Joonhwa Hong

Efficacy of veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock

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).

Is Stopping Heparin Safe in Patients on Extracorporeal Membrane Oxygenation Treatment

Anticoagulation treatment during extracorporeal membrane oxygenation (ECMO) treatment is unavoidable. However, discontinuation of heparin infusion is necessary when challenges associated with the use of heparin, such as bleeding and thrombocytopenia, are encountered. The medical records of 94 adult (age ≥ 18 years) patients treated with ECMO from January 2011 to March 2015, at Chung-Ang University Hospital, Seoul, Korea, were reviewed. Among the 94 patients, 55 patients underwent ECMO treatment for three or more days. In 52.7% of these patients (n = 29, group A), heparin was stopped for three or more days because of thrombocytopenic events (< 50,000 cells/mm3), higher than target range (> 230 seconds) activated clotting time (ACT), bleeding complications, or the need for other surgical procedures. In 43.6% of patients (n = 24, group B), heparin was continuously infused during the entire ECMO process. The mean length of ECMO support after the initiation of heparin discontinuation in patients in group A was 10.2 ± 14.7 days. There were no intracardiac, intravascular, or intracircuit thrombotic complications in group A. There was no difference in the ECMO weaning success rate between the two groups (41.4% in group A vs. 54.2% in group B, p = 0.353). Heparin discontinuation can be considered in a select group of patients with coagulation abnormalities or bleeding.

Mechanical thrombectomy in cardiac myxoma stroke: a case report and review of the literature

Cardiac myxoma is the most common primary tumor of the heart. It is a rare cause of acute ischemic stroke and commonly not detected until after the stroke. There is no current guideline for the treatment of cardiac myxoma stroke and only a few cases of mechanical thrombectomy have been reported. We present a case of cardiac myxoma stroke in a 4-year-old boy treated with a stent-retrieval device and review the literature describing the safety and efficacy of mechanical thrombectomy in cardiac myxoma stroke. We also describe imaging features of the myxoma clot on susceptibility weighted images.

Fulminant myocarditis managed with pulsatile extracorporeal life support; use of Twin Pulse Life support (T-PLS ® )

Fulminant myocarditis frequently results in severe hemodynamic deterioration. High-dose vasopressors or sometimes mechanical circulatory support are required. We report on two cases of fulminant myocarditis successfully treated with pulsatile extracorporeal life support (T-PLS®, Twin Pulse Life support, New heart bio.BHK, Seoul, Korea). With T-PLS, we were able to provide mechanical support to patients until they recovered completely.

Bilateral ischemic lumbosacral plexopathy from chronic aortoiliac occlusion presenting with progressive paraplegia

Spinal cord ischemia is rare but causes significant morbidity and mortality. Spinal cord ischemia has been reported after open and endovascular interventions of the thoracic and abdominal aorta, and, rarely, acute occlusion of aorta from in situ thrombosis or acute embolic occlusion. Acute interruption of the critical blood supply to the spinal cord or root contributes to this devastating neurologic deficit. However, gradually worsening lumbosacral plexopathy and consequent paraplegia related to chronic aortic occlusion is extremely rare. We present a case of a 58-year-old man with progressive lower limb paralysis from atherosclerotic aortoiliac occlusion without history of aortic surgery or evidence of thromboembolism.

Effect of Temperature-Sensitive Poloxamer Solution/Gel Material on Pericardial Adhesion Prevention: Supine Rabbit Model Study Mimicking Cardiac Surgery

Objective We investigated the mobility of a temperature-sensitive poloxamer/Alginate/CaCl2 mixture (PACM) in relation to gravity and cardiac motion and the efficacy of PACM on the prevention of pericardial adhesion in a supine rabbit model. Methods A total of 50 rabbits were randomly divided into two groups according to materials applied after epicardial abrasion: PACM and dye mixture (group PD; n = 25) and saline as the control group (group CO; n = 25). In group PD, rabbits were maintained in a supine position with appropriate sedation, and location of mixture of PACM and dye was assessed by CT scan at the immediate postoperative period and 12 hours after surgery. The grade of adhesions was evaluated macroscopically and microscopically two weeks after surgery. Results In group PD, enhancement was localized in the anterior pericardial space, where PACM and dye mixture was applied, on immediate post-surgical CT scans. However, the volume of the enhancement was significantly decreased at the anterior pericardial space 12 hours later (P < .001). Two weeks after surgery, group PD had significantly lower macroscopic adhesion score (P = .002) and fibrosis score (P = .018) than did group CO. Inflammation score and expression of anti-macrophage antibody in group PD were lower than those in group CO, although the differences were not significant. Conclusions In a supine rabbit model study, the anti-adhesion effect was maintained at the area of PACM application, although PACM shifted with gravity and heart motion. For more potent pericardial adhesion prevention, further research and development on the maintenance of anti-adhesion material position are required.

Application of Lidocaine Jelly on Chest Tubes to Reduce Pain Caused by Drainage Catheter after Coronary Artery Bypass Surgery

The objective of this study was to assess the effect of lidocaine jelly application to chest tubes on the intensity and duration of overall pain, chest tube site pain and the required analgesics for postoperative pain relief in coronary artery bypass graft (CABG) patients. For patients in group L, we applied sterile 2% lidocaine jelly on the chest tubes just before insertion, and for patients in group C, we applied normal saline. Overall visual analogue scale (VAS), maximal pain area with their VAS were documented postoperatively, and the frequency that button of patient-controlled analgesia was pressed (FPB) and total fentanyl consumption were assessed. The number of patients who complained that tube site was the most painful site was significantly higher in group C than in group L (85% vs. 30% at extubation, P<0.001). The overall VAS score was significantly higher in group C than in group L (39.14±12.49 vs. 27.74±13.76 at extubation, P=0.006). After all of the tubes were removed, the VAS score decreased more in group C (5.74±4.77, P<0.001) than in group L (3.05±2.48, P<0.001). FPB and total fentanyl consumption were significantly higher in group C than in group L (73.00, 59.00-78.00 vs. 34.00, 31.00-39.25, P<0.001; 2,214.65±37.01 vs. 1,720.19±361.63, P<0.001, respectively). Lidocaine jelly application is a very simple way to reduce postoperative pain by reducing chest tube site pain after CABG. (Clinical Trials Registry No. ACTRN 12611001215910)

Hemolytic Anemia Case Caused by an Inverted Inner Felt after Bentall Operation

A 26-yr-old male patient reported worsened dyspnea, dizziness one year after an emergency Bentall operation for type A aortic dissection. There was evidence of hemolytic anemia and aortogram revealed a significant stenosis at the distal anastomosis site. During the reoperation, we found the inner felt at the distal anastomosis was inverted causing a significant stenosis. The reoperation successfully resolved this problem. Here, we report a rare case of hemolytic anemia caused by an inverted inner felt after Bentall operation.

An unusual right atrial mass.

MOTS CLES Pheochromocytome ; Oreillette droite ; Veine cave inferieure A 60-year-old woman presented with worsening exertional dyspnoea. She had been having intermittent right heart failure symptoms for 2 years prior to our assessment; however, her functional capacity had recently shown significant deterioration. An echocardiogram revealed a large right atrial mass measuring 63 × 47 mm, which was almost completely occluding the tricuspid valve (Fig. 1). The IVC was also occupied by the mass, with faint flow between the mass and the IVC wall. Contrast-enhanced computed tomography of the chest and abdomen showed a highly enhanced, 10 cm mass with central necrosis in the right suprarenal region (Fig. 2) on arterial phase. The mass extended into the right hepatic vein and the right atrium. Intraluminal thrombi from the suprarenal segments of the IVC to both femoral veins were observed. The liver was congested due to outflow obstruction. A small amount of ascites was also observed. The mass was successfully resected under circulatory arrest. The patient was weaned from the cardiopulmonary bypass successfully; however, her vital signs became unstable repeatedly, even with full inotropic support and, unfortunately, she did not survive. Laboratory studies and pathology were consistent with pheochromocytoma. There have been only a few published cases of a pheochromocytoma from an adrenal mass extending into the right atrium. In the absence of suggestive symptoms (such as high blood pressure, headache or excessive sweating), we suggest that careful preoperative measures are very important if pheochromocytoma is on a list of differential diagnoses.

Neonatal Patent Ductus Arteriosus Ligation Operations Performed by Adult Cardiac Surgeons

Background Patent ductus arteriosus (PDA) ligation is usually performed by congenital cardiac surgeons. However, due to the uneven distribution of congenital cardiac surgeons in South Korea, many institutions depend solely on adult cardiac surgeons for congenital cardiac diseases. We report the outcomes of PDA ligations performed by adult cardiac surgeons at our institution. Methods The electronic medical records of 852 neonates at Chung-Ang University Hospital, Seoul, South Korea from November 2010 to May 2014 were reviewed to identify patients with PDA. Results Of the 111 neonates with a diagnosis of PDA, 26 (23%) underwent PDA ligation. PDAs were ligated within 28 days of birth (mean, 14.5±7.8 days), and the mean gestational age of these patients was 30.3±4.6 weeks (range, 26 to 40 weeks) with a mean birth weight of 1,292.5±703.5 g (range, 480 to 3,020 g). No residual shunts through the PDA were found on postoperative echocardiography. There was 1 case of 30-day mortality (3.8%) due to pneumonia, and 6 cases of in-hospital mortality (23.1%) after 30 days, which is comparable to results from other centers with congenital cardiac surgery programs. Conclusion Although our outcomes may not be generalizable to all hospital settings without a congenital cardiac surgery program, in select centers, PDA ligations can be performed safely by adult cardiac surgeons if no congenital cardiac surgery program is available.