Volatile versus total intravenous anesthesia for 30-day mortality following non-cardiac surgery in patients with preoperative myocardial injury

Abstract

We evaluated whether volatile anesthetics can improve the postoperative outcomes of noncardiac surgery in patients with preoperative myocardial injury defined by the cardiac troponin elevation. From January 2010 to June 2018, 1254 adult patients with preoperative myocardial injury underwent non-cardiac surgery under general anesthesia and were enrolled in this study. Patients were stratified into following two groups according to anesthetic agents; 115 (9.2%) patients whose anesthesia was induced and maintained with continuous infusion of propofol and remifentanil (TIVA group) and 1139 (90.8%) patients whose anesthesia was maintainted with volatile anesthetics (VOLATILE group). The primary outcome was 30day mortality. To diminish the remifentanil effect, a further analysis was conducted after excluding the patients who received only volatile anesthetics without remifentanil infusion. In a propensity-score matched analysis, 30-day mortality was higher in the TIVA group than the VOLATILE group (17.0% vs. 9.1%; hazard ratio [HR] 2.60; 95% confidence interval [CI], 1.14-5.93; p = 0.02). In addition, the TIVA group showed higher 30-day mortality than the VOLATILE group, even after eliminating the effect of remifentanil infusion (15.8% vs. 8.3%; HR 4.62; 95% CI, 1.82-11.74; p = 0.001). In our study, the use of volatile anesthetics showed the significant survival improvement after non-cardiac surgery in patients with preoperative myocardial injury, which appears to be irrelevant to the remifentanil use. Further studies are needed to confirm this beneficial effect of volatile anesthetics. Clinical trial number and registry URL: KCT0004349 (www.cris.nih.go.kr)

Myocardial protection by desflurane: from basic mechanisms to clinical applications

“…63 In 2019, Kwon et al 67 found that volatile anesthetics and TIVA exhibited equivalent effects in patients without preoperative myocardial injury in the observation of myocardial injury after noncardiac surgery. Later, Park et al 106 found that noncardiac surgery patients with preoperative myocardial injury and elevated cardiac troponin demonstrated significantly improved survival with intraoperative volatile anesthetics. However, this study was on volatile anesthetics and not specifically on the protective effects of desflurane, so we need further studies to confirm this beneficial effect of desflurane.…”

Myocardial injury before noncardiac surgery

“…Nevertheless, the controversy persists regarding whether volatile anesthetics provides better outcomes for patients with preoperative myocardial injury during noncardiac surgery compared to total intravenous anesthesia. In a single center, retrospective cohort study of 1,254 patients with preoperative myocardial injury undergoing non-cardiac surgery, the researchers found the use of volatile anesthetics showed the significant survival improvement after non-cardiac surgery in patients with preoperative myocardial injury ( 51 ). However, a different study focusing on abdominal great vessel surgery did not yield positive results ( 52 ).…”