Volatile Anesthetics versus Total Intravenous Anesthesia for Cardiac Surgery.

BACKGROUND: Volatile (inhaled) anesthetic agents have cardioprotective effects, which might improve clinical outcomes in patients undergoing coronary-artery bypass grafting (CABG). METHODS: We conducted a pragmatic, multicenter, single-blind, controlled trial at 36 centers in 13 countries. Patients scheduled to undergo elective CABG were randomly assigned to an intraoperative anesthetic regimen that included a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or to total intravenous anesthesia. The primary outcome was death from any cause at 1 year. RESULTS: A total of 5400 patients were randomly assigned: 2709 to the volatile anesthetics group and 2691 to the total intravenous anesthesia group. On-pump CABG was performed in 64% of patients, with a mean duration of cardiopulmonary bypass of 79 minutes. The two groups were similar with respect to demographic and clinical characteristics at baseline, the duration of cardiopulmonary bypass, and the number of grafts. At the time of the second interim analysis, the data and safety monitoring board advised that the trial should be stopped for futility. No significant difference between the groups with respect to deaths from any cause was seen at 1 year (2.8% in the volatile anesthetics group and 3.0% in the total intravenous anesthesia group; relative risk, 0.94; 95% confidence interval [CI], 0.69 to 1.29; P = 0.71), with data available for 5353 patients (99.1%), or at 30 days (1.4% and 1.3%, respectively; relative risk, 1.11; 95% CI, 0.70 to 1.76), with data available for 5398 patients (99.9%). There were no significant differences between the groups in any of the secondary outcomes or in the incidence of prespecified adverse events, including myocardial infarction. CONCLUSIONS: Among patients undergoing elective CABG, anesthesia with a volatile agent did not result in significantly fewer deaths at 1 year than total intravenous anesthesia. (Funded by the Italian Ministry of Health; MYRIAD ClinicalTrials.gov number, NCT02105610.).

Effect of Volatile Anesthetics on Myocardial Infarction After Coronary Artery Surgery: A Post Hoc Analysis of a Randomized Trial.

OBJECTIVE: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN: A post hoc analysis of a randomized trial. SETTING: Cardiac surgical operating rooms. PARTICIPANTS: Patients undergoing elective, isolated CABG. INTERVENTIONS: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. MEASUREMENTS AND MAIN RESULTS: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.

Lung Ultrasonography and Cardiac Surgery: A Narrative Review.

Pulmonary complications are common after cardiac surgery and are closely related to postoperative heart failure and adverse outcomes. Lung ultrasonography (LUS) is currently a widely accepted diagnostic approach with well-established methodology, nomenclature, accuracy, and prognostic value in numerous clinical conditions. The advantages of LUS are universally recognized and include bedside applicability, high diagnostic sensitivity and reproducibility, no radiation exposure, and low cost. However, routine perioperative ultrasonography during cardiac surgery generally is limited to echocardiography, diagnosis of pleural effusion, and as a diagnostic tool for postoperative complications in different organs, and few studies have explored the clinical outcomes in relation to LUS among cardiac patients. This narrative review presents the clinical evidence regarding LUS application in intensive care and during the perioperative period for cardiac surgery. Furthermore, this review describes the methodology and the diagnostic and prognostic accuracies of LUS. A summary of ongoing clinical trials evaluating the clinical outcomes related to LUS also is provided. Finally, this review discusses the rationale for upcoming clinical research regarding whether routine use of LUS can modify current intensive care practice and potentially affect the clinical outcomes after cardiac surgery.

Hypothermic versus normothermic cardiopulmonary bypass in patients with valvular heart disease.

OBJECTIVE: The aim of this study was to test the hypothesis that normothermic cardiopulmonary bypass (CPB) is as effective as hypothermic CPB in terms of cardiac protection (cTnI level) and outcome in patients with valvular heart disease. DESIGN: Prospective randomized study. SETTING: A tertiary cardiothoracic referral center. PARTICIPANTS: 140 patients who had valvular heart disease, with/without coronary artery disease, surgically treated under CPB. INTERVENTIONS: The patients were allocated randomly to undergo either hypothermic (temperature [T], 31 °C-32 °C) or normothermic CPB (T>36 °C). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the dynamics of troponin I. The secondary endpoints were ventilation time, the need for inotropic support, intensive care unit (ICU) and hospital stay durations, complications, and mortality. There were no significant intergroup differences in dynamics of troponin I. Ventilation time was significantly lower in the hypothermic group (6 (5-9) and 8 (5-12); p = 0.01). CONCLUSIONS: Normothermic CPB in patients with valvular heart disease was as effective as hypothermic perfusion in terms of myocardial protection after the surgery assessed by cTnI release. The short ventilation duration in patients who underwent hypothermic CPB needs to be confirmed in a future investigation.

Mortality prediction in patients with dialysis-dependent acute kidney injury after cardiac surgery with cardiopulmonary bypass.

BACKGROUND: To build a predictive model for patients with dialysis-dependent acute kidney injury (AKI-D) after cardiac surgery with the cardiopulmonary bypass (CPB), according to disease severity. METHODS: A single-centre, retrospective cohort study was performed to determine the demographic and clinical parameters (including the specific factor, CPB duration) for risk of poor outcome in patients requiring RRT after cardiac surgery with CPB. A new model was built for mortality prediction in these patients on the basis of the identified risk factors and Sequential Organ Failure Assessment score. RESULTS: The newly developed model showed good discriminatory ability for predicting death in patients with AKI-D after cardiac surgery with CPB. The area under the receiver-operating characteristic (ROC) curve for the score was 0.892 (95% confidence interval, 0.852-0.925). We also determined the criterion for the choice of RRT modality by applying this model. On applying the new model in intermittent haemodialysis patients, a score of ≤3.2 was found safe for selecting the RRT modality. CONCLUSIONS: The new scoring system was valid and accurate in predicting death for AKI-D patients after open-heart surgery. This system and value for choice of RRT were determined for guidance only, to facilitate decision-making in difficult situations.

Does glutamine promote benefits for patients with diabetes mellitus scheduled for cardiac surgery?

BACKGROUND: We hypothesised, that perioperative use of N(2)-L-alanyl-L-glutamine confers cardioprotection and improves insulin resistance in diabetic patients with coronary artery disease operated under cardiopulmonary bypass. METHODS: This double-blind, placebo-controlled, randomised study included 64 patients with diabetes mellitus type 2 who were scheduled for on-pump coronary artery bypass graft surgery. The protocol group (32 patients) and the control group (32 patients) glutamine (0.4 g/kg/day of 20% solution of N(2)-L-alanyl-L-glutamine ("Dipeptiven(®)" Fresenius Kabi, Germany)) and placebo (0.9% NaCl), respectively. Perioperative concentration of troponin I in plasma was considered as the primary end-point. Whereas the secondary end-points were insulin resistance, insulin sensitivity, ß-cell function, blood glucose, plasma triglycerides and free fatty acids concentrations. Insulin resistance, insulin sensitivity and ß-cell function were measured using HOMA equation. Thermodilution method was used to measure haemodynamics in all the patients. RESULTS: No differences have been found in perioperative dynamics of troponin I, insulin resistance, insulin sensitivity, ß-cell function, blood glucose, plasma triglycerides free fatty acids concentrations and haemodynamics. CONCLUSION: Our results have failed to confirm the cardioprotective properties and modulatory effect on perioperative insulin resistance that are thought to be attributable to parenteral glutamine administration in dose 0.4 g/kg/day among cardiac patients with DM operated on under CPB.

Glutamine is cardioprotective in patients with ischemic heart disease following cardiopulmonary bypass.

BACKGROUND: The aim of the present study was to investigate the cardioprotective effects of the perioperative use of N(2)-L-alanyl-L-glutamine (GLN) in patients with ischemic heart disease (IHD) who undergo their operations under cardiopulmonary bypass (CPB). METHODS: This double-blind, placebo-controlled, randomized study included 50 patients who underwent cardiac surgery with CPB. Exclusion criteria were a left ventricular ejection fraction <50%, diabetes mellitus, <3 months since the onset of myocardial infarction, and emergency surgery. Patients in the study group (n = 25) received 0.4 g/kg GLN (Dipeptiven, 20% solution) per day. Patients in the control group (n = 25) were administered a placebo (0.9% NaCl). The primary end point was the dynamics of troponin I at the following stages: (1) prior to anesthesia, (2) 30 minutes after CPB, (3) 6 hours after CPB, (4) 24 hours after surgery, and (5) 48 hours after surgery. Secondary end points included measurements of hemodynamics with a Swan-Ganz catheter. RESULTS: On the first postoperative day after the surgery, the median troponin I level was significantly lower in the study group than in the placebo group: 1.280 ng/mL (interquartile range [IQR], 0.840-2.230 ng/mL) versus 2.410 ng/mL (IQR, 1.060-6.600 ng/mL) (P = .035). At 4 hours after cardiopulmonary bypass (CPB), the median cardiac index was higher in the patients in the study group: 2.58 L/min per m2 (IQR, 2.34-2.91 L/min per m2) versus 2.03 L/min per m2 (IQR, 1.76-2.32 L/min per m2) (P = .002). The median stroke index also was higher in the patients who received GLN: 32.8 mL/m2 (IQR, 27.8-36.0 mL/m2) versus 26.1 mL/m2 (IQR, 22.6-31.8 mL/m2) (P = .023). The median systemic vascular resistance index was significantly lower in the study group than in the placebo group: 1942 dyn·s/cm5 per m2 (IQR, 1828-2209 dyn·s/cm5 per m2) versus 2456 dyn·s/cm5 per m2 (IQR, 2400-3265 dyn·s/cm5 per m2) (P = .001). CONCLUSION: Perioperative administration of GLN during the first 24 hours has cardioprotective effects in IHD patients following CPB. This technique enhances the troponin concentration at 24 hours after surgery and is associated with improved myocardial function.

Residual Lesion Diagnostics in Pediatric Postcardiotomy Extracorporeal Membrane Oxygenation and Its Outcomes.

BACKGROUND: To assess the impact of diagnostic procedures in identifying residual lesions during extracorporeal membrane oxygenation (ECMO) on survival after pediatric cardiac surgery. METHODS: Between January 2012 and December 2017, 74 patients required postcardiotomy ECMO. Patients were retrospectively divided into 2 groups: Group I underwent only echocardiography ([echo only] 46 patients, 62.2%) and group II (echo+) underwent additional diagnostic tests (ie, computed tomography [CT] or cardiac catheterization; 28 patients, 37.8%). Propensity score matching was used to balance the 2 groups by baseline characteristics. RESULTS: Two equal groups (28 patients in each group) were formed by propensity score matching. Fourteen (50%) patients in the echo-only group and 20 (71%) patients in the echo+ group were successfully weaned from ECMO (P = .17). Four (14.3%) patients survived in the echo-only group and 15 (53.5%) patients survived in the echo+ group (P = .004). Patients in the echo+ group had a lower chance of dying compared to the echo-only group (odds ratio, 0.14.6; 95% CI, 0.039-0.52; P = .003). The residual lesions, which may have served as a mortality factor, were found by autopsy in 8 (40%) patients in the echo-only group, while none were found in the echo+ group (P = .014). CONCLUSIONS: The autopsies of patients who died despite postcardiotomy ECMO support showed that in 40% of cases that had been investigated by echo only, residual lesions that had not been detected by echocardiography were present. The cardiac catheterization and CT during ECMO are effective and safe for identifying residual lesions. Early detection and repair of residual lesions may increase the survival rate of pediatric cardiac patients on ECMO.

Outcomes after aortic arch reconstruction for infants: deep hypothermic circulatory arrest versus moderate hypothermia with selective antegrade cerebral perfusion.

OBJECTIVES: Optimal cerebral and visceral protection is crucial in aortic arch surgery. The main method for this protection has traditionally been deep hypothermic circulatory arrest (DHCA). Recently, antegrade cerebral perfusion with moderate hypothermia has become the preferred strategy for adult patients and some children undergoing aortic arch surgery. Continuous cerebral perfusion should reduce the incidence of neurological complications, but the degree of damage to organs and systems resulting from the lack of blood flow distal to the aortic arch remains unclear. Here, we aimed to evaluate the efficacy and safety of methods of protecting the brain and internal organs during aortic arch surgery in infants. METHODS: We performed a retrospective review of 62 patients who underwent aortic arch reconstruction to assess their neurological status and internal injuries after different methods of cerebral protection. RESULTS: Surgical correction of aortic arch congenital abnormalities was performed under DHCA in 27 patients (Group I), and unilateral selective antegrade cerebral perfusion (SACP) was performed in 35 patients (Group II). In Group I, 30.8% of patients had neurological complications, whereas in Group II 5.9% had neurological complications. The odds ratio for a neurological event was significantly lower in Group II compared with Group I-0.14 [(95% CI 0.02-0.63), P = 0.02]. However, incidence of renal dysfunction was significantly higher in the second group than the first: 21 (61.2%) vs 5 (19.2%) cases, respectively [odds ratio 6.49 (95% CI 1.41-38.26), P = 0.02]. CONCLUSIONS: Aortic arch reconstruction accompanied by SACP has a lower risk of neurological complications compared with DHCA. However, the high incidence of renal complications with SACP requires further study.

Effect of volatile anesthetics on myocardial infarction after coronary artery surgery: a post hoc analysis of a randomized trial

OBJECTIVE: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN: A post hoc analysis of a randomized trial. SETTING: Cardiac surgical operating rooms. PARTICIPANTS: Patients undergoing elective, isolated CABG. INTERVENTIONS: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. Measurements and main Results: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.