Seok In Lee

Veno–veno–arterial extracorporeal membrane oxygenation for acute respiratory distress syndrome with septic-induced cardiomyopathy due to severe pulmonary tuberculosis

We describe the rare experience of veno–veno–arterial (VVA) extracorporeal membrane oxygenation (ECMO) in a patient with acute respiratory distress syndrome and septic-induced cardiomyopathy due to pulmonary tuberculosis (TB). A 24-year-old male patient who developed septic-induced cardiomyopathy secondary to pulmonary TB was administered veno-arterial (VA) ECMO for cardiac support. Six days later, the ECMO configuration mode was changed from VA to VVA to improve hypoxemia of the upper body and to prevent further lung injury. The patient was then successfully managed using an appropriate alternative ECMO strategy.

Early Antithrombotic Therapy after Bioprosthetic Aortic Valve Replacement in Elderly Patients: A Single-Center Experience

PURPOSE Early antithrombotic therapy after bioprosthetic aortic valve replacement (AVR) is controversial. This study aimed to retrospectively compare between warfarin and aspirin treatment in the 3 months after bioprosthetic AVR for elderly patients more than 60 years old, and to determine the optimal antithrombotic therapy. METHODS This retrospective study included 479 patients in single center from January 1994 to June 2014. Patients were divided into two groups (Wa group, warfarin; As group, aspirin). We searched our computerized clinical database for thromboembolic or bleeding events. Propensity score analysis was conducted to adjust for selection bias. RESULTS All patients, except one patient, were followed-up in the out-patient department for 3 months after the operation. In all, 86 propensity-matched patient-pairs were derived. Early operative outcomes were similar in both the groups. There are one patient of thromboembolic event and three patients of bleeding events, but the prevalence was not significantly different (p >0.999). CONCLUSION The incidence of thromboembolic and bleeding events during early 3 months after bioprosthetic AVR were similar in Wa and As groups. If the patient does not have indications of warfarin, early antithrombotic therapy with aspirin only may be easier and more feasible for elderly patients.

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.

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.

A “floppy hat”-shaped reconstruction for giant coronary ostial-aneurysms after a Bentall operation

A 34-year-oldmale presentedwith acute chest pain 10 years following a Bentall procedure (#33 mechanical aortic valve hemashield composite graft; St Jude Inc, St Paul, MN) for an ascending aortic aneurysm with aortoannular ectasia and severe aortic regurgitation. A computed tomographic angiogram (CTA) revealed ostial coronary artery aneurysms, 4.5-5.0 cm, involving the right and left coronary artery buttons (Figure 1A) and an acute aortic dissection involving the aortic arch and descending aorta (Figure 1B). At the time of the redo median sternotomy, cardiopulmonary bypass (CPB) was established with an innominate artery cannula and bicaval cannulation with temperatures as low as 25°C. The composite graft was clamped and the heart arrested with antegrade/retrograde blood cardioplegia. To reconstruct the left coronary ostium, we designed a “floppy hat”shaped graft by excising the 10-mm side branch of a 24-mm hemashield graft (Meadox, Oakland, NJ; Figure 2A and B). The left coronary artery aneurysmal button was excised and the “floppy hat” graft was anastomosed to the defect in the graft using a continuous 5-0 prolene suture (Figure 3). The distal end of this graft was anastomosed to the remnant of the left coronary artery (Figure 3). The aneurysmal right coronary artery button was excised and the defect was patched with a hemashield graft (Figure 3). The right coronary artery was easily mobilized and anastomosed to the previous Bentall graft (Figure 3). The aortic arch was replaced using an elephant trunk technique for future surgery for the descending aorta. The CPB time was 157min and the cross clamp time was 115min. The patient tolerated the procedure well and a CTA performed at 46 months showed patent right and left coronary ostia and no recurrent aneurysmal formation (Figure 4).

Medtronic Duran AnCore versus Edwards MC3 rings for tricuspid annuloplasty

OBJECTIVES Ring annuloplasty is now regarded as the standard surgical technique for the correction of tricuspid regurgitation (TR). However, comparative research on the durability of commercially available annuloplasty rings is limited. We reviewed early and late surgical results of tricuspid annuloplasty using the Duran AnCore and Edwards MC3 rings. METHODS From our institutional prospective cardiac surgical database, we identified 581 adult patients (55.9 ± 12.9 years) undergoing tricuspid ring annuloplasty using either a Duran AnCore ( n  = 370; Duran group) or an Edwards MC3 ring ( n  = 211; MC3 group) from January 2001 through December 2012. Survival rates, valve-related outcomes and late tricuspid functions were compared between the 2 groups. Propensity score analysis was conducted to adjust for selection bias. RESULTS The degree of TR assigned preoperatively was mild in 128 (22.0%), moderate in 205 (35.3%), and severe in 248 patients (42.7%), with a higher prevalence of severe TR in the Duran group than in the MC3 group (46.5% vs 36.0%; P  = 0.014). Over an observation period of 47.0 months, 46 patients developed significant TR (≥ moderate). After propensity score matching, there were no significant differences in the risks of early mortality ( P  = 0.36), early complications ( P  > 0.99) and recurrence of significant TR ( P  = 0.33). CONCLUSIONS Both the Duran and the MC3 rings showed comparable safety and tricuspid valve durability for tricuspid valve annuloplasty.