Kyung Hwa Kim

Tricuspid Leaflet Augmentation to Eliminate Residual Regurgitation in Severe Functional Tricuspid Regurgitation

We describe a technique for treating severe functional tricuspid regurgitation (TR) when residual regurgitation cannot be eliminated with ring annuloplasty alone. The anterior leaflet and the anterior half of the posterior leaflet are augmented with an elliptic pericardial patch before implantation of a rigid annuloplasty ring. We successfully performed this procedure in 9 patients with severe TR due to severe leaflet tethering or short coaptation length and achieved complete elimination of TR with sufficient coaptation length in tricuspid valve leaflets for all patients.

Aortic Valve Replacement Using Continuous Suture Technique in Patients with Aortic Valve Disease

Background The continuous suture (CS) technique has several advantages as a method for simple, fast, and secure aortic valve replacement (AVR). We used a simple CS technique without the use of a pledget for AVR and evaluated the surgical outcomes. Materials and Methods Between October 2007 and 2012, 123 patients with aortic valve disease underwent AVR alone (n=28) or with other concomitant cardiac procedures (n=95), such as mitral, tricuspid, or aortic surgery. The patients were divided into two groups: the interrupted suture (IS) group (n=47), in which the conventional IS technique was used, and the CS group (n=76), in which the simple CS technique was used. Results There were two hospital deaths (1.6%), which were not related to the suture technique. There were no significant differences in cardiopulmonary bypass time or aortic cross-clamp time between the two groups for AVR alone or AVR with concomitant cardiac procedures. In the IS group, two patients had prosthetic endocarditis and one patient experienced significant perivalvular leak. These patients underwent reoperations. In the CS group, there were no complications related to the surgery. Postoperatively, the two groups had similar aortic valve gradients. Conclusion The simple CS method is useful and secure for AVR in patients with aortic valve disease, and it may minimize surgical complications, as neither pledgets nor braided sutures are used.

Routine Shunting is Safe and Reliable for Cerebral Perfusion during Carotid Endarterectomy in Symptomatic Carotid Stenosis

Background The purpose of this report is to describe the perioperative outcomes of standard carotid endarterectomy (CEA) with general anesthesia, routine shunting, and tissue patching in symptomatic carotid stenoses. Materials and Methods Between October 2007 and July 2011, 22 patients with symptomatic carotid stenosis (male/female, 19/3; mean age, 67.2±9.4 years) underwent a combined total of 23 CEAs using a standardized technique. The strict surgical protocol included general anesthesia and standard carotid bifurcation endarterectomy with routine shunting. The 8-French Pruitt-Inahara shunt was used in all the patients. Results During the ischemic time, the shunts were inserted within 2.5 minutes, and 5 patients (22.7%) revealed ischemic cerebral signals (flat wave) in electroencephalographic monitoring but recovered soon after insertion of the shunt. The mean shunting time for CEA was 59.1±10.3 minutes. There was no perioperative mortality or even minor stroke. All patients woke up in the operating room or the operative care room before being moved to the ward. One patient had difficulty swallowing due to hypoglossal nerve palsy, but had completely recovered by 1 month postsurgery. Conclusion Routine shunting is suggested to be a safe and reliable method of brain perfusion and protection during CEA in symptomatic carotid stenoses.

A Modified Tricuspid Ring Annuloplasty to Reduce Residual Regurgitation in Functional Tricuspid Regurgitation

Abstract  We describe a modified technique of tricuspid ring annuloplasty to reduce postoperative residual regurgitation in patients with functional tricuspid regurgitation; first, an adjustable segmental tricuspid annuloplasty is performed to obtain coaptation of the valve leaflets with two 5‐0 monofilament annular sutures, and then a prosthetic ring of the same size as the competent valve area is implanted with continuous 3‐0 polypropylene sutures. (J Card Surg 2010;25:647‐650)

Simultaneous relief of acute visceral and limb ischemia in complicated type B aortic dissection by axillobifemoral bypass.

FIGURE 1. Contrast-enhanced computed tomography shows acute type B dissection (white arrow), originating distal to the left subclavian artery and extending only to the mid descending thoracic aorta. A 78-year-old man with a history of aortic valve replacement and ascending aorta replacement sought treatment with severe back pain. Contrast-enhanced computed tomography revealed a Stanford type B acute aortic dissection (Figure 1). The patient was admitted to the intensive care unit, and antihypertensive drugs were administered. The next day, the patient had sharp pain in right lower extremity, pulse deficit in the right femoral artery, and abdominal pain with decreasing bowel sounds. Urgent computed tomography showed the progression of acute type B aortic dissection, which extended from the distal aortic arch to the bilateral external iliac arteries, and also demonstrated stenosis of the superior mesenteric artery and disappearance of flow in the right common iliac artery (Figure 2). We diagnosed malperfusion in acute type B dissection. The patient had became unstable and irritable. At first, we performed femorofemoral bypass; however, there was no flow in the bypass graft. Right axillobifemoral bypass grafting was therefore performed with an 8-mm ringed polytetrafluoroethylene graft tracked subcutaneously. The next day, the patient’s ischemic signs of right lower limb and abdominal pain were dramatically ameliorated, so the planned aortic fenestration and proximal stent-graft placement were cancelled. One year later, this patient is in good condition, with neither intermittent claudication nor abdominal angina. Follow-up computed tomographic angiograms at 1 and 12 months revealed the restoration of blood flow to the right iliac and mesenteric arteries with adequate aortic remodeling (Figure 3).

Aortic valve leaflet replacement with bovine pericardium to preserve native dynamic capabilities of the aortic annulus.

Valve replacement is typically the most appropriate option for treating aortic valve stenotic insufficiency. However, neither mechanical nor bioprosthetic replacement components preserve the circumferential expansion and contraction of a native aortic annulus during the cardiac cycle, because the prosthetic ring is affixed to the annulus. A 64-year-old man presented with a bicuspid and stenotic aortic valve, and the native annulus was too small to accommodate a porcine replacement valve. We fashioned new aortic leaflets from bovine pericardium with use of a template, and we affixed the sinotubular junction with use of inner and outer stabilization rings. Postoperative echocardiograms revealed coaptation of the 3 new leaflets with no regurgitation. At the patients 5.5-year follow-up examination, echocardiograms showed flexible leaflet movement with a coaptation height of 7 mm, and expansion and contraction of the aortic annulus similar to that of a normal native annulus. The transvalvular pressure gradient was insignificant. If long-term durability of the new leaflets is confirmed, this method of leaflet replacement and fixation of the sinotubular junction might serve as an acceptable alternative to valve replacement in the treatment of aortic valve stenosis. We describe the patients case and present our methods and observations.

Predictive Factors of Sustained Sinus Rhythm and Recurrent Atrial Fibrillation after the Maze Procedure

Background We examined perioperative predictors of sustained sinus rhythm (SR) in patients undergoing the Cox maze operation and concomitant cardiac surgery for structural heart disease. Materials and Methods From October 1999 to December 2008, 90 patients with atrial fibrillation (AF) underwent the Cox maze operation and other concomitant cardiac surgery. Eighty-nine patients, all except for one postoperative death, were followed-up with serial electrocardiographic studies, 24-hour Holter monitoring tests, and regular echocardiographic studies. Results Eighty-nine patients undergoing the maze operation were divided into two groups according to the presence of SR. At the time of last follow-up (mean follow-up period, 51.0±30.8 months), 79 patients (88.8%) showed SR (SR group) and 10 patients (11.2%) had recurrent AF (AF group). Factors predictive of sustained SR were the immediate postoperative conversion to SR (odds ratio, 97.2; p=0.001) and the presence of SR at the 6th month postoperatively (odds ratio, 155.7; p=0.002). Duration of AF, mitral valve surgery, number of valves undergoing surgery, left atrial dimension, and perioperative left ventricular dimensions and ejection fractions were not predictors of postoperative maintenance of SR. Conclusion Immediate postoperative SR conversion and the presence of SR at the 6th postoperative month were independent predictors of sustained SR after the maze operation.

Mitral Valve Re-Repair in an Adolescent Patient with Prosthetic Ring Endocarditis: Posterior Leaflet Augmentation and Posterior Strip Annuloplasty

Abstract  Endocarditis after mitral valve (MV) annuloplasty is uncommon. The ring used in MV annuloplasty is often inadequate because it opposes the growth of the MV leaflets and annulus. We report a 15‐year‐old male that required redo surgery for prosthetic ring endocarditis 40 months after a previous MV annuloplasty. After the previous ring was removed, the undergrown posterior leaflet was repaired with pericardial augmentation and the posterior annulus was stabilized with a Mitra‐Lift® supra‐annular strip to preserve a flexible valve orifice and allow the anterior MV annulus and the commissures to grow in relation to body size. (J Card Surg 2012;27:560‐562)

Bilateral pulmonary sequestration with mixed infection caused by two types of non-tuberculous mycobacteria in pregnancy

Figure 1: (A) Chest X-ray showed a round and well-defined mass consolidation of the right lower lung field and a similar one of the left lower lung field. (B and C) A computed tomographic scan of the chest revealed bilateral, large-sized pneumonic consolidation in the paravertebral region of the left and right lower lobe (B, arrow) with a possible bridging tunnel behind the heart and showed that an aberrant artery, which originated from the coeliac trunk, supplied the sequestration of the right lower lobe, and that a branch from the aberrant artery traversed to the sequestration in the left lower lobe through a bridging isthmus (C, arrows).

Solitary fibrous tumor as a cause of chronic cough.

A 64-year-old man who was a nonsmoker, presented with nonproductive cough for more than 3 months and an abnormal radiologic finding (Figure 1a). His complete blood count, liver and respiratory function tests were within normal limits. On bronchoscopy, the mucosa appeared normal. Contrast-enhanced computed tomography showed a well-circumscribed hypervascular heterogeneous mass in the right lower lobe, adherent to the diaphragm peripherally (Figure 1b). An ultrasound-guided transthoracic biopsy was nondiagnostic. The patient underwent exploration by thoracotomy with a video-assisted thoracoscopic view that showed a large pyramid-shaped pleural-based mass with smooth well-circumscribed encapsulation and a prominently vascularized stalk to the right lower lung (Figure 2a, 2b). The mass was resected with concomitant wedge resection of lung parenchyma at the base of the vascularized stalk. There was no evidence of penetration of the tumor through the visceral pleura or communication with neighboring structures. The diaphragmatic surface of the mass was firmer than the other sides of the pyramidal shape. Microscopically, there were spindle or epithelial cells with a hemangiopericytoma-like vascular pattern (Figure 2c). Mitotic activity was present (3 mitoses per high-power field). These findings indicated a solitary fibrous tumor, probably derived from the visceral pleura. The postoperative course was uneventful, and the patient was doing well without mass recurrence or cough after 2 years. Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 602–603 The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313519806 aan.sagepub.com