Search

Backgrounds The pleating technique is widely used in plication but is difficult to perform with thoracoscopy because of its complex procedure and the limited surgical space. Thus, the invaginating technique was introduced to facilitate thoracoscopic surgery and is now widely used in video-assisted thoracoscopic surgery (VATS) plication. However, the usefulness of the invaginating technique in children has not been established because of the lack of data on long-term outcomes after surgery using the technique. Methods From March 2007 to December 2017, 21 patients who were surgically treated for congenital diaphragmatic eventration and phrenic nerve palsy after congenital cardiac surgery were divided into 2 groups according to the surgical method used (pleating technique: 10 patients, invaginating technique: 11 patients). We evaluated the patients for postoperative outcomes and recurrence of diaphragmatic eventration over 5 years. Postoperative recurrence of diaphragmatic eventration was confirmed by calculating the ratio of the eventration level between the eventrated and normal diaphragms. Results In the 21 patients who underwent diaphragmatic plication, the pleating and invaginating techniques were used in 10 and 11 patients, respectively. The mean follow-up duration was 63.4 ± 48.4 months (pleating group [P] vs invaginating group [I]: 89.1 ± 52.4 vs 40.1 ± 30.8 months, p = 0.022). The mean eventration rates in the 21 patients was 26.7% ± 9.1% (P vs I: 26.6% ± 6.1% vs 26.9% ± 11.3%, p = 0.945) before operation and − 2.1% ± 7.3% (− 2.8% ± 7.5% vs − 1.5% ± 7.4%, p = 0.695) in the immediate postoperative period. From the first to the fifth postoperative year, no recurrence of diaphragmatic eventration was found in any of the groups during the follow-up. Conclusions The invaginating technique was easier to perform but showed a similar long-term result as compared with the pleating technique in terms of the growth and development of the chest cavity in the pediatric patients in this study. Thus, we recommend that the invaginating technique be applied in VATS plication for children as an alternative to the pleating technique. Level of evidence Level III.

Coronary reimplantation after neoaortic reconstruction (CRANR) in the arterial switch operation (ASO) allows easy selection of accurate coronary transfer sites in the distended neoaorta. However, neoaortic valve injury may occur during coronary reimplantation. We determined whether the CRANR procedure increased the incidence of aortic valve regurgitation (AR) after ASO. Between March 1994 and August 2017, 227 patients underwent ASO. Since September 2000 CRANR has been performed on 155 patients and open coronary reimplantation (OCR) on 72. Patients who had undergone aortocoronary flaps procedures (n = 13), had early or late mortality (n = 27), or lacked data (n = 11) were excluded. We enrolled and retrospectively reviewed the medical records of 176 patients who were followed up for postoperative AR: 38 underwent OCR and 138 underwent CRANR. We compared the incidences of early and late postoperative AR in both groups. We defined mild or greater AR as "significant AR." The groups did not differ in body weight at operation, great artery relationship, and coronary artery anatomy. The incidences of significant AR at discharge were 21.1% (8/38) in the OCR group and 16.6% (23/138) in the CRANR group (p = 0.53). The freedom from significant AR at 5 years was 59.9% in the OCR group and 62.4% in the CRANR group with no difference between the two groups (p = 0.73). Moderate AR occurred in one patient in the CRANR group. No surgical intervention was required for the aortic valve in either group. ASO using the CRANR technique did not increase the incidence of postoperative early and late AR.

Background: Left pulmonary vein (PV) obstruction can occur due to compression between the left atrium (LA) and the descending aorta (DA). One of the effective solutions for this problem is posterior aortopexy. In this study, we have reported five cases of posterior aortopexy to relieve left PV obstruction between the LA and the DA. Methods: Since August 2012, five patients have undergone posterior aortopexy for compression of the left PV between the LA and the DA. The median age and weight of the patients at the time of operation were 5.5 months (range, 1-131 months) and 5.2 kg (range, 4.2-29.5 kg), respectively. The left PV obstruction was initially diagnosed on echocardiography in four patients and computed tomography angiography in one patient. The median peak pressure gradient across the obstructed left PV was 7.3 mmHg (range, 4-20 mmHg). Concomitant procedures were ventricular septal defect closure in one patient and patent ductus arteriosus ligation in one patient. Results: There was no PV obstruction on echocardiography in any of the patients after the operation except in the case of one patient who had diffuse pulmonary vein stenosis. The median follow-up duration was 34 months (range, 14-89 months), and during follow-up no incidence of the left PV obstruction was observed in any of the surviving patients. Conclusions: The posterior aortopexy technique could be a good surgical option for the left PV obstruction caused by compression between the LA and the anteriorly positioned DA.

Background Persistent fifth aortic arch (PFAA) is a rare anomaly often associated with aortic coarctation or interruption, and various surgical techniques for this anomaly have been reported. Herein, we show a case of an infant with PFAA and severe aortic coarctation. Case presentation A 41-day-old female infant was admitted for sustained fever. Initially, the patient was diagnosed with bacterial meningitis, and echocardiography showed PFAA with severe aortic coarctation. Because the patient presented progressive oliguria and metabolic acidosis, she was transferred for emergency cardiac surgical intervention. The aortic arch was reconstructed using end-to-side anastomosis between the fifth aortic arch and the descending aorta without any artificial conduit or patching material. Conclusions PFAA with aortic coarctation can be repaired by various surgical methods. Among them, our surgical approach is easy and effective, has growth potential, and an additional surgery is not needed.

Persistent fifth aortic arch (PFAA) is a rare anomaly often associated with aortic coarctation or interruption, and various surgical techniques for this anomaly have been reported. Herein, we show a case of an infant with PFAA and severe aortic coarctation. The aortic arch was reconstructed using end-to-side anastomosis between the fifth aortic arch and the descending aorta without any artificial conduit or patching material. This approach is easy and effective, has growth potential, and an additional surgery is not needed in the future.

To compare the clinical efficacy and safety of arthroscopy-guided continuous suprascapular nerve block and ultrasound-guided continuous interscalene block in postoperative analgesia in patients undergoing arthroscopic rotator cuff repair.A prospective study was performed between March and November 2020. In total, 76 patients were enrolled and divided into 2 groups: in the 38 patients of group 1 (arthroscopy-guided continuous suprascapular nerve block), an indwelling catheter was introduced via the Neviaser portal under arthroscopic view before closing the portal at the end of the surgery; and in the 38 patients of group 2 (ultrasound-guided continuous interscalene block), an indwelling catheter was inserted and directed toward the interscalene brachial plexus prior to the surgery under ultrasound guidance. The primary outcome was the pain score measured by the visual analog scale at postoperative 24 hours during admission. Comparisons were conducted at different time points (postoperative 4, 8, 24, and 48 hours). The secondary outcome was any of these events: neurologic complications, such as sensory/motor change in the upper extremities; hemidiaphragmatic paresis; dyspnea; dysphonia; and Horner's syndrome. Opioid usage until postoperative 3 weeks was compared between the groups.The visual analog scale scores in groups 1 and 2 were comparable at each postoperative time point (analysis of variance, P = .919; trends, P = .132). Neurologic deficits were more common in group 2 than in group 1 (8 vs 32 patients, P.001). Decreased excursion of the diaphragm was more common in group 2 (partial or complete paresis of the hemidiaphragm: 1 vs 29 patients, P .001). Opioid consumption was similar in both groups (morphine milligram equivalents per kilogram; 1.75 vs 1.55, P = .195).Our findings show that arthroscopy-guided continuous suprascapular nerve block is not inferior to ultrasound-guided continuous interscalene block for postoperative pain control after arthroscopic rotator cuff repair while showing fewer temporary neurologic complications.Level II, prospective cohort study, interventional study.

We developed a modified Senning procedure in the double-switch operation for the patients with congenitally corrected transposition of the great arteries (ccTGA). In our technique, the right atrial (RA) free wall is not used as a baffle for draining systemic venous blood to the left atrium. Instead, a patch material is used for the baffling. A wide communication between the pulmonary venous chamber and RA is created by making the triangular double door with the RA-free wall, and the window is closed with in situ pericardial flap. We have successfully adopted this technique in our recent two consecutive ccTGA patients.

We used a suture-and-open technique with a biatrial incision for primary sutureless repair of total anomalous pulmonary venous connection (TAPVC). With this technique, the common pulmonary venous sinus and its branching pulmonary veins are opened after completion of suturing of the left atrial incision to the pericardium around the common pulmonary venous sinus and its branching veins. The technique allows the primary sutureless repair of TAPVC to be done in a less bloody field under full-flow cardiopulmonary bypass. We have performed this technique in our recent 5 consecutive TAPVC patients without significant complications.

We report a case of successful repair of truncus arteriosus (TA) associated with complete atrioventricular septal defect (c-AVSD) using a staged approach. TA associated with c-AVSD is a very rare congenital cardiac anomaly. No report of successful staged repair in South Korea has yet been published. We performed bilateral pulmonary artery banding when the patient was 33 days old, and total correction using an extracardiac conduit was performed at the age of 18 months. The patient recovered uneventfully and is doing well.

Objectives We adopted an operative technique of pulmonary valve (PV) annular enlargement with valve repair in tetralogy of Fallot (TOF) correction to reduce postoperative pulmonary regurgitation (PR) 16 years ago. Here, we have evaluated the long-term results. Methods Between April 2000 and August 2005, 43 patients (26 men) with tetralogy of Fallot with pulmonary stenosis underwent PV annular enlargement with valve repair. The median age and body weight at the time of surgery were 14 months and 10.2 kg, respectively. Results There was no operative mortality. Mean postoperative PR grade at discharge was 0.93 ± 0.40 (none or trivial in 10 patients, mild in 27 patients, mild to moderate in 5 patients and moderate in 1 patient), and the mean postoperative pressure gradient across PV was 13.0 ± 10.9 mmHg. The mean follow-up duration was 131.9 ± 42.9 months. During follow-up, 1 reoperation was performed for residual ventricular septal defect. The mean PR grade at the last follow-up echocardiography was 1.59 ± 0.60 (mild in 17 patients, mild to moderate in 8 patients, moderate in 14 patients, moderate to severe in 1 patient and severe in 3 patients), and the mean pressure gradient was 22.7 ± 9.9 mmHg. We have compared the incidence of moderate or more PR with the incidence of patients who underwent simple transannular patch enlargement through propensity score matching. The PV repair group had a lower incidence of moderate or more PR compared with the simple transannular patch group (40% vs 68%, P = 0.04). Conclusions PV annular enlargement with valve repair has reasonable long-term results and yields a lower long-term incidence of significant PR compared with the simple transannular patch enlargement technique.

Background and Objectives: Female reproductive hormones may affect core body temperature. This study aimed to investigate the effects of female reproductive hormones on inadvertent intraoperative hypothermia in patients who underwent laparoscopic gynecologic surgery under general anesthesia. Materials and Methods: This retrospective study included 660 menstruating and menopausal female patients aged 19–65 years. The patients were divided into two groups according to the occurrence of inadvertent intraoperative hypothermia: non-hypothermia group (N = 472) and hypothermia group (N = 188). After propensity score matching, 312 patients (N = 156 in each group) were analyzed to investigate the association between intraoperative hypothermia and female reproductive hormones. As potential predictors of inadvertent hypothermia, the levels of female reproductive hormones were analyzed using binary logistic regression. Results: The association of estradiol (r = −0.218, p = 0.000) and progesterone (r = −0.235, p = 0.000) levels with inadvertent intraoperative hypothermia was significant but weakly negative before matching, however, it was significant and moderately negative after matching (r = −0.326, p = 0.000 and r = −0.485, p = 0.000, respectively). In a binary logistic analysis, the odds ratio for estradiol was 0.995 (p = 0.014, 0.993 &lt, 95% confidence interval [CI] &lt, 0.998) before matching and 0.993 (p = 0.000, 0.862 &lt, 95% CI &lt, 0.930) after matching, and that for progesterone was 0.895 (p = 0.000, 0.862 &lt, 0.930) before matching and 0.833 (p = 0.014, 0.990 &lt, 0.996) after matching. Conclusions: Estradiol and progesterone levels were associated with inadvertent intraoperative hypothermia. However, the odds ratio for female reproductive hormone levels was close to 1. Therefore, female reproductive hormones may not be a risk factor for hypothermia during gynecologic surgery under general anesthesia. However, a small sample size in this study limits the generalizability of the results.

A selective regional cerebral perfusion has been widely adopted for brain protection in neonatal or infant aortic arch surgeries. The anastomosis of the small polytetrafluoroethylene tube graft to the innominate artery has been used for the selective regional cerebral perfusion in many institutions. We have developed a specially designed cannula tip that allows bidirectional blood flow and provides secure positioning of the polytetrafluoroethylene tube graft at the innominate artery. Innominate artery cannulation using this device reduces arterial clamping time and permits us to perform the arterial cannulation in a much easier and secure manner.

The recently introduced pectoral nerve (Pecs) block is a simple alterative to the conventional thoracic paravertebral block or epidural block for breast surgery. It produces excellent analgesia and can be used to provide balanced anesthesia and as a rescue block in cases where performing a neuraxial blockade is not possible. In the thoracic region, a neuraxial blockade is often used to manage zoster-associated pain. However, this can be challenging for physicians due to the increased risk of hemodynamic instability in the upper thoracic level, and comorbid and contraindicated medical conditions such as coagulopathy. Here, we introduce an ultrasound-guided Pecs block for the management of herpes zoster-associated pain, which could be an effective alternative to other interventional options in the thoracic region.

Objectives We investigated the effect of balloon pulmonary valvuloplasty (BPV) as a palliative procedure for patients with tetralogy of Fallot (TOF). Methods This was a retrospective single-center study conducted between 2008 and 2014. We classified patients into three groups according to palliation: treatment with BPV (group I), with a Blalock–Taussig shunt (group II), and with infundibulectomy (group III). The growth of the pulmonary valve (PV) annulus and need for transannular patching (TAP) during total correction were compared between groups. Results Forty-eight patients were enrolled: 31, 10, and 7 in groups I, II, and III, respectively. The mean ages at palliation were 26.3 ± 23.6, 21.5 ± 16.4, and 15.2 ± 4.2 days in groups I, II, and III, respectively (P = .867). The success rate of BPV was 90.3%. The initial PV z-score before palliation did not differ between groups I, II, and III (−3.14 ± 1.44, −3.84 ± 1.47, and −3.71 ± 1.68; P = .494); the preoperative PV z-score before total correction was larger in group I than in group II (−1.19 ± 1.14 and −3.05 ± 1.19; P = .001), and also larger in group III than in group II (group III: −1.10 ± 0.90; P = .003). The change in pulse oxygen saturation differed significantly between the three groups (P = .031), particularly between groups I and II (P = .010), and the change in PV z-score was greater in groups I and III than in group II (P

Pseudoaneurysm in the left ventricular outflow tract is a rare complication occurring after cardiac surgery. We report on the successful percutaneous device closure of a pseudoaneurysm in the left ventricular outflow tract, which developed in a 23-month-old girl after resection of a subaortic ridge. The pseudoaneurysm was closed using an Amplatzer Vascular Plug II.

In tetralogy of Fallot, whether relieving right ventricular outflow tract obstruction requires transannular patch enlargement (TAPE) of the pulmonary valve depends on pulmonary valvular annulus size. The z-score of pulmonary annulus is most commonly used as a predictor of the need for TAPE. However, the z-score is a complex value affected by height, body weight, body surface area, and different reference populations. Therefore, we hypothesized that the great artery annulus size ratio (pulmonary valvular annulus size to aortic valve annuls size [GA ratio]) may be a better predictor of the need for TAPE.We analyzed 122 patients retrospectively who had undergone total correction of tetralogy of Fallot between January 2007 and March 2015. We categorized the patients into two groups, TAPE versus non-TAPE. Great arterial annuli sizes were evaluated in each group, and the GA ratio cutoff values for TAPE were calculated.In total, 40 patients (32.8%) required TAPE. Both GA ratios and z-scores were smaller in the TAPE group than in the non-TAPE group (0.51 versus 0.67, p0.0001, and -2.46 versus -0.85, p0.0001, respectively). In receiver operating characteristics analyses, the z-score and GA ratio cutoff values were -1.67 (area under the curve = 0.797) and 0.56 (area under the curve = 0.900), respectively, demonstrating that the GA ratio was a more powerful diagnostic tool as a predictor of TAPE (p = 0.014).Our results suggest that the GA ratio is a useful predictor for TAPE and can be applied readily and simply in clinical practice.

A patient with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries without an intrapericardial pulmonary artery (PA) underwent a one-stage total correction, including both branch PA reconstructions, with a bovine pericardial roll at the age of 42 months. She was readmitted 54 months after the operation because of extracardiac conduit bacterial endocarditis and pulmonary infarction. The bovine pericardial roll between the right and left PAs was enucleated, and the surrounding fibrotic tissue (peel) was used as a new branch PA vascular conduit. A cardiac catheterization performed 86 months after the peel operation showed no aneurysmal dilatation, stenosis, or thrombotic occlusion.

Background and aim to read We report the results of a bicuspid expanded polytetrafluoroethylene (ePTFE) valved conduit used for right ventricular outflow tract reconstruction (RVOTR). Methods Between November 2005 and February 2009, 12 conduits were used for RVOTR. The mean age and weight of patients were 43.5 ± 46.4 months and 13.4 ± 8.6 kg. The main diagnosis was tetralogy of Fallot with pulmonary atresia in eight patients. The most common conduit size was 18 mm. The mean follow-up was 88.0 ± 35.9 months. Results There were no operative and late mortalities. At discharge, the mean peak systolic pressure gradient across the RVOT was 14.1 ± 11.3 mmHg. There was no conduit valve regurgitation in nine patients. At the latest echocardiography (mean follow-up: 84.3 ± 35.5 months), the mean peak systolic pressure gradient across the RVOT was 59.7 ± 20.2 mmHg, and there was no conduit valve regurgitation in six patients. Freedom from conduit malfunction was 100% and 83.3%, at 1 and 8 years, respectively. Two conduits were explanted due to sternal compression and four from conduit malfunction. Freedom from explantation was 83.3% and 74.2% at 2 and 8 years, respectively. Conclusions ePTFE bicuspid valved conduit has good late function in terms of valve regurgitation, but the pressure gradient across the conduit increases with time, which is the main cause of conduit failure and explantation.

The surgical management of transposition complex with aortic arch obstruction remains technically demanding due to anatomic complexity. Even in the recent surgical era, there are centers that address this anomaly with a staged strategy. This report presents our experiences with a one-stage repair of transposition complexes with aortic arch obstructions more than the last 10 years. Since 2003, 19 patients with a transposition of the great arteries (TGA, 2 patients) or a double outlet of the right ventricle (DORV, 17 patients) and aortic arch obstruction have undergone one-stage repair of their anomalies. The mean age was 6.7 ± 2.3 days, and the mean body weight was 3.4 ± 0.3 kg. The 2 patients with TGA exhibited coarctation of the aorta. The 17 patients with DORV all exhibited the Taussig–Bing type. The great artery relationships were anteroposterior in 4 patients (21.1 %). The coronary artery anatomies were usual (1LCx; 2R) in 8 patients (42.1 %). There were 2 early deaths (10.5 %). Seven patients (36.8 %) required percutaneous interventions. One patient required re-operation for pulmonary valvar stenosis and left pulmonary artery patch angioplasty. The overall survival was 84.2 %. The freedom from mortality was 83.5 % at 5 years, and the freedom from intervention was 54.4 % at 5 years. The one-stage repair of transposition complexes with aortic arch obstructions resulted in an acceptable survival rate and a relatively high incidence of postoperative catheter interventions. Postoperative catheter interventions are highly effective. Transposition complexes combined with aortic arch obstructions can be managed by one-stage repair with good early and midterm results.

Objectives Postoperative left pulmonary artery (LPA) kinking is problematic in repair of tetralogy of Fallot (TOF). We used angioplasty of the proximal LPA with an anterior wall flap of the main pulmonary artery (MPA) to prevent this problem. Methods We have used an anterior wall of the MPA as a flap for LPA angioplasty in 42 patients with TOF and pulmonary stenosis (26 males and 16 females) since February 2007. During the same period, 116 patients underwent total repair of TOF with pulmonary stenosis. The median age was 7.1 months (range, 3-88.8), and the median weight was 8.4 kg (range, 5-27). The indications for LPA angioplasty were acute-angle proximal LPA in 17 (40.5%), proximal LPA stenosis in 6 (14.3%), acute-angle and stenotic proximal LPA in 18 (43%), and short and small distal MPA in 1 patient. The patches used for MPA and LPA reconstruction were glutaraldehyde-treated autologous pericardium in 34 and bovine pericardium in 8 patients. Results No operative or late death occurred. The mean follow-up duration after surgery was 26.4 ± 18.6 months (range, 0.5-67). During the follow-up period, reoperation for LPA stenosis or kinking was not required in any patient; however, balloon angioplasty was performed with good results in 4 patients (9.5%). No postoperative kinking of the proximal LPA occurred. Echocardiography or computed tomography angiography at the recent follow-up visit demonstrated good branch pulmonary arteries in all patients. Conclusions Angioplasty of the proximal LPA using an anterior wall flap of the MPA in the patients with TOF and pulmonary stenosis is an effective method in the management of acute angle and/or stenosis of LPA without postoperative kinking.

Background Airway compression caused by an enlarged right pulmonary artery (RPA) in patients with a large shunt can usually be managed with intracardiac repair and concomitant anterior aortopexy. However, anterior aortopexy can be less effective or even dangerous in patients with coexisting arch anomaly due to excessive tension at the arch repair site. We have adopted anterior translocation of RPA without aortic transection in the group of patients with a high risk of postoperative airway compression. We reviewed the early and midterm results of this technique. Methods From February 2006 to January 2013, 8 patients underwent RPA anterior translocation as a concomitant procedure in one-stage repair of ventricular septal defect (VSD) and aortic arch anomaly to avoid postoperative airway problems. The enlarged RPA was disconnected from the main pulmonary artery (MPA) at its origin and was relocated anterior to the ascending aorta, and subsequently reimplanted to the U-shaped trapdoor incision at the anterolateral MPA wall. The mean age at operation was 34 days (median, 14 days, 6 to 77 days), and the mean body weight was 3.6 kg (2.15 to 5.5 kg). All patients had coarctation of the aorta and VSD except 1 who had aortic arch interruption. Five patients were dependent on a ventilator preoperatively. Six patients had evidence of preoperative bronchial compression (left; 4, right and left; 2), and 2 had a high probability of postoperative bronchial compression due to unusual anterior location of the descending aorta. Results There was no early or late death. There were no postoperative airway problems such as reintubation or left lung atelectasis. Widely patent RPA was confirmed on postoperative computed tomographic angiography in all patients. The mean follow-up duration was 54.0 ± 17.1 months. One patient required balloon angioplasty for mild stenosis at the clamping site 3 years after the operation. All patients had no RPA stenosis at the latest follow-up evaluation. Conclusions Anterior translocation of the RPA as a concomitant procedure in one-stage repair of VSD and arch anomaly is a safe and effective procedure to avoid postoperative airway problems in high-risk patients.

Malfunction of the unidirectional valve in a breathing circuit system may cause hypercapnia from the rebreathing of expired gas, ventilation failure, and barotrauma. Capnography is a useful method for monitoring the integrity of the unidirectional valve. We experienced two cases of malfunction of a unidirectional valve which caused leakage and reverse flow, diagnosed early as a change of the capnographic waveform. One case was caused by expiratory unidirectional valve breakage. The other was caused by an incorrectly-assembled inspiratory unidirectional valve. (Korean J Anesthesiol 2013; 65: 337-340)

The management of pulmonary atresia with a ventricular septal defect (PA/VSD) depends on the anatomy of the pulmonary artery or on the surgical strategy used at individual institutions. In our institution, we adopted a right ventricle-to-pulmonary artery (RV-PA) shunt in 2011 as a palliative procedure for PA/VSD to overcome the disadvantages of a Blalock-Taussig shunt. We evaluated the results of the RV-PA shunt as initial palliative surgery for PA/VSD. Thirteen patients with ductus-dependent PA/VSD from August 2011 to August 2015 were enrolled. The mean age at surgery was 17.9 ± 15.3 (range 5–60) days, and the mean body weight was 2.9 ± 0.6 (range 2.2–4.0) kg. A Gore-Tex tube graft was used in all patients. We retrospectively observed intra- and postoperative complications, early and late mortality, and palliation duration to definitive repair. Left pulmonary artery angioplasty was performed as a concomitant procedure in three patients. There were no early hospital mortalities, although two inter-stage deaths occurred 34 and 47 days postoperatively: one patient died of aspiration and the other of right ventricular outflow tract (RVOT) pseudoaneurysm rupture. Two patients (15.4%) required the extracorporeal membrane oxygenation support postoperatively: one because of failure to wean from a bypass caused by persistent hypoxemia and the other because of sudden massive bleeding from the RVOT suture line in the intensive care unit 2 days postoperatively. These two patients underwent second-stage definitive repair successfully. Five patients (41.7%) required catheter intervention, for juxtaductal left pulmonary artery stenosis in three patients, right pulmonary artery stenosis in one, and shunt inflow stenosis in one. Two patients (15.4%) required re-operation because of shunt inflow stenosis and RVOT pseudoaneurysm, respectively. All patients who survived the RV-PA shunt underwent total correction at a mean interval of 13.1 months. A RV-PA shunt is an option for the initial palliation of ductus-dependent PA/VSD. Major complications can occur, including RVOT pseudoaneurysm, shunt inflow stenosis, persistent hypoxemia during the immediate postoperative period, and dehiscence of the shunt anastomosis site. Caution should be taken when performing the RV-PA shunt for palliation of PA/VSD.

Background: The intramural coronary artery has been known as a risk factor for early death after an arterial switch operation (ASO). We reviewed the morphological characteristics and evaluated the early and mid-term results of ASO for patients with an intramural coronary artery. Materials and Methods: From March 1994 to September 15th 2010, 158 patients underwent ASO at Dong-A and Pusan National University Hospitals for repair of transposition of the great arteries and double outlet right ventricle. Among these patients, 14 patients (8.9%) had an intramural coronary artery. Mean age at operation was 13.4±10.2 days (4 to 39 days) and mean body weight was 3.48±0.33 ㎏ (2.88 to 3.88 ㎏). All patients except one were male. Eight patients had TGA/IVS and 4 patients had an aortic arch anomaly. Two patients (14.3%) had side-by-side great artery relation, of whom one had an intramural right coronary artery and the other had an intramural left anterior descending coronary artery. Twelve patients had anterior-posterior relation, all of whom had an intramural left coronary artery (LCA). The aortocoronary flap technique was used in coronary transfer in 8 patients, of whom one patient required a switch to the individual coronary button technique 2 days after operation because of myocardial ischemia. An individual coronary button implantation technique was adopted in 6, of whom 2 patients required left subclavian artery free graft to LCA during the same operation due to LCA injury during coronary button mobilization and LCA torsion. Results: There was 1 operative death (7.1%), which occurred in the first patient in our series. This patient underwent an aortocoronary flap procedure for coronary transfer combining aortic arch repair. Overall operative mortality for 144 patients without an intramural coronary artery was 13.2% (19/144). There was no statistical difference in operative mortality between the patients with and without an intramural coronary artery (p＞0.1). There was no late death. The mean follow-up duration was 52.1±43.0 months (0.5 to 132 months). One patient who had a subclavian artery free graft required LCA stenting 6.5 years after surgery for LCA anastomotic site stenosis. No other surviving patient needed any intervention for coronary problems. All patients had normal ventricular function at latest echocardiography and were in NYHA class 1. Conclusion: The arterial switch operation in Transposition of Great Arteries or Double Outlet Right Ventricle patients with intramural coronary can be performed with low mortality; however, there is a high incidence of intraoperative or postoperative coronary problems, which can be managed with conversion to the individual coronary button technique and a bypass procedure using a left subclavian free graft. Both aortocoronary flap and individual coronary button implantation techniques for coronary transfer have excellent mid-term results.

Background: We assessed the early and mid-term results of the modified Norwood procedure for first-stage palliation of hypoplastic left heart syndrome (HLHS) and its variants to identify the risk factors for hospital mortality. Material and Method: Between March, 2003, and December, 2009, 23 patients (18 males and 5 females) with HLHS or variants underwent the modified Norwood procedure. The age at operation ranged from 3 to 60 days (mean, 11.7±13.2 days) and weight at operation ranged from 2.2 to 4.8 ㎏ (mean, 3.17±0.52 ㎏). We used a modified technique that spared the anterior wall of the main pulmonary artery in 20 patients. The sources of pulmonary blood flow were RV-PA conduit in 15 patients (group Ⅰ) and RMBTS in 8 (group Ⅱ). Follow-up was completed in 19 patients (19/20, 95%) in our hospital (mean 26.0±22.8 months). Result: Early death occurred in 3 patients (3/23, 13%), of whom 2 had TAPVC. Fourteen patients underwent subsequent bidirectional cavopulmonary connection (BCPC, stage 2) and seven underwent the Fontan operation (stage 3). Three patients died between stages, 2 before stage 2 and one before stage 3. The estimated 1-year and 5-year survival rates were 78% and 69%, respectively. On multivariate regression analysis, aberrant right subclavian artery (RSCA) and associated total anomalous pulmonary venous connection (TAPVC) were risk factors for hospital mortality after stage 1 Norwood procedure. Conclusion: HLHS and its variants can be palliated by the modified Norwood procedure with low operative mortality. Total anomalous pulmonary venous connection adversely affects the survival after a stage 1 Norwood procedure, and interstage mortality rates need to be improved.

Chest pain is a symptom observed commonly in outpatients and emergency room patients, and its causes are variable. Because treatment and prognosis of chest pain are different depending on its cause, it is more important than anything else to accurately diagnose the cause of chest pain. Most of patients complaining of chest pain undergo basic tests at a private local clinic or at the Internal medicine or chest surgery department of a general hospital and, they are referred to the pain clinic, with a note stating no particular finding. However, if they have sustained severe neuropathic pain in spite of nerve block, accurate diagnosis for chest pain is essential. We experienced rapidly developing spine breakdown and cord compression caused by metastatic spinal tumor in an inpatient who was being treated for chest pain, and thus, we report here in the case with literature review.

Background Reconstruction of branch pulmonary arteries (PAs) can be demanding in redo congenital cardiac surgeries. Sutureless patch angioplasty could be a useful method to solve this problem, and we evaluated the feasibility of sutureless patch angioplasty for postoperative PA stenosis in patients who underwent congenital cardiac surgery. Methods We retrospectively reviewed 28 patients (19 males and 9 females) who underwent sutureless patch angioplasty for postoperative PA stenosis between November 2004 and April 2015. The median age was 7.3 months (range, 4.3 to 54.7), and the median weight was 7.2 kg (range, 5.3 to 12.2 kg). Right PA angioplasty was performed in 5, left PA angioplasty in 10, and both sides in 13 patients. The most common original diagnosis was hypoplastic left heart syndrome (n = 18 of 28, 64.3%). Concomitant surgeries were the bidirectional cavopulmonary shunt in 24 patients, the Fontan operation in 3, and the Rastelli operation in 1 patient. Results No operative death occurred. However, 2 late deaths were recorded, and both were unrelated to PA angioplasty. Mean follow-up duration was 60.9 ± 33.1 months. None of the patients had postoperative bleeding or thrombotic occlusion. No reoperation for PA restenosis was performed, and only 1 patient (3.6%) had a PA balloon angioplasty with a good result 12.9 months after the operation. Echocardiography or computed tomography angiography at the recent follow-up showed good branch PAs in all patients. Conclusions Sutureless patch angioplasty for postoperative PA stenosis could simplify PA angioplasty, and be a safe and effective method for PA reconstruction in patients who undergo congenital cardiac surgery.

A 12-years-old boy (165 cm/72 kg) complained of severe posterior neck pain radiating to the right arm. The resting pain score was VAS 80 of 100 and on moving the neck the VAS was 90/100. X-ray and MRI showed C7-T1 intervertebral disc calcification (IDC) with right C8 nerve compression (Fig. 1). Conservative treatment such as, pain medication, physical therapy, and trigger point injection administered at another hospital, failed to relive his pain. Operation was recommended but parental consent was denied. The patient consulted our clinic for pain management. Laboratory finding were normal, and physical examination showed no neurological signs, with non specific electromyography. The severe pain was unresponsive to conservative treatment. We decided to perform cervical root block (CRB) instead of epidural block that was not suitable to the location, and caused fear in the pediatric patient. Fig. 1 Radiological image of the cervical spine and ultrasound image of C8 nerve root block. Lateral X-ray image (A) and sagittal (B), and axial (C) MRI show C7-T1 intervertebral disc calcification (IDC). This IDC caused C8 nerve root compression. Four ventral ... Dual-guided CRB was performed with the patient in the left lateral position, after pre-scanning with ultrasound. We surgically disinfected both cervical areas and protected the ultrasound probe and cable with a sterile ultrasound probe cover (SonoLab™ 18 × 120 cm, Lucky Medical, Seoul, Korea). Right sided 8th CRB was performed with a portable ultrasound instrument, and a 50 mm linear 15-6 MHz probe (SonoSite M-Turbo™, SonoSite Inc., Bothell, WA, USA). The 8th CRB was performed as follows: The 5th, 6th, 7th and 8th cervical roots were identified by scanning from the supraclavicular area to the 6th transverse process. The skin was infiltrated with 1 ml of lidocaine 1%. A nerve stimulating needle with 30o bevel (22-guage, 50 mm, Stimuplex® D, B.Braun, Melsungen, Germany) was inserted under dual-guidance. We used 2 Hz stimulation frequency and an impulse duration of 0.1 ms. The intensity of the stimulating current initially set to deliver 1.5 mA, was decreased to obtain the minimal stimulating current. The needle was repositioned until the minimal stimulating current was ≤ 0.3 mA (Fig. 1). Five ml ropivacaine 0.2% with 10 mg of triamcinolone acetate was injected surrounding the 8th nerve root after careful air bubble removal and an aspiration test. The block was performed 4 times during 2 weeks. VAS was improved by 50% after the first block and the VAS was 20/100 after the 4th procedure. The patient was discharged after 2 weeks since there was no pain. Subsequently, pain relief was with aceclofenac 100 mg for 2 weeks. We did not administer further medication or nerve block. The patient had no pain and neurologic symptoms at the 2 month follow-up visit. Pediatric IDC is a rare disorder without any clear etiologies and mechanisms. Calcification is mostly reported at the level of C6-7, but it may occur at any location [1]. IDC has a higher incidence in males, aged 7 to 8 years [1]. Various clinical symptoms have been reported. Neck pain and stiffness are most common. Low fever, limitation of motion, and muscle spasm are also commonly reported [1]. Neurologic symptoms appear due to compression of the nerve root and spinal cord from herniation, as a result of calcification. Signs of neurologic deficiency, including weakness, sensory loss, and myelopathy are rare [1]. However, 20% of patients exhibit neurologic symptoms due to epidural calcifications. In this case, the patient complained of severe pain, resulting from irritation of the cervical root by the irritants from the calcified cervical disc. The etiology is unclear. Laboratory tests show mostly normal results or moderate inflammatory syndrome [1]. There were non-specific findings in the study case. Radiographs reveal oval or round shaped calcifications that are most often located in the middle of the disk, but sometimes occupy the entire disk. MRI shows regions of reduced signal intensity on both, the T1- and the T2-weighted images, reflecting low proton density of the herniated calcific nucleus pulposus and its relation with myelin and the nerve roots. Rapid confirmation with MRI is very critical when the patient has neurologic symptoms. The symptom disappears within one month, in most cases. Calcification regresses over the course of months to years, but may linger longer without symptoms. IDC is normally a benign condition. Majority of cases are treated conservatively and have good outcomes [2]. Therefore, the treatment of choice is conservative and symptomatic. It includes analgesics, nonsteroidal antiinflammatory medication, muscle relaxants, cervical soft collar, and limited physical activity [1]. The use of corticosteroids therapy has not been discussed in literature to date. IDC is known to be self limited with favorable results on conservative treatment, as described above. Severe pain, uncontrolled by medication, with successful interventional treatment such as CRB, has not been previously reported. Surgery is required in patients who develop progressive neurological deficit [1,3]. A decompression of the spinal cord with an anterior cervical diskectomy and an anterior fusion is usually required. Few cases in literature comment on recurrent neurological symptoms after surgical treatment [1]. Surgical treatment is a good approach for the short term, but it has not been scientifically validated by long term observation of symptoms [3,4]. It is based on the unique anatomic features of the pediatric spine. Curvature forms at age 10, and the adult skeleton completes from then on [5]. Therefore, careful surgical consideration of the effect on the biomechanism in the postadult spine is necessary. The results from a study with long-term observation of 381 young patients with surgery, showed degenerative changes at the adjacent level, and affected curvature [5]. Conservative management is currently the main treatment modality. However, in situations of uncontrolled pain in patients with IDC, CRB with ultrasound guidance is recommended for good results.

Airway compression by dilated right pulmonary artery (RPA) in infants with congenital heart disease can cause severe respiratory insufficiency and increase postoperative morbidity. Anterior aortopexy can be a good solution. However, in a case in which aortic arch repair is required, anterior aortopexy might not be effective or can be dangerous. Anterior translocation of the RPA can be a good option to avoid postoperative airway obstruction. We adopted this technique in a one-stage complete repair of distal aortopulmonary window, aortic origin of the RPA, interrupted aortic arch, and ventricular septal defect in a neonate with compression of both main bronchi. After 37 months of follow-up, no problem was encountered with her airway or RPA. We describe the technique used and the results obtained.

A 22-years-old female patient at 171 cm and 67 kg visited the Department of Breast Surgery of the hospital with a mass accompanied with pain on the left side breast as chief complaints. Since physical examination revealed a suspected huge mass, breast surgeon decided to perform surgical excision and requested anesthesia to our department. Surgery of breast tumor is often under local anesthesia. However, in case of big size tumor, surgery is usually performed under general anesthesia. The patient feared general anesthesia. Unlike abdominal surgery, there is no need to control visceral pain for breast and anterior thoracic wall surgery. Therefore, we decided to perform resection under regional anesthesia. Herein, we report a successful anesthetic and pain management of the patient undergoing excision of a huge breast fibroadenoma under regional anesthesia using Pecs II and internal intercostal plane block.

OBJECTIVES: This study was undertaken to assess the early and long-term results of total repair of tetralogy of Fallot (TOF) and to identify the risk factors associated with late right ventricular (RV) dilatation. METHODS: The medical records of 326 patients (male:female = 192:134) who underwent total repair of TOF at Pusan National and Dong-A University Hospitals between July 1991 and May 2011 were retrospectively reviewed. Median age and weight at the time of operation were 13.0 months and 8.7 kg, respectively. Right ventricular end-diastolic dimensions and left ventricular end-diastolic dimensions were obtained during follow-up echocardiography to identify the risk factors associated with late RV dilatation. RESULTS: There were one operative death (0.3%) and 8 late deaths (2.5%). Of late deaths, two were related to operation-related cardiac problems. Overall survival rates at 5, 10, and 15 years were 97.0%, 95.4%, and 95.4%, and the corresponding freedom from cardiac death were 98.8%, 98.8%, and 98.8%, respectively. Freedom from re-operation and re-intervention were 84.4%, 74.2% and 74.2%. Six patients underwent pulmonary valve replacement during the follow-up period. Transannular patch (P= 0.036) and postoperative ventilator support period (P< 0.001) were found to be significant risk factors of late RV dilatation in multivariate analysis. CONCLUSIONS: Total correction of TOF can be performed with a very low mortality rate. However, the postoperative re-operation or re-intervention rates remain relatively high. Late RV dilatation after total repair of TOF was found to be associated with transannular patch enlargement and a longer postoperative ventilator support period.

Several methods of making expanded polytetrafluoroethylene valved conduit have been reported, but these techniques are complicated and less reproducible. We have developed a new simplified technique for making a tricuspid expanded polytetrafluoroethylene valved conduit for right ventricular outflow tract reconstruction and have been using this conduit for approximately 3 years with excellent results. Our technique is straightforward and reproducible, and the cusps in the conduit are durable due to the use of a specialized suturing technique.

A 31-year old male patient who was 173 cm tall and weighed 67 kg visited our ENT clinic with dyspnea and laryngeal papilloma as his main complaints. According to laryngoscopic findings, a diffuse large papilloma was observed at the posterior wall of the left subglottis (Fig. 1A). The patient was scheduled for the removal of the papilloma under general anesthesia. Fig. 1 (A) pre-operative laryngoscopic image shows a diffuse large papilloma on the posterior wall of the left subglottis. (B) Intra-operative laryngoscopic image after excision of the papilloma. Laryngoscopic image shows the clear posterior wall of the subglottis ... Since the patient was adamantly opposed to invasive procedures such as a tracheostomy, awake intubation was considered for safety reasons, but finally a fiberoptic bronchoscopy (FOB) and cricothyroidotomy set were prepared in case of trachea obstruction, considering that the size of the tumor was not large enough to obstruct the trachea. Anesthesia was induced with propofol, remifentanil, and rocuronium. Fortunately, ventilation was satisfactory, and tracheal intubation was performed. A tracheal tube 6.0 mm in inner diameter (ID) was inserted. Upon completion of preparations for surgery, an attempt was made to replace the tracheal tube with a tube that was 5.0 mm in ID using a Cook airway exchange catheter® (CAEC: Cook Critical Care, Bloomington, USA) with a 14.0 of French size, 83 cm of length and 3.0 mm of ID, but only the CAEC was left in due to difficulty in surgery, and the tracheal tube was removed to surgery (Fig. 1B). The CAEC was fixed at the teeth after fitting at 22 cm because the length between the teeth and the superior aspect of the carina through FOB using a tracheal tube was 22 cm. In order to immediately reintubate and monitor end-tidal CO2 (EtCO2) in case of problems in ventilation or oxygenation, an adapter and the tracheal tube were left on the CAEC (Fig. 1C). Additionally, an injector for high-frequency jet ventilation (HFJV) was also prepared (Fig. 1D). For preventing aspiration, the patient's position was changed to the Trendelenburg position (Fig. 1C). In an attempt to avoid risks of developing ignition caused by the electrocautery, continuous ventilation was replaced by the on-and-off procedure; when the pulse oximeter oxygen saturation (SpO2) of the patient fell to 90% or below, the procedure was stopped, and the reservoir bag was filled with an O2 flush; and after bagging at 100-120 times/minute, and the peak inspiratory pressure did not exceed 30 cmH2O resulting in an SpO2 of at 95% or greater, the procedure was resumed. At the end of the operation (Fig. 1C), a tracheal tube that had a 6.0 mm ID was intubated. Since microlaryngeal surgeries are performed under general anesthesia, small-diameter endotracheal tubes or jet ventilation are generally used for tracheal airway management according to the size and location of tumors. As one of the most useful methods of airway management in laryngeal surgery, jet ventilation, has been widely used because the view of the larynx is not blocked [1]. Supraglottic jet ventilation is a method of jet oxygenating via the vocal cords, which is ideal for surgical exposure, but anesthesiologists experience difficulty when using this method of airway management. Moreover, supraglottic jet ventilation may cause gastric distension because of high pressure and malalignment, inefficient or ineffective ventilation caused by barotraumas and malposition, and many potential complications including aspiration of blood and debris in the hypercarbia and bronchi [2,3]. Subglottic jet ventilation is a method using a small tube via the glottis below the vocal cord, which requires a tube and an injector. Subglottic jet ventilation provides anesthesiologists with convenience in ventilation, and does not cause aspiration of blood and debris. When a small tube is used, surgical exposure and access are not blocked. Recent animal and human studies proved the superiority of subglottic jet ventilation in microlaryngeal surgery [4]. Despite this, the method is not free from the risk of developing complications including barotraumas. In this case, oxygenation was well maintained to prevent barotraumas by filling the reservoir bag with an O2 flush, and adjusting the water so as not to exceed 30 cmH2O of maximum inhaling pressure through bagging at 100-120 times/min. If oxygenation was not well maintained, a CAEC could be used as a tube, and the airway could be maintained by HFJV using an injector already prepared. If that method was not enough, the tracheal tube could be re-intubated, enabling a controlled mode of ventilation. Accordingly, airway management using a CAEC is considered to be very safe for airway management of patients. If clinics are not well equipped with injectors, a CAEC can be used as a tube, and subglottic jet ventilation may be performed using an O2 flush with the anesthesia machine as an injector. In this case, the anesthesia machine, an S/5 Aespire™ (GE Healthcare, USA), was used. In this machine, the O2 flush is activated by setting the O2 flush button to 241 ± 7 kPa (35 ± 1.0 psi) of pressure, which can be used as an injector in case of an emergency to help airway management. A CAEC is a hollow and semirigid catheter enabling oxygen insufflations, and has a blunt catheter tip, lowering the risk of tracheobronchial trauma or lung laceration, and consequently, it has been used for tube replacements or extubation trials [5]. Unlike the tubes for general jet ventilation, since a CAEC can be used for intubating a tracheal tube by virtue of the catheter functioning as a guide wire, can be connected with a typical circuit or EtCO2 adapter through a RAPI-FIT® adapter (Fig. 1C), and can be connected with the injector for HFJV (Fig. 1D), anesthesiologists may be able to perform airway management much more easily and safely. CAECs with various types and sizes are produced, and anesthesiologists may choose CAECs appropriate to cases for effective airway management during anesthetic procedures. In conclusion, when a CAEC is used in operations using laryngoscopy, the merits are summarized as follows: First, no additional tube is necessary for jet ventilation. Second, a CAEC can be connected to a typical anesthesia machine and a capnograph monitor via a RAPI-FIT® adapter. Third, a tracheal tube can be intubated at any time in an emergency such as unexpected oxygenation and development of ventilation problems or aspiration. Last, the intubated tracheal tube may be usefully used for confirming through FOB.

Background: The tetralogy of Fallot (TOF) with pulmonary atresia (PA) and a ductus-dependent pulmonary circulation (no major aorto-pulmonary collateral arteries (MAPCAs)) has been treated with staged repair or primary repair depending on the preference of surgeons or institutions. We evaluated the 19-year outcome of staged repair for this anomaly to find out whether our surgical strategy should be changed. Materials and Methods: Forty-four patients with TOF/PA with patent ductus arteriosus (PDA) who underwent staged repair from June 1991 to October 2010 were included in this retrospective study. The patients with MAPCAs were excluded. The average age at the first palliative shunt surgery was 40.8±67.5 days (range: 0∼332 days). Thirty-one patients (31/44, 70%) were neonates. The average weight was 3.5±1.6 ㎏ (range: 1.6∼8.7 ㎏). A modified Blalock-Taussig (BT) shunt was performed in 38 patients, classic BT shunt in 4 patients, and central shunt in 2 patients. Six patients required concomitant procedures: pulmonary artery angioplasty was performed in 4 patients, pulmonary artery reconstruction in one patient, and re-implantation of the left pulmonary artery to the main pulmonary artery in one patient. Four patients required a second shunt operation before the definitive repair was performed. Thirty-three patients underwent definitive repair at 24.2±13.3 months (range: 7.3∼68 months) after the first palliative operation. The average age at the time of definitive repair was 25.4±13.5 months (range: 7.6∼68.6 months) and their average weight was 11.0±2.1 ㎏. For definitive repair, 3 types of right ventricular outflow procedures were used: extra-cardiac conduit was performed in 30 patients, trans-annular patch in 2 patients, and REV operation in 1 patient. One patient was lost to follow-up after hospital discharge. The mean follow-up duration for the rest of the patients was 72±37 months (range: 4∼160 months). Results: Ten patients (10/44, 22.7%) died before the definitive repair was performed. Four of them died during hospitalization after the shunt operation. Six deaths were thought to be shunt-related. The average time of shunt-related deaths after shunt procedures was 8.7 months (range: 2 days∼ 25.3 months). There was no operative mortality after the definitive repair, but one patient died from dilated cardiomyopathy caused by myocarditis 8 years and 3 months after the definitive repair. Five-year and 10-year survival rates after the first palliative operation were 76.8% and 69.1%, respectively. Conclusion: There was a high overall mortality rate in staged repair for the patients with TOF/PA with PDA. Majority of deaths occurred before the definitive repair was performed. Therefore, primary repair or early second stage definitive repair should be considered to enhance the survival rate for patients with TOF/PA with PDA.

Breast surgery is a common procedure performed in women. Many women who undergo breast surgery suffer from ill-defined pain syndromes. A nerve block is used in the treatment of the acute and chronic pain, but the effectiveness of the treatment has been limited because of its short duration. Recently, the advent of pulsed radiofrequency lesioning (PRF) has proved a successful treatment for chronic refractory pain involving the peripheral nerves. We experienced a case of a 52-year-old female patient complaining of chronic breast neuropathic pain after breast reduction, which was relieved after PRF lesioning of the 4th thoracic spinal nerve and its root.

Objectives We evaluated our clinical experiences on rehabilitation of native pulmonary arteries (PAs) with a central shunt using an expanded polytetrafluoroethylene (ePTFE) tube graft in management of pulmonary atresia with ventricular septal defect (VSD) and major aortopulmonary collateral arteries (MAPCAs) with diminutive PAs. Methods From March 1993 to June 2013, a total of 28 consecutive patients underwent surgery for pulmonary atresia with VSD and MAPCAs. We identified 15 patients who underwent a central shunt procedure using an ePTFE tube graft. Median age and weight at the initial operation were 1.91 months and 5.22 kg, respectively. Ligation of MAPCAs was performed in 3 patients concomitantly. The techniques used were a U-shaped central shunt in 13 patients, and a side-to-side aorto-ePTFE tube graft anastomosis in 2 patients. Results There was no surgical mortality, and no shunt occlusion. The mean follow-up duration was 70.7 ± 67.1 months. Complete repair was achieved in 13 patients (13 of 14 of the follow-up patients; 92.9%), and the remaining patient is waiting for complete repair. The median age at complete repair was 19.4 months. The mean PA index before the initial central shunt procedure was 22.7 ± 13.2 mm 2 /m 2 , which increased to 149.4 ± 86.6 mm 2 /m 2 at the final recordings before shunt division, and 185.9 ± 84.0 mm 2 /m 2 before complete repair. There were 2 late mortality cases. The overall survival rates were 92.9%, 82.5%, and 82.5%, at 1, 5, and 10 years, respectively. Conclusions A central shunt, using an ePTFE tube graft, is an effective initial palliative procedure for rehabilitation of the diminutive PAs in patients with pulmonary atresia with VSD and MAPCAs.

Background/Purpose The endothelin receptor B (EDNRB) signaling pathway, which is the second major susceptible gene for Hirschsprung's disease (HSCR), is crucial for the development of the enteric nervous system. The allele frequency of polymorphisms was mostly tested in the American and European population, but the data of an ethnically diverse, non-Caucasian population are unclear. To further investigate the variants and haplotypes of the EDNRB gene, this study examined sequence variations in Korean patients with sporadic HSCR. Methods All 8 exons and intron/exon boundaries of the EDNRB gene in 18 Korean patients with sporadic HSCR and 84 healthy individuals were screened using PCR amplification and direct sequencing. Results A total of 8 different nucleotide substitutions were identified. Of these, 4 were new variants (promoter-116C>T; 5′UTR-121G>T; IVS4+62C>A; IVS5+121G>C) and the others were previously described variants. The distribution of variations was even different from that reported for Chinese and Japanese subjects as well as other ethnic groups. This study also analyzed the haplotypes for an association between the variants identified with HSCR. Conclusions This study identified additional sequence variants of the EDNRB gene, but the estimated EDNRB haplotypes did not show any disease risk.

Dear Editor, We experienced a postoperative traumatic left ventricular hematoma that was incidentally found after establishment of rescue mechanical circulatory support (MCS) following sudden postoperative circulatory collapse in the cardiac intensive care unit (CICU). The patient successfully recovered with aggressive and prolonged mechanical circulatory support. We report this case to share a worrisome clinical experience in an intensive care unit. The 4-month-old patient weighing 6.6 kg diagnosed with tetralogy of Fallot and a small secundum atrial septal defect underwent successful total correction in the operation room. However, when he arrived at the cardiac intensive care unit (CICU), sudden bradyarrhythmia developed, leading to acute circulatory collapse. At that moment, we performed open cardiopulmonary resuscitation and established rescue extracorporeal membrane oxygenation (ECMO, Bio-Medicus , Eden Prairie, MN; PHISIO oxygenator, Dideco, Mirandola, Italy). On the 3rd postoperative day, bedside echocardiography showed an unexplained huge hematoma, which was suspected to abut the posterior wall of the left ventricle (LV) in the pericardial space in the first place. On the same day, however, while performing mediastinal irrigation to control bleeding in the operating room, the suspected intrapericardial mass was confirmed to be a swollen hemorrhagic contusion of the posterior wall of the left ventricle, which was also demonstrated in follow-up cardiac computed tomography (Fig. 1). As diffuse oozing from the LV was occurring, packed Gelfoam with thrombin was applied on the LV wall, and massive mediastinal irrigation followed. For anticoagulation, initially heparin was titrated to maintain an ACT around 160 s, followed by exclusion of heparin since LV contusion was confirmed. Packed RBCs and platelets were transfused to achieve Hb [10 g/dl and platelet counts [80,000/mm. On the 4th postoperative day, the oxygenator was changed to a new one because a thrombus had formed in the old one. The patient was weaned from ECMO on the 7th postoperative day, and the divided sternal ends were gradually pulled to the opposite side with a pair of traction strings, accommodating the huge LV. The sternal wound was finally closed on the 14th postoperative day. The patient was able to be discharged with a little motor hypotonia and then completed rehabilitation therapy. The hemorrhagic contusion of the myocardium that developed during ECMO setup was very unusual. In our case, we suspect that the huge contusional hemorrhage of the LV resulted from the procedures used during open cardiac massage and ECMO cannulation. Hemorrhagic problems and bleeding control are always cumbersome issues during ECMO setup [1, 2]. In this case in particular, the contusional wound of the myocardium kept oozing diffusely. However, packing the thrombogenic agent with Gelfoam and maintaining low ACT [2] were relatively effective and sufficient in this puzzling situation. In general, postoperative myocardial edema is decompressed by opening the sternum and covering the wound with a Gore-Tex patch or other materials [3]. However, in our case, the LV was too large to apply

In the literature, 7% of all cases of herpes zoster present as herpes zoster ophthalmicus (HZO). Of these cases, 20 to 79% have orbital involvement [1]. Nearly all orbital tissues, including extra-ocular muscles, can be affected by the varicella zoster virus. Orbital involvement may present as keratitis, uveitis, scleritis, optic neuritis, ocular motor palsy, or postherpetic neuralgia (PHN) [2]. HZO is often suspected when ophthalmic symptoms and signs follow characteristic skin rashes and edema. Here, we report an unusual case where orbital myositis preceded vesicular skin eruptions. A 66 year-old man, who had diabetes for 15 years and hypertension for 10 years, was hospitalized due to a 4-day history of left orbital shooting pain. Cranial nerve examination was nearly normal except for mild ptosis and hyperemic conjunctiva on the left side. Ophthalmic examination revealed normal intraocular pressure and normal eyeground. There were no specific findings in other physical examinations. Orbital CT revealed left orbital myositis involving superior, inferior, medial, and lateral rectus muscles compared with the right orbit (Fig. 1A). We treated him with intra-venous mannitol, 60 mg/day per-oral prednisolone (nisolone®, Kukje, Seongnam, Korea), levofloxin eye-drops (Cravit®, Santen, Shiga, Japan), dorzolamide HCl 2% with timolol 0.5% (Cosopt®, MSD, Seoul, Korea), and latamoprost (Xalost®, Taejoon, Seoul, Korea). Fig. 1 (A) Orbital computed tomography (CT) image with contrast, coronal view. CT shows relatively moderately enhanced and enlarged left superior, inferior, medial, and lateral rectus muscles compared with right orbit. (B) 2 weeks later, a follow-up orbital ... After 3-days, he developed vesicular skin rashes at the distribution of the ophthalmic branch of the left trigeminal nerve and along the nasal ridge (Hutchinson's sign) (Fig. 1C). He complained of severe pain in his left forehead and nose. The pattern of the pain included lancinating, shooting, and itching sensations. The pain measured by the visual analogue scale (VAS) was approximately 90/100 mm. Laboratory data, including routine biochemical and hematological examinations, were normal except for glucose (423 mg/dl) and hemoglobin A1c (10.6%). The erythrocyte sedimentation rate (ESR) was 30 mm/hr and C-reactive protein (CRP) was 0.74 mg/dl. Immunologic studies, including IgA, IgM, C3, C4, antimitochondrial antibody (AMIA), anti-nuclear antibody (ANA), and anti-double stranded DNA, were all within normal limits. Thyroid function test was normal and the VDRL/TPHA test was negative. Immediately, we treated him with 7-day intra-venous (IV) acyclovir, IV dexamethasone, and per-oral (PO) gabapentin. At the same time, we performed supraorbital and supratrochlear nerve blocks. After the nerve block, the headache and allodynia were improved. The eyelid swelling and orbital pain gradually lessened by the time he was discharged. The patient returned to our clinic with persistent left orbital pain and paroxysmal and lancinating pain along the nose ridge and forehead. We performed supraorbital and supratrochlear nerve blocks then and again in two weeks, for a total of three times. The pain was reduced to VAS 10-20/100 mm. A follow-up orbital CT revealed resolved myositis in the rectus muscles (Fig. 1B). The patient was undergoing oral administration of gabapentin (600 mg/day). He revisited the hospital 5 months later without particular exacerbation of the pain or any other inconvenience in his daily tasks. Ophthalmic complications following HZO result directly from inflammatory changes or nerve damage, or indirectly from tissue scarring. These complications vary from mild, which may pass unnoticed, to severe, which may threaten life or sight. Except for diplopia, our patient developed characteristic symptoms of orbital myositis, such as orbital pain worsening with eye movements, proptosis, swollen eyelid, and hyperemic conjunctiva. He had Hutchinson's sign, which is typical for HZO [1]. Normal immunologic and serologic surveys excluded other etiologies of orbital myositis, for example, thyroid disease, syphilis, and auto-immune diseases. His ocular symptoms improved after antiviral therapy and the follow-up orbital MRI four months later revealed total recovery of orbital myositis. Typically, ophthalmic complications of HZO occur between 5 days and 14 days following cutaneous lesions. Our case is unusual in that the orbital myositis preceded vesicular rashes. Two similar patients have been reported previously [3,4]. Both patients came to the hospital for retrobulbar pain with diplopia. Volpe et al. demonstrated orbital myositis on computed tomographic (CT) scans in their patient one day before the development of skin vesicles [3]. As reported by Kawasaki et al., MRI demonstrated orbital myositis three days prior to appearance of typical skin eruptions in their patient [4]. In these two patients and ours, their extraocular myositis had excellent recovery. However, our patient suffered from PHN, which did not occur in the previously reported patients. Although Marsh and Cooper had proposed extraocular myositis as a possible cause of ophthalmoplegia in HZO [2], it was not well documented until these case reports. To date, there is no histopathologic study of orbital myositis in HZO [4]. Orbital myositis preceding vesicular skin eruptions is a diagnostic challenge in HZO. Since zoster rashes may develop one week or more after dermatomal pain [1], serological and immunological tests may be helpful for early diagnosis in extraocular myositis preceding zoster rashes. In 1958, Lewis reported a syndrome of "ophthalmic zoster sine herpete" [5], in which orbital pain, extraocular palsy, and periorbital skin swelling occurred without skin rashes. "Ophthalmic zoster sine herpete" further confounds the diagnosis of HZO. We emphasize that, even without vesicular skin rashes, a diagnosis of extraocular myositis case as idiopathic should not be given before the availability of negative serological and immunological results for herpes zoster. In conclusion, orbital myositis can be the presenting sign of HZO. In these patients, recovery of extraocular myositis is excellent and serological and immunological studies may be helpful for early diagnosis. HZO should be listed as a cause of acute orbital myositis even without skin eruptions. Therefore, early diagnosis of acute orbital myositis and anti-viral therapy will prevent PHN. And, if zoster skin rashes are found, we should control pain aggressively by nerve blocks to prevent the development to PHN.

Airway management is important during general anesthesia. Difficulties with a direct laryngoscopy can be managed successfully in a routine manner using a laryngeal mask airway. A 65-year-old woman was scheduled to undergo gynecologic surgery. After injecting the intravenous induction agents and muscle relaxants, intubation was attempted with a direct laryngoscope. However, the vocal cords could not be observed with only the epiglottis being slightly visible. Although intubation was re-attempted by another anesthesiologist, it failed. Intubation was successfully performed via an intubating laryngeal mask airway (ILMA) after additional 100% oxygen mask ventilation. We report a case of vocal cord palsy subsequent to tracheal extubation after endotracheal intubation via ILMA.

Trigeminal neuralgia is sudden, usually unilateral, severe brief stabbing recurrent pain in the distribution of one or more branches of the 5th cranial nerve. Treatments of trigeminal neuralgia include systemic trials of medications and surgical procedures such as microvascular decompression, stereotactic radiosurgery, percutaneous glycerol or alcohol rhizolysis, percutaneous radiofrequency rhizotomy, and percutaneous balloon compression (PBC). PBC of the trigeminal ganglion using a balloon catheter was introduced by Mullan and Lichtor in 1983. Since then, many papers have been published describing results of this technique. Typically, this procedure is performed under general anesthesia. However, little is known about the use of PBC for the treatment of trigeminal neuralgia in Korea. We report here our anesthetic management of percutaneous balloon compression of trigeminal ganglion for the treatment of the trigeminal neuralgia by total intravenous anesthesia.

Although Guglielmi Detachable Coil (GDC) endovascular treatment of intracranial aneurysms has become an alternative to surgery, the main complication continues to be thromboembolic events. In our patient, we found thrombus at the third branch of the right middle cerebral artery after coil embolization. We added intravenous heparin and gave abciximab, an antiplatelet agent through the catheter. We then elevated the blood pressure and administered intravenous colloid solution to maintain adequate collateral circulation. One day later, the patient presented with acute focal infartion in the right frontal lobe and we treated her with low molecular weight heparin. After seven days, the patient’s symptoms disappeared, and there was no residual neurological deficit. Therefore, we believe potential clinical complications can be avoided through early recognition of thrombus and appropriate medical therapy. Furthermore, it is necessary to prevent hypotension and to maintain proper hematocrit levels during operations in patients having risk factors for thrombosis.

Metastatic spinal tumor may cause pain by direct tumor involvement of bone with activation of local nociceptors or compression of adjacent structures. As an adjunct to pharmacologic therapy, many patients benefit from the use of additional nerve blocks to treat cancer pain. However, they require repeated injections as nerve block under local anesthetic sometimes only give the patient temporary relief of pain. Recently, the advent of pulsed radiofrequency application has proved a successful treatment for refractory pain disorders. A 43 year-old man was presented with a constant, dull, aching pain in the posterior neck with radicular pain referred to right shoulder due to metastatic cervical spinal tumor. Right C5 and C6 medial branch nerve blocks, with local anesthetic-steroid injections were effective, but short pain relief for a couple of days. However, the pain relief lasted longer and was effective with pulsed radiofrequency application over 3 months.