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The purpose of our study was to assess the mid-term outcomes of the patients with grade III blunt thoracic aortic injury (BTAI) who were treated non-operatively and to determine the specific conditions for successful NOM.We retrospectively reviewed patients with grade III BTAI at a single level 1 trauma center between January 2012 and March 2020, and compared the demographics and outcomes of NOM and thoracic endovascular aortic repair (TEVAR). We also examined the factors contributing to the selection of NOM by calculating the odds ratios for age, sex, initial systolic blood pressure, injury severity score, abbreviated injury scale score, pseudoaneurysm/neck (P/N) ratio, and comorbidity.In total, 46 adults were included. Thirty patients underwent NOM and 19 underwent TEVAR. The time from injury to computed tomography, hospital days, intensive care unit length of stay, and follow-up period showed no difference between the two groups. Aorta-related mortality was not observed in either group. Two patients (7.4%) in the NOM group experienced an increase in pseudoaneurysms: one of them underwent delayed surgical repair without complications, and the other maintained regular follow-up. The odds ratio for selecting NOM was significant when the P/N ratio was 1.30 (OR = 4.687 [95% CI, 1.229-17.882], p = 0.024).We suggest that carefully selected patients with BTAI grade III could be observed nonoperatively or treated by delayed intervention on outpatient basis, and a P/N ratio 1.30 can be used as a cutoff to decide treatment options for BTAI grade III.

Cardiac arrest due to thyroid storm is a very rare clinical feature with high mortality that presents as multiorgan dysfunction. The mortality rate under this condition is close to 30%, even with appropriate treatment. Most thyroid storms occur in patients with long-standing untreated hyperthyroidism.A 67-year-old woman, who had no specific medical history, was admitted with stupor mentality after a pedestrian traffic accident.The patient had a Burch and Wartofsky score of 80, well beyond the criteria for diagnosis of a thyroid storm (45 points).Venoarterial extracorporeal membrane oxygenation (ECMO) was performed due to persistent unstable vital signs and findings of right ventricular dysfunction after return of spontaneous circulation after cardiopulmonary resuscitation. Circulatory assist with ECMO was performed for 8 days using a beta blocker, steroids, thionamide, and Lugol iodine solution.Myocardial function and thyroid hormone levels were rapidly normalized. The patient's mental state recovered, and patient was discharged on day 36 maintaining medication.Diagnosis of a thyroid storm in patients with multiple trauma is very difficult, because most trauma patients have symptoms of tachycardia, altered mental status, and abdominal pain that appear in thyrotoxic events. However, when unexplained shock without bleeding evidence occurs in patients with multiple trauma, a thyroid function test should be performed to rule out thyroid storm. Moreover, if hyperthyroidism is observed in a trauma patient, even if there is no history of hyperthyroidism, the possibility of a thyroid storm must be considered along with medical support treatment such as ECMO in patient with cardiogenic shock.

Summary Background This study aimed to demonstrate the safety and reliability of combined preoperative angioplasty and free flap transfer in patients with peripheral arterial occlusive disease (PAOD) by analyzing the surgical outcomes. Methods Between October 2011 and October 2015, patients who had undergone lower extremity angiography and subsequent free flap transfer were retrospectively reviewed. Data collected included demographics, perioperative data, and postoperative outcomes. The cases were divided into two groups: one group with microanastomosis performed on revascularized artery by balloon angioplasty and the other group performed on native artery. Multiple logistic regression model using propensity score and linear regression was computed to determine the association between preoperative angioplasty and the surgical outcomes. Results A total of 62 lower limb reconstruction cases (19 angioplastied cases and 43 nonangioplastied cases) were included in the study. Complications occurred in 6 cases in the angioplastied group and in 11 cases in the control group. The overall limb salvage rate was 100% during the average follow-up of 29.5 months in the angioplastied group and 97.7% in the nonangioplastied control group during the average follow-up of 31.1 months. Preoperative angioplasty was not a significant predictor of increased complications and longer postoperative downtime in logistic and linear regression model, both in the weighted and unweighted model. Conclusions The combined approach of preoperative endovascular revascularization and free flap transfer for limb reconstruction in PAOD patients can be performed safely and effectively with acceptable morbidity.

Vagal reflex during laryngosopy and tracheal intubation may result in cardiac arrhythmia such as bradyarrhythmia and asystole. A 66-year-old woman, scheduled for coronary artery bypass surgery, received intravenous bolus of midazolam 2 mg, sufentanil 50 microgram, and vecuronium 10 mg for induction of general anesthesia. After two minutes of manual ventilation, tracheal intubation was attempted and the patient became asystolic during laryngoscopic manipulation. The laryngoscope was immediately withdrawn, and the patient returned to normal sinus rhythm. Ten minutes later, more experienced practitioner performed the second laryngoscopic intubation, but it eventually induced asystole again. External cardiac massage was commenced and normal sinus rhythm retuned at a rate of 60 beats/min after 1-2 minute later.

Intraoperative transesophageal echocardiography (IOTEE) is an invaluable diagnostic method for management of cardiac surgical patients, including patients undergoing valve replacement surgery. We report a patient who underwent reoperation for mitral valve replacement due to intravalvular regurgitation following mitral valve replacement with a bioprosthetic valve. The condition was detected by IOTEE and caused by suture entrapment.

A 51-year-old male was admitted to the hospital with complaints of fever and hemoptysis. After evaluation of the fever focus, he was diagnosed with pulmonary valve infective endocarditis. Thus pulmonary valve replacement and antibiotics therapy were performed and discharged. He was brought to the emergency unit presenting with a high fever (＞39℃) and general weakness 6 months after the initial operation. The echocardiography revealed prosthetic pulmonary valve endocarditis. Therefore, redo-pulmonary valve replacement using valved conduit was performed in the Rastelli fashion because of the risk of pulmonary arterial wall injury and recurrent endocarditis from the remnant inflammatory tissue. We report here on the successful surgical treatment of prosthetic pulmonary valve endocarditis with an alternative surgical method.

A 76-year-old woman with hypertension was admitted to the hospital with complaints of chest pain and dyspnea. An echocardiogram and pulmonary computed tomography angiography showed right atrial myxoma complicated with pulmonary thromboembolism. An operation to resect the right atrial myxoma and pulmonary embolism was recommended; however, the patient refused and was discharged with anticoagulation therapy. Two years later, she developed dyspnea. Radiological studies and echocardiography showed similar results with the previous findings. The patient underwent mediastinotomy with resection of the right atrial myxoma and pulmonary embolectomy. As there are few reports on right atrial myxoma complicated with pulmonary embolism, we report a successful case of surgical removal of right atrial myxoma and pulmonary embolism.

Aim We analyzed the results of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) necessitating extracorporeal membrane oxygenation (ECMO), and investigated for the associated risk factors for poor clinical outcomes. Methods We retrospectively reviewed the medical records of 27 patients who required ECMO for AMI associated with CS between April 2006 and July 2010. Mean age was 63.7 ± 11.0 (range: 45–81) years, and there were 16 males (59.3%). Results The mean duration of ECMO support was 30.2 ± 30.1 (range: 1–141) h. Cardiopulmonary resuscitations (CPR) were performed in 21 patients (77.8%) before ECMO initiation. Twenty-two patients (81.5%) were successfully weaned off ECMO, and 16 patients (59.3%) survived to discharge. The 30-day mortality was 37.0% (10/27 patients). Complications developed in 17 patients (63.0%: pneumonia in 10 patients, acute renal failure in 10 patients, massive bleeding in 4 patients, and thromboembolic event in 1 patient). The period between CPR initiation and ECMO commencement was a significant risk factor for ECMO weaning failure. High pre-ECMO serum lactate level was identified as a significant risk factor for poor survival on univariated and multivariated analysis. Conclusion ECMO support could improve survival in patients who suffer AMI associated with CS, and early ECMO initiation yields better outcomes (successful ECMO weaning).

Haemodynamic changes occurring during heart displacement, using moist laparotomy pads placed behind the heart (PAD group, n = 26) or deep pericardial traction sutures (DPS group, n = 25) to facilitate exposure of the left anterior descending artery during off-pump coronary artery bypass surgery, were compared. Haemodynamic variables were assessed before and 10 min after displacement of the heart. The central venous pressure, mean pulmonary artery pressure and pulmonary capillary wedge pressure increased in both groups. After heart displacement in the PAD group, the cardiac index, stroke volume index, mixed venous oxygen saturation, right ventricular ejection fraction and left ventricular stroke work index decreased significantly, and the systemic vascular resistance and pulmonary vascular resistance increased significantly; these parameters remained unchanged in the DPS group. It was concluded that displacement of the heart using moist laparotomy pads caused significant haemodynamic derangement compared with that caused by deep pericardial traction sutures.

Infected aortic aneurysms are rare, but the mortality of patients with infected aortic aneurysms remains high. Open surgical procedures are the standard of care for infected aneurysms of aorta, but the surgical results are often disappointing. The risk factors related to the high mortality include aneurysm rupture and a suprarenal aneurysm location. The classic method for treating infected aneurysms has been aneurysm resection, soft tissue debridement, remote arterial reconstruction out of the field of infection and antibiotics. Infected anuerysms located in the suprarenal aorta are highly lethal because of the need to reimplant the visceral or renal arteries and the graft related complications. We reported here on a case of suprarenal infected aortic aneurysm in a 55-years-old man. We also include a review of the relevant medical literature.

Poly(lactic-co-glycolic acid) (PLGA) tubes (5 mm in diameter) were fabricated using an electro spinning method and used as a scaffold for artificial blood vessels through the hybridization of smooth muscle cells (SMCs) and endothelial cells (ECs) differentiated from canine bone marrow under previously reported conditions. The potential clinical applications of these artificial blood vessels were investigated using a canine model. From the results, the tubular-type PLGA scaffolds for artificial blood vessels showed good mechanical strength, and the duallayered blood vessels showed acceptable hybridization behavior with ECs and SMCs. The artificial blood vessels were implanted and substituted for an artery in an adult dog over a 3-week period. The hybridized blood vessels showed neointimal formation with good patency. However, the control vessel (unhybridized vessel) was occluded during the early stages of implantation. These results suggest a shortcut for the development of small diameter, tubular-type, nanofiber blood vessels using a biodegradable material (PLGA).

Urgent coronary artery bypass grafting (CABG) has a higher mortality rate than elective CABG. The purpose of this study was to evaluate the clinical outcome of urgent CABG. From July 1992 to May 2005, 104 patients underwent urgent CABG. All patients required an urgent surgical revascularization within 24 hr of diagnostic coronary angiography. In-hospital mortality after urgent CABG was 17.3% (18/104). We compared preoperative characteristics and postoperative clinical outcomes between the survival group (n=86) and the mortality group (n=18). The mean age was 61.7 yr (range, 35-83). The most common cause of mortality was low cardiac output. The independent preoperative risk factors of mortality included advanced age (>70 yr) (OR=3.998, p=0.046), preoperative shock status (OR=6.542, p=0.011), and low ejection fraction (

Background Cardiopulmonary bypass may exacerbate myocardial damage in compromised left ventricles. Early and mid-term outcomes of off-pump coronary artery bypass grafting (OPCAB) vs on-pump coronary artery bypass grafting (On-pump CABG) were compared in patients with poor left ventricular dysfunction, using an analysis of a propensity score matching. Methods and Results Between December 2000 and November 2005, 1,473 patients underwent isolated coronary artery bypass grafting in our institute and 153 patients who had a left ventricular ejection fraction (LVEF) lower than 35% were enrolled. The OPCAB group contained 100 patients and the On-pump CABG group contained 53 patients. Preoperative risk factors were compared and 50 patients in each group were matched. The mean follow-up time was 35.5±17.3 months. Three deaths (3.0%) occurred in the matched cohort, with no significant difference between 2 groups. The operation time, ventilation time, intensive care unit admission time and occurrence of respiratory failure were significantly lower in the OPCAB group. The mean LVEF of the 2 groups improved significantly. The overall 6-year actuarial survival rates of the OPCAB and On-pump CABG group were 88.2% and 72.4% (p=0.2), respectively, and there were no significant differences in 6-year rates of freedom from major adverse cardiac and cerebrovascular events (p=0.97). Conclusions Coronary artery bypass grafting in patients with poor left ventricular dysfunction improved myocardial function. Postoperative respiratory failure was significantly related to the cardiopulmonary bypass for surgical myocardial revascularization. Off-pump and On-pump surgical revascularization resulted in equivalent mid-term outcomes. (Circ J 2007; 71: 1387 - 1394)

Background Tricuspid valve replacement (TVR) has been performed with mechanical or bioprosthetic valves. However, the relative advantages of the two types are incompletely known. Methods Between 1978 and 2003, we performed 138 TVR (35 bioprosthetic, 103 mechanical) in 125 patients (50 men, 75 women), with a mean age of 43.7 ± 16.6 years. The diseases that required TVR were rheumatic (94), prosthetic valve failure (14), congenital (14), infective endocarditis(5), isolated tricuspid regurgitation (4), and miscellaneous conditions (7). The operations included the following: isolated TVR (41), double valve replacement (58), and triple valve replacement (39). The follow-up rate was 98.3%, and cumulative follow-up was 828.5 patient-years. Results There were 22 in-hospital deaths (17.6%) and 13 (10.4%) late deaths. Fourteen patients required additional operations. There were 33 postoperative valve-related events including 11 thromboembolisms and 3 bleeding episodes. Kaplan-Meier survival for the entire group at 15 years was 73.8 ± 8.5% (bioprosthetic: 70.2 ± 10.4%, mechanical: 66.0 ± 19.4%). At 15 years, freedom from reoperation was 66.3 ± 9.4% (bioprosthetic: 55.1 ± 13.8%, mechanical: 86.0 ± 6.2%) and freedom from valve-related events was 49.9 ± 8.0%. The linearized incidence of valve thrombosis was 1.28%/patient-year (bioprosthetic: 0, mechanical: 1.92), anticoagulation-related bleeding was 0.37%/patient-year (mechanical: 0.54), reoperation was 1.71%/patient-year (bioprosthetic: 2.68, mechanical: 1.25), and valve-related events were 4.33%/patient-year (bioprosthetic: 3.83, mechanical: 4.6). Conclusions Both bioprosthetic and mechanical valves revealed similar long-term outcomes. However, findings suggest that greater care is needed to prevent valve thrombosis in mechanical valves in the early postoperative period, and there is a greater chance for reoperation in bioprosthetic valves.

Clinical results of minimally invasive mitral valve surgery were retrospectively reviewed, and two different surgical approaches were compared in this study. Between 1997 and 2004, a total of 86 patients with mitral valve disease underwent minimally invasive surgery at the Yonsei University Cardiovascular Center. Age of patients averaged 41.6 +/- 14.0 years and 69 patients were female. Surgical approach included low- sternal incisions with mini-sternotomy, and right parasternal or thoracotomy approach. Either direct aortic or femoral arterial and bicaval cannulations were used in all patients. Patients were divided into two groups according to the method of surgical approach (parasternal (P) vs low-sternal (L)), and the results were compared. Postoperative NYHA functional class improved to 1.1 +/- 0.4 in all patients (no significant statistical difference between two groups). Mean wound length (P: 9.21 +/- 1.10 vs L: 11.24 +/- 0.82 cm, p0.05), and mechanical ventilation time (P: 10.42 +/- 4.36 vs L: 12.90 +/- 5.00 min, p=0.04) was significantly shorter in parasternal group, and mean operation time(P:294.74 +/- 59.41 vs. L:259.31 +/- 54.36 min, p=0.03) was significantly shorter in low-sternal group. Mean cardiopulmonary bypass time, and aortic cross clamp time was also shorter in low-sternal group without statistical difference. There were 2 minor wound complications in all patients (p=NS), and no hospital death. Comparing the two different surgical approach of minimally invasive mitral valve surgery, parasternal approach is thought to be more beneficial in reducing postoperative scar, and intubation time.

We compared the haemodynamic effects of β-blockers on dobutamine infusion in 60 patients undergoing coronary artery bypass graft surgery. All patients had been taking propranolol (n = 30) or atenolol (n = 30) pre-operatively for at least 1 month. After sternotomy, dobutamine was infused at 2 μg/kg per min, and the dose increased to 4 μg/kg per min and then 8 μg/kg per min, at 15-min intervals. In both groups, dobutamine infusion did not increase the cardiac index or the heart rate, but was associated with an increase in mean arterial pressure, systemic vascular resistance index and mean pulmonary arterial pressure in a dose-dependent manner. The haemodynamic responses to dobutamine infusion were similar in the two groups. We conclude that pre-operative medication with β-blockers reduced the inotropic and chronotropic effects of dobutamine infusion. There was no difference between the modification produced by propranolol, a non-selective β -blocker, and that produced by atenolol, a selective β1-blocker, however.

We studied patients with valvular heart disease to investigate whether chronic pre-operative treatment with angiotensin-converting enzyme (ACE) inhibitors modulates the effect of phenylephrine (PE) on anaesthesia-induced hypotension. Sixty-five patients were enrolled in the study and hypotension developed after anaesthesia in 36 (18 in the control group and 18 in the ACE inhibitor group). These patients received PE infusions, which were increased in a stepwise fashion at 10-min intervals. Increased mean arterial pressure due to PE infusion was significant only in the control group. There was no significant difference in pressor response or change in haemodynamic variables with PE infusion between the two groups. Treatment with ACE inhibitors did not increase the incidence of hypotensive episodes or significantly modify pressor response after anaesthesia in patients with valvular heart disease.

Objective: The effect of pre-emptive milrinone without bolus during off-pump coronary artery bypass surgery (OPCAB) was evaluated in two groups of patients with low and normal pre-graft cardiac index. Methods: Eighty-two patients were divided into two groups based on their pre-graft cardiac index. Each group was randomly subdivided into two groups to receive either milrinone or normal saline. After the internal mammary artery was harvested, the infusion of milrinone, or normal saline was started and maintained until the end of the anastomosis. The haemodynamic variables were measured: just before the start of milrinone or normal saline after pericardiotomy (baseline value); 10 min after the tissue stabilizer had been applied for the anastomosis of left anterior descending artery, left circumflex artery and right coronary artery; and after the sternal closure. Results: Milrinone reduced the extent of the decrease in cardiac index and stroke volume as well as the extent of the increase in systemic and pulmonary vascular resistance. The extent of the decrease in cardiac index and mixed venous oxygen saturation were greater in normal pre-graft cardiac index group than in low pre-graft cardiac index group regardless of milrinone infusion during anastomoses. The effect of milrinone on haemodynamics showed no significant difference between low and normal pre-graft cardiac index groups. Conclusions: Pre-emptive milrinone infusion without bolus effectively improved cardiac performance during OPCAB and was especially useful for patients with low pre-graft cardiac index to prevent the decrease in cardiac index and stroke volume index below the critical level. q 2004 Elsevier B.V. All rights reserved.

Objectives: Hemodynamic derangement during displacement of beating heart in off-pump coronary artery bypass graft (OPCAB) surgery might be related with right ventricular (RV) dysfunction. We evaluated RV function and hemodynamic alterations using a thermodilution pulmonary artery catheter. Methods: The study included 30 patients undergoing OPCAB, using single pericardial suture and tissue stabilizer. A thermodilution pulmonary artery catheter for continuous monitoring of the cardiac output (CO), right ventricular ejection fraction (RVEF) and RV volume was inserted before anesthesia. The hemodynamic variables were measured after the induction of anesthesia, 5 min after the heart was positioned for each coronary anastomosis and after the sternum was closed. Results: There was no significant change in the RVEF and cardiac index during anastomosis of the left anterior descending artery and right coronary artery. However, the significantly reduced RVEF accompanied by an increase in RV afterload and decrease in the CO was observed during anastomosis of the obtuse marginal (OM) artery. RV volumes did not significantly change during anastomoses, though the right atrial pressure increased during anastomoses of all coronary arteries. Conclusions: The displacement of beating heart for positioning during anastomosis of the graft to OM artery caused significant derangement of RV function and decrease in CO. A thermodilution catheter continuously measuring the CO and RVEF was useful to monitor the change in RV function and volume during OPCAB. q 2004 Elsevier B.V. All rights reserved.

OBJECTIVE This study was conducted to evaluate stent compression in iliac vein compression syndrome (IVCS) and to identify its association with stent patency. MATERIALS AND METHODS Between May 2005 and June 2014, after stent placement for the treatment of IVCS with acute ilio-femoral deep vein thrombosis, follow-up CT venography was performed in 48 patients (35 women, 13 men; age range 23-87 years; median age 56 years). Using follow-up CT venography, the degree of the stent compression was calculated and used to divide patients into two groups. Possible factors associated with stent compression and patency were evaluated. The cumulative degree of stent compression and patency rate were analyzed. RESULTS All of the stents used were laser-cut nitinol stents. The proportion of limbs showing significant stent compression was 33%. Fifty-six percent of limbs in the significant stent compression group developed stent occlusion. On the other hand, only 9% of limbs in the insignificant stent compression group developed stent occlusion. Significant stent compression was inversely correlated with stent patency (p < 0.001). The median patency period evaluated with Kaplan-Meier analysis was 20.0 months for patients with significant stent compression. Other factors including gender, age, and type of stent were not correlated with stent patency. Significant stent compression occurred most frequently (87.5%) at the upper end of the stent (ilio-caval junction). CONCLUSION Significant compression of nitinol stents placed in IVCS highly affects stent patency. Therefore, in order to prevent stent compression in IVCS, nitinol stents with higher radial resistive force may be required.

Summary Objective Most patients with peripheral arterial occlusive disease undergo lower limb amputation due to complex wounds on their lower extremities. We have taken the challenging approach of combining angioplasty and free tissue transfer for limb salvage. Methods Between October 2011 and December 2013, 11 patients (average age of 56.8 years; ranged from 43–72 years old) with peripheral arterial occlusive disease of main tibioperoneal arteries underwent preoperative angioplasty. Afterward, free tissue transfers (nine anterolateral thigh free flaps, one vastus lateralis muscle free flap, and one deep femoral artery perforator flap) were performed on these patients for lower extremity salvage and reconstruction. Results All 11 free tissue transfers after angioplasty were successful without operative mortality or major complications. Minimal wound dehiscence was seen in one case, and partial flap necrosis was seen in the other cases. During the follow-up period, all of the patients had their wounds healed completely and achieved acceptable contour and quality of gait. Conclusion The preoperative angioplasty provides well-vascularized tissue that both controls infection and helps free flaps to survive. Therefore, the patients due to receive leg amputation in spite of the free tissue transfer can achieve limb salvage by using the additional technique of angioplasty. This combined approach was successful in preserving the functional aspects along with the aesthetic results for the lower limb reconstruction.

Objective: Postoperative delirium after cardiac surgery is associated with many consequences such as poorer functional recovery, more frequent postoperative complications, higher mortality, increased length of hospital stay, and higher hospital costs. The aim of this study was to evaluate the efficacy of perioperative psycho-educational intervention in preventing postoperative delirium in post cardiac surgery patients. Method: We conducted a comparative retrospective study between 49 patients who had received perioperative psycho-educational intervention and 46 patients who had received standard care. The primary outcome was the incidence of postoperative delirium. Secondary outcomes included length of ICU stay, and severity and duration of postoperative delirium among the patients who had developed delirium. Results: The incidence of postoperative delirium was significantly lower in the intervention group than that in the control group (12.24% vs. 34.78%, P = 0.009). Among the patients who had developed postoperative delirium, there was no statistical difference between the two groups regarding secondary outcomes. Conclusions: Our results show that the patients who received perioperative psycho-educational intervention were associated with a lower incidence of postoperative delirium after cardiac surgery than those who received standard care. Clinicians would be able to implement this psycho-educational intervention as part of routine practice to reduce delirium.

We evaluated 158 legs from 79 consecutive patients who had undergone both ankle-brachial index (ABI) measurements and angiography for claudication symptoms between January 2007 and December 2008. The diagnosis of peripheral arterial disease (PAD) in the individual legs was established by angiography. Ankle-brachial index was considered abnormal if it was

Drug-eluting stents (DESs) have challenged coronary bypass grafting as the gold standard for 3-vessel coronary artery disease. This study compared the clinical results between percutaneous intervention with DESs vs off-pump coronary bypass surgery (OPCAB).The study included 388 matched patients with 3-vessel coronary artery diseases who were treated either with DESs or OPCAB. We compared 30-day, 12-month, and cumulative major adverse cardiac and cerebrovascular events (MACCE) during the follow-up.The overall follow-up was 98.5%. Follow-up duration was 621.1 +/- 259.9 days (range, 13 to 1117 days). The rates of MAACE in the DES and OPCAB group were, respectively, 1.5% at 30 days (p = 0.315) and 9.8% and 3.6% at 12 months (p = 0.015). During follow-up, five deaths occurred in the DES group and one in OPCAB group (p = 0.1). Three-year survival rate was 95.1% +/- 2.9% in DES group and 99.5% +/- 0.5% in OPCAB group (p = 0.075). Survival free from MACCE at 3 years was 73.3% +/- 5.3% in DES group and 91.3% +/- 2.9% in OPCAB group (p0.001). The major event for the differences between the groups was target vessel revascularization (p0.001): 21 DES patients (10.8%) vs 6 OPCAB patients (3.1%).OPCAB showed better clinical outcome in 12-month and cumulative MACCE rate in 3-vessel coronary artery diseases. The major factor for the difference was target vessel revascularization. Longer follow-up is needed to clarify the differences between the two groups.

Cardiopulmonary bypass may exacerbate myocardial damage in compromised left ventricles. Early and mid-term outcomes of off-pump coronary artery bypass grafting (OPCAB) vs on-pump coronary artery bypass grafting (On-pump CABG) were compared in patients with poor left ventricular dysfunction, using an analysis of a propensity score matching.Between December 2000 and November 2005, 1,473 patients underwent isolated coronary artery bypass grafting in our institute and 153 patients who had a left ventricular ejection fraction (LVEF) lower than 35% were enrolled. The OPCAB group contained 100 patients and the On-pump CABG group contained 53 patients. Preoperative risk factors were compared and 50 patients in each group were matched. The mean follow-up time was 35.5+/-17.3 months. Three deaths (3.0%) occurred in the matched cohort, with no significant difference between 2 groups. The operation time, ventilation time, intensive care unit admission time and occurrence of respiratory failure were significantly lower in the OPCAB group. The mean LVEF of the 2 groups improved significantly. The overall 6-year actuarial survival rates of the OPCAB and On-pump CABG group were 88.2% and 72.4% (p=0.2), respectively, and there were no significant differences in 6-year rates of freedom from major adverse cardiac and cerebrovascular events (p=0.97).Coronary artery bypass grafting in patients with poor left ventricular dysfunction improved myocardial function. Postoperative respiratory failure was significantly related to the cardiopulmonary bypass for surgical myocardial revascularization. Off-pump and On-pump surgical revascularization resulted in equivalent mid-term outcomes.

An 18-year-old pregnant woman had cardiac failure and severe pulmonary edema developed immediately after the delivery of her baby. The patient's respiratory distress was severe and her oxygen saturation was under 50%, despite full mechanical ventilatory support. Echocardiogram revealed an ejection fraction of 18%, and she was diagnosed with peripartum cardiomyopathy. Her vital signs were unstable when she received conventional treatment for acute heart failure. Extracorporeal membrane oxygenation was applied 3 hours after the patient was transferred to the emergency department. The patient was weaned from extracorporeal membrane oxygenation 28 hours afterward, and she was extubated 2 days after extracorporeal membrane oxygenation. The patient was discharged 12 days after admission.

This study aims to investigate surgical outcomes in patients with Behcet’s disease (BD) and to identify risk factors for the occurrence of postoperative complications. The medical records of 37 patients with newly diagnosed BD were reviewed retrospectively. All patients fulfilled the International Study Group criteria for diagnosis of BD and underwent surgeries after diagnosis. Demographic, clinical, and laboratory data at the time when surgeries were performed were collected and surgical modalities, postoperative complications, and postoperative medical treatments were evaluated. Forty-three surgeries were performed in 37 patients. During mean follow-up duration of 78.2 ± 50.3 months, 14 surgeries (32.6%) were complicated by wound dehiscence, infection, and graft occlusion or failure with the mean lag time of 6.0 ± 4.6 months from surgeries. Cumulative incidence of postoperative complications was 7.7% at 3 months, 25.6% at 6 months, 33.3% at 12 months, and 35.9% at 18 months. Postoperative complications occurred more frequently after surgeries that were performed in patients with positive pathergy test (P < 0.001) and after vascular surgeries than after nonvascular surgeries (P < 0.05). Moreover, surgeries that were followed by glucocorticoids with immunosuppressive agents showed a significantly lower postoperative complication rate compared to those that were followed by glucocorticoids alone and those that were not followed by medical treatment (P < 0.05). Multivariate analysis showed that a positive pathergic reaction (P < 0.05, hazard ratio = 1.91) at the time of surgery and surgeries that were not followed by treatment with glucocorticoids and immunosuppressive agent (P < 0.01, hazard ratio = 2.11) was an independent risk factor for the occurrence of postoperative complications. Our findings suggest that the occurrence of postoperative complications can be reduced when postsurgical immunosuppressive treatment was implemented and that the pathergy test can be used as screening methods for occurrence of postoperative complications in patients with BD.

Objectives The Carpentier rigid ring and the Duran flexible ring have been used for mitral valve repair. The Carpentier ring reduces mitral insufficiency very effectively, but it causes minor systolic dysfunction. Meanwhile, the Duran ring interferes less with the normal movements of the mitral annulus during the cardiac cycle than the Carpentier ring. Methods From January 1995 through August 2005, 363 patients underwent mitral valvuloplasty with annuloplasty rings. We chose the ring with randomization for mitral valve repair, and the data were collected prospectively. Seven patients who had undergone re-repair or replacement because of failure of initial repair confirmed by means of intraoperative transesophageal echocardiography were excluded in this study, and 356 patients were enrolled (Carpentier ring group, n=186; Duran ring group, n=170). Mean age was 49.4 years and 50.3 years for the Carpentier and Duran ring groups, respectively. There were no significant differences in age, sex, body surface area, or cause of mitral regurgitation between the 2 groups. Results There were 4 (1.1%) operative mortalities. The patients were followed up for 3 to 126 months (mean, 46.6 months), and total follow-up was 1368.2 patient-years. The left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and left atrial size were significantly decreased in both groups. However, there was no difference in the long-term echocardiographic results between the 2 groups. Overall actuarial survivals at 10 years were 85.9% ± 4.9% in the Carpentier ring group and 75.7% ± 7.2% in the Duran ring group, without a significant difference. Significant mitral regurgitation (grade ≥3) recurred in 23 patients (Carpentier ring group, 8; Duran ring group, 15). The 8-year freedom from recurrence of significant mitral regurgitation was 62.6% ± 19.0% in the Carpentier ring group and 55.5% ± 14.1% in the Duran ring group ( P = .172). Independent prognostic factors for recurrence of mitral regurgitation in logistic regression analysis were preoperative tricuspid regurgitation of grade 3 or greater and residual mitral regurgitation of grade 2 or greater at the 5th ∼ 7th postoperative days. Conclusions Mitral valvuloplasty favors the excellent surgical and long-term results in our prospective randomized study, regardless of the type of annuloplasty ring. There was no difference between the rigid and flexible rings in terms of left ventricular systolic function measured with echocardiography. It seems that timing of the operation before significant tricuspid regurgitation and precise mitral valve repair might prevent late recurrence of mitral regurgitation.

evidence of embolic events. Because of uncontrolled infection and the possibility of pus spreading out into the cardiac structures, we decided to proceed with operation. After resection of the mass with AML, mitral valve was replaced by mechanical prosthetic valve. There was a septated space in the mass. The space was open to the left ventricular side. Histopathology showed suppurative inflammation of the mass (Figure 2). Infective endocarditis caused by P. aeruginosa in patients without i.v. drug use is extremely rare.2 There have been few data on the complications due to P. aeruginosa infective endocarditis. In the present case, an abscess pocket was formed in the vegetation, and this was clearly identified on 3D-TEE. Echocardiography plays a fundamental role in the diagnosis of infective endocarditis, complication recognition, and therapeutic decision making.3 3D-TEE additionally provided detailed anatomic information,4–6 and therefore has increased usefulness in identifying infective endocarditis lesions and their complications. To our knowledge, the present case of P. aeruginosa infec51-year-old woman with end-stage renal disease was admitted with a 1 month history of general weakness and persistent fever. Chronic diabetic foot ulcer was noted on the right heel with calcaneal exposure. Blood and wound cultures had grown Pseudomonas aeruginosa (P. aeruginosa). Transthoracic echocardiography indicated a hypoechoic and homogenous round mass on the left atrial (LA) side of the anterior mitral leaflet (AML), suggesting vegetation. To evaluate associated complications, transesophageal echocardiography (TEE) was done. The 1.4×1.6-cm mass was attached on the LA side of the A3 portion of the AML. The presence of a central halo was noted in the mass. Given that mitral valve aneurysm is frequently associated with infective endocarditis,1 more detailed anatomic information was needed for a differential diagnosis. Three-dimensional TEE (3D-TEE) confirmed the pocket formation in the mass (Figure 1). The echocardiographic findings suggested abscess pocket formation in the vegetation, rather than mitral valve aneurysm. Inside the pocket, there was no evidence of thrombus formation. Also, there was no A

Antiphospholipid syndrome (APS), the most common acquired hypercoagulable condition, is diagnosed by persistent presence of antiphospholipid antibodies and episodes of vascular thrombosis. It may be an important predisposing factor for stent thrombosis, resulting in poor outcomes. Also, anti-platelet therapy non-responsiveness is associated with stent thrombosis. We report a case of a 39-year-old man who after undergoing successful percutaneous coronary intervention for significant coronary artery disease suffered repeated stent thrombosis events leading to ST-segment elevation myocardial infarction. Eventually, he underwent coronary artery bypass surgery because of uncontrolled thrombosis and was diagnosed as having APS and dual antiplatelet therapy non-responsiveness.

We report a rare case of thrombus formation in normal aorta causing myocardial infarction. A 44-year-old man who had no prothrombotic risk factors presented with acute myocardial infarction. Two-dimensional echocardiography revealed a hypoechoic homogenous mass occupying the left coronary sinus and attached at the nonatherosclerotic aorta. The mass seemed to cause myocardial infarction by occluding the left anterior descending artery with oscillating movement according to the cardiac cycles. After surgical resection, the histopathologic examination revealed the mass as an organized thrombus. This case implies that an aortic mural thrombus can form in a nonatherosclerotic aorta without any prothrombotic risk factors.

일반적으로 동맥의 정상 직경보다 50% 이상 늘어나 있는 것을 동맥류라고 정의한다. 그러므로 흉부 대동맥류를 진단 하기 위해서는 정상 혈관의 크기를 아는 것이 중요하다. 대 동맥의 정상 직경은 나이, 성별, 체형과 위치에 따라서 다 르게 나타난다. 남자가 여자보다 대동맥 직경은 좀더 크게 나타나며 체표면적이 클수록 대동맥 직경은 커진다[2]. 대 동맥 직경은 나이가 들어갈수록 커지며 대동맥 근위부에서 말초부위로 갈수록 점차적으로 작아지는 경향을 보인다[3]. Hannuksela 등[2]은 매년 평균 0.17 mm (0.12-0.20 mm) 정도로 대동맥의 직경이 나이가 증가함에 따라 증가하고 체 Thoracic aortic aneurysm (TAA) is the most common pathology of the thoracic aorta. The incidence of TAA is increasing and the true incidence of TAA is likely to be higher than currently reported because of its inherently silent nature. TAAs are an increasingly recognized condition that is diagnosed incidentally on imaging studies performed to evaluate unrelated conditions because most patients with TAA have no symptoms. TAAs normally grow in an indolent manner, but can become rapidly lethal once dissection or rupture occurs. Indeed, aortic aneurysms (both abdominal and thoracic) represent the 15th leading cause of death in individuals older than 55 years, and the 19th leading cause of death in individuals of all ages in the United States. The etiologies underlying TAAs are diverse. Therefore, the evaluation and management of TAAs are complex. The present review summarizes the knowledge of the pathophysiology, natural history and diagnostic modalities, as well as current treatment strategies of TAA on the basis of current literature.

Objective: To evaluate the impact on wound healing and long-term clinical outcomes of endovascular revascularization in patients with critical limb ischemia (CLI). Materials and Methods: This is a retrospective study on 189 limbs with CLI treated with endovascular revascularization between 2008 and 2010 and followed for a mean 21 months. Angiographic outcome was graded to technical success (TS), partial failure (PF) and complete technical failure. The impact on wound healing of revascularization was assessed with univariate analysis and multivariate logistic regression models. Analysis of long-term event-free limb survival, and limb salvage rate (LSR) was performed by Kaplan-Meier method. Results: TS was achieved in 89% of treated limbs, whereas PF and CF were achieved in 9% and 2% of the limbs, respectively. Major complications occurred in 6% of treated limbs. The 30-day mortality was 2%. Wound healing was successful in 85% and failed in 15%. Impact of angiographic outcome on wound healing was statistically significant. The event-free limb survival was 79.3% and 69.5% at 1- and 3-years, respectively. The LSR was 94.8% and 92.0% at 1- and 3-years, respectively. Conclusion: Endovascular revascularization improve wound healing rate and provide good long-term LSRs in CLI. Index terms: Critical limb ischemia; Infrapopliteal angioplasty; Diabetic foot

A 69-year-old male presented with obstructive hypertrophic cardiomyopathy, mitral valve regurgitation, and myxomatous mitral valve prolapse. A spontaneous chordal rupture and acute severe mitral regurgitation resulted in abrupt clinical deterioration despite complete relief of severe left ventricular outflow tract obstruction and systolic anterior motion of the anterior mitral leaflet. The patient underwent extensive cardiac surgery due to intractable heart failure. Surgical procedures included a mitral valve replacement, a septal myectomy, and the Maze procedure. (Korean Circ J 2009;39:292-294)

Background and Objectives = #Ventricular assist systems are used in patients with end-stage heart failure to pro- long life or as a bridge to transplantation. Several types of ventricular assist systems have been developed and they are now being used. We developed a new Biomedlab ® electro-mechanical implantable ventricular assist device ( IVAD ) and we performed in vivo experimentation to evaluate the durability and safety of the device, as well as its hematologic effect. Materials and Methods = #We implanted the newly developed IVAD in the pre-peritoneal cavity of 5 Hallstein calves. The inflow tract was inserted through the left ventricular apex, and the outflow tract was anastomosed to the descending thoracic aorta. Postoperatively, we administered heparin intravenously for 2 days after implantation, and then we administered warfarin sodium daily. We examined, both preoperatively and postoperatively, the serum aspartate aminotransferase ( AST ) , alanine aminotransferase ( ALT ) , blood urea nitrogen ( BUN ) , creatinine, lactate dehydrogenase ( LDH ) , haptoglobin, fibrinogen, whole blood hemoglobin, hematocrit, prothrombin time ( PT ) , partial thromboplastin time ( PTT ) and the plasma hemoglobin. We also recorded the assisted flow rate and the hemodynamic parameters of the animals. After IVAD implantation, the international normalized ratio ( INR ) was monitored and maintained in the range of 3.5-4.0. Postoperatively, when any device- related problems developed, we euthanized the animals and performed autopsy. Results = #After IVAD implantation, the 5 calves lived for 1, 6, 3, 12 and 21 days, respectively. Three of them were euthanized due to mechanical problems such as electrical shorts, and the other calves died suddenly due to blood leakage at the outflow tract on postoperative day 21 and graft disconnection on postoperative day 3, respectively. Autopsy was performed in all the animals and there was no evidence of thromboembolism or hemorrhage in the kidney, liver or lungs. There was also no evidence of thrombosis on the valve, blood sac or inflow/outflow tract. Hematologic and chemical examinations revealed mild hemolysis in the early postoperative period, which stabilized with minimal hemolysis. There was no organ dysfunction. Conclusion = #Our newly developed Biomedlab ® IVAD was feasible for im- plantation and it functioned well in a calf model. Although there were 3 mechanical problems, we did not find any device-related thrombosis and serious hemolysis. With this encouraging result, it may be possible to perform animal experiments with the final version of IVAD, after correcting the mechanical problems, to evaluate the device 鈂s longterm durability and stability. ( Korean Circ J 2008 ; 38 : 7 - 11 )

Intraoperative transesophageal echocardiography (TEE) has become an important monitoring device for patients undergoing repair of congenital heart disease. TEE allows preoperative assessment of ventricular volume and function, pre and postoperative anatomy and the existence of intracardiac air. Although complications associated with TEE are infrequent, interference with ventilation as a result of direct compression of the endotracheal tube, distal trachea, or mainstem bronchi has been reported. Here, we report two cases of intraoperative ventilation interference caused by the TEE probe. (Korean J Anesthesiol 2008; 54: 682～4)

Background : Patients with diabetic nephropathy (DN) and coronary artery disease (CAD) represent a subset of patients with high cardiovascular morbidity and mortality. The optimal revascularization strategy using either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. The purpose of this study was to compare the clinical outcomes of PCI to CABG in DN patients with CAD. Methods : The clinical and angiographic records of DN patients with CAD who underwent either CABG (n=52) or PCI (n=48) were retrospectively analyzed. Results : The baseline characteristics were similar in the two groups except for the severity of the CAD. At 30 days, the death rate (PCI: 2.1% vs. CABG: 9.6%, p=0.21) and major adverse cardiac events (MACE) rate (PCI: 2.1 % vs. CABG: 9.6%, p=0.21) were similar in comparisons between the PCI and CABG groups. At three years, the death rate (PCI: 18.8% vs. CABG: 19.2%, p=0.94) was similar between the PCI and CABG groups but the MACE rate (PCI: 47.9% vs. CABG: 21.2%, p=0.006) was higher in the PCI group compared to the CABG group. In addition, the repeat revascularization rate was higher in the PCI group compared to the CABG group (PCI: 12.5% vs. CABG: 1.9%, p=0.046). Conclusions : The CABG procedure was associated with a lower incidence of MACE and repeat revascularization for up to three years of follow-up in DN patients with CAD. However, the overall survival rate was similar in the CABG and PCI groups. Therefore, CABG may be superior to PCI with regard to MACE and repeat revascularization.

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

Background:The hemodynamic superiority of total cavopulmonary anastomosis (TCPA) over atriopulmonary connection as a modification of Fontan-type operation, began to be acknowledged with more applications to clinical cases. The need of adequate resolutions for the investigation and improvement of residual hemodynamic derangements including abnormal distribution of the pulmonary blood flow, is emerging. Methods:We studied 20 patients (M:F=12:8, age:67.9±41.5 months) who have had the TCPA and were followed-up by cardiac catheterization, angiography and lung perfusion scan 24.5±15.7 months after the operation. Pulmonary arterial growth and hemodynamic influences including the pulmonary blood flow distribution were investigated to verify the appropriateness of the conventional TCPA method and to aid in the determination of the consequences and prognosis of the operation. Results:The mean pulmonary arterial pressure before and after the operation was 15.1±3.2 mmHg and 13.9±4.8 mmHg respectively without significant difference and there was no significant postoperative changes in the cross-sectional area index of pulmonary artery in regard to the variability of body surface area. The pulmonary blood flow was distributed with a greater amount in the ipsilateral side of IVC flow entrance (IVCipsi) than the contralateral side (IVCcontra), with an ipsilateral to contralateral perfusion ratio (i/cPR) of 1.24±0.42. Comparing the subgroups by the type of superior vena caval inflow, unilateral superior cavopulmonary anastomosis (SCPA) group showed significantly higher i/cPR (1.47±0.33) than the bilateral SCPA group (1.07±0.21). Comparing the subgroups by the type of IVC inflow, the i/cPR of the intraatrial tunnel group was higher than the hemiazygous continuation group, but there was no statistical significance. Conclusion:TCPA does not influence the growth of pulmonary artery, and the type of cavopulmonary anastomosis and the bilaterality of superior vena cava may have major influences on the distribution of the pulmonary blood flow. The details of surgical methods should be evaluated case by case in respect to the associated anomalies in order to achieve adequate postoperative pulmonary blood flow distribution. (Korean Circulation J 2000;30(1):90-102)