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702 PAPARELLA ET AL Ann Thorac SurgPREOPERATIVE CARDIAC TROPININ I IN CABG 2010;89:696–703

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urgical or pharmacologic approach to limit periopera-ive myocardial damage in patients undergoing CABGith ongoing laboratory signs of recent AMI.The principle limitation of our study was its retrospec-

ive design and the consequent lack of serial postopera-ive echocardiographic or magnetic resonance imagingvaluation of left ventricular function to possibly corre-ate postoperative myocardial function with survival. Aslready stated, another important limitation was the lackf a cTnI value when AMI was initially diagnosed.We therefore conclude that, if possible, normalization

f cTnI values before CABG operations seems warrantedn patients who have sustained a recent AMI, but thishould be confirmed by specifically designed studies. Iflinical conditions or coronary anatomy require a patientith elevated cTnI values to undergo a CABG operation,

hen surgeons ought to be aware that these patients arender a higher risk of perioperative myocardial damagend, consequently, a higher risk of postoperative ad-erse events, including death, within the 6 monthsfter the operation.

e thank Felicia Kohn Passaro for kindly reviewing theanuscript.

eferences

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2. Weiss ES, Chang DD, Joyce DL, Nwakanma LU, Yuh DD.Optimal timing of coronary artery bypass after acute myo-cardial infarction: a review of California discharge data.J Thorac Cardiovasc Surg 2008;135:503–11.

3. Adams JE, Bodor GS, Davila Roman VG, et al. Cardiactroponin I: a marker with a high specificity for cardiac injury.Circulation 1993;88:101–6.

4. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardialinfarction redefined—a consensus document of The JointEuropean Society of Cardiology/American College of Cardi-ology Committee for the redefinition of myocardial infarc-tion. J Am Coll Cardiol 2000;36:959–69.

5. Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality inpatients with acute coronary syndromes. N Engl J Med

1996;335:1342–9.

isky, and too late may invite another acute coronary

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2010 by The Society of Thoracic Surgeonsublished by Elsevier Inc

6. Thielmann M, Neuhauser M, Marr A, et al. Predictors andoutcomes of coronary artery bypass grafting in st elevationmyocardial infarction. Ann Thorac Surg 2007;84:17–24.

7. Thielmann M, Massoudy P, Neuhauser M, et al. Prognosticvalue of preoperative cardiac troponin I in patients withnon-ST-segment elevation acute coronary syndromes un-dergoing coronary artery bypass surgery. Chest 2005;128:3526–36.

8. Thielmann M, Massoudy P, Neuhauser M, et al. Prognosticvalue of preoperative cardiac troponin I in patients under-going emergency coronary artery bypass surgery with non-ST-elevation or ST-elevation acute coronary syndromes.Circulation 2006;114(suppl I):I-448–53.

9. Carrier M, Pelletier LC, Martineau R, Pellerin M, SolymossBC. In elective coronary artery bypass grafting, preoperativetroponin T level predicts the risk of myocardial infarction.J Thorac Cardiovasc Surg 1998;115:1328–34.

0. Paparella D, Cappabianca G, Visicchio G, et al. Cardiactroponin I release after coronary artery bypass graftingoperation: effects on operative and midterm survival. AnnThorac Surg 2005;80:1758–64.

1. Paparella D, Cappabianca G, Malvindi P, et al. Myocardialinjury after off-pump coronary artery bypass grafting oper-ation. Eur J Cardiothorac Surg 2007;32:481–7.

2. Lasocki S, Provenchère S, Bénessiano J, et al. Cardiac tropo-nin I is an independent predictor of in-hospital death afteradult cardiac surgery. Anesthesiology 2002;97:405–11.

3. Amodio G, Antonelli G, Varraso L, Ruggieri V, Di Serio F.Clinical impact of the troponin 99th percentile cut-off andclinical utility of myoglobin measurement in the early man-agement of chest pain patients admitted to the EmergencyCardiology Department. Coron Artery Dis 2007;18:181–6.

4. Thielmann M, Massoudy P, Neuhauser M, et al. Risk strat-ification with cardiac troponin I in patients undergoingelective coronary artery bypass surgery. Eur J CardiothoracSurg 2005;27:861–9.

5. Steuer J, Bjerner T, Duvernoy O, et al. Visualisation andquantification of peri-operative myocardial infarction aftercoronary artery bypass surgery with contrast-enhancedmagnetic resonance imaging. Eur Heart J 2004;25:1293–9.

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NVITED COMMENTARY

s cardiac surgeons, we are quite frequently faced withhe situation of performing coronary artery bypass graft-ng after acute myocardial infarction (AMI). With thedvent of primary angioplasty, the patients referred to usor surgical intervention will be those who have beeneemed unfit for percutaneous intervention because ofnfavorable anatomy of coronary disease for angioplasty,iffuse disease, or poor left ventricular function. Theost important clinical decision in these situations ishen to perform the operation. Too soon may be too

vent. Various studies, as quoted by Paparella and col-eagues [1], have tried to inform us about the risk of theperation according to the time elapsed since the AMI.It is appreciated that authors in this study have tried to

nvestigate whether one can have a guideline based onhe measurement of cardiac troponin I (cTnI). In thistudy, the patients with a cTnI level of less than 0.15g/mL had an advantage in terms of less postoperativeorbidity and death at 6 months. Assuming that now we

ut this in practice, would we wait to perform surgical

evascularization in patients with AMI until the cTnI falls

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elow 0.15 ng/mL? The number of days for this reductionould be dictated by various factors, such as the size of

he infarct, whether or not it was transmural, andhether external cardiac massage was part of the resus-

itation at the presentation with AMI.I think as much as we would all like a single, simple

nvestigation like cTnI to help us decide, we would stille mainly guided by the patient’s clinical condition and

he presence or absence of critical coronary anatomy.hese factors permitting, we would wait about a weekefore operating, which would bring the cTnI level downs well. This study has certainly given us an importantariable to inform ourselves, and our patients, about thessociated risk of surgical intervention and the postop-

rative prognosis.

rvind Singh, FRCS, MCh (CVTS)

epartment of Cardiothoracic Surgeryrent Cardiac Centreottingham City Hospitalucknall Rdottingham NG5 1PB, UK

-mail: arvindvsingh@yahoo.com

eference

. Paparella D, Scrascia G, Paramythiotis A, et al. Preoperativecardiac troponin I to assess midterm risks of coronary bypassgrafting operations in patients with recent myocardial infarc-

tion. Ann Thorac Surg 2010;89:696–703.