Myeloid sarcoma without circulating leukemia mimicking gastrointestinal malignancy and lymphoma.

We present an unusual case of myeloid sarcoma with ascites and abdominal pain in which initial clinical, laboratory, and imaging studies suggested a gastrointestinal malignancy or lymphoma. Subsequent detection of leukemic ascites and blasts in a gastric, small bowel, and skin biopsy supported a diagnosis of myeloid sarcoma. Bone marrow biopsy revealed 15% blasts, and cytogenetics with an inversion 16 rearrangement was diagnostic of acute myeloid leukemia (AML). Positron emission tomography-computed tomography performed at presentation to stage a presumptive lymphoma found later utility in following the burden of extramedullary disease. Standard AML induction chemotherapy resulted in complete remission and was followed by three rounds of high dose cytarabine consolidation. The patient unfortunately relapsed leading to re-induction followed by allogeneic stem cell transplantation. This report describes the presentation, assessment, and management of myeloid sarcoma.

Impact of preoperative renal dysfunction on long-term survival for patients undergoing aortic valve replacement.

BACKGROUND: The impact of the degrees of renal dysfunction (RD) after aortic valve replacement (AVR) has not been well described. The purpose of this study was to compare patients undergoing AVR with a range of renal function from normal to dialysis-dependence. METHODS: A retrospective review of 2,408 patients undergoing AVR with or without coronary artery bypass graft surgery (CABG) from January 1996 to March 2009 was performed. Glomerular filtration rate (GFR) was estimated for patients using the Modification of Diet in Renal Disease formula. Multivariable logistic and Cox regression methods were used to determine the independent association of GFR with outcomes. Adjusted odds ratios were calculated for in-hospital outcomes, and Kaplan-Meier curves were created to estimate long-term survival. RESULTS: In all, 1,512 patients (62.8%) had isolated AVR, and 896 (37.2%) underwent AVR plus CABG. Preoperative RD was common among all patients: 1,148 of 2,408 (47.7%) with mild RD (GFR 60 to 90 mL·min(-1)·1.73 m(-2)), 644 of 2,408 (26.7%) moderate RD (GFR 30 to 59 mL·min(-1)·1.73 m(-2)), 59 of 2,408 (2.5%) severe RD (GFR 15 to 30 mL·min(-1)·1.73 m(-2)), and 114 (4.7%) with kidney failure (GFR<15) or requiring dialysis. In-hospital mortality generally rose with RD, from 2.9% for patients with no RD to 15.8% for patients with severe RD, and 17.3% for patients requiring dialysis. Patients with severe RD or preoperative dialysis were associated with significantly poorer outcomes. Adjusted long-term survival is progressively worse across levels of RD, as was postoperative length of stay (p<0.001). CONCLUSIONS: Preoperative RD is common among the AVR population and is associated with diminished long-term survival. The association between RD and worse outcomes after AVR surgery has significant clinical implications.

Long-term survival for patients with preoperative renal failure undergoing bioprosthetic or mechanical valve replacement.

BACKGROUND: The objective of this study was to assess short-term and long-term outcomes after valve replacement with biologic or mechanical prostheses in patients with preoperative end-stage renal disease on chronic dialysis. METHODS: A retrospective review of patients with end-stage renal disease undergoing valve replacement from January 1996 through March 2008 at Emory Healthcare Hospitals was performed. Outcomes were compared using χ(2) tests and 2-sample t tests. Adjusted long-term survival up to 10 years was assessed with Kaplan-Meier plots and compared between biologic and mechanical replacements using the Cox proportional hazards model. RESULTS: A total of 202 patients underwent 211 valve replacement operations. Patient age was 20 to 83 years (mean age, 54.8 ± 14.0); 115 of 211 (54.5%) were male. Operations included the following: 100 of 211 (47.4%) isolated aortic; 49 of 211 (23.2%) isolated mitral; 4 of 211 (1.9%) isolated tricuspid; and 58 of 211 (27.5%) combined replacements. Thirteen (6.2%) patients underwent reoperative valve replacements. Most patients received bioprosthetic valves (143 of 211, 67.8%), while 68 of 211 (32.2%) received mechanical valves. Concomitant coronary artery bypass was performed in 53 of 211 (25.1%) patients. Thirty-day mortality was in 42 of 211 patients (19.9%) and was not different between bioprosthetic and mechanical replacements. Overall 10-year survival was 18.1% for all patients and was not influenced by valve type implanted. CONCLUSIONS: For patients with end-stage renal disease treated with dialysis, valve replacement carries acceptable operative mortality. Long-term survival is similar among patients receiving bioprosthetic versus mechanical valve replacement. Careful risk assessment and choice of valve prosthesis should be performed prior to surgical intervention in this high-risk patient population.

Short- and long-term outcomes in octogenarian patients undergoing off-pump coronary artery bypass grafting compared with on-pump coronary artery bypass grafting.

OBJECTIVE: : Coronary artery bypass grafting (CAB) on elderly patients presenting with multivessel coronary artery disease has become routine in modern day operating rooms. The aim of our study was to compare short- and long-term outcomes in octogenarian patients undergoing off-pump CAB (OPCAB) versus on-pump CAB (ONCAB). METHODS: : A propensity-adjusted, retrospective review of patients older than 80 years who underwent primary CAB from January 1996 to September 2008 at our institution's hospitals was performed. Nine hundred thirty-seven patients were divided into two groups: OPCAB (n = 540) or ONCAB (n = 397). A propensity score was calculated based on 29 preoperative risk factors to adjust for selection bias when comparing the groups for differences in death, stroke, myocardial infarction incidence, and their composite (major adverse cardiac events). Long-term survival status was determined by cross-referencing patient records with the Social Security Death Index. Logistic regression analysis and Cox proportional hazards analysis were used to determine group differences in short- and long-term survival, respectively, adjusted for the propensity score. Kaplan-Meier curves were fit to estimate 10-year survival. RESULTS: : The mean age (OPCAB: 82.9 ± 2.8 years vs ONCAB: 82.3 ± 2.4, P = 0.003) and male sex (OPCAB: 292/540, 54.1% vs ONCAB: 220/397, 55.4%, P = 0.68) were clinically similar between groups. Although the ejection fraction (OPCAB: 52.1 ± 12.5% vs ONCAB: 50.6 ± 13.1, P = 0.10) were similar between groups, the mean number of distal anastomoses [OPCAB: 2.7 ± 1.0 (median 3) vs ONCAB: 3.4 ± 0.9 (median 3), P < 0.001] were less in the OPCAB group. The median postoperative length of stay was 7 days for OPCAB group and 6 for the ONCAB group (P = 0.31). The Society of Thoracic Surgery predicted risk of in-hospital mortality was similar for OPCAB (5.4%) and ONCAB (5.3%) patients (P = 0.81). However, observed in-hospital mortality was improved for patients in the OPCAB group (OPCAB: 15/540, 2.8% vs ONCAB: 37/397, 9.3%, P = 0.007). Ten-year survival was similar between groups (OPCAB: 28.8% vs ONCAB: 26.3%, P = 0.22). CONCLUSIONS: : In this series, OPCAB reduced the incidence of in-hospital mortality compared with ONCAB. Long-term mortality was similar between groups.

Outcomes of off-pump aortic valve bypass surgery for the relief of aortic stenosis in adults.

BACKGROUND: Elderly patients with aortic stenosis presenting for an aortic valve replacement with a hostile ascending aorta remain a challenging patient cohort. The purpose of this study was to assess outcomes after the use of an aortic valve bypass performed without cardiopulmonary bypass. METHODS: A retrospective review was performed on 21 high-risk patients who underwent primary, isolated aortic valve bypass from September 2004 to June 2009 at Emory Healthcare Hospitals. Aortic valve bypass was used for a porcelain aorta alone in 6 (28.6%) patients, previous coronary artery bypass grafting in 4 (19.0%), or both in 10 (47.6%). One patient (4.8%) was thought not to be a candidate for cardiopulmonary bypass secondary to a severe cirrhosis. RESULTS: Mean age was 73.9±7.0 years (median, 75.0 years), and 15 patients (71.4%) were male. Mean New York Heart Association classification was 3.0±1.0 (median, 3.0), and preoperative ejection fraction was 0.460±0.163 (median, 0.500). Preoperative comorbidities included peripheral vascular disease (n=10; 47.6%), chronic lung disease (n=16; 76.2%), diabetes mellitus (n=10; 47.6%), and dialysis-dependence (n=2; 9.5%). Either an 18-mm (n=11; 52.4%) or 20-mm (n=10; 47.6%) conduit was used, with an interposed Freestyle 21 porcine root in all patients. All operations were performed without cardiopulmonary bypass. There were no intraoperative mortalities. The mean intensive care unit stay was 133.7±161.3 hours (median, 80.2 hours), and overall postoperative length of stay was 12.9±10.8 days (median, 9.0 days). In-hospital mortality occurred in 3 patients (14.3%). Mid-term follow-up shows an additional 4 patients died at a median follow-up of 1.3 years. CONCLUSIONS: Aortic valve bypass without cardiopulmonary bypass is a feasible alternative for the treatment of severe aortic stenosis with acceptable short-term morbidity and minimal mortality in this extremely high-risk surgical population.