Tae-Gook Jun

Relation of Fragmented QRS Complex to Right Ventricular Fibrosis Detected by Late Gadolinium Enhancement Cardiac Magnetic Resonance in Adults With Repaired Tetralogy of Fallot

Fragmented QRS (fQRS) on 12-lead electrocardiography reflects conduction delay caused by myocardial fibrosis and dysfunction. Ventricular fibrosis detected by late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) is reportedly correlated with worse clinical outcomes in adults with repaired tetralogy of Fallot (TOF). The aim of this study was to assess whether the presence of fQRS is associated with right ventricular (RV) fibrosis or dysfunction in this patient group. In 37 consecutive patients (median age 30 years, median age at repair 6.6 years), the number of leads showing fQRS, defined as the presence of >2 notches on the R/S wave in ≥2 contiguous leads, was counted. RV systolic function, dilatation, and LGE score were measured using LGE CMR. Ventricular LGE was observed mainly at the previous surgical sites: the RV outflow tract (33 of 37), ventricular septal defect patch region (15 of 37), and RV anterior wall (11 of 37). Fragmented QRS was found mostly in the right and mid precordial leads. The fQRS group (n = 20) demonstrated higher RV LGE scores (p <0.001) and lower RV ejection fractions (p = 0.02) and a trend toward larger RV end-diastolic and end-systolic volumes (p = 0.12 and p = 0.06, respectively) compared to the non-fQRS group (n = 17). The number of electrocardiographic leads showing fQRS was positively correlated with RV LGE score (r = 0.75, p <0.001). The presence of fQRS remained independently associated with the presence of supramedian RV LGE score, even after adjusting for relevant parameters. In conclusion, fQRS was closely associated with more extensive RV fibrosis and dysfunction in adults with repaired tetralogy of Fallot.

Video-assisted thoracic surgery as a primary therapy for primary spontaneous pneumothorax Decision making by the guideline of high-resolution computed tomography

AbstractBackground: Because blebs are confirmed in most of the patients undergoing thoracotomy, identification of blebs by high-resolution computed tomography (HRCT) can be proposed as a surgical indication in primary spontaneous pneumothorax (PSP). If an apical bleb is identified, we treat the patient by video-assisted thoracic surgery (VATS). Methods: From May 1995 to September 1997, 61 patients (21.9 ± 4.6 years) were seen for initial episodes of PSP. Only seven showed bullae on simple chest radiography. However, by HRCT, 48 had sizable blebs (>5 mm), and 45 were treated surgically by VATS. Results: The mean duration of chest tube use after surgery was 3.2 ± 1.9 days, and the mean hospital stay was 4.5 ± 1.9 days. Only one recurrence developed 5 weeks after VATS. Conclusions: Our protocol is effective in controlling an initial episode of PSP. It shortens the observation time before definitive surgical treatment, shortens the hospital stay, and decreases the likelihood of recurrence.

Is tricuspid valve replacement a catastrophic operation

OBJECTIVE Tricuspid valve replacement (TVR) has a high postoperative mortality, despite recent advances in perioperative care. We report the results of our experience in TVR with an emphasis on early mortality and morbidity and long-term follow-up. METHODS Between October 1994 and August 2007, 80 consecutive TVRs were performed in 78 patients. The mean age was 48+/-14 (range: 20-70) years. The underlying disease of the patients was classified as rheumatic (n=54), congenital (n=12), endocarditis (n=10) or degenerative (n=4). Previous cardiac surgery had been performed in 40 patients (50%). Isolated TVR was performed in 24 patients (30%). RESULTS Hospital mortality occurred in one patient (1.4%). Postoperative morbidities included intra-aortic balloon pump (n=5), bleeding re-operation (n=4), delayed sternal closure (n=3), acute renal failure (n=3), subdural haematoma (n=3), extracorporeal membrane oxygenation (n=1), mediastinitis (n=1) and pacemaker insertion (n=4). In 42 patients, ventilator support was needed for more than 72 h. Based on multivariate analysis, age (p<0.001) and the cardiopulmonary time (p=0.004) were the identified risk factors. Follow-up was completed in all patients with a mean duration of 56+/-37 (range: 0-158) months. During the follow-up period, there were seven deaths (8.8%), including five cardiac deaths. The 5- and 8-year survival rates were 95+/-3% and 79+/-9% and event-free survival rates were 76+/-6% and 61+/-9%, respectively. Based on multivariate analysis, the only identified predictors of late deaths was a postoperative low cardiac output (p=0.024). CONCLUSIONS TVR can be performed and low operative mortality can be achieved thorough optimal perioperative management in the current era.

Total Arterial Revascularization in Triple-Vessel Disease With Off-Pump and Aortic No-Touch Technique

BACKGROUND We evaluated the outcomes in patients who have undergone total arterial revascularization using the bilateral internal thoracic arteries (BITA) with off-pump and aorta no-touch technique. METHODS From March 2001 to September 2007, 512 consecutive patients with triple-vessel disease underwent total arterial revascularization with off-pump and aortic no-touch technique, using BITA or the right gastroepiploic artery (RGEA) in addition to BITA. Only BITA grafts were used for bypass to coronary arteries in 353 patients, and additionally in situ RGEA was bypassed to right coronary arteries in 159 patients. The mean number of distal anastomoses was 4.15 +/- 0.8 per patient. RESULTS One 30-day death occurred. Deep sternal wound infection occurred in 2 patients. The rate of perioperative stroke was 0.8%. The patients were followed for as long as 6 years (mean follow-up, 37.9 +/- 17.7 months). The 1-year and 5-year actuarial freedom from cardiac death was 98.3% and 96.7%, respectively. The 1-year and 5-year actuarial freedom from cardiac events was 97.1% and 89.3%, respectively. Using RGEA was a significant predictor of cardiac event-free survival (p = 0.046). CONCLUSIONS Total arterial revascularization using off-pump coronary bypass and aortic no-touch techniqe with BITA grafts was safe and effective, with low mortality among patients with triple-vessel disease. Patients undergoing in-situ RGEA grafting for right coronary arteries appeared to have fewer cardiac events than did patients undergoing only BITA grafting in triple-vessel disease.

Outcomes of biventricular repair for congenitally corrected transposition of the great arteries.

BACKGROUND This study was undertaken to evaluate long-term results of biventricular repairs for congenitally corrected transposition of the great arteries, and to analyze the risk factors that affect mortality and morbidity. METHODS Between 1983 and 2009, 167 patients with congenitally corrected transposition of the great arteries underwent biventricular repairs. The physiologic repairs were performed in 123 patients, and anatomic repairs in 44. Average follow-up was 9.3 +/- 6.6 years. RESULTS Kaplan-Meier estimated survival was 83.3% +/- 0.5% at 25 years in biventricular repair. In anatomic repair, left ventricular training and right ventricular dysfunction had negative impact on survival, but bidirectional cavopulmonary shunt had positive impact on survival. The reoperation-free ratio was 10.1% +/- 7.8% at 22 years after physiologic repair, and 46.2% +/- 12.4% at 15 years after anatomic repair (p = 0.885). Freedom from any arrhythmia was 49.6% +/- 7.5% at 22 years after physiologic repair, and 60.8% +/- 14.8% at 18 years after anatomic repair (p = 0.458). Freedom from systemic atrioventricular valve and ventricular dysfunction as well as tricuspid valve and right ventricular dysfunction was significantly higher in anatomic repair than in physiologic repair. CONCLUSIONS Long-term results of biventricular repair were satisfactory. Patients presenting with right ventricular dysfunction or need for left ventricular training represent a high-risk group of anatomic repair for which selection criteria are particularly important. Late functional outcomes of anatomic repair were excellent compared with physiologic repair. Anatomic repair is the procedure of choice for those patients if both ventricles are adequate or if surgical technique is modified with the help of additional a bidirectional cavopulmonary shunt.

Early and Midterm Outcomes for Tricuspid Valve Surgery After Left-Sided Valve Surgery

BACKGROUND The purpose of this study was to compare the early and midterm results of tricuspid valve replacement (TVR) versus tricuspid valve repair (TVr) for late tricuspid regurgitation after left-sided valve surgery. METHODS Fifty-one consecutive patients who underwent tricuspid valve surgery after left-sided valve surgery between January 1995 and April 2008 were included. Thirty-seven patients underwent TVR, and 14 patients underwent TVr. Tricuspid valve replacement was performed along with concomitant procedures in 27 patients (73.0%). Patients undergoing TVR were more likely to have severe tricuspid regurgitation (64.3% versus 89.2%; p = 0.037), or a previous history of tricuspid regurgitation repair (7.1% versus 51.4%; p = 0.004). RESULTS There was no hospital death in both TVr and TVR groups. However, in comparison to TVr patients, TVR patients needed a greater amount of hemofiltration (59 +/- 23 versus 80 +/- 36; p = 0.026) and had longer periods of hospital stays (13.5 +/- 4.4 versus 26.9 +/- 25.7 days; p = 0.049). Survival rates at 1, 5, and 10 years were 97%, 93%, and 63% for patients undergoing TVR, and 93%, 93%, and 81% for patients undergoing TVr, respectively. There was no statistical difference in midterm survival rates between the two groups. Cox regression analysis revealed that left ventricular ejection fraction of 0.40 or less (p = 0.034) and age (p = 0.035) were independent predictors of late mortality after TVR or TVr. CONCLUSIONS Patients undergoing TVR had a more advanced preoperative tricuspid regurgitation grade and significantly prolonged hospital stays. However, there were no statistical differences in early and midterm outcomes between the two groups.

Fate of functional tricuspid regurgitation in aortic stenosis after aortic valve replacement.

OBJECTIVE Functional tricuspid regurgitation (TR) is found not infrequently in conjunction with aortic stenosis. The aim of the present study was to evaluate the changes in TR and to identify the predictors of late progression after aortic valve replacement. METHODS We evaluated 354 patients who had undergone aortic valve replacement for aortic stenosis from January 1995 to December 2009. Patients with mitral regurgitation were excluded. Of the 354 patients, 54 had TR greater than mild. The mean follow-up duration was 4.4±4.3 years (maximum, 15). The serial echocardiographic and clinical data were analyzed. RESULTS No early mortality occurred, and the late cardiac mortality rate was 3.9% (14 of 354). In the 48 patients with TR greater than mild, TR did not improve in 23 (49.1%) during the follow-up period. Freedom from cardiac mortality at 10 years was lower in those with TR greater than mild than in patients without TR (61.6%±16.7% vs 93.0%±2.9%, P=.008). Left ventricular diastolic function correlated with right ventricular systolic pressure (P<.001) and the degree of TR during follow-up (P=.001). Multivariate analysis showed that postoperative atrial fibrillation (odds ratio, 6.8; P=.001) and the aortic transprosthetic mean pressure gradient (odds ratio, 1.1; P=.028) predicted late TR greater than mild. CONCLUSIONS Not only did TR in patients with aortic stenosis frequently persist after aortic valve replacement, it was progressive in some. This finding was associated with left ventricular diastolic dysfunction. A concomitant tricuspid valve procedure could be considered in selected patients with aortic stenosis to avoid late TR.

Fragmented QRS complex in adult patients with Ebstein anomaly and its association with arrhythmic risk and the severity of the anomaly.

Background—Fragmented QRS complex (fQRS) on 12-lead ECG, a marker of myocardial scar, is a predictor of arrhythmic events in patients with ischemic and nonischemic cardiomyopathy. We investigated whether the presence of fQRS is associated with the severity of the anomaly and with increased arrhythmic events in adult patients with Ebstein anomaly (EA). Methods and Results—In 51 consecutive adult patients with EA (median age, 37 years; 18 males), the severity index of EA calculated from echocardiographic data and clinical arrhythmic events were analyzed. The extent of fQRS in each patient was measured by counting the number of ECG leads showing fQRS. There were 35 (68.6%) patients with fQRS (fQRS group) and 16 (31.4%) patients without fQRS (non-fQRS group). fQRS was observed more frequently in the inferior (n=26) and precordial (n=25) leads versus the lateral leads (n=5). The patients in the fQRS group had a worse functional class, greater cardiothoracic ratios, more severe tricuspid regurgitation, larger atrialized right ventricular areas, higher EA severity scores, and more frequent arrhythmic events compared with those in the non-fQRS group. The atrialized right ventricular area showed a positive correlation with the fQRS extent (r=0.51; P<0.001). In multivariable Cox regression models, the presence of fQRS was independently associated with arrhythmic events (P=0.036). Conclusions—Fragmented QRS on 12-lead ECG was associated with larger atrialized right ventricular area and an increased risk of arrhythmic events in adult patients with EA.

Factors influencing depression in adolescents with congenital heart disease

OBJECTIVE This study was designed to identify variables associated with depression in adolescents who underwent operation for congenital heart disease (CHD). METHODS Data were collected from 231 adolescents, aged 13 to 18 years with CHD, during outpatient clinic follow-up after open heart surgery in 3 major cardiac centers in Korea. Adolescents completed measures of resilience, depression, and parental attitude. Their New York Heart Association functional class, CHD functional index, and noninvasive saturation of arterial oxygen were also measured. RESULTS There were significantly positive relations between depression and the 3 variables: older age, worse New York Heart Association functional class, and higher CHD functional index. Negative relations were found between depression and higher saturation of arterial oxygen, higher academic achievements, affectionate parental attitude, and higher resilience. The multiple regression analysis also showed that 62% of the variance in depression in adolescents with CHD could be explained by resilience and parental attitude. CONCLUSION This study demonstrated that adolescents with higher resilience and an affectionate parent were less depressed.

Successful repair of critical tricuspid regurgitation secondary to ruptured papillary muscle in a newborn

We report a rare case of an isolated critical tricuspid regurgitation due to rupture of a papillary muscle. This patient presented with a cyanosis immediately after birth. Despite mechanical ventilation and medical management to decrease the pulmonary vascular resistance, the low cardiac output persisted, along with the cyanosis. Repair of the tricuspid valve was performed, using an artificial tendinous cord, on the 4th day of life. The short-term result of the surgery is satisfactory, but the patient requires long-term follow-up.