Effective cardiomyocyte functional protection during a perioperative insult stress requires a balanced preservation vs blunting of -adrenergic signaling. Adrenergic sensitization optimizes postischemic functional recovery while desensitiza- tion protects against intraoperative oxygen supply: demand imbalance. In a similar study, Schwinn et al

3have reported that -desensitization during CABG reduced postoperative cardiac dysfunction. The deleterious effects of adrenergic stimulation on -adrenergic receptor density and -adrenergic receptor coupling have been well documented. 4 Hence, attenuation of the stress response via -blockade and/or selective anesthetic regimens has the potential to prevent adverse events. Berendes et al propose high TEA as a way of alleviating this adrenergic overactivation. The beneficial effects of high TEA for postoperative pain relief in patients undergoing CABG are well known; furthermore, as the authors point out, high TEA offers antianginal and anti-ischemic effects in patients with unstable angina. 5 The autonomic sympathectomy induced with high TEA mitigates the stress response of CABG. 5 Recently, high-dose intrathecal bupivicaine combined with general anesthesia was reported to decrease the stress response and decrease -adrenergic receptor dysfunction following CABG. 6 The authors’ data are impressive. They report a 50% reduction in postoperative left ventricular dysfunction in the general anesthesia and high TEA group. The protection afforded by high TEA may last beyond surgery since postoperative cardiac troponin I concentrations were 3.5-fold lower in that treatment group. In the cost-conscious United States, these German investigators did place the thoracic epidural catheter the evening prior to surgery and did protect against spinal bleeding with relatively expensive aprotinin therapy. If cardiomyocytes, and even lives, were saved, however, it appears that combination neurohormonal -adrenergic blockade is warranted, especially in high-stress procedures involving CABG.