Hyun Oh Park

Blunt Traumatic Cardiac Rupture: Single-Institution Experiences over 14 Years

Background Blunt traumatic cardiac rupture is rare. However, such cardiac ruptures carry a high mortality rate. This study reviews our experience treating blunt traumatic cardiac rupture. Methods This retrospective study included 21 patients who experienced blunt traumatic cardiac rupture from 1999 to 2015. Every patient underwent surgery. Several variables were compared between survivors and fatalities. Results Sixteen of the 21 patients survived, and 5 (24%) died. No instances of intraoperative mortality occurred. The most common cause of injury was a traffic accident (81%). The right atrium was the most common location of injury (43%). Ten of the 21 patients were suspected to have cardiac tamponade. Significant differences were found in preoperative creatine kinase–myocardial band (CK-MB) levels (p=0.042) and platelet counts (p= 0.004) between the survivors and fatalities. The patients who died had higher preoperative Glasgow Coma Scale scores (p=0.007), worse Trauma and Injury Severity Scores (p=0.007), and higher Injury Severity Scores (p=0.004) than those who survived. Conclusion We found that elevated CK-MB levels, a low platelet count, and multi-organ traumatic injury were prognostic factors predicting poor outcomes of blunt cardiac rupture. If a patient with blunt traumatic cardiac rupture has these factors, clinicians should be especially attentive and respond promptly in order to save the patient’s life.

Intracardiac Foreign Body (Bone Cement) after Percutaneous Vertebroplasty

Percutaneous vertebroplasty is a relatively easy and minimally invasive procedure used in treating vertebral fractures. However, the procedure has many complications, one of which is bone cement leakage, which happens frequently. Leakage to the paravertebral venous system, in particular, may lead to especially devastating consequences. Here we report a case of a 65-year-old male patient with an intracardiac foreign body (bone cement) that generated a perforation on the right ventricle, and result in hemopericardium after percutaneous vertebroplasty. We performed open heart surgery to remove the foreign body.

Adventitial cystic disease of the common femoral artery: a case report and literature review.

Arterial adventitial cystic disease is an uncommon type of non-atherosclerotic peripheral vessel disease. Most cases of arterial adventitial cystic disease occur in the popliteal arteries; however, fewer cases have been reported in the femoral arteries. A 59-year-old male patient visited the hospital with a complaint of a swelling on the lower extremity that had begun two months earlier. Suspecting deep vein thrombosis based on a physical examination and ultrasonography from another hospital, tests were performed. Magnetic resonance imaging (MRI) was performed for exact diagnosis because venous adventitial cystic disease was suspected by computed tomography venography. The MRI indicated venous adventitial cystic disease as well. Thus, a cystic mass excision was performed. In the end, a cystic mass compressing the common femoral vein that originated from the common femoral artery was diagnosed based on the macroscopic findings. This case is reported because blood circulation in the vein was impeded due to arterial adventitial cystic disease, and the symptoms improved after the cystic mass excision and polytetrafluoroethylene roofing angioplasty.

Relationship between the Occurrence of Thromboembolism and INR Measurement Interval in Low Intensity Anticoagulation after Aortic Mechanical Valve Replacement.

Background We investigated changes in the International Normalized Ratio (INR) and its measurement interval in patients with thromboembolic events who were treated by low intensity anticoagulation therapy after isolated mechanical aortic valve replacement. Materials and Methods Seventy-seven patients who underwent surgery from June 1990 to September 2006 were enrolled in the study and observed until August 2008. The patients were followed up at 4~8 week intervals and their warfarin (Coumadin)® dosage was adjusted aiming for a target range of INR 1.5~2.5. The rate of thromboembolic events was obtained. Changes in the mean INR and INR measurement interval were comparatively analyzed between the normal group (event free group, N=52) who had no anticoagulation-related complications and the thromboembolic group (N=10). Hospital records were reviewed retrospectively. Results The observation period was 666.75 patient-years. Thromboembolic events occurred in 10 patients. The linearized occurrence rate of thromboembolism was 1.50%/patient-years. Actuarial thromboembolism-free rates were 97.10±2.02% at 5 years, 84.30±5.22% at 10 years, and 67.44±12.14% at 15 years. The percentages of INR within the target range and mean INR were not statistically significantly different for the normal and thromboembolic groups. However, the mean INR during the segmented period just before the events showed a significantly lower level in the thromboembolic group (during a 4 month period: normal group, 1.86±0.14 vs. thromboembolic group, 1.50±0.28, p<0.001). The mean intervals of INR measurement during the whole observation period showed no significant differences between groups, but in the segmented period just before the events, the interval was significantly longer in thromboembolic group (during a 6 month period: normal group, 49.04±9.47 days vs. thromboembolic group, 65.89±44.88 days, p<0.01). Conclusion To prevent the occurrence of thromboembolic events in patients who receive isolated aortic valve replacement and low intensity anticoagulation therapy, we suggest that it would be safe to maintain an INR level above 1.8 and to measure the INR at least every 7~8 weeks.

Clinical Results of Ascending Aorta and Aortic Arch Replacement under Moderate Hypothermia with Right Brachial and Femoral Artery Perfusion

Background Selective antegrade perfusion via axillary artery cannulation along with circulatory arrest under deep hypothermia has became a recent trend for performing surgery on the ascending aorta and aortic arch and when direct aortic cannulation is not feasible. The authors of this study tried using moderate hypothermia with right brachial and femoral artery perfusion to complement the pitfalls of single axillary artery cannulation and deep hypothermia. Materials and Methods A retrospective analysis was performed on 36 patients who received ascending aorta or aortic arch replacement between July 2005 and May 2010. The adverse outcomes included operative mortality, permanent neurologic dysfunction and temporary neurologic dysfunction. Results Of these 36 patients, 32 (88%) were treated as emergencies. The mean age of the patients was 61.9 years (ranging from 29 to 79 years) and there were 19 males and 17 females. The principal diagnoses for the operation were acute type A aortic dissection (31, 86%) and aneurysmal disease without aortic dissection (5, 14%). The performed operations were ascending aorta replacement (9, 25%), ascending aorta and hemiarch replacement (13, 36%), ascending aorta and total arch replacement (13, 36%) and total arch replacement only (1, 3%). The mean cardiopulmonary bypass time was 209.4±85.1 minutes, and the circulatory arrest with selective antegrade perfusion time was 36.1±24.2 minutes. The lowest core temperature was 24±2.1℃. There were five deaths within 30 post-op days (mortality: 13.8%). Two patients (5.5%) had minor neurologic dysfunction and six patients, including three patients who had preoperative cerebral infarction or unconsciousness, had major neurologic dysfunction (16.6%). Conclusion When direct aortic cannulation is not feasible for ascending aorta and aortic arch replacement, the right brachial and femoral artery can be used as arterial perfusion routes with the patient under moderate hypothermia. This technique resulted in acceptable outcomes.

Risk Factors for Pneumonia in Ventilated Trauma Patients with Multiple Rib Fractures

Background Ventilator-associated pneumonia (VAP) is a common disease that may contribute to morbidity and mortality among trauma patients in the intensive care unit (ICU). This study evaluated the associations between trauma factors and the development of VAP in ventilated patients with multiple rib fractures. Methods We retrospectively and consecutively evaluated 101 patients with multiple rib fractures who were ventilated and managed at our hospital between January 2010 and December 2015, analyzing the associations between VAP and trauma factors in these patients. Trauma factors included sternal fracture, flail chest, diaphragm injury, traumatic aortic dissection, combined cardiac injury, pulmonary contusion, pneumothorax, hemothorax, hemopneumothorax, abbreviated injury scale score, thoracic trauma severity score, and injury severity score. Results Forty-six patients (45.5%) had at least 1 episode of VAP, 10 (21.7%) of whom died in the ICU. Of the 55 (54.5%) patients who did not have pneumonia, 9 (16.4%) died in the ICU. Using logistic regression analysis, we found that VAP was associated with severe lung contusion (odds ratio, 3.07; 95% confidence interval, 1.12 to 8.39; p=0.029). Conclusion Severe pulmonary contusion (pulmonary lung contusion score 6–12) is an independent risk factor for VAP in ventilated trauma patients with multiple rib fractures.

Biochemical Markers as Predictors of In-Hospital Mortality in Patients with Severe Trauma: A Retrospective Cohort Study

Background Initial evaluation of injury severity in trauma patients is an important and challenging task. We aimed to assess whether easily measurable biochemical parameters (hemoglobin, pH, and prothrombin time/international normalized ratio [PT/INR]) can predict in-hospital mortality in patients with severe trauma. Methods This retrospective study involved review of the medical records of 315 patients with severe trauma and an injury severity score >15 who were managed at Gyeongsang National University Hospital between January 2005 and December 2015. We extracted the following data: in-hospital mortality, injury severity score, and initial hemoglobin level, pH, and PT/INR. The predictive values of these variables were compared using receiver operation characteristic curves. Results Of the 315 patients, 72 (22.9%) died. The in-hospital mortality rates of patients with hemoglobin levels <8.4 g/dl and ≥8.4 g/dl were 49.8% and 9.9%, respectively (P < 0.001). At a cutoff hemoglobin level of 8.4 g/dl, the sensitivity and specificity values for mortality were 81.9% and 86.4%, respectively. At a pH cutoff of 7.25, the sensitivity and specificity values for mortality were 66.7% and 77.8%, respectively; 66.7% of patients with a pH <7.25 died versus 22.2% with a pH ≥7.25 (P < 0.001). The in-hospital mortality rates for patients with PT/INR values ≥1.4 and <1.4 were 37.5% and 16%, respectively (P < 0.001; sensitivity, 37.5%; specificity, 84%). Conclusions Using the suggested cutoff values, hemoglobin level, pH, and PT/INR can simply and easily be used to predict in-hospital mortality in patients with severe trauma.

The thorax trauma severity score and the trauma and injury severity score: Do they predict in-hospital mortality in patients with severe thoracic trauma?

Abstract Several scoring systems are commonly used to evaluate severity in patients with traumatic injuries. However, there is no generally accepted standard scoring system to assess the severity of thoracic trauma, specifically in patients who have sustained severe injuries. The present study aimed to evaluate the validity of the trauma and injury severity score (TRISS) and the thorax trauma severity score (TTSS) as predictors of in-hospital mortality in patients with severe thoracic trauma. We conducted a retrospective, consecutive review of the medical records of patients with severe thoracic trauma who were managed at our institution between January 2005 and December 2015. Inclusion criteria were patients with severe thoracic injury (injury severity score > 18) who required intensive care therapy and who had no local or systemic infection. We analyzed the association between the trauma severity scores (TTSS and TRISS) and in-hospital mortality in these patients. We also determined the predictive value of the scores using receiver-operating characteristic (ROC) curves. A total of 228 patients with severe thoracic trauma were included in this study. The in-hospital mortality rate was 21.9%. There was a statistically significant association between the TRISS and in-hospital mortality (P < .001), but the association between the TTSS and in-hospital mortality was not statistically significant (P = .547). The ROC curve demonstrated adequate discrimination, as demonstrated by an area under the curve value of 0.787 for the TRISS. At a cut-off value of 25.9%, the TRISS had a sensitivity of 83.6% and specificity of 73.5% to predict in-hospital mortality. The present study demonstrated that the TRISS, but not the TTSS, can be used to predict in-hospital mortality in patients with severe thoracic trauma; hence, additional prospective studies are required.

Side effects associated with the treatment of multidrug-resistant tuberculosis at a tuberculosis referral hospital in South Korea: A retrospective study

Abstract Patients with drug-susceptible tuberculosis (TB) show good tolerance of the medications used and have few side effects. However, medications used to treat multidrug-resistant tuberculosis (MDR-TB) have many known side effects. Here, we studied the occurrence of side effects due to treatment of patients with MDR-TB. We conducted a retrospective and consecutive review of the medical records of 256 patients who received treatment for MDR-TB between January 2006 and December 2011. One or more side effects were observed in 95 (37.1%) of the 256 patients. These side effects led to the suspension of the use of 1 or more drugs from the regimen of individualized treatment prescribed for 44 of the patients (17.2%). The side effects observed most frequently included gastrointestinal disturbance (18.4%), psychiatric disorder (5.5%), arthralgia (4.7%), hepatitis (3.9%), peripheral neuropathy (3.1%), hypothyroidism (2.3%), epileptic seizures (2%), dermatological effects (2%), ototoxicity (1.6%), and nephrotoxicity (1.2%). The treatment was successful in 220 (85.9%) patients with MDR-TB. Our study may help in formulating strategies for the timely and aggressive management of drug side effects. This may reduce the suspension of therapy and increase the rate of clinical success.

Flow Rate Through Pigtail Catheter Used for Left Heart Decompression in an Artificial Model of Extracorporeal Membrane Oxygenation Circuit

In refractory cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (ECMO) can be initiated. Although left heart decompression can be accomplished by insertion of a left atrial (LA) or left ventricular (LV) cannula using a percutaneous pigtail catheter, the venting flow rate according to catheter size and ECMO flow rate is unknown. We developed an artificial ECMO circuit. One liter saline bag with its pressure set to 20 mm Hg was connected to ECMO to mimic LV failure. A pigtail catheter was inserted into the 1 L saline bag to simulate LV unloading. For each pigtail catheter size (5–8 Fr) and ECMO flow rate (2.0–4.0 L/min), the moving distance of an air bubble that was injected through a three-way stopcock was measured in the arterial pressure line between the pigtail catheter and ECMO inflow limb. The flow rate was then calculated. We obtained the following equation to estimate the pigtail catheter flow rate. Pigtail vent catheter flow rate (ml/min) = 8×ECMOflow rate(L /min)+9×pigtail catheter size(Fr)- 57 This equation would aid in designing of a further study to determine optimal venting flow rate. To achieve optimal venting flow, our equation would enable selection of an adequate catheter size.