Volatile Anesthetics versus Propofol for Cardiac Surgery with Cardiopulmonary Bypass

Abstract

Background The aim of this systematic review and meta-analysis was to assess the effect of anesthesia maintenance with volatile agents compared with propofol on both short- and long-term mortality (primary outcomes) and major clinical events in adults undergoing cardiac surgery with cardiopulmonary bypass. Methods Randomized clinical trials on the effects of current volatile anesthetics versus propofol in adults undergoing cardiac surgery with cardiopulmonary bypass were searched (1965 to September 30, 2019) in PubMed, the Cochrane Library, and article reference lists. A random effect model on standardized mean difference for continuous outcomes and odds ratio for dichotomous outcomes were used to meta-analyze data. Results In total, 37 full-text articles (42 studies, 8,197 participants) were included. The class of volatile anesthetics compared with propofol was associated with lower 1-yr mortality (5.5 vs. 6.8%; odds ratio, 0.76 [95% CI, 0.60 to 0.96]; P = 0.023), myocardial infarction (odds ratio, 0.60 [95% CI, 0.39 to 0.92]; P = 0.023), cardiac troponin release (standardized mean difference, −0.39 [95% CI, −0.59 to −0.18], P = 0.0002), need for inotropic medications (odds ratio, 0.40 [95% CI, 0.24 to 0.67]; P = 0.0004), extubation time (standardized mean difference, −0.35 [95% CI, −0.68 to −0.02]; P = 0.038), and with higher cardiac index/output (standardized mean difference, 0.70 [95% CI, 0.37 to 1.04]; P < 0.0001). The class of volatile anesthetics was not associated with changes in short-term mortality (1.63 vs. 1.65%; odds ratio, 1.04 [95% CI, 0.73 to 1.49]; P = 0.820) and acute kidney injury (odds ratio, 1.25 [95% CI, 0.77 to 2.03]; P = 0.358). Conclusions In adults undergoing cardiac surgery with cardiopulmonary bypass, the class of volatile anesthetics was superior to propofol with regard to long-term mortality, as well as to many secondary outcomes indicating myocardial protection. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Contradictory Findings of Two Recent Meta-Analyses: What Are We Supposed to Believe About Anesthetic Technique in Patients Undergoing Cardiac Surgery?

“…The authors' analysis of 64 randomized controlled trials (RCTs) demonstrated that one-year mortality was similar between groups 1 . This conclusion stands in stark contrast to that from another recent large meta-analysis of 42 studies showing that use of a volatile anesthetic was associated with decreased one-year mortality compared with total intravenous anesthesia in patients undergoing cardiac surgery using cardiopulmonary bypass 2 . This apparent contradiction occurred despite fundamental similarities between the two meta-analyses: both studies followed strict PRISMA guidelines 3 ; both used the recommended Cochrane Risk of Bias Tool 4 ; both included most of the same original RCTs; and both designated one-year mortality as a primary outcome variable.…”

Remimazolam Anesthesia for MitraClip Implantation in a Patient with Advanced Heart Failure

“…In cardiac surgery, it has been well known that volatile, but not intravenous, anesthetics (propofol and midazolam) have cardioprotective effects [ 16 , 17 ]. When intravenous anesthetics are administered with volatile anesthetics, there may be interference with the cardioprotective effects of volatile anesthetics [ 18 ]. The cardioprotective effects of remimazolam and interactions between remimazolam and volatile anesthetics have not been elucidated.…”

Molecular Aspects of Volatile Anesthetic-Induced Organ Protection and Its Potential in Kidney Transplantation

“…Modes of application of the VA in these studies ranged from specific pre-or postconditioning protocols to administration of the VA during the entire surgical procedure. The most recent and largest meta-analysis, performed by Bonnani et al including 42 trials and 8197 patients, however, showed that VA are superior to propofol on long term mortality and postoperative morbidity [30]. In their analysis, the use of VA in patients undergoing cardiac surgery with the use of cardiac pulmonary bypass was associated with a lower one-year mortality, myocardial infarction, lower cTnT release, less need for inotropic support, shorter extubation time, and higher cardiac index/cardiac output compared to the use of propofol, indicating a myocardial protective effect of VA in this setting [30].…”