Myocardial protection with volatile anaesthetic agents during coronary artery bypass surgery: a meta-analysis [see comment]. Br J Anaesth

Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Monash University, Melbourne, Victoria, Australia.
BJA British Journal of Anaesthesia (Impact Factor: 4.35). 09/2006; 97(2):127-36. DOI: 10.1093/bja/ael149
Source: PubMed

ABSTRACT Previous studies have investigated the role of volatile anaesthetic agents in myocardial protection during coronary artery bypass graft (CABG) surgery, and some have identified beneficial effects. However, these studies have been too small to identify a significant effect on myocardial infarction (MI) or mortality. We undertook a systematic overview and meta-analysis of all randomized trials comparing volatile with non-volatile anaesthesia in CABG surgery. We identified 27 trials that included 2979 patients. There was no significant difference in myocardial ischaemia, MI, intensive care unit length of stay or hospital mortality between the groups (all P>0.05). Post-bypass, patients randomized to receive volatile anaesthetics had 20% higher cardiac indices (P=0.006), significantly lower troponin I serum concentrations (P=0.002) and lesser requirement for inotropic support (P=0.004) compared with those randomized to receive i.v. anaesthetics. Duration of mechanical ventilation was reduced by 2.7 h (P=0.04), and there was a 1 day decrease in hospital length of stay (P<0.001). Some of these outcomes were based on a smaller number of trials because of incomplete data, largely because the individual trials focused on one or more surrogate endpoints. We found some evidence that volatile anaesthetic agents provide myocardial protection in CABG surgery, but larger adequately powered trials with agreed, defined outcomes need to be done to fully assess a possible beneficial effect of volatile anaesthetic agents on the risk of MI and mortality.

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Available from: Joel Ari Symons, Aug 25, 2014
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    • "Additionally , some authors have noted similarities between endotoxin-induced immune defect and cardiac surgery (Codaccioni et al. 2009). This inflammatory response is initiated by surgical trauma, blood contact with artificial surfaces in CPB circuit and ischemia–reperfusion injury, and the degree of inflammatory response corresponds to postoperative outcome, including neuropsychological disorders (Symons and Myles 2006; Yue et al. 2008). In the present study, we observed an overall correlation between plasma KYNA concentration and NLR, a marker of inflammation (de Jager et al. 2010; Gibson et al. 2010; Zahorec 2001), in the NonSEV group. "
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    ABSTRACT: Increases in plasma kynurenic acid (KYNA) concentration relate to the severity of inflammation. The aim of this study was to analyse changes in plasma KYNA concentration and neutrophil/lymphocyte ratio (NLR) in cardiac surgery patients. Additionally, the effect of anaesthesia was analysed. Adult cardiac surgery patients under intravenous general anaesthesia were studied. Additionally, some patients received sevoflurane (SEV) prior to cardiopulmonary bypass. Plasma KYNA concentration and NLR were measured before anaesthesia, just after surgery and on postoperative days 1, 2 and 3. Patients were assigned to two groups: patients who did not receive SEV (NonSEV group) and patients who received SEV (SEV group). Forty-three patients were studied. Twenty-four of them received SEV. KYNA increased immediately after surgery and remained elevated through postoperative day 3 in the NonSEV group, whereas it was similar to the preoperative concentration in the SEV group. NLR increased immediately after surgery in both groups, and higher values were noted in the NonSEV group than in the SEV group at postoperative days 2 and 3. Plasma KYNA concentration correlated with NLR in the NonSEV group. Cardiac surgery caused an increase in NLR. Plasma KYNA increased in the NonSEV group and correlated with NLR. Administration of SEV inhibited the increase in KYNA, most likely due to its anti-inflammatory properties.
    Archivum Immunologiae et Therapiae Experimentalis 09/2014; 63(2). DOI:10.1007/s00005-014-0312-z · 2.82 Impact Factor
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    • "Volatile anesthetics, including isoflurane, have been proven to provide cardioprotective effects against reversible or irreversible myocardial ischemia/reperfusion injury by limiting infarct size and ameliorating contractile and diastolic function (Hanley et al., 2002; Symons and Myles, 2006; Tanaka et al., 2002, 2004). Similar cardioprotective effects by propofol have also been observed in some animal and clinical studies (Javadov et al., 2000; Kobayashi et al., 2008; Searle and Sahab, 1993; Xia et al., 2003). "
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    ABSTRACT: Our previous clinical study reported that isoflurane preconditioning and high-dose propofol posttreatment attenuated myocardial ischemia/reperfusion injury of patients in surgery with cardiopulmonary bypass (CPB). This study was designed to confirm this cardiac protection by use of a dog CPB model and to elucidate the related mechanism. Adult mongrel male dogs undergoing standard CPB were assigned into 4 groups: Sham group, Propofol group, Isoflurane (Iso) group and isoflurane in combination of propofol (pre-Iso+P) group. After induction, anesthesia was maintained with propofol (Propofol group), isoflurane (Iso group) or isoflurane preconditioning in combination with propofol posttreatment (pre-Iso+P group). After 2 h cardiac arrest and CPB, aortic cross-clamping was released to allow 2 h reperfusion. The results demonstrated that joint use of isoflurane and propofol facilitated cardiac functional recovery, improved myocardial oxygen utilization and decreased cardiac enzyme release. Also, the oxidative damage caused by ischemia/reperfusion injury was remarkably attenuated. Linear regression analysis showed that cardiac function performance and oxidative stress status were inversely correlated, indicating the improved cardiac function was in closed association with the attenuation of oxidative stress. In addition, the cardiac oxygen consumption (VO(2)) was found to be significantly associated with the above cardiac function and oxidative stress parameters, suggesting VO(2) was predictive for the levels of cardiac damage and oxidative stress. Therefore, we conclude that alternative use of isoflurane and propofol confers superior cardioprotection against postischemic myocardial injury and dysfunction, and this protection was probably mediated by attenuation of cardiac oxidative damage.
    European journal of pharmacology 02/2012; 677(1-3):138-46. DOI:10.1016/j.ejphar.2011.12.030 · 2.68 Impact Factor
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    • "However , volatile anaesthetics are widely selected in clinical practice for being cardioprotective . A recent extensive systematic overview and meta - analysis of randomized trials comparing volatile with non - volatile anaesthesia in CABG surgery has shown that volatile anaesthetics are associated with better myocardial protection compared with intravenous anaesthetics ( Symons and Myles , 2006 ) , as shown by improvement in cardiac index and a reduced level in troponin I release . The anti - inflammatory effect of volatile anaesthetics ( for example , sevoflurane ) seen during CABG surgery is likely to be an important cardioprotective characteristic and supports its use ( Kawamura et al . "
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    ABSTRACT: Open-heart surgery triggers an inflammatory response that is largely the result of surgical trauma, cardiopulmonary bypass, and organ reperfusion injury (e.g. heart). The heart sustains injury triggered by ischaemia and reperfusion and also as a result of the effects of systemic inflammatory mediators. In addition, the heart itself is a source of inflammatory mediators and reactive oxygen species that are likely to contribute to the impairment of cardiac pump function. Formulating strategies to protect the heart during open heart surgery by attenuating reperfusion injury and systemic inflammatory response is essential to reduce morbidity. Although many anaesthetic drugs have cardioprotective actions, the diversity of the proposed mechanisms for protection (e.g. attenuating Ca2+ overload, anti-inflammatory and antioxidant effects, pre- and post-conditioning-like protection) may have contributed to the slow adoption of anaesthetics as cardioprotective agents during open heart surgery. Clinical trials have suggested at least some cardioprotective effects of volatile anaesthetics. Whether these benefits are relevant in terms of morbidity and mortality is unclear and needs further investigation. This review describes the main mediators of myocardial injury during open heart surgery, explores available evidence of anaesthetics induced cardioprotection and addresses the efforts made to translate bench work into clinical practice. British Journal of Pharmacology (2008) 153, 21–33; doi:10.1038/sj.bjp.0707526; published online 22 October 2007
    British Journal of Pharmacology 02/2008; 153(1):21-33. DOI:10.1038/sj.bjp.0707526 · 4.99 Impact Factor
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