• Journal of Chest Surgery
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• v.30 no.3
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• pp.282-286
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• 1997

In the era of coronary artery bypass grafting, the intraaortic balloon pump (IABP) is more widely used and its indication has been ex anded. We perf'orbed retrospective clinical analysis on the patients who have received IABP pre andfor postoperatively during the course of CABG. From January 1981 to June 1995, total 322 patients have received CABG at the Seoul National University Hospital and among them 50 patients (15.5%) were supported by IABP during the course of the operation. The mean age at the time. of the operation was 57.2 years (39∼ 75 years) and the male to female ratio was 33 : 17. The preoperative diagnosis was unstable angina in 33 (66%), stable angina in 7 (14%) and postinfarct angina in 8 patients(16%). As for the indications of the IABP, there were 13 cases(26%) with left main disease, 13 (26%) with class IV angina, 12 (24%) with difficulty in CPB weaning, 6 (12%) with postinfarct angina and 3 (6%) with severe LV dysfunction. In the remaining 3 cases, one patient was operated on after PTCA failure in emergency basis, another was a patient with AMI, and the other was one who had postoperative low c rdiac output syndrome. All IABPS were introduced via femoral artery and among them 45 cases (90%) percutaneously. The mean postoperative assist time was 22.3 hours (0.5 ∼ 168 hours) and IABP could be removed within 48 hours in most of them (44150). The operative mortality was 6.1% (3 cases) and postoperative morbidity was only one with lower extremity ischemia. The more general application of the IABP during the course of the CABG ,especially in patients with high preoperative risk factors or difficulty in CPB weaning is a good measure of protecting and recovering myocardial function with minimal risk.

• Clinical and Experimental Pediatrics
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• v.49 no.10
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• pp.1093-1099
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• 2006

Purpose : Homocysteine is a strong and independent risk factor for cardiovascular disease. The deleterious effects of homocysteine included endothelial dysfunction, arterial intimal-medial thickening, wall stiffness and procoagulant activity. However, the precise mechanism responsible for homocysteine release in children with coronary artery disease is still unknown. The purpose of this study was to investigate serum homocysteine and tumor necrosis $factor(TNF)-{\alpha}$ levels and identify whether these levels had any association with the development of coronary artery lesions in Kawasaki disease(KD). Methods : Serum homocysteine and $TNF-{\alpha}$ levels were measured in 24 KD patients(group 1, eight patients with normal coronary artery; group 2, 16 patients with coronary artery lesions) and 21 controls(group 3, 10 afebrile controls; group 4, 11 febrile controls). Blood samples were drawn from each study group before and after intravenous immunoglobulin(IVIG) therapy and in the convalescent stage. Results : The homocysteine levels before IVIG therapy were significantly higher in group 1 than in group 3, and in group 2 than in group 3 and 4. The $TNF-{\alpha}$ levels before IVIG therapy were significantly higher in group 2 than group 3 and 4. Serum homocysteine and $TNF-{\alpha}$ levels were highest in group 2 before IVIG therapy. In the acute KD patients, serum homocysteine levels correlated significantly with $TNF-{\alpha}$ levels. Conclusion : The increased serum homocysteine levels in the acute stage increase the susceptibility to coronary arterial lesions in KD. $TNF-{\alpha}$ may also play an important role in the formation of coronary arterial lesions in KD.

• Clinical and Experimental Pediatrics
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• v.49 no.4
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• pp.368-374
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• 2006

Purpose : The prevalence of obesity in children is increasing rapidly. Epidemiologic studies suggest that obesity induced atherosclerosis may start in childhood. We investigated whether obese children show early abnormalities of the arterial wall and endothelial dysfunction. Methods : Thirty-eight obese children(14-16 years old of age, male, body mass index $29.40{\pm}3.18kg/m^2$) and forty-five age and sex-matched healthy control children(body mass index $18.43{\pm}1.01kg/m^2$) were enrolled. Their carotid artery intima-media thickness(IMT) and brachial artery flowmediated dilation(FMD) response were measured by high-quality ultrasound system, and compliance, distensibility, stiffness index, incremental elastic modulus and wall stress were calculated by equation. In addition, we looked at the relations between these arterial features and metabolic cardiovascular risk factors. Results : The obese children had significantly increased IMT($0.52{\pm}0.09mm$ vs $0.40{\pm}0.07mm$, P< 0.001) and markedly impaired FMD($7.35{\pm}7.78$ percent vs $20.34{\pm}16.81$ percent, P<0.001) than the healthy controls. But the compliance and distensibility were lower, and the stiffness index, incremental elastic modules and wall stress were higher in the obese group than the control group, but not statistically significantly. Body mass index was highly associated with increased IMT(r=0.612, P<0.001) and reduced FMD(r=-0.414, P<0.001). Conclusion : We showed the deleterious effect of child obesity on both early functional and structural atherosclerotic markers. The ultrasonic findings will be used for screening and follow up markers to identify high-risk patients among obese children.

• Journal of Chest Surgery
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• v.32 no.4
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• pp.358-363
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• 1999

Background: Recently, many cardiac centers have been using aprotinin to reduce operative bleeding in cardiac operations using cardiopulmonary bypass. A variety of reports have confirmed the effectiveness of the drug in cardiac operations. In addition to the operations which could be considered to cause severe operative bleeding such as redo operation, long cardiopulmonary bypass operation and etc, the use of aprotinin is increasing in the field of primary cardiac operations. Varying doses of regimen have been introduced since the first report by Royston et al, and also various opinions on the effectiveness and safeness of the each regimen have been reported. We reviewed our own experience of the full dose aprotinin regimen(Hammersmith regimen) retrospectively. Material and Method: From October 1994 to February 1998, 40 cases of cardiac operative patients were randomized into two groups: aprotinin group(20 patients) which received a full dose aprotinin regimen and control group(20 patients) which did not receive aprotinin. To evaluate the degree of bleeding decrease, we analysed and compared the amount of postoperative 6 hours and 24 hours bleeding in the each group. To confirm the renal dysfunction, we measured the postoperative creatinine level. Result: In the amount of postoperative 6 hours bleeding, a statistically significant bleeding decrease was demonstrated in the aprotinin group compared to the control group(aprotinin group: 186${\pm}$40cc, control group:409${\pm}$69cc, P=0.010). Similar result was observed in the postoperative 24 hours(aprotinin group:317${\pm}$53cc, control group: 671${\pm}$133cc, P=0.024). Conclusion: We concluded that full dose regimen of aprotinin can remarkably reduce postoperative bleeding in cardiac operations without significant renal dysfunctions.

• Journal of Chest Surgery
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• v.35 no.5
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• pp.356-364
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• 2002

Background: This study was undertaken to investigate the outcome of composite graft aortic root replacement using coronary button reimplantation technique for the treatment of aneurysms of the ascending aorta involving the aortic root. Material and Method: Between April 1995 and September 2001, 54 patients having aortic root replacement with a composite valve graft using direct coronary button reimplantation were reviewed retrospectively. Left ventricular dysfunction was present in 14 patients(25.9%), aortic regurgitation in 48(89%), and Marfan's syndrome in 17(31.5%). The indications for operation were annuloaortic ectasia in 29 patients(53.7%), aortic dissection in 11(20.4%), aneurysms of the ascending aorta involving aortic root in 12(22.2%), and aortitis in 2(3.7%). Six patients(11.1%) had previous cardiac or ascending aortic operations. Concomitant procedures were arch replacement in 21 patients(38.9%), coronary artery bypass graft in 7(13%), mitral valve repair or replacement in 4(7.4%), and others in 6. The mean time of circulatory arrest, total bypass, and aortic crossclamp were 18 $\pm$ 9 minutes, 177 $\pm$ 42 minutes, and 127 $\pm$ 31 minutes, respectively. Result: There was 1 early death(1.9%). Mean follow-up was 24.6$\pm$ 19.5 months. There were two late deaths(3.8%) including one death due to the traumatic cerebral hemorrhage. The Kaplan-Meier survival rate was 98.0 $\pm$ 2.0% and 93.1 $\pm$ 5.1% at 1 and 6 years, respectively. Two patients required reoperation owing to a false aneurysm at the root anastomosis site and a malfunction of prosthetic aortic valve(3.8%). Staged operation for dissection of the remaining thoracoabdominal aorta was performed in 1 patient. The freedom rate from reoperation was 97.8 $\pm$ 2.0% and 65.3 $\pm$ 26.7% at 1 and 6 years, respectively.

• Journal of Chest Surgery
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• v.35 no.2
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• pp.102-112
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• 2002

This study was undertaken to analyze the outcome of composite valve graftreplacement(CVGR) for the treatment of aneurysms of the ascending aorta involving the aortic root. Material and Method: Between April 1995 and June 2001, 56 patients had replacement of the ascending aorta and aortic root with a composite graft valve and were reviewed retrospectively. Aortic regurgitation was present in 50 patients(89%), Marfan's syndrome in 18 patients(32%), and bicuspid aortic valve in 7(12.5%). The indications for operation were annuloaortic ectasia(AAE) in 30 patients(53.6%), aortic dissection in 13(23.2%), aneurysms of the ascending aorta involving aortic root in 11(19.6%), and aortitis in 2(3.6%). Cardiogenic shock due to the aortic rupture was present in 2 patients. Nine patients(16%) had previous operations on the ascending aorta or open heart surgery. The operative techniques used for CVGR were the aortic button technique in 51 patients(91%), the modified Cabrol technique in 4, and the classic Bentall technique in 1. The concomitant procedures were aortic arch replacement in 24 patients(43%), coronary artery bypass graft in 8(14.3%), mitral valve repair in 2, redo mitral valve replacement in 1, and the others in 7 The mean time of circulatory arrest, total bypass, and aortic crossclamp were 21$\pm$14 minutes, 186$\pm$68 minutes, and 132$\pm$42 minutes, respectively. Result: Early mortality was 1.8%(1/56). The postoperative complications were left ventricular dysfunction in 16 patients(28.6%), reoperation for bleeding in 7(12.5%), pericardial effusion in 2, and the others in 7. Fifty-three patients out of 55 hospital survivors were followed up for a mean of 23.2 $\pm$ 18.7 months(1-75 months). There were two late deaths(3.8%) including one death due to the traumatic cerebral hemorrhage, and CVGR-related late mortality was 1.9%. The 1- and 6-year actuarial survival was 98.1$\pm$1.9% and 93.2$\pm$5.1%, respectively. Two patients required reoperation for complication of CYGR(3.8%) and two other patients required subsequent operations for dissection of the remaining thoracoabdominal aorta. The 1- and 6-year actuarial freedom from reoperation was 97.8$\pm$2.0% and 65.3$\pm$26.7%, respectively.

• Journal of Chest Surgery
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• v.36 no.4
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• pp.242-254
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• 2003

Most of the studies conducted have investigated the beneficial effects of ischemic preconditioning on normothermic myocardial ischemia. However, the effect of preconditioning could be attenuated through the use of multidose cold cardioplegia as practiced in contemporary clinical heart surgical procedures. The purpose of this study was to investigate whether preconditioning improves postischemic cardiac function in a model of 25℃ moderate hypothermic ischemic heart induced by cold cardioplegia in isolated rat hearts. Material and Method: The isolated Sprague-Dawley rat hearts were randomly assigned to four groups. All hearts were perfused at 37℃ for 20 minutes with Krebs-Henseleit solution before the baseline hemodynamic data were obtained. Group 1 consisted of preconditioned hearts that received 3 minutes of global ischemic preconditioning at 37℃, followed by 5 minutes of reperfusion before 120 minutes of cardioplegic arrest (n=6). Cold (4℃) St. Thomas Hospital cardioplegia solution was infused to induce cardioplegic arrest. Maintaining the heart at 25℃, infusion of the cardioplegia solution was repeated every 20 minutes throughout the 120 minutes of ischemic period. Group 2 consisted of control hearts that underwent no manipulations between the periods of equilibrium and 120 minutes of cardioplegic arrest (n=6). After 2 hours of cardioplegic arrest, Krebs solution was infused and hemodynamic data were obtained for 30 minutes (group 1, 2: cold cardioplegia group). Group 3 received two episodes of ischemic preconditioning before 30 min of 37℃ normothermic ischemia and 30 minutes of reperfusion (n=6). Group 4 served as ischemic controls for group 3 (group 3, 4: warm ischemia group). Result: Preconditioning did not influence parameters such as left ventricular systolic pressure (LVSP), left ventricular end-diastolic pressure (LVEDP), rate-pressure product (RPP) and left ventricular dp/dt (LV dp/dt) in the cold cardioplegia group. (p=NS) However, preconditioning before warm ischemia attenuated the ischemia induced cardiac dysfunction, improving the LVSP, LVEDP, RPP, and LVdp/dt. Less leakage of CPK and LDH were observed in the ischemic preconditioning group compared to the control group (p<0.05). Conclusion: Ischemic preconditioning improved postischemic cardiac function after warm ischemia, but did not protect cold cardioplegic hearts.

• Journal of Chest Surgery
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• v.37 no.8
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• pp.644-651
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• 2004

Background: Refractory atrial arrhythmias in patients late after the Fontan operation result in significant morbidity and mortality. We reviewed our experience with arrhythmia surgery in patients who had Fontan operation. Material and Method: Between July 1986 and December 2003, 275 early survivors after Fontan operation were reviewed. Fourteen patients underwent. arrhythmia surgery at reoperation after Fontan operation, and mean age at reoperation was 16.8$\pm$7.1 (range: 4.5 ∼ 30.6) years. Mechanisms of arrhythmia included atrial flutter in 8 patients, and atrial fibrillation in 2. Arrhythmia surgery has evolved from isthmus cryoablation in 12 patients to right-sided maze in 2 patients. Thirty-two patients. underwent prophylactic isthmus cryoablation concomitantly at initial Fontan operation. Result: Postoperative arrhythmias occurred in 68 patients (24.7%) among 275. There was no early and late mortality after the arrhythmia surgery. After redo Fontan operation, all patients maintained normal sinus rhythm. Atrial flutter recurred in 3 patients who had sinus conversion with medication and 7 required permanent pacemakers with a mean follow-up of 26.5$\pm$29.1 (range: 2 ∼ 73) months. All patients have improved to NYHA class I or II. After prophylactic cryoablation at initial Fontan operation, 29 patients (90.6%) had sinus rhythm, 1 patient had junctional tachycardia, 1 patient had sinus nodal dysfunction, and 1 patient had AV block with a mean follow-up of 51.3$\pm$19.8 (range: 4∼80) months. Conclusion: Redo Fontan operation, and concomitant arrhythmia surgery reduced atrial arrhythmias and improved NYHA functional classification.

• Journal of Chest Surgery
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• v.36 no.5
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• pp.242-254
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• 2003

Background: Most of the studies conducted have investigated the beneficial effects of ischemic preconditioning on normothermic myocardial ischemia. However, the effect of preconditioning could be attenuated through the use of multidose cold cardioplegia as practiced in contemporary clinical heart surgical procedures. The purpose of this study was to investigate whether preconditioning improves postischemic cardiac function in a model of $25^{\circ}C$ moderate hypothermic ischemic heart induced by cold cardioplegia in isolated rat hearts. Material and Method: The isolated Sprague-Dawley rat hearts were randomly assigned to four groups All hearts were perfused at 37$^{\circ}C$ for 20 minutes with Krebs-Henseleit solution before the baseline hemodynamic data were obtained, Group 1 consisted of preconditioned hearts that received 3 minutes of global ischemic preconditioning at 37$^{\circ}C$, followed by 5 minutes of reperfusion before 120 minutes of cardioplegic arrest (n=6). Cold (4$^{\circ}C$) St. Thomas Hospital cardioplegia solution was infused to induce cardioplegic arrest. Maintaining the heart at $25^{\circ}C$, infusion of the cardioplegia solution was repeated every 20 minutes throughout the 120 minutes of ischemic period. Group 2 consisted of control hearts that underwent no manipulations between the periods of equilibrium and 120 minutes of cardioplegic arrest (n=6). After 2 hours of cardioplegic arrest, Krebs solution was infused and hemodynamic data were obtained for 30 minuts (group 1, 2: cold cardioplegia group). Group 3 received two episodes of ischemic preconditioning before 30 min of 37$^{\circ}C$ normothermic ischemia and 30 minutes of reperfusion (n=6) Group 4 soloed as ischemic controls for group 3 (group 3, 4: warm ischemia group). Result: Preconditioning did not influence parameters such as left ventricular systolic pressure (LVSP), left ventricular end-diastolic pressure (LVEDP), rate-pressure product (RPP) and left ventricular dp/dt (LV dp/dt) in the cold cardioplegia group. (p=NS) However, preconditioning before warm ischemia attenuated the ischemia induced cardiac dysfunction, Improving the LVSP, LVEDP, RPP, and LV dp/dt. Less leakage of CPK and LDH were observed in the ischemic preconditioning group compared to the control group (p<0.05). Conclusion: Ischemic preconditioning improved postischemic cardiac function after warm ischemia, but did not protect cold cardioplegic hearts.

• Journal of Chest Surgery
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• v.35 no.3
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• pp.171-176
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• 2002

Background: Blood-foreign interaction cause activation of coagulation and inflammatory process that may lead to multiorgan dysfunction and determine the surgical outcomes. Of the methods for assessing the biocompatibility, the platelet adhesion study is considered as the most valuable evaluation step in blood-foreign interaction. As the most studies have used in-vitro or ex-vivo conditions, we have developed a technique of quantification for platelet adhesion on the blood contact surface by using in-vivo injection of radioactive platelets. Material and Method: A coupled bypass circuit was designed to connect the proximal and descending thoracic aorta in 6 piglets(20∼25 Kg). One side of the circuit tube was consisted of a heparin coated PVC tube(10mm in ID, n=6, Experimental group), and the other, a non-heparin coated PVC tube(10mm in ID, n=6, Control group). After cannulation, the blood was circulated through the circuit for 2 hours. Platelet concentrate was prepared from homologous pig blood 24 hours before the experiment. The platelet concentrate was incubated with Tc-99m-HMPAO for 30 min and then centrifuged for 10 min. The supernatant was discarded and the radio-labeling efficacy was measured. The radio-labeled platelet concentrate was mixed with the autologous plasma to make the volume 5 ml, and the mixture was injected intravenously into the experimental animal. After 2 hour circulation, 5 pieces of the specimen(10mm in length each) were obtained from each PVC tube. The radioisotopes were counted with a gamma counter(Cobra ll, Packard, USA), and the ratio of radioisotope count was compared between the control and experimental group. Result: The radioisotope count number was 537.3221.1 Ci/min in the control group and 311.1 184.5 Ci/min in the experimental group(p=0.0104). The ratio between the groups was 1 to 0.58 (p=0.004). Conclusion: In vivo quantification using technetium-99m-HMPAO labeled platelets is simple and reproducible in evaluating platelet adhesion on a foreign surface. We suggest this technique to be a useful tool for blood compatibility test.