Association of preoperative hemoglobin a1c with in-hospital mortality following valvular heart surgery

Abstract Objective: To determine the association between the preoperative level of hemoglobin A1c (HbA1c) and in-hospital mortality in patients who underwent valvular heart surgery in our center in a retrospective cohort. Methods: In this retrospective consecutive cohort study, patients with type 2 diabetes mellitus who were referred to our center for elective valvular surgery were enrolled and followed up. The endpoint of this study was in-hospital mortality. Based on the level of HbA1c, patients were dichotomized around a level of 7% into two groups: exposed patients with HbA1c ≥ 7% and unexposed patients with HbA1c < 7%. Then, the study variables were compared between the two groups. Results: Two hundred twenty-four diabetic patients who were candidates for valvular surgery were enrolled; 106 patients (47.3%) had HbA1c < 7%, and 118 patients (52.6%) had HbA1c ≥ 7%. The duration of diabetes was higher in patients with HbA1c ≥ 7% (P=0.007). Thirteen (5.8%) patients died during hospital admission, of which nine patients were in the high HbA1c group. There was no significant difference between the groups regarding in-hospital mortality (P=0.899). Both the unadjusted and adjusted logistic regression models showed that HbA1c was not a predictor for in-hospital mortality (P=0.227 and P=0.388, respectively) Conclusion: This study showed no association between preoperative HbA1c levels and in-hospital mortality in candidates for valvular heart surgery.

Acceleration of skin wound healing with tragacanth [Astragalus] preparation: an experimental pilot study in rats

Gum tragacanth is a natural complex mixture of polysaccharides and alkaline minerals extracted from species of Astragalus plant, which is found widely in arid regions of the Middle East. In a pilot experimental study we examined the effects of its topical application on wound healing in ten albino adult male rats. Two similar parasagittal elliptical full-thickness wounds [control vs. test samples] were created on the dorsum of each animal. Test group samples were fully covered by a thin layer of gum tragacanth daily. The extent of wound healing was evaluated by planimetric analysis on multiple occasions during the 10-day study period. On the 7[th] day of the study, the percent of wound closure was significantly higher in gum tragacanth-treated specimens compared to the control samples [87% +/- 2% vs. 70% +/- 4%, P<0.001]. The majority of wounds in the test group were completely closed by the 10[th] day of the study. The difference in wound healing index measured by histological examination on day 10 of the study was also statistically meaningful between the two groups [0.624 +/- 0.097 vs. 0.255 +/- 0.063, P<0.05]. The results of this study clearly showed the useful effects of topical application of gum tragacanth in acceleration of skin wound contraction and healing. More studies are encouraged to identify the implicating agents and precisely understand the mechanism by which they exert their wound healing effects

Central venous line and acute neurological deficit: a case series

Central venous catheter [CVC] insertion is a practical way to assess patients hemodynamic specially in cardiovascular surgery but this relatively simple junior level procedure is not risk free and its common reported complications include; pneumothorax, hydrothorax, hemothorax, local hematoma, cardiac tamponade, vascular injury, thrombosis, embolism, and catheter disruption. Here in this article we are going to present 6 patients with very unusual presentation of CVC complication which was neurological deficit presented by agitation, unconsciousness, disorientation to time and place and hemiparesis. All patients undergone neurologic consult and brain computed tomography. Final diagnosis was brain ischemic damage and finally we kept them on conservative management; fortunately we did not have any permanent damage

Positive family history as the single traditional risk factor for developing extensive very premature coronary artery disease: a case report

Although coronary artery disease [CAD] is not common among individuals younger than 40-45 years of age, a small percentage of this age group needs to undergo surgical revascularization because of CAD. Why some people are at higher risk of developing premature CAD is not clearly known. Increased number of traditional risk factors or genetic predisposition may play significant roles in this regard. A 22-year-old man with a negative history for all traditional risk factors except for a family history of premature CAD referred to our center due to an episode ofmyocardial infarction of one month s duration. He had no congenital heart disease and no hypercoagulable state, and there was a negative history of drug abuse. His coronary angiography showed extensive CAD. He underwent coronary artery bypass grafting and he left the hospital in good healthy condition. One year after surgery, his follow-up showed that he was symptom free and he still had no new traditional risk factor. It seems that a positive family history of premature CAD is an important and independent risk factor for developing premature CAD and individuals with this type of history should be treated more cautiously

comparative study of recombinant human basic fibroblast growth factor [bFGF] and erythropoietin [EPO] in prevention of skin flap ischemic necrosis in rats

Impaired wound healing in ischemic tissues such as skin flaps resulting from inefficient perfusion is one major cause of complications in plastic surgery. In present experimental study, we investigated the effects of fibroblast growth factor-2 [FGF-2 or bFGF] and erythropoietin [EPO] in prevention of skin flap necrosis in rats. 30 adult albino rats were randomized into 3 groups: in control group, normal saline solution; in EPO group, erythropoietin [100U/ kg/day]: and in FGF-2 group, fibroblast growth factor-2 [2,5 microg/day] were injected subcutaneously in 3 daily consecutive doses in the designated flap areas before creating 4:1 random pattern skin flaps on the dorsum of animals. Areas of ischemic [S] and necrotic [S[N]] zones were measured and compared in all groups one week after the flap creations. The necrotic zone [S[N]], as well as the ratio of the necrotic zone to the total discolored zone [S[N]/[S[I]+S[N]]] were substantially larger in the control group [41% +/- 7%, 90% +/- 6%] compared to the EPO [20% +/- 2%,42% +/- 4%] and the FGF-2 [8% +/- 2%,19% +/- 3%] groups [p < 0.001]. The differences in these values were also meaningful between the EPO and FGF-2 groups [p < 0.001].Vascular density in ischemic area of the control group was less than those in the EPO and the FGF-2 groups; however, the differences were not statistically significant between any of the groups [p > 0.05]. Local administration of erythropoietin or fibroblast growth factor-2 in skin flaps could remarkably increase tissue viability and accelerate the wound healing process. However, the therapeutic effect of fibroblast growth factor-2 in preventing the necrotic event in, ischemic zones of skin flaps is much more considerable than that of erythropoietin

Knowledge management in cardiac surgery: the second Tehran heart center adult cardiac surgery database report

The Adult Cardiac Surgery Databank [ACSD] of Tehran Heart Center was established in 2002 with a view to providing clinical prediction rules for outcomes of cardiac procedures, developing risk score systems, and devising clinical guidelines. This is a general analysis of the collected data. All the patients referred to Tehran Heart Center for any kind of heart surgery between 2002 and 2008 were included, and their demographic, medical, clinical, operative, and postoperative data were gathered. This report presents general information as well as in-hospital mortality rates regarding all the cardiac procedures performed in the above time period. There were 24959 procedures performed: 19663 [78.8%] isolated coronary artery bypass grafting surgeries [CABGs]; 1492 [6.0%] isolated valve surgeries; 1437 [5.8%] CABGs concomitant with other procedures; 832 [3.3%] CABGs combined with valve surgeries; 722 [2.9%] valve surgeries concomitant with other procedures; 545 [2.2%] surgeries other than CABG or valve surgery; and 267 [1.1%] CABGs concomitant with valve and other types of surgery. The overall mortality was 205 [1.04%], with the lowest mortality rate [0.47%] in the isolated CABGs and the highest [4.49%] in the CABGs concomitant with valve surgeries and other types of surgery. Meanwhile, the overall mortality rate was higher in the female patients than in the males [1.90% vs. 0.74%, respectively]. Isolated CABG was the most prevalent procedure at our center with the lowest mortality rate. However, the overall mortality was more prevalent in our female patients. This database can serve as a platform for the participation of the other countries in the region in the creation of a regional ACSD.

Prosthetic tricuspid valve thrombosis: three case reports and literature review

A common complication of prosthetic heart valves is thrombosis. Although the incidence of prosthetic valve thrombosis [PVT] in the tricuspid position is high, there are not enough data on the management of it, in contrast to left-sided PVT. Here, we describe three cases of tricuspid PVT with three different management approaches: thrombolytic therapy; close observation with oral anticoagulants; and surgery. The first case was a woman who suffered from recurrent PVT, for which we successfully used Tenecteplase for second and third episodes. We employed Tenecteplase in this case for the first time in the therapy of tricuspid PVT. The second case had fixed leaflets in open position while being symptomless. At six months' follow-up, with the patient having taken oral anticoagulants, the motion of the leaflets was restricted and she was symptom-free. The last case was a woman who had a large thrombus in the right atrium immediately after mitral and tricuspid valvular replacement. The patient underwent re-replacement surgery and a new biological valve was implanted in the tricuspid position. Also, we review the literature on the pathology, signs and symptoms, diagnosis, and management of tricuspid PVT

Impact of diabetes mellitus on peripheral vascular disease concomitant with coronary artery disease

The aim of this study was to evaluate the impact of diabetes mellitus [DM] on peripheral vascular disease [PVD] in patients with coronary artery disease [CAD]. A total of 13702 consecutive patients who underwent coronary artery bypass grafting [CABG] at Tehran Heart Center between January 2002 and March 2007 were included in this study. The demographic data, PVD, and outcome of these patients were reviewed. CABG patients before surgery were detected for PVD [stenosis >/= 70% in the abdominal aorta; renal, carotid, and iliac arteries; or any other peripheral vascular system] with physical examination and past medical history. The suspected cases of PVD were, thereafter, confirmed via Doppler sonography or invasive angiography. This study recruited 4344 diabetic patients [mean age 59.30 +/- 8.7 years] and 9358 non-diabetic patients [mean age 58.42 +/- 9.9 years]. The diabetics were significantly older and had a higher incidence of PVD [2.7% vs. 1.8%], female gender, hypertension, renal failure, smoking, and dyslipidemia than the non-diabetics [P < 0.05]. There was no significant difference between the two groups with regard to family history and left main disease. Also, the mean ejection fraction [EF] was 48.85% +/- 10.4 and 49.35% +/- 10. In the patients with and without DM, respectively; and the difference was significant [P = 0.008]. The in-hospital mortality rate [mortality over a 30-day post-operative period] was 1.8% in the diabetics and 0.7% in the non-diabetics [P < 0.001]. In the multivariate analysis, PVD, left main disease, age, female gender, and EF were significant in the development of mortality amongst the diabetic patients with a respective odds ratio of 4.17, 5.54, 1.03, 2.86, and 0.95 [P

Early outcome of coronary artery bypass grafting in patients with severe left ventricular dysfunction

Left ventricular dysfunction is one of the most powerful predictors of early and late outcomes in patients who undergo coronary artery bypass grafting [CABG]. The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay [LOS] after CABG in patients with an ejection fraction [EF] of 30% or less. Seven hundred seven patients who underwent CABG with EF 30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. The thirty-day mortality rate [2.3% vs. 0.8%, P<0.0001], the mean of LOS [P<0.0001], and the mean of the length of ICU stay [P<0.0001] were higher in the severe left ventricular dysfunction group than in the control group. In patients with severe left ventricular dysfunction, the mean of NYHA score [P=0.0081], prolonged ventilation [P=0.0051], and renal failure [P=0.0606] were related to the 30-day mortality rate. Also, the prolonged LOS in these patients was correlated with the female gender [P=0.0018] and atrial fibrillation [P=0.0164]. Although left ventricular dysfunction is itself an important strong risk factor in patients undergoing CABG, the early outcome of CABG in patients with left ventricular dysfunction is acceptable and the management of this factor will help to reduce the mortality and total length of stay in hospital

Comparison between transepicardial cell transplantations: Autologus undifferentiated versus differentiated marrow mesenchymal stem cells

Marrow-derived mesenchymal stem cells [MSCs] have been heralded as a source of great promise for the regeneration of the infarcted heart. There are no clear data as to whether or not in vitro differentiation of MSCs into major myocardial cells can increase the beneficial effects of MSCs. The aim of this study was to address this issue. To induce MSCs to transdifferentiate into cardiomyocytes and endothelial cells, 5-Azacytidine and vascular endothelial growth factor [VEGF] were used, respectively. Myocardial infarction in rabbits was generated by ligating the left anterior descending coronary artery. The animals were divided into three experimental groups: I] control group, II] undifferentiated mesenchymal stem cell transplantation group, and III] differentiated mesenchymal stem cell transplantation group. The three groups received peri-infarct injections of culture media, autologous undifferentiated MSCs, and autologous differentiated MSCs, respectively. Echocardiography and pathology were performed in order to search for improvement in the cardiac function and reduction in the infarct size. Improvements in the left ventricular function and reductions in the infarcted area were observed in both cell transplanted groups [Groups II and III] to the same degree. There is no need for prior differentiation induction of marrow-derived MSCs before transplantation, and peri-infarct implantation of MSCs can effectively reduce the size of the infarct and improve the cardiac function

Impact of Dialysis on Open Cardiac Surgery

Dialysis patients frequently have coronary artery disease but are regarded as high risk patients for coronary artery bypass grafting [CABG]. Between February 2002 and September 2006, seventeen dialysis-dependent patients underwent isolated CABG at our center. CABG was performed under cardiopulmonary bypass [CPB] for all the patients. All cases had been maintained on hemodialysis and the duration of preoperative hemodialysis ranged from 6 to 24 months [mean 13.4 +/- 6.4]. The patients' characteristics, clinical and operative data as well as preoperative and mid-term outcome were reviewed. All patients were men with a mean age of 53 +/- 8.4 years. Mean preoperative ejection fraction was 45.5% +/- 10.4% [range 25 to 60%]. One internal mammary graft was used in 16 [94.1%] patients. Cardiopulmonary bypass and aortic cross-clamp times were 71.3 +/- 18.7 and 40.5 +/- 8.3 minutes respectively. The more frequent complication was prolonged mechanical ventilation in 2 [11.7%], there was no preoperative mortality. In mid-term follow-up [mean time: 11.8 +/- 9.5 months] the mid-term mortality rate was 20% [3 patients]. CABG in chronic renal dialysis patients can be accomplished with acceptable short and mid-term morbidity and mortality