Bardzo tanie apteki z dostawą w całej Polsce kupic levitra i ogromny wybór pigułek.

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CORRESPONDENCE
Ann Thorac Surg
2012;94:1782–9
References
Davide Pacini, MD
1. Parolari A, Pesce LL, Pacini D, et al. Monzino Research
Department of Cardiac Surgery
Group on Cardiac Surgery Outcomes. Risk factors for
S Orsola-Malpighi Hospital
perioperative acute kidney injury after adult cardiac sur-
University of Bologna
gery: role of perioperative management. Ann Thorac Surg
Bologna, Italy
2012;93:584 –91.
Francesco Alamanni, MD
2. Tekumit H, Riza Cenal A, Tataroglu C, Polat A, Uzun K,
Akinci E. Off-pump coronary artery bypass surgery can be
Unit for Clinical Research in Atherothrombosis
completed safely in high risk patients. Kardiol Pol 2010;68:
Centro Cardiologico Monzino IRCCS
166 –72.
Department of Cardiovascular Sciences
3. Jassar AS, Ford PA, Haber HL, et al. Cardiac surgery in
University of Milan, Milan, Italy
Jehovah’s Witness patients: ten-year experience. Ann Thorac
Surg 2012;93:19 –25.

References
4. Erentug V, Hasan Erdogan HB, Kayalar N, et al. Is off-pump
coronary bypass a good choice in patients with chronic
1. Polat A, Polat EB, Kayalar N. Perioperative acute kidney
renal failure? Turkish J Thorac Cardiovasc Surg
injury after cardiac surgery (letter). Ann Thorac Surg 2012;94:
2006;14:111– 6.
1785– 6.
2. Parolari A, Pesce LL, Pacini D, et al. Risk factors for periop-
erative acute kidney injury after adult cardiac surgery: role of
Reply
perioperative management. Ann Thorac Surg 2012;93:584 –91.
To the Editor:
3. Bell M, Liljestam E, Granath F, Fryckstedt J, Ekbom A, Martling
CR. Optimal follow-up time after continuous renal replacement
We appreciate the interest and thoughtful comments of our
therapy in actual renal failure patients stratified with the RIFLE
criteria. Nephrol Dial Transplant 2005;20:354–60.

colleagues regarding our study on acute kidney injury
4. Koch CG, Li L, Duncan AI, et al. Morbidity and mortality risk
(AKI) and we are glad to provide more details and
associated with red blood cell and blood-component transfu-
thoughts. AKI definition followed the indications of the Acute
sion in isolated coronary artery bypass grafting. Crit Care
Kidney Injury Network where a postoperative twofold
Med 2006;34:1608 –16.
creatinine increase or a urine output less than Ͻ0.5 mL/kg/12
5. Lamy A, Devereaux PJ, Prabhakaran D, et al. Off-pump or
h means kidney injury. Moreover, inasmuch as our patients
on-pump coronary-artery bypass grafting at 30 days. N Engl
were somehow low-risk (92.5% elective procedures, 6.6%
J Med 2012;366:1489 –97.
repeated procedures, average serum creatinine 1.06 mg/dL),
6. Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, Gluud
C. Off-pump versus on-pump coronary artery bypass grafting
only a very few (13/3219, 0.4%) required intraoperative hemo-
for ischaemic heart disease. Cochrane Database Syst Rev 2012
filtration. Moreover, it is well known that preoperative ane-
Mar 14;3:CD007224.
mia is a major predictor of unfavorable outcomes and that
blood transfusion is needed in these patients
We were
unable to assess the role of preoperative hemoglobin level on
the occurrence of AKI and on the need for blood transfusions

Dexamethasone and Myocardial Protection in Neonatal
in our patients because this variable had more than 4% of
Arterial Switch Operation
missing data and was for this reason excluded from analysis,
To the Editor:
inasmuch as logistic regression requires complete patient
data for each case. However, the fact that all multivariate

We read the recent article by Heying and coworkers with
models including intraoperative variables retained the num-
great interest and have some brief comments. The authors
ber of units of red blood cells that were transfused during
reported that 1 mg/kg of dexamethasone was given 4 hours
surgery as an independent predictor of AKI is an indirect
before cardiopulmonary bypass (CPB) to provide antiinflamma-
demonstration that even in our patient population preopera-
tory and myocardial protection in a neonatal arterial switch
tive anemia is detrimental for patients. Finally, we chose not
operation. Preoperative administration of glucocoticosteroids
to study off-pump patients for the following reasons: (1) they
attenuates the release of some proinflammatory cytokines and
were limited in number (330 patients, less than 10% of our
also increases the production of an antiinflammatory cytokine,
coronary bypass patient population), and this would have
interleukin-10, in pediatric and adult cardiac surgical proce-
precluded obtaining robust AKI predictors at multivariable
dures The other result of the study was lower myocardial
models; (2) one of the major aims of our study was to assess
cell damage in dexamethasone-treated patients. Serum cardiac
the role of cardiopulmonary bypass and of cardiopulmonary
troponin T (cTnT) increases approximately 100 times at the
bypass–related variables on AKI occurrence, and patients
second postoperative day in both groups. There was no differ-
undergoing operation off pump could not, obviously, be
ence between two groups with respect to cTnT levels at 10
included. Given that the role of on-pump and off-pump
minutes after the beginning of CPB, the end of CPB, 4 hours after
coronary bypass surgical procedures in perioperative AKI
CPB, and at postoperative days 1, 2, 3, 5, and 10. However, there
was a difference in the cTnT levels only at the first hour after

occurrence is still uncertain further studies are eagerly
CPB. The cTnT levels were related mainly to aortic cross-clamp
MISCELLANEOUS
waited to clarify this point.
time and presence of ventriculotomy, atriotomy, ventricular
septal defect closure, and hemodilution. The authors reported

Alessandro Parolari, MD, PhD
that aortic cross-clamp duration was longer in the control group
Unit for Clinical Research in Atherothrombosis
(72 minutes) than in the dexamethasone group (64 minutes)
Centro Cardiologico Monzino IRCCS
(p value 0.05). There were 11 patients in the control group and 9
Department of Cardiovascular Sciences
patients in the dexamethasone group. Sometimes a small conal
University of Milan, Milan, Italy
branch may necessitate division to create more length for the
e-mail:
coronary transfer in an arterial switch operation. We are not
2012 by The Society of Thoracic Surgeons
0003-4975/$36.00
Published by Elsevier Inc
Ann Thorac Surg
CORRESPONDENCE
2012;94:1782–9
given enough information about the number of patients with a
lating levels of cTnT in the early postoperative period. This
small conal branch division. The division affects more myocar-
association has been shown by others to allow discrimination
dial damage and causes more troponin release than the afore-
among adults with or without subclinical myocardial cell dam-
mentioned factors listed above.
age and also with lower catecholamine requirement in the
In conclusion, the antiinflammatory effects of dexamethasone
postoperative period Interestingly, in the present series, the
are clearly demonstrated, with significant results. However, the
known relationship between duration of myocardial ischemia
increase in cTnT level was different in only one period (cTnT
and postoperative cTnT levels shown in the control group was
measured at the first hour after CPB) among eight periods
abolished in the treated group, suggesting protection of myo-
between the two groups, which consisted of very limited num-
cardial tissue against operative stress.
bers of patients. Many factors can affect the cTnT levels in
Thus, based on current knowledge, our results confirm in-
arterial switch operations. Therefore, we think it is inaccurate to
tramyocardial and systemic antiinflammatory shift of the peri-
state that dexamethasone leads to less myocardial damage and
operative cytokine balance in neonates treated with dexameth-
is effective in myocardial protection in the arterial switch
asone that is associated with a certain degree of myocardial
operation.
protection.
As pointed out by Pouard and Bojan in their invited commen-
Rıza Turkoz, MD
tary the important questions that need to be answered are:
Emre Özker, MD
Ayda Turkoz, MD

1. Is the dose of dexamethasone (1 mg/kg) optimal?
2. Is the time point of dexamethasone administration (4 h

Departments of Cardiovascular Surgery and Anesthesia
before connection to CPB) optimal?
Baskent University
Istanbul Teaching and Medical Research Center

Marie-Christine Seghaye, MD, PhD
Altunizade
I˙stanbul 34662, Turkey

Department of Pediatrics
e-mail:
Pediatric Cardiology
University Liège

References
Rue de Gaillarmont 600
4032 Liège, Belgium

1. Heying R, Wehage E, Schumacher K, et al. Dexamethasone
e-mail:
pretreatment provides antiinflammatory and myocardial pro-
tection in neonatal arterial switch operation. Ann Thorac Surg

References
2012;93:869 –76.
2. Hall RI, Smith MS, Rocker G. The systemic inflammatory
1. Turkoz R, Özker E, Turkoz A. Dexamethasone and myocar-
response to cardiopulmonary bypass: pathophysiological,
dial protection in neonatal arterial switch operation (letter).
therapeutic, and pharmacological considerations. Anesth
Ann Thorac Surg 2012;94:1786 –7.
Analg 1997;85:766 – 82.
2. Heying R, Wehage E, Schumacher K, et al. Dexamethasone
3. Turkoz A, Cigli A, But K, et al. The effects of aprotinin and
pretreatment provides antiinflammatory and myocardial pro-
steroids on generation of cytokines during coronary artery
tection in neonatal arterial switch operation. Ann Thorac Surg
surgery. J Cardiothorac Vasc Anesth 2001;15:603–10.
2012;93:869 –76.
3. Gordon JW, Shaw JA, Kirshenbaum LA. Multiple facets of
NF-B in the heart: to be or not to NF-B. Circ Res 2011;108:
Reply
1122–32.
To the Editor:
4. Suleiman MS, Zacharowski K, Angelini GD. Inflammatory
response and cardioprotection during open-heart surgery:
In their comment, Turkoz and colleagues disagreed with the
the importance of anaesthetics. Br J Pharmacol 2008;153:
21–33.

conclusions of our study that myocardial protection was pro-
5. Hovels-Gurich HH, Vazquez-Jimenez JF, Silvestri A, et al.
vided by dexamethasone administration They suggest that
Production of proinflammatory cytokines and myocardial
lower cTnT levels were likely associated with the shorter period
dysfunction after arterial switch operation in neonates with
of myocardial ischemia in treated patients.
transposition of the great arteries. J Thorac Cardiovasc Surg
Since it might appear evident to relate postoperative myocar-
2002;124:811–20.
dial cell damage only to the duration of myocardial ischemia
6. Lim CC, Cuculi F, van Gaal WJ, et al. Early diagnosis of
during cardiopulmonary bypass (CPB), previous studies gave
perioperative myocardial infarction after coronary bypass
evidence of the deleterious role of proinflammatory cytokines on
grafting: a study using biomarkers and cardiac magnetic
the heart cytokines known to be upregulated by myocardial
resonance imaging. Ann Thorac Surg 2011;92:2046 –53.
7. Pouard P, Bojan M. Invited commentary. Ann Thorac Surg
ischemia and reperfusion Our previous series conducted in
2012;93:876 –7.
a larger number of a similar patient population of neonates
undergoing arterial switch operation showed that postoperative
myocardial dysfunction associated with higher cTnT release was
in turn related to the amount of interleukin (IL) 6 released

The Safety of Selective Cerebral Perfusion With
during cardiac surgery The multivariate analysis of several
Normothermia in Pediatric Patients
independent risk factors for the occurrence of myocardial dys-
To the Editor:
function (including aortic clamping time) revealed that postop-
erative IL-6 levels were the predictive ones.

I read with great interest the article by Ly and colleagues on
Our present results show that pretreated neonates displayed
their retrospective study of antegrade selective cerebral perfu-
less intramyocardial expression of proinflammatory cytokines
sion (SCP) with hypothermia (Յ28°C) versus normothermia
harmful to the myocardium already before connection to CPB
(Ն34°C) in pediatric patients undergoing arch repairs. They
and myocardial ischemia. A shift of the cytokine balance toward
reported that the time to extubation, stay in the intensive care
MISCELLANEOUS
the antiinflammatory response was associated with lower circu-
unit, and early mortality were similar between the hypothermic
2012 by The Society of Thoracic Surgeons
0003-4975/$36.00
Published by Elsevier Inc

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