Joung Hun Byun

Initial Experience of Transaortic Catheter Venting in Patients with Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock.

Extracorporeal membrane oxygenation (ECMO) has become one of the often applied mechanical support for acute cardiogenic shock. During venoarterial (VA) ECMO support, left heart decompression should be considered when left ventricular (LV) distension develops with pulmonary edema and LV dysfunction. The aim of this study was to report the results of transaortic catheter venting (TACV), as an alternative venting method, performed during VA-ECMO in patients with acute cardiogenic shock. We retrospectively reviewed the records of seven patients who underwent both ECMO and TACV between February 2013 and February 2014. Extracorporeal membrane oxygenation was performed uneventfully, and TACV was introduced under transthoracic echocardiographic guidance in all cases. Hemodynamic parameters, LV ejection fraction, and LV end-diastolic dimension (LVEDD) were measured 24 hours after initiating TACV in survivors. There were no procedure-related complications. Four of the seven patients (58%) survived. Transaortic catheter venting led to an increase in mean blood pressure in all patients (p = 0.050). There was a significant difference between pre- and post-TACV-LVEDD (59 ± 14 vs. 50 ± 12 mm, p = 0.044), with a 10–23% reduction in LVEDD in survivors. Transaortic catheter venting might be an acceptable alternative to venting procedures and useful for LV recovery during VA-ECMO in patients with severe LV dysfunction.

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.

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.

Invasive thymoma with multiple ring calcifications and osseous metaplasia: A case report: A rare case of invasive thymoma

An 8.0 × 7.0 × 3.0 cm calcified anterior mediastinal mass was found in a 57‐year‐old man during a regular health checkup. The tumor had invaded the pericardium and phrenic nerve. The Masaoka–Koga classification was stage III. Multiple ring calcifications were present in the gross feature, and osseous metaplasia was observed in the histologic examination. World Health Organization histologic classification of the tumor was type B2. The patient is currently undergoing chemotherapy and radiation therapy to prevent tumor recurrence. To our knowledge, this is the first case of multiple ring calcifications and osseous metaplasia in invasive thymoma.

A Report of Two Cases of Adventitial Cystic Disease of the Popliteal Artery

Two patients were admitted to our department because of recent aggravation of claudication in the leg, which was exacerbated by walking. They were diagnosed as having a Baker cyst or acute thrombosis in the popliteal fossa at another hospital. There was no evidence of ischemia, and the ankle brachial index was normal. Computed tomography and magnetic resonance imaging were performed, revealing a cystic mass of the popliteal artery (PA). Intraoperatively, the cystic lesion was found within the adventitia of the PA; based on the biopsy findings, both patients were diagnosed as having adventitial cystic disease of the PA.

Evaluation of Preoperative Predictors of 30-Day Mortality in Patients with Ruptured Abdominal Aortic Aneurysm

Purpose Ruptured abdominal aortic aneurysm (RAAA) is a rare, extremely dangerous condition. Previous studies have published preoperative, intraoperative, and postoperative data; however, there are not enough studies on the preoperative factors alone. Here we studied the preoperative predictors of 30-day mortality in patients with RAAA. Materials and Methods We conducted a retrospective, consecutive review of the medical records of 57 patients who received management for RAAA between February 2005 and December 2016. We analyzed the association between preoperative predictors and 30-day mortality in patients with RAAA. The initial systolic blood pressure (SBP) and hemoglobin level (HbL), which were proven as significant predictors by multivariate logistic regression analysis, were compared using receiver operating characteristic curves. Results Overall, early mortality was 29.8%. Results of logistic regression analysis found that 30-day mortality in patients with RAAA was associated with the initial SBP (odds ratio [OR], 0.922; 95% confidence interval [CI], 0.874–0.973; P=0.003) and initial HbL (OR, 0.513; 95% CI, 0.289–0.91; P=0.023). Area under the curves were 0.89 for the initial SBP and 0.78 for the initial HbL. The initial SBP with a cut-off value of 90 mmHg had a sensitivity of 85% and specificity of 88.2%. At a cut-off of 10.5, the sensitivity and specificity of HbL for death were 75% and 70.6%, respectively. Conclusion The initial SBP and HbL are independent preoperative predictors of early mortality in patients with RAAA.

Autotransplantation of the Heart for Recurrent Inflammatory Myofibroblastic Tumor

We report a rare case of dyspnea caused by a cardiac tumor in a 53-year-old woman. The patient had undergone a cardiac tumor (inflammatory myofibroblastic tumor, 6.2 × 4.2 × 3.3 cm) resection at our institute 13 months earlier. We performed preoperative evaluations which revealed a cardiac tumor originating from the posterior wall of the left atrium. Cardiac autotransplantation surgery (cardiac explantation, ex vivo tumor resection, cardiac reconstruction, and cardiac reimplantation) was successfully performed for the complete resection of the recurrent tumor without major postoperative complications. The patient showed good physical conditions for 21 months after the surgery. Cardiac autotransplantation is a safe and feasible technique for the complete resection of complex left atrial tumors.

Successful Application of Veno-Venoarterial Extracorporeal Membrane Oxygenation for Acute Exacerbation of Asthma Followed by Stress Cardiomyopathy

We report a case treated by veno-venoarterial extracorporeal membrane oxygenation (vva-ECMO) for stress cardiomyopathy due to exacerbation of asthma. A 45-year-old woman with a history of asthma was transferred to our emergency department from a local medical center. She had developed severe dyspnea and wheezing an hour before. At the time of arrival at our hospital, she was already intubated and had been administered systemic corticosteroid. The initial blood pressure (BP) was 140/90 mm Hg, and heart rate was 130 beats per minute. Her arterial blood gas analysis (ABGA) showed PaO2 18 mm Hg, PaCO2 88 mm Hg, and SaO2 9%. She initiated on ventilator care with FiO2 1.0. Initial transthoracic echocardiography (TTE) showed that left ventricular ejection fraction (LVEF) was 45%. Her electrocardiogram (ECG) was sinus tachycardia without ST-segment abnormalities, and troponin I was 0.11 ng/mL. Computed tomography revealed diffuse tracheobronchial narrowing in both lung fields, which was compatible with acute exacerbation of chronic asthma. Despite 12 hours of ventilator care, hypoxia and hypercapnia developed (PaO2/FiO2 73 mm Hg/0.5, PaCO2 118 mm Hg). Our ECMO team was contacted and decided to apply veno-venous extracorporeal membrane oxygenation (vv-ECMO) via bilateral femoral veins: RotaFlow centrifugal pump (Maquet cardiopulmonary AG, Hirrlingen, Germany), a 20 Fr femoral venous cannula (Fem-Flex II, Edwards Lifescience, LLC, Irvine, CA, USA), a 21 Fr femoral venous cannula (DLP, Medtronic Inc., Minneapolis, MN, USA). ECMO was initiated and gas exchange improved: PaO2 172 mm Hg on ventilator FiO2 0.4, PaCO2 43 mm Hg, peripheral SaO2 99%. Thirty minutes after the start of ECMO, arterial BP dropped below 40/20 mm Hg. Despite the high dose of catecholamines, systolic BP was below 60 mm Hg. TTE showed LVEF of 15% and global wall motion abnormality of LV. ECG presented nonspecific T-wave inversion and troponin I was slightly increased (2.18 ng/mL). We postulated that she developed stress cardiomyopathy due to exacerbation of asthma, because she had no clinical history suggestive of acute coronary syndrome. We converted vv-ECMO to vva-ECMO by insertion of an arterial cannula via the left femoral artery: a 16 Fr femoral arterial cannula (Fem-Flex II, Edwards Lifescience), connected to ECMO via the Y-connector. After 15 hours of vva-ECMO support, follow-up TTE showed LVEF of 35% and mid-ventricular akinesia and apical hypokinesia (Fig. 1). We reverted to vv-ECMO on the 3rd day. On the 4th day, the ECMO was weaned off without significant complications. On the 7th day, she was extubated, and transferred to a general ward the following day. She underwent rehabilitation for 2 weeks, and was subsequently discharged from the hospital. Fig. 1 On the 2nd day ECMO insertion, transthoracic echocardiography (TTE) shows mid-ventricular akinesia and apical hypokinesia. Asthma has a high prevalence world-wide, and can be fatal in some cases. Asthma with acute exacerbation often leads to respiratory failure requiring mechanical ventilation.1 vv-ECMO is helpful when a patient has persistent hypoxemia and hypercapnia despite maximal ventilator support.2 We initially provided our patient with vv-ECMO for respiratory support. After a while, her cardiac function deteriorated rapidly with low BP, low LVEF, global wall motion abnormality of LV, nonspecific T-wave inversion on ECG, and increased troponin I. We considered that she developed stress cardiomyopathy due to severe respiratory failure. Coronary angiography to exclude obstructive coronary disease was not performed, since the patient had no implicating history. She was in cardiogenic shock refractory to fluid and high dose inotropic drugs. The studies on vva-ECMO are limited. A small-cohort study showed that vva-ECMO appears to further improve survival in the acute respiratory distress syndrome.3 Because vva-ECMO provides well-oxygenated blood to the systemic and pulmonary circulation, it helps reduce the pulmonary resistance and the existence of intrapulmonary-shunts in the pulmonary circulation. It also supplies sufficient oxygen to the coronary and peripheral organs. vva-ECMO is beneficial for supporting both cardiac function and respiratory function in acute respiratory failure combined with cardiac failure, as in the current case.

Successful Anticoagulation Therapy for Antiphospholipid Syndrome with Mobile Aortic Thrombi.

Hypercoagulable states have been associated with aortic thrombosis. Antiphospholipid syndrome (APS) is one of the commonest types of acquired thrombophilia. We report the case of successful anticoagulation management in an APS patient with mobile thrombi within the aorta. A 58-year-old male patient presented to the emergency department (ED) with right-sided hemiparesis. His first symptoms were noted approximately 12–16 hours before presentation to the ED. Magnetic resonance imaging of the brain showed acute embolic infarction of the left frontal and parietotemporal lobes. Transesophageal echocardiography (TEE) and computed tomography angiography (CTA) demonstrated mobile thrombi attached to the wall of the ascending aorta and aortic arch. The patient was diagnosed with APS based on positivity of anti-beta-2 glycoprotein 1 antibodies, and was initiated on anticoagulation therapy. Repeated TEE and CTA revealed complete resolution of the thrombi after 12 days of treatment; the patient was discharged well.