Comparison of haemodynamics and myocardial injury markers under desflurane vs. propofol anaesthesia for off-pump coronary surgery. A prospective randomised trial

Abstract

Background: Several studies have highlighted that volatile anaesthetics improve myocardial protection in cardiopulmonary bypass coronary surgery. However, the haemodynamic effect of desflurane in off-pump coronary surgery has not been clarified yet. Our study hypothesis was that desflurane-fentanyl anaesthesia could decrease myocardial injury markers and improve haemodynamics compared to propofol-fentanyl in patients undergoing off-pump coronary surgery. Methods: Design: Prospective randomised open-label study. Sixty elective patients with left ventricular ejection fraction above 30% received either desflurane (group D, n = 32) or propofol (group P, n = 28), in addition to fentanyl and vecuronium bromide anaesthesia for off-pump coronary surgery. Assessment of haemodynamic function included thermodilution continuous cardiac output and right ventricular end diastolic volume. Results: No significant differences in cardiac output, stroke volume and mean arterial pressure were noted between groups. The only observed difference in haemodynamic profile was that group D demonstrated improved stability, expressed as left ventricular stroke work index (LVSWI). Decrease in LVSWI after performing distal anastomoses was smaller in D compared to P (median value: -14.3 and -19.8 [g m m -2 beat -1 ]), respectively (P = 0.029). Oxygen uptake index (VO 2 I) and oxygen extraction ratio (OER) after skin incision were lower in D, while blood lactate concentration was slightly higher after surgery in D compared to P. The groups did not differ with respect to CK-MB and troponin I concentration. Conclusions: This study demonstrated no difference between desflurane and propofol anaesthesia for off-pump coronary surgery in major haemodynamic parameters, as well as in myocardial injury markers and the long-term outcome. However, the study indicated that desflurane might accelerate recovery of myocardial contractility, as assessed by LVSWI. Lower oxygen uptake and elevated lactate under desflurane anaesthesia indicated a discrete shift towards anaerobic metabolism. Clinical trial registration information: NCT00528515

Inhalation versus intravenous anaesthesia for adults undergoing on-pump or off-pump coronary artery bypass grafting: A systematic review and meta-analysis of randomized controlled trials

“…Sixteen trials included participants under 60 years of age [27,35,41,42,44,50,52,55,65,68,70,73,74,[77][78][79]. Five trials did not report the age of the participants [27,28,49,61,64]. Of the remaining trials, the mean age of the participants in each group trials ranged from 48.9 years to 76 years, with an average mean age for the groups of 63.7 years (range 50.0 to 75.0 years) ( Table 2).…”

“…The overall methodological quality of the included studies was about evenly split between those in which the classification was unclear and those in which the studies were categorised as low risk of bias. Allocation concealment was a major risk of bias limitation in three trials [28,45,66] and blinding of participants and personnel and outcome assessors in eight [30,35,36,37,53,61,63,70].…”

On- or Off-Pump Coronary Artery Bypass: What Is the Evidence?

“…Equal success has been achieved using both thoracic epidural anesthesia and general anesthesia techniques for OPCAB surgery (40,(47)(48)(49). OP-CAB with thoracic epidural anesthesia allows efficient cerebral blood flow management, reduces the rate of postoperative arrhythmias, and improves pain control with overall satisfactory recovery (45).…”

“…The choice of general anesthetic agents has been variable, and many have claimed their unique aspect of advantage. Some studies have suggested that using inhalational anesthetic agents for OPCAB might decrease myocardial injury and accelerate recovery of myocardial contractility (49,50). On the other hand, many different types of total intravenous (IV) anesthesia medication, including propofol, have been utilized for OPCAB surgery (48,(51)(52)(53).…”

Myocardial conditioning techniques in off-pump coronary artery bypass grafting

“…Other authors on the contrary did not find differences in terms of troponin release when it was compared to a propofol group of patients [ 39 ]. Desflurane was reported to improve LSWI when compared to a propofol anesthetic regime, although no differences in troponin release were observed [ 40 ], and moreover was found to be less effective in reducing incidence of arrhythmias than sevoflurane [ 34 ]. Guarracino et al observed a significant reduction in troponin release in a cohort of 57 patients anesthetized with desflurane [ 41 ].…”