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Ann Thorac Surg 2001;72:666-667
© 2001 The Society of Thoracic Surgeons

Correspondence

S100 protein: its use as a marker of cerebral damage in cardiac operations

Natasha E. Khan, MRCSa, Anthony C. De Souza, FRCSa, John R. Pepper, FRCSa

a Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust, Sydney St, London, England SW3 6NP, United Kingdom

e-mail: n.khan{at}rbh.nthames.nhs.uk

To the Editor

We read with interest the paper by Wandschneider and colleagues [1] on the reduced S100ß release in off-pump operations and congratulate them on their commitment to a randomized design. However, in light of recent other publications, the design of their project may not be satisfactory to draw conclusions on the suitability of S100ß as a marker of cerebral damage during bypass operations [2, 3]. It is becoming clear that during operations, levels of S100ß in pericardial and operative field blood are dramatically high, and these high levels are recorded immediately after sternotomy and pericardiotomy, before bypass is even instituted [3]. We have confirmed this finding with average concentrations of S100ß in operative field blood immediately after sternotomy of 52.3 ± 36.0 µg/L, (range 7.9 to 89.0 µg/L) compared with less than 0.2 µg/L in all simultaneous serum samples (p < 0.03). In many cardiac units, the operative field blood is returned to the circulation through cardiotomy pump suckers in operations using cardiopulmonary bypass, whereas in off-pump procedures this method is obviously not used, and if operative field blood is returned it is only after being washed in a cell-saver device. It has been shown that the levels of S100ß in washed blood are normal, or rather, undetectable [3]. The above observations have some important implications:

  1. Either there is an extracerebral source of S100ß, released from pericardium or bone and marrow, or our assays are nonspecific for S100ß.
  2. The return of operative field blood with high levels of S100ß to the circulation will affect the serum concentration of S100ß. Serum S100ß may therefore increase purely from the addition of operative field blood to the circulation; therefore, increases may not reflect S100ß released by cerebral damage.

Even before the work cited above there was a suspicion that S100ß levels after cardiopulmonary bypass represented the leakage of S100ß through a damaged blood–brain barrier rather than actual cerebral damage, as levels seemed to normalize rapidly compared with levels in nonsurgical patients with strokes, in whom levels remain raised for more than 72 hours [4].

There must be a further clarification of the specificity of S100ß tests currently in use, and also a further investigation of other sources of S100ß; other sources already identified include adipose tissue, bladder, skin, and myocardium. Whether these sources are sufficient to explain the high levels of S100ß seen in operative field blood immediately after sternotomy and pericardiotomy is not yet clear. The difference in serum levels of S100ß between patients undergoing cardiopulmonary bypass compared with those having off-pump procedures can no longer be said to be because of reduced cerebral damage with off-pump techniques. S100ß cannot be seen as a surrogate for neurocognitive analysis of cerebral damage associated with cardiac operations.

References

  1. Wandschneider W., Thalmann M., Trampitsch E., Ziervogel G., Kobinia G. Off-pump coronary bypass operations significantly reduce S100 release: an indicator for less cerebral damage?. Ann Thorac Surg 2000;70:1577-1579.[Abstract/Free Full Text]
  2. Jonsson H., Johnsson P., Alling C., Backstrom M., Bergh C., Blomquist S. S100 after coronary artery surgery: release pattern, source of contamination, and relation to neuropsychological outcome. Ann Thorac Surg 1999;68:2202-2208.[Abstract/Free Full Text]
  3. Anderson R.E., Hansson L.-O., Liska J., Settergen G., Vaage J. The effect of cardiotomy suction on the brain injury marker S100 after cardiopulmonary bypass. Ann Thorac Surg 2000;69:847-850.[Abstract/Free Full Text]
  4. Buttner T., Weyers S., Postert T., Sprengelmeyer R., Kuhn W. S100 protein: serum marker of focal brain damage after ischaemic territorial MCA infarction. Stroke 1997;28:1961-1965.[Abstract/Free Full Text]




This Article
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