Gwan Sic Kim

Mild-to-moderate functional tricuspid regurgitation in patients undergoing valve replacement for rheumatic mitral disease: the influence of tricuspid valve repair on clinical and echocardiographic outcomes

Background The decision to repair mild-to-moderate functional tricuspid regurgitation (TR) during left-side heart surgery remains controversial. Objectives To avoid heterogeneity in patient population, patients with TR undergoing isolated mechanical mitral valve (MV) replacement for rheumatic mitral diseases were evaluated. Methods Between 1997 and 2009, 236 patients with mild-to-moderate functional TR underwent first-time isolated mechanical MV replacement for rheumatic mitral diseases with (n=123; repair group) or without (n=113; non-repair group) tricuspid valve (TV) repair. Survival, valve-related complications, and TV function in these two groups were compared after adjustment for baseline characteristics using inverse-probability-of-treatment weighting. Results Follow-up was complete in 225 patients (95.3%) with a median follow-up of 48.7 months (IQR 20.2–89.5 months), during which time 991 echocardiographic assessments were done. Freedom from moderate-to-severe TR at 5 years was 92.9±2.9% in the repair group and 60.8±6.9% in the non-repair group (p<0.001 and 0.048 in crude and adjusted analyses, respectively). After adjustment, both groups had similar risks of death (HR=0.57, p=0.43), tricuspid reoperation (HR=0.10, p=0.080) and congestive heart failure (HR=1.12, p=0.87). Postoperative moderate-to-severe TR was an independent predictor of poorer event-free survival (HR=2.90, p=0.038). Conclusions These findings support the strategy of correcting mild-to-moderate functional TR at the time of MV replacement to maintain TV function and improve clinical outcomes.

Epicardial Cyst Originating from Right Ventricle

Pericardial cysts are reported by some authors, but epicardial cysts are extremely rare. We report one case of epicardial cyst that was detected incidentally and was removed successfully. Furthermore, unusually, pathological examinations confirmed that the cyst wall was looked like a vessel wall.

Mitral valve repair versus replacement for moderate-to-severe mitral regurgitation in patients undergoing concomitant aortic valve replacement

OBJECTIVES Whether to repair or replace the mitral valve for patients with significant mitral regurgitation undergoing aortic valve replacement is still controversial. METHODS From January 1990 to December 2011, a total of 663 patients underwent aortic valve replacement combined with mitral valve surgery. Among these, 253 patients (mean age 55.9 ± 14.5 years, 91 females) with moderate-to-severe mitral regurgitation were enrolled to compare the outcomes between double valve replacement (DVR group, n = 158) and aortic valve replacement plus mitral valve repair (AVR plus MVr group, n = 95). Survival and valve-related events were compared by the inverse-probability-treatment-weighted method using propensity scores to reduce treatment selection bias. RESULTS Early mortality was similar between the groups (1.9% in the DVR group when compared with 3.2% in the AVR plus MVr group, P = 0.55). During the mean follow-up period of 72.1 ± 56.7 months, 45 patients died (28 in DVR and 17 in AVR plus MVr) and 31 experienced valve-related events including valve reoperation in 11, anticoagulation-related bleeding in 14, thromboembolism complications in 9 and infective endocarditis in 3. After adjustment for baseline risk profiles, the DVR group showed no difference with regard to risks of death (hazard ratio [HR], 1.79; 95% confidence interval [CI], 0.79-4.01; P = 0.16) and valve-related events (HR, 1.15; 95% CI, 0.40-3.30; P = 0.80) compared with the AVR plus MVr group. CONCLUSIONS Although the outcomes of either mitral valve repair or replacement for moderate-to-severe mitral regurgitation in patients undergoing concomitant aortic valve replacement show no statistical significance in terms of long-term survival and valve-related event rates, DVR seems more hazardous than AVR plus MVr based on the estimated HR in terms of survival.

Surgical Management of Infective Endocarditis Complicated by Embolic Stroke: Early versus Delayed Surgery

Background The optimal timing of surgery for infective endocarditis complicated by embolic stroke is unclear. We compared early versus delayed surgery in these patients. Materials and Methods Between 1992 and 2007, 56 consecutive patients underwent open cardiac surgery for the treatment of infective endocarditis complicated by acute septic embolic stroke, 34 within 2 weeks (early group) and 22 more than 2 weeks (delayed group) after the onset of stroke. Results The mean age at time of surgery was 45.7±14.8 years. Stroke was ischemic in 42 patients and hemorrhagic in 14. Patients in the early group were more likely to have highly mobile, large (>1 cm in diameter) vegetation and less likely to have hemorrhagic infarction than those in the delayed group. There were two (3.7%) intraoperative deaths, both in the early group and attributed to neurologic aggravation. Among the 54 survivors, 4 (7.1%), that is, 2 in each group, showed neurologic aggravation. During a median follow-up of 61.7 months (range, 0.4~170.4 months), there were 5 late deaths. Overall 5-year neurologic aggravation-free survival rates were 79.1±7.0% in the early group and 90.9±6.1% in the delayed group (p=0.113). Conclusion Outcomes of early operation for infective endocarditis in stroke patients were similar to those of the conventional approach. Early surgical intervention may be preferable for patients at high risk of life-threatening septic embolism.

Surgical Outcomes of Congenital Atrial Septal Defect Using da VinciTM Surgical Robot System

Background Minimally invasive cardiac surgery has emerged as an alternative to conventional open surgery. This report reviews our experience with atrial septal defect using the da VinciTM surgical robot system. Materials and Methods This retrospective study included 50 consecutive patients who underwent atrial septal defect repair using the da VinciTM surgical robot system between October 2007 and May 2011. Among these, 13 patients (26%) were approached through a totally endoscopic approach and the others by mini-thoracotomy. Nineteen patients had concomitant procedures including tricuspid annuloplasty (n=10), mitral valvuloplasty (n=9), and maze procedure (n=4). The mean follow-up duration was 16.9±10.4 months. Results No remnant interatrial shunt was detected by intraoperative or postoperative echocardiography. The atrial septal defects were mainly repaired by Gore-Tex patch closure (80%). There was no operative mortality or serious surgical complications. The aortic cross clamping time and cardiopulmonary bypass time were 74.1±32.2 and 157.6±49.7 minutes, respectively. The postoperative hospital stay was 5.5±3.3 days. Conclusion The atrial septal defect repair with concomitant procedures like mitral valve repair or tricuspid valve repair using the da VinciTM system is a feasible method. In addition, in selected patients, complete port access can be helpful for better cosmetic results and less musculoskeletal injury.

Titanium plate fixation for sternal dehiscence in major cardiac surgery.

Background Sternal dehiscence is one of the most troublesome complications following cardiac surgery. Treatment failure and consequent lethal outcomes are very common. The aim of this study was to evaluate titanium plate fixation as a treatment for sternal dehiscence following major cardiac surgery. Materials and Methods Between 2010 and 2012, 17 patients underwent sternal reconstruction using horizontal titanium plating for the treatment of post-cardiac-surgery sternal dehiscence. The plates were cut and shaped, and then were fixed to corresponding costal segments using 2-3 titanium screws per each side. Results The median age of our patients was 66 years (range, 50 to 78 years) and 9 were female. Indications for sternal reconstruction included aseptic sternal dehiscence in 3 patients and osteomyelitis in 14 patients including 6 patients who were diagnosed with mediastinitis. During the operation, sternal resection and autologous flap interposition were combined in 11 patients. One patient died due to sepsis. Two patients required additional soft tissue wound revisions. Another patient presented with a tuberculous wound infection which was resolved using anti-tuberculosis medications. The postoperative course was uncomplicated in the other 13 patients. Conclusion Titanium plate fixation that combines appropriate debridement and flap interposition is very effective for the treatment of sternal dehiscence following major cardiac surgery.

Minimally Invasive Approach for Redo Mitral Valve Replacement: No Aortic Cross-Clamping and No Cardioplegia

A 75-year-old woman who had previously undergone a double valve replacement was admitted to Asan Medical Center because of severe bioprosthetic mitral valve dysfunction and tricuspid regurgitation. Under hypothermic fibrillatory arrest without aortic cross-clamping, minimally invasive mitral and tricuspid valve surgery was performed via a right minithoracotomy.