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J Thorac Cardiovasc Surg 2001;122:402
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Tatu Juvonen, MD, PhD, Fausto Biancari, MD, PhD, Jussi Rimpiläinen, MD

Department of Cardio-thoracic and Vascular Surgery, Oulu University Hospital, PO Box 22, 90221
Oulu, Finland

Reply to the Editor:

Miyamoto and Miyamoto addressed some comments regarding our articleGo 1 which, in our opinion, will not provide the readers with further insights into the pathophysiology of brain ischemia during hypothermic circulatory arrest.

It is evident that cytokine production can be stimulated by surgical trauma, cardiopulmonary bypass, and ischemia during hypothermic circulatory arrest. It has been shown that cytokines are produced by several cells other than leukocytes. Endothelium, platelets, myocardium, liver, microglia, astrocytes, and neurons have been shown to produce pro-inflammatory cytokines.Go Go 2-5 These observations support the hypothesis expressed in our article that a decrease of cytokines in systemic blood is probably not a valid end point in evaluating the efficacy of leukocyte filtration in hypothermic circulatory arrest. The value of leukocyte filtration in mitigating reperfusion injury, which has been shown by several studies, is likely to reside mainly in its ability to deplete activated neutrophils.

It is still a matter of debate whether alpha-stat or pH-stat should be used as the acid-base management strategy during hypothermic circulatory arrest. Our study was not planned to address this topic. However, because of perceived benefits with the use of alpha-stat strategy, the latter has been used increasingly during the past few years.Go 6 Although the results of recent studies support the use of pH-stat strategy in infants undergoing hypothermic circulatory arrest, there is evidence that alpha-stat strategy is particularly beneficial in an adult population because it may cause less disruption in cerebral blood flow autoregulation.Go 7

The choice of acid-base management strategy should not have any impact on the results of this randomized study, inasmuch as alpha-stat strategy was used in all animals of this series. It is not clear how Miyamoto and Miyamoto could detect the deleterious effect of the alpha-stat method without any control pH-stat group for comparison and without any data showing the inhibiting effect of pH-stat management on cytokine production.

12/8/115237

References

  1. Rimpiläinen J, Pokela M, Kiviluoma K, Anttila V, Vainionpää V, Hirvonen J, et al. Leukocyte filtration improves brain protection after a prolonged period of hypothermic circulatory arrest: a study in a chronic porcine model. J Thorac Cardiovasc Surg. 2000;120:1131-41.[Abstract/Free Full Text]
  2. Coletti LM, Kunkel SL, Walz A, Burdick MD, Kunkel RG, Wilke CA, et al. The role of cytokine networks in the local liver injury following hepatic ischemia/reperfusion in the rat. Hepatology. 1996;23:506-14.[Medline]
  3. Feuerstein GZ, Wang X, Barone FC. The role of cytokines in the neuropathology of stroke and neurotrauma. Neuroimmunomodulation. 1998;5:143-59.[Medline]
  4. Sawa Y, Ichikawa H, Kagisaki K, Ohata T, Matsuda H. Interleukin-6 derived from hypoxic myocytes promotes neutrophil-mediated reperfusion injury in myocardium. J Thorac Cardiovasc Surg. 1996;116:511-5.[Abstract/Free Full Text]
  5. Wan S, DeSmet JM, Barvais L, Goldstein M, Vincent JL, LeClerc JL. Myocardium is a major source of proinflammatory cytokines in patients undergoing cardiopulmonary bypass. J Thorac Cardiovasc Surg. 1996;112:806-11.[Abstract/Free Full Text]
  6. Goldsack C, Berridge JC. Acid-base management during cardiopulmonary bypass: current trends in the United Kingdom. Anaesthesia. 1996;51:396-8.[Medline]
  7. Patel RL, Turtle MR, Chambers DJ, James DN, Newman S, Venn GE. Alpha-stat acid-base regulation during cardiopulmonary bypass improves neuropsychologic outcome in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1996;111:1267-79.[Abstract/Free Full Text]




This Article
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