• Journal of Chest Surgery
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• 제40권12호
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• pp.855-858
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• 2007

승모판막 치환술 후 발생하는 좌심실파열은 치명적인 합병증이다. 30년 전 국외에서 승모판막에 대한 수술을 받은 병력이 있는 54세 여자 환자가 심한 승모판막 협착증과 심한 삼첨판막 폐쇄부전을 주소로 내원하여 승모판막 치환술 및 삼첨판막륜 성형술을 시행받았다. 심폐기 이탈 후 수술장 내에서 발생한 대량출혈로 심폐기 재가동 상태에서 평가한 결과 좌심방으로부터 3 cm 후방부위의 방실 골짜기에서 발생한 급성 제I형 좌심실 파열로 진단하고 심외막 접근법으로 테프론 펠트를 이용한 일차 봉합술, 심막첨포를 이용한 밀봉 봉합술 및 피브린 접착제를 적용하여 성공적으로 봉합하였으며 환자는 수술 14일째 합병증 없이 퇴원하였다. 이에 승모판막 치환술 후 발생하는 제I형 좌심실 파열에 대한 문헌고찰과 함께 증례를 보고하고자 한다.

• Journal of Chest Surgery
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• 제40권12호
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• pp.817-824
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• 2007

목적: 심장판막치환술 시에 선택하는 판막에는 크게 기계판막과 조직판막이 있다. 두 가지는 각기 피할 수 없는 단점이 있는데 조직판막의 경우 판막의 퇴행성 변화에 따른 재수술이 가장 문제가 되며 판막재치환술의 위험도가 적다면 조직판막의 사용이 증가되리라 생각된다. 이에 저자들은 심장판막치환술 후 재치환술의 위험도 및 사망률을 심장판막 일차치환술과 비교 평가하였다. 대상 및 방법: 1995년 1월부터 2004년 12월까지 최근 10년간 본 병원에서 연속적으로 시행한 심장판막수술 환자 239명 중 심장판막치환술 후 재치환술을 받은 25명과 심장판막일차치환술을 받은 158명의 한자를 후향적으로 비교, 분석하였다. 결과: 심장판막 재치환술군과 심장판막 일차치환술군 간의 나이, 성별, 술전심박출률 등은 통계적으로 큰 차이가 없었다. 재치환군에서 첫 수술의 판막은 기계판막 3예, 조직판막 22예로 이중 대동맥판막과 승모판막을 동시에 조직판막으로 치환한 경우가 1명 있었으며, 재수술까지의 기간은 기계판막의 경우 92개월, 조직판막인 경우 평균 160개월이었다. 체외순환 및 대동맥차단의 평균시간은 재치환술의 경우 152분, 108분, 일차치환술의 경우 130분, 89분으로 통계적인 유의함을 보였다. IABP의 사용은 재치환술의 경우 2예(8%), 일차치환술은 6예(3.8%)로 차이를 보였으며, 수술사망은 재치환술의 경우 1예(4%), 일차치환술의 경우 9예(5.1%)였다. 술 후 합병증 중에서 술 후 48시간 이상의 인공호흡이 재수술에서는 13.6%, 1차 수술에서 5.7%로 차이를 보였고 다른 인자에서는 큰 차이를 보이지 않았다. 수술 후 평균 추적기간은 $6.5{\pm}3.2$년이고 재치환술 환자의 5년 생존율은 74%였으며 일차치환술의 경우 5년 생존율은 95%를 보여 유의한 차이를 보였다. 결론: 심장판막재치환술은 일차치환술과 비교하여 볼 때 수술 위험도는 약간 증가되나 사망률에서는 큰 차이를 보이지 않았다. 따라서 재수술 위험을 고려하여 조직판막을 너무 기피하는 것은 재고되어야 하며 다른 장점이 많은 조직판막의 선택적인 사용이 권장된다. 그러나 재치한술의 경우 술전 상태가 나빴던 환자에서 만기사망률이 높으므로 일차치환술 후 적절한 심장기능 및 환자상태의 평가가 필요하며 너무 늦지 않은 적정한 시기에 재치환술을 고려해야 겠다.

• Journal of Chest Surgery
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• 제30권8호
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• pp.815-818
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• 1997

인공판막심내막염은 드물지만 합병증으로 판막주위가 감염으로 파괴되고 농양이 형성되는 경우가 있어 높 은 사망율을 가져온다. 그러나 적절한 항생제의 사용, 심장초음파 검사에 기초를 둔 조기 진단,수술시 효과적인 심근보호. 그리고 수술경험의 축적으로 인공판막심내막염에 있어서 보다좋은 장단기 결과를 얻을 수 있다. 35세 남자 환자가 94년 8월에 대동맥판막, 승모판막대치술과 함께 삼첨판륜성형술을 받은후 특별한 증상 없이 지내다가 갑자기 시작된 실어증, 양안구의 좌측편위, 고열로 입원하여 심장초음파 검사를 시행한 결과 인공판막 심내막염 소견을 보여 6주간의 항생제 치료후 수술을 시행하였다. 수술소견상 대동맥 판륜을 따라 증식물 소견과 판막 주위의 누출, 농양주머니가 형성되어 있었고 승모판막은 비교적 건강해 보였다. 수술은 감염된 조직의 전체적인 제거와 냉동저장된 대동맥 동종이식편을 이용하여 재대치 수술을 시행했다. 환자는 수술후 63일째 퇴원했으며 퇴원후 7개월 동안 외래 추적 관찰결과 특별한 이상소견 없이 지내고 있다.

• Journal of Chest Surgery
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• 제21권6호
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• pp.1020-1029
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• 1988

The authors evaluated 153 patients who had undergone cardiac valve replacement between October 1979 and July 1988. The results are as follows: l. Out of 153 patients, there were 56 males and 97 females ranging from 15 to 62 years of age with a mean of 37 years. 2. Isolated mitral valve replacement took place in 82 patients, aortic valve replacement[AVR] in 16, double valve replacement[DVR] in 34, AVR combined with open mitral commissurotomy in 19, and tricuspid valve replacement[TVR] was done in 2 patients. 3. 153 patients had 187 prosthetic valves replaced with Ionescu-Shiley valves[16], Carpentier-Edwards[36], Bjork-Shiley[19], St. Jude Medical[108], and Duromedics[8]. 4. Our of 98 patients with atrial fibrillation[ 64% of a total 153 patients ] during the preoperative period, 22 patients recovered NSR[ 22/98, NSR recovery rate 22.4%] after valvular surgery and remaining 76 patients revealed persisting atrial fibrillation[76/153, 49.7% ]. 5. Preoperative episodes of systemic arterial embolization were attained in 9 patients[9/153, 6% ], and left atrial thrombi were confirmed in 22 patients intraoperatively[ 22/153, 14% ]. Of these, only one patient, however, demonstrated the correspondence of preoperative embolization and intraoperative existence of LA thrombi. 6. With mechanical prostheses, anticoagulant therapy was begun 48 hours after operation with sodium warfarin[2.5-5.0mg/day], maintaining the prothrombin time between 16 and 18 seconds or 30 to 50% of control values and continued for life. With tissue prostheses, sodium warfarin was continued for 3 to 6 months and converted into buffered ASA[ 325 mg/day ] for one year. 7. The mean follow-up for the survivors was 30.1 months, with a range from 3 months to 9 years. All suspected or confirmed thromboembolic episodes counted as events and occurred in 4 patients[ 1.04%/patient-year] with mechanical valve replacement. No persistent paralysis or death was noted. Late complications have not yet occurred in the patients with isolated MVR and AVR. 8. There were remarkable structural failures of tissue valves in 3 patients[ 1.9%/patient-year ], while no instance of failure of a mechanical valve. 9. There were 10 operative early deaths[10/153, 6.5%] and 5 late deaths[5/153, 3.3%]. Consequently, overall mortality was 9.8%[ 15/153] during follow-up period. 10. We currently favor using the St. Jude Medical valve in all patients requiring valve replacement except in those who can not take warfarin anticoagulation.

• Journal of Chest Surgery
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• 제16권4호
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• pp.506-510
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• 1983

Valve dysfunction can be caused by thickening or contraction of a fibrous sheath covering a cusp of a porcine bioprosthesis, but this is uncommon. This complication appears to more frequent in other bioprostheses, such as fascia late valves and homografts, in which fibrous sheaths seems to grow more rapidly. rapidly. Thus the slow and limited growth of fibrous sheath in porcine bioprostheses is advantageous in this respect. Recently, we experienced a case of valve dysfunction caused by fibrous tissue overgrowth on Hancock mitral xenograft in 45 year old female. 3.5 years ago, the patient was received valve replacement due to mitral stenoinsufficiency. But since 2.5 years elapsed after operation, she has complained of generalized edema and dyspnea, and their symptoms were aggravated progressively. So reoperation was performed under the diagnosis as valve dysfunction of mitral xenograft and newly developed tricuspid insufficiency. Her postoperative courses were good.

• Journal of Chest Surgery
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• 제41권5호
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• pp.580-585
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• 2008

배경: 기능성 삼첨판막부전증의 수술치료에 여러 방법의 판륜성형술이 이용된다. 저자들은 기능성 삼첨판막부전증에 삼첨판후판륜주름술(posterior annular plication technique; Davits technique)을 이용하고 그 중장기결과를 알아보았다. 대상 및 방법: 1991년 1월부터 2006년 8월까지 기능성 삼첨판부 전정도가 2도(판막부전 범위, $1{\sim}4$도) 이상이거나 판막부전증이 2도 미만이더라도 삼첨판판륜이 직경 5.0cm 이상으로 늘어난 58예의 성인환자들(남, 22예; 여, 36예)에서 후판륜주름술을 시행하였다. 수술 전 26예(44.9%)가 3도 이상의 기능성 삼첨판부전증을 가지고 있었다. 모든 환자에서 승모판막치환술이 시행되었고 이 중 20예(34.5%)는 대동맥판막치환술도 같이 시행되었다. 결과: $101.4{\pm}51.6$개월의 추적기간 동안에 기능성 삼첨판막부전증은 28예(49.1%)에서 거의 완전히 소실되거나 흔적만 보였고, 8예(14.0%)에서 2도 이상 3도 미만을 보였으며, 2예(3.5%)에서는 3도의 삼첨판막부전을 보였다. 모든 환자에서 수술 전에 비해 수술 후 삼첨판막 부전정도는 평균 $2.66{\pm}0.73$에서 $0.82{\pm}0.89$로 호전되었다(p<0.0001). 삼첨판막에 대한 재수술이나 판막부전 정도가 수술 전보다 더 악화된 예는 없었다. 결론: 기능성 삼첨판막부전증에 대한 변형식 Davila 후판륜주름술은 의의 있는 중장기적 결과를 보였으며 유용한 수술방법으로 생각된다.

• Journal of Chest Surgery
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• 제21권2호
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• pp.351-365
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• 1988

During one year[1987], 110 cases of open heart surgeries were performed in the department of Thoracic and Cardiovascular Surgery, Pusan Paik Hospital, Inje Medical College. And the results were summarized as follows. 1. Among the 110 cases, there were 77 cases of congenital heart diseases and 33 cases of acquired heart diseases. Age range of the congenital patients was 8 months to 30 years with the mean age of 8 years, and acquired patients was 16 to 56 years with the mean age was 32 years. 2. The heart lung machine used for cardiopulmonary bypass was Sarns 7000, 5-head roller pump, and the number and type of oxygenators were 50 of membrane type and 60 of bubble type. For all cases GIK[glucose-insulin-potassium] solution was used as cardioplegic solution for myocardial protection during operation. 3. Among the 77 congenital anomalies, there were 67 cases of acyanotic patients[ASD: 12, VSD: 50, PS: 1, AP window: 1, Gerbode defect: 1, ECD: 2] and 10 cases of cyanotic patients[TOF: 10], and to all of which the appropriate radical operations were applied. 4. Among the 33 acquired diseases, there were one case of left atrial myxoma, one of annuloaortic ectasia, 20 of mitral valve diseases[MS: 2, MSr: 8, MR: 2, MRs: 8], 9 of double valve diseases[MRs+AR: 1, MRs+ARs: 2, MRs+TR: 1, MSr+TR: 3, MSr+ASr: 1, MSr+ARs: 1], 2 of triple valve diseases[MSr+AR+TR: 1, MSr+ASr+TR: 1]. The left atrial myxoma was removed well with right atriotomy and atrial septal approach. And to the annuloaortic ectasia, Bentall operation was applied with good result. Mitral valve replacement[MVR] was applied to 20 cases of mitral valve diseases, double valve replacement[MVR+AVR] was applied to 6 cases of double valve diseases, MVR & tricuspid annuloplasty[TVA] was applied to 3 cases of mitral 5. The number of replaced valve were 39 in 31 cases. In MVR, 5 of mechanical valves[St. Jude Medical Valve] and 26 of tissue valves[Carpentier-Edward valve] were used. In AVR, 3 of mechanical valves and 5 of tissue valves were used. 6. Postoperative complications were occurred in 23 cases, and among them 21 cases were recovered with intensive cares, but 2 cases were expired[mortality: 1.8%].

• Journal of Chest Surgery
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• 제25권2호
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• pp.149-157
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• 1992

Total 145 cases mitral vlave replacement were performed in Department of Thoracic and Cardiovascular Surgery in Chungnam National University Hospital during the period from May 1983 to July 1991. Sixty-one patients were male and 84 patients were female and the range of age was from 12 to 66 years old with the mean of 37.9[$\pm$11.6] years. Valvular lesions were 49 cases of mitral stenosis, 18 cases of regurgitation and 78 cases of combined lesion. Used valve were Ionescu-Shiley[42 cases], Bjork-Shiley[49 cases], Inact[6 cases], St. Jude Medical[11 cases] and CarboMedics[37 cases]. Mean size of valve was 29.8$\pm$1.68mm. Early morality was 13.8%[20 cases] and low output syndrome was most common cause[9 cases]. Age, functional classification and biventricular hypertrophy were risk factors. All survived cases were followed up without missing. Mean follow up period were 3 years and 3 months. Total 14 cases of death[9.7%] were observed and heart failure, unexplained sudden death and bleeding were the causes in that order. Common late complications were heart failure and bleeding related with anticoagulation. Actuarial survival rate at 5 years was 83$\pm$5.4% in overall, 78$\pm$7.2% in tissue valve group, 87$\pm$6.8% in mechanical valve group. The actuarial freedom rate from thromboembolism at 7 years was 89$\pm$8.3% in overall, 86$\pm$9.9% in tissue valve group and 97$\pm$1.9% in mechanical valve group. Actuarial freedom rate from bleeding at 5 years with anticoagulation was 88.9$\pm$4.2% in overall, 96$\pm$3.9% in tissue valve group, 86$\pm$4.6% in mechanical valve group. Reoperation was done in 3 cases with heart failure with tricuspid regurgitation and thromboembolism in 2 cases. The functional status of survived cases was I or II.

• Journal of Chest Surgery
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• 제27권4호
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• pp.272-280
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• 1994

Total 400 St.Jude Medical Bileaflet Valves were implanted in 336 pts from January 1983 to June 1993; 64 were aortic, 205 were mitral, 64 were double valve and 3 were tricuspid position. The follow up period extended from 6 months to 10 years[mean 24.3 months]. Male to female ratio was 1:1.7. There were total 27 deaths[cardiac related 20, cardiac non-related 7]. Overall mortality was 2.9%/pt-yr. There were 10 early deaths[3.0%] and 10 late cardiac related deaths [3.0%]. Prosthetic valve related complications occurred in 19 patients[5.7%] and among them, seven died; four died of thromboembolic events, two died of anticoagulants therapy related hemorrhagic complications and one died of bacterial endocarditis. NYHA class improved significantly especially in aortic valve replacement and double valve replacement. In AVR cases, the mean NYHA was 2.8 preoperatively and 1.3 postoperatively. And in DVR cases, 3.3 preoperatively and 2.2 postoperatively. The decision to employ a particular prosthesis was made according to the anticipated or known complications of the valve. The St.Jude Medical Valve retains all the hazards of other mechanical valves, most notably, thromboembolism. But the hemodynamic performance of St.Jude Medical Valve compared most favorably with other substitute valves in many reports. 0ur experience didn`t show any differences compared other authors in terms of valve related complication. So we concluded St. Jude Medical Valve can be primarily considered in the selection of artificial valve except in the patients when the usage of anticoagulant therapy is contraindicated.

• Journal of Chest Surgery
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• 제21권4호
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• pp.619-629
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• 1988

The increasing number of replacement of the substitute cardiac valves were seen in these 2 years. Out of a total 1,408 patients with cardiac valve replacement, 54 required replacement of the substitute valves. Fifty-nine substitute valves replaced were 43 in mitral, 14 in aortic and 2 in tricuspid positions; and they were 36 Ionescu-Shiley, 15 Hancock and 3 Angell-Shiley bioprosthetic valves and 3 St. Jude Medical and 2 Bjork-Shiley prosthetic valves. Primary tissue failure was the most frequent reason of replacement[38 patients] followed by paravalvular leak[9 patients], prosthetic valve endocarditis[6 patients] and valve thrombosis[1 patient] in order. The most pronounced pathology of the failed xenograft valves seen in the primary tissue failure group was calcification and fixation of the cusps with or without tear and defect of the cuspal tissue. The operative mortality rate was 7.4%. Fifty early survivors were followed up for a total of 82.6 patient-years and there was no late death. Actuarial survival rate was 92.3*3.8% at 6 years after surgery. Although the definite tendency toward early and accelerated degeneration of the xenograft valves has been seen in patients younger than 20 to 25 years of age, no strict age limit from where the tissue failure slows down could be determined. The requirement of the ideal substitute valves would be the durability of the recently developed mechanical prostheses armed with the low thrombogenicity of the bioprostheses. At the present time, the need of compromise in selection between less thrombogenic bioprosthetic and more durable mechanical valves should be stressed. The difficulty in choice is yet important in patients of middle age and children where the use of homograft valves may be one of the solution despite of certain limitations from sociomedical reasons.