Bakhtiary F, Therapidis P, Dzemali O, et al. Impact of high thoracic epidural anesthesia on incidence of perioperative atrial fibrillation in off-pump coronary bypass grafting: a prospective randomized study

Department of Thoracic & Cardiovascular Surgery, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany.
The Journal of thoracic and cardiovascular surgery (Impact Factor: 3.99). 08/2007; 134(2):460-4. DOI: 10.1016/j.jtcvs.2007.03.043
Source: PubMed

ABSTRACT Atrial fibrillation is one of the most common complications in patients undergoing coronary artery bypass grafting. The goal of this study was to investigate the impact of high thoracic epidural anesthesia on reduction of perioperative arrhythmia in patients undergoing off-pump coronary artery bypass grafting.
We prospectively randomized 132 patients undergoing elective off-pump coronary bypass grafting using either general anesthesia (GA) (n = 66) or combined general and high thoracic epidural anesthesia (GA+TEA) (n = 66). Incidence of perioperative arrhythmias such as atrial fibrillation, serum epinephrine levels, heart rate variability, and hemodynamic parameters were compared between groups.
The incidence of perioperative dysarrhythmias was significantly lower (P < .01) in the GA+TEA group (3%) than in the GA group (23.7%). Intraoperative sinus bradycardia occurred in 91% of the patients in the GA+TEA group versus 5.3% in the GA group. After induction of anesthesia, the mean systolic arterial pressure decreased significantly from 128 +/- 5 to 92 +/- 4 mm Hg and the heart rate from 74 +/- 9 to 52 +/- 8 beats . min(-1) in the GA+TEA group, whereas in the GA group no significant hemodynamic changes were observed (P < .001). Serum epinephrine levels were significantly lower in the GA+TEA group (69 +/- 11 to 35 +/- 7 ng/dL) than in the GA group (72 +/- 9 to 70 +/- 9 ng/dL).
In our study cohort, high thoracic epidural anesthesia in combination with general anesthesia reduced significantly the incidence of perioperative arrhythmias such as atrial fibrillation. Furthermore, we observed a significant reduction of epinephrine serum levels in this patient group. The results of this study support a combination of general anesthesia with thoracic epidural anesthesia as a multidisciplinary approach, which may lead to a better patient outcome, improvement of early analgesia, and reduction of perioperative complications in off-pump coronary artery bypass procedures. The potential risks of thoracic epidural anesthesia during off-pump coronary artery bypass procedures should not be underestimated.

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    • "Yes 13/41 29/80 RCT/2 Nygard/2004 [16] 163 elective CABG CPB 4 days T1-T3, the day before surgery Intraoperative and postoperative : bolus doses of 4 mL of bupivacaine, 5 mg/mL, given hourly Yes 28/79 25/84 RCT/3 Bakhtiary/2007 [17] "
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    ABSTRACT: Background Postoperative atrial fibrillation (POAF) is one of the most common complications in patients undergoing coronary artery bypass grafting (CABG). The goal of this meta-analysis was to evaluate the efficacy of thoracic epidural anesthesia (TEA) in preventing POAF in adult patients undergoing CABG. Methods MEDLINE and EMBASE were searched to identify randomized controlled trails in adult patients undergoing CABG who were randomly assigned to receive general anesthesia plus thoracic epidural anesthesia (GA + TEA) or general anesthesia only (GA). Two authors independently extracted data using a standardized Excel file. The primary outcome measure was the incidence of POAF. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals. Results Five studies involving 540 patients met our inclusion criteria. No significant difference in the incidence of POAF was observed between the two groups (risk ratio, 0.61; 95% confidence interval, 0.33 to 1.12; P = 0.11), with significant heterogeneity among the studies (I2 = 73%, P = 0.005). Sensitivity analyses by primary endpoint, methodological quality and surgical technique yielded similar results. Conclusions The limited evidence suggests that TEA shows no beneficial efficacy in preventing POAF in adult patients undergoing CABG. However, the results of this meta-analysis should be interpreted with caution due to significant heterogeneity of the studies included. Thus, the potential infuence of TEA on the incidence of atrial fibrillation following CABG warrants further investigation.
    BMC Cardiovascular Disorders 08/2012; 12(1):67. DOI:10.1186/1471-2261-12-67 · 1.50 Impact Factor
  • The Journal of thoracic and cardiovascular surgery 03/2008; 135(2):466-7; author reply 467. DOI:10.1016/j.jtcvs.2007.09.063 · 3.99 Impact Factor
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    ABSTRACT: We sought to determine the effectiveness of continuous intrathecal thoracic analgesia (ITA) in comparison with continuous epidural thoracic analgesia (ETA) for the management of postoperative pain after abdominal cancer surgery in a randomised controlled study. Catheters were inserted at T8-10 level for both techniques. Sixty patients were randomized to receive ITA providing levobupivacaine 0.25%, at 0.5-0-7 ml/h, associated with a single bolus of morphine 0.15 mg, or ETA with levobupivacaine 0.25% 4-6 ml/h and a single bolus of epidural morphine 2-3 mg. Data were collected before discharging from recovery room to the surgical ward, 1, 2, 3, 8, 12, 24 h, and 48 h after operation. The primary outcome was pain intensity evaluation. Postoperative morphine consumption, hemodynamics, fluids, and blood losses for the first postoperative 48 h, surgical outcome, hospital stay, and complications were also collected. Pain intensity at rest mean values ranged from 1.12 to 1.44 and from 1.04 to 1.20 in ITA group and ETA group, respectively. Dynamic pain intensity mean values ranged from 1.28 to 1.70 and from 1.16 to 1.80 in ITA group and ETA group, respectively. No significant differences were found between the two groups. Total amount morphine consumption was minimal in both groups, 4.4 mg (+/-2.9) and 3.1 mg (+/-2.4), for ITA and ETA groups, respectively. There were no severly sedated patients. Hemodynamic variables, diuresis, amounts of fluids, and red cell transfusion were equivalent between the groups. No important technical complications were reported in both groups and postoperative surgical complications were not related to the examined techniques. ITA and ETA produced the same levels of analgesia, without relevant complications.
    Journal of Clinical Monitoring and Computing 09/2008; 22(4):293-8. DOI:10.1007/s10877-008-9132-1 · 1.45 Impact Factor
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