Annals of Cardiac AnaesthesiaAnnals of Cardiac AnaesthesiaAnnals of Cardiac Anaesthesia
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Table of Contents
INVITED COMMENTARY  
Year : 2013  |  Volume : 16  |  Issue : 1  |  Page : 9-10
Invited Commentary


Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Via Olgettina 60, Milano, 20132, Italy

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Date of Web Publication2-Jan-2013
 

How to cite this article:
Landoni G, Mucchetti M. Invited Commentary. Ann Card Anaesth 2013;16:9-10

How to cite this URL:
Landoni G, Mucchetti M. Invited Commentary. Ann Card Anaesth [serial online] 2013 [cited 2014 Sep 2];16:9-10. Available from: http://www.annals.in/text.asp?2013/16/1/9/105362


The study by Suryaprakash and colleagues published in this issue of Annals of Cardiac Anaesthesia is the largest randomized controlled trial (RCT) ever performed, comparing volatile anesthesia versus total intravenous anesthesia (TIVA) in off-pump coronary artery bypass (OPCAB) surgery. The authors did not find any difference in postoperative levels of cardiac troponin (cTn) among the three study groups receiving sevoflurane, desflurane, or propofol as the main hypnotic drug during anesthesia. [1]

This is the eighth randomized trial investigating the cardioprotective proprieties of volatile agents [sevoflurane, [1],[2],[3],[4],[5] desflurane, [1],[6] or isoflurane [7],[8] versus TIVA (always propofol in these eight studies)]. Three papers showed a reduction in the release of cTn with the use of volatile agents. [2],[6],[7] One paper demonstrated better cardiac performance during intraoperative echocardiography in the volatile group, although there was no difference in the release of cTn between groups. [3] Ballester and colleagues demonstrated that sevoflurane had better antioxidative proprieties than propofol, collecting coronary sinus blood samples intraoperatively to assess oxidative stress markers (F2-isoprostanes and nitrates/nitrites). [5] Three of the eight studies showed no difference in the release of cTn between the two anesthetic regimes. [1],[4],[8] All studies published so far were characterized by small sample size, with only two of them enrolling more then 100 patients. [1],[6] Unfortunately, these eight studies used different troponin assays (cTn I or cTn T), and several authors did not report the data with mean ± standard deviation values. Therefore, it is not possible to meta-analyze their findings properly and we cannot draw final conclusions on the effect of volatile agents on the release of cTn after OPCAB. Moreover, only three deaths out of 291 patients (1.0%) occurred in six papers, [one patient died in the volatile group (0.7%) and two patients died in the TIVA group (1.4%)]. Two studies did not report mortality data [1],[4] and none of the eight authors performed midterm or long-term follow-up. As a consequence, no indication can be given on the effect of volatile agents on survival. Nevertheless, it should be underlined that of more than 80 RCTs performed in cardiac surgery so far and comparing volatile agents with TIVA, no study has ever reported clinically relevant results in favor of TIVA, whereas several papers reported clinically relevant findings in favor of volatile agents. A recent International Consensus Conference [9] suggested that volatile agents might reduce 30-day mortality in hemodynamically stable patients undergoing coronary artery bypass (CAB). Therefore, it is reasonable to assume that cardioprotective effects of volatile anesthesia are attenuated in some studies or in some settings by some factors yet to be completely understood. As a matter of fact, the literature shows impressive results concerning volatile anesthesia in CAB surgery with cardiopulmonary bypass, [10] but evidence in other settings, such as OPCAB, valvular surgery, [11] stenting procedures, and noncardiac surgery, [12] are weak and inconsistent. A recent, adequately powered, multicenter RCT demonstrated that sevoflurane did not reduce the incidence of myocardial ischemia in high-risk patients undergoing major noncardiac surgery. No difference was noted in postoperative release of cTn, N-terminal prohormone of brain natriuretic peptide, major adverse cardiac events, and survival at one year. [12] These patients could be similar to those undergoing OPCAB. The use of intracoronary shunts during OPCAB as in the paper of Suryaprakash reduces or averts intraoperative myocardial ischemia and may, at list in part, explain the negative findings of this study.

In conclusion, the authors of this paper should be lauded for completing the largest trial ever performed on volatile versus intravenous anesthesia in OPCAB. Unfortunately, their study is still underpowered to draw final conclusions, and, as they did not report levels of cTn in the standard way (mean ± standard deviation) and did not report mortality data, it does not add much to the existing literature.

Finally, we think this prestigious and worldwide-read journal offers a good opportunity to invite authors of all RCTs to report short- and long-term survival of the patients included in their studies even when the sample size is limited. This will allow future meta-analyses of RCTs to be performed and will help to plan adequately powered multicenter RCTs.

 
   References Top

1.Suryaprakash S, Chakravarthy M, Muniraju G, Pandey S, Mitra S, Shivalingappa B, et al. Myocardial protection during off pump coronary artery bypass surgery: A comparison of inhalational anesthesia with sevoflurane or desflurane and total intravenous anesthesia. Ann Card Anaesth 2013;16:4-8.  Back to cited text no. 1
  Medknow Journal  
2.Conzen PF, Fischer S, Detter, C, Peter K. Sevoflurane provides greater protection of the myocardium than propofol in patients undergoing off-pump coronary artery bypass surgery. Anesthesiology 2003;99:826-33.  Back to cited text no. 2
    
3.Bein B, Renner J, Caliebe D, Scholz J, Paris A, Fraund S, et al. Sevoflurane but not propofol preserves myocardial function during minimally invasive direct coronary artery bypass surgery. Anesth Analg 2005;100:610-6.  Back to cited text no. 3
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4.Law-Koune JD, Raynaud C, Liu N, Dubois C, Romano M, Fischler M. Sevoflurane-remifentanil versus propofol-remifentanil anesthesia at a similar bispectral level for off-pump coronary artery surgery: no evidence of reduced myocardial ischemia. J Cardiothorac Vasc Anesth 2006;20:484-92.  Back to cited text no. 4
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5.Ballester M, Llorens J, Garcia-de-la-Asuncion J, Perez-Griera J, Tebar E, Martinez-Leon J, et al. Myocardial oxidative stress protection by sevoflurane vs. propofol: a randomised controlled study in patients undergoing off-pump coronary artery bypass graft surgery. Eur J Anaesthesiol 2011;28:874-81.  Back to cited text no. 5
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6.Guarracino F, Landoni G, Tritapepe L, Pompei F, Leoni A, Aletti G, et al. myocardial damage prevented by volatile anesthetics: a multicenter randomized controlled study. J Cardiothorac Vasc Anesth 2006;20:477-83.  Back to cited text no. 6
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7.Tempe DK, Dutta D, Garg M, Minhas H, Tomar A, Virmani S. Myocardial protection with isoflurane during off-pump coronary artery bypass grafting: a randomized trial. J Cardiothorac Vasc Anesth 2011;25:59-65.  Back to cited text no. 7
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8.Kendall JB, Russell GN, Scawn DA, Akrofi M, Cowan CM, Fox MA. A prospective, randomized, single-blind pilot study to determine the effect of anesthetic technique on troponin release after off-pump coronary artery surgery. Anesthesia 2004;59:545-9.  Back to cited text no. 8
    
9.Landoni G, Augoustides JG, Guarracino F, Santini F, Ponschab M, Pasero D, et al. Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference. HSR Proc Intensive Care Cardiovasc Anesth 2011;3:9-19.  Back to cited text no. 9
    
10.Landoni G, Biondi-Zoccai GG, Zangrillo A, Bignami E, D'Avolio S, Marchetti C, et al. Desflurane and sevoflurane in cardiac surgery: a meta-analysis of randomized clinical trials. J Cardiothorac Vasc Anesth 2007;21:502-11.  Back to cited text no. 10
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11.Bignami E, Landoni G, Gerli C, Testa V, Mizzi A, Fano G, et al. Sevoflurane vs. propofol in patients with coronary disease undergoing mitral surgery: a randomised study. Acta Anaesthesiol Scand 2012;56:482-90.   Back to cited text no. 11
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12.Lurati Buse GA, Schumacher P, Seeberger E, Studer W, Schuman RM, Fassl J, et al. Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery. Circulation 2012;126:2696-704.  Back to cited text no. 12
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Correspondence Address:
Giovanni Landoni
Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Via Olgettina 60, Milano, 20132
Italy
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