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J Thorac Cardiovasc Surg 2001;122:1052-1053
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Associate Professor
Associate Director, Cardiac Anesthesia
Head of Adult Cardiac Anesthesia
Department of Anesthesia and Critical Care
The University of Chicago Hospital
5842 S Maryland Ave, MC 4028
Chicago, IL 60636

Reply to the Editor:

The comments by Corbi and associates relating to our investigation involving methylprednisolone and cardiopulmonary bypass (CPB) are appreciated. They are correct in stating that the systemic inflammatory response may be initiated by perioperative factors other than exposure to CPB. In addition to (and in agreement with) their references, other investigators have shown that avoidance of CPB does not necessarily attenuate the systemic inflammatory response. ^1,2 On the other hand, other investigators have shown that avoidance of CPB does attenuate the systemic inflammatory response. ^3,4 Investigations in this area are always somewhat difficult to interpret because of the wide variety of mediators used by various investigators to assess the systemic inflammatory response (eg, interleukins, endotoxins, cytokines, complement fragments, and tumor necrosis factor). Each investigation defines and assesses the systemic inflammatory response in a unique way (there is no standard definition). What is clear when one examines the large number of studies investigating this topic is that although factors other than exposure to CPB certainly can initiate the systemic inflammatory response (however defined) in patients undergoing cardiac surgery, the primary culprit remains the CPB circuit. More important (I believe), no investigation has (yet) definitively shown that perioperative attenuation of the systemic inflammatory response (however defined) in patients undergoing cardiac surgery truly affects outcome. Our study was a clinical investigation focusing on hemodynamic parameters, pulmonary parameters, fluid balance, perioperative weights, perioperative blood glucose levels, and postoperative tracheal extubation times. ⁵ We did not assess the systemic inflammatory response. Furthermore, we stand by our conclusions that methylprednisolone, as used in our investigation, offers no clinical benefits to patients undergoing elective coronary artery bypass grafting with CPB; it may, in fact, be detrimental by initiating postoperative hyperglycemia and possibly hindering early postoperative tracheal extubation for undetermined reasons, ⁵ findings consistent with our previous work in this area. ^6,7
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References

1. Diegeler A, Doll N, Rauch T, Haberer D, Walther T, Falk V, et al. Humoral immune response during coronary artery bypass grafting: a comparison of limited approach, "off-pump" technique, and conventional cardiopulmonary bypass. Circulation. 2000;102(Suppl):III-95-100.
   
2. Lockowandt U, Owall A, Franco-Cereceda A. Myocardial outflow of prostacyclin in relation to metabolic stress during off-pump coronary artery bypass grafting. Ann Thorac Surg. 2000;70:206-11.[Abstract/Free Full Text]
   
3. Ascione R, Lloyd CT, Underwood MJ, Lotto AA, Pitsis AA, Angelini GD. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. Ann Thorac Surg. 2000;69:1198-204.[Abstract/Free Full Text]
   
4. Matata BM, Sosnowski AW, Galinanes M. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation. Ann Thorac Surg. 2000;69:785-91.[Abstract/Free Full Text]
   
5. Chaney MA, Durazo-Arvizu RA, Nikolov MP, Blakeman BP, Bakhos M. Methylprednisolone does not benefit patients undergoing coronary artery bypass grafting and early tracheal extubation. J Thorac Cardiovasc Surg. 2001;121:561-9.[Abstract/Free Full Text]
   
6. Chaney MA, Nikolov MP, Blakeman BP, Bakhos M, Slogoff S. Hemodynamic effects of methylprednisolone in patients undergoing cardiac operation and early extubation. Ann Thorac Surg. 1999;67:1006-11.[Abstract/Free Full Text]
   
7. Chaney MA, Nikolov MP, Blakeman B, Bakhos M, Slogoff S. Pulmonary effects of methylprednisolone in patients undergoing coronary artery bypass grafting and early tracheal extubation. Anesth Analg. 1998;87:27-33.[Abstract/Free Full Text]
   

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