Asian Cardiovascular and Thoracic Annals

Background: The aim of this study was to investigate the effect of preoperative low ejection fraction (≤30%) on postoperative morbidity and mortality in patients undergoing isolated on-pump coronary artery bypass grafting. We also investigated the effect of pre- and perioperative factors on survival.

Methods: Between January 2002 and December 2009, 103 (6.2%) patients with an ejection fraction ≤30% and 1554 (93.8%) with an ejection fraction >30% underwent coronary artery bypass grafting.

Results: In multivariate logistic regression analysis, cardiopulmonary bypass time, operation time, prolonged inotropic support, and intensive care unit stay were independent predictors of mortality in patients with low ejection fraction. Intensive care unit and hospital stays were significantly longer in these patients, and the postoperative mortality rate was significantly higher. Advanced age (≥70 years) influenced mortality during the follow-up of patients with low ejection fraction. Midterm survival was significantly reduced in patients with ejection fraction ≤30%. Smoking, prolonged inotropic support, and prolonged ventilatory support were independent predictors of midterm survival in patients with ejection fraction ≤30%.

Conclusion: On-pump coronary artery bypass grafting can be performed in patients with ejection fraction ≤30%, with reasonable mortality and morbidity rates.

Objective: The aim of this study was to compare the prognostic value of matrix metalloproteinase-3 and -9, and NT-pro-natriuretic peptide for fatal and nonfatal complications in Q-wave myocardial infarction patients in the acute and postinfarction periods.

Patients and methods: 85 men and women with documented Q-wave myocardial infarction were observed for 1 year after hospitalization. Clinical endpoints were identified through the hospital patient-tracking system, with a review of medical records for each recorded endpoint. Left ventricular ejection fraction and wall motion index were calculated. Measurements of matrix metalloproteinases and NT-pro-natriuretic peptide were performed by an enzyme-linked immunosorbent assay.

Results: A cutoff value of 9.7 ng·mL⁻¹ for matrix metalloproteinase-3 showed the best discriminatory power (sensitivity = 77.8%, specificity = 90.8%). The optimal cutoff value of matrix metalloproteinase-9 was 18.1 ng·mL⁻¹ (sensitivity, 70.5%; specificity, 75%), and the cutoff for NT-pro-natriuretic peptide was 885 pmol·L⁻¹ (sensitivity, 58%; specificity, 68.6%). Matrix metalloproteinase-3 and -9 were strongly related with a positive prognostic value of 70% (sensitivity and specificity, 84% and 82%, respectively).

Conclusion: These data may be helpful for further stratification of patients into cardiovascular mortality risk groups.

Background: Endovascular repair of the aortic arch is often unsatisfactory due to poor stent-vessel conformity and inadequate landing zones.

Objective: To study the anatomical characteristics of the aortic arch and provide basic information for the development of arch-specific endovascular devices.

Materials and methods: Three-dimensional models were reconstructed in Mimics (image segmentation software) from computed tomography aortograms of 120 elderly Asian patients, by manual segmentation. The centerline of each Three-dimensional aortic model was calculated using a repulsive force field method. Measurements of the aorta and supra-aortic branches were analyzed using Patran (finite-element software). A three-dimensional statistical aortic arch model was built using principal component analysis.

Results: The mean diameters of the ascending and descending aorta, and the origins of the innominate, left common carotid, and left subclavian artery were 39.4 ± 6.7, 34.5 ± 7.9, 18.0 ± 3.8, 12.6 ± 2.7, and 14.1 ± 2.5 mm, respectively. The length of the ascending aorta, innominate to left common carotid artery, and left common carotid to left subclavian artery were 62.6 ± 11.4, 12.0 ± 5.6, and 18.7 ± 5.6 mm along the centerline. The mean angle of curvature was 103.8 ± 25 degrees. Principal component analysis of the three-dimensional centerlines derived 3 main modes of variation, which account for 61% of the overall shape range.

Conclusion: Aortic arch anatomical information from an elderly Asian population can be useful for the development of future endovascular devices.

Background: serum level of amino-terminal pro-B-type natriuretic peptide, a cardiac hormone produced by the heart, is elevated in patients with left ventricular dysfunction. The purpose of this study was to compare the abilities of serum and pericardial fluid levels of amino-terminal pro-B-type natriuretic peptide to detect the left ventricular systolic dysfunction determined by echocardiography.

Methods: 50 patients undergoing coronary artery bypass grafting were included in this study. Left ventricular systolic function was assessed using echocardiography before coronary artery bypass grafting. The samples of serum and pericardial fluid were collected during surgery, and amino-terminal pro-B-type natriuretic peptide levels were assessed by an electrochemiluminescence immunoassay. The log value of amino-terminal pro-B-type natriuretic peptide concentrations was calculated.

Results: the pericardial fluid levels of log amino-terminal pro-B-type natriuretic peptide were significantly elevated compared to the serum levels in patients with impaired left ventricular systolic function. Both serum and pericardial fluid levels of log amino-terminal pro-B-type natriuretic peptide correlated significantly with left ventricular ejection fraction and end-diastolic and end-systolic volume indices. Furthermore, a paired comparison of receiver operating characteristic curves showed a similar performance of amino-terminal pro-B-type natriuretic peptide levels both in serum and pericardial fluid to discriminate left ventricular systolic dysfunction.

Conclusion: serum amino-terminal pro-B-type natriuretic peptide levels have comparable diagnostic value for left ventricular systolic dysfunction with its pericardial fluid levels in patients undergoing CABG.

Background and objective: only a few studies have compared surgical outcomes in children with and without Down’s syndrome. The purpose of this study was to investigate the surgical outcome in children with Down’s syndrome and congenital heart disease and to compare it with that in age- and sex-matched non-Down controls.

Patients and methods: the charts of 32 consecutive Down’s syndrome patients who underwent surgery for congenital heart disease in a single center from January 2006 to May 2010, were compared with the data of 32 age- and sex-matched non-Down controls, focusing on comparative echocardiographic details, surgical outcome, and intensive care unit data. The data were compared using the 2-group t test. The children were followed up for a median period of 48 months.

Results: the most common cardiac lesion in the study group was ventricular septal defect (41%) followed by atrioventricular septal defect (28%). Ventilation and intensive care unit stay were significantly longer in Down’s syndrome children, with a trend towards more respiratory complications. At a median follow-up of 48 months, there were no cardiac events or mortality in the study group. Simple lesions were more common than atrioventricular septal defect in Down’s syndrome.

Conclusion: children with Down’s syndrome can be operated on with negligible mortality and good functional outcome, but with a higher surgical morbidity.

Objectives: many studies have shown that oral beta blockers reduce the incidence of atrial fibrillation after coronary artery bypass. The goal of this study was to determine whether landiolol, an intravenous beta blocker, reduces the incidence of atrial fibrillation after off-pump coronary artery bypass.

Methods: 39 consecutive patients were given landiolol after coronary artery bypass, and 20 who were not given landiolol served as a control group. Landiolol was intravenously administered at 1 µgċkg⁻¹ċmin⁻¹ in the intensive care unit.

Results: the mean dose of landiolol was 2.3 ± 1.2 1 µgċkg⁻¹ċmin⁻¹. The incidence of atrial fibrillation during intensive care unit stay was significantly lower in the landiolol group compared to the control group: 2.6% (1/39) vs. 20% (4/20). Heart rate after landiolol administration was significantly lower than that before administration, whereas landiolol had no effect on blood pressure. C-reactive protein and creatine kinase levels 7 days after surgery were significantly lower in the landiolol group.

Conclusion: continuous administration of landiolol at a low dose after off-pump coronary artery bypass reduced the incidence of atrial fibrillation.

Objective: Increased body mass index has been associated with increased postoperative morbidity. We studied the effect of body mass index in our population, using a modified scale suggested by the World Health Organization.

Methods: From January 2006 to December 2008, 1019 patients undergoing first-time isolated elective coronary artery bypass grafting were selected from our cardiac surgery database. Data were analyzed by univariate and multivariate analyses.

Results: Of the 1019 elective coronary artery bypass patients, 168 (15.8%) had a normal body mass index (18.5–22.9 kg·m⁻²) and 894 (84.2%) had a high body mass index (≥23.0 kg·m⁻²). There were 921 (86.7%) patients with 3-vessel disease, and 1012 (95.3%) had internal mammary artery grafts. The 30-day mortality was 0.8%. Multivariate analysis revealed age, hospital stay, perfusion time, and renal failure were significantly associated with hospital complications. High body mass index was not significantly associated with morbidity or mortality. The model had an adequate fit at p = 0.708 by the Hosmer and Lemeshow test.

Conclusion: Increased body mass index alone is not a predictor of increased mortality and morbidity. In fact, these outcomes were associated with advanced age, hospital stay, perfusion time, and renal failure.

Objectives: Post-intubation tracheal stenosis is a serious disease caused by cuff pressure during tracheal intubation. The reported prevalence of post-intubation tracheal stenosis is 10%–22% in intubated patients. Invasive diagnostic methods based on fiberoptic or rigid bronchoscopy are suggested for initial assessment and treatment. This study aimed to evaluate plethysmography as an alternative diagnostic tool for post-intubation tracheal stenosis. We also assessed the relationship between plethysmography and bronchoscopy findings in patients with post-intubation tracheal stenosis.

Methods: The sample included 30 patients who were admitted to our intensive care unit or surgical ward during the course of a year, and diagnosed with post-intubation tracheal stenosis. All patients underwent plethysmography and rigid bronchoscopy. The relationship between the plethysmography and bronchoscopy findings was examined.

Results: Stricture intensity had the strongest correlation with upper airway resistance (p = 0.001). The relationship of length of stricture to forced expiratory volume in 1 s and maximum expiratory flow 50 and 75 was significant in univariate analysis, and to reserve volume and total lung capacity in multivariate analysis.

Conclusion: Significant relationships were found between plethysmography variables and rigid bronchoscopy findings in patients with post-intubation tracheal stenosis, and some formulas were developed to give an alternative estimate of stricture severity, without bronchoscopy.

Introduction: Anterior mediastinal tracheostomy is indicated in extensive cervicothoracic malignancy with cervical mediastinal involvement of the trachea. This study was designed to assess the therapeutic outcome of anterior mediastinal tracheostomy.

Methods: From 2001 to 2010, 10 men and 2 women, with a median age of 64.5 years, underwent anterior mediastinal tracheostomy and were followed up for at least for 1 year. Seven patients had stomal recurrence following laryngectomy, 3 had carcinoma of the cervical esophagus, 1 had squamous cell carcinoma of the trachea invading the subglottic larynx, and 1 had adenoid cystic carcinoma of the trachea invading the subglottic larynx. They were evaluated in terms of etiology of the primary lesion, previous treatment, complications, hospital death, and Kaplan-Meier survival estimate.

Results: The tumor was completely resected in all cases. Postoperative complications included atelectasis (3 patients), stomal necrosis (1 patient), and anastomotic leak (1 patient). There were 2 (16.6%) postoperative hospital deaths. The mean duration of follow-up was 23 months, and the mean overall survival time was 25.59 months. Survival was calculated for 3 groups based on primary etiology: stomal recurrence of laryngeal carcinoma (12.85 months), cervical esophageal cancer (28 months), and primary malignancy of the trachea (29 months).

Conclusion: Because of the small number of patients, a definitive conclusion was difficult, but acceptable morbidity, mortality, and relative survival in selected patients, in whom an extensive cervicothoracic operation was performed by an experienced and skilled team of surgeons, demonstrated that anterior mediastinal tracheostomy can be a helpful procedure for patient survival.

We describe a rare case of aorta-to-right ventricular fistula in a 20-year-old man who presented with signs and symptoms of congestive heart failure. He was successfully treated by closing the fistula with a Dacron patch from the aortic side. At follow-up, he was asymptomatic with no left-to-right shunt.

Nonobstructive prosthetic valve thrombosis occurs more frequently during the early postoperative period due to increased thrombogenicity precipitated by inadequate anticoagulation. There is currently no consensus in the management of prosthetic valve thrombosis. We describe a patient with acute stroke secondary to nonobstructive prosthetic valve thrombosis that was due to inadequate anticoagulation. He was managed with intravenous anticoagulation with no resolution of the thrombus. Subsequently, he underwent successful surgical thrombectomy without valve replacement.

A 36-year-old man with a short neck, low hairline, and mild kyphoscoliosis, presented with history of syncope. Chest radiography revealed a diaphragmatic hernia. Computed tomography demonstrated fusion of C2–C6 vertebral bodies, Electrocardiography indicated complete heart block. Ultrasonography showed a right pelvic kidney. He was diagnosed with Klippel-Feil syndrome and underwent permanent pacemaker implantation and corrective surgery for the congenital diaphragmatic hernia.

Patients with transposition of the great arteries have good survival after surgery, but some have complications ranging from heart failure to valve dysfunction. A 42-year-old woman who underwent surgical correction in childhood, presented with aortic dissection and had a valve-sparing root operation, but died immediately postoperatively. Both aortic dissection and valve-sparing root operations in this setting have not been described before. This case highlights facts to consider in the treatment of this presentation.

Myxomas are the most common benign tumors of the heart. They can arise from any heart chamber, but have rarely been described as originating from the left atrial appendage. We describe a case of left atrial appendage myxoma mimicking a left atrial appendage thrombus, and presenting with microembolization to the coronaries.

Myxofibrosarcomas are rare cardiac neoplasms that usually involve the left atrium and present as unicentric or multicentric tumor masses. They can arise from both myocardial and valvular tissue, and can be locally aggressive or show distant metastasis. We describe an unusual case of myxofibrosarcoma involving both the right atrium and ventricle in a 30-year-old man, which was surgically resected. After 12 months of follow-up, there was no recurrence or metastasis.

A 47-year-old man who had a pacemaker implanted 2 years earlier, recently developed a fever and had been on antibiotics for 2 months. He presented with pulmonary emboli, and underwent lead extraction and emboli removal. Histopathology demonstrated Aspergillus. Amphotericin B was continued postoperatively. This rare case of pacemaker lead endocarditis suggests that vigorous medical and surgical intervention can be curative.

A 19-year-old woman, who had a recent extensive cerebral infarction caused by a septic embolization in the left-sided territory of the middle cerebral artery, successfully underwent mitral valve repair for severe mitral regurgitation caused by active infective endocarditis, 24 h after the onset of stroke. Anticoagulation during cardiopulmonary bypass was maintained with low-dose heparin and additional nafamostat mesilate. She had no further aggravation of the brain complication and recovered well with midterm mitral valve durability.

A 1-month-old neonate was admitted in respiratory distress. Two-dimensional echocardiography and computed tomography scan showed a mass anterior to the left ventricle and right ventricular outflow tract. A biopsy revealed an inflammatory myofibroblastic tumor. A tuberculin test showed an 18-mm diameter induration. Three of the 6 household contacts were also positive for pulmonary tuberculosis. Antituberculosis medication was started. After 1 year, echocardiography and computed tomography scan showed complete resolution of the mass.

A 62-year-old woman underwent a reduction of a proximal reduced humeral fracture, which was fixed by 3 Kirschner pins. One year later, the orthopedic surgeon failed to remove one of the wires. The patient was lost to follow-up, and 4 years later, she presented with hemoptysis, revealing migration of the pin to the lung. The pin was removed through a thoracotomy. Migration to the lung is often revealed by hemoptysis or pneumothorax. Close follow-up and early removal of the pins are mandatory.

A 27-year-old man was referred with typical features of severe Cushing’s syndrome. A bilateral adrenalectomy was performed. Three months later, a triangular nodular mediastinal enlargement, evocative of a right anterior thymic tumor, was discovered. Thymectomy was undertaken. Histological examination revealed diffuse thymic hyperplasia with negative immunostaining for adrenocorticotropic hormone. Five years later, a right endobronchial tumor corresponding to a carcinoid tumor was removed.

We describe a case of bronchial artery aneurysm presenting as a solitary lung mass (4 × 5 cm) in a 53-year-old man with symptoms of cough for 3 months. The aneurysm was only detected at surgery, and resected by performing a middle lobectomy.

We describe a case of pleomorphic carcinoma showing a recurrent tumor with massive hemorrhage and myxoid change in the chest wall 2 months after complete resection. Whereas specimens from the initial surgery revealed both adenosquamous carcinoma and sarcomatous elements, the recurrent tumor predominantly consisted of a sarcomatous element. The recurrent tumor had stronger immunoreactivity for mesenchymal markers than the primary tumor, indicating that the sarcomatous element had more malignant potential than the epithelial element.

Combined tracheobronchial and thoracic vascular injury in children following blunt trauma to the chest is potentially life-threatening and almost certain to be fatal unless managed promptly. We report one such incident where prompt identification and early aggressive surgical management prevented an almost certain fatal outcome in a 5-year-old girl with complete disruption of the right main bronchus just distal to the carina, and a tear in the right pulmonary artery.