327Vitamin D is mainly synthesized through exposure to sunlight and ingested from the diet and/or through supplements, which are metabolized to the major circulating form of vitamin D, 25-hydroxyvitamin D (25OHD) in the liver. 25OHD is metabolized in the kidneys by 25-hydroxyvitamin D-1␣-hydroxylase (1␣OHase) to its active form, 1,25-dihyroxyvitamin D (1,25OHD); serum levels of 1,25OHD are tightly regulated in the range of 20 to 60 pg/mL by parathyroid hormone (PTH) as well as calcium (Ca) and phosphate levels (1). Secretion of 1,25OHD into the serum facilitates not only intestinal Ca and phosphate absorption, but also bone calcifi cation. Defi ciency of 1,25OHD is known to cause rickets, osteopenia, osteoporosis, and osteomalacia, and to simultaneously increase the risk of fracture.In addition to these bone diseases, recent epidemiologic evidence suggests that 25OHD defi ciency, but not 1,25OHD defi ciency, is associated with an increased risk of many chronic diseases including cardiovascular disease (CVD), various cancers, and infectious diseases (2). In the Framingham Offspring Study, 25OHD defi ciency was associated with incident CVD (3). The risk for CVD may be associated with ubiquitous expression of both 1␣OHase and vitamin D receptor (VDR) in a variety of cell types including vascular smooth muscle cells, endothelial cells, and cardiomyocytes (4). Various experimental studies also suggest that vitamin D supplements provide cardiovascular protection including anti-atherosclerotic, anti-infl ammatory, and direct cardio-protective actions, as well as benefi cial effects on classic cardiovascular risk factors and suppression of PTH levels (5). Observational studies and meta-analyses of randomized controlled trials indicate that vitamin D supplements may reduce CVD-related disease and all-cause mortality (6), although a cause and effect relationship is still controversial (7). Of critically ill patients, similarly, Lee et al. identifi ed the possibility of a relationship between low levels of 25OHD, and high morbidity and mortality Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan 3 Department of Anesthesiology, Intensive Care Unit, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama 330-8503, Japan (Received April 6, 2012) Summary Recent studies have suggested that low levels of 25-hydroxyvitamin D (25OHD) are associated with cardiovascular risks in medical patients. However, these associations have not been well documented in high risk surgical patients. We hypothesized that serum 25OHD, 1,25-dihydroxyvitamin D (1,25OHD) would be associated with the cardiac operative risk stratifi cation score. The study was conducted with a cross-sectional design at a single academic medical center in Japan. Two hundred fi ve adult patients scheduled for major cardiovascular surgery were included consecutively. Cardiac operative risk was evaluated with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) scoring system. Correlations betwe...