Increased levels of S-100 protein after cardiac surgery with cardiopulmonary bypass and general surgery in children

Utility of Brain Injury Biomarkers in Children With Congenital Heart Disease Undergoing Cardiac Surgery

BACKGROUND

Congenital heart disease (CHD) affects roughly 40,000 children annually. Despite advancements, children undergoing surgery for CHD are at an increased risk for adverse neurological outcomes. At present, there is no gold standard for the diagnosis of cerebral injury during the perioperative period.

OBJECTIVE

To determine the utility of brain injury biomarkers in children undergoing cardiac surgery.

METHODS

We searched PUBMED, EMBASE, LILACS, EBSCO, ClinicalTrials.gov, Cochrane Databases, and OVID interface to search MEDLINE through July 2021 and assessed the literature following the snowball method. The search terms used were "congenital heart disease," "cardiopulmonary bypass," "biomarkers," "diagnosis," "prognosis," and "children." No language or publication date restrictions were used. Papers studying inflammatory and imaging biomarkers were excluded. The risk of bias, strengths, and limitations of the study were reported. Study was registered in PROSPERO ID: CRD42021258385.

RESULTS

A total of 1449 articles were retrieved, and 27 were included. Eight neurological biomarkers were examined. Outcomes assessed included prognosis of poor neurological outcome, mortality, readmission, and diagnosis of brain injury. Results from these studies support that significant perioperative elevations in brain injury biomarkers in cerebrospinal fluid and serum, including S100B, GFAP, NSE, and activin A, may be diagnostic of real-time brain injury and serve as an independent predictor of adverse neurological outcomes in patients with CHD undergoing cardiopulmonary bypass.

CONCLUSIONS

There are limited homogeneous data in the field, limiting the generalizability and comparability of the results. Further large-scale longitudinal studies addressing neurological biomarkers in children undergoing CHD corrective surgery are required to support the routine use of neuronal biomarkers in this population.

S100B and its relation to cerebral oxygenation in neonates and infants undergoing surgery for congenital heart disease

OBJECTIVES

Neonates and infants undergoing surgery for congenital heart disease are at risk for developmental impairment. Hypoxic-ischemic brain injury might be one contributing factor. We aimed to investigate the perioperative release of the astrocyte protein S100B and its relation to cerebral oxygenation.

METHODS

Serum S100B was measured before and 0, 12, 24, and 48 hours after surgery. Cerebral oxygen saturation was derived by near-infrared spectroscopy. S100B reference values based on preoperative samples; concentrations above the 75th percentile were defined as elevated. Patients with elevated S100B at 24 or 48 hours were compared to cases with S100B in the normal range. Neonates (≤28 days) and infants (>28 and ≤365 days) were analyzed separately due to age-dependent release of S100B.

RESULTS

Seventy-four patients underwent 94 surgical procedures (neonates, n = 38; infants, n = 56). S100B concentrations were higher in neonates before and after surgery at all time points (P ≤ .015). Highest values were noticed immediately after surgery. Postoperative S100B was elevated after 15 (40.5%) surgeries in neonates. There was no difference in pre-, intra-, or postoperative cerebral oxygenation. In infants, postoperative S100B was elevated after 23 (41.8%) procedures. Preoperative cerebral oxygen saturations tended to be lower (53 ± 12% vs 59 ± 12%, P = .069) and arterial-cerebral oxygen saturation difference was higher (35 ± 11% vs 28 ± 11%, P = .018) in infants with elevated postoperative S100B. In the early postoperative course, cerebral oxygen saturation was lower (54 ± 13% vs 63 ± 12%, P = .011) and arterial-cerebral oxygen saturation difference was wider (38 ± 11% vs 30 ± 10%, P = .008). Cerebral oxygen saturation was also lower for the entire postoperative course (62 ± 18% vs 67 ± 9%, P = .047).

CONCLUSIONS

Postoperative S100B was elevated in about 40% of neonates and infants undergoing cardiac surgery. Infants with elevated postoperative S100B had impaired perioperative cerebral tissue oxygenation. No relation between S100B and cerebral oxygenation could be demonstrated in neonates.

S100 and S100β: biomarkers of cerebral damage in cardiac surgery with or without the use of cardiopulmonary bypass

OBJECTIVE

The present study is to describe the clinical impact of S100 and S100β for the evaluation of cerebral damage in cardiac surgery with or without the use of cardiopulmonary bypass (CPB).

METHODS

Quantitative results of S100 and S100β reported in the literature of the year range 1990-2014 were collected, screened and analyzed.

RESULTS

Cerebrospinal fluid and serum S100 levels showed a same trend reaching a peak at the end of CPB. The cerebrospinal fluid/serum S100 ratio decreased during CPB, reached a nadir at 6 h after CPB and then increased and kept high untill 24 h after CPB. Serum S100 at the end of CPB was much higher in infant than in adults, and in on-pump than in off-pump coronary artery bypass patients. ∆S100 increased with age and CPB time but lack of statistical significances. Patients receiving an aorta replacement had a much higher ∆S100 than those receiving a congenital heart defect repair. Serum S100β reached a peak at the end of CPB, whereas cerebrospinal fluid S100 continued to increase and reached a peak at 6 h after CPB. The cerebrospinal fluid/serum S100β ratio decreased during CPB, increased at the end of CPB, peaked 1 h after CPB, and then decreased abruptly. The increase of serum S100β at the end of CPB was associated with type of operation, younger age, lower core temperature and cerebral damages. ∆S100β displayed a decreasing trend with age, type of operation, shortening of CPB duration, increasing core temperature, lessening severity of cerebral damage and the application of intervenes. Linear correlation analysis revealed that serum S100β concentration at the end of CPB correlated closely with CPB duration.

CONCLUSION

S100 and S100β in cerebrospinal fluid can be more accurate than in the serum for the evaluations of cerebral damage in cardiac surgery. However, cerebrospinal fluid biopsies are limited. But serum S100β and ∆S100β seem to be more sensitive than serum S100 and ∆S100. The cerebral damage in cardiac surgery might be associated with younger age, lower core temperature and longer CPB duration during the operation. Effective intervenes with modified CPB circuit filters or oxygenators and supplemented anesthetic agents or priming components may alleviate the cerebral damage.

Development of a rapid and high-performance chemiluminescence immunoassay based on magnetic particles for protein S100B in human serum

Protein S100B is a clinically useful non-invasive biomarker for brain cell damage. A rapid chemiluminescence immunoassay (CLIA) for S100B in human serum has been developed. Fluorescein isothiocyanate (FITC) and N-(aminobutyl)-N-(ethylisoluminol) (ABEI) are used to label two different monoclonal antibodies of anti-S100B. Protein S100B in serum combines with labeled antibodies and can form a sandwiched immunoreaction. A simplified separation procedure based on the use of magnetic particles (MPs) that were coated with anti-FITC antibody is performed to remove the unwanted materials. After adding the substrate solution, the relative light unit (RLU) of ABEI is measured and is found to be directly proportional to the concentration of S100B in serum. The relevant variables involved in the CLIA signals are optimized and the parameters of the proposed method are evaluated. The results demonstrate that the method is linear to 25 ng/mL S100B with a detection limit of 0.02 ng/mL. The coefficient of variation (CV) is < 5% and < 6% for intra- and interassay precision, respectively. The average recoveries are between 97 and 107%. The linearity-dilution effect produces a linear correlation coefficient of 0.9988. Compared with the commercial kit, the proposed method shows a correlation of 0.9897. The proposed method displays acceptable performance for quantification of S100B and is appropriate for use in clinical diagnosis.

[Biochemical alterations in patients with Down syndrome]

Down syndrome is a chromosome abnormality with specific clinical symptoms and mental retardation caused by trisomy of chromosome 21. The basic genetic change cannot be cured, the control of the associated symptoms, however, may improve the patients' quality of life.

AIMS

Authors studied the possible correlations between the Down-specific genes and the related biochemical changes. Expression of superoxide dismutase, cystathionine-beta-synthase and S100 protein was investigated. Further aim of the study was to determine the total serum antioxidant capacity (transferrin, ferritin, total protein, albumin and bilirubin) along with the extracellular antioxidants as well as concentrations of homocysteine, folic acid, and vitamin B 12 . To assess the vascular damage, the activity of NAG and S100B level was measured.

METHODS

Standard laboratory methods were used to determine the antioxidant capacity (Stocks, 1974), homocysteine (HPLC), folic acid (capture, IMX-Abbott), vitamin B 12 (MEIA, IMX-Abbott), S100 B protein (chemiluminescence sandwich immunoassay) levels, and N-acetyl-beta-D-glucosaminidase (spectrophotometry).

RESULTS

Plasma homocysteine value proved to be lower in 7 of the 30 and higher in 6 of the 30 patients studied than the reference range. Plasma homocysteine was found 95 +/- 21% of the reference value. Relative value of plasma folic acid - expressed in percent of the normal value - was 85 +/- 51%, and that of B 12 was 78 +/- 30%. Deficiency of folic acid was detected in 2 of the 30, decreased level of B 12 in 2 of the 30 patients enrolled. No difference was found in antioxidant activity values between Down syndrome patients and healthy controls, however, neither of them reached the adult reference range. S100 protein concentration of 4-8 times higher values (average value: 0.68 +/- 0.27 microg/l) than upper limit of the reference range was observed (> 1 year: > 0.15 microg/l). Mean value of serum N-acetyl-beta-D-glucosaminidase remained within the reference range (10-30 U/l). No statistically significant correlation between the antioxidant activity and N-acetyl-beta-D-glucosaminidase values could be observed.

CONCLUSION

The lower homocysteine, folic acid and B 12 values may be considered as the consequence of an increased cystathionine-beta-synthase activity ("atheroma free model"). There was no significant alteration in antioxidant activity level. It can be supposed that the hydrogene peroxide produced due to increased expression of superoxide dismutase is metabolized by the induced glutathione-peroxidase and catalase keeping by this the balance of the antioxidant system. This hypothesis is supported by the normal N-acetyl-beta-D-glucosaminidase values not indicating any vascular damage. The high S100 values, however, reflect certain brain damage which shows a progress with the age. Based on these experiences, regular control of these parameters is recommended. Furthermore authors think that folic acid supplementation is indicated in order to improve the patients' learning capacity, inhibit the development of Alzheimer symptoms and improve the quality of life.

Surrogate markers for neurological outcome in children after deep hypothermic circulatory arrest

Improved survival for infants with congenital heart disease (CHD) has led to increased focus on the most significant morbidities that are neurodevelopmental. Neurologic injury in neurodevelopmental outcome may have many causes in children with complex CHD undergoing cardiopulmonary bypass and deep hypothermic circulatory arrest, including genetic syndromes, abnormal blood flow patterns, prenatal insults, and hemodynamic instability. Although gross neurological injury can be detected in the perinatal and postoperative period, more subtle injury may not be identified until much later. Disabilities in speech and language, motor skills, and attention deficit disorder are present by school age in up to 50% of the complex CHD population. It is imperative that the mechanisms of these injuries be identified to enable the application of neuroprotective interventions. To facilitate clinical investigation, evaluation of surrogate markers for these longer term "real" outcomes continues. Because some abnormalities may not be detected for years, the evaluation of a surrogate marker takes a long time. Thus, identification of surrogate markers is in its infancy. Serologic proteins, seizures, magnetic resonance findings, cerebral oxygenation, and the neurologic examination have all been studied. Continuing innovation in the use of magnetic resonance imaging techniques and the application of physiologic measures including near-infrared spectroscopy currently pose the greatest potential for advances. This article summarizes the state of the art and an admission about how far we have yet to travel as we strive to make the neurodevelopmental outcomes of patients with CHD comparable to their healthy peers.

The cerebroprotective effects of pentoxifylline and aprotinin during cardiopulmonary bypass in dogs

OBJECTIVE

The purpose of this study was to investigate the cerebroprotective effects of pentoxifylline (PNX) and aprotinin in dogs using cardiopulmonary bypass (CPB).

MATERIALS AND METHODS

Eighteen clinically healthy dogs were divided into three groups: Group 1 (control, n = 6), Group 2 (PNX, n = 6), and Group 3 (aprotinin, n = 6). PNX was administered at a dose of 300 mg/day in Group 2 three days before the operation and during the operation. Half a million IU aprotinin were added to the prime solution and 500,000 IU were transfused via a central venous jugular catheter preoperatively in Group 3. Blood samples were taken from the central jugular vein before and after CPB and interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and S100beta protein were measured. Gliosis was investigated histopathologically in cerebral cortex biopsy samples under light microscopy.

RESULTS

The preoperative results of IL-6, TNF-alpha, and S100beta protein values were found to be significantly higher (p < 0.001) when compared with postoperative values. This significant difference was observed in the same parameters between Groups 1 and 2, and 1 and 3 (p < 0.001). There was no significant difference between Groups 2 and 3. Comparison between pre- and postoperative levels of IL-6 and TNF-alpha for Group 2 and Group 3 revealed statistically significant differences (p < 0.001), whereas S100beta protein levels did not. Histopathological examinations showed significant differences between the control group and PNX and aprotinin, and between aprotinin and PNX groups (p < 0.001).

CONCLUSION

PNX and aprotinin might be useful in order to reduce postoperative cerebral damage in patients undergoing cardiac surgery with CPB.

Perioperative predictors of developmental outcome following cardiac surgery in infancy

At 1 year we assessed the neurodevelopmental outcomes in infants undergoing cardiac surgery, seeking to explore the predictive value of perioperative markers of cerebral injury. We prospectively enrolled 47 neurodevelopmentally normal infants prior to planned cardiac surgery. Postoperative monitoring consisted of 10-channel video synchronised, continuous electroencephalography from 6 to 30 h, Doppler assessment of cerebral blood flow in the anterior cerebral artery at 1, 2, 3 and 5 h, and measurement of serum S-100B at 0 and 24 h. Neurodevelopmental assessments were performed using the second edition of the Bayley Scale of Infant Development. Follow-up at 1 year was available on 35 infants. The mean age of these patients at surgery had been 57 +/- 15 days. We observed clinical seizures in 1 patient, with 3 other patients having electroencephalographic abnormalities. At follow-up of 1 year, neurodevelopmental scores were lower than preoperative scores, with mean mental scores changing from 103 +/- 5 to 94 +/- 13 (p = 0.001), and mean motor scores changing from 99 +/- 8 to 89 +/- 20 (p = 0.004). No association was found between electroencephalographic abnormalities, reduced cerebral blood flow, or elevation of serum S-100B levels and impaired neurodevelopmental outcome at 1 year. Infants with electroencephalographic abnormalities had elevation of the levels of S-100B in the serum (p = 0.02). At 1 year of follow-up, infants undergoing cardiac surgery demonstrated a reduction in the scores achieved using the second edition of the Bayley Scale of Infant Development. They require ongoing assessment of their progress. Electroencephalographic abnormalities, cerebral blood flow, or levels of S-100B in the serum were not useful perioperative markers for predicting a poor neurodevelopmental outcome in the clinical setting.

Delayed rises in serum S100B levels and adverse neurological outcome in infants and children undergoing cardiopulmonary bypass

BACKGROUND

The protein S100B is a marker of brain injury. Early after cardiopulmonary bypass (CPB), serum S100B levels are artefactually high. We investigated whether delayed (48 h) rise in S100B levels may have a role in detecting brain injury after CPB.

METHODS

Data from 43 children were analysed in this study. Samples were collected at preincision and 30 min, 24 and 48 h postbypass and then analysed by using a commercially available radioimmunoassay (Sangtec100). Charts were reviewed at 3-5 months for evidence of neurological injury.

RESULTS

S100B levels were high preoperatively in neonates and universally high immediately postbypass. In 36 children, samples were available for all time points. Compared with preoperative levels, rises occurred at both 24 and 48 h in three patients, only at 24 h in four patients and only at 48 h in three patients. Two patients had evidence of neurological injury. A rise at 48 h was associated with neurological injury (odds ratio 33.9, P < 0.03, 95% CI 1.39-827). There was no association between neurological injury and S100B levels at 24 h. Both the patients with neurological injury had rises at 48 h that were significantly higher than patients with rises at 48 h without injury.

CONCLUSIONS

The results of this study suggest that monitoring S100B levels in the late postoperative period may still have a role in detecting neurological injury after cardiac surgery in children. Consistent with previous observations, S100B is high preoperatively in neonates and early postbypass in all patients.

A glial-derived protein, S100B, in neonates and infants with congenital heart disease: evidence for preexisting neurologic injury

The glial-derived protein S100B is a serum marker of cerebral ischemia and correlates with negative neurological outcome after cardiopulmonary bypass (CPB) in adults. We sought to characterize the S100B release pattern before and after CPB in neonates and infants with congenital heart disease and correlate it with surgical mortality. Serum was collected before surgery and at 24 postoperative h from 109 neonates and infants with congenital heart disease. All patients had presurgical transthoracic echocardiograms and CPB with or without hypothermic circulatory arrest. S100B concentrations were determined using a two-site immunoluminometric assay (Sangtec 100). Thirty-day surgical mortality was observed. All neonates had significantly increased S100B concentrations before surgery that decreased by 24 postoperative h. Preoperative S100B concentrations in 32 neonates with hypoplastic left heart syndrome correlated inversely with the forward flow and size of the ascending aorta and postoperative mortality (r(2) = -0.63; P = 0.03). Among infants, increased pulmonary blood flow was associated with higher S100B levels before surgery than cyanosis. There was no correlation with postoperative S100B and time on CPB, hypothermic circulatory arrest, or 30-day surgical mortality. In conclusion, preoperative S100B concentrations correlate inversely with the size of the ascending aorta in hypoplastic left heart syndrome and may serve as a marker for preexisting brain injury and mortality.

IMPLICATIONS

Neonates with hypoplastic left heart syndrome and no forward flow in the ascending aorta may have brain injury at birth before heart surgery.

Serotonin and brain development: role in human developmental diseases

Serotonin is known to play a role in brain development prior to the time it assumes its role as a neurotransmitter in the mature brain. Serotonin regulates both the development of serotonergic neurons (termed autoregulation of development) and the development of target tissues. In both cases, the astroglial-derived protein, S-100beta plays a role. Disruption of serotonergic development can leave permanent alterations in brain function and behavior. This may be the case in such human developmental illnesses as autism and Down Syndrome.

The systemic inflammatory response after cardiac surgery with cardiopulmonary bypass in children

Paediatric cardiac surgery often requires cardiopulmonary bypass (CPB) during the surgical intervention. CPB is known to elicit a systemic inflammatory response with activation of the complement and coagulation systems, stimulation of cytokine production, cellular entrapment in organs, neutrophil activation with degranulation, platelet activation, and endothelial dysfunction. These changes are associated with a risk of postoperative organ dysfunction and increased morbidity and mortality in the postoperative period. Clinical studies have concentrated on measurement of inflammatory markers and mediators in peripheral blood, where the systemic inflammatory response in the paediatric cardiac patient seems to be different from the adult case. Looking at the organ level, experimental studies have the advantage of providing information contributing to a better understanding of the pathological events that may lead to the deteriorated organ function. This review focuses on the systemic inflammatory response after cardiac surgery with CPB in children and experimental CPB models.