Young Tak Lee

Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation*

Objective:We investigated whether the survival of patients with inhospital cardiac arrest could be extended by extracorporeal cardiopulmonary resuscitation supported with extracorporeal membrane oxygenation compared with those of conventional cardiopulmonary resuscitation. Design:A retrospective, single-center, observational study. Setting:A tertiary care university hospital. Patients:We retrospectively analyzed a total of 406 adult patients with witnessed inhospital cardiac arrest receiving cardiopulmonary resuscitation for >10 mins from January 2003 to June 2009 (85 in the extracorporeal cardiopulmonary resuscitation group and 321 in the conventional cardiopulmonary resuscitation group). Interventions:None. Measurements and Main Results:The primary end point was a survival discharge with minimal neurologic impairment. Propensity score matching was used to balance the baseline characteristics and cardiopulmonary resuscitation variables that could potentially affect prognosis. In the matched population (n = 120), the survival discharge rate with minimal neurologic impairment in the extracorporeal cardiopulmonary resuscitation group was significantly higher than that in the conventional cardiopulmonary resuscitation group (odds ratio of mortality or significant neurologic deficit, 0.17; 95% confidence interval, 0.04–0.68; p = .012). In addition, there was a significant difference in the 6-month survival rates with minimal neurologic impairment (hazard ratio, 0.48; 95% confidence interval, 0.29–0.77; p = .003; p <.001 by stratified log-rank test). In the subgroup based on cardiac origin, extracorporeal cardiopulmonary resuscitation also showed benefits for survival discharge (odds ratio, 0.19; 95% confidence interval, 0.04–0.82; p = .026) and 6-month survival with minimal neurologic impairment (hazard ratio, 0.56; 95% confidence interval, 0.33–0.97; p = .038; p = .013 by stratified log-rank test). Conclusions:Extracorporeal cardiopulmonary resuscitation showed a survival benefit over conventional cardiopulmonary resuscitation in patients who received cardiopulmonary resuscitation for >10 mins after witnessed inhospital arrest, especially in cases with cardiac origins.

The effects of atorvastatin on the occurrence of postoperative atrial fibrillation after off-pump coronary artery bypass grafting surgery.

BACKGROUND Atrial fibrillation (AF) after coronary artery bypass graft (CABG) surgery is still the most common arrhythmic complication. This study evaluated whether pretreatment with atorvastatin protects against AF after off-pump CABG. METHODS One hundred twenty-four patients without a history of AF or previous statin use, who were scheduled to undergo elective off-pump CABG, were enrolled. Patients were randomized to control group (n = 62) or to atorvastatin group (n = 62) who were administered atorvastatin 20 mg/d for 3 days before the surgery. Primary outcome was the incidence of postoperative AF. Secondary outcomes were major adverse cardiac and cerebrovascular events, persistent AF at 1 month, and identification of the markers to predict inhospital postoperative AF. RESULTS The incidence of AF was significantly lower in the atorvastatin group than in the control group (13% vs 27%, P = .04). The incidence of major adverse cardiac and cerebrovascular events and persistent AF at 1 month was similar in comparisons between the groups. Postoperative peak N-terminal pro-brain natriuretic peptide levels were significantly higher in the patients with AF (P = .03). Multivariate analysis identified pretreatment with atorvastatin as an independent factor associated with a significant reduction in postoperative AF (odds ratio 0.34, P = .04). Higher postoperative peak N-terminus pro-B-type natriuretic peptide levels were associated with the development of postoperative AF (odds ratio 1.02 per 100 pg/mL, P = .03). CONCLUSIONS Pretreatment with atorvastatin significantly reduced the occurrence of postoperative AF after off-pump CABG.

Long-Term Survival Benefit of Revascularization Compared With Medical Therapy in Patients With Coronary Chronic Total Occlusion and Well-Developed Collateral Circulation

OBJECTIVES The purpose of this study was to compare the long-term clinical outcomes of patients with chronic total occlusion (CTO) and well-developed collateral circulation treated with revascularization versus medical therapy. BACKGROUND Little is known about the clinical outcomes and optimal treatment strategies of CTO with well-developed collateral circulation. METHODS We screened 2,024 consecutive patients with at least 1 CTO detected on coronary angiogram. Of these, we analyzed data from 738 patients with Rentrop 3 grade collateral circulation who were treated with medical therapy alone (n = 236), coronary artery bypass grafting (n = 170) or percutaneous coronary intervention (n = 332; 80.1% successful). Patients who underwent revascularization and medical therapy (revascularization group, n = 502) were compared with those who underwent medical therapy alone (medication group, n = 236) in terms of cardiac death and major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction, and repeat revascularization. RESULTS During a median follow-up duration of 42 months, multivariate analysis revealed a significantly lower incidence of cardiac death (hazard ratio [HR]: 0.29; 95% confidence interval [CI]: 0.15 to 0.58; p < 0.01) and MACE (HR: 0.32; 95% CI: 0.21 to 0.49; p < 0.01) in the revascularization group compared with the medication group. After propensity score matching, the incidence of cardiac death (HR: 0.27; 95% CI: 0.09 to 0.80; p = 0.02) and MACE (HR: 0.44; 95% CI: 0.23 to 0.82; p = 0.01) were still significantly lower in the revascularization group than in the medication group. CONCLUSIONS In patients with coronary CTO and well-developed collateral circulation, aggressive revascularization may reduce the risk of cardiac mortality and MACE.

Prevalence of Aortic Intimal Defect in Surgically Treated Acute Type A Intramural Hematoma

BACKGROUND Controversies exist regarding the pathogenesis and adequate management of intramural hematoma (IMH) of the aorta that has been commonly defined as a dissection without intimal tear. Recent studies reported that intimal defects are found in some patients diagnosed as IMH. We aimed to investigate the prevalence of such cases in surgically treated patients. METHODS Preoperative and postoperative computed tomographic (CT) scan images were retrospectively reviewed for 37 patients who underwent surgery for Stanford type A acute IMH. Operative findings were also reviewed from the medical records. RESULTS In 18 patients (48.6%), intimal defects were suggested in preoperative computed tomography (CT). During surgery, 27 patients (73.0%) had small intimal defects in the ascending aorta or arch, while 14 of them (51.9%) did not have preoperative CT findings suggestive of intimal defects. In 18 patients, the defects were located in the arch or distal ascending aorta, where they would not have been found if not inspected under total circulatory arrest. In all patients, the identified intimal defects were included in the aortic resection, or locally closed. Follow-up CT done at 4 months or longer after surgery showed that the IMH in the descending aorta disappeared or markedly improved in all patients. CONCLUSIONS On the basis of our results, we think that a large proportion of IMH may have a similar pathogenic mechanism as classic dissection and the conventional definition of IMH should be changed. For type A lesions treated with surgery, we recommend thorough inspection of the ascending aorta and the arch under hypothermic circulatory arrest.

Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation☆

BACKGROUND The clinical benefit of extracorporeal cardiopulmonary resuscitation (E-CPR) has been proved in short-term follow-up studies. However, the benefit of E-CPR beyond 1 year has been not known. We investigated 2-year outcome of patients who received E-CPR or conventional CPR (C-CPR). METHODS We analyzed a total of 406 adult in-hospital cardiac arrest victims who underwent CPR for more than 10 min from 2003 to 2009. The two-year survival and neurological outcome of E-CPR (n=85) and C-CPR (n=321) were compared using propensity score-matched analysis. RESULTS The 2-year survival with minimal neurological impairment was 4-fold higher in the E-CPR group than the C-CPR group (23.5% versus 5.9%, hazard ratio (HR)=0.57, 95% confidence interval (CI)=0.43-0.75, p<0.001) by unadjusted analysis. After propensity-score matching, it was still 4-fold higher in the E-CPR group than the C-CPR group (20.0% versus 5.0%, HR=0.53, 95% CI=0.36-0.80, p=0.002). In the E-CPR group, the independent predictors associated with minimal neurological impairment were age ≤65 years (HR=0.46; 95% CI=0.26-0.81; p=0.008), CPR duration ≤35 min (HR=0.37; 95% CI=0.18-0.76; p=0.007), and subsequent cardiovascular intervention including coronary intervention or cardiac surgery (HR=0.36; 95% CI=0.18-0.68; p=0.002). CONCLUSIONS The initial survival benefit of E-CPR for cardiac arrest patients persisted at 2 years.

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.

Clinical Treatment for Pulmonary Artery Sarcoma

Objective: Pulmonary artery sarcomas are exceedingly rare and the prognosis for patients with pulmonary artery sarcoma is very poor. We retrospectively reviewedthe early andlate outcomesafter treatmentfor pulmonaryarterysarcoma,and the purposeof thisstudyis to report our surgicalexperiencewiththisfataldisease.Methods:Between1999and2007,atotalofninepatients(meanage,47.4years;M:F = 4:5)underwent operations for pulmonary artery sarcoma at our institution. The tumor was radically resected and every effort was made to remove the tumor as completely as possible. Seven patients underwent surgical resection with the aid of hypothermic cardiopulmonary bypass. The completeness of resection was determined intraoperatively by frozen section biopsy of the resection margin. Results: There was no in-hospital mortality. No patients suffered from significant complications related to the operation. Follow-up was completed for all the patients with a mean duration of 19.2 months. During follow-up, six patients died with a median survival time of 17.6 months. The cause of death was related to the recurrence of pulmonary artery sarcoma in all cases. The pattern of recurrence was local recurrence and distant metastasis in three and four patients, respectively.Conclusions:Theearlyoutcomesaftersurgicaltreatmentforpulmonaryarterysarcomawereexcellent,andthelateoutcomesinthis series were no worse than those in the previous reports. We suggest that the use of cardiopulmonary bypass is important to obtain a complete resection and the completeness of the resection should be confirmed intraoperatively by frozen section biopsy of the resection margin. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

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.

Isolated left main coronary ostial stenosis in oriental people: Operative, histopathologic and clinical findings in six patients

OBJECTIVES This study was performed to determine whether there are differences in the operative, histopathologic, angiographic and clinical findings of isolated ostial stenosis between Oriental and western patients. BACKGROUND Angiographic, clinical and histologic findings in isolated ostial stenosis have been reported in western but not in Oriental patients. METHODS Six patients, all women (0.88% of a total of 684 patients who underwent coronary angiography between March 1989 and July 1991), were found to have isolated left main coronary ostial stenosis. We performed surgical ostial angioplasty with the autologous pericardial or saphenous venous patch and biopsy at the aortic arteriotomy site in four of the six patients. RESULTS All six patients presented with severe angina (angina class III or IV) of short duration (mean +/- SD 6.2 +/- 6.2 months) and had a very low incidence of risk factors, although histopathologic examination showed typical atherosclerosis in four of the six patients. They were young to middle-aged women (mean 45 +/- 3 years) except for Patient 6 (62 years). Exercise duration was short and ST segment depression, accompanied by typical angina, was observed in many leads in the warm-up period or stage I. Despite the crucial location of the lesion, most patients had well preserved left ventricular function and normal wall motion. There was no angiographically definable collateral circulation from either ipsilateral or contralateral vessels except for grade I collateral circulation in Patient 5. Operative findings demonstrated mostly yellow atheroma in the aortic wall and left coronary ostium. Coronary angiography showed only ostial stenosis of the left coronary artery in all six patients, but operative findings documented atheromatous change in the left main coronary artery in two of the six. CONCLUSIONS The clinical, angiographic, histopathologic and operative findings of Oriental patients were similar to those reported in western patients, but the incidence of isolated left main coronary ostial stenosis was higher in the Oriental group. Angiographically definable isolated coronary ostial stenosis may often not be true isolated ostial stenosis.

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.