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• W2014863271 abstract "Dr Park and associates [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] reported an association between subclinical hypothyroidism (SCH) (defined as high thyroid-stimulating hormone [TSH] concentration in the presence of normal T4) and postoperative atrial fibrillation. We read this article with extreme interest and would like to add some comments on the topic.Free triiodothyronine (fT3), the biologically active form of the thyroid hormone, is frequently reduced in cardiac patients due to the reduced activity of the 5'-monodeiodinase responsible for converting T4 into T3 in peripheral tissues [2Iervasi G. Pingitore A. Landi P. et al.Low-T3 syndrome A strong prognostic predictor of death in patients with heart disease.Circulation. 2003; 107: 708Crossref PubMed Scopus (379) Google Scholar]. This condition, known as the “low T3 syndrome,” has been described in patients with acute myocardial infarction and heart failure, and in adults and children after cardiopulmonary bypass [2Iervasi G. Pingitore A. Landi P. et al.Low-T3 syndrome A strong prognostic predictor of death in patients with heart disease.Circulation. 2003; 107: 708Crossref PubMed Scopus (379) Google Scholar, 3Cerillo A.G. Bevilacqua S. Storti S. et al.Free triiodothyronine: a novel predictor of postoperative atrial fibrillation.Eur J Cardiothorac Surg. 2003; 24: 487-492Crossref PubMed Scopus (24) Google Scholar]. The SCH, also called “mild thyroid failure,” represents a different entity, the most frequent cause of which is a subtle autoimmune thyroid disease [4Iervasi G. Molinaro S. Landi P. et al.Association between increased mortality and mild thyroid dysfunction in cardiac patients.Arch Intern Med. 2007; 167: 1526-1532Crossref PubMed Scopus (227) Google Scholar].In 2003, we found a strong relationship between low preoperative fT3 concentration and increased risk of postoperative AF in a series of 107 consecutive coronary artery bypass graft (CABG) patients, and gave a possible explanation for this phenomenon [3Cerillo A.G. Bevilacqua S. Storti S. et al.Free triiodothyronine: a novel predictor of postoperative atrial fibrillation.Eur J Cardiothorac Surg. 2003; 24: 487-492Crossref PubMed Scopus (24) Google Scholar]. During the same year, a strong negative correlation between the “low T3 syndrome” and the 1-year survival in a population of 573 nonsurgical, cardiac patients was documented at our institution [2Iervasi G. Pingitore A. Landi P. et al.Low-T3 syndrome A strong prognostic predictor of death in patients with heart disease.Circulation. 2003; 107: 708Crossref PubMed Scopus (379) Google Scholar]. Finally, we have recently found that low preoperative fT3 is a powerful predictor of a bad outcome in CABG patients (unpublished data [5Cerillo AG, Tiwari KK, Latsuzbaia K, et al. Basal free triiodothyronine is a powerful predictor of low cardiac output and hospital death in CABG patients. Abstract submitted for review to: 23rd EACTS Annual Meeting, October 17–21, 2009; Vienna, Austria (Abstract No. 98).Google Scholar]): in a series of 513 consecutive patients, the fT3 (odds ratio = 0.34, 95% confidence interval: 0.16–0.72; p = 0.005) and the left ventricular ejection fraction (odds ratio = 0.94, 95% confidence interval: 0.89–0.99; p = 0.03) were the only independent predictors of hospital death. Given these premises, we were extremely surprised to find that Park and associates [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] did not measure the fT3 concentration and did not look for the “low T3 syndrome” in their patients.Indeed, some of the 36 patients found to have a SCH in the Park and colleagues' [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] series could have had a preoperative low T3 syndrome; for example, low T3 is particularly frequent in patients with chronic kidney disease and in patients with a recent myocardial infarction [2Iervasi G. Pingitore A. Landi P. et al.Low-T3 syndrome A strong prognostic predictor of death in patients with heart disease.Circulation. 2003; 107: 708Crossref PubMed Scopus (379) Google Scholar]. These categories were included in the Park and colleagues [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] series, and this could explain the higher incidence of postoperative AF observed in the SCH group. On the other hand, some of the patients with SCH (especially those with TSH levels < 10 mIU/L) could have had normal fT3 levels, and were therefore free from thyroid-related cardiac dysfunction [4Iervasi G. Molinaro S. Landi P. et al.Association between increased mortality and mild thyroid dysfunction in cardiac patients.Arch Intern Med. 2007; 167: 1526-1532Crossref PubMed Scopus (227) Google Scholar]. This could be the reason why Park and colleagues' [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] series overall prognosis was not influenced by the presence of SCH, even if patients with SCH who showed a trend to have more complications than did the euthyroid patients.In conclusion, we completely share the authors' statement that “… the routine assessment of thyroid function might be important in CABG patients,” but we would strongly recommend to include the fT3 level assessment in the routine preoperative checklist. The findings by Park and coworkers [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] represent further evidence of the importance of the thyroid homeostasis in the cardiac patient, and reinforce the concept that the thyroid profile should be carefully evaluated in patients undergoing cardiac surgery. We congratulate the authors of this very interesting article. Dr Park and associates [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] reported an association between subclinical hypothyroidism (SCH) (defined as high thyroid-stimulating hormone [TSH] concentration in the presence of normal T4) and postoperative atrial fibrillation. We read this article with extreme interest and would like to add some comments on the topic. Free triiodothyronine (fT3), the biologically active form of the thyroid hormone, is frequently reduced in cardiac patients due to the reduced activity of the 5'-monodeiodinase responsible for converting T4 into T3 in peripheral tissues [2Iervasi G. Pingitore A. Landi P. et al.Low-T3 syndrome A strong prognostic predictor of death in patients with heart disease.Circulation. 2003; 107: 708Crossref PubMed Scopus (379) Google Scholar]. This condition, known as the “low T3 syndrome,” has been described in patients with acute myocardial infarction and heart failure, and in adults and children after cardiopulmonary bypass [2Iervasi G. Pingitore A. Landi P. et al.Low-T3 syndrome A strong prognostic predictor of death in patients with heart disease.Circulation. 2003; 107: 708Crossref PubMed Scopus (379) Google Scholar, 3Cerillo A.G. Bevilacqua S. Storti S. et al.Free triiodothyronine: a novel predictor of postoperative atrial fibrillation.Eur J Cardiothorac Surg. 2003; 24: 487-492Crossref PubMed Scopus (24) Google Scholar]. The SCH, also called “mild thyroid failure,” represents a different entity, the most frequent cause of which is a subtle autoimmune thyroid disease [4Iervasi G. Molinaro S. Landi P. et al.Association between increased mortality and mild thyroid dysfunction in cardiac patients.Arch Intern Med. 2007; 167: 1526-1532Crossref PubMed Scopus (227) Google Scholar]. In 2003, we found a strong relationship between low preoperative fT3 concentration and increased risk of postoperative AF in a series of 107 consecutive coronary artery bypass graft (CABG) patients, and gave a possible explanation for this phenomenon [3Cerillo A.G. Bevilacqua S. Storti S. et al.Free triiodothyronine: a novel predictor of postoperative atrial fibrillation.Eur J Cardiothorac Surg. 2003; 24: 487-492Crossref PubMed Scopus (24) Google Scholar]. During the same year, a strong negative correlation between the “low T3 syndrome” and the 1-year survival in a population of 573 nonsurgical, cardiac patients was documented at our institution [2Iervasi G. Pingitore A. Landi P. et al.Low-T3 syndrome A strong prognostic predictor of death in patients with heart disease.Circulation. 2003; 107: 708Crossref PubMed Scopus (379) Google Scholar]. Finally, we have recently found that low preoperative fT3 is a powerful predictor of a bad outcome in CABG patients (unpublished data [5Cerillo AG, Tiwari KK, Latsuzbaia K, et al. Basal free triiodothyronine is a powerful predictor of low cardiac output and hospital death in CABG patients. Abstract submitted for review to: 23rd EACTS Annual Meeting, October 17–21, 2009; Vienna, Austria (Abstract No. 98).Google Scholar]): in a series of 513 consecutive patients, the fT3 (odds ratio = 0.34, 95% confidence interval: 0.16–0.72; p = 0.005) and the left ventricular ejection fraction (odds ratio = 0.94, 95% confidence interval: 0.89–0.99; p = 0.03) were the only independent predictors of hospital death. Given these premises, we were extremely surprised to find that Park and associates [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] did not measure the fT3 concentration and did not look for the “low T3 syndrome” in their patients. Indeed, some of the 36 patients found to have a SCH in the Park and colleagues' [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] series could have had a preoperative low T3 syndrome; for example, low T3 is particularly frequent in patients with chronic kidney disease and in patients with a recent myocardial infarction [2Iervasi G. Pingitore A. Landi P. et al.Low-T3 syndrome A strong prognostic predictor of death in patients with heart disease.Circulation. 2003; 107: 708Crossref PubMed Scopus (379) Google Scholar]. These categories were included in the Park and colleagues [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] series, and this could explain the higher incidence of postoperative AF observed in the SCH group. On the other hand, some of the patients with SCH (especially those with TSH levels < 10 mIU/L) could have had normal fT3 levels, and were therefore free from thyroid-related cardiac dysfunction [4Iervasi G. Molinaro S. Landi P. et al.Association between increased mortality and mild thyroid dysfunction in cardiac patients.Arch Intern Med. 2007; 167: 1526-1532Crossref PubMed Scopus (227) Google Scholar]. This could be the reason why Park and colleagues' [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] series overall prognosis was not influenced by the presence of SCH, even if patients with SCH who showed a trend to have more complications than did the euthyroid patients. In conclusion, we completely share the authors' statement that “… the routine assessment of thyroid function might be important in CABG patients,” but we would strongly recommend to include the fT3 level assessment in the routine preoperative checklist. The findings by Park and coworkers [1Park Y.J. Yoon J.W. Kim K.I. et al.Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting.Ann Thorac Surg. 2009; 87: 1846-1852Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] represent further evidence of the importance of the thyroid homeostasis in the cardiac patient, and reinforce the concept that the thyroid profile should be carefully evaluated in patients undergoing cardiac surgery. We congratulate the authors of this very interesting article. ReplyThe Annals of Thoracic SurgeryVol. 89Issue 3PreviewWe would like to thank Dr Cerillo and colleagues [1] for their interest in our report [2], and we appreciate the editor for giving us the opportunity to reply. Full-Text PDF" @default.
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• W2014863271 title "Thyroid Function and Cardiac Surgery: What Should We Measure, and When?" @default.
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