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.

Myositis ossificans causing ulnar neuropathy: a case report.

Myositis ossificans (MO) can compress peripheral nerves and cause neuropathy. We herein describe a patient with ulnar neuropathy caused by MO at the medial elbow. A 28-year-old man with a drowsy mentality and multiple organ damage following a traffic accident was admitted to our hospital. After 3 weeks of postoperative care, the patient's mental status recovered. However, he complained of severe sharp pain in his left medial forearm and fourth and fifth fingers. He exhibited weak fifth finger abduction and wrist adduction. Severe elbow joint pain was elicited during range-of-motion testing of his left elbow. Ultrasound also showed an edematous, enlarged, hypoechoic ulnar nerve lying above the MO, and the MO outwardly displaced the ulnar nerve. Elbow radiographic examination, computed tomography, and magnetic resonance imaging revealed MO development and compression of the left ulnar nerve. The patient underwent surgery; the following day, his left medial forearm pain completely disappeared with slight improvement in the motor weakness of fifth finger abduction. Ultrasound is a useful tool to easily evaluate the presence of MO and compression of peripheral nerves caused by MO.

Mid-back pain due to a penetrating atherosclerotic aortic ulcer: do not miss the diagnosis-a case report.

In clinical practice, clinicians often meet patients suffering from mid-back pain. One of the possible causes of mid-back pain is penetrating atherosclerotic aortic ulcer (PAU), but the diagnosis is often delayed owing to its low incidence. Here, we report a patient with mid-back pain due to a PAU, who was diagnosed after receiving several procedures for reducing musculoskeletal pain. A 65-year-old man visited our pain clinic for mid-back pain [numeric rating scale (NRS): 7] experienced for 2 months. The pain was radiated to the lateral chest area and was aggravated when in the supine and standing positions. Trigger point injection, medial branch block, and pulsed radiofrequency were ineffective. The cardiac evaluation and abdominal computed tomography (CT) results showed no abnormalities. On CT aortography at 3 months after pain onset, intraluminal thrombus, multiple ruptured PAUs, and aneurysmal change of the descending thoracic aorta were found. Accordingly, PAU was diagnosed as the origin of the patient's pain. We administered nicardipine with a rate of 1.15 mcg/kg/min and esmolol with a rate of 100 mcg/kg/min for controlling the systolic blood pressure. In addition, an anticoagulant was administered orally. To alleviate the pain, we further administered intravenous opioid. Approximately 6 h after, the systolic blood pressure decreased to 100-120 mmHg, and the pain rating decreased to NRS 1. Two weeks after the discharge, the patient's pain rating was sustained at NRS 1. Clinicians should be aware of the fact that PAU can be a cause of mid-back or chest pain.

Retropharyngeal hematoma secondary to cervical hyperextension in a minor collision trauma presenting with dyspnoea: A case report.

RATIONALE: Massive retropharyngeal hematoma secondary to a minor blunt trauma is rare and easy to be missed in emergency settings due to the absence of visible tissue injury, especially in young patients. However, missing this pathology is dangerous and can result in airway obstruction and even death. Therefore, an effective diagnostic strategy must be developed and thoroughly performed to minimize missed retropharyngeal hematoma. PATIENT CONCERNS: A 49-year-old man with a brief cervical hyperextension secondary to a minor collision presented with mild respiratory discomfort. No externally visible injuries were found; however, dyspnea was persistent and aggravating. DIAGNOSIS: Lateral neck X-ray, neck computed tomography, and spine magnetic resonance imaging revealed a huge retropharyngeal hematoma obstructing the upper airway, without any severe fracture or ligament injury. INTERVENTIONS: An emergent orotracheal intubation followed by imaging studies was performed to resolve the aggravating dyspnea. Neck exploration surgery was immediately performed for rapid absorption of the hematoma, bleeding control, and identification of the reason of the pathology. OUTCOMES: The surgery was successful, and the patient was discharged without any postoperative sequelae on the 30 postoperative day. CONCLUSION: Retropharyngeal hematoma that develops in young patients without visible injuries or severe symptoms after a minor trauma can easily go undetected. Although most hematomas under observation resolve spontaneously, the retropharyngeal hematomas missed at initial assessment may result in critical complications. High level of suspicion, repeated neck CT, and thorough tertiary survey in emergency rooms are helpful in avoiding missed life-threatening retropharyngeal hematoma.

Lessons from South Korea Regarding the Early Stage of the COVID-19 Outbreak.

South Korea has experienced difficulty in controlling the spread of the novel coronavirus disease (COVID-19) during the early stages of the outbreak. South Korea remains passionately determined to protect Koreans against COVID-19 and through trial and error hopes to improve the strategies used to limit the outbreak. Here, we review how COVID-19 spread and what prevention strategies were implemented during the early stages of the outbreak in South Korea. We investigated online newspapers published in South Korea from 21 January 2020 to 20 March 2020, and reviewed academic medical articles related to COVID-19. Additionally, we acquired data on COVID-19 cases through the official website for COVID-19 in South Korea. To date, numerous measures have been applied by the government and the medical community during the early stages of the COVID-19 outbreak including the reporting of methods for diagnostic testing, patient classification, the introduction of drive-through screening centers, COVID-19 preventive measures, implementation of government policies for the shortage of face masks, and entry restrictions. Here, we present data from the early stages of the COVID-19 outbreak and measures to prevent its spread in South Korea. We believe that sharing the experience of South Korea during the COVID-19 outbreak can help other countries to implement strategies to prevent its rapid transmission.

Transient Budd-Chiari syndrome as an unpredictable complication of supradiaphragmatic inferior vena cava reconstruction after blunt thoracic trauma: A case report.

RATIONALE: Supradiaphragmatic inferior vena cava (IVC) injury due to blunt thoracic trauma is extremely rare. Budd-Chiari syndrome (BCS) is also rare and presents with ascites, abdominal pain, hepatomegaly, leg swelling, and jaundice. Its etiology is diverse, and it is rarely caused by trauma. PATIENT CONCERNS: A 36-year-old man with blunt trauma from a traffic accident presented with chest pain. Chest computed (CT) and emergency surgery with CPB revealed completely transected supradiaphragmatic inferior vena cava (IVC), which reconstruction was essential. DIAGNOSES: BCS caused by impaired hepatic venous drainage through a reconstructed neo-IVC after severe blunt trauma injury to the supradiaphragmatic IVC was diagnosed. INTERVENTION: Hepatic failure, ascites, leg swelling, and jaundice were resolved post-insertion of a veno-venous extracorporeal membrane oxygenator (V-V ECMO) for hepatic venous drainage, but these clinical symptoms reappeared after ECMO removal. OUTCOME: The patient died from rapidly progressing sepsis, pneumonia, and acute renal failure during repeated insertion of ECMO and weaning off ECMO. LESSONS: Reconstructing and improving the patency of the supradiaphragmatic IVC is essential for successful hepatic venous drainage. Additionally, a surgical strategy focused on graft selection can prevent kinking stenosis, and possibly BCS, especially in emergency surgeries. A ring-supported synthetic graft should be considered an alternative to improve long-term patency and survival rate.

A Challenging Case of Intracardiac Leiomyomatosis Accompanied by Pseudo-Meigs Syndrome Originating from Uterine Leiomyoma.

BACKGROUND: Pseudo-Meigs syndrome is an unusual condition involving pelvic tumors, excluding ovarian fibroma, and is associated with ascites and hydrothorax. Pseudo-Meigs syndrome originating from uterine leiomyoma is an even rarer condition. Intravenous leiomyomatosis originating from uterine tumors, which extend from the inferior vena cava to the right heart chambers, is also extremely rare. CASE REPORT: This report presents an extremely rare case of intravenous leiomyomatosis with intracardiac extension accompanied by Pseudo-Meigs syndrome caused by uterine leiomyoma. To the best of our knowledge, this is the first reported case of two different rare conditions originating simultaneously from one common pelvic benign tumor. We could only partially resect the tumor owing to its firm adherence to the vessel wall. It is crucial to remember that a pelvic neoplasm in a woman with various manifestations, such as hydrothorax, ascites, intravascular leiomyomatosis, intracardiac mass, and even elevated CA125 levels, does not always imply malignancy. All the accompanying symptoms can be resolved by simple surgical removal of the mass. CONCLUSIONS: Accurate preoperative assessment and detailed preparation for the surgery according to the nature of the tumor may yield successful results.

Thoracic endovascular repair technique for the treatment of patent ductus arteriosus in an elderly patient: A case report.

RATIONALE: Patent ductus arteriosus (PDA) ligation by open surgery is more difficult and dangerous in elderly patients than in infants. Nowadays, simple and safe interventional catheterization technology is used for the closure of uncomplicated isolated PDAs. Therefore, an alternative less invasive therapeutic option must be developed to treat complicated PDA. PATIENT CONCERNS: A 53-year-old woman presented with gradually exacerbated dyspnea on effort and continuous cardiac murmurs. DIAGNOSIS: Transthoracic echocardiography (TTE) and contrast-enhanced 3D computed tomography (CT) were performed and revealed a conically shaped large PDA with calcification. INTERVENTIONS: We used a nontouch exclusion technique with thoracic endovascular repair (TEVAR) for the treatment of this rare complicated PDA. The patient had an adequate proximal landing zone, and a tapered stent graft (S&G, Bio 34-30 mm × 110 mm, Korea) was used. OUTCOMES: Aortography after stent graft implantation revealed complete occlusion of PDA and no endoleaks. The procedure was successful, and the patient showed no vascular or other complications during follow-up. LESSONS: TEVAR is a less invasive solution for pathologies of the thoracic aorta, such as aortic dissection or aneurysm. TEVAR is an established, simple, and safe method for repairing the thoracic aorta and can be a new alternative to other transcatheter techniques for complicated PDAs in elderly patients.

Rupture of right sinus of Valsalva aneurysm protruding into the pulmonary artery with aortic and pulmonary valve endocarditis.

Rupture of right sinus of Valsalva aneurysm (SVA) protruding into the pulmonary artery with aortic and pulmonary valve endocarditis is rare. A 42-year-old man was admitted with fever and dyspnea. He was diagnosed with right sinus of Valsalva rupture with ventricular septal defect (VSD) and vegetation on both aortic and pulmonary valves. Dual exposure technique was performed. The base of the aneurysm sac was closed off, and, together with the VSD, was covered by a Gore-Tex patch. Aortic and pulmonary valves were replaced with mechanical valves. After surgery, antibiotics were administered for 5 weeks, and patient was discharged without complications.

Late cardiac tamponade following Nuss procedure for pectus excavatum.

The Nuss procedure is a recently developed technique for correction of pectus excavatum. A 23-year-old female patient presented at our emergency department with clinical signs of cardiac tamponade, which required an emergency procedure. Sixteen months ago, she underwent the Nuss procedure with a single bar. Her preoperative Haller index was 5. We report on a case of delayed recurrent cardiac tamponade that occurred 16 and 18 months after the patient underwent the Nuss procedure; in this case, we treated the patient with pericardiocentesis the first time and performed pericardial window creation with bar removal the second time. She was discharged on day 10 in good condition and follow-up chest radiographs showed no fluid collection.

Early Aggressive Surgical Treatment of Multiloculated Empyema.

BACKGROUND: Empyema is the collection of purulent exudate within the pleural space. Overall, 36%-65% of patients with empyema cannot be treated by medical therapy alone and require surgery. Multiloculated empyema is particularly difficult to treat with percutaneous drainage. Therefore, we describe our experiences with early aggressive surgical treatment for rapid progressive multiloculated empyema. METHODS: From January 2001 to October 2015, we retrospectively reviewed 149 patients diagnosed with empyema who received surgery. The patients were divided into 2 groups according to whether they underwent emergency surgery or not. We then compared surgical outcomes between these groups. RESULTS: The patients in group A (emergency surgery, n=102) showed a more severe infectious state, but a lower complication rate and shorter length of hospital stay. The incidence of lung abscess was higher in group A, and abscesses were associated with diabetes and severe alcoholism. CONCLUSION: Early aggressive surgical treatment resulted in good surgical outcomes for patients with rapid progressive multiloculated empyema. Furthermore, we suspect that the most likely causes of multiloculated empyema are lung abscesses found in patients with diabetes mellitus as well as severe alcoholism.

Prolonged Air Leakage Caused by Mesenchymal Cystic Hamartoma of the Lung.

A 16-year-old girl was transferred to the department of thoracic and cardiovascular surgery because of a spontaneous pneumothorax with prolonged air leakage. Chest computed tomography demonstrated a cystic lesion measuring 2×3 cm and involving the left upper lobe. Left upper lobectomy was performed via video-assisted thoracoscopic surgery. A pathologic examination of the specimen revealed a mesenchymal cystic hamartoma. Despite the rarity of pulmonary mesenchymal cystic hamartoma, it should be considered a potential cause of pneumothorax for patients with a large pulmonary cyst. Further, surgical resection must be considered because serious complications such as hemothorax, hemoptysis, and malignant transformation have been reported.

Systemic inflammation response syndrome score predicts the mortality in multiple trauma patients.

BACKGROUND: Numerous statistical models have been developed to accurately predict outcomes in multiple trauma patients. However, such trauma scoring systems reflect the patient's physiological condition, which can only be determined to a limited extent, and are difficult to use when performing a rapid initial assessment. We studied the predictive ability of the systemic inflammatory response syndrome (SIRS) score compared to other scoring systems. METHODS: We retrospectively reviewed 229 patients with multiple trauma combined with chest injury from January 2006 to June 2011. A SIRS score was calculated for patients based on their presentation to the emergency room. The patients were divided into two groups: those with an SIRS score of two points or above and those with an SIRS score of one or zero. Then, the outcomes between the two groups were compared. Furthermore, the ability of the SIRS score and other injury severity scoring systems to predict mortality was compared. RESULTS: Hospital death occurred in 12 patients (5.2%). There were no significant differences in the general characteristics of patients, but the trauma severity scores were significantly different between the two groups. The SIRS scores, number of complications, and mortality rate were significantly higher in those with a SIRS score of two or above (p<0.001). In the multivariant analysis, the SIRS score was the only independent factor related to mortality. CONCLUSION: The SIRS score is easily calculated on admission and may accurately predict mortality in patients with multiple traumas.

Pulmonary actinomycosis associated with endobronchial vegetable foreign body.

A 51-year-old woman visited our hospital with massive hemoptysis. She had suffered from recurrent hemoptysis for five years and had undergone bronchial artery embolization many times. The patient had a history of pulmonary tuberculosis and bronchiectasis. Chest radiography showed consolidation around the nodule in the lateral basal segment of the right lower lobe. We successfully performed a right lower lobectomy. The histological study of the resected specimen showed a vegetable foreign body and clumps of Actinomyces, indicating actinomycosis, which was suggested to be the cause of the hemoptysis. This was a very rare case of hemoptysis caused by a vegetable foreign body and actinomycosis.

Pulmonary valve leaflet extension with bovine pericardium: for treatment of pulmonary insufficiency.

Using a homograft in a pulmonic area is sometimes inadvisable due to the lack of optimal graft materials. We report a case of pulmonary valve insufficiency that we treated by leaflet extension using the commercially available E-Leafcon template and bovine pericardium. We suggest that this method can be an acceptable alternative for treating pulmonary valve insufficiency because the pulmonary valve area is similar to that of the aortic valve (for which application the template was designed). Further, the durability of bovine pericardium is comparable to that of a homograft or a xenograft.

Preoperative Extracorporeal Membrane Oxygenation for Severe Ischemic Mitral Regurgitation - 2 case reports -.

Indication for extracorporeal membrane oxygenation (ECMO) has been extended as the experience of ECMO in various clinical settings accumulates and the outcome after ECMO installation improves. We report two cases of successful mitral valve surgery for severe ischemic mitral regurgitation in patients on ECMO support for cardiogenic shock which developed upon coronary angiography.

Aortic root and ascending aortic aneurysm in an adult with a repaired tetralogy of fallot.

Surgical repair of the tetralogy of Fallot is one of the most successful operations in the treatment of congenital heart diseases. We report the case of a 65-year-old man who had an aortic valve replacement at the time of complete repair of the tetralogy of Fallot at the age of forty-three. He subsequently had progressive aortic root and ascending aorta dilation to 9 cm. The aortic root and ascending aorta replacement was done using a composite valve-graft and was performed along with other procedures. Thus, meticulous follow-up of aortic root and ascending aorta after corrective surgery for tetralogy of Fallot is recommended following initial curative surgery.

Native coronary artery and grafted artery spasm just after coronary artery bypass grafting: a case report.

Native coronary artery spasm after coronary artery bypass grafting (CABG) is scarce. It frequently causes disastrous circulatory collapse. We report a 72-yr-old male, who experienced native coronary artery spasm and grafted artery spasm following CABG, which was successfully treated with coronary angiography and intracoronary injection of nitroglycerine.