The Impact of an Attending Intensivist on the Clinical Outcomes of Patients Admitted to the Cardiac Surgical Intensive Care Unit after Coronary Artery Bypass Grafting

Background@#We aimed to investigate the associations of critical care provided in a cardiac surgical intensive care unit (CSICU) staffed by an attending intensivist with improvements in intensive care unit (ICU) quality and reductions in postoperative complications. @*Methods@#Patients who underwent elective isolated coronary artery bypass grafting (CABG) between January 2007 and December 2012 (the control group) were propensity- matched (1:1) to CABG patients between January 2013 and June 2018 (the intensivist group). @*Results@#Using propensity score matching, 302 patients were extracted from each group. The proportion of patients with at least 1 postoperative complication was significantly lower in the intensivist group than in the control group (17.2% vs. 28.5%, p=0.001). In the intensivist group, the duration of mechanical ventilation (6.4±13.7 hours vs. 13.7±49.3 hours, p=0.013) and length of ICU stay (28.7±33.9 hours vs. 41.7±90.4 hours, p=0.018) were significantly shorter than in the control group. The proportions of patients with prolonged mechanical ventilation (2.3% vs. 7.6%, p=0.006), delirium (1.3% vs. 6.3%, p=0.003) and acute kidney injury (1.3% vs. 5.3%, p=0.012) were significantly lower in the intensivist group than in the control group. @*Conclusion@#A transition from an open ICU model with trainee coverage to a closed ICU model with attending intensivist coverage can be expected to yield improvements in CSICU quality and reductions in postoperative complications.

Clinical Outcomes of Surgical Repair with a Composite Graft for Abdominal Aortic Aneurysm Accompanied by Iliac Artery Aneurysm

Background@#Iliac artery aneurysm is frequently found in patients undergoing surgical repair of an abdominal aortic aneurysm. The use of commercial bifurcated grafts is insufficient for aorto-biiliac replacement with complete iliac artery aneurysm resection. We evaluated the effectiveness of handmade composite grafts for this purpose. @*Methods@#A total of 233 patients underwent open surgery for abdominal aortic aneurysm between 2003 and 2019, including 155 patients (67%) treated with commercial grafts and 78 patients (33%) treated with handmade composite grafts. Their operative characteristics, postoperative outcomes, and late outcomes were retrospectively reviewed. @*Results@#The early mortality rate did not differ significantly between the groups. On average, the handmade composite graft technique took approximately 15 minutes longer than the commercial graft technique (p=0.037). Among patients who underwent elective surgery, no significant differences between the conventional and composite groups were observed in the major outcomes, including red blood cell transfusion volume (2.8±4.7 units vs. 3.1±4.7 units, respectively; p=0.680), reoperation for bleeding (2.7% vs. 3.1%, respectively; p>0.999), bowel ischemia (0% vs. 1.6%, respectively; p=0.364), and intensive care unit stay duration (1.9±6.6 days vs. 1.6±2.4 days, respectively; p=0.680). The incidence of target vessel occlusion also did not differ significantly between groups. @*Conclusion@#The increased technical demand involved with handmade composite grafting did not negatively impact the outcomes. This technique may be a viable option because it overcomes problems associated with commercial grafts.

The Influence of Unfavorable Aortoiliac Anatomy on Short-Term Outcomes after Endovascular Aortic Repair

BACKGROUND: Endovascular aortic repair (EVAR) is widely performed to treat infrarenal abdominal aortic aneurysms (AAAs), and related techniques and devices continue to be developed. Although continuous attempts have been made to perform EVAR in patients with unfavorable aortic anatomy, the outcomes are still controversial. This study examined the short-term outcomes of EVAR for the treatment of infrarenal AAAs in patients with a 'hostile' neck and unfavorable iliac anatomy. METHODS: Thirty-eight patients who underwent EVAR from January 2012 to December 2017 were enrolled in this study. A hostile neck was defined based on neck length, angulation, the presence of an associated thrombus, or a conical shape. Unfavorable iliac anatomy was considered to be present in patients with a short common iliac artery (< 15 mm) or the presence of aneurysmal changes. RESULTS: No perioperative mortality was recorded. No significant differences were found depending on the presence of a hostile neck, but aneurysmal sac shrinkage was significantly less common in the group with unfavorable iliac anatomy (p=0.04). A multivariate analysis performed to analyze the risk factors for aneurysmal progression revealed only unfavorable iliac anatomy to be a risk factor (p=0.02). CONCLUSION: Patients with unfavorable aortic anatomy showed relatively satisfactory short-term outcomes after EVAR. No difference in the surgical outcomes was observed in patients with a hostile neck. However, unfavorable iliac anatomy was found to inhibit the shrinkage of the aneurysmal sac.

Hemodialysis as a life-sustaining treatment at the end of life

The Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life came into effect on February 4th, 2018, in South Korea. Based on the Act, all Koreans over the age of 19 years can decide whether to refuse life-sustaining treatments at the end of life via advance directive or physician orders. Hemodialysis is one of the options designated in the Act as a life-sustaining treatment that can be withheld or withdrawn near death. However, hemodialysis has unique features. So, it is not easy to determine the best candidates for withholding/withdrawing hemodialysis at the end of life. Thus, it is necessary to investigate the meaning and implications of hemodialysis at the end of life with ethical consideration of futility and withholding or withdrawal of intervention.

Delayed Type III Endoleak Caused by Fabric Erosion after Endovascular Repair of an Abdominal Aortic Aneurysm

A 74-year-old patient presented with recurrent aneurysms in the infrarenal abdominal aorta and right common iliac artery 6 years after endovascular aortic repair using endografts in the same location. The patient underwent an aorto-bi-iliac replacement with removal of the stent graft. Two holes measuring 2 mm each were found in the removed graft, and they appeared to have been caused by wear from continuous friction between the endograft and the aortic wall.

Does Additional Aortic Procedure Carry a Higher Risk in Patients Undergoing Aortic Valve Replacement?

BACKGROUND: With growing attention to the aortopathy associated with aortic valve diseases, the number of candidates for accompanying ascending aorta and/or root replacement is increasing among the patients who require aortic valve replacement (AVR). However, such procedures have been considered more risky than AVR alone. This study aimed to compare the surgical outcome of isolated AVR and AVR combined with aortic procedures. MATERIALS AND METHODS: A total of 86 patients who underwent elective AVR between 2004 and June 2010 were divided into two groups: complex AVR (n=50, AVR with ascending aorta replacement in 24 and the Bentall procedure in 26) and simple AVR (n=36). Preoperative characteristics, surgical data, intra- and postoperative allogenic blood transfusion requirement, the postoperative clinical course, and major complications were retrospectively reviewed and compared. RESULTS: The preoperative mean logistic European System for Cardiac Operative Risk Evaluation (%) did not differ between the groups: 11.0+/-7.8% in the complex AVR group and 12.3+/-8.0% in the simple AVR group. Although complex AVR required longer cardiopulmonary bypass (152.4+/-52.6 minutes vs. 109.7+/-22.7 minutes, p=0.001), the quantity of allogenic blood products did not differ (13.4+/-14.7 units vs. 13.9+/-11.2 units). There was no mortality, mechanical circulatory support, stroke, or renal failure requiring hemodialysis/filtration. No difference was found in the incidence of bleeding (40% vs. 33.3%) which was defined as red blood cell transfusion > or =5 units, reoperation, or intentional delayed closure. The incidence of mediastinitis (2.0% vs. 0%), ventilator > or =24 hours (4.0% vs. 2.8%), atrial fibrillation (18.0% vs. 25.0%), mean intensive care unit stay (34.5 hours vs. 38.8 hours), and median hospital stay (8 days vs. 7 days) did not differ, either. CONCLUSION: AVR combined with additional aortic or root replacement showed an excellent outcome and recovery course equivalent to that after isolated AVR.

Surgical Outcomes of Cox-maze IV Procedure Using Bipolar Irrigated Radiofrequency Ablation and Cryothermy in Valvular Heart Disease

BACKGROUND: We evaluated the efficacy of Cox-maze IV procedure using bipolar irrigated radiofrequency ablation and cryothermy in chronic atrial fibrillation associated with valvular heart disease. MATERIAL AND METHODS: From November 2005 to June 2009, ninety four patients have undergone valvular heart surgery with Cox-maze IV procedure. Preoperative duration of atrial fibrillation was 7.6+/-6.5 years and follow-up duration was 22.7+/-12.3 months. RESULTS: There were two (2.1%) postoperative deaths not related to maze procedure. Two cerebrovascular accidents, five low cardiac output syndromes and two permanent pacemaker implantations have occurred after surgery. Preoperative ejection fraction on echocardiography was 55.3+/-8.1% and ejection fraction of postoperative six month was 54.7+/-6.5%. Left atrial size of preoperative and postoperative were 61.5+/-11.6 mm and 53.1+/-8.4 mm at each. Freedom from atrial fibrillation rate at postoperative six-month was 80.7% and the cases of recurrence of atrial fibrillation after six months were three (3.3%). Risk factors for failure or recurrence of maze procedure were old age (p=.010) and preoperative moderate or severe tricuspid regurgitation (p=.033). CONCLUSION: The Cox-maze IV procedure using RFBP2 and cryothermy is quite safe and freedom from atrial fibrillation at postoperative 6 month was 82.5%. Risk factors for failure or recurrence of atrial fibrillation after Cox-maze IV were old age and preoperative over moderate tricuspid regurgitation.

Suitability of Endovascular Repair with Current Stent Grafts for Abdominal Aortic Aneurysm in Korean Patients

Suitability rate of endovascular aneurysm repair (EVAR) and the anatomic features causing unsuitability have not been well determined in Asian patients who have abdominal aortic aneurysm (AAA). In a single Korean center, a total of 191 patients with abdominal aortic aneurysm (maximal diameter > or = 4 cm) were identified. Aortoiliac morphologic characteristics in contrast-enhanced computed tomography images were retrospectively reviewed to determine suitability for EVAR with four FDA-approved stent-grafts. AAA was considered ideally suitable for EVAR in 46.6% of patients. The most frequent causes for unsuitability were common iliac artery (CIA) aneurysm (61.8%) and excessive neck angulation (52.9%). Problems such as small and/or short neck and small access were found in minor incidences. If CIA aneurysm is dealt by overstenting with sacrifice of internal iliac artery, suitability rate can increase to 65%. Larger aneurysms were more frequently unsuitable for EVAR and had more chance of having multiple unfavorable features. In conclusion, the overall feasibility rate for EVAR in Korean patients was not different from that in Western patients. However, considering the difference in the major causes of unsuitability, more attention has to be paid to neck angulation and CIA aneurysm to provide EVAR for more Korean patients especially who have large aneurysm.

Cardiac Transplantation for a Patient with Intra-aortic Balloon Pump and Extracorporeal Membrane Oxygenator due to Cardiogenic Shock after Acute Myocardial Infarction: A Case Report / 대한구급학회지

A 66-year-old male patient who suffered from chest pain and dyspnea was admitted to our hospital. He was diagnosed as having an acute myocardial infarction, and recovered from cardiogenic shock after cardiopulmonary-cerebral resuscitation. Under the support of extracorporeal membrane oxygenator (ECMO) he underwent successful percutaneous coronary intervention. After this, an intra-aortic balloon pump (IABP) was inserted to increase coronary perfusion and reduce the impedance to left ventricular ejection. After 6 days, the patient was weaned from ECMO support; however, IABP therapy and infusion of inotropic agents were required to maintain adequate hemodynamic status. One week later, cardiac transplantation was performed successfully without major complications.

Aorto-esophageal Fistula That Developed after Endovascular Stent-grafting of a Mycotic Aneurysm: A case report / 대한흉부외과학회지

A 74-year-old woman presented at our hospital with hemoptysis. Three months ago, she had endovascular stent-grafting done by a general surgeon for a saccular thoracic aneurysm that was found accidentally following an episode of fever and chills. Despite a lasting fever after the procedure, she was discharged without further treatment and follow-up. She was subsequently admitted to the hospital for evaluation and several exams were performed. Chest CT scans and an esophagoscopy identified an aorto-esophageal fistula at the level of the aorta that was covered by a previous stent-graft. After extensive administration of antibiotics, surgery was done - esophagectomy, cervical esophago-gastrostomy and replacement of the thoracic aorta. She was later discharged uneventfully.

Suspected Intimal Sarcoma in the Abdominal Aorta: A case report / 대한흉부외과학회지

A 68 year-old man visited our institution due to chest pain. Coronary angiography revealed triple vessel disease. A computed tomographic angiogram performed as a routine preoperative examination demonstrated an intraluminal spider-web-like mass from the infrarenal abdominal aorta to both common iliac arteries. The infrarenal aorta and both common iliac arteries were excised and replaced with concomitant off-pump coronary artery bypass grafts. Histologic examination of the aorta suggested an intimal sarcoma. A postoperative computed tomographic angiogram performed 3 months postoperatively showed no evidence of a residual or a recurred lesion.

Saphenous Vein Graft as a Composite Graft in Patients Who AreUndergoing Off-pump Coronary Artery Bypass: The Early Results / 대한흉부외과학회지

BACKGROUND: The long term patency of the free saphenous vein graft, which is the most commonly used conduit, anastomosed to the ascending aorta has been reported to be lower than that of arterial grafts. We evaluated the early clinical outcome and the angiographic patency of the saphenous vein composite graft based on the left internal thoracic artery, and compared these results with those of using arterial composite grafts. MATERIAL AND METHOD: From September 2006 to October 2008, 419 patients underwent off-pump coronary revascularization. Among those, 295 patients (70.4%) were revascularized using composite grafts (group I: saphenous vein composite graft, n=71, group II: arterial composite graft, n=224). The clinical results were compared between the 2 groups. Early postoperative coronary angiograms were performed in all the patients. (1.6+/-.6 days) RESULT: The number of the distal anastomosis per patient was 3.5+/-.0 and 3.1+/-.8 in group I and II, respectively (p=.002). The operative mortality (n=2, 0.7%) and postoperative complications such as atrial fibrillation (n=73, 24.7%), perioperative myocardial infarct (n=6, 2.0%), acute renal failure (n=6, 2.0%), reoperation for bleeding (n=5, 1.7%), cerebrovascular accident (n=3, 1.0%), and mediastinitis (n=1, 0.3%) were not related with the use of saphenous vein graft. Early coronary angiograms revealed a 96.9% (126/130) for the saphenous vein grafts and a 98.8% (479/485) for the composite graft in group II (p=.231). CONCLUSION: Our data suggested that a saphenous vein graft might be used as an alternative conduit to the arterial graft for constructing a composite graft, as based on our early clinical and angiographic results. Further study is required to establish the long-term efficacy of using a saphenous vein as a composite graft.

Synchrotron Microangiography of the Rat Heart Using the Langendorff Model

BACKGROUND AND OBJECTIVES: The ability to study microvessels of a beating heart in real time at the level of the capillary is essential for research. However, there are no proven methods currently available to achieve this. The conventional absorption-contrast agents have limitations for studying capillaries. Microangiography with using synchrotron phase-contrast X-ray technology and no contrast agent has recently been reported on. We tried to verify this previous report, and we wanted to visualize the microvessels of a rat heart using air as a contrast agent. MATERIALS AND METHODS: We made the Langendorff apparatus in a hutch of the Pohang Accelerator Laboratory. The images were obtained with a white beam and a monochromatic beam. The visual images were magnified using 3x and 20x optical microscope lenses, and the images were captured with a charge-coupled device camera. RESULTS: We could not duplicate the previously reported findings in which microvessels were visualized without the use of contrast agent. But with using air as a contrast agent, the microvasculature of rat hearts was clearly identified at a spatial resolution of 1.2 microm. Air being absorbed inside a capillary was also observed. Vessels under 10 microm diameter were unable to be visualized with using iodine as a contrast agent. CONCLUSION: Phase contrast imaging already allows spatial resolution of 1 microm, which is enough to inspect capillaries. We were able to obtain images of cardiac capillaries with using air as a contrast agent. Yet air has the fatal limitations in that it causes embolism and ischemia. A more suitable contrast agent or imaging method needs to be developed in order to study the microvessels of a beating heart.

Off-pump Coronary Artery Bypass Surgery Versus Drug Eluting Stent for Multi-vessel Coronary Artery Disease / 대한흉부외과학회지

BACKGROUND: The introduction of Drug Eluting Stents (DES) decreased the number of patients referred for coronary artery bypass grafting (CABG). The impact of DES on CABG (Step 1) was studied and compared with the 1-year outcome after CABG with DES (Step 2). MATERIAL AND METHOD: Surgical results for patients who underwent off-pump CABG (OPCAB) before the introduction of DES(n=298) were compared with those who underwent OPCAB after the introduction of DES (n=288) (Step 1). Postoperative 30-day and 1-year results were also compared between the patients who underwent percutaneous coronary intervention (PCI) using DES (n=220) and those who underwent OPCAB (n=255) (Step 2). RESULT: Since the introduction of DES, the ratio of CABG versus PCI decreased. In the CABG group, the number of high risk patients such as elderly patients (age 62 vs. 64, p=0.023), those with chronic renal failure (4% vs. 9%, p=0.021), calcification of the ascending aorta (9% vs. 15%, p=0.043), or frequency of urgent or emergent operations (12% vs. 22%, p=0.002) increased. However, there were no differences in the cardiac death and graft patency rates between the two groups (step 1). During the one-year follow up period, the rate of target vessel revascularization (12.3% vs. 2.4%, p<0.001) and major adverse cardiac events (MACE: death, myocardial infarct, TVR) were higher in the DES than the CABG group (13.6% vs 4.3%) (stage 2). CONCLUSION: Introduction of DES decreased the number of patients referred for surgery, and increased the comorbidity in patients who underwent CABG. DES increased the rate of target vessel revascularization, and the occurrence of MACE during the 1-year follow-up. However, there was no difference in the incidence of myocardial infarction and cardiac death between the two groups.

Video-assisted Diaphragm Plication in Children with Diaphragm Eventration Associated with Congenital Myopathy : Report of 2 Cases / 대한흉부외과학회지

A six-month old boy and a thirty-month old girl who suffered from dyspnea were admitted to our hospital. Their primary disease was congenital myopathy, and both of them had a history of recurrent pneumonia. Chest X-ray scan showed unilateral diaphragmatic eventration. To minimize the injury of weakened respiratory muscle in children with myopathy, VATS plication was performed under double lung ventilation. Each of the two patients were discharged on the 17th and 24th postoperative day. We report two cases of successful VATS plication in children with diaphragmatic eventration associated with congenital myopathy.

Extended Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy : Report of a case / 대한흉부외과학회지

Hypertrophic cardiomyopathy is characterized by inappropriate hypertrophy of the myocardium and is associated with various clinical presentations ranging from complete absence of symptoms to sudden, unexpected death. These are caused by dynamic obstruction of the left ventricular outflow tract and surgical approaches were initiated. But, the complete resection of hypertrophied midventricular septum is impossible by standard, transaortic approach, because of narrow vision and limited approach. And it leads to inadequate excision, will leave residual left vetnricular outflow tract obstruction or systolic anterior motion of mitral leaflet, and limit symptomatic improvement and patient's survival. We report a case of extended septal myectomy for hypertrophic cardiomyopathy of mid-septum in a child. The extended septal myectomy was performed by aortotomy and left ventricular apical incision, and made possible the complete resection of mid-ventricular septum, abnormal papillary muscles and chordae. The patient's symptom was improved and the postoperative course was uneventful.

Unilateral Pulmonary Vein Stenosis with Life-threatening Hemoptysis: A case report / 대한흉부외과학회지

A case is described in a girl who presented with recurrent life-threatening hemoptysis at the age of 18 months, and had been diagnosed as atrial septal defect with severe cardiomegaly which was presumed to result in pulmonary vein stenosis at the age of 6 months. Closure of atrial septal defect was associated with decreased heart size and improved pulmonary venous flow. However, recurrent life-threatening hemoptysis occurred during follow-up. Computed tomography scan demonstrated left pulmonary vein stenosis and extrinsic compression of the left bronchus by multiple soft tissue density-masses. Exploratory thoracotomy revealed single stenotic left pulmonary vein, and flat left main bronchus compressed by multiple hypertrophied lymph nodes. Unexpected endotrachial tube bleeding during left hilar dissection mandated to proceed to left pneumonectomy. The patient's postoperative course was uneventful. Follow-up chest roentgenography revealed acceptable left hydrothorax without mediastinal shifting. Nevertheless, a long-term follow-up is necessary.