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J Thorac Cardiovasc Surg 1996;112:560-561
© 1996 Mosby, Inc.

LETTERS TO THE EDITOR

Human cytokine responses to cardiac operations: Prebypass factors

Department of Anesthesiology
Duke University Medical Center
Durham, NC 27710

To the Editor:

We congratulate Wan and colleagues ¹ for their interesting article, |P`Human Cytokine Responses to Cardiac Transplantation and Coronary Artery Bypass Grafting." They suggested that the interleukin-10 response in elective coronary artery bypass graft and heart transplant operations formed part of a protective antiinflammatory response to cardiopulmonary bypass (CPB). We are delighted to see that researchers are now evaluating the balance of proinflammatory and antiinflammatory cytokine activity during cardiac operations.

A phased antiinflammatory response has already been demonstrated at elective coronary bypass operations. This response consists in a significant increase in plasma interleukin-10 concentration 10 minutes after release of the aortic crossclamp, reaching a peak 2 hours later. ² Lagging slightly behind the interleukin-10 response is an increase in plasma interleukin-1 receptor antagonist, which becomes significant 2 hours after CPB. Twenty-four hours later, concentrations of interleukin-10 and interleukin-1 receptor antagonist have returned almost to baseline levels, but there is a significant increase in plasma-soluble tumor necrosis factor receptors. This phased antiinflammatory cytokine response has also been demonstrated during pediatric cardiac operations. ³

Small but significant pre-CPB increases in proinflammatory cytokine concentrations after induction of anesthesia with high-dose fentanyl and after heparinization have been described. Immediately after commencement of CPB these proinflammatory cytokine levels fall to baseline, possibly as a result of hemodilution. ² It would have been interesting in Dr. Wan's study to know whether induction of anesthesia alone with sufentanil and midazolam and later heparinization were associated with increases of differing magnitudes in the levels of proinflammatory cytokines in both groups. Such a difference between groups may exist, as indicated by the higher preheparinization interleukin-8 level in the transplant group. It is also possible that differing proinflammatory cytokine levels prime the immune system before CPB and result in a differing magnitude of antiinflammatory cytokine responses later. ² Without sampling before and after induction of anesthesia, this phenomenon is not detected.

References

1. Wan S, Marchant A, DeSmet J-M, Antoine M, Zhang H, Vachiery J-L, et al. Human cytokine responses to cardiac transplantation and coronary artery bypass grafting. J THORAC CARDIOVASC SURG 1996;111:469-77.[Abstract/Free Full Text]
   
2. McBride WT, Armstrong MA, Crockard AD, McMurray TJ, Rea JM. Cytokine balance and immunosuppressive changes at cardiac surgery: contrasting response between patients and isolated CPB circuits. Br J Anaesth 1995;75:724-33.[Abstract/Free Full Text]
   
3. McBride WT, Armstrong MA, Gilliland H, McMurray TJ. The balance of pro and anti-inflammatory cytokines in plasma and bronchoalveolar lavage (BAL) at paediatric cardiac surgery. Cytokine. In press.
   

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