HbA1c predicts length of stay in patients admitted for coronary artery bypass surgery.

Diabetes mellitus is associated with coronary artery disease, and diabetic patients are frequently referred for coronary bypass graft surgery. It is well known that HbA1c, which reflects long-term glycemic control, is related to diabetic morbidity and mortality. It is not known whether HbA1c is related to postoperative length of stay among patients who undergo coronary artery bypass surgery. The authors evaluated 135 patients who underwent bypass surgery at the Westchester Medical Center (Valhalla, NY). HbA1c was measured in all patients preoperatively; a value of 7% or greater was used as a threshold for uncontrolled hyperglycemia. A postoperative length of stay of 6 days or more was used as the cutoff for an extended length of stay. Linear regression was used to assess the relationship between HbA1c, adjusted for age, and length of stay in days. Logistic regression, with length of stay a binary variable <6, > or =6 days, was used to assess the accuracy of HbA1c <7%, > or =7%, adjusted for age, in predicting length of stay. An HbA1c of 7% or greater was found to be a strong predictor of a length of stay of 6 days or longer. These data suggest that HbA1c can be used as a surrogate marker for cardiac and noncardiac morbidity that prolongs hospitalization after coronary artery bypass surgery.

Successful management of an aneurysmal aortoesophageal fistula.

We report a case of aortoesophgeal fistula secondary to the aneurysm of the descending thoracic aorta. The patient presented with massive hematemesis with bright red blood. Patient was operated upon emergently and survived without complication. Six other such cases with successful outcome have been reported before, which depends on the prompt diagnosis and early surgical intervention.

Is it descending thoracic aortic dissection?

Complex thoracoabdominal aortic aneurysm repairs are preferably done by a staged approach, using the elephant trunk procedure. Postoperatively, such patients can present as a diagnostic dilemma if subjected to radiologic diagnostic studies such as computerized tomographic (CT) scanning or magnetic resonance imaging (MRI) of the thoracic cavity. The authors report a patient who presented with symptoms of chest pain and underwent CT scanning and subsequently MRI of the chest. Both scans were interpreted to be consistent with aortic dissection; however, the elephant trunk prosthesis was responsible for simulating a dissection.

Malignant renal tumor with extension to the inferior vena cava.

BACKGROUND: Management of malignant renal tumors involving the inferior vena cava (IVC) depends on tumor extension within the cava. METHODS: Of 295 patients treated for renal cancer, propagation of tumor mass through the renal vein to IVC was seen in 22 (7%) patients. Cephalad extension of the tumor was suprarenal: infrahepatic in 12, retrohepatic in 6, and within the right atrium in 4 patients. All patients had radical nephrectomy, cavotomy, and complete resection of tumors except 1 with diffuse peritoneal metastasis. RESULTS: Twenty-one patients had curative resections. No operative deaths and no instances of pulmonary embolism or exsanguination occurred. Seventeen patients were alive at 2 years and 12 at 5 years, resulting in 77% and 55% survival rates, respectively. CONCLUSIONS: An aggressive approach for vena cava involvement from malignant renal neoplasms resulted in prevention of tumor embolus, minimization of blood loss, and maintenance of venous return to the heart.

Cardiac cavernous hemangioma mimicking pericardial cyst: atypical echocardiographic appearance of a rare cardiac tumor.

Cavernous hemangioma is a rare tumor with infrequent cardiac involvement. Preoperative or antemortem diagnosis may be difficult. Several prior case reports have described echocardiographic findings of cavernous hemangioma. We report here a 50-year-old white female patient with this tumor. Transesophageal echocardiography detected a mass with an echocardiographic appearance not previously described for cavernous hemangioma. The tumor appeared as a large echolucent unilocular cystic mass, leading to an erroneous preoperative diagnosis of pericardial cyst. This previously unreported finding should be recognized by echocardiographers in the evaluation of cardiac masses.

Pretreatment of human myocardium with adenosine during open heart surgery.

BACKGROUND: Depressed myocardial performance after cardiac surgery can be contributed to ischemic reperfusion injury (IRI) incurred during and following the cardiopulmonary bypass (CPB). Myocardial preconditioning (PC) achieved by brief ischemia and subsequent reperfusion appears to be a clinically useful method of improved cardiac protection during surgery involving CPB by retarding IRI. Based on animal studies, activation of cardiac adenosine (ADO) receptors prior to the prolonged ischemic period appears to mimic this PC phenomenon. AIMS AND METHODS: We investigated whether the human myocardial PC can be mimicked with ADO in the setting of the coronary artery bypass graft (CABG). The specific proposed objective of this study was to determine whether ADO infusion just prior to starting the CPB can improve post-CPB myocardial hemodynamics. Patients undergoing elective CABG with poor ventricular function (ejection fraction approximately 30%), and with at least three-vessel disease were selected for this study (n = 7 ADO, and n = 7 control). RESULTS: Our results show that ADO infusion (250-350 micrograms/kg X 10 min) just prior to CPB resulted in an immediately improved postbypass cardiac index (CI) in the OR (CI increase of 41.5% +/- 11.1% for ADO vs 9.7% +/- 6.0% for control, p < 0.05). Forty hours postoperatively in the intensive care unit, ADO patients had improved CI (3.3 +/- 0.2 L/min per m2 for ADO, vs 2.6 +/- 4 L/min per m2 for control, p < 0.05). ADO patients maintained lowered resting heart rate (90 +/- 6 for ADO, vs 108 +/- 4 for control, p < 0.05) 40 hours after surgery. ADO patients also released significantly less CPK during the first 24 hours of the postoperative period. CONCLUSION: Based on these measurements, ADO pretreated patients had improved ventricular performance postoperatively. It also appears that ADO pretreatment results in lowered postoperative myocardial energy demand and less myocellular injury during CPB. To our knowledge, this is the first study to demonstrate that human myocardium can be hemodynamically improved with ADO pretreatment, and may be protected against IRI incurred during and following the CPB. We believe that a cardiac surgeon may now have the unique opportunity to confer myocardial protection during and after a cardiac surgical procedure.