Comparison of lateral tunnel and extracardiac conduit Fontan procedure

The purpose of this study was to compare the outcomes of lateral tunnel (LT) and extracardiac conduit (ECC) Fontan procedures at a single institution. From April 1995 to December 2006, 165 Fontan procedures were performed (67 LT, 98 ECC). Pre-, intra- and postoperative variable values were compared between two different techniques. Operative mortality was 5 (3 LT, 2 ECC). Immediate postoperative transpulmonary gradient (LT 8.5+/-ECC 2.5 vs. 6.6+/-2.4 mmHg) and central venous pressure (LT 18.3+/-3.8 vs. ECC 15.6+/-2.4 mmHg) showed significant difference (P<0.001). The LT patients had a higher incidence of sinus node dysfunction in the postoperative period (22.4% vs. ECC 11.2%; P=0.05). Mean follow-up was 74.1+/-31.5 months in LT, and 31.7+/-28.1 months in ECC patients. There was one late death. Actuarial survival at 10 years is 92% for LT, and 89% for ECC patients (P=0.796). The LT and ECC, both, showed comparable early and mid-term outcomes in operative morbidity and mortality, postoperative hemodynamics, survival. Use of ECC for modified Fontan operation reduces the risk of sinus node dysfunction and shows better outcome of immediate postoperative hemodynamics

Aprotinin Attenuates the Elevation of Pulmonary Vascular Resistance After Cardiopulmonary Bypass

Pulmonary vascular resistance (PVR) is generally believed to be elevated after cardiopulmonary bypass (CPB) due to whole body inflammation. Aprotinin has an anti-inflammatory action, and it was hypothesized that aprotinin would attenuate the PVR increase induced by CPB. Ten mongrel dogs were placed under moderately hypothermic CPB for 2 hr. The experimental animals were divided into a control group (n=5, group I) and an aprotinin group (n=5, group II). In group II, aprotinin was administered during pre-bypass (50,000 KIU/kg) and post-bypass (10,000 KIU/kg) periods. Additional aprotinin (50,000 KIU/kg) was mixed in CPB priming solution. PVRs at pre-bypass and post-bypass 0, 1, 2, 3 hr were calculated, and lung tissue was obtained after the experiment. Post-bypass PVRs were significantly higher than prebypass levels in all animals (n=10, p<0.001). PVR elevation in group II was less than in group I at 3 hr post-bypass (p=0.0047). Water content of the lung was lower in group II (74±9.4%) compared to that of group I (83±9.5%), but the difference did not reach significance (p=0.076). Pathological examination showed a near normal lung structure in group II, whereas various inflammatory reactions were observed in group I. We concluded that aprotinin may attenuate CPB-induced PVR elevation through its anti-inflammatory effect

소아 중환자 관리의 고찰

After reviewing the pediatric intensive care for the 742 patients at PICU for 11 months from February to December, 1986, we obtained the following results: The patients in thoracic surgery occupied 78.2% of all patients at PICU. The rate of admission to PICU was 86.8% in thoracic surgery and 33.9% in neurosurgery. The patients in pediatrics stayed at PICU for 11.3 days, in neurosurgery for 5.7 days and in thoracic surgery for 5.1 days. Duration of ventilatory support was 198.4 hours in pediatrics, 59.7 hours in pediatric surgery and 50.6 hours in thoracic surgery. Fatality rate reached 18.4% in pediatrics, 14.6% in pediatric surgery and 6.0% in thoracic surgery. Among patients who were below 1 year of age and who stayed longer than 8 days, fatality rate was highest 46.4% of deaths at PICU was due to the low cardiac output syndrome. All the patients admitted to PICU had their TISS scores more than 10, which meant an increased level of critical care. TISS scores for survivors were lower than those for nonsurvivors and were decreased with time. The fatality rate of the patients with TISS scores more then 50 was 19.4%, so TISS scores could be used to assess the severity of patients indirectly. With above results, we should suggest minimal requirement of equipments for modern PICU and some guidelines for the maintenance of PICU in Korea

총폐정맥 환류 이상증 -7례 부검 분석

We studied 7 autopsied cases of total anomalous pulmonary venous connecton (TAPVC). Three cases were supracardiac types, showing drainage to the innominate vein through the left vertical vein. Stenosis at the beginning of the vertical vein was associated in Case 1. The left upper pulmonary vein was connected distal to the stenosis, and the left upper pulmonary lobe were severely congested after surgical ligation of the upper portion of the vertical vein and anastomosis between the common pulmonary vein and left atrium. The vertical vein in Case 2 was interposed between the left pulmonary artery and the left main bronchus, and the long segment was stenotic. The collateral channel through the paraesophageal venous plexus was present. An obstructing or stenotic segment was not found along the whole pulmonary venous pathway in Case 3. One case was a cardiac type in which both right and left pulmonary veins united to produce a common pulmonary venous channel draining into a huge coronary sinus (Case 4). Case 5 and Case 6 were infracardiac types draining into a common hepatic vein through a small opening. The vertical segment of the common pulmonary veins was short, and individual pulmonary veins were slender and long. Case 7 was a mixed form of an anomalous drainage through the portal vein and the right superior caval vein, respectively. We could find the common features of the long and slender individual pulmonary veins in these cases and short transverse common pulmonary vein segments. Unifocal narrowing of 1 pulmonary vein was seen in 1 supracardiac type case, as well as in a mixed supracardiac type and infracardiac type case, which may be present as an unexplained pulmonary infiltration before and after surgery

Fontan conversion with arrhythmia surgery

OBJECTIVE: Hemodynamic abnormalities and refractory atrial arrhythmias in patients late after the Fontan operation result in significant morbidity and mortality. We reviewed our experience with Fontan conversion and concomitant arrhythmia surgery. METHODS: Between January 1996 and February 2004, 16 patients underwent Fontan conversion and arrhythmia surgery. Mean age at the initial Fontan operation was 5.1+/-3.5 (range: 2-15) years and mean age at Fontan conversion was 17.0+/-5.8 (range: 6-30). The initial Fontan operations were atriopulmonary connections in 14 patients, extracardiac lateral tunnel in 1, and intracardiac lateral tunnel in 1. The types of arrhythmia included atrial flutter in 10 patients and atrial fibrillation in 3. Fontan conversion operation was performed with intracardiac lateral tunnel in 5 patients and extracardiac conduit in 11. Arrhythmia surgery included isthmus cryoablation in 10 patients and right-sided maze in 3. RESULTS: There has been no mortality. At Fontan conversion operation, 7 patients required permanent pacemaker. All patients have improved to New York Heart Association class I or II. With a mean follow-up of 26.9+/-30.6 (range:1-87) months, 16 patients had sinus rhythm, 2 patients had transient atrial flutter which was well controlled, and 2 patients required permanent pacemaker during follow-up. CONCLUSIONS: Fontan conversion with concomitant arrhythmia surgery and permanent pacemaker placement is safe, improves New York Heart Association functional class, and has a low incidence of recurrent arrhythmias. In most patients, concomitant permanent pacemakers are needed

하대정맥 막성폐쇄의 초음파소견 - 하대정맥조영술과의 비교를 중심으로

Membranous obstruction of upper cava is one of the frequent causes of inferior vena caval obstruction in this country. Since it can be cured by transcardiac membranotomy or other interventions, accurate diagnosis of the disease is important. Sonographic findings in 6 cases of membranous obstruction of inferior vena cava were analysed and correlated with the findings of the inferior venacavography. At the obstructed site, the membrane was detected as a high echogenic focal or segmental obliteration of the lumen sonographically. The lumen of vena cava below the obstruction was easily delineated without normal respiratory changes. Venacavography was superior in demonstrating all collateral channels except transhepatic collaterals which were depicted well in sonography

Mid-term follow-up of neoaortic regurgitation after the arterial switch operation for transposition of the great arteries

OBJECTIVE: The aim of this study was to determine the outcome of the neoaortic valve after the arterial switch operation for transposition of the great arteries. METHODS: A retrospective review of arterial switch operations that were performed during the period from 1991 to 2003 was conducted. We followed patients with echocardiography. When regurgitation of the neoaortic valve was observed we analyzed the risk factors. RESULTS: One hundred and three patients underwent a successful arterial switch operation. Eighty-one males and 22 females participated in the study. Follow-up period was 77+/-42 months. The age and body weight at the time of the arterial switch operation were 1.4+/-2.8 months and 3.8+/-1.0 kg, respectively. Preoperative pulmonary valve regurgitation was found in six patients (two patients had grade I and four patients had grade II). In the postoperative echocardiography, 52 patients demonstrated neoaortic valve regurgitation (26 patients had grade I, 25 patients had grade II, and 1 patient had grade III). At the last follow-up visit, 61 patients demonstrated neoaortic regurgitation (18 patients had grade I, 37 patients had grade II, 5 patients had grade III, and 1 patient had grade IV). Neoaortic valve regurgitation increased progressively with follow-up (p-value<0.01). The size discrepancy between the aorta and the pulmonary artery was correlated with neoaortic valve regurgitation (p-value=0.02). The age and body surface area, relationship of the great arteries, coronary arterial pattern, pulmonary artery banding, use of trap-door technique, myocardial ischemic time, use of total circulatory arrest, and existence of ventricular septal defect were not significant risk factors. CONCLUSIONS: Neoaortic valve regurgitation progressed after the arterial switch operation. The degree of regurgitation was more severe in patients with a size discrepancy between the aorta and the pulmonary artery preoperatively

원추형 이동작동기 방식 완전 인공심장의 개발 및 동물 실험

A new version of a moving actuator electromechanical total artificial heart was designed to improve the total efficiency, durability, and fit inside the thoracic cavity. Compared with our present type of rolling-cylinder actuator, this new model has a pendulum- type actuator with reciprocating motion around a fixed circular path connected through the gear mechanisms to the motor. By using this mechanism, efficiency and "durability improved by replacing the sliding mechanism with rolling contact elements. Also, the height of the pump decreased from 9 cm to 7 cm with a static stroke volume of 65 cc. With this new pump, we performed two animal experiments. We also evaluated the engineering feasibility of implanting this pump into a small, human-size animal (less than 70 Kg)