• Journal of Chest Surgery
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• v.30 no.7
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• pp.647-655
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• 1997

We evaluated the feasibility and safety of this method by reviewing the early outcome of the patients who underwent coronary artery bypass grafting(CABG) utili ing parallel sequential anastomoses with saphenous vein grafts, comparing with the outcome of the patients revascularized with grafts having only single distal anastomosis. During the one-year period of 1995, a total of 79 patients underwent isolated CABG, among whom 39 patients with sequential vein grafts(sequential group) and 40 patients without sequential grafts(non-sequential group). There was no difference between the two groups in terms of preoperative status, except in the extent of the coronary disease; 87.2% of the sequential group and 45.0% of the non-sequential group had left main andlor triple vessel involvement. 318 distal coronary anastomoses were done; 198 for the sequential group(5.1/patient) and 120 for the non-sequential group(3.0/patient). In the sequential group, the mean durations of cardiopulmonary bypass and aortic clamp per one distal anastomosis were 33.5 and 21.1 minutes, respectively. In the non-sequential group, these were 41.8 and 22.7 minutes. There were two operative deaths, both in the non-sequential group. There was no difference in the incidence of postoperative complications including myocardial infarction. During the follow-up period(2 to 15 months), 8 patients(3 in the sequential and 5 in the nonsequential group) complained of residual or recurrent angina. Comparison of preoperative and postoperative ."'Thallium myocardial perfusion scans in 30 patients showed improved or normal perfusion reserve in 83.3% of segments bypassed with sequential grafts and 82.5% of segments bypassed with non-sequential graft(5), These results show that, utilizing parallel sequential anastomoses with saphenous vein grafts, we could achieve satisfactory short-term clinical results in patients with extensive coronary stenoses. So, we conclude that this technique is a safe, technically feasible strategy for CABG, which can achieve the aim of complete myocardial revascularization with a limited length of graft.raft.

• Journal of Chest Surgery
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• v.38 no.6 s.251
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• pp.434-437
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• 2005

Since the operative mortality rate of the Acute aortic dissection has been reducing, a more extensive primary repair of the dissected aorta is preferred for acute aortic dissection to reduce the needs of secondary procedures. We performed a total aortic arch replacement with distal stent-grafting in acute type A aortic dissection. The patient was a 50-years old man. He recovered from the operation and was followed up for 7 months. The pseudolumen in the descending aorta was obliterated with the stent.

• Journal of Chest Surgery
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• v.32 no.4
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• pp.373-378
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• 1999

Background: Minimally invasive technique for various cardiac surgeries has become widely accepted since it has been proven to have distinct advantages for the patients. We describe here the results of our experiences of minimal incision in cardiac surgery. Material and Method: From February 1997 to November 1998, we successfully performed 31 cases of minimally invasive cardiac surgery. Male and female ratio was 17:14, and the patients age ranged from 1 to 75 years. A left parasternal incision was used in 9 patients with single vessel coronary heart disease. A direct coronary bypass grafting was done under the condition of the beating heart without cardiopulmonary bypass support(MIDCAB). Among these, one was a case of a reoperation 1 week after the first operation due to a kinked mammary artery graft. A right parasternal incision was used in one case of a redo mitral valve replacement. Mini-sternotomy was used in the remaining 21 patients. The procedures were mitral valve replacement and tricuspid annuloplasty in 6 patients, mitral valve replacement 5, double valve replacement 2, aortic valve replacement 1, removal of left atrial myxoma 1, closure of atrial septal defect 2, repair of ventricular septal defect 2, and primary closure of r ght ventricular stab wound 1. The initial 5 cases underwent a T-shaped mini-sternotomy, however, we adopted an arrow-shaped ministernotomy in the remaining cases because it provided better exposure of the aortic root and stability of the sternum after a sternal wiring. Result: The operation time, the cardiopulmonary bypass time, the aorta cross-clamping time, the mechanical ventilation time, the amount of chest tube drainage until POD#1, the chest tube indwelling time, and the duration of intensive care unit staying were in an acceptable range. There were two surgical mortalities. One was due to a rupture of the aorta cannulation site after double valve replacement on POD#1 in the mini-sternotomy case, and the other was due to a sudden ventricular arrhythmia after MIDCAB on POD#2 in the parasternal incision case. Postoperative complications were observed in 2 cases in which a cerebral embolism developed on POD#2 after a mini-sternotomy in mitral valve replacement and wound hematoma developed after a right parasternal incision in a single coronary bypass grafting. Neither mortality nor complication was directly related to the incision technique itself. Conclusion: Minimally invasive surgery using parasternal or mini-sternotomy incision can be used in cardiac surgeries since it is as safe as the standard full sternotomy incisions.

• The Korean Journal of Nuclear Medicine
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• v.37 no.5
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• pp.278-287
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• 2003

Purpose: The performance of nitroglycerin-challenged Tc-99m-MIBI quantitative gated SPECT for the detection of viable myocardium was compared with rest/24-hour redistribution Tl-201 SPECT Materials and Methods: In 22 patients with coronary artery disease, rest Tl-20l/ dipyridamole stress Tc-99m-MIBI gated/24-hour redistribution Tl-201 SPECT were peformed, and gated SPECT was repeated on-site after sublingual administration of nitroglycerin (0.6 mg). Follow-up gated SPECT was done 3 months after coronary artery bypass graft surgery. For 20 segments per patient, perfusion at rest and 24-hour redistribution, and wall motion and thickening at baseline and nitroglycerin-challenged state were quantified. Quantitative viability markers were evaluated and compared;(1) rest thallium uptake, (2) thallium uptake on 24-hour redistribution SPECT, (3) systolic wall thickening at baseline, and (4) systolic wall thickening with nitroglycerin-challenge. Results: Among 100 revascularized dysfunctional segments, wall motion improved in 66 segments (66%) on follow-up gated myocardial SPECT after bypass surgery. On receiver operating characteristic (ROC) curve analysis, the sensitivity and specificity of rest and 24-hour delayed redistribution Tl-201 SPECT were 79%, 44% and 82%, 44%, respectively, at the optimal cutoff value of 50% of Tl-201 uptake. The sensitivity and specificity of systolic wall thickening at baseline and nitroglycerin-challenge were 49%, 50% and 64%, 65% at the optimal cutoff value of 15% of systolic wall thickening. Area under the ROC curve of nitroglycerin-challenged systolic wall thickening was significantly larger than that of baseline systolic wall thickening (p=0.004). Conclusion: Nitroglycerin-challenged quantitative gated Tc-99m-MIBI SPECT was a useful method for predicting functional recovery of dysfunctional myocardium.

• The Korean Society of Law and Medicine
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• v.18 no.2
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• pp.163-194
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• 2017

Coronary artery disease has increased in Korea as the country enters the aged society. It is well known that the incidence of coronary artery disease is related to aging, hypertension, diabetes, hyperlipidemia, and dietary habit. For effective treatment of significant coronary stenosis, close coordination between cardiac surgery and cardiology team is essential. Especially cardiologists' decision whether to do the stent placement or CABG is very important because the cardiologists usually start to consult the patients for their treatment. Recently, non-surgical interventions(that is stent placement) in cardiology field have dramatically increased as the national insurance system removed the limitation of the number of stents deployed. However, accidents are often caused by inappropriate use of stents, especially in patients with triple coronary disease or left main disease with heavy coronary calcifications. Another aspect of stent placement is to cope with an emergency case in the event of coronary rupture or pericardial tamponade during coronary interventions without cardiac surgeons. In the past two years, the Korea Consumer Agency (Consumer Dispute Coordination Committee) analyzed eight cases of medical dispute settlement. Only two hospitals were manned with both cardiologists and cardiac surgeons. Seven patients died of procedures of stenting and five patients died on the day of the procedure. Among the 8 cases, 5 cases showed 3 vessel disease and the rest of the cases had either severe calcification, complete occlusion or poor coronary antomies for stenting According to a 2017 national data registry of coronary stenting, less than 3 drug-eluting stents were implanted in 98% of all patients. In 2015, the number of stent procedures was 38,922, and approximately in 800 (2%) cases, more than four stents were used per patient. We emphasize that it is necessary to seriously consider the cost-benefit analysis between stent and CABG. The patient has the right to choose the right procedure by asking the liability of 'instruction explanation obligation'. He should be well informed of the pros and cons of both procedures to avoid overuse of stent. It can be solved by intimate discussion of individual cases with the cardiac surgeon and the patient. Unilateral dialogue with the patient, forceful restriction on the number of stenting, lack of surgeon's backup in difficult cases should all be avoided. It is also necessary to solve the problem not only at the hospital level, such as multidisciplinary integrated medical care, but also a nationwide solution such as expanding cardiac surgeons as essential personnel to public officials.

• Journal of Chest Surgery
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• v.34 no.12
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• pp.895-900
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• 2001

Background : This study aimed to evaluate the usefulness of preoperative placement of intraaortic balloon pump(IABP) in reducing operative risk and facilitating posterior vessel OPCAB in high risk patients with left main disease( 75％ stenosis), intractable resting angina, postinfarction angina, or left ventricular dysfunction(ejection fraction 35％). Material and Method : One hundred eighty- nine consecutive patients who underwent multi-vessel OPCAB including posterior vessel revascularization were studied. The patients were divided into group I(n=74) that received preoperative or intraoperative IABP and group II(n=115) that did not receive IABP. In group I, there were 39 patients with left main disease, 40 patients with intractable resting angina, 14 patients with left ventricular dysfunction and 7 patients with postinfarction angina. Ten patients received intraoperative IABP support due to hemodynamic instability during OPCAB. Result : There was one operative mortality in group I and two mortalities in group II. The average number of distal anastomoses was not different between group I and group II(3.5$\pm$0.9 vs 3.4$\pm$0.9, p=ns). There were no significant differences in the number of posterior vessel anastomosis per patient between the two groups. There were no differences in ventilator support time, length of hospital stay, and morbidity between the two groups. There was one case of IABP-related complication in group I. Conclusion : IABP facilitates posterior vessel OPCAB in high risk patients, with comparable surgical results to low risk patients

• Journal of Chest Surgery
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• v.31 no.12
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• pp.1183-1194
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• 1998

Background: From Sept. 1985 to Sept. 1997, 2,000 cases of open heart surgery(OHS) were performed in the Department of Thoracic & Cardiovascular Surgery, Pusan Paik Hospital, College of Medicine, Inje University. Material and Method: Among the total of 2,000 cases of OHS, 1532 cases were congenital heart disease(CHD) and 468 cases were acquired heart disease(AHD). The age distribution was 9 days(4.0kg) to 68 years in CHD and 11 to 66 years in AHD. In 1532 cases of CHD, there were 1403 acyanotic cases and 129 cyanotic cases. Result: The CHD cases consisted of 940 ventricular septal defects(61.4%), 324 atrial septal defects(21.1%), 112 tetralogy of Fallot(7.3%), 46 pulmonary stenosis(3%), 38 endocardial cushion defects(2.5%), 15 valsalva sinus ruptures(1%), 4 transposition of great arteries (0.3%), 4 double outlet right ventricles(0.3%), and etc. Corrective operations were applied for congenital heart disease with a result of 3.1% hospital mortality. Of 468 AHD, 381 cases were valvular heart diseases, 48 ischemic heart diseases, 12 cardiac tumors, 8 annuloaortic ectasias, 16 dissecting aortic aneurysms and etc. In the 381 valvular heart diseases, there were 226 single valve replacements(36 aortic valve replacements(AVR), 188 mitral valve replacements(MVR), and 2 tricuspid valve replacements(TVR), among these were 71 cases of double valve replacements(AVR & MVR), 54 cases of MVR with tricuspid valve annuloplasty(TVA), and 18 cases of AVR, MVR with TVA. The total implanted prosthetic valves were 466. In MVR, 123 St. Jude Medical valves, 90 Carpentier-Edwards valves, 65 CarboMedics valves, 42 Sorin valves and 16 other valves were used. In AVR, 68 St. Jude Medical valves, 36 CarboMedics valves, 14 Carpentier-Edwards valves and 9 other valves were used. Coronary Artery Bypass Surgery(CABG) were performed in 48 cases. The patterns of bypass graft were 14 patients of single vessel graft, 21 patients of two vessels graft, 10 patients of three vessels graft and 3 patients of four vessels graft. Conclusion: The hospital operation mortality rate of congenital acyanotic, cyanotic and acquired heart diseases were 2.0%, 15.5%, and 5.1% respectively. The overall mortality rate was 3.6%(72/2,000).

• Journal of Chest Surgery
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• v.37 no.10
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• pp.827-832
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• 2004

Background: The significance of MIDCAB is emerging topics recently as OPCAB is going to be universalized, and long-term outcome of bypass graft surgery was proved to be more excellent than balloon dilation or stent insertion. We report our MIDCAB results in 73 patients in the last three years. Material and Method: Retrospective analysis of medical records was done from November 1, 2000 through November 31, 2003. There were 47 males and 26 females ranging in age from 31 years to 79 years (average $61.3\pm9.8$ years). Observation periods after operative procedures were 10 to 1238 days (average $763\pm319.8$ days). Left longitudinal parasternal incision as a standard procedure was done to approach the heart after dissection of the left internal thoracic artery by partial or total resection of 3rd to 5th ribs. Result: Of those patients, 46 patients were transferred to ICU after extubation at operation room and 58 patients were extubated within 3 hours after operation. Average ICU staying periods was $26.8\pm11.5$ hours. Follow-up angiography during admission was done in 36 patients and showed 100% patency. Only one patient died on the 10$^{th}$ post operative day because of sudden CVA. Complications included wound problems in 4 patients, and constructing pericardial window using thoracoscopy due to continuous pericardial effusion in 1. Permanent pacemaker was inserted in one patient owing to sick sinus syndrome. In one patient with recurrence of angina 8 months after operation, stenosis at anastomic site was found and improved with balloon dilatation. Conclusion: We were satisfied with our results of MIDCAB in single and multi-vessel coronary artery disease. These results have made the cardiologists tried to operate positively and we expect widening operative indications including hybrid revascularization.

• Journal of Chest Surgery
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• v.40 no.1 s.270
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• pp.32-36
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• 2007

Background: Although acute renal failure (ARF) after coronary artery bypass graft (CABG) is relatively rare, but devastating complication with high mortality. Our study aims to evaluate the effectiveness of early application of CRRT in patients with ARF which developed after on-pump CABG. Material and Method: Two hundred and eighty seven patients underwent isolated on-pump CABG between May 2002 and Feb. 2006 at our institution, of whom 15 (5.2%) needed CRRT (11 patients for postoperatively developed ARF and the remaining 4 patients with preexisting dialysis-dependent chronic renal failure (CRF) for postoperative hemodynamic and metabolic control). Criteria for early application of CRRT were as follows; decreased urine output less than 0.5cc/h/kg for 2 consecutive hours and elevated serum creatinine level greater than 2.0 mg/dL. Result: The incidence of ARF requiring CRRT after on-pump CABG was 3.9% (11/283) and the overall hospital mortality of patient with CRRT was 33.3% (5/15). Of 5 deaths, 4 were patients with postoperatively developed ARF, and 1 was a patient with pre-existing dialysis-dependent CRF patient. The mean time between the operation and the initiation of CRRT was $25.8{\pm}5.8$ hours and the mean duration of CRRT was $62.1{\pm}41.2$ hours. Of the 7 survivors who were not on dialysis-dependent preoperatively, 6 patients fully recovered renal function during hospital stay and 1 patient required permanent renal supportive treatment after discharge from hospital. Conclusion: Early application of CRRT could maintain stable postoperative hemodynamic status and make outcomes better than those of previous reports in patients with ARF which developed after on-pump CABG.

• 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.