Aprotinin을 투여한 개심술 환자에서 Kaolin과 Celite Activator를 이용한 Activated Coagulation Time(ACT) 측정의 비교

김정택,선경,이춘수,백완기,조상록,김현태,김혜숙,박현희,김광호,Kim, Joung-Taek,Sun, Kyung,Lee, Choon-Soo,Baik, Wan-Ki,Cho, Sang-Rock,Kim, Hyun-Tae,Kim, Hea-Sook,Park, Hyun-Hee,Kim, Kwang-Ho 대한흉부심장혈관외과학회 1998 Journal of Chest Surgery (J Chest Surg) Vol.31 No.9

개심수술에서 Aprotinin에 의한 ACT가 연장되는가를 알아보기 위해 서로 다른 표면 촉매제인 kaolin (K-ACT)과 celite(C-ACT)를 이용하여 동시에 측정 비교하였다. 개심수술을 받은 22명의 성인을 대상으로 하여 Hemocron 8000 system을 이용하여 동시에 ACT를 측정 하였는데 aprotinin과 heparin 투여 전(Phase I), Aprotinin투여 후 heparin 투여 전(Phase II), heparin투여 5분 후(Phase III), haparin투여 30분 후(Phase IV), heparin투여 60분 후(Phase V), heparin투여 90분 후(Phase VI), protamin투여 30분 후(Phase VII)에 각각 측정하였다. Phase I, II, III에 두 군간에 차이가 없었으나 heparin투여 30분 후에는 C-ACT가 928$\pm$400초 K-ACT가 572$\pm$159초였고 60분 후에는 C-ACT가 888$\pm$254초 K-ACT가 535$\pm$186초 90분 후에는 C-ACT가 686$\pm$141초 K-ACT가 484$\pm$54초로 K-ACT에 비해 C-ACT가 통계학적으로 의의있게 증가하였다. 그러나 protamin투여 후에는 C-ACT가 137$\pm$26초 K-ACT가 139$\pm$28초로 두군간에 차이가 없었다. 이상의 결과에서 aprotinin투여 후 ACT는 연장이 되는 것이 아니라 activator로 celite를 사용했기 때문인 것으로 생각된다. 결론적으로 aprotinin을 투여한 개심수술에서 정확한 ACT수준을 측정하기 위하여 celite activator보다 kaolin activator를 사용해야 하며 heparin은 보통용량을 투입하여야 할 것으로 생각된다. Background: High-dose aprotinin has been reported to enhance the anticoagulant effects of heparin during cardiopulmonary bypass ; hence, som authors have advocated reducing the dose of heparin in patients treated with aprotinin. Material and Method: The ACT was measured before, during and after cardiopulmonary bypass, with Hemochron 801 system using two activators of celite(C-ACT) and kaolin(K- ACT) as surface activator. From June, 1996 to February, 1997, 22 adult patients who were scheduled for elective operation were enrolled in this study. Result: The ACT without heparin did not differ between C-ACT and K-ACT. At 30 minutes after anticoagulation with heparin and cardiopulmonary bypass, the average C-ACT was 928${\pm}$400 s; K-ACT was 572${\pm}$159s(p<0.05). After administration of protamine, C-ACT was 137${\pm}$26 s; K-ACT was 139${\pm}$28s, which were not statistically significant. Conclusion: Our results showed that the significant increase in the ACT during heparin- induced anticoagulation in the presence of aprotinin was due to the use of celite as surface activator, rather than due to enhanced anticoagulation of heparin by aprotinin. We conclude that the ACT measured with kaolin provides better monitoring of cardiac surgical patients treated with high dose aprotinin than does the ACT measured with celite. The patients treated with aprotinin should receive the usual doses of heparin.

소절개선을 이용한 심장수술의 임상고찰

김광호,김정택,이서원,김혜숙,임현경,이춘수,선경,Kim, Kwang-Ho,Kim, Joung-Taek,Lee, Seo-Won,Kim, Hae-Sook,Lim, Hyun-Kung,Lee, Choon-Soo,Sun, Kyung 대한흉부심장혈관외과학회 1999 Journal of Chest Surgery (J Chest Surg) Vol.32 No.4

배경: 최근에 시작된 소절개선을 이용한 심장수은술 환자에게 미용상 효과가 좋으며, 통증이 적으며 빠른 회복을 가져온다. 본 교실에서는 그간 실시한 소절개심장수술의 현황을 임상고찰하였다. 대상 및 방법: 1997년 2월 흉골좌연종절개선으로 관상동맥우회술을 실시한 이후 1998년 11월까지 총 31례의 소절개술을 이용한 심장수술을 실시하였다. 남녀 비는 17:14였으며, 1세에서 75세까지의 연령분포를 보였다. 흉골좌연종절개술을 실시한 예는 9례로 관상동맥 질환으로 인공심폐기의 사용없이 박동상태에서 내유동맥으로 좌전행지관상동맥에 우회술을 실시하였는데, 그 중 1례는 내유동맥의 비꼬임으로 술 후 1주일 째 재수술한 경우였다. 흉골우연종절개는 1례로 승모판교련절개술 후 재발된 협착증에 대해 승모판치환술을 실시한 경우였다. 소흉골절개선으로 수술한 예는 21례로, 승모판치환 및 삼첨판성형술이 6례, 승모판치환술 5례, 중복판치환술 2례, 대동맥판치환술 1례, 좌심방점액종 1례, 심방중격결손증 2례, 심실중격결손증 2례, 우심실 자창 1례였다. 처음 5례는 T형의 흉골소절개를 실시하였으나 경험이 쌓이면서 대동맥기저부의 노출이 좋고 흉골 봉합시 안정감이 높은 화살모양의 흉골소절개를 실시하였다. 결과: 수술시간, 인공심폐 구동시간, 대동맥차단시간, 인공호흡기 사용기간, 수술 1일까지의 흉관배액양, 흉관 거치기간, 집중치료실 입원기간 등은 기존의 정중흉골절개선 예들에 비하여 큰 차이가 없었다. 수술 후 사망 예는 2례였으며 1례는 흉골소절개선으로 승모판치환 수술 1일에 대동맥 삽관부위의 파열로 출혈 사망하였고, 다른 1례는 흉골좌연종절개선으로 관상동맥우회술 후 2일에 부정맥으로 사망하였다. 사망의 원인과 수술절개선의 선택과는 직접적인 관련이 없었다. 합병증은 뇌색전증 1례, 창상의 혈종 1 례가 있었다. 결론: 소절개선으로도 정중흉골절개선과 마찬가지로 심장 수술을 효과적으로 실시할 수 있을 것으로 생각된다. Background: Minimally invasive technique for various cardiac surgeries has become widely accepted since it has been proven to have distinct advantages for the patients. We describe here the results of our experiences of minimal incision in cardiac surgery. Material and Method: From February 1997 to November 1998, we successfully performed 31 cases of minimally invasive cardiac surgery. Male and female ratio was 17:14, and the patients age ranged from 1 to 75 years. A left parasternal incision was used in 9 patients with single vessel coronary heart disease. A direct coronary bypass grafting was done under the condition of the beating heart without cardiopulmonary bypass support(MIDCAB). Among these, one was a case of a reoperation 1 week after the first operation due to a kinked mammary artery graft. A right parasternal incision was used in one case of a redo mitral valve replacement. Mini-sternotomy was used in the remaining 21 patients. The procedures were mitral valve replacement and tricuspid annuloplasty in 6 patients, mitral valve replacement 5, double valve replacement 2, aortic valve replacement 1, removal of left atrial myxoma 1, closure of atrial septal defect 2, repair of ventricular septal defect 2, and primary closure of r ght ventricular stab wound 1. The initial 5 cases underwent a T-shaped mini-sternotomy, however, we adopted an arrow-shaped ministernotomy in the remaining cases because it provided better exposure of the aortic root and stability of the sternum after a sternal wiring. Result: The operation time, the cardiopulmonary bypass time, the aorta cross-clamping time, the mechanical ventilation time, the amount of chest tube drainage until POD#1, the chest tube indwelling time, and the duration of intensive care unit staying were in an acceptable range. There were two surgical mortalities. One was due to a rupture of the aorta cannulation site after double valve replacement on POD#1 in the mini-sternotomy case, and the other was due to a sudden ventricular arrhythmia after MIDCAB on POD#2 in the parasternal incision case. Postoperative complications were observed in 2 cases in which a cerebral embolism developed on POD#2 after a mini-sternotomy in mitral valve replacement and wound hematoma developed after a right parasternal incision in a single coronary bypass grafting. Neither mortality nor complication was directly related to the incision technique itself. Conclusion: Minimally invasive surgery using parasternal or mini-sternotomy incision can be used in cardiac surgeries since it is as safe as the standard full sternotomy incisions.

만성 흡인을 유발하는 위 식도 역류 모델

윤용한,김루시아,조정수,김정택,백완기,김광호,Yoon, Yong-Han,Kim, Lucia,Cho, Jung-Soo,Kim, Joung-Taek,Baek, Wan-Ki,Kim, Kwang-Ho 대한기관식도과학회 2008 大韓氣管食道科學會誌 Vol.14 No.2

Background : Anti-reflux procedures treat gastroesophageal reflux (GER) disease. It is known that gastroesophageal reflux is likelyrelated to the increased incidence of chronic rejection in lung transplantation recipients. Because experimental animal studies areto verify this, we have tried to make an animal model of GER in a rat. Material and Methods : Using the SD rats weighing 250-300 g, we surgically induced gastroesophageal reflux and measured the gastrostomy time under anesthesia. Of three groups, Group I was the control, Group II had lower esophageal and anterior myotomy, and Group III had lower esophageal and anterior myotomy plusdiaphragmatic crural myotomy.The animals were scarified, and lung biopsies and histological examinations were performed 1 week, 2 weeks, 4 weeks, 8 weeks and 3 months after gastroesophageal reflux surgery. Results : Baseline animals (n=5) had no GER after charcoal instillation through a gastrostomy tube in Group I. Charcoal-laden macrophages were observed in GroupsII and III. To determine evidence of GER evidence, charcoal was instillated through the gastrostomy tube in group III. In contrast, Group II demonstrated severe neurophil infiltration in the bronchioles and alveolar walls after procedure. After 12 weeks, we observed the disappearance of neurophil, lymphocyte and histiocyte infiltration, and also occasional focal bronchopneumonia and bronchitis. Group III demonstrated neurophil and basophil infiltration in the bronchioles and alveolar walls which was more severe than that in Group II. Interstitial fibrotic changes were observed in Group III.Conclusion : The purpose of our gastroesophageal reflux model was to find evidence of aspiration. There was more evidence of aspiration in Group II than in either of theother two groups.

전방 기관성형술 -2례 보고-

선경,이서원,김정택,김광호,임현경,Sun, Kyung,Lee, Seo-Won,Kim, Joung-Taek,Kim, Kwang-Ho,Lim, Hyun-Kyoung 대한흉부심장혈관외과학회 1999 Journal of Chest Surgery (J Chest Surg) Vol.32 No.7

소아의 흉부기관협착증 2례에 대해 자가심막을 이용해 전방 기관성형술을 실시\ulcorner였다. 증례 1은 9세된 여 아에서 발견된 선천성 기관협착증의 경우로 인공폐의 보조 아래 기관성형과 동반된 좌폐동맥 기시이상을 동 시에 근치하였다. 환아는 이식된 심막편이 종격조직에 고정될 때까지 수술 후 10일 간 기계호흡을 실시하였 다. 증례 2는 8세된 남아에서 기관절개술 후 하부기관협착이 발생한 경우로, 심막편 바깥을 늑연골편으로 보 강함으로써 수술 직후 기도삽관을 제거할 수 있었다. 2례 모두 수술 후 1년 이상의 관찰기간 동안 기관내경 이 잘 유지되고 있으며, 기관재건부위가 성장하는 소견을 보인다. We describe here two cases of anterior tracheoplasty utilizing an autologous pericardial patch. One patient was a 9 year-old female who had a congenital long tracheal stenosis associated with major vascular anomalies including pulmonary artery sling. One-stage correction was done under the support of an extracorporeal membrane oxygenation system. She required a prolonged ventilation support for 10 days postoperatively until the implanted pericardium was fixed to the mediastinal structures. The other patient was a 8 year-old male who had acquired tracheal stenosis following a complicated tracheostomy. By applying additional support over the pericardial patch with the costal cartilage, an endotracheal tube could be removed immediately after the operation. Both patients have been doing well in a postoperative follow-up of over a year, and there have been evidences of growth in the reconstructed trachea.

대동맥 절단증

김광호,이춘수,강성권,김준식,선경,김정택 대한외상학회 1998 大韓外傷學會誌 Vol.11 No.1

We experienced a case of aortic transection or interruption developed by acute deceleration in a motor vehicle accident. Despite of no apparent chest trauma, simple chest radiographic and CT scan findings were suggestive of injury on the aortic isthmus and this was confirmed by aortogram. Treatment consisted of resection and graft interposition after placing a bypass shunt between the aortic arch and the distal descending aorta. Early recognition and diagnosis based on suspi- cious indices are important in salvaging patient with this type of injury.

좌심방의 원발성 미분화성 육종 1예

김영신,최새로운,이문희,김인호,주영채,김정택,김철수 대한내과학회 2004 대한내과학회지 Vol.66 No.4

원발성 미분화 심장육종은 그 빈도가 매우 드물고 공격적인 국소진행을 보인다. 그러므로 수술로 완전절제를 하고, 이후 보조적 항암화학요법 또는 방사선 치료를 하더라도 예후는 아주 불량한 것으로 알려져 있다. 저자들은 33세의 여자 환자에서 원발성 심장종양 중 미분화성육종을 확인한 경우로 수술 후 항암화학요법과 방사선 치료를 하였음에도 불구하고 재발하여 진단 후 11개월만에 사망한 증례 보고와 이에 관한 문헌고찰을 보고하는 바 있다. Primary undifferentiated cardiac sarcomas are extremely rare, and typically undergo aggressive local spread. The prognosis of undifferentiated sarcoma is reported to be very poor even if surgical resection, with or without adjuvant chemotherapy and radiotherapy, is performed. Here we present our case of primary undifferentiated sarcoma of the left atrium. A 33-year-old woman presented with a month history of progressive breathlessness and exertional chest pain. Transthoracic echocardiography showed a large mobile mass obstructing much of the left atrium. At surgery a superseptal approach to the atria enabled removal of all the left heart tumor which was attached to the left upper pulmonary vein. Immunochemistry staining revealed the undifferentiated atrial sarcoma. She received three cycles of darcabazine and adriamycin and after three months three was evidence of tumor recurrence. Eleven months later from operation, she died with congestive heart failure.

개심술에서 고농도 Aprotinin의 지혈효과

김정택 梨花女子大學校 醫科大學 醫科學硏究所 1994 EMJ (Ewha medical journal) Vol.17 No.3

Two groups of patients were studied to evaluate the hemostatic effects of high-does aprotinin in open heart operations. Aprotinin group patients(n=8) received aprotinin during entire surgical procedure. The other group patients(n=10) were served as control. Two groups were homogenous for base variables and for cardiopulmonary bypass duration. Post operative bleeding was lower in aprotinin group(mean, 599ml) than control group(886ml, p<0.05). The need for banked blood decreased in aprotinin group(aprotinin group mean, 106ml ; control group mean, 387ml). Perioperative hemoglobin & platelet counts were similar each other. We concluded that the use of high-does aprotinin was safe and effective. It decreased blood loss and reduced the need for banked blood in open heart operations.

교통사고에 의한 좌심방 파열 : 증례 A Case Report

이용주,백광제,김준식,김정택 대한외상학회 2001 大韓外傷學會誌 Vol.14 No.1

Blunt or nonpenetrating chest injuries are common after motor vehicle accidents or falls. Blunt traumatic cardiac rupture is a rare and lethal injury. From 50% to 80% of patients with cardiac rupture caused by blunt chest trauma die at scene or during transport to the hospital. We treated a 32-year-old male patient who suffered cardiac rupture due to a motor vehicle accident. The patient was presented with severe hypotension with a right hemothorax on arrival at our hospital. The hemothorax was relieved via an emergency closed thoracostomy, but bleeding via the chest tube and hypotension continued. The patient who had an impressed right hemothorax was sent to the operating room. During the operation, a left atrial rupture was detected and repaired with simple suture. The clinical course of the patient was uneventful, and he was discharged without problems.