"Wings of a Butterfly" Technique in Modified Bentall's Procedure.

Many surgeons have modified the technique to reduce bleeding from anastomosis line since Bentall and De Bono introduced aortic root replacement using a composite graft. We present a new composite, butterfly wing-shaped, valve graft fixated using hand-made double sewing cuff. The "wings of a butterfly" technique is a method of reinforcement suturing between an added sewing cuff and residual aortic wall at the proximal stump and helps to reduce bleeding after the modified Bentall's procedure.

Importance of pulse pressure after extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Recent reports have revealed better clinical outcomes for extracorporeal cardiopulmonary resuscitation (ECPR) than conventional cardiopulmonary resuscitation (CPR). In this retrospective study, we attempted to identify predictors associated with successful weaning off extracorporeal membrane oxygenation (ECMO) support after ECPR. METHODS: The demographic and clinical data of 30 ECPR patients aged over 18 years treated between August 2016 and January 2019 were analyzed. All clinical data were retrospectively collected. The primary endpoint was successful weaning off ECMO support after ECPR. Patients were divided into two groups based on successful or unsuccessful weaning off ECMO support (Weaned (n = 14) vs. Failed (n = 16)). RESULTS: Univariate logistic regression analysis showed that age, CPR duration, ECMO complications, and loss of pulse pressure significantly predicted the results of weaning off ECMO support. However, multivariate logistic regression analysis showed that only CPR duration and loss of pulse pressure independently predicted unsuccessful weaning from ECMO support. CONCLUSION: We conclude that long CPR duration and loss of pulse pressure after ECPR predict unsuccessful weaning from ECMO. However, unlike CPR duration, loss of pulse pressure during post-ECPR was related to subsequent management. In patients with reduced pulse pressure after ECPR, careful management is warranted because this reduction is closely associated with unsuccessful weaning off ECMO support after ECPR.

Femoral neuropathy following venoarterial-extracorporeal membrane oxygenation therapy: a case report.

BACKGROUND: Although life-threatening complications of extracorporeal membrane oxygenation (ECMO) are well described, non-life threatening complications are less known. Herein, we report a case of femoral neuropathy (FN) due to nerve compression caused by cannula compression and deep vein thrombosis (DVT) after successful ECMO therapy, which seriously undermined one's quality of life. CASE PRESENTATION: A 70-year old male presented to the emergency department for chest pain. The patient had cardiac arrest before percutaneous coronary intervention (PCI) and was inserted with ECMO. Although he was successfully weaned from ECMO 4 days after PCI, he consistently complained swelling, abnormal sensation, and weakness in his right lower extremity, where the cannulas were inserted. Imaging studies showed deep vein thrombosis (DVT) in his right leg, which was further treated with anticoagulants. Symptoms, however, remained after the regression of DVT. Nerve conduction study revealed femoral neuropathy, which may have been caused by ECMO cannula compression and tissue swelling. CONCLUSION: The current case proposes that non-life threatening complications of ECMO therapy can seriously affect quality of life. Venous drainage distant from the arterial cannula may prevent such complications.

Rapid evaluation of acute pulmonary embolism with thromboembolism-in-transit.

We report a case of thromboembolism-in-transit through a patent foramen ovale that could cause systemic embolism in a patient with pulmonary embolism. An accurate and quick diagnosis by transthoracic echocardiography and computed tomography allowed emergent surgical thromboembolectomy to be performed without complications. Integral diagnostic workup should be performed in case of acute pulmonary thromboembolism whether the patient is hemodynamically stable or not.

Explantation of a failed endovascular stent graft in a patient with a type B dissection.

We report a patient who underwent insertion of an endovascular stent graft in the descending aorta for an aneurysmal type B dissection. The patient developed a proximal type I endoleak which required explantation of the graft and replacement of the descending aorta. Carotid artery cannulation was utilized for antegrade perfusion during the period of circulatory arrest.

Left Heart Decompression in Acute Complicated Myocardial Infarction During Extracorporeal Membrane Oxygenation.

Acute myocardial infarction (AMI) can progress to cardiogenic shock and mechanical complications. When extracorporeal membrane oxygenation (ECMO) is applied to a patient with AMI with cardiogenic shock and mechanical complications, left ventricular (LV) decompression is an important recovery factor because LV dilation increases myocardial wall stress and oxygen consumption. The authors present the case of a 72-year-old man with AMI and LV dilation who developed cardiogenic shock and papillary muscle rupture and who was treated successfully by ECMO with a left atrial venting.

Thoracoscopic Bilateral Bullectomy for Simultaneously Developed Bilateral Primary Spontaneous Pneumothorax: Ipsilateral Transmediastinal versus Bilateral Sequential Approach.

Background Simultaneously developed bilateral primary spontaneous pneumothorax (BPSP) is an indication for thoracic surgery of both sides. Recently, we have reported a new technique for BPSP, which is ipsilateral apicoposterior transmediastinal (TM) bullectomy of both sides using video-assisted thoracoscopic surgery (VATS), and we compared this TM VATS with bilateral sequential (BS) VATS for BPSP. Materials and Methods From June 2003 to May 2014, 11 and 14 patients were performed VATS TM and BS bullectomy for BPSP, respectively. We reviewed the medical records and compared the clinical data between the two groups. For TM group, we first performed the right VATS bullectomy and approached through the apicoposterior mediastinal region for contralateral VATS. In the other group, conventional BS VATS bullectomy was performed in the lateral decubitus position change. Results The mean follow-up was 62.0 ± 32.6 months. No mortality and major complications were observed. The operative time (68.18 ± 24.93 vs. 96.07 ± 37.73, p = 0.046), duration of left pleural drainage (1.00 ± 0.45 vs. 3.21 ± 1.37, p = 0.000), and length of hospital stay (3.82 ± 1.54 vs. 4.93 ± 1.07, p = 0.044) were significantly shorter in the TM group than in the BS group. No significant differences were seen in duration of general anesthesia, total number of wedge resections and endostaplers used in both lungs, duration of right drainage, and postoperative recurrence. Conclusion The TM VATS approach may be a safe and feasible modality for BPSP. It may decrease the operative time, patients inconvenience such as bilateral multiple wounds and longstanding placement of chest tubes, and decrease the hospital stay compared with the BS VATS approach.

Veno-veno-arterial extracorporeal membrane oxygenation for acute respiratory distress syndrome with septic-induced cardiomyopathy due to severe pulmonary tuberculosis.

We describe the rare experience of veno-veno-arterial (VVA) extracorporeal membrane oxygenation (ECMO) in a patient with acute respiratory distress syndrome and septic-induced cardiomyopathy due to pulmonary tuberculosis (TB). A 24-year-old male patient who developed septic-induced cardiomyopathy secondary to pulmonary TB was administered veno-arterial (VA) ECMO for cardiac support. Six days later, the ECMO configuration mode was changed from VA to VVA to improve hypoxemia of the upper body and to prevent further lung injury. The patient was then successfully managed using an appropriate alternative ECMO strategy.

Pulmonary Vein Extension for Large Left Atrium Size Mismatch During Heart Transplantation.

In cases with a large recipient left atrium (LA), matching of the donor and recipient anastomoses can be challenging. In the presented case, this is addressed by reducing the circumference of the recipient LA cuff by extending the pulmonary veins. The inferior pulmonary veins were extended by making neopulmonary veins using the remnant recipient LA cuff; the circumference of the recipient LA cuff could then be reduced to easily make an anastomosis. This new technique could be an alternative method to resolve LA size discrepancies in orthotopic heart transplantation.

Nutritional indices for screening sarcopenia before adult cardiac surgery.

Background: Malnutrition can increase and exacerbate sarcopenia, and preoperative nutritional indices could have potential use as screening tools for sarcopenia in all patients, not only those with limited activity. Muscle strengths, such as grip strength, chair stand test, are used to screen for sarcopenia, but these measurements are time-consuming and cannot be applied to all patients. This retrospective study was conducted to determine whether nutritional indices can predict the presence of sarcopenia before adult cardiac surgery. Methods: The study subjects were 499 patients aged ≥18 who had undergone cardiac surgery using a cardiopulmonary bypass (CPB). Bilateral psoas muscle mass areas at the top level of the iliac crest were measured by abdominal computed tomography. Preoperative nutritional statuses were evaluated using COntrolling NUTritional status (CONUT) score, Prognostic Nutritional Index (PNI), and Nutritional Risk Index (NRI). Receiver operating characteristic (ROC) curve analysis was used to identify the nutritional index that best predicted the presence of sarcopenia. Results: The 124 patients (24.8%) in the sarcopenic group were older (69.0 vs. 62.0 years; P<0.001), and had a lower mean body weight (58.90 vs. 65.70 kg; P<0.001) and body mass index (BMI) (2.22 vs. 2.49 kg/m2; P<0.001), and a poorer nutritional status than the 375 patients in the non-sarcopenic group. ROC curve analysis showed that NRI [area under the curve (AUC) 0.716, confidence intervals (CI): 0.664-0.768] better predicted the presence of sarcopenia than CONUT score (AUC 0.607, CI: 0.549-0.665) or PNI (AUC 0.574, CI: 0.515-0.633). The optimal NRI cut-off value was 105.25, which provided a sensitivity of 67.7% and a specificity of 65.1% for the prevalence of sarcopenia. The median durations of mechanical support (17 vs. 16 hours; P=0.008) and intensive care unit stay (3 vs. 2 days; P=0.001) were significantly longer in the sarcopenic group. Conclusions: NRI offers a more straightforward, faster, and reproducible screening tool than muscle strength or mass measurement for identifying sarcopenia, and an alternative means of assessment in patients with limited activity before adult cardiac surgery.

Alternative position of cannulae in veno-venous extracorporeal membrane oxygenation for maintaining sufficient flow support.

Blood flow disturbance of veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be a risk factor of weaning failure. We report an alternative position of cannulae of VV-ECMO which can maintain blood flow. The recirculation rate could be controlled by adjusting a position of return cannula using dilutional ultrasound monitoring.

Iatrogenic aortic dissection during right transradial intervention in a patient with aberrant right subclavian artery: A case report.

BACKGROUND: Aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. When patients having such anomalies receive transradial intervention (TRI), aortic dissection (AD) may occur. Herein, we discuss a case of iatrogenic type B AD occurring during right TRI in an ARSA patient, that was later salvaged by percutaneous angioplasty. CASE SUMMARY: A 73-year-old man presented to our hospital with intermittent chest pain. Coronary computed tomography (CT) angiography revealed significant stenosis in the left anterior descending artery. Diagnostic coronary angiography was performed via the right radial artery without difficulty. However, we were unable to advance the guiding catheter past the ostium of the right subclavian artery to the aortic arch for percutaneous coronary intervention, while the guidewire tended to go down the descending aorta. The patient suddenly complained of chest and back pain. Emergent CT aortography revealed type B AD propagating to the left renal artery (RA) with preserved renal perfusion. However, after 2 d, the patient suddenly complained of right lower limb pain where the femoral pulse was suddenly undetectable. Follow-up CT indicated further progression of dissection to the right external iliac artery (EIA) and left RA with limited flow. We performed percutaneous angioplasty of the right EIA and left RA without complications. Follow-up CT aortography at 8 mo showed optimal results. CONCLUSION: A caution is required during right TRI in ARSA to avoid AD. Percutaneous angioplasty can be a treatment option.

Effects of Ti-doping amount and annealing temperature on electrochromic performance of sol-gel derived WO3.

Fine control of structural and morphological features in electrochromic materials is of paramount importance for realizing practical electrochromic devices (ECDs), which can dynamically adjust indoor light and temperature of buildings. To this end, herein we investigate impacts of two variants such as Ti-doping amount and the annealing temperature on physical and chemical properties of sol-gel derived electrochromic WO3 films. We use a wide range of titanium coupling agents (TCAs) as Ti-dopants ranging from 0 wt% to 20 wt% and vary the annealing temperature between 200 °C and 400 °C with 50 °C interval. Both variants greatly influence the physical properties of the resulting WO3 films, resulting in different crystallinities and morphologies. Through complementary analytical techniques, we find that the WO3 film featuring an amorphous phase with nano-porous morphology enhances the electrochemical and electrochromic performances. The specific TCA used in this study helps stabilize the amorphous WO3 structure and generate the nano-pores during the following thermal treatment via its thermal decomposition. As a result, the WO3 film having an optimal 8 wt% TCA annealed at 300 °C shows a high optical density of 73.78% in visible light (400-780 nm), rapid switching speed (t c = 5.12 s and t b = 4.74 s), and high coloration efficiency of 52.58 cm2 C-1 along with a superior cyclic stability. Thus, understanding a structure-property relationship is of paramount importance in engineering the advanced electrochromic WO3 for use in practical ECDs and other optoelectronic applications.

Hyperglycemia and Hypoglycemia Are Associated with In-Hospital Mortality among Patients with Coronavirus Disease 2019 Supported with Extracorporeal Membrane Oxygenation.

Metabolic abnormalities, such as preexisting diabetes or hyperglycemia or hypoglycemia during hospitalization aggravated the severity of COVID-19. We evaluated whether diabetes history, hyperglycemia before and during extracorporeal membrane oxygenation (ECMO) support, and hypoglycemia were risk factors for mortality in patients with COVID-19. This study included data on 195 patients with COVID-19, who were aged ≥19 years and were treated with ECMO. The proportion of patients with diabetes history among nonsurvivors was higher than that among survivors. Univariate Cox regression analysis showed that in-hospital mortality after ECMO support was associated with diabetes history, renal replacement therapy (RRT), and body mass index (BMI) < 18.5 kg/m2. Glucose at admission >200 mg/dL and glucose levels before ventilator >200 mg/dL were not associated with in-hospital mortality. However, glucose levels before ECMO >200 mg/dL and minimal glucose levels during hospitalization <70 mg/dL were associated with in-hospital mortality. Multivariable Cox regression analysis showed that glucose >200 mg/dL before ECMO and minimal glucose <70 mg/dL during hospitalization remained risk factors for in-hospital mortality after adjustment for age, BMI, and RRT. In conclusion, glucose >200 mg/dL before ECMO and minimal glucose level <70 mg/dL during hospitalization were risk factors for in-hospital mortality among COVID-19 patients who underwent ECMO.

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019: Expert Recommendations from The Korean Society for Thoracic and Cardiovascular Surgery.

Since the first reported case of coronavirus disease 2019 (COVID-19) in December 2019, the numbers of confirmed cases and deaths have continued to increase exponentially despite multi-factorial efforts. Although various attempts have been made to improve the level of evidence for extracorporeal membrane oxygenation (ECMO) treatment over the past 10 years, most experts still hesitate to take an active position on whether to apply ECMO in COVID-19 patients. Several ECMO management guidelines have been published recently, but they reflect some important differences from the Korean medical system and aspects of real-world medical practice in Korea. We aimed to find evidence on the efficacy of ECMO for COVID-19 patients by reviewing the published literature and to propose expert recommendations by analyzing the Korean COVID-19 ECMO registry data.

A Rare Combination of CYP2C9*3/*3 and VKORC1 1639AA in a Patient Who Had Myxoma and Thromboembolism.

We report a case of intolerance to warfarin. A 20-year-old woman with toe pain was diagnosed with myxoma with multiple systemic embolisms. She was prescribed warfarin for remaining embolic pain after myxoma excision and mitral annuloplasty. Even on 1 mg of warfarin, the international normalized ratio was much increased. The patient was found to have cytochrome P450 2C9 (CYP2C9)*3/*3 and vitamin K epoxide reductase complex subunit 1 (VKORC1) 1639AA genotype, which is extremely rare in Koreans. Based on this result, we assessed the potential risks and benefits of warfarin and decided to switch to aspirin because the risk of bleeding was considered to be too high.

Does the prognostic nutritional index have a predictive role in the outcomes of adult cardiac surgery?

OBJECTIVE: Malnutrition is known to affect postoperative outcomes, but only a limited number of assessment methods are available for evaluating nutritional status before cardiac surgery. The purpose of this study was to investigate the clinical significance of the prognostic nutritional index for adult patients undergoing cardiac surgery. METHODS: We retrospectively reviewed the medical records of 374 patients aged more than 18 years who underwent cardiac surgery with cardiopulmonary bypass. Patients were divided into 2 groups based on the cutoff prognostic nutritional index, and these groups were compared with respect to early morbidity and mortality rates, intensive care unit stays, and long-term outcomes. Logistic regression analyses were performed to identify the risk factors of early outcomes. RESULTS: The calculated cutoff value of the prognostic nutritional index was 46.13. Early mortality and morbidity were significantly more common in the high-risk group (9.0% vs 2.9%: P = .02, 58.0% vs 42.0%: P = .01). The median duration of mechanical ventilation support (18.0 vs 16.0 hours: P < .01) and intensive care unit stays (3.0 vs 2.0 days: P < .01) were also longer in the high-risk group. However, no significant intergroup difference was observed for the long-term clinical outcomes. Multivariate analysis showed that the prognostic nutritional index, age, cardiopulmonary bypass time, and aortic crossclamp time independently predicted early outcomes. Of these, only the prognostic nutritional index and age were significant preoperative variables (P = .01 and P < .01). CONCLUSIONS: The prognostic nutritional index may be a useful preoperative nutrition screening tool for predicting the early clinical outcomes of adult patients after cardiac surgery using cardiopulmonary bypass.