Kook Yang Park

The Effects of Perioperative Inhaled Iloprost on Pulmonary Hypertension with Congenital Heart Disease

Objectives: The treatment of choice for congenital heart disease (CHD) with pulmonary arterial hypertension (PAH) is still controversial. We assessed the efficacy and safety of perioperative inhaled iloprost therapy in CHD with PAH. Methods: Among 45 patients with a ventricular septal defect and/or an atrial septal defect with PAH, 28 patients were treated with inhaled iloprost before and after surgery. Perioperative clinical parameters and plasma B-type natriuretic peptide (BNP) were evaluated. Results: No statistical difference in the estimated right ventricular systolic pressure (e-RVP), the e-RVP-to-systemic pressure ratio, and preoperative BNP levels between the iloprost group and the control group were found. Among the iloprost group, oxygen saturation was increased significantly after iloprost inhalation therapy (p = 0.0052). The iloprost group was also significantly correlated with less use of inhaled nitric oxide in the immediate postoperative period compared to the control group (p = 0.021). The durations of mechanical ventilation (p = 0.018), ICU stay (p = 0.005), and chest tube use (p = 0.039) were significantly shorter in the iloprost group compared to the control group. The plasma BNP, checked on 7th day of postoperatively, was lower in the iloprost group than in the control group (p = 0.008). Conclusion: Perioperative inhaled iloprost therapy showed the benefit of cardiac functional improvement and early weaning of postoperative supportive care in the management of CHD with PAH.

Relation between changes in red blood cell distribution width after coronary artery bypass grafting and early postoperative morbidity

Background Red blood cell distribution width (RDW) is highly associated with various clinical states. In the present study, we aimed to determine the natures of associations between RDW changes and early adverse events after isolated coronary artery bypass grafting (CABG). Methods We retrospectively analyzed medical records of enrolled 117 patients. Patients were classified into two groups depending on early adverse events (No-event vs. Event). Delta RDW values were calculated (ΔRDW: Post-Peak RDW minus Pre-RDW). Patients were divided into tertiles based on ΔRDW. The ΔRDW cut-off point for an adverse event was determined by receiver operating characteristic curve analysis. In addition, logistic regression analysis was performed to identify independent factors of early adverse events. Results Thirty eight patients experienced 53 early adverse events. ΔRDW and ΔC-reactive protein were significantly higher in the Events group than in the No-event group. Incidences of early adverse events increased significantly between ΔRDW tertiles (P<0.001). The ROC curve of ΔRDW showed that a ΔRDW of ≥1.45 had a sensitivity of 71.1% and a specificity of 78.2% for predicting an early adverse event after CABG (P<0.001). Multivariable analysis showed ΔRDW (P=0.042) and length of ICU stay (P<0.001) independently predicted an adverse event. Conclusions ΔRDW was identified to be an independent predictor of early adverse events, and a ΔRDW cut-off of 1.45 was found to predict early adverse events after CABG. Careful monitoring of RDW trends after isolated CABG provides a simple, inexpensive and objective means of predicting early adverse events.

Explantation of a failed endovascular stent graft in a patient with a type B dissection

We report a patient who underwent insertion of an endovascular stent graft in the descending aorta for an aneurysmal type B dissection. The patient developed a proximal type I endoleak which required explantation of the graft and replacement of the descending aorta. Carotid artery cannulation was utilized for antegrade perfusion during the period of circulatory arrest.

Prosthetic Grafting and Arteriovenous Fistula for the Surgical Management of a Common Femoral Vein Injury Using a Staged Approach

A 27-year-old female patient was referred due to an edematous left lower extremity. Both saphenous veins had been ablated with an endovenous laser procedure used to treat varicose veins. Venography revealed that the left common femoral vein had been divided and that thrombosis was present at the site of division. No veins were available around the thighs. The patient was treated using a staged procedure. During the first stage, a ringed polytetrafluoroethylene graft was used to repair the common femoral vein, and an arteriovenous fistula was constructed from the femoral artery to the graft using a short segment of cephalic vein to increase graft patency. The edema was relieved postoperatively and the graft was patent. During the second stage, which was performed 6 months later, the fistula was occluded by coil embolization. The staged procedure described herein provides an alternative for venous reconstruction when autologous vein is unavailable.

Spontaneous Echo Contrast Mistaken for Left Ventricular Thrombus during Venoarterial Extracorporeal Membrane Oxygenation

Spontaneous echo contrast (SEC) is often observed in patients with mitral stenosis, atrial fibrillation, cardiomyopathy, or a ventricular aneurysm [1]. SEC is a smoke-like echo density observed on echocardiograms, and is caused by increased red blood cell aggregation during low-flow states. It is also a risk factor of thromboembolism [2]. SEC can be observed in patients with severe ventricular dysfunction receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We present a case in which left ventricular-SEC (LV-SEC) was mistaken for a LV thrombus during VA-ECMO for severe LV dysfunction. A 36-year-old female patient diagnosed with acute fulminant myocarditis was provided VA-ECMO support on hospital day (HD) 1. Briefly, VA-ECMO (RotaFlow; Maquet Inc., Hirrlingen, Germany) was implanted in the right femoral artery (15-French arterial cannula) and the left femoral vein (20-French venous cannula). Her height and body weight are 163 cm and 52 kg (body surface area, 1.53 m). VAECMO was initiated with a circuit flow of 3.5 L/min (cardiac index, 2.3 2L/min/m). Her creatine kinase-myocardial band and troponin-I levels at admission were 188.03 ng/ml (normal range, 0 to 5 ng/ml) and >50.0 ng/ml (normal range, 0 to 0.78 ng/ml), respectively. Impaired ventricular function (ejection fraction, 22%) suspected as acute fulminant myocarditis was detected by transthoracic echocardiography (TTE) at admission. TTE revealed decreased LV function (ejection fraction, 10%) with mild mitral regurgitation (grade II) immediately after VA-ECMO. Opening of the aortic valve and arterial pulsatility were not observed. Pulmonary edema was aggravated on HD 4. Left atrial (LA) decompression was achieved using a LA catheter (20-French femoral venous cannula) by balloon atrial septostomy through the right femoral

Left Heart Decompression in Acute Complicated Myocardial Infarction During Extracorporeal Membrane Oxygenation

Acute myocardial infarction (AMI) can progress to cardiogenic shock and mechanical complications. When extracorporeal membrane oxygenation (ECMO) is applied to a patient with AMI with cardiogenic shock and mechanical complications, left ventricular (LV) decompression is an important recovery factor because LV dilation increases myocardial wall stress and oxygen consumption. The authors present the case of a 72-year-old man with AMI and LV dilation who developed cardiogenic shock and papillary muscle rupture and who was treated successfully by ECMO with a left atrial venting.

Which Variables Should be Considered as Confounders of p38-Mitogen Activated Protein Kinase Activation Measurements?

Pectus excavatum repair in adults has traditionally been performed through an open approach using a modified Ravitch repair, with excellent long-term results [1]. A minimally invasive approach, the Nuss procedure, was introduced in 1998 for pectus repair in children [2]. The Nuss procedure has been used in adult patients with pectus excavatum, with conflicting results related to an increase in bar dislodgement, significant pain, less than perfect cosmetic results, and increased recurrence after bar removal. Therefore controversy exists about which technique is most appropriate for adults with primary and recurrent pectus deformities. In 2009, we published a series of 41 adult patients who underwent operative treatment for primary and recurrent pectus deformities within the Emory Healthcare System from 1999 through 2006; 13 cases (32%) were reoperations, and the median patient age was 26 years (range, 16–46 years). Eight patients (62%) had undergone a Nuss procedure with a pectus index (PI) greater than 4.0 and an asymmetrical defect. Bar removal was at a median of 18 months (range, 14–36 months) after placement. Because of those poor results, we suggested that when adults have a PI greater than 4.0 and an asymmetrical defect, they are at a greater risk of recurrence after a Nuss procedure and should undergo an open modified Ravitch repair [3]. In their Letter to the Editor, Oncel and colleagues [4] noted that our recommendation that patients with a PI greater than 4.0, an asymmetrical defect, and calcified costal cartilages should not undergo a Nuss procedure for correction of pectus excavatum is contrary to their practice of successful Nuss procedures, in which “most patients with a pectus index of 6.0” and is superior to open surgical techniques in every aspect. Oncel and colleagues [4] referenced an article from their institution published in 2013 [5]. That series of 77 patients with pectus deformities was from 2004 through 2011 and they underwent repair with an open Ravitch procedure and a K-wire for posterior sternal support. The mean age of their patients was 17 years (range, 10–22 years), and 52% of them were younger than 17 years of age. Follow-up was by telephone only (at 3–36 months) and was available in only 81% of patients; results were good or excellent. The recurrence rate was 4.8%. Oncel and colleagues [4] stated

Which Variables Should be Considered as Confounders of Florescence Intensity During Indocyanine Green Bronchoscopy

1. Bleiziffer S, Eichinger WB, Hettich I, et al. Prediction of valve prosthesis-patient mismatch prior to aortic valve replacement: which is the best method. Heart 2007;93:615–20. 2. Hernandez-Vaquero D. Patient prosthesis mismatch in adult congenital heart disease. Heart 2016;102:89–90. 3. Swinkels BM, de Mol BA, Kelder JC, Vermeulen FE, ten Berg JM. Prosthesis-patient mismatch after aortic valve replacement: effect on long-term survival. Ann Thorac Surg 2016;101:1388–94.