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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Donation supports more successful futures for young people Young people who have struggled to get on in school have received a helping hand from local company, Procter & Gamble (P&G). The Weybridge-based business has made a major donation to the Surrey Care Trust and its education work. P&G, whose UK head office is at Broorlands, owns many of the world’s leading brands of consum