Hwan Wook Kim

Infective endocarditis in transcatheter aortic valve implantation

An 85-year old man with a history of transcatheter aortic valve implantation (TAVI) for severe symptomatic aortic stenosis was readmitted with cerebral stroke accompanied by fever. An infected prosthetic valve was revealed by echocardiography (Supplementary Video 1) and retrieved successfully with a surgical approach (Fig. 1). Supplementary material (Video 1) is available at EJCTS online. Video 1: Transoesophageal echocardiographic evaulation showing shaggy materials attached to the prosthetic valve with 1-cm floating linear vegetations.

Cardiac perforation caused by bone cement embolism.

MOTS CLÉS Embolisation ; We report a case of right ventricle perforation caused by bone cement embolism in an 86-year-old woman who had complained of progressive chest pain and fever for 6 days. She had a percutaneous vertebroplasty due to a compression fracture of L3—4, 5 years previously. A chest X-ray obtained on admission showed a linear fishbone-like radiopaque material within the cardiac shadow (Fig. 1A). A computed tomography (CT) scan showed this structure to be stuck in the ventricular septum, penetrating the right ventricular free wall. There was no evidence of pulmonary cement embolism on chest CT scan. A transthoracic echocardiogram confirmed that the hyperechoic linear structure, embedded in the apical

Identification of Genomic Aberrations by Array Comparative Genomic Hybridization in Patients with Aortic Dissections

Background The aim of the present study was to identify chromosomal loci that contribute to the pathogenesis of aortic dissection (AD) in a Korean population using array comparative genomic hybridization (CGH) and to confirm the results using real-time polymerase chain reaction (PCR). Materials and Methods Eighteen patients with ADs were enrolled in this study. Genomic DNA was extracted from individual blood samples, and array CGH analyses were performed. Four corresponding genes with obvious genomic changes were analyzed using real-time PCR in order to assess the level of genomic imbalance identified by array CGH. Results Genomic gains were most frequently detected at 8q24.3 (56%), followed by regions 7q35, 11q12.2, and 15q25.2 (50%). Genomic losses were most frequently observed at 4q35.2 (56%). Real-time PCR confirmed the results of the array CGH studies of the COL6A2, DGCR14, PCSK6, and SDHA genes. Conclusion This is the first study to identify candidate regions by array CGH in patients with ADs. The identification of genes that may predispose an individual to AD may lead to a better understanding of the mechanism of AD formation. Further multicenter studies comparing cohorts of patients of different ethnicities are warranted.

Postoperative acute superior mesenteric venous thrombosis after cardiac surgery in a patient with anti-phospholipid syndrome.

Fig. 1. A 45-year-old female was admitted with chest pain and dyspnoea for 2 days. She had a medical history of anti-phospholipid syndrome. Coronary angiogram showed total occlusion of left circumflex artery (A). Moreover, severe ischaemic mitral regurgitation without papillary muscle rupture was found on echocardiography (ECG showing regular sinus rhythm) (B). Preoperative computerised tomography (CT) scan showed no abnormal findings of abdominal visceral and vascular structures (C-1 and C-2). After myocardial revascularisation and mitral valvuloplasty, extubation was performed with minimal inotropic support (dopamine 9 mg/kg/min) 8 h later. However, mild LLQ abdominal discomfort was developed on postoperative 1 day. CA, coeliac axis; ECG, electrocardiography; LLQ, left lower quadrant; SMA, superior mesenteric artery.

Early Outcomes of Endoscopic Vein Harvesting during the Initial Learning Period

Background The endoscopic vein harvesting (EVH) method has been used in coronary artery bypass surgery in many countries. We started using the EVH method recently, and investigated the results during the early learning period. Methods Between March 2012 and June 2014, 75 patients (31 patients in the EVH method group, and 44 patients in the open method group) who underwent isolated first-time coronary artery bypass grafting using vein grafts were retrospectively analyzed with respect to the early outcomes including graft patency and risk factors for leg wound complications. For assessing the patency of vein graft, we performed coronary computed tomography angiography during the immediate postoperative period and 6 months later. Results Mean harvesting time of endoscopic method was about 15 minutes. Patency rate during the immediate operative period and the 6-month patency rate were similar between the two groups (postoperative period: EVH 100% vs. open method 94.4%, p=0.493; at 6 months: EVH 93.3% vs. open method 90.9%, p=0.791). Leg wound complications occurred more frequently in the open method group (EVH 3.2% vs. open method 13.6%, p=0.127). According to the analysis, age was an independent risk factor for leg wound complications. Conclusion EVH is a feasible method even for beginners and can be performed satisfactorily during their learning period.

Adventitial fibroblast abormality in thoracic aortic aneurysms and aortic dissections.

Background Development of thoracic aortic aneurysms and aortic dissections (TAAD) is attributed to unbearable wall tension superimposed on defective aortic wall integrity and impaired aortic repair mechanisms. Central to this repair mechanisms are well-balanced and adequately functional cellular components of the aortic wall, including endothelial cells, smooth muscle cells (SMCs), inflammatory cells, and adventitial fibroblasts. Adventitial fibroblasts naturally produce aortic extracellular matrix (ECM), and, when aortic wall is injured, they can be transformed into SMCs, which in turn are involved in aortic remodeling. We postulated the hypothesis that adventitial fibroblasts in patients with TAAD may have defects in ECM production and SMC transformation. Materials and Methods Adventitial fibroblasts were procured from the adventitial layer of fresh aortic tissues of patients with TAAD (Group I) and of multi-organ donors (Group II), and 4-passage cell culture was performed prior to the experiment. To assess ECM production, cells were treated with TNF-α (50 pM) and the expression of MMP-2 / MMP-3 was analyzed using western blot technique. To assess SMC transformation capacity, cells were treated with TGF-β1 and expression of SM α-actin, SM-MHC, Ki-67 and SM calponin was evaluated using western blot technique. Fibroblasts were then treated with TGF-β1 (10 pM) for up to 10 days with TGF-β1 supplementation every 2 days, and the proportion of transformed SMC in the cell line was measured using immunofluorescence assay for fibroblast surface antigen every 2 days. Results MMP-3 expression was significantly lower in group I than in group II. TGF-β1-stimulated adventitial fibroblasts in group I expressed less SM α-actin, SM-MHC, and Ki-67 than in group II. SM-calponin expression was not different between the two groups. Presence of fibroblast was observed on immunofluorescence assay after more than 6 days of TGF-β1 treatment in group I, while most fibroblasts were transformed to SMC within 4 days in group II. Conclusion ECM production and SMC transformation are compromised in adventitial fibroblasts from patients with TAAD. This result suggests that functional restoration of adventitial fibroblasts could well be a novel approach for the prevention and treatment of TAAD.

Neurologic outcomes after early surgery for infective endocarditis in patients with combined cerebral septic embolism

Objectives This study followed the results of any development of neurologic outcomes according to the presence or absence of cerebral stroke in infective endocarditis patients after early cardiac surgery. We also analysed the neurologic outcomes regardless of cerebral microbleeds in cerebral embolic patients after cardiac surgery. Methods We retrospectively studied 55 patients with left-sided infective endocarditis who underwent early surgery and hospitalization between May 2010 and May 2015. Preoperatively, there were 33 patients in the cerebral embolic group and 22 patients in the non-embolic event group. Among the cerebral embolic patients, 13 patients had additional cerebral microbleeds on brain imaging. Results After cardiac surgery, intracranial haemorrhage and haemorrhagic complications occurred in 2 patients (9.1%) in the non-embolic group and 5 patients (15.1%) in the embolic group. There was no statistically significant difference in postoperative neurologic problems between the non-embolic group and the embolic group (22.7% vs 30.3%, respectively, P  = 0.54). Early mortality was 4.5% in the non-embolic group and 9.1% in the embolic group ( P  = 1.00). In the cerebral microbleeds combined with septic embolism group, the neurologic problem rate (38.5%) was higher than in the non-cerebral microbleeds group (20.0%), but the difference was not statistically significant. Conclusions Our analysis showed that the rate of postoperative neurologic problems was not high in patients with cerebral septic embolism. Despite this, early surgery is not contraindicated in cerebral septic emboli patients. Cerebral microbleeds related to septic embolism were suspected to increase the rate of neurologic problems after cardiac surgery. So, further studies are needed to assess about the influence of cerebral microbleeds in cardiac operation.

Myocardial abscess, a rare form of cardiac aspergillosis

MOTS CLÉS Abcès myocardique ; Aspergillose ; Aspergillus fumigates A 63-year-old woman with aplastic anaemia was admitted to hospital for fever and malaise. Computed tomography (CT) scan showed a cavitary nodular lesion in the left lower lobe, which was highly suspicious for pulmonary aspergilloma (Fig. 1A-1). A semilunar shaped, low-density lesion within the left ventricular free wall accompanied by mild pericardial effusion was found on the CT scan and magnetic resonance image (Fig. 1A-2 and B). Transthoracic echocardiography showed an echo-free lesion within the left ventricular anterolateral wall (Fig. 1C). A serological study confirmed the presence of the specific antigen of Aspergillus fumigates in the blood, and antifungal treatment was started. Two weeks later, the echolucent space did not show any changes on follow-up echocardiogram, so surgery was performed. After starting standard cardiopulmonary bypass, needle aspiration of the swelling on the left ventricle confirmed the presence of pus (Fig. 2A). The abscess pocket was incised, debrided, irrigated, and obliterated with an autologous pericardial strip (Fig. 2B). A cavitary mass in the left lower lobe was resected. Microscopic examination did not reveal any evidence of microorganisms in the abscess fluid; however, Aspergillus was detected on the pathological report of the resected pulmonary lesion. The patient was discharged without complication after completing 4 weeks of antifungal therapy. Follow-up CT scan did not show any evidence of low-density lesion in the ventricle, and the patient remains free of symptoms 1 year later (Fig. 1D).

Concomitant left and right coronary to bronchial artery fistulae resulting in myocardial ischaemia

Fig. 2. The changes of myocardial ischaemia resulting from steal phenomenon were demonstrated by Thallium-201 myocardial perfusion scan (A-1: pre-embolisation, A-2: post-embolisation). Computed tomographic scan showed that the convoluted fistulous tract, originating from left circumflex coronary artery, passed through the subcarinal and left hilar region. These tortuous fistulae divided into multiple branches, which communicated with the left bronchial collateral circulations (B: arrow — the passage of convoluted fistula originating from left coronary artery, arrow head — the origin of right coronary fistulous tract). The patient was discharged on the 2nd postprocedural day without any other complications. Ao, aorta; LA, left atrium; LPA, left pulmonary artery; MPA, main pulmonary artery; RA, right atrium; RPA, right pulmonary artery.

Total occlusion of both right-sided pulmonary veins after radiofrequency ablation for atrial fibrillation.

Fig. 1. For ectopic origin from the right superior pulmonary vein, the encircling ablatio under the electroanatomic mapping system 7 months earlier. The patient was anticoa 2.0—2.5 for 6 months after the procedure. On admission, the chest radiograph showe After thoracostomy tube drainage, multiple interstitial infiltrate of the right-sided tomographic scan (B). In addition, complete occlusion of the right-sided pulmonary v LLA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior p occlusion of right-sided pulmonary veins.