대동맥궁 단절을 동반한 동맥간

김관창,최세훈,장우성,여인권,김웅한 대한흉부외과학회 2005 Journal of Chest Surgery (J Chest Surg) Vol.38 No.12

A 85-day-old infant was successfully operated on for truncus arteriosus (type I) with interrupted aortic arch (type A) using one-stage anterior approach without circulatory arrest. Aortic arch was reconstructed by direct anastomosis of ascending aorta and descending aorta with regional perfusion and continuity of right ventricle to pulmonary artery was established with ShelhighⓇ pulmonic conduit. The patient experienced left bronchus compression by descending aorta immediately postoperatively, which was improved with positional change and physiotherapy. The patient had reoperation due to stenosis of valved conduit at 13 months later. The patient is currently well under follow-up of 14 months from initial repair. 생후 85일 된 대동맥궁 단절이 동반된 총동맥간 환자에서 완전순환정지 없이 1차 완전 교정술을 성공적으로 시행하였다. 대동맥 단절 교정은 국소순환하에 상행 및 하행대동맥을 문합하였고 우심실유출로 재건은 Shelhigh 판막도관을 이용하였다. 술 후 혈관에 의해 일시적으로 좌측 기관지가 눌리는 합병증이 발생하였으나 자세변화와 흉부물리치료로 호전되었다. 술 후 13개월 뒤에 판막도관의 협착으로 우심실 유출로에 대한 재수술이 필요했으며 환아는 현재 건강한 상태로 첫 교정술 후 14개월째 외래 추적중이다.

돼지의 심낭을 이용한 이종이식 보철편의 개발 (장력-두께 간의 구조적 특성)

김관창,이철,최창휴,이창하,오삼세,박성식,김경환,김웅한,김용진 대한흉부외과학회 2008 Journal of Chest Surgery (J Chest Surg) Vol.41 No.2

Background: Bioprosthetic devices for treating cardiovascular diseases and defects may provide alternatives to autologous and homograft tissue. We evaluated the mechanical and physical conditions of a porcine pericardial bioprosthesis treated with Glutaraldehyde (GA), Ethanol, or Sodium dodecylsulfate (SDS) before implantation. Material and Method: 1) Thirty square-shaped pieces of porcine pericardium were fixed in 0.625%, 1.5% or 3% GA solution. 2) The tensile strength and thickness of these and other bioprosthesis, including fresh porcine pericardium, fresh human pericardium, and commercially produced heterografts, were measured. 3) The tensile strength and thickness of the six treated groups (GA-Ethanol, Ethanol-GA, SDS only, SDS-GA, Ethanol-SDS-GA and SDS-Ethanol-GA) were measured. Result: 1) Porcine pericardium fixed in 0.625% GA the thinnest and had the lowest tensile strength, with thickness and tensile strength increasing with the concentration of GA solution. The relationship between tensile strength and thickness of porcine pericardium increased at thicknesses greater than 0.1 mm (correlation-coefficient 0.514, 0<0.001). 2) There were no differences in tensile strength or thickness between commercially-produced heterografts. 3) Treatment of GA, ethanol, or SDS minimally influenced thickness and tensile strength of porcine pericardium, except for SDS alone. Conclusion: Porcine pericardial bioprosthesis greater than 0.1 mm thick provide better handling and advantageous tensile strength. GA fixation did not cause physical or mechanical damage during anticalcification or decellularization treatment, but combining SDS-ethanol pre-treatment and GA fixation provided the best tensile strength and thickness.

글루타르알데하이드 고정 돼지 심낭에서 Ethanol, L-lysine, NaBH4 병합 처치시 상승효과

김관창,김용진,김수환,최승화 대한흉부외과학회 2009 Journal of Chest Surgery (J Chest Surg) Vol.42 No.6

Background: Calcification is the most frequent cause of clinical failure of bioprosthetic tissues that are fabricated from Glutaraldehyde (GA)-fixed porcine valve or bovine pericardium. We recently used a multi-factorial approach of employing different mechanisms to investigate how to reduce the calcification of bioprosthetic tissues. The purpose of the present study was to evaluate the synchronized synergism using ethanol, L-lysine and NaBH4 in glutaraldehyde treated porcine pericardium from the standpoint of calcification and tissue elasticity. Material and Method: Porcine pericardium was fixed with 0.625% GA (commercial fixation). An interim step of ethanol (80%; 1 day at room temperature) or L-lysine (0.1 M; 2 days at 37℃) or NaBH4 (0.1 M; 2 days at room temperature) was followed by completion of the GA fixation (2 days at 4℃ and 7 days at room temperature). The tensile strength and thickness of the samples were measured. The treated pericardiums were implanted subcutaneously into three-week old Sprague-Dawley rats for 8 weeks. The calcium content was assessed by atomic absorption spectroscopy and the histology of the samples. Result: The amount of calcium in the pericardium pretreated with ethanol (13.6±10.0 ug/mg, p=0.008), L-lysine (15.3±1.0 ug/mg, p=0.002) and both (16.1±11.1 ug/mg, p=0.012) was significantly reduced compared with the control (51.2±8.5 ug/mg). However, NaBH4 pretreatment (65.7±61.8 ug/mg, p=0.653) and combined pretreatment that including ethanol, L-lysine and NaBH4 (92.9±58.3 ug/mg, p=0.288) were not significantly different from the controls (51.2±8.5 ug/mg). Both the combined pretreatment using ethanol and L-lysine (7.60±1.55, p=0.76) and the combined pretreatment that included ethanol, L-lysine and NaBH4 (7.47±1.85, p=0.33) increased the tensile strength/thickness ratio compared with that of the controls (4.75±1.88). Conclusion: The combined pretreatment using ethanol and L-lysine seemed to decrease the calcification of porcine pericardium fixed with glutaraldehyde, as compared to single pretreatment, and it increase the tissue elasticity, but to the degree that showed synchronized synergism. NaBH4 pretreatment seemed to increase the calcification of porcine pericardium, irrespective of whether single or combined pretreatment was used. 배경: 이종조직의 석회화는 기존에 사용된 돼지 판막이나 소 심낭을 이용한 생체 인공조직의 임상 실패의 주된 원인으로 알려져 있다. 최근에 항석회화 효과를 높이고자 기전이 다른 여러 처치를 병합하는 시도들이 보고되고 있다. 본 연구에서는 작용기전이 다른 ethanol, L-lysine, NaBH4을 병합 처리하였을 때 예상되는 상승 효과를 석회화와 조직의 신축력(elasticity)을 통해 알아보고자 하였다. 대상 및 방법: 0.625% Glutaraldehyde (4℃에서 2일, 상온에서 7일간) 고정한 돼지 심낭을 80% Ethanol (상온에서 1일), 혹은 0.1 M L-lysine (37℃에서 2일), 혹은 0.1 M NaBH4 (상온에서 2일)로 처리 한 후 각각의 두께(thickness)와 장력(tensile strength)을 측정하였다. 각각의 항석회화 처리한 돼지심낭을 생후 3주된 쥐의 피하조직에 이식하고 8주 뒤 칼슘을 정량하고 조직학적 소견을 관찰하였다. 결과: 0.625% glutaraldehyde 고정만 시행한 군(51.2±8.5 ug/mg)과 비교하여 80% Ethanol 처리한 군(13.6±10.0 ug/mg, p=0.008)과, L-lysine 처리한 군(15.3±1.0 ug/mg, p=0.002), 그리고 80% Ethanol과 L-lysine 처리한 군(16.1±11.1 ug/mg, p=0.012)은 통계적으로 의미 있게 칼슘의 침착량이 적었지만, NaBH4만 처리한 군(65.7±61.8 ug/mg, p=0.653)과 80% Ethanol, L-lysine, NaBH4로 모두 처리한 군(92.9±58.3 ug/mg, p=0.288)은 칼슘의 침착량이 더 많았다. 80% Ethanol과 L-lysine으로 처리한 군과 80% Ethanol, L-lysine, NaBH4로 모두 처리한 군의 장력/두께 비율(tensile strength/thickness ratio)은 각각 7.60±1.55, 7.47±1.85로 glutaraldehyde 고정만 시행한 군의 4.75±1.88보다 증가되어 있는 경향을 보였다(p=0.76, p=0.33). 결론: Ethanol과 L-lysine을 돼지심낭에 병합처치 하였을 때, Ethanol과 L-lysine을 단독처치 하였을 때와 비교하여, 비슷한 항석회화 효과와 조직의 신축력을 증가시키는 경향을 보였지만 병합처치에 의한 상승효과를 확인하지는 못하였다. NaBH4는 단독처치 혹은 병합처치 하였을 때 모두 석회화를 증가시키는 경향을 보였다.

돼지의 심낭, 판막을 이용한 이종이식 보철편의 개발 (고정 방법에 따른 조직학적 분석)

김관창,최창휴,이창하,이철,오삼세,박성식,김웅한,김경환,김용진 대한흉부외과학회 2008 Journal of Chest Surgery (J Chest Surg) Vol.41 No.3

Background: Various experimental trials for the development of bioprosthetic devices are actively underway, secondary to the limited supply of autologous and homograft tissue to treat cardiac diseases. In this study, porcine bioprostheses that were treated with glutaraldehyde (GA), ethanol, or sodium dodecylsulfate (SDS) were examined with light microscopy and transmission electron microscopy for mechanical and physical imperfections before implantation. Material and Method: 1) Porcine pericardium, aortic valve, and pulmonary valve were examined using light microscopy and JEM-100CX II transmission electron microscopy, then compared with human pericardium and commercially produced heterografts. 2) Sections from six treated groups (GA-Ethanol, Ethanol-GA, SDS only, SDS-GA, Ethanol-SDS-GA and SDS-Ethanol-GA) were observed using the same methods. Result: 1) Porcine pericardium was composed of a serosal layer, fibrosa, and epicardial connective tissue. Treatment with GA, ethanol, or SDS had little influence on the collagen skeleton of porcine pericardium, except in the case of SDS pre-treatment. There was no alteration in the collagen skeleton of the porcine pericardium compared to commercially produced heterografts. 2) Porcine aortic valve was composed of lamina fibrosa, lamina spongiosa, and lamina ventricularis. Treatment with GA, ethanol, or SDS had little influence on these three layers and the collagen skeleton of porcine aortic valve, except in the case of SDS pre-treatment. There were no alterations in the three layers or the collagen skeleton of porcine aortic valve compared to commercially produced heterografts. Conclusion: There was little physical and mechanical damage incurred in porcine bioprosthesis structures during various glutaraldehyde fixation processes combined with anti-calcification or decellularization treatments. However, SDS treatment preceding GA fixation changed the collagen fibers into a slightly condensed form, which degraded during transmission electron micrograph. The optimal methods and conditions for sodium dodecylsulfate (SDS) treatment need to be modified.

소아 환자에서 Duran Ring 사용 후 발생한 승모판협착 -2예 보고-

김관창,김웅한,최세훈,장우성,여인권,김용진 대한흉부외과학회 2005 Journal of Chest Surgery (J Chest Surg) Vol.38 No.12

Mitral stenosis was developed after Duran ring annuloplasty in two growing children during follow up period of 8 years and 5 years respectively, which may be due to pannus overgrowth and patient’s growing. Only removal of pannus and prosthetic ring has resulted in complete relieving of Mitral stenosis. With time, even adult-sized annuloplasty ring may induce stenosis in growing children. Duran ring을 이용하여 승모판막륜 성형술을 시행 받은 두 명의 소아 환자에서 술 후 8년과 5년 뒤에 판누스와 환자의 성장에 기인한 승모판협착이 발생하였다. 판누스와 Duran ring을 제거함으로써 승모판협착증은 호전되었다. 비록 어른에서 사용되는 충분한 크기의 판막륜 성형링이 사용되더라도 성장하는 소아에서는 시간이 지남에 따라 협착이 발생할 수 있다.

비정형적인 대동맥궁 축착 환자에서 상행 대동맥과 하행 대동맥간 우회로 조성술 -1예 보고-

김관창,김창영,최세훈,손국희,조광리,김경환,안혁 대한흉부외과학회 2006 Journal of Chest Surgery (J Chest Surg) Vol.39 No.4

대동맥궁의 형성 저하증과 비정형 대동맥궁 축착을 가진 환자에서 정중 흉골 절개술과 좌측 개흉술하에서 인공 심폐 바이패스 없이 상행 대동맥-하행 대동맥간 우회로 조성술을 시행하여 좋은 결과를 얻었기에 보고하는 바이다. 상행 대동맥-하행 대동맥간 우회로 조성술은 복잡한 대동맥궁 재건술이 필요한 경우에 다른 술식으로서 고려될 수 있을 것이다.

Detoxification of Glutaraldehyde Treated Porcine Pericardium Using L-arginine & NABH₄

김관창,Soo-Hwan Kim,김용진 대한흉부외과학회 2011 Journal of Chest Surgery (J Chest Surg) Vol.44 No.2

Background: Calcification is the most frequent cause of clinical failure of bioprosthetic tissues fabricated from GA-fixed porcine valves or bovine pericardium. A multi-factorial approach using different mechanisms was recently developed to reduce the calcification of bioprosthetic tissues. The purpose of the present study was to evaluate the synchronized synergism of using L-arginine and NaBH₄, compared with ethanol and L-lysine, in glutaraldehyde treated porcine pericardium from the standpoint of calcification and tissue elasticity. Materials and Methods: Porcine pericardium was fixed at 0.625% GA (7 days at room temperature after 2 days at 4℃). An interim step of ethanol (80%; 1 day at room temperature) or L-lysine (0.1 M; 2 days at 37℃) or L-arginine (0.1 M; 2 days at 37℃)was followed by completion of the GA fixation. A final step of NaBH₄(0.1 M; 2 days at room temperature) was followed. Their tensile strength, thickness, and thermal stability were measured. Treated pericardia were implanted subcutaneously into three-week-old Sprague-Dawley rats for 8 weeks. Calcium content was assessed by atomic absorption spectroscopy and histology. Results: L-arginine and NaBH4 pretreatment (1.81±0.39 kgf/5 mm p=0.001,0.30±0.08 mm p<0.001) significantly increased tensile strength and thickness compared with the control (0.53±0.34kgf/5 mm, 0.10±0.02 mm). In a thermal stability test, L-arginine and NaBH₄pretreatment (84.25±1.12oC, p=0.023)caused a significant difference from the control (86.25±0.00℃). L-lysine and NaBH4 pretreatment (183.8±42.6 ug/mg, p=0.804), and L-arginine and NaBH₄pretreatment (163.3±27.5 ug/mg, p=0.621) did not significantly inhibit calcification compared to the control (175.5±45.3 ug/mg), but ethanol and NaBH₄pretreatment did (38.5±37.3 ug/mg,p=0.003). Conclusion: The combined pretreatment using L-arginine and NaBH₄after GA fixation seemed to increase the tensile strength and thickness of porcine pericardium, fixed with GA. Additionally, it seemed to keep thermal stability. However it could not decrease the calcification of porcine pericardium fixed with GA. NaBH₄pretreatment seemed to decrease the calcification of porcine pericardium fixed with GA, but only with ethanol.

Changes of Gene Expression after Bone Marrow Cell Transfusion in Rats with Monocrotaline-Induced Pulmonary Hypertension

김관창,이혜련,김성진,조민선,홍영미 대한의학회 2012 Journal of Korean medical science Vol.27 No.6

Pulmonary artery hypertension (PAH) causes right ventricular failure and possibly even death by a progressive increase in pulmonary vascular resistance. Bone marrow-derived mesenchymal stem cell therapy has provided an alternative treatment for ailments of various organs by promoting cell regeneration at the site of pathology. The purpose of this study was to investigate changes of pulmonary haemodynamics, pathology and expressions of various genes, including ET (endothelin)-1, ET receptor A (ERA), endothelial nitric oxide synthase (NOS) 3, matrix metalloproteinase (MMP) 2, tissue inhibitor of matrix metalloproteinase (TIMP), interleukin (IL)-6 and tumor necrosis factor (TNF)-α in monocrotaline (MCT)-induced PAH rat models after bone marrow cell (BMC) transfusion. The rats were grouped as the control (C) group, monocrotaline (M) group, and BMC transfusion (B) group. M and B groups received subcutaneous (sc) injection of MCT (60 mg/kg). BMCs were transfused by intravenous injection at the tail 1 week after MCT injection in B group. Results showed that the average RV pressure significantly decreased in the B group compared with the M group. RV weight and the ratio of RH/LH+septum significantly decreased in the B group compared to the M group. Gene expressions of ET-1,ERA, NOS 3, MMP 2, TIMP, IL-6, and TNF-α significantly decreased in week 4 in the B group compared with the M group. In conclusion, BMC transfusion appears to improve survival rate, RVH, and mean RV pressure, and decreases gene expressions of ET-1, ERA,NOS 3, MMP 2, TIMP, IL-6, and TNF-α.

글루타르알데하이드 고정 돼지 심낭에서 L-lysine을 이용한 Diamine Bridge 효과

김관창,최윤경,김수환,김용진 대한흉부외과학회 2009 Journal of Chest Surgery (J Chest Surg) Vol.42 No.2

Background: Various studies and experimental trials have been done to develop bioprosthetic devices to treat complex congenital heart disease due to the limited usage of homograft tissue. The purpose of the present study was to evaluate the effect of diamine bridges with using L-lysine, as compared with using ethanol. Material and Method: Porcine pericardium was fixed at 0.625% GA (commercial fixation). An interim step of ethanol (80%; 1 day at room temperature) or L-lysine (0.1 M; 2 days at 37°C) was followed by completion of the GA fixation (2 days at 4°C and 7 days at room temperature). The tensile strength and thickness of the porcine percardium were measured, respectively. The treated pericardiums were implanted subcutaneously into three-week old Long-Evans rats for 8 weeks. The calcium content of the implants was assessed by atomic absorption spectroscopy and the histology. Result: Ethanol pretreatment (13.6±10.0 ug/mg, p=0.008), L-lysine pretreatment (15.3±1.0 ug/mg, p=0.002), and both treatment (16.1±11.1 ug/mg, p=0.012) significantly inhibited calcification, as compared with the controls (51.2±8.5 ug/mg). L-lysine pretreatment (0.18±0.02 mm, 1.20±0.30 kg f/5 mm) significantly increased the thickness and tensile strength, as compared with ethanol pretreatment (0.13±0.03 mm, 0.85±0.36 1.0 kg f/5 mm) (p<0.01, p=0.035). Conclusion: The diamine bridges using L-lysine seemed to decrease the calcification of porcine pericardium fixed with glutaraldehyde, and this was comparable with Ethanol. Additionally, it seemed to enhance the thickness and tensile strength. 배경: 폐동맥 판막 협착 혹은 형성 부전을 동반한 여러 선천성 심장기형의 수술적 치료를 위하여, 다양한 종류의 우심실-폐동맥간 도관이 사용되었다. 장기 성적이 우수한 냉동동종 이식편(cryopreserved homograft)의 공급의 제한으로 이를 대체할 이종 조직 이식편의 석회화 방지를 위한 효과적인 기법의 확립이 필요하다. 본 연구에서는 L-lysine을 이용한 diamine bridge의 항석회화 효과를 Ethanol과 비교하여 알아 보고자 하였다. 대상 및 방법: 0.625% glutaraldehyde (4°C에서 2일, 상온에서 7일간) 고정한 돼지 심낭을 80% Ethanol (상온에서 1일), 혹은 0.1 M L-lysine (37°C에서 2일)로 처리 한 후 각각의 두께(thickness)와 장력(tensile strength)을 측정하였다. 각각의 항석회화 처리한 돼지심낭을 생후 3주된 쥐의 피하조직에 이식하고 8주 뒤 칼슘을 정량하고 조직학적 소견을 관찰하였다. 결과: 0.625% glutaraldehyde 고정만 시행한 군(51.2±8.5 ug/mg)과 비교하여 0.625% glutaraldehyde 고정 후에 80% Ethanol 처리한 군(13.6±10.0 ug/mg, p=0.008)과, 0.625% glutaraldehyde 고정 후에 L-lysine 처리한 군(15.3±1.0 ug/mg, p=0.002), 그리고 0.625% glutaraldehyde 고정 후에 80% Ethanol과 L-lysine 처리한 군(16.1±11.1 ug/mg, p=0.012)은 통계적으로 의미 있게 칼슘의 침착량이 적었다. 0.625% glutaraldehyde 고정 후에 80% Ethanol 처리한 군의 두께와 장력은 각각 0.18±0.02 mm, 1.20±0.30 kg 중/5 mm로 0.625% glutaraldehyde 고정 후에 L-lysine 처리한 군의 0.13±0.03 mm, 0.85±0.36 1.0 kg 중/5 mm 보다 증가되어 있었다(p<0.01, p=0.035). 결론: L-lysine을 이용한 diamine bridge는 Ethanol과 비교하여 비슷한 항석회화 효과를 보여 주었으며 Cross-link를 증가시켜 이종 이식편의 두께와 장력을 증가시켜 주는 효과가 있었다.

요골동맥과 복재정맥을 이용한 관상동맥우회술의 조기성적

김관창,원태희,한재진,최수승,안재호 이화여자대학교 의과학연구소 2008 EMJ (Ewha medical journal) Vol.31 No.2

Background:Increasing interest and use of arterial conduits is based on the better patency of left internal thoracic artery(LITA) than that of saphenous vein(SV) graft. We compared the early result of coronary artery bypass grafting(CABG) using LITA and radial artery(RA group) with CABG using LITA and SV only(SV group). Material and Method:We compared the early operative results of 6 cases in RA group with 18 cases in SV group selected from 24 cases that had CABG between January 2006 and December 2006. We analyzed each group on the preoperative risk factors and operative results. Results:We can’t find significant differences in clinical and hemodynamic characteristics before surgery. There were no statically significant difference between two groups in operative mortality and each morbidities(postoperative intraaortic balloon pump insertion, bleeding, stroke, perioperative myocardial infarction, wound dehiscence), respectively. However, the overall incidence of conventional CABG using cardiopulmonary bypass was higher in RA group compared to SV group(p=0.016). Accordingly, RA group had longer duration of ventilation time(p=0.004) and ICU stay(p=0.003) than SV group with statically significant difference between two groups in hospital stay. The graft patency on postoperative coronary angiography or computerized tomographic angiography at 7-14 days after operation in both group patients were 100%(includeing LITA, RA and SV). Conclusion:We had early good operative results in RA group and SV group. 관상동맥우회술에서 내흉동맥의 장기개통률이 복재정맥보다 우수하다는 것이 알려짐과 더불어 두 개의 내흉동맥을 이용한 군에서의 장기 임상 성적이 하나의 내흉동맥만을 이용한 군에서의 성적보다 우월하다 것이 알려지면서 최근에는 동맥이식편의 사용이 증가하고 있다1)2). 좌내흉동맥이 동맥이식편중 가장 많이 그리고 오래 전부터 사용되어왔고 그 장기 개통률이 매우 우수한 것으로 증명되면서, 이식편으로 사용 가능한 다른 동맥이식편에 대한 사용이 늘어나고 있는 추세이다. 좌내흉동맥 이외에 사용될 수 있는 동맥이식편으로는 요골동맥, 우내흉동맥, 우위망막동맥 등이 있다. 이 중 우내흉동맥은 좌내흉동맥과 같이 사용한 경우 장기 생존율이 높다는 보고도 있지만 가용길이가 짧아 이용에 한계가 있고 수술시간이 길어지며 상처 합병증과 기술적인 문제 등이 있다2). 요골동맥은 Carpentier 등3)에 의해 1970년대 초 처음 이식편으로 소개되었으나 추적 관상동맥조영술상 높은 이식편 부전으로 인해 사용이 중단되었다가 1989년 다시 소개되어 주목을 받게 되었고4), 요골동맥박리술의 기술적인 변형과 항연축제의 사용으로 요골동맥의 연축을 최소화하여 사용하면서 많은 저자들에 의해 좋은 임상 성적과 높은 개통률을 보이고 있다5-7). 본 이화여자대학교 목동병원 흉부외과에서도 요골동맥을 좌내흉동맥에 이은 두 번째 동맥이식편으로 사용하고 있는데 본 연구에서는 본원에서 경험한 요골동맥을 사용하여 시행한 관상동맥우회술의 임상 성적과 수술 후 관상동맥조영술 혹은 컴퓨터 단층 혈관조영술 결과를 분석해 보고 아울러 이를 요골동맥을 사용하지 않고 내흉동맥과 복재정맥만을 이용한 군의 성적과 비교 분석해 보았다.