Background: The prognostic value of preoperative hemoglobin A1c (HbA1c) in patients undergoing cardiac surgery remains uncertain. This study investigated the association between preoperative HbA1c levels and the risk of postoperative low cardiac output syndrome (LCOS) and in-hospital mortality in patients undergoing elective cardiac and/or thoracic aortic surgery. Methods: This single-center retrospective cohort study included consecutive adult patients who underwent elective cardiac and/or thoracic aortic surgery between 1 November 2019 and 30 June 2021. Patients younger than 18 years, pregnant, or lacking a preoperative HbA1c measurement within one week before surgery were excluded. A total of 728 patients were analyzed. Baseline clinical characteristics, operative variables, and postoperative outcomes were collected. Associations between HbA1c and perioperative parameters were assessed using univariate analyses, and independent predictors of LCOS and in-hospital mortality were identified using multivariate logistic regression. Results: Higher HbA1c levels were associated with greater body mass index (BMI; r = 0.08, p = 0.025), higher New York Heart Association (NYHA) functional class (III vs. I–II: 6.86 ± 1.60% vs. 6.15 ± 1.13%, p = 0.001), postoperative LCOS (7.05 ± 1.72% vs. 6.15 ± 1.13%, p = 0.013), and in-hospital mortality (6.79 ± 1.50% vs. 6.15 ± 1.13%, p = 0.011). In multivariate analysis, HbA1c independently predicted LCOS (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.09–2.12; p = 0.015), together with reduced left ventricular ejection fraction and postoperative atrial fibrillation. Independent predictors of in-hospital mortality included BMI, HbA1c (OR 1.81; 95% CI 1.19–2.74; p = 0.005), EuroScore II, prolonged cardiopulmonary bypass time, impaired glomerular filtration rate, postoperative septicemia, continuous renal replacement therapy, re-intubation, and prolonged mechanical ventilation. Conclusions: Higher preoperative HbA1c levels were independently associated with an increased risk of postoperative LCOS and in-hospital mortality in patients undergoing elective cardiac and/or thoracic aortic surgery. These findings support the role of HbA1c as a prognostic biomarker and its potential integration into preoperative risk stratification models for cardiac surgery.

Introduction: Atrial fibrillation (AF) is the most common arrhythmia following cardiac surgery. Although many risk factors have been studied, none has emerged as a dominant and widely applicable prophylactic measure. Aim: The aim of our study was to investigate the relationship between the amount of shed mediastinal blood and the occurrence of postoperative AF. Material and methods: From February 2021 to March 2024, 1140 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) were evaluated for the occurrence of postoperative AF (POAF). The following parameters were recorded and analyzed: age, gender, diabetes mellitus, hypertension, smoking, dyslipidemia, chronic obstructive pulmonary disease (COPD), history of stroke, pre-operative ejection fraction, CPB, aortic cross clamp time, and amount of mediastinal drainage. All variables were analyzed using logistic regression to assess their association with new-onset AF. Results: A total of 388 (33.59%) patients developed paroxysmal AF. According to our study, after multiple regression analysis, new onset atrial fibrillation showed statistically significant relationships with age (p = 0.001), hypertension (p = 0.001), duration of CPB (p = 0.04), and the amount of mediastinal drainage (p = 0.04). Conclusions: The occurrence of postoperative AF is strongly associated with the amount of shed mediastinal blood.

BACKGROUND:Levothyroxine overdose rarely causes severe symptoms in adults. We present an unusual case of isolated coma after massive levothyroxine ingestion. CASE REPORT:A 33-year-old woman presented to the Emergency Department comatose (Glasgow Coma Scale score 3/15) but hemodynamically stable. Computed tomography of the brain was normal. History revealed ingestion of 10.5 mg levothyroxine 2 h prior in a suicide attempt. Gastric lavage and activated charcoal were administered. The patient was intubated and admitted to the intensive care unit (ICU). Treatment included cholestyramine for enhanced thyroxine elimination. Thyroid function tests showed elevated free T4 and T3 with initially normal, but later suppressed, thyroid-stimulating hormone. The patient developed fever at 20 h, attributed to aspiration pneumonia rather than thyroid storm. She regained consciousness and was extubated at 28 h. Total ICU stay was 72 h. She was discharged after 10 days, with no complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case is notable for isolated coma without typical thyrotoxicosis symptoms, in spite of massive levothyroxine ingestion. Although altered mental status has been reported in levothyroxine overdose, coma as the sole presenting symptom is extremely rare. Emergency physicians should consider levothyroxine toxicity in cases of unexplained coma, even without other thyrotoxicosis signs. Prompt supportive care and gastrointestinal decontamination can lead to favorable outcomes in severe overdose.

Pneumothorax can be a rare but significant adverse event in patients with sarcoma and pulmonary metastases. This case report presents an instance of bilateral pneumothorax in a patient with metastatic leiomyosarcoma treated with pazopanib. A 74-year-old man with a history of grade 3 leiomyosarcoma and lung metastases was admitted with severe respiratory distress. He had been receiving pazopanib therapy following previous treatment with high-dose ifosfamide, doxorubicin, and radiotherapy. Imaging revealed bilateral pneumothorax, and the patient subsequently experienced respiratory arrest requiring immediate resuscitation measures including needle decompression followed by chest tube placement. The patient had experienced a unilateral pneumothorax two months prior to this presentation, which had resolved with standard interventions. While the bilateral pneumothorax eventually resolved after nine days of chest tube drainage, the patient exhibited no neurological recovery following the arrest, with brain imaging revealing bilateral cortical laminar necrosis. His clinical condition deteriorated significantly after 28 days in the intensive care unit (ICU), culminating in septic shock and death. This case highlights a serious pulmonary complication that can occur during the treatment of metastatic leiomyosarcoma, particularly in patients with lung metastases. The relationship between the development of pneumothorax and pazopanib therapy, along with the challenges in management and poor clinical outcome, merits consideration when treating similar patients.

ABSTRACT Tracheal rupture is a very rare but life-threatening complication of endotracheal intubation. It is more common in women and patients older than 50 years old. Overinflation of endotracheal tube cuff and tracheal wall weakening are the most important pathogenetic mechanisms. Laceration sites are located in the posterior membranous wall in most cases. Subcutaneous and mediastinal emphysema and respiratory distress are the most common manifestations. A 55-year-old female presented with postoperative subcutaneous and mediastinal emphysema without dyspnea because of a tear in the posterior tracheal wall. The diagnosis was based on clinical manifestation, chest computer tomography scans (CT), and endoscopic findings. A conservative approach by broad-spectrum antibiotic therapy was decided because of patients’ vital signs stability and the absence of esophageal injury. The follow-up showed that there was no lesion in the posterior tracheal wall. Our case showed that in clinically stable patients without mediastinitis and with spontaneous breathing, conservative management of tracheal tears is a safe procedure.

Introduction:The fate of the aorta after tube graft replacement remains unclear. Aim:We investigated the evolution of aortic dilatation after non-aortic cardiac operations and the dimensions of the root and arch after ascending aorta replacement. Material and methods:From 252 patients with aortic dilatation operated on between January 2010 and June 2019, 160 were followed with CT angiography. Two groups were formed according to the initial operation. Group I (n = 36) included patients with a dilated aorta, unreplaced during different indication cardiac surgery. Group II (n = 124) included patients receiving tube graft aorta replacement with or without aortic valve replacement. Mean preoperative and follow-up diameters of the different aortic segments were compared in both groups using the two-sided paired t-test for repeated measurements. Results:Eighteen patients died during follow-up, with one death occurring during reoperation for a false aneurysm of the distal anastomosis on the aortic arch. There was no other re-operation for aortic aneurysm, rupture or dissection. In group I the aortic arch diameter increased slightly, while the rest of the aortic segments remained stable. In group II the aortic root diameter decreased slightly while the aortic arch remained stable. Conclusions:Ascending aorta replacement with a tube graft remodeled the aortic root and did not allow progressive dilatation of the aortic arch. In patients with moderate ascending aorta dilatation, the unreplaced ascending aorta and aortic root remained relatively stable but the aortic arch increased slightly during follow-up.

Address for correspondence: Dr. Fotini Ampatzidou, Department of Cardiac Surgery, ICU, General Hospital “G. Papanikolaou”, Exohi, 57010, Thessaloniki, Greece, e-mail: fampatzidou@gmail.com Received: 27.12.2022, accepted: 17.03.2023. Pulmonary artery sarcoma (PAS) is an extremely rare neoplasm arising from mesenchymal cells of the pulmonary artery [1]. PAS was first described in 1923, its incidence is about 0.001% to 0.03% and it is characterized by a very poor prognosis [2]. Early and correct diagnosis is crucial. Unfortunately misdiagnosis is quite common due to overlapping clinical characteristics with pulmonary embolism (PE) or chronic thromboembolic pulmonary hypertension (CTEPH), leading not only to delayed therapeutic management but also to unnecessary (and associated with hemorrhagic risks) thrombolytic and anticoagulation therapy [3]. A 68-year-old woman was referred to our Cardiothoracic Department with a case of chronic pulmonary thromboembolic disease in order to undergo pulmonary endarterectomy. She had a history of dyspnea one year ago with gradual deterioration during the last 3 months. A few days before, she was admitted to the Pneumonology Department suffering from thoracic pain. D-dimer levels were mildly elevated. She underwent a chest computed tomography (CT) scan which revealed an inhomogeneous mass arising into the medial bronchopulmonary segment with irregular borders. Triplex vascular ultrasound was performed twice and was negative for deep venous thrombosis. CT pulmonary angiography was suggestive for pulmonary embolism based on the following signs: filling defects in right main bronchus expanded peripherally to medial and lower lobe. Ventilation/perfusion lung scan showed normal ventilation with complete absence of perfusion of the right lung. Dilated right ventricle and estimated systolic pulmonary artery of 39 mm Hg were the main echocardiographic findings. She underwent an elective cardiothoracic surgical procedure with the use of a cardiopulmonary bypass under deep hypothermia (lowest 19°C). Intraoperatively, material from the right pulmonary artery was obtained and examined in frozen sections (Figure 1). The main finding is a mass protruding in the lumen of the pulmonary artery and filling its branches in a mold-like manner (Figure 2). The frozen sections (Figure 3) demonstrated a malignant neoplasm with sarcomatous features. It consisted of highly pleomorphic cells with evident mitotic activity, in an edematous or slightly myxoid background. The cells were either spindle-shaped with enlarged, elongated nuclei, or round to oval-shaped with vesicular nuclei. There were also scattered multi-nucleated cells with lobular nuclei. Subsequently, a right pneumonectomy was performed. Duration of mechanical ventilation was 20 hours and ICU stay lasted 3 days. The patient was discharged on the 6th postoperative day without complications. She underwent chemotherapy and survived 11 months. Intimal sarcoma of the pulmonary artery was first described by Moritz Mandelstamm in 1923 [4]. The true incidence of pulmonary artery intimal sarcoma is unknown, because it is most often misdiagnosed. A high level of suspicion is required due to resemblance in clinical presentation to acute or chronic pulmonary embolism (dyspnea, chest pain, cough, hemoptysis). Hemodynamic instability is suggestive for PE while IPAS is characterized by more long standing symptoms. Diagnosis is based on contemPulmonary artery sarcoma presenting as chronic thromboembolic pulmonary hypertension (CTEPH)

Introduction. Cardiac complications have been documented in COVID-19 patients, including arrhythmias. Ventricular arrhythmias and electrical storm, a state of recurrent ventricular arrhythmias, are a rare complication of COVID-19. We describe a case of electrical storm in a COVID-19 patient. Case presentation. A 56-year-old woman presenting with shortness of breath, edema of lower extremities, and palpitations was subjected to synchronized cardioversion for atrial fibrillation. She then presented episodes of non-sustained ventricular tachycardia and one episode of unstable polymorphic ventricular tachycardia which was treated with defibrillation. Following a low-grade fever, she was tested positive for SARS-CoV-2. She suffered a cardiac arrest and underwent advanced life support resuscitation. After resuscitation she manifested electrical storm of polymorphic ventricular tachycardia in the context of QT prolongation. Intravenous magnesium was administered and a temporary transvenous pacer was placed for overdrive pacing. There were no crucial respiratory complications. The patient stabilized and was weaned off the ventilator. She was diagnosed with bilateral cortical laminar necrosis secondary to cardiac arrest. During a 3-month follow-up, she remained stable, with no recurrence of arrhythmias. Discussion. Electrical storm rarely manifests with polymorphic ventricular tachycardia, as in this case. Arrhythmogenesis in COVID-19 can be life-threatening even in patients with mild lung involvement.

Aim. Early discontinuation of metformin before cardiac surgery is advised by several national societies but no hard evidence exist supporting this practice. This precaution is mostly extrapolated by data on different clinical settings. The aim of this study is to investigate the impact of preoperative metformin use on lactate concentrations and lactate clearance during the first postoperative day after cardiac surgery.Methods. Among 367 consecutive patients who underwent elective on-pump cardiac surgery from January 2019 to October 2019, 109 were diabetics, 74 of which were treated with metformin. Data on lactate concentrations and clearance during the first postoperative day were prospectively collected on arrival, H6, H12 and H24 in the ICU and compared. A subgroup analysis focusing only on diabetic patients was also performed. Repeated measures multivariate analysis of variance (MANOVA) was used to investigate the data based on group, time and their interaction effects.Results. Lactate concentrations were the same for both groups upon arrival in the ICU. Interestingly, metformin users had lower lactate concentrations than non-users on the following measurements (p = 0.003 at 6 h and p = 0.01 at 24 h). No significant interaction was found between the two groups (p = 0.76). No difference was found between the two groups in terms of lactate clearance (p = 0.53). In the subgroup analysis no difference was found between metformin users and non-users neither on lactate concentrations (p = 0.61) nor on lactate clearance (p = 0.86).Conclusions. In a post cardiac surgery ICU setting, using metformin up until the night before surgery was not associated with increased postoperative lactate concentrations or impaired lactate clearance.

Aim. Early discontinuation of metformin before cardiac surgery is advised by several national societies, although no hard evidence exist supporting this practice. This precaution is mostly extrapolated by data on different clinical settings. The aim of this study is to investigate the impact of preoperative metformin use on lactate concentrations and lactate clearance during the first postoperative day following cardiac surgery. Material and Methods. Among 367 consecutive patients who underwent elective on -pump cardiac surgery from January 2019 to October 2019, 109 were diabetics, 74 of whom were treated with metformin. Data on lactate concentrations and clearance during the first postoperative day were prospectively collected on arrival in the ICU, as well as after H6, H12 and H24 in the ICU and subsequently compared. A subgroup analysis focusing only on the diabetic patients was also performed. Repeated measures multivariate analysis of variance (MANOVA) was used to investigate the data on the basis of the group, time and their interaction effects. Results. Lactate concentrations were the same for both groups upon arrival in the ICU. Interestingly, metformin users presented lower lactate concentrations than non -users on the following measurements (p = 0.003 at 6 h and p = 0.01 at 24 h). No significant interaction was found between the two groups (p = 0.76). No difference was found between the two groups in terms of lactate clearance (p = 0.53). In the subgroup analysis no difference was observed between metformin users and non -users, either on lactate concentrations (p = 0.61), or on lactate clearance (p = 0.86). Conclusions. In the intensive care unit setting following heart surgery, the use of metformin up until the night before surgery was not associated with increased postoperative lactate concentrations or impaired lactate clearance.

Objective: Tobacco smoking represents a major risk factor for coronary artery disease. Our study aimed to investigate whether Coronary Artery Bypass Graft (CABG) surgery could act as a motivating factor to enforce smoking cessation. Specifically, we observed the success rate in individuals who quitted smoking, along with the number and reasons of relapse(s) at least one year after the operation. Methods: The pre-operative characteristics, pre-operative tobacco exposure, socioeconomic factors and perioperative complications in patients who underwent isolated Coronary Artery Bypass Graft surgery in our Department from June 2012 to September 2016 were reviewed. Our survey was conducted via phone interview and using a standardized questionnaire. Only patients who were current smokers at the time of surgery were interviewed. Results: Our study group consisted of a total of 120 patients, 91 (75.8') reported initially quitting tobacco smoking. Because of relapse(s), one year after the procedure the number of patients who were still non-smokers dropped to 69 (57.5'). Smoking cessation attempts were not supported by professional assistance. Conclusions: Our findings demonstrate that there is a desire from CABG patients to quit smoking, as indicated by the high percentage of initial attempts in early postoperative period. However, a year after the procedure, only 57.5' of CABG patients were able to achieve or maintain smoking cessation. Patients who were retired or who were unemployed at the time of the surgery, found it easier to stop smoking than patients who were active employees. Patients who lived alone at the time of surgery also found it harder to stop smoking. Finally, patients with COPD also found quitting smoking harder in the post-operative period.

BACKGROUND:The variable life-adjusted display (VLAD) method shows the difference between predicted and observed outcomes over time. Our study aims to implement routine in-house monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery.METHODS:The Society of Thoracic Surgeons (STS) risk score was calculated for 249 isolated and combined coronary and aortic or mitral valve cases performed during a 6-month period. The nine predicted STS variables were operative mortality, permanent stroke, renal failure (RF), prolonged ventilation, deep sternal wound (DSW) infection, reoperation for any reason, short and long length of stay (LOS), and major morbidity or operative mortality. EuroSCORE II was also calculated for the study population. VLAD plots were generated for each variable indicating whether performance is better or worse than expected on the basis of predicted risk of failure.RESULTS:The mortality plot was fluctuating close to baseline risk. The prolonged ventilation, RF, reoperation, morbidity/mortality, and LOS plots were consistently positive, indicating favorable results. The stroke chart showed an upward trend for most of the period until two incidents toward last month led to a steep descent. The DSW infections plot though, indicated a worse-than-expected performance. The VLAD charts were shared in multidisciplinary meetings and clinicians were able to confront the performance with the population-specific expectancies and respond to adverse trends with further actions.CONCLUSION:Graphical tool monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery is feasible and allows detection of underperformance and implementation of changes in clinical practice.

BACKGROUND:Respiratory complications remain a major cause of morbidity in cardiac surgery patients. This study aimed to determine the prognostic parameters associated with the application of noninvasive ventilation (NIV) for the treatment of acute respiratory failure, along with the possible predictors associated with NIV failure, among the subjects who underwent cardiac surgery. METHODS:This was a retrospective cohort study. Data on all adult patients who underwent cardiac surgery in a single center between May 2012 and December 2016 were analyzed. Multivariate regression analysis with bootstrapping was used to identify which baseline and intraoperative parameters were associated with the application of NIV to treat acute postoperative respiratory failure. A univariate analysis was also applied to identify potential variables associated with NIV failure. P < .05 was considered significant. RESULTS:A total of 1,657 subjects (mean ± SD age 65.2 ± 10.7 y; 21.7% females) constituted the study population, 145 (8.8%) of whom were treated with NIV due to acute postoperative respiratory failure. Body mass index adjusted odds ratio 1.02, bias-corrected 95% CI 1.01-1.04), EuroSCORE (European System for Cardiac Operative Risk Evaluation) II (adjusted odds ratio 1.11, bias-corrected 95% CI 1.02-1.32), COPD (adjusted odds ratio 4.004, bias-corrected 95% CI 2.53-8.93), and preoperative estimated glomerular filtration rate (adjusted odds ratio 0.99, bias-corrected 95% CI 0.98-0.99) independently predicted NIV application. NIV treatment failed in 16 of the 145 subjects (11%) and age, EuroSCORE II, COPD, heart failure, renal replacement therapy, and postoperative stroke were all univariately associated with the outcome. CONCLUSIONS:NIV successfully treated acute respiratory failure in the vast majority of cardiac surgery subjects and COPD, EuroSCORE II, body mass index, and preoperative renal function were independently associated with its application.

Internal thoracic artery (ITA) is an excellent conduit for coronary artery bypass surgery (CABG). We present a patient with known preoperative aortoiliac disease with anterior collateral pathway who had an indication for elective coronary bypass. The use of ITA in these patients may cause lower limb ischemia. Detecting Winslow's anastomotic pathway before CABG is of utmost importance.

Background/Aim Deep sternal wound infection (DSWI) after cardiac surgery, is a rare complication that can be fatal. Due to a lack of available data, we compared early in-hospital, 1-year and long-term mortality in patients with DSWI. Methods Patients undergoing any type of cardiac surgery, in the Cardiothoracic Surgery Department of G. Papanikolaou Hospital, between May 2012 and December 2016, were investigated. All patients who developed DWSI postoperatively, treated with negative pressure wound therapy (NPWT), were included in the group of cases. A random population from the rest of the patients was selected in a 1:2 ratio, representing controls. Results From a total of 2104 patients, 80 patients (3.8%) developed DSWI (cases group), whereas 180 patients were randomly selected as controls. Early (within 30 days) mortality was significantly higher in the DSWI group compared with controls (15% vs 3.9%, respectively; P = .002). Similarly, more deaths occurred in the cases group compared with controls during the follow-up (ie, 19 vs 12, respectively; P < .001); the majority of deaths (84.2%) occurred within the first year. Long-term survival did not differ between the two study groups during follow-up (median duration = 1072 vs 1022 days for cases and controls, respectively). Conclusions DSWI significantly increased early and 1-year mortality in poststernotomy patients treated with NPWT compared with those not developing this complication. However, long-term survival was similar between the two study groups, thus highlighting the beneficial effect of NPWT in terms of clinical outcomes in patients with DWSI.

To suggest a simplified method for strong ion gap ([SIG]) calculation.

Background: Most studies evaluating predictors of renal replacement therapy (RRT) following cardiac surgery use arbitrary defined limits of preoperative serum creatinine. The aim of this study was to evaluate the effect of preoperative renal function using either estimated-glomerular filtration rate (eGFR) derived using Chronic Kidney Disease-Epidemiology (CKD-EPI) or serum creatinine alone as a predictor for RRT after cardiac surgery. Methods: In this prospective cohort study, baseline, intraoperative, and postoperative data of all patients who underwent an elective, urgent, or emergency cardiac surgery between 2012 and 2016 in a single center were analyzed in order to identify multivariate parameters determining the need for RRT after surgery. For preoperative renal function, we used serum creatinine levels and eGFR-derived CKD-EPI equation. We also divided our cohort into eGFR groups following the thresholds of the currently proposed CKD classification. Results: From the 1,614 patients (mean age: 65.4 ± 10.6 years; male: 77.6%) that constituted the study population, 42 (2.6%) underwent RRT postoperatively. EUROSCORE II, cardiopulmonary bypass time, cross clamp time, red blood cell (RBC) units transfused, type and urgency of surgery, combined/non combined operation, peripheral vascular disease, heart failure, chronic obstructive pulmonary disease, dyslipidemia, and preoperative renal function were all univariately associated with RRT use. Multivariate regression with bootstrap utilization indicated that CKD-EPI eGFR (OR 0.979; 95% CI 0.956–0.998), heart failure with the New York Heart Association class ≥2 (OR 4.695; 95% CI 1.756–14.061) and RBC units transfused (OR 1.287; 95% CI 1.081–1.850) were independently associated with RRT need. When serum creatinine (OR 2.920, 95% CI1.056–8.074) was used in the model, the associations with RRT were also significant. Conclusion: Preoperative renal function, defined by serum creatinine or eGFR by CKD-EPI, NYHA class II–IV, and the number of blood units transfused were all independent predictors of RRT postoperatively.

Lipomatous hypertrophy of atrial septum (LHAS) is a rare benign cardiac condition characterized by fatty tissue infiltration located in the atrial septum. We presented a rare case of LHAS resulting in recurrent syncopal attacks.

Abdominal compartment syndrome is associated with severe dysfunction of intra-abdominal and intrathoracic organs. Medical therapy, with the goal of reducing intra-abdominal pressure, leads to improvement in organ perfusion.