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We have read with interest the study by Kim and colleagues 1 on the relationship between cardiac troponin I (cTnI) concentration and perioperative morbidity and 6-month mortality of patients undergoing vascular surgery. We remain unsure as to whether the authors when stating "postoperative surveillance with cardiac enzymes is not routinely performed in these patients" refer to creatinine kinase and its MB isoenzyme or to cTnI, a contractile protein, reported to be more specific for the diagnosis of myocardial infarction during surgery. 2 We agree that screening with cardiac enzymes is not routinely performed after vascular surgery. However, it has been our practice to measure cTnI levels routinely, in all high-and intermediate-risk surgery groups, immediately after surgery and in the postoperative days 1 to 3 beginning in September 1995. The surveillance of this marker is not unique to our center and has been reported by other groups in France. 3 Our unit has already published the results of a study consisting of 329 consecutive patients, undergoing infrarenal aortic surgery, included in a prospective manner and followed up for 1 year. 4 We have limited our patient number to a specific surgical risk group with a standardized anesthetic protocol and 1-year follow-up visit. We have used the same immunoassay technique (Stratus fluorometric enzyme immunoassay; Dade Pharmaceuticals) as the authors used. Our study aim was to determine whether there is a cutoff value for cTnI that may predict cardiac complications perioperatively and at 1 year postoperatively, and we employed a receiver-operator characteristics curve for evaluation of the ideal discrimination value between the complicated and uncomplicated patient groups. We have found cTnI to correlate with immediate but not with short-to medium-term mortality.From our experience, we find the perioperative incidence of 12% of cTnI Ͼ1.5 ng/mL much greater than ours, which was 8.2% (27 of 329 patients). It is not entirely clear whether the authors have considered all 9 perioperative deaths to be of cardiovascular origin, as this too, would contrast with our findings of only 5 patients' having a clear cardiac cause of death. From our follow-up, mortality at 1 year is 1.2%, with a comparable cardiac morbidity of 12.6%. This may be related to the difference in perioperative incidence of cTnI Ͼ1.5 ng/mL.Our last comment regards the aim of the study and the authors' recognition "that the primary outcome of the main study has not yet been reviewed." Kim et al 1 used multivariate analysis with cTnI as a dichotomous variable and considered 6-month survival in patients with cTnI above and below 1.5 ng/mL. However, all the causespecific mortality data were not available (7 of 18 deaths, not including those lost to follow-up) to them.

An audit of 100 patients undergoing elective abdominal aortic surgery either by open aortic repair (OAR group 50 patients) or endovascular aortic repair (EAR group 50 patients) was undertaken to document changes in anaesthetic technique and perioperative outcome. The data for the OAR group was collected retrospectively and that for the EAR group prospectively. Combined general anaesthesia and thoracic epidural anaesthesia was used in 44 of the OAR group whereas lumbar central neural blockade alone was used in 47 of the EAR group. The major differences between the two groups were that intraoperative blood loss was significantly less in the EAR group (OAR 1674±1008 ml, EAR 459±350 ml, P<0.001) and that no patient in the EAR group required admission to the Intensive Care Unit (ICU), whereas ICU time for the OAR patients was 29±22 hours. Hospital stay was also significantly different between the two groups (OAR 13±6 days, EAR 5±3 days, P<0.001). Major complications occurred in 20 patients in the OAR group but only 4 patients in the EAR group (P<0.001). EAR reduces blood loss, the requirement for ICU admission, and hospital stay. Central neural blockade is a satisfactory anaesthetic technique for EAR.

breastfeeding. Interestingly, the group with the longest duration of breastfeeding was the group that did not receive an epidural or IV analgesia with pethidine. Perhaps those who want the least medical intervention during labor are most committed to continued breastfeeding.An important difference between the Wilson et al study 9 and the Beilin et al 8 study is that Wilson et al evaluated breastfeeding success at 12 months postpartum via a postal questionnaire with a roughly 70% to 75% response rate. The women were asked how long they breastfed but there are no data as to the percentage of women breastfeeding at 6 weeks postpartum. Therefore comparison to the Beilin et al study is not possible. Furthermore, Beilin et al evaluated multiparous women who planned to breastfeed. Wilson et al evaluated nulliparous women, and there is no information as to the desire of those women to breastfeed. Indeed, 30% to 35% were not breastfeeding while in the hospital on postpartum day 1.An important limitation of the Wilson et al study is that it was not designed to assess breastfeeding but rather mode of delivery. Therefore, it is only a secondary analysis of outcome, and the study may have been insufficiently powered to detect a significant difference among the groups in breastfeeding. Furthermore, there is no information as to why the women stopped breastfeeding, and the accuracy of information collected at 1 year postpartum is debatable, especially since only 6% to 7% were still breastfeeding and most had stopped 8 months earlier.There are many reasons why women initiate and then stop breastfeeding. Most are probably practical issues, such as family support and having dedicated time to breastfeed. If epidural analgesia or epidural analgesia with fentanyl does have an impact on breastfeeding, it is clear from all the studies to date that the influence is small. This study, despite its limitations, supports that conclusion. A randomized controlled study in nulliparous women with breastfeeding as the primary outcome is still needed. Comment by Yaakov Beilin, MD

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