Effect of Xenon Anesthesia Compared to Sevoflurane and Total Intravenous Anesthesia for Coronary Artery Bypass Graft Surgery on Postoperative Cardiac Troponin Release: An International, Multicenter, Phase 3, Single-blinded, Randomized Noninferiority Trial.

BACKGROUND: Ischemic myocardial damage accompanying coronary artery bypass graft surgery remains a clinical challenge. We investigated whether xenon anesthesia could limit myocardial damage in coronary artery bypass graft surgery patients, as has been reported for animal ischemia models. METHODS: In 17 university hospitals in France, Germany, Italy, and The Netherlands, low-risk elective, on-pump coronary artery bypass graft surgery patients were randomized to receive xenon, sevoflurane, or propofol-based total intravenous anesthesia for anesthesia maintenance. The primary outcome was the cardiac troponin I concentration in the blood 24 h postsurgery. The noninferiority margin for the mean difference in cardiac troponin I release between the xenon and sevoflurane groups was less than 0.15 ng/ml. Secondary outcomes were the safety and feasibility of xenon anesthesia. RESULTS: The first patient included at each center received xenon anesthesia for practical reasons. For all other patients, anesthesia maintenance was randomized (intention-to-treat: n = 492; per-protocol/without major protocol deviation: n = 446). Median 24-h postoperative cardiac troponin I concentrations (ng/ml [interquartile range]) were 1.14 [0.76 to 2.10] with xenon, 1.30 [0.78 to 2.67] with sevoflurane, and 1.48 [0.94 to 2.78] with total intravenous anesthesia [per-protocol]). The mean difference in cardiac troponin I release between xenon and sevoflurane was -0.09 ng/ml (95% CI, -0.30 to 0.11; per-protocol: P = 0.02). Postoperative cardiac troponin I release was significantly less with xenon than with total intravenous anesthesia (intention-to-treat: P = 0.05; per-protocol: P = 0.02). Perioperative variables and postoperative outcomes were comparable across all groups, with no safety concerns. CONCLUSIONS: In postoperative cardiac troponin I release, xenon was noninferior to sevoflurane in low-risk, on-pump coronary artery bypass graft surgery patients. Only with xenon was cardiac troponin I release less than with total intravenous anesthesia. Xenon anesthesia appeared safe and feasible.

Association of Robotic Totally Endoscopic Coronary Artery Bypass Graft Surgery Associated With a Preliminary Cardiac Enhanced Recovery After Surgery Program: A Retrospective Analysis.

OBJECTIVES: The robotic totally endoscopic coronary artery bypass graft (TECAB) surgery reduces patients' recovery time. The present trial investigated the feasibility and safety of an initial enhanced recovery after surgery (ERAS) path for patients undergoing robotic beating-heart TECAB and compared it with both conventional surgery and traditional perioperative care. It was hypothesized that the preliminary ERAS pathway associated with a beating-heart TECAB procedure could have a synergistic effect on postoperative patient care. DESIGN: Observational retrospective study. SETTING: University hospital. PARTICIPANTS: Patients scheduled for coronary artery bypass graft and undergoing robotic beating-heart TECAB (n = 38) were compared with those undergoing standard surgery and perioperative care (n = 33). The outcomes were the possibility of tracheal extubation at the end of the surgery and the incidence of postoperative complications. MEASUREMENTS AND MAIN RESULTS: The main comorbidities were similar between the 2 groups. Extubation on the operating table in the TECAB group was possible in all cases without requiring prompt endotracheal tube reinsertion. The proportion of patients transfused was significantly lower in the TECAB group (p = 0.009). In addition, the duration of intensive care unit and hospital stay were reduced significantly by 24 hours and by 4 days, respectively, in the TECAB group compared with the standard group (p< 0.05). CONCLUSIONS: The present results suggested that a program coupling a beating-heart TECAB with a preliminary ERAS path for patients requiring a single coronary revascularization is feasible and safe. This approach could reduce postoperative mechanical ventilation time, transfusion rate, and both intensive care unit and hospital stay.

Prospective randomized study of early pulmonary evaluation of patients scheduled for aortic valve surgery performed by ministernotomy or total median sternotomy.

OBJECTIVE: The purpose of this study was to compare the respiratory function of patients operated either with a ministernotomy or with a conventional sternotomy for an aortic valve replacement. DESIGN: A prospective randomized study. SETTING: A single-institution university hospital. PARTICIPANTS: Seventy-eight patients scheduled for aortic valve replacement. INTERVENTIONS: Patients were assigned to have minimal sternotomy access (ministernotomy) or conventional median total sternotomy. Pulmonary function was measured using a mobile respiratory spirometric device preoperatively and after 1 (POD1), 2 (POD2), and 7 days (POD7) postoperatively. MEASUREMENTS AND MAIN RESULTS: There was no significant difference in any respiratory parameter measured between the 2 groups of patients. Almost all respiratory volumes decreased significantly with the same intensity in the 2 groups on POD1 (p <0.05), by about 50% from baseline. Only functional residual capacity was unchanged from baseline in the postoperative period, except for a small but significant reduction of this parameter to 60.3% +/- 27.4% in the standard sternotomy group on POD1 and 60.9% +/- 27.1% and 58.8% +/- 30.4%, respectively, in the ministernotomy and the standard group at POD7. The only significant difference concerned the intraoperative blood loss measured at 450 +/- 280 mL and 720 +/- 450 mL, respectively, in the ministernotomy and the standard group (p < 0.05), but this was not significantly associated with a reduction of total blood use. CONCLUSION: This study failed to show any improvement of respiratory function by a smaller chest incision. However, it showed a significant reduction in intraoperative bleeding but without a reduction in transfusion. Further investigations are required to assess whether this procedure could improve the outcome of cardiac surgery patients with a greater predicted risk score or pulmonary diseases.