Early respiratory outcomes following cardiac surgery in patients with COVID-19.

BACKGROUND: Both coronavirus disease (COVID-19) and cardiac surgery have a negative impact on pulmonary function. This study aimed to determine the postoperative respiratory outcomes of patients with COVID-19 who underwent cardiac surgery. METHODS: In this retrospective study, we reviewed and analyzed the patient characteristics and clinical data of 25 asymptomatic patients with COVID-19 who underwent urgent or emergency cardiac surgery at Tehran Heart Center Hospital, Iran, between 29 February and 10 April 2020. RESULTS: The mean age, EuroSCORE, and body mass index were 57.3 ± 15.1 years, 6.65 ± 1.29, and 25.7 ± 3.7 kg/m2 , respectively. Four patients underwent off-pump cardiac surgery and 21 underwent on-pump cardiac surgery with a median cardiopulmonary bypass time of 85 minutes (interquartile range (IQR, 50-147). The overall mortality rate and the length of stay in the intensive care unit (ICU) were higher compared to those of a propensity-matched group of patients who underwent cardiac surgery in the pre-COVID era. The median intubation time was 13 hours (IQR, 9.5-18), which was comparable to that of pre-COVID cardiac surgery patients. The readmission rate to the ICU was 16%. In this ICU readmitted group, the mean oxygen index, FiO2 , and mortality rate were higher and the PaO2 /FiO2 ratio was lower than those of the nonreadmitted patients. CONCLUSIONS: Although early respiratory outcomes of asymptomatic COVID-19 patients who underwent early cardiac surgery appeared to be satisfactory, compared to the propensity-scored matched non-COVID group, the postoperative outcomes were worse, especially in the ICU readmitted patients. We suggest postponing cardiac operations unless the patient requires emergency surgery.

Bilateral proximal deep vein thrombosis and COVID-19 in a patient with absence of inferior vena cava: A case report and review of literature.

Bilateral proximal deep vein thrombosis (DVT) in the lower extremities of young patients should raise suspicion over pro-thrombotic conditions and venous anatomical abnormalities, even in the presence of other precipitating factors, such as viral infection. The authors present a 33-year-old man with bilateral DVT and absence of inferior vena cava (AIVC), who also had concurrent COVID-19, and discuss the management of this patient.

The association between different body mass index levels and midterm surgical revascularization outcomes.

BACKGROUND: There are conflicting results regarding the relationship between overweight/obesity and the outcomes of coronary artery bypass graft surgery (CABG), termed "the obesity paradox". This study aimed to evaluate the effects of body mass index (BMI) on the midterm outcomes of CABG. METHODS: This historical cohort study included all patients who underwent isolated CABG at our center between 2007 and 2016. The patients were divided into five categories based on their preoperative BMIs (kg/m2): 18.5≤BMI<25, 25≤BMI<30, 30≤BMI<35, 35≤BMI<40, and BMI≥40. Patients with BMIs below 18.5 kg/m2 were excluded. The endpoints of this study were all-cause mortality and major adverse cardio-cerebrovascular events (MACCEs), comprising acute coronary syndromes, cerebrovascular accidents, and all-cause mortality at five years. For the assessment of the linearity of the relationship between continuous BMI and the outcomes, plots for time varying hazard ratio of BMI with outcomes were provided. RESULTS: Of 17 751 patients (BMI = 27.30 ±4.17 kg/m2) who underwent isolated CABG at our center, 17 602 patients (mean age = 61.16±9.47 y, 75.4% male) were included in this study. Multivariable analysis demonstrated that patients with pre-obesity and normal weight had similar outcomes, whereas patients with preoperative BMIs exceeding 30 kg/m2 kg/m2 had a significantly higher risk of 5-year all-cause mortality and 5-year MACCEs than those with pre-obesity. Additionally, a positive association existed between obesity degree and all-cause mortality and MACCEs. Further, BMIs of 40 kg/m2 or higher showed a trend toward higher MACCE risks (adjusted hazard ratio, 1.32; 95% confidence interval, 0.89 to 1.95), possibly due to the small sample size. A nonlinear, albeit negligible, association was also found between continuous BMI and the study endpoints. CONCLUSIONS: Our findings suggest that preoperative obesity (BMI>30 kg/m2) in patients who survive early after CABG is associated with an increased risk of 5-year all-cause mortality and 5-year MACCEs. These findings indicate that physicians and cardiac surgeons should encourage patients with high BMIs to reduce weight for risk modification.

Isolated tricuspid valve surgery; long-term outcomes based on Tehran Heart Center data bank report.

BACKGROUND: Given that isolated tricuspid valve (TV) repair or replacement is performed relatively rarely, we sought to evaluate the rate of long-term mortality and readmission following this surgery. METHODS: The current study was conducted in Tehran Heart Center on patients who underwent isolated TV repair or replacement between 2010 and 2018. Totally, 197 patients (repair = 150 vs replacement = 47) were included in our study and were then followed right after surgery for a median of 8 years to assess the incidence of postoperative events, readmission, and all-cause mortality. RESULTS: The final analysis was conducted on 197 patients at a mean age of 44.4 ± 13.8 years. Most of the patients were female (56.9%). Ejection fraction, TAPSE, and right ventricular function improved in both groups after TV surgery. Length of stay in the intensive care unit per hour and hospitalization per day were higher in the replacement group and compared to the repair group (158.34 vs. 55.11 and 18.21 vs. 9.34, respectively). In-hospital mortality occurred in 20 patients, of whom 15 had TV replacement. Readmission occurred in five (2.5%) patients,all were in the repair group. CONCLUSIONS: The result of this single-center study showed that TV replacement is associated with a higher rate of postoperative events and all-cause mortality compared to TV repair. Whereas, repair group had a higher rate of readmission. Therefore, the overwhelming tendency is toward repair; nonetheless, no hesitation is permissible if a replacement is adjudged to confer a better outcome for the patient.

Predictors and early outcome of prolonged mechanical ventilation in contemporary heart valve surgery.

BACKGROUND: During last decades mechanical ventilation has been an important support in the postoperative management of patients undergoing cardiac surgery. This study was designed to determine the predictors of prolonged mechanical ventilation (PMV) in patients undergoing heart valve surgery. METHODS: This retrospective study considered of 1056 patients who underwent isolated valve surgery at Tehran Heart Center from March 2002 to March 2009. PMV is considered as mechanical ventilation period of > or =24 hours at postoperative hospital stay in this study. RESULTS: PMV occurred in 6.6% of patients. Initial ventilation hours, atrial fibrillation, cardiac arrest and reintubation were the most prevalent postoperative complications. Preoperative renal failure, postoperative stroke, intra aortic balloon pump insertion, emergent operation, complete heart block, longer perfusion time were independent predictors of PMV in our patients. CONCLUSION: PMV is associated with significant comorbidities and increased hospital mortality. Strategies to delineate the patients at risk and to modify these risk factors by prophylactic measures should probably lead to a lower incidence of prolonged mechanical ventilation for patients undergoing isolated valve surgery.

Smoking Cessation After Surgery and Midterm Outcomes of Surgical Revascularization.

BACKGROUND: Although multiple studies have reported the devastating effect of cigarette smoking (CS) on short-term outcomes of patients who underwent coronary artery bypass grafting surgery (CABG), its effect on long-term outcomes is still questionable. We aimed to evaluate the long-term outcomes of CS cessation after CABG surgery. METHODS: This retrospective cohort study included all patients who underwent isolated CABG at our center between 2007 and 2016 and were cigarette smokers either just before or at the time of surgery. Patients were stratified into those who continued CS and those who were persistently CS abstinent after CABG. The endpoints of the study were 5-year mortality and 5-year major adverse cardiovascular and cerebrovascular events. RESULTS: Of 28,945 patients who underwent isolated CABG, 9173 current cigarette smokers (93.5% men; mean age, 58.6 years) met our selection criteria and were included in the final analysis. Of these 3302 patients (40.0%) continued CS after surgery and 5688 patients were persistently abstinent. Multivariable survival analysis demonstrated that CS cessation after CABG, adjusted for major coronary risk factors, could reduce the 5-year mortality by 35% (hazard ratio, 0.65; 95% confidence interval, 0.54-0.77; P < .001) and 5-year major adverse cardiovascular and cerebrovascular events by 18% (hazard ratio, 0.82; 95% confidence interval, 0.74-0.92; P = .001). CONCLUSIONS: Our study shows that CS abstinence after CABG significantly reduces long-term mortality and number of major adverse events. As a result, patients who smoke should be encouraged to participate in CS cessation programs after CABG surgery.

Giant unruptured noncoronary sinus of Valsalva aneurysm.

Huge unruptured sinus of Valsalva aneurysms is rarely observed. We report a 32-year-old woman presenting with exertional dyspnea in which a giant unruptured noncoronary sinus of Valsalva aneurysm was detected after echocardiography. The aneurysm was surgically repaired and the aortic and mitral valves were replaced.

Coronary artery bypass grafting in patients with low ejection fraction: the effect of intra-aortic balloon pump insertion on early outcome.

BACKGROUND: Survival benefit with intra-aortic balloon pump (IABP) insertion for coronary artery bypass grafting (CABG) patients with left ventricular dysfunction is controversial. The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay (LOS) after isolated CABG and the role of IABP application as a main predictor in patients with an ejection fraction (EF) of 30% or less. MATERIALS AND METHODS: Eight hundred and thirty-three patients who underwent isolated CABG with EF < or = 30% were entered and compared with 10881 patients with EF > 30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. Data were analyzed using the student's t-test and chi-square test for univariate analysis and the analysis of covariance and logistic regression for multivariate analysis. RESULTS: The thirty-day mortality rate (1.6% vs. 0.7%, P P P = 0.002) and prolonged LOS (P = 0.009). Also, urinary tract infection, prolonged ventilation, and renal failure as postoperative complications were statistically more in the group with the application of IABP. CONCLUSION: Low ejection fraction can positively affect thirty-day mortality and prolonged LOS and ICU stay in patients who undergo CABG. In these patients, IABP insertion is a strong predictor for early complication and mortality.

Endovascular Aortic Aneurysm and Dissection Repair (EVAR) in Iran: Descriptive Midterm Follow-up Results.

BACKGROUND: Endovascular repair of aorta in comparison to open surgery has a low early operative mortality rate, but its long-term results are uncertain. OBJECTIVES: The current study describes for the first time our initial four-year experience of elective endovascular aortic repair (EVAR) at Tehran heart center, the first and a major referral heart center in Iran, as a pioneer of EVAR in Iran. PATIENTS AND METHODS: A total of 51 patients (46 men) who had the diagnosis of either an abdominal aortic aneurysm (AAA) (n = 36), thoracic aortic aneurysm (TAA) (n = 7), or thoracic aortic dissection (TAD) (n = 8) who had undergone EVAR by Medtronic stent grafts by our team between December 2006 and June 2009 were reviewed. RESULTS: The rate of in-hospital aneurysm-related deaths in the group with AAA stood at 2.8% (one case), while there was no in-hospital mortality in the other groups. All patients were followed up for 13-18 months. The cumulative death rate in follow-up was nine cases from the total 51 cases (18%), out of which six cases were in the AAA group (four patients due to non-cardiac causes and two patients due to aneurysm-related causes), one case in the TAA group (following a severe hemoptysis), and two cases in the TAD group (following an expansion of dissection from re-entrance). The major event-free survival rate was 80.7% for endovascular repair of AAA, 85.7% for endovascular repair of TAA, and 65.6% for endovascular repair of TAD. CONCLUSION: The endovascular stent-graft repair of the abdominal and thoracic aortic aneurysm and aortic dissection had high technical success rates in tandem with low-rate early mortality and morbidity, short hospital stay, and acceptable mid-term free symptom survival among Iranian patients.

Percutaneous aortic valve implantation in bicuspid aortic valve: A case report.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) was known as an alternative technique for treatment of severe aortic stenosis (AS). This technique is controversial in bicuspid aortic valve (BAV). Here, we report TAVI for severe AS in a BAV setting in a patient with serious lung disease. CASE REPORT: A 68-year-old woman with a history of coronary artery bypass graft, BAV and severe AS, asthma, who had repeatedly denied any suggestion for open heart surgery, was our volunteer candidate for TAVI. The peak and mean pressure gradient decreased from 53 and 43 mm Hg to 13and 6 mm Hg respectively. CONCLUSION: TAVI could be a viable option for highly selected patients with AS and BAV who have a prohibitive risk for open heart surgery.

Suitable bone markers assessing bone status in patients with both coronary artery disease and diabetes.

BACKGROUND: We aimed to investigate the bone turnover markers in coronary artery disease (CAD) patients with and without type 2 diabetes (T2DM) in comparison with control subjects without CAD and T2DM. METHODS: This cross-sectional study was performed on 45 subjects undergoing elective heart surgery; either for coronary artery bypass grafting or for valve surgery. According to angiographic results, participants were grouped in two groups with CAD (n = 33) and without CAD (n = 12). The serum levels of osteocalcin (OC), procollagen I aminoterminal propeptide (P1NP) and carboxy-terminal collagen crosslinks (CTX), as bone turnover markers, as well as serum levels of 25 (OH) vitamin D3, PTH, and common metabolic factors were analyzed in all participants. RESULTS: Serum levels of bone markers did not differ in patients with CAD compared to non-CAD subjects. Regarding metabolic factors, serum levels of FBG had invert correlation with OC in CAD patients (p = 0.004). The data of subgroup analysis showed serum levels of OC and CTX were statistically significant lower in CAD-DM than CAD-non DM (p < 0.05). There were not any significant differences in the P1NP levels between groups. CONCLUSIONS: Our data suggest that CTX and OC would be used as suitable bone markers in CAD patients with T2DM. However, further clinical studies need to establish the role of these markers in CAD patients with diabetes.

The effect of continuous low dose methylprednisolone infusion on inflammatory parameters in patients undergoing coronary artery bypass graft surgery: a randomized-controlled clinical trial.

This trial was performed to determine if a continuous low-dose infusion of methylprednisolone is as effective as its bolus of high-dose in reducing inflammatory response. The study was single-center, double-blinded randomized clinical trial and performed in a surgical intensive care unit of an academic hospital. In this study, 72 consecutive patients undergoing elective coronary artery bypass grafting (CABG) were assigned to receive either a methylprednisolone loading dose (1mg/kg) followed by continuous infusion (2mg/Kg/24 hours for 1 day) (low-dose regime) or a single dose of methylprednisolone (15 mg/kg) before cardiopulmonary bypass (high dose regime). Serum concentrations of IL-6 and C- reactive protein (CRP) were measured preoperatively and 6, 24 and 48 hours after surgery, and serum creatinine was measured before the operation and 24, 48 and 72 hours postoperatively. The measurements were then compared between the groups to evaluate the efficacy of each regimen. The basic characteristics and measurements were not different between the study groups. There was no significant difference in IL-6 and CRP elevation (P=0.52 and P=0.46, respectively). Early outcomes such as the length of stay in the intensive care unit, intubation time, changes in serum creatinine and blood glucose levels, inotropic support, insulin requirements, and rate of infection were also similar in both groups. A continuous low dose infusion of methylprednisolone was as effective as a single high dose methylprednisolone in reducing the inflammatory response after CABG with extracorporeal circulation with no significant difference in the postoperative measurements and outcomes.

Transseptal Approach versus Left Atrial Approach to Mitral Valve: A Propensity Score Matching Study.

BACKGROUND: Many patients with mitral valve diseases need surgical procedures for the repair or replacement of their mitral valve. There is a great deal of controversy over the outcomes of the transseptal (TS) and left atrial (LA) approaches to the mitral valve. We sought to evaluate the outcomes of each approach more accurately by eliminating the possible biases in case selection and matching. METHODS: This retrospective study included patients who had surgery for mitral valve diseases via either the TS approach or the LA approach between 2004 and 2011 in Tehran Heart Center. Patients with surgical approaches other than the TS and LA were excluded. To control for the confounding effects, a propensity score matching technique was applied and the patients were matched for 14 demographic and preoperative variables. After the selection of controls, the effect of the TS approach (163 patients) versus the LA approach (652 patients) on the outcomes was presented through odds ratio (OR) with 95% confidence intervals (CI). RESULTS: The mean age of the patients was 53.15 ± 12.02 years in the TS group and 52.93 ± 13.56 years in the LA group. Females comprised 119 (73.0%) patients in the TS group and 462 (70.9%) in the LA group. There was a significant association in the prevalence of new postoperative atrial fibrillation in the two groups (OR = 1.539, 95%CI: 1.072-2.210; p value = 0.019). Temporary pacemaker placement had no statistically significant difference between the two groups (p value = 0.418). The TS patients had significantly longer pump (p value < 0.001) and cross-clamp (p value < 0.001) times. The mortality rate was 4.1% (27 patients) in the LA group and 6.1% (10 patients) in the TS group (p value = 0.274). CONCLUSION: In our study population, the TS approach was associated with higher pump and cross-clamp times as well as risk of postoperative atrial fibrillation, but it did not increase the rates of permanent pacemaker placement, re-operations, and mortality.

Treatment of hyperfunctioning thyroid nodules by percutaneous ethanol injection.

BACKGROUND: Autonomous thyroid nodules can be treated by a variety of methods. We assessed the efficacy of percutaneous ethanol injection in treating autonomous thyroid nodules. METHODS: 35 patients diagnosed by technetium-99 scanning with hyperfunctioning nodules and suppressed sensitive TSH (sTSH) were given sterile ethanol injections under ultrasound guidance. 29 patients had clinical and biochemical hyperthyroidism. The other 6 had sub-clinical hyperthyroidism with suppressed sTSH levels (<0.24 &mgr;IU/ml) and normal thyroid hormone levels. Ethanol injections were performed once every 1-4 weeks. Ethanol injections were stopped when serum T3, T4 and sTSH levels had returned to normal, or else injections could no longer be performed because significant side effects. Patients were followed up at 3, 6 and, in 15 patients, 24 months after the last injection. RESULTS: Average pre-treatment nodule volume [18.2 PlusMinus; 12.7 ml] decreased to 5.7 PlusMinus; 4.6 ml at 6 months follow-up [P < 0.001]. All patients had normal thyroid hormone levels at 3 and 6 months follow-up [P < 0.001 relative to baseline]. sTSH levels increased from 0.09 PlusMinus; 0.02 &mgr;IU/ml to 0.65 PlusMinus; 0.8 &mgr;IU/ml at the end of therapy [P < 0.05]. Only 3 patients had persistent sTSH suppression at 6 months post-therapy. T4 and sTSH did not change significantly between 6 months and 2 years [P > 0.05]. Ethanol injections were well tolerated by the patients, with only 2 cases of transient dysphonia. CONCLUSION: Our findings indicate that ethanol injection is an alternative to surgery or radioactive iodine in the treatment of autonomous thyroid nodules.

Diagnostic value of frozen section examination in thyroid nodule--surgery at the Shariati Hospital (1997-2000).

INTRODUCTION: There is controversy regarding the use and accuracy of frozen section (FS) in managing thyroid nodules. We compared the diagnostic value of FS with that of permanent histopathology examination and fine needle aspiration (FNA). MATERIALS AND METHODS: Permanent, FS, and FNA sample reports were compared in 214 patients between 1997 and 2000. FS, FNA, and permanent pathology (gold standard) results were compared using McNemar's test. RESULTS: 160 women and 54 men (mean age: 42.3 +/- 5.4 yr) took part in the study; 163 patients (76%) had benign and 51 (24%) malignant lesions; 76% of our thyroid cancer cases were papillary, 13.5% follicular, 6% medullary carcinoma, 4% Hürthle cell carcinoma, and 0.5% anaplastic carcinoma. FNA yielded definite results in 150 patients (sensitivity 72%, specificity 96%, and precision 90%). In 64 patients with equivocal FNA, FS was performed (sensitivity 36%, specificity 73%, and precision 85%). The observed difference between FNA and FS was not statistically significant. DISCUSSION: When FNA results are inconclusive, FS does not provide any further information. In suspected cases of papillary, undifferentiated, or medullary carcinomas, FS can confirm FNA findings and guide surgical therapy.

An atypical suicide attempt: self-inflicted intra-cardiac injury with sewing needle.

Atypical cases of suicide are less likely to be seen in general hospitals, nonetheless require further investigation into the precipitating factors as well as proper follow-up. This paper illustrates a 61-year-old woman with major depressive disorder who experienced auditory hallucinations during delirious periods of taking low-dose benzodiazepines, who referred to the hospital with a sewing needle stuck in her chest wall. The needle was successfully removed. Psychiatric problems are often underdiagnosed, therefore undertreated in general hospitals. Thus close monitoring of the patients during the hospitalization and after discharge is crucial.

Endovascular Repair of Supra-Celiac and Abdominal Aortic Pseudo Aneurysms Concomitant with a Right Atrial Mass in a Patient with Behçet's Disease: A Case Report.

Behcet's disease is a rare immune mediated systemic vasculitis which besides it's more frequent involvement of eyes and skin, sometimes present with aortic pseudo aneurysm and more rarely cardiac inflammatory masses.A 51-year-old patient with Behçet's Disease presented with two symptomatic aortic pseudoaneurysms concomitant with a right atrial mass. Computed tomography (CT) revealed one supra-celiac and another infrarenal aortic pseudoaneurysms. Echocardiography showed a large mobile mass in the right atrium. Both pseudoaneurysms were successfully excluded simultaneously via endovascular approach with Zenith stent-grafts, and the atrial mass was surgically removed 10 days later. Post-implant CT showed successful exclusion of both pseudo-aneurysms, patency of all relevant arteries, and patient is now asymptomatic and has returned to normal lifestyle. Multiple pseudoaneurysms concomitant with a right atrial mass can be an initial manifestation of Behçet's disease. Endovascular repair can be a good treatment option for the pseudoaneurysms.

Central venous line and acute neurological deficit: a case series.

Central venous catheter (CVC) insertion is a practical way to assess patients hemodynamic specially in cardiovascular surgery but this relatively simple junior level procedure is not risk free and its common reported complications include; pneumothorax, hydrothorax, hemothorax, local hematoma, cardiac tamponade, vascular injury, thrombosis, embolism, and catheter disruption. Here in this article we are going to present 6 patients with very unusual presentation of CVC complication which was neurological deficit presented by agitation, unconsciousness, disorientation to time and place and hemiparesis. All patients undergone neurologic consult and brain computed tomography. Final diagnosis was brain ischemic damage and finally we kept them on conservative management; fortunately we did not have any permanent damage.

Early outcome of off-pump versus on-pump coronary revascularization.

INTRODUCTION: The use of coronary artery bypass surgery (CABG) with cardiopulmonary bypass (CPB) or without CPB technique (off-pump) can be associated with different mortality and morbidity and their outcomes remain uncertain. The goal of this study was to evaluate the early outcome of on-pump versus off-pump CABG. METHODS: We conducted a retrospective database review of 13866 patients (13560 patients undergoing on-pump CABG and 306 patients undergoing off-pump CABG) at Tehran Heart Center between January 2002 and January 2007. We compared preoperative, operative, and postoperative characteristics between them. RESULTS: In-hospital mortality in the on-pump group was 0.8% compared to 0.7% in the off-pump group (P=0.999) and in-hospital morbidity was 11.7% and 6.5%, respectively (OR: 1.533, 95%CI: 0.902-2.605, P=0.114). Postoperative atrial fibrillation was more prevalent in on-pump versus off-pump surgery (6.0% vs 3.0%, P=0.028), however there were no statistical significant differences in other postoperative complications with regard to cardiac arrest (P=0.733), prolonged ventilation (P=0.363), brain stroke (P=0.999), renal failure (P=0.525), and postoperative bleeding (P=0.999). The mean length of stay in hospital (P=0.156) and in ICU (P=0.498) was also similar between the two groups. CONCLUSION: The results from an Iranian population-based study showed similar early mortality and morbidity of off-pump CABG in comparison to on-pump surgery.

The role of vitamin D deficiency and vitamin d receptor genotypes on the degree of collateralization in patients with suspected coronary artery disease.

We determined the association of vitamin D deficiency and the FokI polymorphism of the vitamin D receptor (VDR) gene in 760 patients who underwent angiography due to suspected coronary artery disease (CAD). Angiography and the Rentrop scoring system were used to classify the severity of CAD in each patient and to grade the extent of collateral development, respectively. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to determine the FokI VDR gene polymorphism. The prevalence of severe vitamin D deficiency (serum 25(OH)D<10 ng/mL) was significantly higher in patients with at least one stenotic coronary artery compared to those without any stenotic coronary arteries. Severe vitamin D deficiency was not independently associated with collateralization, but it was significantly associated with the VDR genotypes. In turn, VDR genotype was independently associated with the degree of collateralization; the Rentrop scores were the highest in FF, intermediate in Ff, and the lowest in the ff genotype. The results show that FokI polymorphism is independently associated with collateralization. Additionally, vitamin D deficiency is more prevalent in patients with CAD that may result from FokI polymorphism. Therefore, maintaining a normal vitamin D status should be a high priority for patients with CAD.