Asian Cardiovascular and Thoracic Annals

A 21-year-old woman presented with almost complete extrinsic airway obstruction due to a massive mediastinal tumor. Venovenous extracorporeal membrane oxygenation support for 3 days with concurrent chemotherapy allowed time for tumor shrinkage, ventilation via the endotracheal route, and subsequent successful extubation on the fifth day.

A 56-year-old man complained of dyspnea and cough 9 days after coronary artery bypass grafting. Chest radiography showed opacity and left lung collapse. Following removal of clots from the pleural cavity by videothoracoscopy, he recovered without further incident. Video-assisted thoracic surgery is a feasible and safe option in the management of early hemothorax.

A 62-year-old woman underwent aortic valve replacement for aortic stenosis. Her hemodynamics deteriorated with ST-T depression 6 hours postoperatively. Emergency coronary catheterization showed diffuse right coronary artery spasm. The spasm persisted despite intracoronary infusion of nitrates and calcium antagonists. Intracoronary adenosine triphosphate infusion finally resolved the spasm and stabilized the cardiac function.

A 47-year-old man with total anomalous pulmonary venous return met all the conditions necessary for long survival. In particular, his pulmonary vascular resistance was almost normal because of right ventricular outflow tract obstruction. Surgical treatment was performed with a good result.

Twenty-five cases of neuroendocrine carcinoma of the thymus associated with Cushing's syndrome have been reported since 1972. ¹ We report two new cases of thymic carcinoid, one of which presented with Cushing's disease. These patients were successfully treated and were asymptomatic at the time of first follow-up.

Coronary artery bypass grafting was performed successfully on a patient by anastomosing the left internal thoracic artery and its pericardiacophrenic branch to the obtuse marginal and the posterior descending coronary artery, respectively, to form a Y graft. Preoperative angiography of the internal thoracic artery had revealed the presence of an unusually large pericardiacophrenic branch almost the size of the main trunk, which allowed us to plan for bifurcated artery grafting.

A 35-year-old woman was found on echocardiography to have a pseudoaneurysm of the mitral-aortic intervalvular fibrosa, residual ventricular septal defect, and aortic regurgitation. She had undergone surgical closure of a ventricular septal defect at age 7 and was found to have residual shunt several years later. She had been followed nonsurgically and had symptoms of cardiac failure during her 2 pregnancies. The pseudoaneurysm and the septal defect were successfully repaired.

Melioidosis is a tropical disease caused by Burkholderia pseudomallei and is prevalent in South East Asia and Northern Australia. It can infect any organ system and is potentially deadly. Melioidosis causing a mycotic aneurysm of the aorta is rare. We present a patient with a melioidosis mycotic aneurysm of the descending aorta presenting with fever and right pleural effusion, managed successfully with initial Dacron graft repair with staged omental reinforcement, and subsequent endovascular stent grafting of a late anastomotic leak.

Early, aggressive debridement followed by closure with muscle flaps is thought to improve the resolution of deep sternal wound infection that occurs after sternotomy. However, persistently discharging sternal osteomyelitis remains difficult to resolve. We successfully treated 2 patients who developed deep sternal wound infection after cardiac surgery by combining one-stage debridement with implantation of gentamicin beads to fill up the evacuated bone marrow space. This approach provides a simple and effective solution for sternal osteomyelitis.

This study was carried out to assess the outcome in patients who had aortic valve replacement compared to those who underwent aortic valve repair for aortic regurgitation associated with a ventricular septal defect. Of 300 patients undergoing ventricular septal defect closure between May 1990 and December 2003, 36 (12%) had moderate to severe aortic regurgitation; 7 underwent concomitant aortic valve repair and 29 had aortic valve replacement. The mean age of these 36 patients was 17.72 ± 6.84 years, and 69% were male. Follow-up was 8.20 ± 4.97 years in the valve replacement group and 4.1 ± 0.8 years in the valve repair group. The freedom from re-operation after valve repair was 76% after 4 years. After one year of follow-up in 35 patients, 27 were in New York Heart Association class I (77%) and 8 were in class II (23%). After 8 years, 12/21 (57%) patients were in class I, 5 (24%) in class II, and 2 (10%) in class III. Of 22 patients who had a dilated left ventricle, 15 regained normal left ventricular function and volume. Valve repair is preferred, but increasing age makes valve replacement a better alternative.

The proper management of empyema thoracis in children continues to be a source of debate. This study assessed the clinical profile and outcome of patients managed by tube thoracostomy. Chart review was performed in 31 patients managed from January 1989 to December 2003. Outcome measures were duration and outcome of thoracostomy, number of days to radiologic lung re-expansion, length of hospitalization, and microbiologic flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly affected group were those aged 1 year and below. Staphylococcus aureus was the most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks. Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of the patients were hospitalized for at least 5 weeks. There were 3 recurrences and 3 deaths, 2 of which were most likely associated with empyema. Empyema managed by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged drainage and hospitalization, and unfavorable outcome.

Between January 1993 and June 2003, 106 patients underwent surgical treatment of a mediastinal mass. Ages ranged from 6 months to 62 years, with peak incidence in the third and fourth decade of life (56%). The male to female ratio was 1.9:1. The anterosuperior mediastinum was involved in 76 patients (72%), middle mediastinum in 13 (12%), and posterior mediastinum in 17 (16%). Myasthenia gravis was present in 27% of cases. Complete surgical excision was possible in 68% of patients. Histopathologically, 41 (39%) patients had thymic pathology, 31 (29%) had lymphoma, 14 (13%) had germ cell tumors, 12 (11%) had neurofibroma, 4 (4%) had ganglioneuroma, 2 (2%) had bronchogenic cyst, and 1 each had thymic cyst and mesothelioma. The overall mortality was 3.8%.

The feasibility of using modified Allen tests to evaluate arterial circulation in the forearm for possible radial artery grafting, and the correlation of these tests with Doppler ultrasonography, were examined. The hand circulation of 50 patients scheduled for coronary artery bypass grafting was assessed by plethysmography, pulse oximetry, and pencil Doppler, as well as Doppler ultrasonography. Flow, velocity, and diameter of the radial, ulnar, and snuffbox arteries were recorded, and radiological screening indices were evaluated to establish a standard set of criteria. The results of modified Allen tests by plethysmography and pulse oximetry demonstrated the dominance of the ulnar artery. The indices of flow × diameter and velocity × diameter, obtained from Doppler ultrasound measurements, confirmed the dominance of the ulnar artery. When compression was applied to the arteries sequentially, significant alterations were found. The arterial circulation in the forearm can be safely evaluated by the modified Allen tests with plethysmography, pulse oximetry, and pencil Doppler, as these results correlated with Doppler ultrasound.

Minimally invasive cardiac surgery has captured the interest and attention of cardiac surgeons throughout the world. We reviewed our experience of minimal access cardiac operations performed through a lower median ministernotomy. Between January 1997 and August 2003, 100 congenital, 178 valvular, 168 coronary, 12 aneurysmal, and 2 other operations were performed via a 6 to 9 cm lower ministernotomy in 460 consecutive patients. No special instruments were required. Four patients died, and 2 re-operations were necessary. Complications occurred in 28 patients (6.1%). The mean cardiopulmonary bypass time was 88.50 ± 65.16 min, crossclamp time was 55.81 ± 31.89 min, time to extubation was 14.71 ± 29.33 h, and total chest drainage was 7.28 ± 5.07 mL·kg⁻¹. Blood transfusions of 951.42 ± 642.34 mL were needed in 282 patients. Postoperative hospital stay was 11.6 ± 6.0 days. Our experience shows that many types of cardiac operations can be performed through a lower ministernotomy. This technique results in less trauma, quick recovery, and reduces the risk of infection and blood loss. It is a safe and easy procedure that can bring about favorable early outcomes in a wide range of cardiac operations.

The study evaluated rates and determinants of hospital morbidity, serious morbid events, and prolonged intensive care unit stay associated with isolated coronary artery bypass. The medical records of 391 patients undergoing isolated coronary artery bypass at our center during 2003 were reviewed. The observed crude hospital mortality rate was 2.05%, similar to the EuroSCORE predicted mortality rate of 2.34%. Arrhythmia was the most frequent postoperative complication (17.6%). The serious hospital morbidity rate was 5.9%. The final logistic regression model of serious morbid events identified the following predictors: drug allergy, diabetes, and EuroSCORE. Prolonged intensive care unit stay (≥ 3 days) was observed in 9.5% of patients. Multivariable logistic regression analysis revealed age, preoperative rhythm disturbances, previous cardiac operation, and hypertension as independent predictors of prolonged intensive care unit stay. The rates of hospital mortality, morbidity, and prolonged intensive care unit stay were comparable to those of other major international cardiac surgery centers. These data can be used as a benchmark for further self- and peer-assessment quality improvement activities.

The aim of the study was to investigate the relationship of ABO and Rh blood groups with lipid profile in patients with established multivessel coronary artery disease in a population with low levels of high-density lipoprotein cholesterol. The records of 978 patients with multivessel coronary artery disease, in whom coronary bypass surgery was performed, were investigated. Coronary risk factors including diabetes, hypertension, smoking, and obesity were noted for each patient. Serum lipid profiles: total cholesterol, low-density and high-density lipoprotein cholesterol, and triglyceride levels, were also recorded. The mean age of the patients was 59.3 ± 9.7 years (range, 25–84 years) and 80% were male. The risk factors and lipid profiles of ABO blood types were similar. Rh-negative patients had higher levels of high-density lipoprotein cholesterol (46.9 ± 9.9 vs. 41.6 ± 10.4 mg·dL⁻¹, p = 0.001) and a lower total/high-density lipoprotein cholesterol ratio (4.8 ± 1.3 vs. 5.2 ± 1.6, p = 0.029) compared to Rh-positive patients. The other lipid levels and risk factors had no association with Rh typing. These results indicate a significant association between rhesus positivity and low levels of high-density lipoprotein cholesterol in patients with multivessel coronary artery disease.

The strategic management of primary lung cancer in patients with poor cardiopulmonary status is still controversial. The aim of this study was to ascertain the early and late results of wide-margin wedge resection with curative intent in this group of patients. Between January 1995 and January 2002, 24 patients (13 males; mean age, 69.96 years) with baseline poor cardiopulmonary status underwent wide-margin wedge resection of preoperatively diagnosed primary lung cancer. All patients suffered from chronic obstructive pulmonary disease and 9 (37.5%) also had symptomatic ischemic heart disease. Eight patients were in New York Heart Association class III and 12 were in class IV. There were no post-operative deaths. Complications included chest infection in 3, surgical emphysema with prolonged air leak in 1, and atrial fibrillation in 6. Overall 7-year survival was 23.3%. Three patients with ischemic heart disease suffered late non-cancer-related death due to myocardial infarction at 48, 60, and 60 months postoperatively. Cancer-free 5-year survival was 54.3%, with 7/24 (29%) late recurrences. Our study suggests that wide-margin wedge resection is a valuable surgical option for primary lung cancer in patients with poor cardiopulmonary status.

The Pericarbon Freedom stentless valve has shown excellent hemodynamics. A continuous suture technique at the inflow site may reduce cardiopulmonary bypass and crossclamp times and affect postoperative hemodynamics. In a prospective case-matched study, interrupted and continuous suture line techniques were used in 68 and 71 patients, respectively. Isolated valve replacement was performed in 70.4% of the continuous suture group and 67.6% of the interrupted suture group. Hemodynamic data were obtained by echocardiography (mean and peak gradients, regurgitation) at discharge and after 1 year. Overall mortality was 5.0% and due to non-valve-related causes. Bypass and crossclamp times were shorter by 22.4 and 20.6 min, respectively, in the continuous suture group. The suture technique at the inflow site did not result in significant differences in the mean (11.8 ± 6.3 vs. 12.5 ± 6.2 mm Hg) or peak gradients (21.0 ± 9.6 vs. 22.0 ± 10.9 mm Hg), or degree of regurgitation. Follow-up showed a further decrease in the gradients.

Terminal warm blood cardioplegia has had a profound impact on cardiac surgery, especially in coronary artery bypass surgery, but there have been few studies on its use in mitral valve replacement. The purpose of this study was to determine whether terminal warm blood cardioplegia offers any advantages in mitral valve replacement. Forty patients with mitral valve disease were prospectively randomized to one of two groups of 20 with different techniques of myocardial protection: group A had cold blood cardioplegia, and group B had cold blood cardioplegia with terminal warm blood cardioplegia. Intraoperative and postoperative variables were used to assess primary outcomes. Postoperative troponin T release was measured as a secondary outcome. Improved spontaneous recovery of sinus rhythm was observed in group B, but the difference was not significant. The maximum doses of inotropics, duration of inotropic support, intensive care unit stay, and postoperative left ventricular ejection fraction were similar in both groups. Troponin T release at 0 and 6 h postoperatively was not different between the two groups. This study did not find any benefit of terminal warm blood cardioplegia in either clinical outcome or troponin T release after mitral valve replacement.

To clarify the prognostic factors for disease-free survival in completely resected pT2N0 non-small cell lung cancer, 81 consecutive patients who were treated between 1998 and 2001 were retrospectively reviewed. Follow-up was complete for all patients and the median follow-up time was 37.5 months. The overall 5-year survival rate was 68.6%, and the 5-year disease-free survival rate was 62.5%. Four factors (age, sex, visceral pleural invasion, and administration of tegafur and uracil) were proposed as prognostic factors for disease-free survival by univariate analysis. In multivariate analysis, visceral pleural invasion by the tumor (hazard ratio = 2.709, 95% confidence interval: 1.085 to 6.765, p = 0.033) and administration of tegafur and uracil (hazard ratio = 0.327, 95% confidence interval: 0.147 to 0.730, p = 0.006) were significant factors. Visceral pleural invasion was a prognostic factor for reduced disease-free survival in completely resected pT2N0 non-small cell lung cancer, and postoperative treatment with tegafur and uracil significantly improved disease-free survival.

Bilateral axillary arterial cannulation for selective cerebral perfusion might minimize cerebral embolic complications during surgery on the ascending aorta and aortic arch. From March 2002 through February 2004, bilateral axillary arterial perfusion was applied in 12 consecutive patients (mean age, 61.3 years). Operative procedures were total arch replacement in 8 patients, hemiarch replacement in 1, and ascending aorta replacement in 3. Antegrade selective cerebral perfusion was established through vascular grafts anastomosed to the bilateral axillary arteries and a perfusion catheter placed directly into the left carotid artery. Bilateral axillary arterial perfusion through the grafts was successful in all patients. There were no early or late deaths and no incidence of neurologic deficit. There were no complications related to cannulation of the axillary arteries. Bleeding, temporary renal failure, acute respiratory distress syndrome, and graft infection occurred in one patient each; all recovered from these complications. Bilateral axillary arterial perfusion is feasible and effective for brain protection during surgery on the ascending aorta and aortic arch.

Cardiovascular syphilis, which used to be a well-recognized manifestation of tertiary syphilis, has become a rarity. In this report we describe a 47-year-old man presenting with an aneurysm of the distal arch and proximal descending aorta, a somewhat unusual presentation for a syphilitic aneurysm, and discuss the clinical features of cardiovascular syphilis.

Hydatid disease rarely involves the aortic wall. We report a case of hydatidosis involving the ascending aorta and the left atrium. The patient underwent replacement of the ascending aorta with a prosthetic Dacron graft and left atrial cystectomy. At the 6-month follow-up, she was leading a normal life.

Y-grafting is a common coronary grafting technique for performing composite coronary grafts. The outcome and efficacy of this technique have not been studied in detail in the literature. We report a case of an occlusion in the proximal limb of a Y-graft, changing it into a C-shaped conduit and causing a steal syndrome. Our aim is to raise the level of caution when performing this type of composite graft and to suggest how this complication can be managed postoperatively.

We report a case of lethal spasm of non-grafted coronary arteries after an uncomplicated off-pump coronary artery bypass grafting in a patient with no predisposing factors other than smoking. Transcatheter intraluminal injection of several vasodilators failed to relieve the spasm. The patient remained in profound cardiogenic shock due to broad acute myocardial infarction and died of multiple organ failure.

A rare and previously unreported combination of Holt-Oram syndrome, atrial septal defect, patent ductus arteriosus, isolated left atrial isomerism and inferior vena caval interruption with hemiazygous continuation to the left superior vena cava is described.

The internal mammary artery (IMA) in patients with small body surface area, frequently found in the Asian population, is often small and delicate and can be easily damaged during suturing, particularly at the “toe” of the anastomosis. This may lead to less frequent utilization of the IMA as a bypass conduit. We describe a technique for anastomosing a small-caliber IMA to a coronary artery, using the tip of the graft as an autologous buttress to reinforce the toe of the anastomosis.

Atherosclerosis is a lipid-related chronic inflammatory disease in which immune mechanisms play a pivotal role. The lesions are filled with large numbers of immune cells. During the last decade, dendritic cells have been identified in atherosclerotic plaques and are thought to play an important role in atherogenesis. Dendritic cells express major histocompatibility complex I and II, human leukocyte antigen-DR, CD1a, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and co-stimulatory molecule on their surfaces and this explains their unique ability to activate naive T cells. Factors such as oxidized low-density lipoprotein, hypoxia, nicotine, heat shock proteins, and altered nitric oxide synthase activity of the endothelium, all of which cause endothelial dysfunction, have a significant impact on dendritic cell adherence to endothelium and maturation. Mature dendritic cells are capable of presenting antigens to T cells, and activation of T cells leads to release of cytokines, which play an important role in the progression of disease. Drugs such as statins and diltiazem have been shown to protect endothelial function by inhibition of dendritic cell-endothelial cell interaction, and can be applied to delay the progression of cardiovascular diseases.