLN, associated vascular anomaly, and proper surgical methods for preventing nerve damage. Materials and Methods: Between January 1998 and March 2006 3,381 thyroidectomy were performed at our institution, and during these operations a nonrecurrent laryngeal nerve was observed in 13 cases (0.38%). There were 1 men and 12 women with a median age of 48 years(range 28-57). All of them are identified on the right side. Results: In all cases, there were no clinical symptoms observed preoperatively. The nerve anomaly was diagnosed preoperatively in only one case. There were type I variations of right RLN in 2 cases and type II variations in 11 cases. The retroesophageal aberrant right subcalvian artery; no innominate(brachiocephalic) artery was found and the right common carotic artery was arising directly from the aortic arch, was seen in 12 cases. A vocal cord palaysis caused by NRLN damage during operation was observed in one patient(7.6%) , where the nerve was close to the superior thyroid artery. No other complications were noted. Conclusion: It can be possible to predict NRLN from signs associated with the vascular anomaly; clinical symptoms or imaging studies. When an vascular anomaly is not detected preoperatively, overlooking possibility of NRLN may lead to severe operative morbidity. Hence, It is most important to identify all the thyroid structures carefully during thyroid surgery and to be aware of the possibility of anatomic variations of RLN.