Analysis of transthoracic echocardiographic data in major vascular surgery from a prospective randomised trial comparing sevoflurane and fentanyl with propofol and remifentanil anaesthesia

Abstract

SummaryThe aim of this study was to define pre-operative echocardiographic data and explore if postoperative indices of cardiac function after open abdominal aortic surgery were affected by the anaesthetic regimen. We hypothesised that volatile anaesthesia would improve indices of cardiac function compared with total intravenous anaesthesia. Transthoracic echocardiography was performed pre-operatively in 78 patients randomly assigned to volatile anaesthesia and 76 to total intravenous anaesthesia, and compared with postoperative data. Pre-operatively, 16 patients (10%) had left ventricular ejection fraction < 46%. In 138 patients with normal left ventricular ejection fraction, 5/8 (62%) with left ventricular dilatation and 41/130 (33%) without left ventricular dilatation had evidence of left ventricular diastolic dysfunction (p < 0.001). Compared with pre-operative findings, significant increases in left ventricular enddiastolic volume, left atrial maximal volume, cardiac output, velocity of early mitral flow and early myocardial relaxation occurred postoperatively (all p < 0.001). The ratio of the velocity of early mitral flow to early myocardial relaxation remained unchanged. There were no significant differences in postoperative echocardiographic findings between patients anaesthetised with volatile anaesthesia or total intravenous anaesthesia. Patients had an iatrogenic surplus of approximately 4.1 l of fluid volume by the first postoperative day. N-terminal prohormone of brain natriuretic peptide increased on the first postoperative day (p < 0.001) and remained elevated after 30 days (p < 0.001) in both groups. Although postoperative echocardiographic alterations were most likely to be related to increased preload due to a substantial iatrogenic surplus of fluid, a component of peri-operative myocardial ischaemia cannot be excluded. Our hypothesis that volatile anaesthesia improved indices of cardiac function compared with total intravenous anaesthesia could not be verified.

Effects of sevoflurane on left ventricular function by speckle-tracking echocardiography in coronary bypass patients: A randomized trial

“…Even if sevoflurane offered cellular protection via different mechanisms, such as intracellular signaling pathways [ 30 ] , mitochondrial function [ 31 ] , and potassium channels [ 32 ] , recent studies have suggested that sevoflurane does not significantly reduce mortality or major postoperative complications, such as myocardial infarction, ventilation time and intensive care unit stay [ 7 – 8 ] . The myocardial compensatory ability is significantly decreased in patients undergoing CABG, which might explain our finding that sevoflurane improved LV GLS, SV, and CO in patients with CAD, whereas Lindholm et al [ 33 ] found no significant echocardiographic differences between sevoflurane and TIVA in abdominal aortic surgery.…”

“…In the present study, postoperative complications and cTnT discharge did not show notable differences; however, the cTnT levels decreased more quickly on postoperative day 1 and day 2. Consistent with these results, the recent mortality in cardiac surgery (MYRIAD) trial suggested that volatile agents might reduce postoperative myocardial injury in CABG patients [ 33 ] . The present results also showed that sevoflurane enhanced blood flow but reduced RI in the LIMA-LAD graft.…”

Sample-size determination and adherence in randomised controlled trials published in anaesthetic journals

“…Chance corrected inter-observer agreement for trial eligibility was excellent (kappa = 0.82). Twenty-four trials were subsequently excluded for the following reasons: Not randomized (2), 5,6 pilot trial (4), 7-10 cross-over trial (2), 11,12 factorial (2), 13,14 multiple outcomes (5), [15][16][17][18][19] secondary analysis (4), [20][21][22][23] using dynamic sample size calculations (1), 24 non-inferiority trial (2), 25,26 and trial stopped early (2). 27,28 Trial selection process is shown in 0 1, sample-size calculation details of the 28 included trials are reported in Table 1, and a comparison of expected and actual treatment effects are provided in Table 2.…”

Perioperative aspects of abdominal aortic surgery; focus on choice of anesthetics

“…Pre‐ and post‐operative echocardiographic examinations were performed in 154 patients . Compared to pre‐operative findings, significant increases in left ventricular end‐diastolic volume, left ventricular ejection fraction, left atrial max volume, cardiac output, E and É were observed post‐operatively (for all: P < 0.001).…”