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WILLIAM J. GREELEY

A Glial-Derived Protein, S100B, in Neonates and Infants with

Congenital Heart Disease: Evidence for Preexisting
Neurologic Injury
Paula M. Bokesch, MD*, Elumalai Appachi,
and Roger B.B. Mee, MB, ChB, FRACS

MD,

Marco Cavaglia,

MD*,

Emad Mossad,

MD*,

Departments of *Cardiothoracic Anesthesia, Pediatric Critical Care, and the Center for Congenital Heart Disease and
Surgery, The Cleveland Clinic Foundation, Ohio

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

mproved techniques in cardiopulmonary bypass

(CPB) combined with deep hypothermia and hypothermic circulatory arrest have enabled correction
of complex congenital heart defects in the neonatal
and early infancy periods. Although advances in technological, surgical, and anesthetic techniques have improved morbidity and mortality for these critically ill
babies, developmental and neurological abnormalities
in follow-up studies may still occur in neonates, infants, and children (13).
Neurological dysfunction after heart surgery is usually attributed to intraoperative ischemic events occurring during CPB, hypothermic circulatory arrest
(HCA), and after reperfusion and rewarming (1,4).
Another important factor that may contribute to the
Presented by Dr. Julie Tome, Department of Cardiothoracic Anesthesia, at the Annual Meeting of the American Society of Anesthesiologists, New Orleans, LA, October 2001.
Accepted for publication June 3, 2002.
Address correspondence and reprint requests to Paula M.
Bokesch, MD, Department of Cardiothoracic Anesthesia, G30 Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195.
Address e-mail to bokescp@ccf.org.
DOI: 10.1213/01.ANE.0000026490.66200.43
2002 by the International Anesthesia Research Society
0003-2999/02

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 (r2 ! "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.
(Anesth Analg 2002;95:889 92)

neurologic morbidity after open-heart surgery is a

preexisting brain abnormality secondary to the defective cardiac anatomy and physiology in utero and
at birth. Brain and developmental abnormalities are
very difficult to detect in a newborn baby. Neuropsychological examinations are not useful or feasible in a critically ill neonate. Imaging techniques or
cranial ultrasounds do not provide functional data.
A biochemical marker of cerebral injury is highly
desirable both before CPB to detect and quantify
preexisting brain injury as well as to determine the
extent of cerebral injury in association with CPB and
HCA.
The glial-derived protein S100B is a serum marker
of cerebral ischemia. Patients suffering from stroke,
subarachnoid hemorrhage, and head trauma release
S100B into the cerebrospinal fluid and blood (5,6).
In adults, serum concentrations of S100B after
CPB correlate with detrimental neurological outcome (7). We sought to characterize the S100B release pattern before and after CPB in neonates and
infants and determine its relationship to patient
mortality.
Anesth Analg 2002;95:88992

889

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PEDIATRIC ANESTHESIA BOKESCH ET AL.

A GLIAL-DERIVED PROTEIN, NEUROLOGIC INJURY, AND HEART DISEASE

ANESTH ANALG
2002;95:889 92

Methods

Results

After IRB approval and parental informed consent,

109 term neonates or infants undergoing elective
cardiac surgery using CPB were sequentially enrolled in this study. Patients with Down syndrome
and neonates who suffered a cardiac arrest, hypotension, or severe acidosis, with a pH value #7.2,
within 24 h before surgery were excluded. Patients
were grouped by type of repair: Stage I repair of
hypoplastic left heart syndrome (HLHS, Group 1),
transposition of the great arteries (Group 2), tetralogy of Fallot (Group 3), bi-directional cavopulmonary anastomosis (Group 4), or ventricular septal
defects (VSD, Group 5). All neonates had preoperative renal and head ultrasounds before surgery as
per standard procedure at Cleveland Clinic Foundation. Only those with normal ultrasounds were
included in this study. All patients had preoperative
echocardiograms that determined chamber and
valve size and antegrade or retrograde flow in the
aorta. Demographic, intra-, and postoperative data
on each patient were collected from patient records.
Surgical mortality for 30 days after surgery was
documented.
After the induction of anesthesia, all patients had
4.55.0F double-lumen catheters placed in the internal
jugular vein as per standard procedure for monitoring, drug infusion, and blood sample collection. In
most patients, a right atrial catheter inserted by the
surgeon replaced this catheter at the end of surgery.
These catheters were used for venous sampling to
assay S100B concentrations. One milliliter of venous
blood was obtained from all patients before the incision and 24 h after arrival in the pediatric intensive
care unit (ICU). The samples were immediately centrifuged and the serum stored at "80C until analysis.
Serum S100B concentrations were determined using
a monoclonal two-site immunoluminometric assay according to the manufacturers directions (LIA-MAT
Sangtec 100, AB Sangtec Medical, Bromma, Sweden). The precision was #10.0% coefficient of variation. The lower level of detection was 0.1 !g/L, and
the upper level was 20.0 !g/L.
If not otherwise stated, all data are presented as
mean $ sem. Data were analyzed using SigmaStat
(Jandel Scientific, San Rafael, CA). For comparisons
of means, continuous variables were analyzed with
Students t-tests if the sample was large or had a
normal distribution. Otherwise, a nonparametric
test was used (Mann-Whitney). Regression analysis
was performed using the least square method with
case-wise deletion of missing data. Correlation coefficients were determined using the Pearson Product Moment Correlation. A P value #0.05 was considered significant.

The pre- and postoperative serum concentrations of

S100B are presented in Table 1. Group 1 patients with
HLHS had the largest mean S100B concentrations
before and 24 h after surgery compared with all
other groups (P # 0.01). Preoperative S100B concentrations correlated significantly (P ! 0.003) and inversely (r2 ! "0.64) with the size of the ascending
aorta and the presence of forward flow through the
aortic valve documented by transthoracic echocardiography (Fig. 1). All patients who died (n ! 5) had
preoperative serum concentrations "3.6 !g/L and
small ascending aorta diameters without forward
flow. None of these patients were acidotic at the
time of sampling or within 24 h of surgery. If these
patients were excluded from data analysis, the mean
preoperative S100B concentration was 1.75 $ 1.7
!g/L, which was similar to Group 2 patients.
As with Group 1, Group 2 patients with transposition of the great arteries also had increased preoperative S100B, as compared with Groups 3 and 4,
that decreased 24 h after surgery (Table 1). Within
this group, patients with VSD (n ! 17) did not have
preoperative concentrations of S100B significantly
different from patients with intact ventricular septum (1.95 $ 1.7 !g/L versus 2.2 $ 1.4 !g/L, respectively; P ! 0.3). All infants (Groups 3 and 4) had
significantly smaller preoperative concentrations of
S100B than patients in Groups 1 and 2 (P # 0.01). However, among infants, cyanotic infants (Groups 3 and 4)
had significantly smaller preoperative S100B concentrations than noncyanotic infants with VSD and increased
pulmonary circulation (Group 5; P # 0.05).
Although S100B concentrations were larger at
24 h than before surgery in Group 4, all of these
infants were extubated and discharged from the
ICU on the first postoperative day. As expected, all
of these patients had significantly (P # 0.01) increased pressure in the superior vena cava on arrival in the ICU (12.2 $ 2 mm Hg versus 5.6 $ 1 mm
Hg before CPB). There was no correlation between
the 24-h postoperative S100B concentrations and the
duration of CPB or HCA, aortic cross-clamp time, or
survival in any of the groups.

Discussion
S100B has been established as a useful serum marker
of cerebral injury caused by minor and major head
trauma, global anoxia, focal ischemia, metastatic malignant melanoma, and cardiac surgery (57). All of
these conditions involve disruption of the blood-brain
barrier. Johnsson et al. (8) first reported the relationship of increased S100B and cerebral complications
after cardiac surgery in adults. These authors and
others subsequently determined that shed mediastinal

ANESTH ANALG
2002;95:889 92

PEDIATRIC ANESTHESIA
BOKESCH ET AL.
A GLIAL-DERIVED PROTEIN, NEUROLOGIC INJURY, AND HEART DISEASE

891

Table 1. Pre- and Postoperative Serum S100B Concentrations

S100B !g/L
1
2
3
4
5

Group

Preop

24 h Postop

Stage I HLHS (32) 8.6 $ 1.2 days

TGA Switch (28) 10.4 $ 3.8 days
TOF Infants (10) 6.0 $ .8 months
BDCP Infants (21) 5.1 $ 1.4 months
VSD Infants (18) 5.8 $ 1.2 months

2.5 $ 0.4*
2.1 $ 0.4*
0.5 $ 0.3
0.4 $ 0.1
1.1 $ 0.2

2.0 $ 0.4
1.5 $ 0.3
0.5 $ 0.4
0.9 $ 0.3
1.0 $ 0.2

HLHS ! hypoplastic left heart syndrome; TGA ! transposition of the great arteries; TOF ! tetralogy of Fallot; BDCP ! bidirectional cavo-pulmonary
anastomosis; VSD ! ventricular septal defect; preop ! preoperative; postop ! postoperative.
* P # 0.01 Groups 1 and 2 versus Groups 3 4 preop; P # 0.05 postop versus preop Group 4; P # 0.05 Group 5 versus Groups 3 and 4.

Figure 1. Preoperative [S100B] versus ascending aorta diameter

normalized to body surface area. Dark squares (5) are neonates who
died after Stage I repair of HLHS. r2 ! "0.64; P ! 0.003; n ! 32 Stage
I repair of HLHS.

blood collected during surgery by cardiotomy suction

also contained high levels of S100B as well as chest
tube blood that was used for autotransfusion after
surgery (9). Therefore, earlier reports that correlated
serum S100B levels immediately after pediatric cardiac operations with duration of CPB and HCA may
have been contaminated by extra-cerebral sources of
S100B (10,11).
Our study did not find any relationship between
CPB duration, cross-clamp time, or use of HCA and
serum concentrations of S100B 24 hours after surgery.
Also, serum concentrations of S100B at 24 hours after
surgery did not correlate with 30-day surgical mortality. Unlike adult studies, neonates and infants had
smaller concentrations of S100B at 24 hours after surgery than before surgery. However, this finding may
reflect dilution of the protein in serum from postoperative blood, colloid, and crystalloid infusions in
small babies.
Although neonates in Groups 1 and 2 had larger
S100B levels than previously reported in adults, these
values were not necessarily abnormal. Age-related serum S100B concentrations before surgery have been
described in children with congenital heart disease

with the highest values in neonates (12,13). Erb et al.

(14) reported serum concentrations of 1.97 !g/L in
12 healthy neonates on the day of birth. Maschmann et
al. (15) reported serum S100B concentrations in 66
term newborns to be 0.66 3.33 !g/L in the first week
of life. Newborns with signs of hypoxic-ischemic encephalopathy after perinatal acidosis had increased
serum concentrations of S100B %4.0 !g/L in the first
week of life. However, compared with serum levels of
adult patients (usually #0.2 !g/L), even nonacidotic
newborns have significantly larger S100B concentrations. The reason for the higher S100B serum levels in
healthy newborns is unclear. Some possibilities are
immaturity of the blood-brain barrier with subsequent
leakage of S100B from the brain into the blood, extracerebral sources of S100B such as brown fat, or decreased elimination by immature kidneys. In adults,
S100B is eliminated, unchanged by the kidneys with a
half-life of 25.3 $ 5.1 minutes after CPB, and is not
affected by a moderate decrease in glomerular filtration rate (9).
The most intriguing observation in our study was
the relationship between preoperative S100B concentrations and the size of the ascending aorta normalized
to body surface area in neonates undergoing the Norwood operation (Stage I repair of HLHS). Smaller
ascending aorta correlated with larger concentrations
of S100B (Fig. 1; P ! 0.003). Patients with Shones
complex (mitral stenosis and aortic stenosis without
atresia) and other variants of HLHS, who had forward
flow through their aortic valve (confirmed by preoperative echocardiography), had smaller preoperative
concentrations of S100B. These data suggest that neonates with little or no forward flow in the ascending
aorta have brain injury before surgery. None of these
neonates were acidotic or hypotensive at this time.
Group 5 infants had a similar finding as Group 1
neonates, namely decreased forward flow in the ascending aorta. Patients with VSDs have excessive pulmonary circulation through the VSD, thereby decreasing forward flow in the ascending aorta. Age-matched
cyanotic patients with normal or increased flow patterns in the ascending aorta (Groups 3 and 4) had
smaller preoperative S100B concentrations.

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PEDIATRIC ANESTHESIA BOKESCH ET AL.

A GLIAL-DERIVED PROTEIN, NEUROLOGIC INJURY, AND HEART DISEASE

Group 4 infants were all previous Stage I repair of

HLHS and its variants. At 5.8 $ 2 months of age, these
infants had significantly smaller concentrations of
S100B before surgery than they did as neonates. The
significant increase of S100B after surgery in this
group may reflect the increased pressure in the superior vena cava, although more patients are required to
determine if this correlation is consistent.
In summary, preoperative serum concentrations of
S100B are increased in neonates and infants with congenital heart disease. Preoperative serum S100B concentrations correlate inversely with the forward flow
and size of the ascending aorta in HLHS and may
serve as an indicator of preoperative brain injury and
a predictor of survival.

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ANESTH ANALG
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