Abstract
Purpose
Coronary artery bypass graft surgery (CABG) is associated with cardiac complications, including ischemia, acute myocardial infarction (AMI), and death. Volatile anesthetics have been shown to have a preconditioning-like effect. This systematic review assesses the effects of volatile anesthetics on cardiac ischemic complications and morbidity after CABG.
Methods
Data were obtained, without language restriction, from searches of MEDLINE, Science Citation Index, PubMed, and reference lists. We included only prospective randomized controlled trials evaluating volatile anesthetics during CABG. Two reviewers independently abstracted data on myocardial ischemia, acute myocardial infarction (AMI), and death. Treatment effects were calculated as odds ratio (OR) with 95% confidence intervals (CI) for binary data, and weighted mean difference (WMD) with 95% CI for continuous data.
Principal findings
Thirty-two studies (2,841 patients) were included. In comparison withiv anesthesia, volatile anesthetics were associated with reduced all-cause mortality (OR, 0.65; 95% CI, 0.36-1.18;P = 0.16). Enflurane was associated with increased AMI (OR, 1.34; 95% CI, 0.68–2.64;P = 0.40), whereas sevoflurane and desflurane reduced cardiac troponin I (cTnI) at six hours, 12 hr, 24 hr [WMD,-1.45; 95% CI (-1.73,-1.16);P < 0.00001 ], and 48 hr after operation.
Conclusion
This meta-analysis demonstrates sevoflurane and desflurane reduce the postoperative rise in cTnI. Sevoflurane-mediated reduction in cardiac troponin was associated with improved long-term outcomes in one study. This meta-analysis was not able to show that these positive effects on troponin were translated into improved clinical outcomes. Well-designed large randomized control trials are needed to further elucidate the differential cardio-protective effects of volatile anesthetics.
Objectif
Le pontage aortocoronarien (PAC) est associé à des complications cardiaques comme l’ischémie, l’infarctus aigu du myocarde (IAM) et la mort. Un effet semblable à celui du préconditionnement a été démontré avec les anesthésiques volatils. Dans la présente revue systématique, nous évaluons les effets des anesthésiques volatils sur les complications ischémiques et la morbidité cardiaques après un PAC.
Méthode
Les données obtenues, sans restriction de langue, proviennent de MEDLINE, Science Citation Index, PubMed et des listes de références. Seules les études prospectives, randomisées et contrôlées qui évaluent les anesthésiques volatils pendant le PAC ont été retenues. Deux réviseurs indépendants ont résumé les données sur l’ischémie myocardique, l’IAM et la mort. Les effets ont été calculés par le risque relatif approché (RRA) avec un intervalle de confiance (IC) de 95 % pour les données binaires et la différence moyenne pondérée (DMP) avec un IC de 95 % pour les données en continu.
Constatations principales
Trente-deux études, sur 2 841 patients, ont été retenues. Comparés aux anesthésiques iv, les anesthésiques volatils réduisent toutes les causes de mortalité (RRA de 0,65; IC de 95 %, 0,36 - 1,18; P = 0,16). L’enflurane augmente l’IAM (RRA de 1,34; IC de 95 %, 0,68 - 2,64;P = 0,40), tandis que le sévoflurane et le desflurane réduisent la troponine cardiaque I (cTnI) à six heures, 12 h, 24 h [DMP,-1,45; IC de 95 % (-1,73,-1,16);P < 0,00001] et 48 h après l’opération.
Conclusion
Cette méta-analyse démontre que le sévoflurane et le desflurane réduisent la hausse postopératoire de cTnI. La réduction de troponine cardiaque induite par le sévoflurane est associée à une meilleure évolution à long terme dans l’une des études. La méta-analyse n’a pu montrer que ces effets positifs sur la troponine présentaient des avantages cliniques. De grandes études bien définies randomisées et contrôlées devront élucider les effets cardio-protecteurs différentiels des anesthésiques volatils.
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Dr. Beattie is the R. Fraser Elliot Chair in Cardiac Anesthesia and this investigation was supported by the R. Fraser Elliot endowment.
Competing interests: None declared.
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Yu, C.H., Beattie, W.S. The effects of volatile anesthetics on cardiac ischemic complications and mortality in CABG: a meta-analysis. Can J Anesth 53, 906–918 (2006). https://doi.org/10.1007/BF03022834
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DOI: https://doi.org/10.1007/BF03022834