Clinical Outcome of Urgent Coronary Artery Bypass Grafting

Urgent coronary artery bypass grafting (CABG) has a higher mortality rate than elective CABG. The purpose of this study was to evaluate the clinical outcome of urgent CABG. From July 1992 to May 2005, 104 patients underwent urgent CABG. All patients required an urgent surgical revascularization within 24 hr of diagnostic coronary angiography. In-hospital mortality after urgent CABG was 17.3% (18/104). We compared preoperative characteristics and postoperative clinical outcomes between the survival group (n=86) and the mortality group (n=18). The mean age was 61.7 yr (range, 35-83). The most common cause of mortality was low cardiac output. The independent preoperative risk factors of mortality included advanced age (>70 yr) (OR=3.998, p=0.046), preoperative shock status (OR=6.542, p=0.011), and low ejection fraction (<40%) (OR=4.492, p=0.034). Other risk factors of mortality included prolonged cardiopulmonary bypass time, prolonged ventilator use, and extended intensive care unit stay. The 10-yr actuarial survival rate was 61%. Although the operative mortality rate was high after urgent CABG, a favorable long-term clinical outcome can be expected if the patients survive.

Clinical Outcome of Emergency Coronary Artery Bypass Grafting after Failed Percutaneous Transluminal Coronary Angioplasty / 대한흉부외과학회지

BACKGROUND: Failed percutaneous transluminal coronary angioplasty (PTCA) is occasionally required for emergency coronary artery bypass grafting (CABG). The aim of this study was to assess the outcome of patients receiving emergency CABG after failed PTCA. MATERIAL AND METHOD: Between May 1988 and May 2005, 5712 patients underwent PTCA, where 84 (1.4%) failed. 27 patients underwent emergency CABG after failed PTCA. The mean age was 63.7+/-8.9 (46~80) years, with 14 male patients (51.9%). RESULT: All patients underwent emergent surgical revascularization within 6 hours. 22 patients underwent conventional CABG and 5 underwent off-pump CABG. The causes of PTCA failure were coronary obstruction due to new thrombi formation during the procedure (n=4), coronary dissection (n=17), coronary artery rupture (n=3) and 3 due to other causes. The rate of in-hospital operative mortality after emergent operation was 18.5% (5/27). A univariate analysis revealed that patients who died more often had left anterior descending artery disease, a preprocedural shock status, postoperative use of multiple isotropics and postoperative use of intra-aortic balloon pump. The mean follow up duration was 53.6+/-63.4 months. CONCLUSION: Although PTCA is known to be life saving, there is still a high risk for morbidity and mortality following emergency CABG after failed PTCA, despite the advancement in PTCA techniques. This result will help identify and more effectively treat patients selected for PTCA when emergency CABG is required.

Surgical Repair of Left Coronary Artery Pseudoaneurysm 10 Years after a Bentall's Procudure / 대한흉부외과학회지

The aortic inclusion technique is frequently used in the original Bentall's procedure for the control of excessive postoperative bleeding. Although this procedure has improved the outcome of patients with aortic root disease, there is a high incidence of both early and late complications, including coronary artery stenosis, kinking or pseudoaneurysm formation at the coronary suture lines. Pseudoaneurysm of the ascending aorta is a relatively rare, but fatal complication, which occurs after wrap-inclusion composite graft replacement. Herein, the case of a 45-year-old female, who developed a perigraft aortic pseudoaneurysm 10 years after a Bentall's procedure (wrap-inclusion technique), but was successfully managed using the Cabrol's method, is reported.

Clinical Results of Minimally Invasive Open-Heart Surgery in Patients with Mitral Valve Disease: Comparison of Parasternal and Low-Sternal Approach

Clinical results of minimally invasive mitral valve surgery were retrospectively reviewed, and two different surgical approaches were compared in this study. Between 1997 and 2004, a total of 86 patients with mitral valve disease underwent minimally invasive surgery at theYonsei University Cardiovascular Center. Age of patients averaged 41.6 +/- 14.0 years and 69 patients were female. Surgical approach included low-sternal incisions with mini-sternotomy, and right parasternal or thoracotomy approach. Either direct aortic or femoral arterial and bicaval cannulations were used in all patients. Patients were divided into two groups according to the method of surgical approach (parasternal (P) vs low-sternal (L)), and the results were compared. Postoperative NYHA functional class improved to 1.1 +/- 0.4 in all patients (no significant statistical difference between two groups). Mean wound length (P: 9.21 +/- 1.10 vs L: 11.24 +/- 0.82 cm, p < 0.05), and mechanical ventilation time (P: 10.42 +/- 4.36 vs L: 12.90 +/- 5.00 min, p=0.04) was significantly shorter in parasternal group, and mean operation time(P:294.74 +/- 59.41 vs. L:259.31 +/- 54.36 min, p=0.03) was significantly shorter in low-sternal group. Mean cardiopulmonary bypass time, and aortic cross clamp time was also shorter in low-sternal group without statistical difference. There were 2 minor wound complications in all patients (p=NS), and no hospital death. Comparing the two different surgical approach of minimally invasive mitral valve surgery, parasternal approach is thought to be more beneficial in reducing postoperative scar, and intubation time.

Clinical Results of Mitral Valvular Surgery in Patients with Moderate Ischemic Mitral Regurgitation Undergoing Coronary Artery Bypass Grafting / 대한흉부외과학회지

BACKGROUND: There have been controversies whether mitral valvular surgery is necessary in the patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting. The purpose of this study is to evaluate the long term clinical results of patients with moderate ischemic mitral regurgitation. MATERIAL AND METHOD: Between January 1992 and February 2005, 44 patients with moderate ischemic mitral regurgitation underwent coronary artery bypass grafting. Concomitant mitral valvular procedure was performed in 20 patients (group 1) and isolated coronary artery bypass grafting was performed in 24 patients (group 2). There were no significant difference between groups except cardiopulmonary bypass time (p<0.01). Postoperative follow up duration was 30.1+/-29.6 months and last follow up echocardiographic examination was performed at 21.2+/-28.0 months. RESULT: There was no difference in operative mortality between groups (group 1 vs group 2, 15.0% vs 8.3%, p=0.493). Grade of mitral regurgitation (0.81+/- 0.91 vs 1.50+/- 0.05, p=0.046) and reduction in regurgitation grade (1.75 +/-0.93 vs 0.70 +/-1.26, p=0.009) were different between two groups. But there were no significant differences in left ventricular ejection fraction (34.1+/-11.4% vs 41.6+/-12.9%), left ventricular end systolic volume (118.2+/-63.9 mL vs 85.6+/-28.1 mL), New York Heart Association functional class (2.1+/-0.2 vs 2.4+/-1.2) and 5 year survival rate (85+/-8% vs 82+/-8%). There was no risk factor for operative mortality and the only risk factor for late death was preoperative atrial fibrillation (p=0.042). There was no significant correlation between mitral valvular surgery and late death. CONCLUSION: Concomitant mitral valvular procedure in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting had no significant positive effect on survival and ventricular function compared with isolated coronary artery bypass grafting. Prospective randomized study may be needed to evaluate the necessity of concomitant mitral procedure and to find more effective method for the improvement of ventricular function.

Clinical Results of Mitral Valvular Surgery in Patients with Moderate Ischemic Mitral Regurgitation Undergoing Coronary Artery Bypass Grafting / 대한흉부외과학회지

BACKGROUND: There have been controversies whether mitral valvular surgery is necessary in the patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting. The purpose of this study is to evaluate the long term clinical results of patients with moderate ischemic mitral regurgitation. MATERIAL AND METHOD: Between January 1992 and February 2005, 44 patients with moderate ischemic mitral regurgitation underwent coronary artery bypass grafting. Concomitant mitral valvular procedure was performed in 20 patients (group 1) and isolated coronary artery bypass grafting was performed in 24 patients (group 2). There were no significant difference between groups except cardiopulmonary bypass time (p<0.01). Postoperative follow up duration was 30.1+/-29.6 months and last follow up echocardiographic examination was performed at 21.2+/-28.0 months. RESULT: There was no difference in operative mortality between groups (group 1 vs group 2, 15.0% vs 8.3%, p=0.493). Grade of mitral regurgitation (0.81+/- 0.91 vs 1.50+/- 0.05, p=0.046) and reduction in regurgitation grade (1.75 +/-0.93 vs 0.70 +/-1.26, p=0.009) were different between two groups. But there were no significant differences in left ventricular ejection fraction (34.1+/-11.4% vs 41.6+/-12.9%), left ventricular end systolic volume (118.2+/-63.9 mL vs 85.6+/-28.1 mL), New York Heart Association functional class (2.1+/-0.2 vs 2.4+/-1.2) and 5 year survival rate (85+/-8% vs 82+/-8%). There was no risk factor for operative mortality and the only risk factor for late death was preoperative atrial fibrillation (p=0.042). There was no significant correlation between mitral valvular surgery and late death. CONCLUSION: Concomitant mitral valvular procedure in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting had no significant positive effect on survival and ventricular function compared with isolated coronary artery bypass grafting. Prospective randomized study may be needed to evaluate the necessity of concomitant mitral procedure and to find more effective method for the improvement of ventricular function.

Clinical Experiences of Cardiac Myxoma

Although cardiac myxoma is rare, it is the most common primary cardiac tumor. Seventy-four cases of cardiac myxoma that were surgically treated in our center between August 1980 and February 2005 were retrospectively reviewed. The mean patient age was 50.4+/-15.0 (range 7-80) years, and 53 patients (71.6%) were female. The most common preoperative symptom, occurring in 44 patients, was dyspnea. The interval from onset of symptoms to surgery was 9 months. Seventy cases were located in the left atrium, 3 in the right atrium and 1 in the right ventricle. The myxoma in the right ventricle could not be resected completely, due to severe infiltration. Cardiopulmonary bypass and aortic cross clamp times were 100.4+/-37.1 and 64.8+/-29.8 minutes, respectively. There were no hospital deaths, and 7 patients suffered from postoperative complications including atrial fibrillation in 2 cases. During the follow up period (mean 105.7+/-73.6 months), there was no tumor recurrence and 6 late deaths that were not related to the underlying tumor. There was no evidence of tumor growth in the cases with incomplete resection during the 14-month follow-up. In conclusion, in this study there was no recurrence of tumors after complete resection and surgical resection is considered to be the curative method of treatment for cardiac myxoma.

Clinical Experiences of Cardiac Myxoma

Although cardiac myxoma is rare, it is the most common primary cardiac tumor. Seventy-four cases of cardiac myxoma that were surgically treated in our center between August 1980 and February 2005 were retrospectively reviewed. The mean patient age was 50.4+/-15.0 (range 7-80) years, and 53 patients (71.6%) were female. The most common preoperative symptom, occurring in 44 patients, was dyspnea. The interval from onset of symptoms to surgery was 9 months. Seventy cases were located in the left atrium, 3 in the right atrium and 1 in the right ventricle. The myxoma in the right ventricle could not be resected completely, due to severe infiltration. Cardiopulmonary bypass and aortic cross clamp times were 100.4+/-37.1 and 64.8+/-29.8 minutes, respectively. There were no hospital deaths, and 7 patients suffered from postoperative complications including atrial fibrillation in 2 cases. During the follow up period (mean 105.7+/-73.6 months), there was no tumor recurrence and 6 late deaths that were not related to the underlying tumor. There was no evidence of tumor growth in the cases with incomplete resection during the 14-month follow-up. In conclusion, in this study there was no recurrence of tumors after complete resection and surgical resection is considered to be the curative method of treatment for cardiac myxoma.

Clinical Experiences for Primary Cardiac Tumors / 대한흉부외과학회지

BACKGROUND: Primary cardiac tumors are known to be rare. We studied the surgical results for primary cardiac tumors. MATERIAL AND METHOD: Between August 1980 and December 2003, we classified 86 patients who had operation for primary cardiac tumors in our center into 3 groups; myxoma, nonmyxoma benign tumors, and malignant tumors. The mean age was 44.3+/-20.8 years and 59 patients (66.3%) were female. In postoperative pathologic diagnosis, there were 81 cases (94.2%) of benign tumors in which myxoma was the most common tumor (70 cases, 78.7%); 5 fibroma (5.6%), 3 rhabdomyoma (3.4%), and 5 malignant tumors (5.8%). RESULT: 86.4% of benign tumor was myxoma and the mean age was 50.4+/-15.4 (range 7~80) years. Tumor was more common in females (49 cases) and most common preoperative symptom was dyspnea (62.9%). 57 cases were located at left atrial septum and only one case, which was located at right ventricular septum, was resected incompletely. There were no hospital deaths and one patient had mitral valve replacement on the first operative day due to newly developed postoperative mitral regurgitation. The mean follow up period was 109.3+/-71.8 months and there was no evidence of recurrence in this period. 11 cases (12.8%) were nonmyxoma benign tumors; 5 fibromas, 3 rhabdomyomas, etc. There were two hospital deaths and the causes of death were fungal endocarditis and hypoxia. There were no reoperations in nonmyxoma benign tumors. Malignant tumors were in 5 cases (5.8%); undifferentiated sarcoma in 2, rhabdomyosarcoma in 1, etc. Although there were no hospital mortalities, 3 patients who were followed up died from complications of tumors. CONCLUSION: Myxomas showed very excellent prognosis after complete resection and nonmyxoma benign tumors showed relatively good results for relief of symptoms. Surgery helped to relieve symptoms for malignant tumors, but the prognosis was poor.

Long Term Clinical Results of Triple Valve Replacement / 대한흉부외과학회지

BACKGROUND: Clinical reports on replacement of all three (AV+MV+TV) valves are rare. MATERIAL AND METHOD: From January 1992 to December 2003, 38 patients received triple valve replacement (aortic, mitral, tricuspid) at Yonsei Cardiovascular Center. Mean age of patients was 49.5+/-10.7 (28~69) years, and 24 patients (63.1%) were female. Rheumatic valve disease was the most common cause of operation (n=37). Preoperative New York Heart Association functional class were II in 4, III in 24 and IV in 10. Fifteen patients (group 1) received triple valve replacement at their first operation. Twenty three patients (group 2) received one or more operations before tricuspid valve replacement (TVR). Seven patients received tricuspid valve annuloplasty at first operation and received TVR later. RESULT: Six patients died at hospital after operation (15.8%) and all these patients were in group 2. All patients in group I survived and were discharged. Three patients (9.4%) died during follow up periods. Most of the survivors had improved functional class (I in 22, II in 8, III in 1, IV in 1). During follow up period, there were 4 valve related complications. The 10-year survival rate was 68.8% and survival rate for free from valve related event at 10 years was 85.5%. CONCLUSION: After triple valve replacement, most patients showed improvement of symptoms. And during follow up period, valve related complications and survival were acceptable. Therefore, if indicated, triple valve replacement is recommended before the patients' conditions get worse.

Long-term Result after Repair of Sinus Valsalva Aneurysm Rupture / 대한흉부외과학회지

BACKGROUND: Sinus valsalva aneurysm (SVA) is a rare disease, and it is frequently accompanied by ventricular septal defect and aortic valve regurgitaion. For treatment of SVA, several surgical mordalities were applied, but there was no report on the long-term result after surgical repair in Korea. We reviewed our 28 years of experiences and analyzed the long-term results after treatment of sinus valsalva aneurysm with or without rupture. MATERIAL AND METHOD: Between March 1974 and February 2002, 81 patients were operated under the impression of sinus valvsalva aneurysm or sinus valsalva aneurym rupture. Retrospectively we reviewed the patients' record. Mean age of patients was 29.2+/-11.5 and there were 49 males. Accompanyng diseases were as follows: VSD in 50, PDA in 2, Behcet's disease in 2, TOF in 1, RVOTO in 1, AAE in 1. Seventy-seven (95%) patients had sinus valsalva rupture and in 14 patients, subacute bacterial endocarditis was accompanied. Degree of aortic valve regurgitation was as follows: grade I: 8, II: 10, III: 9, IV: 4. Most common rupture site was right coronary sinus (66 patients, 81%) and most common communication site was right ventricle (53 patients). In repair of sinus valsalva rupture, patch was used in 37 patients, and direct suture was done in 38 patients. RESULT: There was one surgical death (1.2%). Follow up was done in 78 patients (97.5%), mean follow up period was 123.3+/-80.9 (3~330 months). During the follow up period, 3 patients died (3.8%). One patient died of heart failure, another patient died of arrhythmia and the other one died of unknown cause. In two patients, complete atrio-ventricular block was developed during follow up period, and there was no operation related event or complication. Kaplan-Meier survival analysis revealed 92.5+/-3.5% survival at 15 and 27 years and it seems to be satisfactory. CONCLUSION: Long-term surgical results and survival is satisfactory after repair of sinus valsalva aneurysm with or without rupture.

Clinical Evaluation of Coronary Artery Fistula / 대한흉부외과학회지

BACKGROUND: Coronary artery fistula is rare congenital anomaly, which account for 0.27~0.40% of all congenital heart diseases. We report the clinical observations of 45 patients with coronary artery fistula. MATERIAL AND METHOD: We reviewed all patients presented with or without symptoms of coronary artery fistula between 1987 and 2004. Age ranged from 1 to 83 years. Twenty-six patients were female. The patients were divided into 2 groups according to the presenting symptoms. Twelve patients were in group A (asymptomatic) and 33 patients in group B (symptomatic). The most common clinical presentation in group B was angina (18) followed by dyspnea (7), atypical chest pain (5), syncope (1), fatigue (1), and palpitation (1). Twenty-five patients were associated with other cardiac diseases, which were atrial septal defect (4), coronary artery occlusive disease (6), hypertension (12), and valvular heart disease (2). RESULT: Patients were followed-up for a mean period of 64.8+/-62.7 months. There was no complication related to coronary artery fistula during the follow-up period in both group. There was no mortality related to coronary artery fistula. CONCLUSION: In symptomatic patients, early surgical treatment is recommended considering the low perioperative morbidity. In asymptomatic patients receiving medical treatment, close follow up may be necessary.

Clinical Analysis of Surgical Results for Discrete Subaortic Stenosis / 대한흉부외과학회지

BACKGROUND: Discrete subaortic stenosis is known to recur frequently even after surgical resection. We retrospectively reviewed the preoperative and postoperative changes in pressure gradient through left ventricular outflow tract, and the recurrence rate. MATERIAL AND METHOD: Between September 1984 and December 2004, 34 patients underwent surgical treatment. Mean age of patients was 17.1+/-15.2 years and 19 patients (55.9%) were male. 16 patients (47.1%) had previous operations and associated diseases were aortic regurgitation (11), coarctation of aorta (3), and others. RESULT: Immediate postoperative peak pressure gradient was significantly lower than preoperative peak pressure gradient (21.8 mmHg vs 75.8 mmHg, p<0.01). Peak pressure gradient measured after 50.3 months of follow up was 20.2 mmHg, which was also significantly lower than that of preoperative value but not significantly different from that of immediate postoperative value. There was no surgical mortality but one patient developed cerebral infarction. Mean follow up duration was 69.8+/-54.6 months. During this period, 5 patients (14.7%) had reoperation, 3 (8.8%) of whom were due to recurred subaortic stenosis. We found no risk factors for recurrence and survival for free from reoperation was 76.4%. CONCLUSION: Excision of subaortic membrane combined with or without myectomy in discrete subaortic stenosis showed sufficient relief of left ventricular outflow tract obstruction with low mortality and morbidity, but careful long term follow up is necessary for recurrence, since it is not predictable.

Long-Term Clinical Results of Tricuspid Valve Replacement / 대한흉부외과학회지

BACKGROUND: There are only limited numbers of reports about long-term results of tricuspid valve replacement (TVR) with bioprosthetic and mechanical prostheses. We analyzed risk factors for tricuspid valve replacement and compared long-term clinical results of bioprosthetic and mechanical valves in tricuspid position. MATERIAL AND METHOD: We reviewed 77 cases of TVR, which were performed between October 1978 and December 1996. Mean age was 38.8 15.9 years. Bioprostheses were implanted in 26 cases and mechanical prostheses were implanted in 51 cases. RESULT: The operative mortality was 15.6% and late mortality was 12.3%. Survival for bioprosthetic and mechanical valve group at 5, 10 and 13 years was 81.3% vs. 100%, 66.1% vs. 100%, 60.6% vs. 100% (p= 0.0175). Free from valve related re-operation for bioprosthetic and mechanical valve group at 5, 10 and 13 years was 100 % vs. 93.9%, 100% vs. 93.9% and 58.3% vs. 93.9% (p=0.3274). Linealized incidences of valve related re-operation for bioprosthetic and mechanical valve group was 2.27 %/patient-years and 1.10 %/patient-years. Risk factor analysis showed that presence of preoperative ascites, hepatomegaly larger than 2 finger breaths, poor preoperative NYHA functional class and number of tricuspid valve replacement were risk factors for early mortality, and the use of bioprosthetic valve and number of open heart surgery were risk factors for late mortality. CONCLUSION: Long-term survival of mechanical valve was superior to bioprosthetic valve in tricuspid position. We recommend mechanical valve in tricuspid position if the patient can be closely followed up.

Comparison of Clinical Outcomes of Off-pump versus On-pump Coronary Artery Bypass Grafting in Diabetes Patients / 대한흉부외과학회지

BACKGROUND: Avoiding cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) has been known to reduce early mortality and morbidity. Diabetes Mellitus is a significant risk factor for adverse early and late outcomes after CABG. We compared the clinical results of off-pump CABG versus on-pump CABG in diabetes patients. MATERIAL AND METHOD: 682 patients (424 off-pump CABG and 258 on-pump CABG) underwent isolated coronary artery bypass grafting between January 2001 and June 2003. Data were collected 242 patient who had diabetes. Among them, 154 patients underwent off-pump CABG and 90 patients underwent on-pump CABG. We analyzed the preoperative risk factors and postoperative results between 2 groups. RESULT: Two groups did not show statistical differences in age, sex, coronary and operative risk factors. Operative time was significantly shorter in off-pump CABG, however, number of grafts was fewer in off-pump CABG. Postoperative inotropic usage was lower in off-pump CABG. Postoperative CK-MB level was lower in off-pump CABG, and ICU stay and ventilation time was significantly shorter in off-pump CABG. However, there was no statistical difference between 2 groups in operative mortality, reoperation rate, perioperative myocardial infarction, wound infection, renal failure, neurological complications and hospital stay. CONCLUSION: Off-pump CABG group showed less myocardial damage and early recovery. We concluded that off-pump CABG is the more reasonable technique in diabetes patients although two techniques showed good results. The long-term follow up and prospective study may be warranted.

Clinical Experience of Abdominal Aortic Aneurysm / 대한흉부외과학회지

BACKGROUND: Surgery of abdominal aortic aneurysm revealed high operative mortality. We reviewed our 11-years' experiences of abdominal aortic aneurysm operation and wish to obtain information on the treatment. MATERIAL AND METHOD: From Jan. 1990 to Dec. 2000, 48 patients were operated due to abdominal aortic aneurysm in Yonsei Cardiovascular Center. Mean age was 62.8+/-12.7 and there were 40 males and 8 females. Among 48 patients, nine patients had ruptured abdominal aortic aneurysm, and mean aneurysm diameter of non-ruptured cases was 8.8+/-2.4 cm. RESULT: There were 6 early deaths, and early mortality was 12.5%. Among 9 patients of preoperative aneurysm rupture, three patients died (33.3%), and among 39 patients of non-ruptured cases, 3 patients died (7.7%). Among preoperative variables, age (p<0.05), preoperative BUN level (p<0.05), and DM (p<0.05) were risk factors of early mortality. Among discharged 42 patients, 40 patients were followed up (f/u rate=95.2%) and mean follow up was 3.6+/-0.2 years. During follow up periods, five patients died (late mortality=11.9%), and Kaplan-Meier survival analysis revealed 81.7+/-7.6% survival rate at five and ten year. Linealized incidence of graft related event was 3.53% per patient-year. CONCLUSION: Surgical mortality of ruptured abdominal aortic aneurysm was higher than non-ruptured cases; therefore, early resection of the aneurysm can decrease the surgical mortality.

Early and Late Surgical Result of Post MI-VSD / 대한흉부외과학회지

BACKGROUND: Despite early aggressive treatment, post myocardial infarction(MI) ventricular septal defect(VSD) revealed high surgical mortality. We reviewed the 10-year experiences of surgically treated post-MI VSD in Yonsei University. MATERIAL AND METHOD: From Jan. 1991 to May 2001, 17 patients underwent surgical repair of post-MI VSD. Ages ranged between 47 and 77 years (mean age=63.2+/-9.1). There were 10 males and 7 females. VSD was located at anterior in 16 patients and at posterior in one. IABP was inserted preoperatively in 12 patients due to cardiogenic shock. Mean interval from MI to occurrence of VSD was 5.6 days. Among patients undergoing early surgical correction(n=13), mean interval from occurrence of VSD to operation was 2.5 days. In 11 patients, concomitant CABG was performed during repair of VSD. RESULT: Four patients died within 30 days after the operation (30 day mortality=23.5%). Among 12 patients with preoperative cardiogenic shock, 4 patients died within 30 days (30-day mortality=33.3%). During mean follow up period of 52 months, one patient died of unknown cause and 10-year survival of discharged patients was 66.7%. All follow-up patients were in NYHA functional class I or II when their last OPD visit. CONCLUSION: In the treatment of post-MI VSD, aggressive medical treatment with early surgical correction seems to be very important in terms early and long-term survival of patients.

Prognostic Factors Affecting Postoperative Morbidity and Mortality in Destroyed Lung / 대한흉부외과학회지

BACKGROUND: Postoperative morbidity and mortality in destroyed lung are relatively high. We tried to identify the prognostic factors affecting postoperative morbidity and mortality in destroyed lung through a retrospective study. MATERIAL AND METHOD: The retrospective study was undertaken in 112 patients who had undergone pneumonectomy or pleuropneumonectomy for destroyed lung at Severance Hospital from 1970 to 2000. We analyzed the correlation between postoperative morbidity and mortality and etiology, duration of disease, preoperative FEV1, presence or absence of preoperative empyema, operation timing, the side of operation, duration of operation, and operation type. RESULT: There were 55 men and 57 women, aged 20 to 81 years (mean 44 years). Etiologic diseases were tuberculosis in 86 patients(76.8%) including tuberculous empyema in 20 and tuberculous bronchiectasis in 4, pyogenic empyema in 12(10.7%), bronchiectasis in 12(10.7%), and lung abscess in 2(1.8%). Postoperative morbidity were 25%(n=28) and postoperative mortality was 6%(n=7). The presence of preoperative of empyema(p=0.016), pleuropneumonectomy(p=0.037) and preoperative FEV1 of less than 1.75 L(P=0.048) significantly increased the postoperative morbidity. If operation time was less than 300min, postoperative morbidity(p=0.002) and mortality(p=0.03) were significantly low. CONCLUSION: Postoperative morbidity and mortality in destroyed lung were acceptable. Postoperative morbidity and mortality were significantly low when operation time was less than 300 min. Preoperative existence of empyema, pleuropneumonectomy and preoperative FEV1 of less than 1.75 L significantly increased postoperative morbidity.

Clinical Experiences of redo-CABG / 대한흉부외과학회지

BACKGROUND: Recently, the number of coronary artery bypass surgery(CABG) is increasing according to the increasing incidence of coronary artery disease. However, CABG is not a definite corrective surgery; therefore, in some patients, redo-CABG may be required. We retrospectively reviewed our redo-CABG experiences to help future redo-CABG. MATERIAL AND METHOD: From January 1991 to April 2001, 14 cases of redo-CABG were performed in Yonsei Cardiovascular Center(M:F=12:2) and mean age was 61.7+/-7.1(47-72) years. Mean time from 1st. CABG to redo-CABG was 121.9+/-50.5(6.1-179.6) months. Thirteen cases were conventional on-pump CABG and one case was off-pump CABG. In two patients, mitral valve re-replacement and mitral valve repair were performed each. All redo-CABG were performed through mid-sternotomy. During redo-CABG, left internal mammary artery and saphenous vein grafts were used in 6 patients, left internal mammary artery and left radial artery grafts were used in 2 patients, left internal mammary artery and gastroepiploic artery were used in one patient and only greater saphenous veins were used in 5 cases(In one case, cephalic vein was also used). The number of mean distal anastomosis was 2.1+/-0.9(1-4). RESULT: There were no operative death and no perioperative myocardial infarctions and cerebrovascular accidents or other heart related complications. Mean follow up duration was 40.1+/-38.6(1.1-118.5) months. During follow up period, angina was re-developed in one patient 13 months after operation. Two patients died of end-stage renal failure 14.8 months and 116.3 months after redo-CABG, respectively. During follow up period, coronary angiography was performed in 3 patients, and all grafts were patent. At last follow up, mean Canadian class was 1.3. Kaplan-Meier survival at 9 years was 90.0+/-9.5% and event free survival at 9 years was 71.4+/-6.9%. CONCLUSION: After redo-CABG,all patients improved their angina symptom and daily activity. And long-term survival after redo-CABG was excellent. Therefore, if patients have indications for redo-CABG, thenredo-CABG must be strongly recommended and performed.

Dobutamine Echocardiography in Chronic Coronary Artery Disease with Left Ventricular Dysfunction

BACKGROUND: Dobutamine echocardiography has been shown to be a valuable tool for determining myocardial viability in both acute and chronic coronary artery disease with left ventricular dysfunction. The purpose of the our study was to identify the role of dobutamine echocardiography in the prediction of improvement of regional left ventricular (LV) dysfunction after revascularization of chronic coronary artery disease. METHODS: Twenty-three patients (mean age 61.2+/-9.0 years;20 men) with chronic LV dysfunction underwent dobuta-mine echocardiography (dobutamine:baseline, 5, 10, 20 microgram/Kg/min) before coronary revascularization (coronary artery bypass graft surgery 16, percutaneous coronary angioplasty 7). The mean LV ejection fraction was 42.9+/-8.8% with ranging from 26% to 58%. Follow-up echocardiography was performed at 2 to 21 months (mean 9.0+/-6.2 months) after revascularization. RESULTS: During dobutamine echocardiography, there was no major complication. Improvement of the dysfunctional myocardium was observed in 12 of 23 patients in dobutamine echocardiography. Among them, 10 patients showed functonal recovery after revascularization. Another 11 patients did not show improvement of dysfunctional myocardium in dobutamine echocardiography, however 3 of them showed functional recovery after revascularization. One hundred fifteen dysfunctional segments were found in 368 segments of 23 patients, and improvement of wall motion abnormality was observed in 46 of 115 segments in dobutamine echocardiography. Among them, 31 segments showed functional recovery after revascularization. Another 69 segments did not show wall motion improvement in dobutamine echocardiography. But among them, 13 segments showed functional recovery after revas-cularization. The sensitivity and specificity of dobutamine echocardiography for the prediction of postoperative improvement of segmental wall motion were 70% and 79%, respectively. The positive and negative predictive value of dobutamine echocardiography were 67% and 81%, respectively. CONCLUSION: In patients with chronic LV dysfunction, dobutamine echocardiography can be used as a predictor of the improvement of dysfunctional segments after revascularization.