성인의 심방중격 결손의 외과적 치료

이동협,이정철,한승세 영남대학교 의과대학 1992 Yeungnam University Journal of Medicine Vol.9 No.2

영남대학교 의과대학 흉부외과학 교실에서는 1985년 6월부터 1992년 8월까지 35세 이상의 성인 심방중격환자를 수술로 치험한 15례에서 다음과 같은 결과를 얻었다. 1. 수술은 11례(73%)에서 인조포편 및 자가심막을 사용하여 봉합하였다. 2. 단락정도와 수축기 폐동맥압과의 관계에서 특이한 상관관계가 없었다. 3. 술전의 뉴욕심장협회 기능분류 Ⅱ가 6명 Ⅲ이 8명이었는데 술 후 Ⅰ이 8명, Ⅱ가 6명으로 증상의 호전 있었다. 4. 심방세동 4례중 술후 3례에서 지속적으로 나타났고 1례에서는 정상리듬으로 돌아왔다. 5. 수술사망율은 없었고 수술결과는 만족하였다. The study consisted of all patients over 35years old undergoing surgical repair of atrial septal defect for the period from June 1985, to August 1992. The following results were observed. 1. ASD was closed with patch in 11(73%) patients. 2. The relationship of pulmonary artery systolic pressure to Qp/Qs ratio was not significant. 3. Before operation 6 patients were in NYHA functional class Ⅱ, 8 were in class Ⅲ, After operation 8 patients were in class Ⅰ, 6 were in class Ⅱ. 4. Atrial fibrillation has persisted in 3 patients and returned regular rhythm in 1 patient after surgery. 5. There was no operative mortality and we had good surgical results regardless of patient's age.

개심술에 따른 혈액응고 및 Fibriniolysis의 변화

한승세,이종태,김규태,이성행 慶北大學校 醫科大學 1981 慶北醫大誌 Vol.22 No.2

경북의대 흉부외과에서 1981년 1년간 무작위로 선택된 7예의 개심술 환자에서 혈액응고장애와 술후출혈에 관한 임상적인 관찰을 해서 다음과 같은 결과를 얻었다. 환자들은 모두 술전에 혈액응고장애를 나타내지 않았다. PT는 술전에 11.7"(113%)에서 관류중에 매우 연장되어 prothrombin 활성치 10%이하였다가 술후 제 1일에 14.1"(76%)까지 회복하였다. APTT는 관류중에 매우 연장되었다가 술후 제 1일에 정상으로 회복하였다. 혈소판 수는 관류중에 11.9만/㎣, 관류직후에 7.9만/㎣으로 감소하였고 술후 제 1일에 13.3만/㎣으로 다소 상승했으나 술전치인 20.2만/㎣에는 미치지 않았다. FDP는 술전에 다소 상승해 있었으나(8.8㎍/㎖) 관류중에 매우 증가했으며 술후 제 1일에는 하강하여 술전치보다 약간 높은치를 나타내었다. ELT는 특이하게도 관류중 단축되지 않고 2시간 이상으로 정상범위를 유지했다. Fibrinogen은 술전치 292.5㎎/㎗ 에서 관류중에 매우 감소하여 68.3㎎/㎗ 까지 하강하였고 술후 제 1일에 295.5㎎/㎗로 정상범위까지 회복하였다. 개심술후 출혈은 평균 987±417㎖/M^2/24hr으로 상당히 높게 나타났다. 결론적으로 관류중에 혈액응고의 제 1단계 및 제 2단계에 장애가 있고 혈소판은 감소했다. Fibrino-gen은 관류중에 매우 감소했고 FDP는 증가했으나 ELT는 정상이었기 때문에 일관성 있는 fibrinolysis를 증명하고 있지는 않았다. 술후 제 1일에는 대체로 회복하여 술전치에 접근하거나 정상치를 나타내었다. Significant blood loss still remains one of potential hazards of open heart surgery. Thrombocy-topenia, deficiency in coagulation factors, fibrinolysis, and inadequate neutralization of heparin have been recorded after cardiopulmonary bypass. This study was performed to analyze changes in certain coagulation mechanism and fibrinolytic activity associated with open heart surgery. Seven cases of patients were selected randomly for this study. They were examined by 6tests such as prothrombin time, activated partial thromboplastin time, platelet count, fibrin degradation products, euglobulin lysis time, and fibrinogen. Blood samples were obtained at pre-, intra- and postoperative periods. Patients who revealed abnormal values of tests examined preoperatively were excluded from this study. Prothrombin activity decreased to 10% during bypass from 110% of preoperative level. This activity recovered to 76% on first postoperative day. APTT was significantly prolonged during bypass and returned to normal level after surgery. Mean value of preoperative platelet count was 203,000/mm^3. Platelet decreased markedly to 79,000/mm^3 at the end of bypass and failed to reach to preoperative level at the immediate postoperative phase. The fibrin degradation products increased remarkably during bypass up to more than 40μg/ml from preoperative value of 8.8μg/ml. The fibrinogen significantly decreased from the preoperative level of 292.5mg/dl to 68.3mg/dl at the end of bypass and it returned to normal the day after surgery. Euglobulin lysis time remained within normal limits during the time of observations. The mean value of postoperative bleeding was 987ml/M^2/day.

개심술시 혈액 응고 인자의 변화

한승세,이성행,강덕식 慶北大學校 醫科大學 1982 慶北醫大誌 Vol.23 No.2

경북의대 흉부외과학 교실에서 1982년도에 개심술을 시행한 환자 중 무작위로 10예를 선택하여 혈액응고인자를 검사한 바 다음과 같은 성적을 얻었다. 혈액응고인자 즉 Ⅰ,Ⅱ,Ⅴ, 및 Ⅷ의 활성치는 모두 관류초기 및 관류말기에 심한 감소를 보였고 (p<0.001) 관류후 2-4시간에 대조치인 전신마취 중의 검사치로 회복하는 추세를 보였다. 술후 출혈량은 517±329ml/M^2/day 였으며 결론적으로 관류중 혈액응고인자의 심한 감소현상이 술후 비교적 빠른시간내에 관류전치로 회복하고 있는 것으로 보아 술후 과도한 출혈의 중요한 원인이 되지는 않는 것으로 본다. This study was performed to analyze the magnitude and duration of changes in certain clotting factors during and following cardiopulmonary bypass and to correlate these changes with excessive bleeding, if it occurred. Ten cases of patients were randomly selected for this study. They were examined factor assays such as Ⅰ,Ⅱ,Ⅴ, and Ⅷ, using a Coag-stat BC-2210 Blood Coagulation Analyzer. Blood samples were obtained during general anesthesia, at the beginning of the bypass, at the end of bypass and 2-4 hours after bypass. Factor activities such as Ⅰ,Ⅱ,Ⅴ, and Ⅷ decreased markedly during bypass(p<0.001) and returned promptly to control levels which are values during general anesthesia at 2-4 hours after bypass. Postoperative bleeding presented as 517±329ml/M^2/day.

자가관류법에 의한 체외심폐의 혈역학적 변동에 관한 실험적 연구

한승세 대한흉부심장혈관외과학회 1989 Journal of Chest Surgery (J Chest Surg) Vol.22 No.2

The experimental study for extracorporeal preservation of the heart-lung preparation by autoperfusion system was performed in 10 dogs. Under intravenous Pentothal endotracheal anesthesia bilateral thoracotomies were performed. A 24F cannula connected to a plastic reservoir bag located 100 cm above the level of the heart was introduced into the aortic arch. Left subclavian, innominate artery, and descending aorta were ligated and divided. Both vena cavae were ligated and divided after the bag was half filled with blood. A 24F catheter inserted into right atrium and connected to the plastic bag in order to keep constant the preload. The thoracic trachea was intubated and the lungs were ventilated. The heart-lung preparations were removed en bloc and floated in a $34^{\circ}C$ bath of Hartmann solution. The preparations were observed for from 2 hours to 8 hours, with the average of 5.2 hours. Hemodynamic and hematologic variables were measured during preharvest and autoperfusion. The pH revealed severe respiratory alkalosis due to very low $PaCO_2$ during autoperfusion ; $PaO_2$ remained constant for 130-140 mmHg; $A-aDO_2$ increased markedly. The static inspiratory pressure [SIP] at late autoperfusion [6hr] increased significantly as compared with at early autoperfusion [2hr]. There was no difference between white blood cell counts from right atrium and those of left atrium. Heart rates remained constant for 110-120/min; cardiac outputs maintained to approximately 0.6L/min; mean aortic pressures, 75 mmHg; mean pulmonary arterial pressures, 15-18 mmHg; mean right atrial pressures, 9-13 mmHg; mean left atrial pressures, 12 mmHg lower than those of right atrium. Serum Na maintained with normal range during autoperfusion; K increased significantly; Ca decreased progressively. Hemoglobin and hematocrit decreased significantly during autoperfusion. The study demonstrated that stable hemodynamics could be maintained throughout the experiment and the preparation of the lung seemed to be inadequate, especially after 3-4 hours, such as high $A-aDO_2$, increased SIP, and scattered atelectasis and edema in their gross appearances.

開心術後出血로 인한 再開胸術의 臨床的 觀察

韓承世 慶北大學校 醫科大學 1980 慶北醫大誌 Vol.21 No.2

慶北醫大 胸部外科에서 1975年 12月부터 1980年 12月까지 體外循環下에서 開心術을 施行한 총 98例 中에서 術後出血로 인하여 再開胸을 해야했던 8例를 對象으로 臨床的인 관찰을 하였다. 8예중 7예는 男性이었고 1예는 女性이었으며 年齡은 2歲부터 21歲까지였다. 全例가 先天性 心疾患이었으며 활로 4徵이 3예, 心室中隔缺損症이 2예였고 心方中隔缺損症은 3예였다. 術前 血色索, 血球溶積, 白血球, 血小板 및 出血, 凝固時間 그리고 prothrombin time은 특별한 血液學時 異常所見이 없었고, 術後 血色素 및 血球溶積은 감소하였으며 白血球는 증가하였다. 開心術後 再開胸時까지의 時間은 6시간 이하 4예, 7시간 2예, 10시간 1예 및 38시간이 1예였고 術後 出血量은 平均 8.7㎖/㎏/hr였으며 靑色症을 가진 心疾患에서 다소 심한 출혈경향을 보였다. 再開胸時 發見된 出血點은 心소尖의 vent 카테타를 삽입한 부위가 1예, innominate vein의 출혈이 1예, 횡격막부위의 심낭막에서 출혈한 것이 1예이고 흉골의 후면에서 1예가 출혈했으며 나머지 4예는 특별한 출현점을 발견할 수 없었다. 死亡例는 2예였는데 心房中隔缺損症 1예는 低心搏出量으로, 心室中隔缺損症 1예는 부정맥으로 死亡하였고 술후 출혈이 직접적인 死因이 되지는 않았다. Total 98 cases were performed open heart surgery with the extracorporeal circulation from Dec. 1975 to Dec. 1980 at the Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital. 8 cases of these underwent reexploration because of excessive postoperative bleeding. The perccntage of reexploration in the total group of patients was 8 percent. These were male 7 cases and female 1 case. Patients were classified with all congenital heart diseases as the following;atrial septal defect 3 cases, ventricular septal defect 2 cases, and Tetralogy of Fallot 3 cases. The total bypass time was average 76 minutes, between 40 and 135 minutes. The average amount of postoperative bleeding until reexploration was recorded from 1.7㎖/㎏/hr. to 20.6㎖/㎏/hr., with mean value of 8.7㎖/㎏/hr. and in two cases with repair of Tetralogy of Fallot there showed much more postoperative bleeding such as 15.7㎖/㎏/hr. and 20.6㎖/㎏/hr. than the mean value of it. 4 cases were reexplored during the first 6 postoperative hours, 2 cases at 7 postoperative hours. and 2 cases past over 10 postoperative hours. The source of bleeding was found in 4 of the 8 patients who underwent reoperation and those varied from the cardiac apex at insertion site of vent catheter 1 case, innominate vein 1 case, posterior side of sternum 1 case, and diaphragmatic pericardium 1 case. No specific point of bleeding was found in 4 cases, 2 of whom died after reexploration, but the death was not caused primarily because of bleeding. The causes of death were due to low cardiac output syndrome and supraventricular tachyarrhythmia respectively.

기관지확장증의 외과적 치료

한승세 대한흉부심장혈관외과학회 1984 Journal of Chest Surgery (J Chest Surg) Vol.17 No.3

Since the advent of potent chemotherapy, the incidence and severity of bronchiectasis have been on the decrease. Up to date, however, the medical treatment of bronchiectasis has not given us much satisfaction. Our purpose here is to show our experiences with pulmonary resections of bronchiectasis to clarify its surgical results and define its surgical indications. Sixty-five patients with bronchiectasis, treated surgically from January 1973 to December, 1982 at the Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, were given clinical assessment. Of the 65 patients involved in the series, 49 were male and 16, female. The patients ranged from 8 to 51 in ages, with 59 cases [91%] between 10 and 39 years old. The prominent clinical features were as follows: cough [88%], sputum production [78%], recurrent upper respiratory infection [51%], and frequent hemoptysis [32%]. The past history of the patients included measles 29%, whooping cough 14%, pulmonary tuberculosis 12%, and pneumonia or bronchitis 12%. The cylindrical type of the bronchiectasis was found to be most common, accounting for 43% of the cases. The operations were performed on the left lung in 52 cases and the right lung in 13 cases. The most common operative procedure was the left lower lobectomy and lingular segmentectomy, which showed 34%. The second most frequent procedure was the simple left lower lobectomy which was 22%. Incomplete resections of the multisegmental bronchiectasis were carried out in 12 cases, of which 7 cases were satisfactory Four patients underwent bilateral pulmonary resections for the severe multisegmental bilateral bronchiectases, during the first and second operations. Improvement in pulmonary symptoms was generally obtained in all four cases. The follow-up ranged from 1 week to 7 tears, with an average of 18.8 months. The overall results revealed that 87% of these and excellent or good conditions, but 13% had persistent symptoms. There was one operative death, which is a 1.5% mortality.

동맥전환술을 시행한 대혈관전위 환자에서 심초음파를 이용한 술후 추적

한승세,정태은,이동협,오정훈,이정철 대한흉부심장혈관외과학회 2001 Journal of Chest Surgery (J Chest Surg) Vol.34 No.10

배경: 영낡치대 흥부외과학교실에서 1989년부터 1998년 사이에 대혈관전위로 동맥전환술을 받고 6개월 이상 추적관찰한 환자 8례를 대상으로, 동맥 전환술의 효용도를 평가하기 위해 반복적인 심초음파 검사를 시행한 후 그 자료를 후향적으로 분석하였다. 대상 및 방법: 추적관찰기간은 평균 4.1년이었고 최단 6개월에서 최장 11년이었다. 대성환자의 연령은 평균 29일(범위 3∼56일)이었고 체중은 평균 3.6kg(범위 2.6∼4.8kg)이었다. 술 전 진단은 TGA+VSD가 5례, TGA+IVS가 3례이었다. 좌심실 shortening fraction, 좌심실 수축기 시간간격(left ventricle systolic time interval, LVSTI), 우심실 수축기 시간간격(right ventricle systolic time interval, RVSTI), 그리고 좌심실구축률(EF)을 측정하여 좌심실의 기능을 평가하였다. 대동맥과 폐동맥의 최고 수축기압차 속도 (peak systolic pressure gradient velocity, PSPGV), 판막의 폐쇄부전상태, 좌심방/대동맥비(LA/Ao ratio), 대동맥과 폐동맥 근부의 크기, 등을 정상치와 비교하여 판막의 기능과 대혈관의 성장을 평가하였다. 결과: 좌심실구축률은 평균 65.0+9.03%이었으며 추적관찰 동안 시간이 경가함에 따라 대체로 증가하는 경향을 보였다. 좌심실상행대동맥압차는 평균 15.9mmHg이었고 우심실폐동맥압차는 평균 27.5mmHg이었다. 수축기말 대동맥근부 크기(aortic root dimension at end-systole)는 8례 중 6례에서 동일 연령군의 정상발육 평균치보다 발육이 증가하는 양상이었고 발육과정에 따라 증가하는 양상을 보였다. 수축기말 폐동맥 근부 크기(PA root dimension at end-systole)는 동일연령군의 정상발육 평균치와 비교할 때 비슷한 성장경과를 보였다. 술후 판막 폐쇄부전의 변동을 보면 폐동맥판막폐쇄부전은 8례 중 5례에서 있었고 1례에서 2도이었고 그 외는 1도 이하이었다. 대동맥판막폐쇄부전은 8례 중 술전 0도에서 술후 1도로 변동한 경우가 6례였다. 이상과 간이 폐쇄부전이 있더라도 대부분 1도 이하이었기 때문에 인상적인 의의는 없었다 Background: To evaluate the efficacy of arterial switch operation for transposition of great arteries, serial echocardiographic studies were performed in 8 patients who underwent the surgery between 1989 and 1998 at Dept. of Thoracic & Cardiovascular Surgery, Yeungnam University Hospital in Daegu City, Korea. Material and Method: Follow-up period ranged from 6 months to 11 years(average of 4.1 years). Body weight ranged from 2.6kg to 4.8kg, with average of 3.6kg. 5 of 8 patients were preoperatively diagnosed as TGA+VSD, and 3 as TGA+IVS. LV function was evaluated by the measurement of LV shortening fraction, LVSTI, and LVEF. RVSTI was also measured. Postoperative function of valve and growth of great vessels were analyzed by the measurement of PSPGV, valvular regurgitation, LA/AO ratio, root dimension of aorta and pulmonary artery, comparing with the age matched controls, respectively. Result: LVEF had an average of 65.0+9.03% which is tended to increase serially. LVAOPG had an average of 15.9mmHg. RVPAPG, 27.5mmHg. From the measurement of aortic root dimension of 6 patients at end-systole, aortic root growth was assumed to increase more than the mean value of normal growth. PA root dimension at end-systole showed a similar growth progress when compared with age matched normal controls. Postoperative pulmonic valve regurgitation was noted in 5 of total 8 patients, in which 1 patient who showed grade 2 and 4 showed below grade 1. AR, in 6 patients and all grade 1 Except 1 patient, all the valvular regurgitations were below grade 1, which was presumed to be clinically insignificant.

폐동맥 교약술

한승세 慶北大學校 醫科大學 1986 慶北醫大誌 Vol.27 No.4

경북의대 흉부외과에서 1986년 1년간 5예의 폐동맥교약술을 치험하여 좋은 성적을 얻었기에 이를 보고하면서 문헌 고찰을 하였다. 1) 증예는 남 1예 여 4예였고 연령은 3개월에서 14개월사이였으며 체중은 4㎏에서 6㎏사이로서 매우 낮은 성장측도를 보였다. 2) 5예 모두 심한 심부전, 호흡기증상 및 발육부전을 호소하였다. 3) 단순심실중격결손은 2예였고 복합심실중격결손은 3예였는데 각각 개존동맥관, 심방중격결손, 또는 개존난원공을 합병하였다. 전예에서 폐고혈압을 동반하였다. 4) 4예에서 심도자법을 시행하였다. Qp/Qs는 1.2와 4.0 사이였고 Rp/Rs는 0.22와 0.67사이 이었다. 이 중 3예는 반응성폐고혈압이 인지되었다. Qp/Qs 1.2의 1예는 높은 Rp/Rs(0.67)에 의한 상대적인 저하로 생각되었다. Pp/Ps는 0.78과 0.98로 상승하여 있었다. 5) 수술은 좌전흉부절개로 개흉하였다. 폭 4-5㎜의 Dacron band를 교약띠로 하였다. band의 둘레는 21와 25㎜ 사이였다. 폐동맥교약술후에 수축기동맥압은 수축기동맥압의 약 반으로 하강하였다. 6) 술후 경과중 호흡기증상이 3예에서 발생하였으며 이 중 2예는 보조호흡치료를 필요로 하였다. 1예는 질식으로 심정지를 일으켰으나 소생술로 회복하였다. 1예는 별다른 합병증없이 양호한 경과를 보였다. 사망예는 없었다. 퇴원후 관찰기간은 최소 18일에서 최고 7개월까지 였으며 전예 모두 전신상태가 양호하였고 디곡신 및 이뇨제를 복용중이었다. 결론적으로 단순 또는 복합심실중격결손에서 폐동맥교약술은 선별된 환자에 적용될 때 좋은 성적을 얻을 수 있을 것으로 사료되었다. Five patients with ventriclar septal defect underwent pulmonary artery banding at the Thoracic and Cardiovascular Surgtery, Kyungpook National University Hospital in 1986. There were one male and four female. The ages of the patients ranged between 3 months and 14 months. Their body weight ranged from 4 ㎏ to 6 ㎏ which were below the third percentile level. All patients had suffered from severe congestive heart failure, respiratory symptoms, and failure to thrive. In two patients ventricular septal defect was present as simple wheras in the remaining three, it was associated with patent ductus arteriosus, atrial septal defect, or patent foramen ovale, respectively. All patients were complicated with pulmonary hypertension. Cardiac catheterization was performed in four patients. Qp/Qs ranged from 1.2 to 4.0. Rp/Rs from 0.22 to 0.67, and Pp/Ps from 0.78 to 0.98. Three of them were confirmed to have a reactive pulmonary hypertension. One patient showed low Qp/Ps(1.2) and significantly high Rp/Rs(0.67) which was suggested to be a pulmonary vascular disease. However, her postoperative course was uneventful. Left anterior thoracotomy were done in all patients. Dacron tape 4-5㎜ wide was used for all bandings. The circumference of band appeared to range between 21 and 25 ㎜. An average rise in systemic systolic pressure of 15 mmHg occurred following the pulmonary artery banding. Postband pulmonary artery pressure dropped to approximately half of the systemic pressure. Postoperative course were complicated with respiratory symptoms in three patients, two of whom needed an assisted ventilation. One patient had an asphyxia and subsequent cardiac arrest and then was resuscitated. There was no operative mortality. Follow-up ranged from 18 days to 7 months. All patients did well with normal growth rate at their last follow-up. They were all taking digoxin and diuretic. It is concluded that pulmonary artery banding in simple and complex ventricular septal defect might prove to be beneficial in the selected patients.

외상성 기관 및 기관지 파열: 3례 보고

한승세 대한흉부심장혈관외과학회 1977 Journal of Chest Surgery (J Chest Surg) Vol.10 No.1

With the adevance of widespread mechanization and high-speed era, the incidence of traumatic rupture of the tracheobronchial tree has been increased considerably. We have experienced these diseased of the 3 cases in our department. The first case was a 25 year old male who was severe dyspneic and subcutaneous emphysema, hemoptysis, and hemopneumothorax of both side were noted. During tracheostomy, it was found that the 2net ring of the trachea was ruptured. No definitive procedure was made on admission. Corrective surgery was performed with end-to-end anastomosis on 31 post-traumatic day. The second case was a 43 year old female who received multiple stab wounds on the anterior neck and it was found that the cricoid cartilage was transected partially. The injured cartilage was approximated with interrupted suture of No. 600 wire. The third case was a 19 year old male who had sustained a compression chest injury without external wound or rib fracture. At five days after trauma, he had suffered from dyspnea, and obstruction of the left main bronchus due to traumatic bronchial rupture was confirmed by means of bronchoscopy and bronchography at two weeks after the trauma. End-to-end anastomosis of the bronchus was performed and the left lung was aerated well. Mild postoperative stenosis of trachea was remained in the first case. Others were uneventful.

상행 대동맥 동맥류를 동반한 Marfan씨증후군 환자에서 생긴 대동맥 박리(Aortic Dissection) 1례

윤봉영,양창헌,김영조,심봉섭,이현우,류한영,정태은,박이태,한승세 영남대학교 의과대학 1989 Yeungnam University Journal of Medicine Vol.6 No.1

본원에서는 Marfan씨증후군과 대동맥류, 대동맥판 역류로 진단받은 환자가 1년후 흉통을 주소로 내원하여 대동맥 박리로 이행한 것으로 밝혀져 응급수술을 성공적으로 치룬 1례를 경험하였기에 보고하는 바이다. The Marfans syndrome is a generalized connective tissue disease involving eye, musculoskeletal system, cardiovascular system, and inherited autosomal dominant with various expression type. The cardiovascular complications such as aortic aneurysm, aortic dissection, aortic regurgitation, mitral regurgitation and aortic dissection which usually occurs in previously normal sized aorta are poor prognostic factors. However, the aortic dissection which developed in patient with Marfan syndrome and aortic aneurysm was rare. We experienced one case of dissecting aneurysm in patient diagnosed as previous aortic aneurysm, aortic regurgitation, and Marfan syndrome, receiving successful operation.