Case report: Transesophageal echocardiography detected severe regional wall motion abnormalities signifying failed reimplantation of an anomalous left main coronary artery

Purpose

Anomalous coronary arteries comprise a spectrum ranging from benign to fatal. The most ominous lesion that occurs is the left main coronary artery (LMCA) originating from the opposite aortic sinus. This defect usually presents as sudden death in a healthy young adult immediately after exercise. We report a case of reimplantation of an anomalous LMCA, discovered in a 15-yr-old girl during investigations for atypical chest pain.

Clinical features

The intraoperative transesophageal echocardiography (TEE) confirmed that the anomalous LMCA originated from the right aortic sinus. The anomalous LMCA was reimplanted to the left aortic sinus, but the patient could not be weaned from cardiopulmonary bypass because of severe hypotension. The TEE demonstrated severe regional wall motion abnormalities (RWMA) in the territory of the LMCA with akinesis of the septal, antero-septal, anterior, and lateral walls. Using TEE, flow could not be seen in the reimplanted LMCA, hence, the differential diagnosis was established as failed reimplantation of the LMCA, coronary air embolism, or poor myocardial preservation, but the latter two causes were extremely unlikely. Surgical inspection of the reimplanted LMCA did not reveal a correctable problem. A left internal mammary artery to proximal left anterior descending (LAD) artery graft was completed with resolution of the previous RWMA. Recovery of function in the lateral wall confirmed retrograde flow from the LAD into the circumflex artery.

Conclusions

Transesophageal echocardiography was critical in rapidly determining the cause of hemodynamic instability following this uncommon operation. Despite the availability of newer techniques to detect and quantify RWMA, the assessment of wall motion and contractility remains subjective.     

Significance and clinical value of the transitional zone volume (TZV) or index (TZI) in assessing the degree of lower urinary tract obstruction: Revisited

Introduction

A lot of diagnostic tools are present for assessing the degree of LUTs. Pressure-flow studies are invasive and cannot be justified in all patients suffering from LUTs. From here came the clinical importance of searching for another clinical tool, to help in assessing the degree of LUTS.

Relationship between dobutamine-induced regional wall motion abnormalities and coronary flow reserve in heart transplant patients without angiographic coronary artery disease.

BACKGROUND: Regional wall motion abnormalities (RWMA) demonstrated by dobutamine stress echocardiography (DSE) are a sensitive predictor of coronary artery disease (CAD) in heart transplant recipients. However, RWMA have been shown to occur in patients with angiographically "normal" coronary arteries. The reasons for this are unknown. We sought to determine if abnormal responses to dobutamine in this setting can be explained by microvascular dysfunction in the coronary circulation as detected by decreased coronary flow reserve (CFR). METHODS: Twenty-six consecutive heart transplant patients were evaluated prospectively. Five of 26 (19.2%) patients (seven coronary arteries) were excluded for poor acoustic windows on echocardiography. Another three patients were excluded for angiographically apparent CAD. CFR and wall motion score index (WMSI) derived from DSE were measured in the remaining 18 patients and formed the basis of this study. Patients were divided into two groups based on the absence (Group 1; n = 5) or presence (Group 2; n = 13) of RWMA on DSE. CFR was measured with the Doppler Flo-Wire in 34 coronary arteries (18 patients) and correlated with WMSI. RESULTS: In Group 1 patients, CFR measured in eight coronary arteries was normal (2.6 +/- 0.4). In Group 2 patients, CFR measured in 26 coronary arteries also was normal (2.2 +/- 0.6; p = NS vs Group 1). In Group 2, CFR was measured in 20 of 24 vessels assigned to segments that developed RWMA. Only 6 of these 20 vessels (30%) had abnormal CFR. Overall, there was no correlation between decreased CFR and the presence of RWMA induced by dobutamine. CONCLUSIONS: These data suggest that, in cardiac transplant patients with angiographically "normal" coronary arteries, inducible wall motion abnormalities during DSE cannot be attributed to coronary microvascular dysfunction as manifested by decreased CFR.     

Preoperative calculation of risk for prolonged intensive care unit stay following coronary artery bypass grafting

Objective  

Patients who have prolonged stay in intensive care unit (ICU) are associated with adverse outcomes. Such patients have cost implications and can lead to shortage of ICU beds. We aimed to develop a preoperative risk prediction tool for prolonged ICU stay following coronary artery surgery (CABG).     

Minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries: Will this be the future?

Objective

The aim was to show that total arterial revascularization via a left minithoracotomy using bilateral internal thoracic arteries was not only feasible but also a safe and reproducible procedure with excellent midterm outcomes.

Prognostic importance of postbypass regional wall-motion abnormalities in patients undergoing coronary artery bypass graft surgery. SPI Research Group

Regional wall motion abnormalities (RWMA) detected by intraoperative transesophageal echocardiography (TEE) are thought to be sensitive markers of myocardial ischemia. To assess the prognostic significance of RWMA as compared with other less costly technologies such as electrocardiography (ECG) and hemodynamic measurements [blood pressure (BP) and pulmonary artery (PA) pressure], 50 patients were prospectively studied who were undergoing elective coronary artery bypass graft (CABG) surgery using continuous TEE, ECG (Holter), and hemodynamic measurements during the prebypass, postbypass, and early postoperative intensive care unit (ICU) periods (first 4 h). Echocardiographic and ECG evidence of ischemia was characterized during each of these three periods and related to adverse clinical outcomes (postoperative myocardial infarction, ventricular failure, and cardiac death). Clinicians were blinded to the TEE and ECG information. The prevalence of myocardial ischemia during the perioperative periods was as follows: prebypass, 20% (TEE) versus 7% (ECG); postbypass, 36% (TEE) versus 25% (ECG); ICU 25% (TEE) versus 16% (ECG). Neither prebypass TEE ischemia nor ECG ischemia occurring in any of the three periods predicted adverse outcome. In contrast, postbypass TEE ischemia was predictive of outcome: six of 18 patients with postbypass TEE ischemia had adverse outcomes versus 0 of 32 without TEE ischemia (P = 0.001). Seventy-three percent of the echocardiographic ischemic episodes occurred without acute change (+/- 20% of control) in heart rate, BP, or PA pressure. The authors conclude that: 1) prebypass myocardial ischemia was relatively uncommon, 2) the incidence of ECG and TEE ischemia was highest in the postbypass period, and 3) postbypass RWMA were related to adverse clinical outcome.     

Association of pre and intraoperative variables with postoperative complications in coronary artery bypass graft surgery

Objective

To associate the pre- and intraoperative variables with postoperative complications of patients undergoing coronary artery bypass graft surgery.

Methods

The pre- and intraoperative risk factors of individuals of both genders with diagnosis of coronary insufficiency undergoing coronary artery bypass graft have been studied.

Results

Fifty-eight individuals with median age 62 ± 10 year-old were included in the study, 67% of whom were male. Fourteen (24.1%) patients were smokers, 39 (67.2%) had previous myocardial infarction history, 11 (19%) had undergone coronary angioplasty, 74% had hypertension, 27% had diabetes mellitus, 64% had dyslipidemia and 15.5% had chronic obstructive pulmonary disease. Eighteen (31%) patients presented postoperative complications, most frequent being: infection in surgical incision, difficulties in deambulation, dyspnea, urinary infection and generalized weakness. Male patients had fewer complications than females (P=0.005). Patients with chronic obstructive pulmonary disease remained hospitalized for longer time periods (P=0.019). Postoperative complications occurred in 50% of the patients with creatinine increased, while only 27.1% of the patients with normal value of creatinine had complications (P=0.049). In addition, complications occurred in 50% of the patients with diabetes mellitus, while only 23.8% of patients without diabetes mellitus had complications (P=0.032). The intraoperative factors showed no statistically significant differences.

Conclusion

The preoperative factors are associated with postoperative complications in patients undergoing coronary artery bypass graft surgery.     

Value of Stress Myocardial Perfusion Scanning in Diagnosis of Severe Coronary Artery Disease in Liver Transplantation Candidates

Background

The significant potential for perioperative and late cardiovascular complications makes careful preoperative cardiac risk assessment imperative in liver transplantation candidates.

Objective

To determine the sensitivity and specificity of myocardial perfusion scanning for detection of coronary artery disease (CAD) in liver transplantation candidates.

Patients and Methods

We prospectively evaluated 93 liver transplantation candidates. Patients with known CAD were excluded. All patients, regardless of symptoms and risk factors, underwent myocardial perfusion scanning and coronary angiography.

Results

Results of myocardial perfusion scanning were abnormal in 64 patients (68.8%) and normal in 29 patients (31.2%). Of patients with abnormal scans, only 6 (9.4%) had severe CAD at coronary angiography. None of the 29 patients with normal perfusion scans and the 24 patients with fixed defects had severe CAD; however, 6 of 40 patients (15.0%) with reversible perfusion defects had severe CAD at coronary angiography (P = .005). Alcoholic liver disease, reversible perfusion defects at myocardial perfusion scanning, left ventricular systolic dysfunction, and higher low-density lipoprotein (LDL) cholesterol and triglyceride levels were significantly associated with CAD. Defining reversible perfusion defects as a sign of ischemia, and fixed defects and normal perfusion as nonischemic, myocardial perfusion scanning had 100% sensitivity but 61% specificity for severe CAD. The test's accuracy was low (38%).

Conclusions

The results of reversible perfusion defects on myocardial perfusion scanning were sensitive but not specific for CAD in liver transplantation candidates. The high number of false-positive results decreased the test's accuracy.     

Myocardial protection during revascularization for myocardial ischemia

Operations that reestablish flow to proximally obstructed coronary arteries are being applied with greater frequency and greater success. The long-term effects of such operations will ultimately be measured by increased longevity for patients with coronary artery disease, providing that perioperative injury is held to an absolute minimum and technical expertise is maintained at an absolute maximum. Application of myocardial protective techniques requires a knowledge of coronary and myocardial physiology. The use of nonrandomized applications of new protective techniques is strongly discouraged since such adventures provide little insight for the future. Further elucidation of the safe intervals for brief periods of ischemia in hearts with and without obstructed coronary arteries is needed, as are more refined measurements of physiologic and biochemical effects of revascularization techniques in regions of myocardium supplied by heterogeneously affected coronary arteries.     

Indications for intensive care unit care after carotid endarterectomy

Objectives

To describe the complications of carotid endarterectomy and the interventions performed in the intensive care unit (ICU) after carotid endarterectomy. To identify preoperative and recovery room (RR) risk markers for these complications and interventions.

Design

A retrospective case study.

Setting

The ICU of a university hospital.

Patients

One hundred and one patients who required carotid endarterectomy over a 15-month period.

Intervention

Carotid endarterectomy (bilateral procedures in 11 patients).

Outcome Measures

Demographic data including Goldman’s cardiac risk index and the therapeutic intervention scoring system (TISS) score to measure the risk of complications.

Results

Most of interventions conducted in the RR and ICU were to control high blood pressure. In the RR, three patients experienced a neurologic event, one patient was reintubated for vocal cord paralysis and one had electrocardiographic abnormalities. Overall, 5 of the 101 patients had neurologic complications and 2 suffered a myocardial infarction. Two patients died, one as a result of a massive stroke and the other of myocardial infarction with cardiogenic shock. The mean (and standard deviation ) TISS score in the ICU was 12.6 (3.8). Analysis of all events in the RR was not predictive of events in the ICU. However, the absence of major complications in the RR had a negative predictive value of 97%.

Conclusions

The decision to admit patients to the ICU after carotid endarterectomy should be based on major complications occurring in the RR. A low TISS score and low incidence of complications does not warrant routine admission.     

17β-estradiol effects on human coronaries and grafts employed in myocardial revascularization: a preliminary study

Background  

This study was undertaken to compare the in vitro effects of 17β-estradiol on human epicardial coronary arteries, resistance coronary arteries and on arterial vessels usually employed as grafts in surgical myocardial revascularization.     

Can clinicians predict ICU length of stay following cardiac surgery?

Purpose

To determine whether a group of experienced clinicians can predict intensive care unit (ICU) length of stay (LOS) following cardiac surgery.

Methods

A cohort of 265 adult patients undergoing cardiacsurgery at St. Michael’s Hospital, Toronto, Ontario, between January 2, 1992, and June 26, 1992, were seen preoperatively by the clinicians participating in the study and ICU length of stay was predicted based on the clinicians’ preoperative assessment and/or information recorded in the patient’s chart.

Results

Five hundred and ten ICU length of stay predictions were obtained from a group of eight experienced clinicians (anaeslhetists/intensivists, cardiologists, nurses). The clinicians predicted the exact ICU length of stay (in days) correctly 51.2% of the time and were within ± 1 day 84.5% of the time. The clinicians correctly predicted short ICU stays (≤ 2 days) for 87.6% of the patients who had short ICU stays but only predicted long ICU stays (> 2 days) in 39.4% of the patients who had long ICU stays.

Conclusions

Experienced clinicians can predict preoperatively with a considerable degree of accuracy patients who will have short ICU lengths of stay following cardiac surgery. However, many patients who had long ICU stays were not correctly identified preoperatively. Unidentified preoperative risk factors or unanticipated intraoperative/postoperative events may be causing these patients to have longer than expected ICU stays.     

Management des akuten Myokardinfarkts – 1991 bis 2009

Background

Ischemic heart disease is a leading cause of morbidity and mortality. At the Medical University of Vienna the Department of Emergency Medicine and the Division of Cardiology are jointly responsible for the management of patients with acute myocardial infarction. During the last 20 years knowledge on this topic has undergone vast changes.

Material and methods

All patients treated for acute myocardial infarction have been included in a register since 1991. This register is based on the recommendations of the European Society of Cardiology and contains demographic data, risk factors, prior medication and diseases, vital signs and symptoms, electrocardiogram (ECG) and laboratory parameters, as well as information on prehospital and inhospital treatment.

Results

A total of 7144 patients from 1991 to 2009 were included. An ST elevation myocardial infarction (STEMI) was diagnosed in 4171 (58.4%) cases, non-ST elevation myocardial infarction (NSTEMI) in 2417 (33.8%) cases and no classification was possible in 556 (7.8%) cases. The annual number of patients rose from 160 to 549, 1377 (19.3%) patients were referred from another hospital by emergency medical services (EMS) and 919 (12.9%) received cardiopulmonary resuscitation. During the observation period the focus of primary reperfusion therapy for STEMI shifted from thrombolysis (down from 65.3% to 2.6%) to percutaneous coronary intervention (up from 5.3% to 85.9%). The 30 day mortality was 7% for STEMI and 6% for NSTEMI.

Conclusions

Treatment strategies for acute myocardial infarction are constantly changing and it is therefore an ongoing challenge for emergency departments and all involved to keep pace with new developments.     

Simultaneous lung resection for cancer and myocardial revascularization without cardiopulmonary bypass (off-pump coronary artery bypass grafting)

Backround

Patients with resectable lung cancer and unstable coronary heart disease are at high risk of postoperative death or severe cardiovascular complications. The aim of this study was to present the early results of radical lung resection for cancer with simultaneous myocardial revascularization on the beating heart (off-pump coronary artery bypass [OPCAB]).

Methods

From 1999 to 2002, thirteen patients (9 men and 4 women, aged 54 to 71 years, mean age 64 yrs) with resectable lung cancer and unstable angina or a recent history of myocardial infarction, were operated on. All of them underwent coronary angiography and neither coronary angioplasty nor stenting were feasible. Eight lobectomies, three pneumonectomies, and two wedge resections were carried out together with aortocoronary graft implantation (mean number of grafts: 1.7 per patient). Myocardial revascularization without cardiopulmonary bypass (OPCAB) preceded the lung resections. The preferred approach to the heart and lung was by sternotomy.

Results

There were no postoperative deaths in this group of patients. The most frequent postoperative complication was prolonged air leakage and one patient required respiratory support for two days. In one patient, significant blood loss was observed with a need for rethoracotomy. Transient supraventricular cardiac arrhythmias occurred in three patients. None of the patients showed evidence of myocardial ischemia after surgery. Patients were followed up for 7 to 36 months. None had acute myocardial infarction. In one patient, who underwent lobectomy, local recurrence was found. In another patient, who underwent pneumonectomy, distant metastases occurred in the third year of observation.

Conclusions

Lung resection carried out simultaneously with OPCAB is a safe and effective method for the treatment of lung cancer and myocardial ischemia.     

Cardiopulmonary bypass increases the risk of vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure

Objective

Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group.

Methods

A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately.

Results

There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences.

Conclusion

Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.     

Intensive care unit admission after endovascular aortic aneurysm repair is primarily determined by hospital factors,adds significant cost,and is often unnecessary

Background

A large proportion of endovascular aortic aneurysm repair (EVAR) patients are routinely admitted to the intensive care unit (ICU) for postoperative observation. In this study, we aimed to describe the factors associated with ICU admission after EVAR and to compare the outcomes and costs associated with ICU vs non-ICU observation.

Outcome in patients with long-term treatment in a surgical intensive care unit

Background

This study aimed to evaluate the outcome of patients with abdominal, thoracic or vascular operations and long-term intensive care unit (ICU) treatment.

Patients and methods

The present retrospective observational cohort study was performed at the authors' surgical ICU at the Marburg University Medical Centre. All patients who stayed at the ICU longer than 48?h and underwent visceral, thoracic or vascular surgery between January 2005 and December 2006 were retrospectively analysed. Patients with an ICU stay of 20 or more days were defined as the long-term study group. Clinical variables were tested for prognostic value.

Results

In 2?years, 852 patients were treated at the intensive care unit. Follow-up was available in 502 patients, with 219 patients treated for two and more days and a median of 16.4?days. Sixty-seven long-term patients were compared to 152 (69.4?%) patients treated between 2 and 20?days. Overall survival after 12?months was 50.2?% (110/219), while 65.8?% (144/219) were discharged from ICU. Older age, longer treatment at the ICU and increased simplified acute physiology score (SAPS) at admission were associated with decreased 12-month survival, while no statistical differences were observed for the underlying and malignant disease by univariate analysis. The risk of death was 29, 56 and 61?% for patients treated 2–4, 5–19 and ≥20?days at the ICU. Decreased survival of patients treated for 5–19 and ≥20?days were confirmed by logrank test (p?=?0.001).

Conclusions

Patients with long-term ICU stay showed decreased survival than patients who are treated less than 5?days but similar survival as patients which stayed between 5 and 19?days. Malignant disease is not associated with an unfavourable 12-month survival while older age, higher SAPS index at discharge and longer stay at ICU are. Long-term ICU survivors have no increased risk to succumb after discharge from ICU.     

Carotid endarterectomy in awake patients: safety,tolerability and results

Objective

To analyze the results of 125 carotid endarterectomies under loco-regional anesthesia, with selective use of shunt and bovine pericardium patch.

Methods

One hundred and seventeen patients with stenosis ≥ 70% in the internal carotid artery on duplex-scan + arteriography or magnetic resonance angiography underwent 125 carotid endarterectomies. Intraoperative pharmacological cerebral protection included intravenous administration of alfentanil and dexametasone. Clopidogrel, aspirin and statins were used in all cases. Seventy-seven patients were males (65.8%). Mean age was 70.8 years, ranging from 48 to 88 years. Surgery was performed to treat symptomatic stenosis in 69 arteries (55.2%) and asymptomatic stenosis in 56 arteries (44.8%).

Results

A carotid shunt was used in 3 cases (2.4%) due to signs and symptoms of cerebral ischemia after carotid artery clamping during the operation, and all 3 patients had a good outcome. Bovine pericardium patch was used in 71 arteries ≤ 6 mm in diameter (56.8%). Perioperative mortality was 0.8%: one patient died from a myocardial infarction. Two patients (1.6%) had minor ipsilateral strokes with good recovery, and 2 patients (1.6%) had non-fatal myocardial infarctions with good recovery. The mean follow-up period was 32 months. In the late postoperative period, there was restenosis in only three arteries (2.4%).

Conclusion

Carotid artery endarterectomy can be safely performed in the awake patient, with low morbidity and mortality rates.     

Results of Coronary Artery Bypass Grafting in Myocardial Bridging of Left Anterior Descending Artery

Background

We aimed to evaluate the graft patency rate following coronary artery bypass grafting (CABG) to the left anterior descending artery (LAD) with proximal myocardial bridging (MB). While MB is generally a benign coronary abnormality, ischemia, stunning, and sudden death have been reported. In symptomatic patients with proximal LAD systolic compression of >50%, positive for ischemic noninvasive testing and noneffective optimal medical therapy, coronary intervention could be indicated. Few studies of CABG in myocardial bridging have been reported. The influence of high flow in coronaries with MB on graft patency is cause for concern.

Methods

We retrospectively studied 39 patients operated on for isolated MB of proximal LAD with >50% systolic compression. All patients were severely symptomatic despite optimal medical therapy and positive noninvasive tests for myocardial ischemia. CABG was performed through the midsternotomy with cardiopulmonary bypass and cardioplegia. Patients were divided into two groups: in 20 patients, LAD was bypassed with left internal mammary artery (LIMA) (Group 1) and in 19 patients with saphenous vein graft (SVG) (Group 2). All patients underwent follow‐up coronary angiography.

Results

Demographics and degree of systolic compression of the LAD were similar in both groups. There was no mortality or major morbidity. Freedom from angina was 68% in Group 1 and 94% in Group 2 at 18 months postoperatively (p = 0.58). Twelve LIMA grafts and three SVGs were found occluded (p = 0.002).

Conclusions

LIMA patency in myocardial bridging of the LAD can be low. SVGs should be considered in cases of CABG for myocardial bridging. doi: 10.1111/jocs.12101 (J Card Surg 2013;28:218–221)     

Associations among serum trimethylamine-N-oxide (TMAO) levels,kidney function and infarcted coronary artery number in patients undergoing cardiovascular surgery: a cross-sectional study

Background

Trimethylamine-N-oxide (TMAO) is a metabolite of phosphatidylcholine generated by gut microbiota and liver enzymes, and has recently been recognized as contributing to atherosclerosis. Elevated serum TMAO levels have been shown to increase the risk of cardiovascular disease (sudden death, myocardial infarction, or stroke) in patients undergoing elective coronary angiography. We aimed to clarify whether TMAO levels are associated with the number of infarcted coronary arteries as a measure of the severity of atherosclerosis, with adjustment using a priori-defined covariates such as kidney function.

Methods

By conducting a cross-sectional study of 227 patients who underwent cardiovascular surgery for coronary artery disease, valvular heart disease, or aortic disease, the association between serum TMAO levels as measured by HPLC-APCI-MS/MS and the number of infarcted coronary arteries was evaluated using ordered logistic regression models with adjustment of 10 covariates, including chronic kidney disease (CKD) stage. Unadjusted and adjusted odds ratios (ORs) and 95 % confidence intervals (95 % CIs) were determined.

Results

Significantly higher TMAO levels were observed in advanced-stage CKD (p ≤ 0.001). In fully adjusted models with the 10 covariates, a significantly increased number of infarcted coronary arteries was identified in the highest quartile and quintile of TMAO compared to the lowest quartile (OR 11.9; 95 % CI 3.88–36.7, p ≤ 0.001) and quintile (OR 14.1; 95 % CI 3.88–51.2; p ≤ 0.001), respectively, independent of dyslipidemia.

Conclusions

Higher serum TMAO levels may be associated with advanced CKD stages and with an increased number of infarcted coronary arteries in patients who undergo cardiovascular surgery.