Jun Sung Kim

Long-term experience of surgical treatment for aortic regurgitation attributable to Behçet's disease.

BACKGROUNDnCardiac involvement in Behçets disease is a rare but severe complication and presents challenges to cardiac surgeons as a result of late valve detachment or pseudoaneurysms of the aortic root after valve surgery. Few reports have been published on this topic. In this article, clinical data and surgical outcomes in patients with aortic regurgitation attributable to Behçets disease were analyzed.nnnMETHODSnNineteen patients with aortic regurgitation attributable to Behçets disease were surgically treated between March 1986 and June 2008. There were 15 men and 4 women with ages ranging from 24 to 55 years (mean, 39 +/- 7 years). Mean follow-up duration from index operations was 77.4 +/- 68.1 months (range, 9 to 271 months).nnnRESULTSnOverall mortality was 47.3% (9 of 19 patients), but no early deaths occurred at index operations. All deaths occurred after second operations, and the causes of death were low cardiac output (n = 6) and sudden aggravation of aortic regurgitation (n = 3). Erythrocyte sedimentation rates and C-reactive protein concentrations were negatively correlated with event-free period. Event-free survival at 13 years was 39.2% +/- 14.1% in patients who underwent aortic root replacement, but this was 4% +/- 3.9% in patients who underwent valve replacement (p = 0.001). Event-free survival at 13 years in patients who were administered immunosuppressive therapies was 33.7% +/- 11.0% and 0% in patients not administered immunosuppressive therapy (p = 0.001).nnnCONCLUSIONSnThe mortality in this condition was very high and was found to depend on levels of postoperative inflammatory markers. Aortic root replacement and postoperative immunosuppressive therapy may be helpful.

Bilateral Internal Thoracic Artery In Situ Versus Y-Composite Graftings: Five-Year Angiographic Patency and Long-Term Clinical Outcomes

BACKGROUNDnWe compared 5-year graft patency rates and long-term clinical outcomes after off-pump coronary artery bypass grafting (OPCAB) using bilateral internal thoracic arteries (ITAs) as in situ grafts with those using bilateral ITAs as a Y-composite graft.nnnMETHODSnOf 398 patients who underwent OPCAB, bilateral ITAs were used as in situ grafts in 164 patients and as a Y-composite graft in 234 patients. A propensity score-matched analysis was used to match patients using bilateral ITA in situ grafts (group I, n=110) with patients using bilateral ITA Y-composite grafts (group Y, n=110). Postoperative early, 1-year, and 5-year angiographic patency rates and long-term clinical outcomes during follow-up of 104 (1 to 149) months were compared.nnnRESULTSnThere were no differences in operative mortalities (2 of 110 vs 1 of 110; p>0.999) and postoperative complications between groups I and Y. Early, 1-year, and 5-year postoperative angiographies showed no significant differences in bilateral ITA graft patency rates between groups I and Y (early, 98.2% vs 99.3%, p=0.450; 1-year, 92.5% vs 95.7%, p=0.138; 5-year, 92.5% vs 92.4%, p=0.978). No differences in overall survival (p=0.347) and freedom from cardiac death (p=0.780) rates were observed between the groups; 10-year freedom from cardiac death rates were 95.1% and 94.2% in groups I and Y, respectively. Reintervention-free survival (p=0.379) and major adverse cardiac event-free survival (p=0.338) rates were also similar between the groups.nnnCONCLUSIONSnThe OPCAB using both bilateral ITA configurations demonstrated that there were no differences in terms of 5-year patency rates and long-term clinical outcomes between the groups.

Ten-year experience with off-pump coronary artery bypass grafting: Lessons learned from early postoperative angiography

OBJECTIVEnWe performed early postoperative angiography to assess anastomosis accuracy and patency after off-pump coronary artery bypass grafting.nnnMETHODSnOne thousand three hundred forty-five patients who underwent off-pump coronary artery bypass grafting between January 1998 and December 2007 were studied. Grafts for distal anastomoses were left internal thoracic artery (n=1281), right internal thoracic artery (n=679), right gastroepiploic artery (n=836), radial artery (n=14), and saphenous vein (n=188). Groups underwent off-pump coronary artery bypass grafting without (group I, n=234) or with (group II, n=1111) intraoperative graft flowmetry. Early postoperative (< or = 7 days) angiography was performed in 1278 cases (95.0%) at 1.6+/-1.2 postoperative days.nnnRESULTSnOperative mortality was 1.6%. Average number of distal anastomoses was 3.0+/-1.0. Postoperative angiography showed early patencies of 98.9% for arterial grafts and 88.2% for venous grafts (P < .001). In group II, intraoperative flowmetry-guided revision was performed in 2.2% of distal anastomoses. Patency of arterial grafts was significantly higher in group II than group I (97.2% vs 99.1%, P < .001); however, patency of venous grafts was not significantly different (86.0% vs 92.2%, P=.099). Early reoperation for graft revision according to angiographic findings was performed in 35 patients.nnnCONCLUSIONSnEarly patency of venous grafts was significantly lower than that of arterial grafts. Intraoperative flowmetry and revision of abnormal grafts improved early graft patency, and reoperation according to early angiographic findings may further improve graft patency.

Surgical Outcomes of Cox-maze IV Procedure Using Bipolar Irrigated Radiofrequency Ablation and Cryothermy in Valvular Heart Disease.

Background We evaluated the efficacy of Cox-maze IV procedure using bipolar irrigated radiofrequency ablation and cryothermy in chronic atrial fibrillation associated with valvular heart disease. Material and Methods From November 2005 to June 2009, ninety four patients have undergone valvular heart surgery with Cox-maze IV procedure. Preoperative duration of atrial fibrillation was 7.6±6.5 years and follow-up duration was 22.7±12.3 months. Results There were two (2.1%) postoperative deaths not related to maze procedure. Two cerebrovascular accidents, five low cardiac output syndromes and two permanent pacemaker implantations have occurred after surgery. Preoperative ejection fraction on echocardiography was 55.3±8.1% and ejection fraction of postoperative six month was 54.7±6.5%. Left atrial size of preoperative and postoperative were 61.5±11.6 mm and 53.1±8.4 mm at each. Freedom from atrial fibrillation rate at postoperative six-month was 80.7% and the cases of recurrence of atrial fibrillation after six months were three (3.3%). Risk factors for failure or recurrence of maze procedure were old age (p=.010) and preoperative moderate or severe tricuspid regurgitation (p=.033). Conclusion The Cox-maze IV procedure using RFBP2 and cryothermy is quite safe and freedom from atrial fibrillation at postoperative 6 month was 82.5%. Risk factors for failure or recurrence of atrial fibrillation after Cox-maze IV were old age and preoperative over moderate tricuspid regurgitation.

Left atrial metastasis from hepatocellular carcinoma with liver cirrhosis

Surgical treatment in hepatocellular carcinoma patients with cardiac involvement is challenging, and its prognosis remains unclear because of its rarity. A 48-year-old male hepatocellular carcinoma patient presented with right atrial involvement through the inferior vena cava and a left atrial mass, which nearly occluded the mitral valve, and extended from a pulmonary metastasis. Emergent surgery was performed due to sudden severe respiratory failure despite profound liver cirrhosis (Child-Pugh class B). Nevertheless, the patients postoperative course was uneventful, and over six months of follow-up, he has shown no remarkable symptoms and has maintained a tolerable liver function.

Right Gastroepiploic Artery Graft for Myocardial Revascularization: Prevalence of Atherosclerosis and Availability as a Conduit

BACKGROUNDnWe evaluated prevalence of atherosclerosis and availability of right gastroepiploic artery graft in patients undergoing coronary artery bypass graft surgery.nnnMETHODSnAmong the 1,579 patients who underwent isolated coronary artery bypass grafting between January 1999 and December 2008, we opened the peritoneum to examine the right gastroepiploic artery for use as a graft in 1,128 patients (71.4%). A computer-based patient database system was utilized for this retrospective study.nnnRESULTSnOf 1,128 patients, 139 patients (12.3%) had atherosclerotic right gastroepiploic arteries at gross examination. Seventy-three of 139 atherosclerotic right gastroepiploic arteries had multiple or diffuse atherosclerotic lesions that precluded their use as a bypass graft; the remaining 66 right gastroepiploic arteries were used as a bypass graft including the atheromatous segment or after exclusion of the atherosclerotic segment. Another 60 nonatherosclerotic right gastroepiploic arteries were unavailable to use as a graft because of their short length, small caliber, and weak pulsation. Overall availability of the right gastroepiploic arteries as a graft was 88.2% (995 of 1,128). Multivariable logistic regression analysis showed older age (≥65 years; p < 0.001), insulin-treated diabetes mellitus (p = 0.001), and chronic renal failure (p < 0.001) as independent risk factors for atherosclerosis.nnnCONCLUSIONSnThe prevalence of atherosclerosis and availability of the right gastroepiploic artery graft in patients undergoing isolated coronary artery bypass grafting was 12.3% and 88.2%, respectively. Older age (≥65 years), insulin-treated diabetes mellitus, and chronic renal failure were identified as independent predictors for the atherosclerotic right gastroepiploic artery.

Saphenous vein versus right internal thoracic artery as a Y-composite graft: Five-year angiographic and clinical results of a randomized trial

Objectives We compared the 5‐year graft occlusion rates and midterm clinical outcomes of saphenous vein composite grafts with those of right internal thoracic artery composite grafts in patients who were enrolled in the SAphenous VEin versus Right Internal Thoracic Artery as a Y‐Composite Graft trial. Methods Of 224 eligible patients with multivessel coronary artery disease who were randomized to undergo off‐pump revascularization using the saphenous vein (saphenous vein group, n = 112) or right internal thoracic artery (right internal thoracic artery group, n = 112) as Y‐composite grafts based on the in situ left internal thoracic artery from September 2008 to October 2011, 219 patients (saphenous vein group, n = 109; right internal thoracic artery group, n = 110) entered the analysis. A third limb conduit to lengthen the graft limb for complete revascularization was used in 47 patients (saphenous vein group vs right internal thoracic artery group, 8 vs 39). Postoperative 5‐year (61.7 ± 5.2 months) angiograms were performed in 186 patients (84.9%; saphenous vein group = 95; right internal thoracic artery group = 91). Follow‐up was complete in 97.7% (214/219) of patients with a median follow‐up of 80.7 months. Results The overall graft occlusion rate was 3.6% at 5 years (3.5% in the saphenous vein group vs 3.7% in the right internal thoracic artery group, P = .910). The 5‐year occlusion rate of the second limb conduits in the saphenous vein group was 4.3% and was noninferior to that of the right internal thoracic artery group (2.4%) within the 95% 2‐sided confidence interval of −1.4% to 5.2% (P < .001 for noninferiority). No statistically significant differences were found in the overall survival (P = .439) and the freedom from major adverse cardiac and cerebrovascular event rates (P = .354) at 5 and 8 years between the 2 groups. Conclusions The saphenous vein composite grafts were noninferior to the right internal thoracic artery composite grafts in terms of 5‐year graft occlusion rates and midterm clinical outcomes.

Natural history of moderately dilated tubular ascending aorta: implications for determining the optimal imaging interval†

OBJECTIVESnFor a moderately dilated ascending aorta (diameter 35-54u2009mm), current guidelines recommend continuous annual or semi-annual examinations with computed tomography or magnetic resonance imaging. However, few data have shown the yield and benefit of such a protocol. This study aimed to investigate the fate of a moderately dilated ascending aorta and thereby determine the adequate imaging interval.nnnMETHODSnIn our institutional database, we identified adult patients having an ascending aortic diameteru2009≥40u2009mm in contrast-enhanced computed tomography and follow-up imaging(s) afteru2009≥1 year. Of the 509 patients (mean age 67.2u2009±u200910.4 years) enrolled in the study, the maximal diameter of the ascending aorta was compared between the first and last images. Also, their medical records were reviewed to investigate the associated illness and clinical events.nnnRESULTSnThe mean growth rate of the patients with a 40-44u2009mm ( n u2009=u2009321), 45-49u2009mm ( n u2009=u2009142) andu2009≥50u2009mm ( n u2009=u200946) ascending aorta was 0.3u2009±u20090.5, 0.3u2009±u20090.5 and 0.7u2009±u20090.9u2009mm/year, respectively. During the mean interval of 4.3u2009±u20092.4 years, significant progression (diameter increase byu2009≥5u2009mm) occurred in 3.4, 5.6 and 21.7%, respectively. The 3- to 5-year rates of freedom from significant progression were 99.1%-96.5% (40-44u2009mm) and 97.8%-96.4% (45-49u2009mm). In multivariate analysis, initial ascending aortic diameteru2009≥45u2009mm and aortic valve regurgitation were significantly associated with significant progression. Acute type A aortic dissection occurred in 5 patients (1%), before the maximal diameter of the ascending aorta reached 55u2009mm or significant progression was observed.nnnCONCLUSIONSnFor a moderately dilated ascending aorta not exceeding 45u2009mm in maximal diameter and stable in the first annual follow-up image, a 3- to 4-year interval would be reasonable before subsequent imaging. More frequent imaging may be warranted in patients with aortic valve insufficiency or with an aortic diameteru2009≥45u2009mm.

Early Results of Novel Bovine Pericardial Patch Using Comprehensive Anticalcification Procedure in a Swine Model.

We evaluated the short-term safety and effectiveness of our comprehensive anticalcification procedure in swine model. Our comprehensive anticalcification procedure consisted of four steps, including decellularization with sodium dodecyl sulfate and tritonX-100, space filler treatment with polyethylene glycol (PEG), glutaraldehyde cross-linking with organic solvent, and detoxification with glycine. We simultaneously implanted both the commercially available bovine pericardial patch (Supple Peri-Guard) and novel bovine pericardial patch processed by the comprehensive anticalcification procedure into the main pulmonary artery in seven pigs. Every pig underwent a cardiac angiography and was killed on the postoperative day 28. The extracted patches were stained with hematoxylin and eosin. All pigs survived for 4 weeks without any complication. Cardiac angiography showed the absence of leakage and structural problem. Neointimas were formed evenly without intimal hyperplasia. There were no significant differences in the degree of inflammation, necrosis, and calcification between the novel and commercially available patch (p = 0.450, p = 0.317, p = 0.999). Novel bovine pericardial patch using comprehensive anticalcification procedure was similar to existing cardiovascular patch in early surgical results in a swine model. The comprehensive anticalcification procedure could facilitate appropriate bioprosthetic properties of the bovine pericardium.

Mid-Term Results of Minimally Invasive Direct Coronary Artery Bypass Grafting

Background Minimally invasive direct coronary artery bypass grafting (MIDCAB) has the advantage of allowing arterial grafting on the left anterior descending artery without a sternotomy incision. We present our single-center clinical experience of 66 consecutive patients. Methods All patients underwent MIDCAB through a left anterior small thoracotomy between August 2007 and July 2015. Preoperative, intraoperative, postoperative and follow-up data—including major adverse cardiovascular and cerebrovascular events (MACCE), graft patency, and the need for re-intervention—were collected. Results The mean age of the patients was 69.4±11.1 years and 73% were male. There was no conversion to an on-pump procedure or a sternotomy incision. The 30-day mortality rate was 1.5%. There were no cases of stroke, although 2 patients had to be re-explored for bleeding, and 81.8% were extubated in the operating room or on the day of surgery. The median stay in the intensive care unit and in the hospital were 1.5 and 9.6 days, respectively. The median follow-up period was 11 months, with a 5-year overall survival rate of 85.3%±0.09% and a 5-year MACCE-free survival rate of 72.8%±0.1%. Of the 66 patients, 32 patients with 36 grafts underwent a postoperative graft patency study with computed tomography angiography or coronary angiography, and 88.9% of the grafts were patent at 9.7±10.8 months postoperatively. Conclusion MIDCAB is a safe procedure with low postoperative morbidity and mortality and favorable mid-term MACCE-free survival.