Ann Thorac Surg 2000;69:1204
© 2000 The Society of Thoracic Surgeons
ORIGINAL ARTICLES: CARDIOVASCULAR
Invited commentary
Erik Fosse, MD, PhDa
a Intervensjonssenteret, Rikshospitalet, 0027 Oslo, Norway
 |
Introduction
|
|---|
This study by Ascione and coworkers addresses the important issue of inflammatory response during coronary surgery with or without cardiopulmonary by-pass. The inflammatory response during cardiac surgery is well documented in literature and has several causes. Tissue injury, tissue ischemia due to circulatory instability, transfusion and the blood surface interaction during extracorporeal circulation may all effect inflammatory response. However, it is well documented both in vitro and in vivo that the strongest factor for the inflammatory response and particularly the complement and white blood cell activation is blood surface contact in the extracorporeal circuit. This response can be modified by coating the tubing and oxygenated surfaces with biological materials and by improving the hemodynamic performance of the system. Therefore, theoretically, by eliminating the heart-lung machine altogether, the inflammatory response should be reduced.
The complication rate in coronary surgery is already very low and it is therefore difficult to demonstrate the improvement in complication rate. It is generally acknowledged that a reduction in the inflammatory response is an indicator of a less traumatising procedure. The first randomized trial demonstrating differences in plasma C3a in coronary surgery with and without heart-lung machine was published in 1998 by Gu and colleagues [1]. In that paper the authors also demonstrated an increased coagulation activity due to the reduced systemic heparinisation. In the present study, the authors have reproduced the findings demonstrating reduced C3a and elastase postoperatively. They have also added two other important markers, namely C5a and IL-8. Unfortunately, they did not include intraoperative blood samples. This is unfortunate as the halvation time of both C3a and C5a in plasma is short, and it has previously been demonstrated that these values normally peak shortly after start of cardiopulmonary bypass. It is therefore likely that the difference in inflammatory response between the two groups may be much greater than is documented in this paper.
This is thus an important contribution to the study of the inflammatory response during cardiac surgery with and without heart-lung machines. It indicates that surgery without heart-lung machine is a less traumatizing procedure than surgery on extracorporeal circulation. This is further supported by their clinical data, demonstrating reduced infection rate in the off pump group. However, the material is limited and it remains to be seen if the clinical results can be reproduced in larger clinical trials.
I congratulate them on this paper.
|
References
|
|---|
-
Gu Y.J., Mariany M.A., van Oeveren W., Grandjean J.G., Boonstra P.W. Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1998;65:420-424.[Abstract/Free Full Text]
Related Article
-
Inflammatory response after coronary revascularization with or without cardiopulmonary bypass
- Raimondo Ascione, Clinton T. Lloyd, Malcolm J. Underwood, Attilio A. Lotto, Antonis A. Pitsis, and Gianni D. Angelini
Ann. Thorac. Surg. 2000 69: 1198-1204.
[Abstract]
[Full Text]
[PDF]
Top
Introduction
References