개심술(開心術) 2,000례의 임상적 고찰

김하늘루,박경택,곽기오,한일용,소영환,최강주,이양행,조광현 대한흉부심장혈관외과학회 1998 Journal of Chest Surgery (J Chest Surg) Vol.31 No.12

배경: 인제 대학교 의과대학 부산 백병원 흉부외과학 교실에서는 1985년 9월부터 1997년 9월까지 총 2,000례의 개심술을 시행하였다. 대상 및 방법: 전체 2,000례의 개심술 중 선천성 심질환이 1532례, 후천성 심질환이 468례였다. 연령별 분포는 선천성 심질환에서는 생후 9일에서 68세 까지였고, 후천성 심질환에서는 11세부터 66세 까지였다. 결과: 선천성 심질환군은 심실중격 결손증(VSD)이 940례, 심방중격 결손증(ASD)이 324례, 팔로 4징증(TOF)이 112례, 폐동맥 협착(PS)이 46례, 심내막상 결손(ECD)이 38례, 발살바동 파열(Valsalva sinus rupture)이 15례, 완전 대혈관 전위증(TGA) 과 양대혈관 우심실 기시증(DORV) 각각 4례 등으로 구성되었다. 선천성 심질환군에서는 근치적 수술후 3.1%의 사망률을 보였다. 후천성 심질환군 468례 중 심장 판막질환이 381례, 허혈성 심질환이 48례, 심장종양이 12례, Annuloaortic ectasia가 8례, 박리성 대동맥류가 16례 등이었다. 381례의 판막질환 중 단일 판막 치환술이 226례(대동맥 판막 치환술 36례, 승모판막 치환술 188례, 삼첨판막 치환술 2례), 이중 판막 치환술이 71례(대동맥 판막 치환술 과 승모판막 치환술), 승모판막 치환술과 삼첨판막 성형술을 동시에 시행한 경우가 54례, 이중 판막치환술과 삼첨판막 성형술을 동시에 시행한 경우가 18례 등이었다. 사용된 인공판막은 총 466개 였다. 승모판막 치환술에 사용된 인공판막은 St. Jude Medical 판막이 123개, Carpentier-Edwrads 판막이 90개, CarboMedics 판막이 65개, Sorin 판막이 42개, 기타 판막이 16개였다. 대동맥 판막 치환술에 사용된 인공 판막은 St. Jude Medical 판막이 68개, CarboMedics 판막이 36개, Carpentier-Edwards 판막이 14개, 기타 판막이 9개 였다. 관상동맥 우회술(CABG)은 48례에서 시행되었다. 혈관 이식편의 수는 단일 혈관 이식이 14례, 이중 혈관 이식이 21례, 삼중 혈관 이식이 10례, 사중 혈관 이식이 3례였다. 결론: 술후 재원 기간내 사망률은 비청색증 선천성 심질환에서 2.0%, 청색증 선천성 심질환에서 15.5%, 후천성 심질환에서 5.1%였다. 전체 사망률은 2,000례 중 72명이 사망하여 3.6%였다 Background: From Sept. 1985 to Sept. 1997, 2,000 cases of open heart surgery(OHS) were performed in the Department of Thoracic & Cardiovascular Surgery, Pusan Paik Hospital, College of Medicine, Inje University. Material and Method: Among the total of 2,000 cases of OHS, 1532 cases were congenital heart disease(CHD) and 468 cases were acquired heart disease(AHD). The age distribution was 9 days(4.0kg) to 68 years in CHD and 11 to 66 years in AHD. In 1532 cases of CHD, there were 1403 acyanotic cases and 129 cyanotic cases. Result: The CHD cases consisted of 940 ventricular septal defects(61.4%), 324 atrial septal defects(21.1%), 112 tetralogy of Fallot(7.3%), 46 pulmonary stenosis(3%), 38 endocardial cushion defects(2.5%), 15 valsalva sinus ruptures(1%), 4 transposition of great arteries (0.3%), 4 double outlet right ventricles(0.3%), and etc. Corrective operations were applied for congenital heart disease with a result of 3.1% hospital mortality. Of 468 AHD, 381 cases were valvular heart diseases, 48 ischemic heart diseases, 12 cardiac tumors, 8 annuloaortic ectasias, 16 dissecting aortic aneurysms and etc. In the 381 valvular heart diseases, there were 226 single valve replacements(36 aortic valve replacements(AVR), 188 mitral valve replacements(MVR), and 2 tricuspid valve replacements(TVR), among these were 71 cases of double valve replacements(AVR & MVR), 54 cases of MVR with tricuspid valve annuloplasty(TVA), and 18 cases of AVR, MVR with TVA. The total implanted prosthetic valves were 466. In MVR, 123 St. Jude Medical valves, 90 Carpentier-Edwards valves, 65 CarboMedics valves, 42 Sorin valves and 16 other valves were used. In AVR, 68 St. Jude Medical valves, 36 CarboMedics valves, 14 Carpentier-Edwards valves and 9 other valves were used. Coronary Artery Bypass Surgery(CABG) were performed in 48 cases. The patterns of bypass graft were 14 patients of single vessel graft, 21 patients of two vessels graft, 10 patients of three vessels graft and 3 patients of four vessels graft. Conclusion: The hospital operation mortality rate of congenital acyanotic, cyanotic and acquired heart diseases were 2.0%, 15.5%, and 5.1% respectively. The overall mortality rate was 3.6%(72/2,000).

Ravitch 술식으로 교정한 누두흉 치험

김하늘루,최강주,이양행,조광현 대한흉부심장혈관외과학회 1999 Journal of Chest Surgery (J Chest Surg) Vol.32 No.10

Background: The purpose of this study is to analyze the clinical results ad operative compatability by Ravitch methods with pectus excavatum. Material and Method: From 1984 to 1997, were performed Ravitch operations in 40 patients of pectus excavatum and analyzed the effects of correction and postoperative complication according to time of operation retrospectively. The group comprised 35 mem and women whose mean age was 8.9$\pm$7.9 years(between 2 to 35 years). All patients had corrected with Ravitch operation or its modified operation. Modified fixations were accomplished with K-wire in 15 patients and internal plate in 2 and the materials were removed 3 months after operation. The result of correction was estimated with the degree of changed distance between inner surface of sternal body and vertebral in 3 months after correction. Result: Postoperative complications were wound disruption in 14 patients. Estimated distances after correction ranged 0.4 cm to 4 cm. The acceptability for chest wall correction was high(6 excellent, 29 good in criteria of Humphreys). Conclusion: We concluded that the benefits of Ravitch operation were a high acceptability of patients and their family, and sufficient correction with no specific complications related operation.

체외순환에 따른 혈액학적 변화와 술후 출혈에 관계하는 인자에 관한 연구

김하늘루,황윤호,최석철,최국렬,김승우,조광현 대한흉부심장혈관외과학회 1998 Journal of Chest Surgery (J Chest Surg) Vol.31 No.10

연구배경 : 체외 순환으로 인한 지혈 기전의 심각한 손상은 술후 과다 출혈을 일으켜 환자의 생명을 위협하고, 대량 수혈에 따른 부작용과 재수술의 우려마저 증가시킬 수 있다. 특히, 심장 수술동안 섬유소 용해계의 활성화와 혈소판의 숫적, 기능적 변화가 술후 상당 시간동안 출혈의 원인이 된다고 보고하고 있다 대상 및 방법 : 본 연구는 체외 순환 동안 및 그 후에 있어, 체외 순환에 의한 섬유소 용해계의 활성화를 포함한 다양한 혈액학적 변화를 조사하고, 이러한 변화들이 술후 비외과적 출혈의 정도와 어떤 상관성이 있는가를 규명하기위해 체외 순환을 실시할 성인 환자 20명을 대상으로 전향적으로 계획되었다. 혈소판 수, 섬유소원 및 plasminogen 농도, FDP, D-dimer, BT, aPTT, PT와 같은 혈액학적 변수의 측정을 위해 수술동안 또는 술후 시기에 혈액을 연속적으로 채취하였다. 출혈량은 흉부 삽관을 통한 배출량을 술후 3, 6, 12, 24, 48시간의 양과 총혈액량을 각각 측정하였다. 결과 : 연구 결과를 요약하면 다음과 같다:혈소판 수는 체외 순환으로 인해 급격히 감소되었다 (p<0.01). 총 체외 순환 시간이 길수록 혈소판 수의 감소률은 더 높았으며 (r=0.55, p=0.01) 술후 7일이 되어서야 비로소 술전치에 근접하였다. 체외 순환동안 FDP와 D-dimer의 농도가 의미있게 증가하였고 (p<0.0001), 섬유소원 및 plasminogen 농도 둘 다 서로간에 상관성을 보이면서 감소하였다 (r=0.57, p<0.01). 술후 2hr-BT, 2hr-PT, 2hr-aPTT 모두 술전치에 비해 유의하게 연장되었다(각각 p<0.05, p<0.0001, p<0.0001). 술후 총 출혈량과 환자의 연령, 대동맥 차단 시간, 체외 순환 시간은 각각 양의 상관관계 (positive correlation)가 있었다. 술전 기준치 혈소판 수와 술후 3시간 출혈량, 체외 순환 종료시의 혈소판 수와 술후 3시간, 6시간 및 총 출혈량 그리고 술후 1일의 혈소판 수와 48시간 출혈량 사이에는 각각 음의 상관관계 (negative correlation)가 있었다. 술후 2hr-aPTT는 술후 6시간 및 48시간대의 출혈량에 상관성이 있었고 (r=0.53, p=0.02) 술후 2hr-PT는 48시간 출혈량과 각각 양의 상관성이 있었으나 (r=0.43, p=0.05). 이 두가지 변수와 총 출혈량 간에는 상관성이 없었고, 술후 2hr-BT와 술후 출혈량 사이에도 유의한 상관성을 발견하지 못하였다. 결론 : 이상의 관찰 결과들은 체외 순환이 섬유소 용해계의 활성화와 혈소판 수의 심한 감소를 포함한 다양한 혈액학적 변화를 유도하고 환자의 연령, 혈소판 수, 대동맥 차단 시간, 체외 순환 시간, 술후 PT 및 aPTT와 같은 다인적 상황들이 술후 출혈에 영향을 미친다는 점들을 시사하고 있다. 본 연구 결과들은 체외 순환에 따른 지혈적 손상에 관한 이해와 술후 출혈을 감소시키기 위한 기초 자료로 활용 가능하리라 사료된다. Background: Cardiopulmonary bypass(CPB)-induced hemostatic defects may result increased possibility of excessive hemorrhage and additional multiple transfusion reactions or reoperation. Particularly, fibrinolytic activation and decreased platelet count and function by CPB were proposed as a predictor of hemorrhage during postoperative periods in several reports. Materials and methods: Present study, which was conducted in 20 adult patients undergoing CPB, was prospectively designed to examine the hematologic changes, including fibrinolytic activation during and after CPB and to clarify the relationships between these changes and the magnitude of the postoperative nonsurgical blood loss. The serial blood samples for measurment of hematologic parameters were taken during operation and postoperative periods. Blood loss was respectively counted via thoracic catheter drainage at postoperative 3, 6, 12, 24, 48 hours and total period. Results: The results were obtained as follows:Platelet count rapidly declined following CPB(p<0.01), which its decreasing rate was an inverse proportion to total bypass time(TBT, r=0.55, p=0.01), And platelet count in postoperative 7th day was barely near to its control value. Fibrinogen degradating product(FDP) and D-dimer level significantly increased during CPB(p<0.0001, p<0.0001, respectively), and both of fibrinogen and plasminogen concentration correlatively decreased during CPB(r=0.57, p<0.01), implying activation of fibrinolytic system. Postoperative bleeding time (BT), postoperative activated partial thromboplastin time(aPTT) and postoperative prothrombin time (PT) were significantly prolonged as compare with each control value (p=0.05, p<0.0001, p<0.0001, respectively). Total blood loss was positively correlated with patient's age, aortic clamping time (ACT) and TBT, while there was negative correlation between platelet count and blood loss at pre-CPB, CPB-off and the 1st postoperative day, and in some periods. Postoperative aPTT and postoperative PTwere positively related to postoperative 6 hr and 48 hr blood loss(r=0.53, p=0.02; r=0.43, p=0.05) but not to total blood loss, whereas there was no relationship between postoperative BT and blood loss at any period. Conclusions: These observations suggest that CPB results various hematologic changes, including fibrinolytic activation and severe reduction in platelet count. Diverse factors such as age, platelet count, ACT, TBT and postoperative aPTT and PT may magnify the postoperative bleeding. This study will be a basic reference in understanding CPB-induced hemostatic injuries and in decreasing the postoperative hemorrhage

협소 대동맥 판륜을 가진 환자에서의 대동맥치환술시 판륜 확장술의 중기 성적

박광훈,김하늘루,최강주,이양행,황윤호,조광현 대한흉부심장혈관외과학회 2000 Journal of Chest Surgery (J Chest Surg) Vol.33 No.4

Background: For AVR using conventional prosthetic valves in adult patients with a narrow aortic root, aortic root enlargement is necessary to reduce postoperative pressure gradient across the aortic valve (ΔP). An evaluation of early and mid-term results of aortic root enlargement with AVR and echocardiographic follow up of ΔP and left ventricular function was performed. Method: From Aug. 1991 to Feb. 1998, eighteen patients aged 17 to 59 years(mean, 38$\pm$12 years) underwent Manouguian procedure with AVR. Aortic annular circumstance was enlarged 10.0mm to 18.0mm(mean, 12.6$\pm$6.3mm). Eight patients(44.0%) had NYHA class III status before operation, and seven cases of them underwent concomitant MVR. Valve pathology was ASr in 6 cases, AS in 4 cases, nd ASr+MSr in 8 cases. Replaced valve size was 21mm in 8 cases and 23 mm in 10 cases, and St. Jude Medical mechanical valve was used in 10 cases and Carbomedics in 8 cases. Result: Follow-up duration was 6 to 57 months (mean, 26$\pm$18 months), and total follow-up was 287 patient-year. There were one hospital death and one late death, therefore, actuarial survival rate was 85.7% at 56 months. Peak ΔP wad decreased significantly at postoperative mid-term period as 13$\pm$5mmHg, compared with thepreoperative one (42$\pm$8mmHg) (p<0.01). LVM(gm/$m^2$) was also diminished as 35.8%(115$\pm$36gm/$m^2$)at postoperative mid-term period, compared with preoperative one (179$\pm$56gm/$m^2$)(p<0.05). Conclusion: There were no specific complications related to the procedure. And we could have adequate enlargement of aortic annulus to suitable prosthetic valve that have no effect of patient-prosthese mismatch.