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One-year outcome of the sevoflurane in acute myocardial infarction randomized trial. Can J Anaesth 2015; 62:1279-86. [DOI: 10.1007/s12630-015-0456-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/29/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022] Open
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53
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Lotz C, Kehl F. Volatile Anesthetic-Induced Cardiac Protection: Molecular Mechanisms, Clinical Aspects, and Interactions With Nonvolatile Agents. J Cardiothorac Vasc Anesth 2015; 29:749-60. [DOI: 10.1053/j.jvca.2014.11.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Indexed: 02/07/2023]
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Miller TE, Gan TJ. Total Intravenous Anesthesia and Anesthetic Outcomes. J Cardiothorac Vasc Anesth 2015; 29 Suppl 1:S11-5. [DOI: 10.1053/j.jvca.2015.01.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 11/11/2022]
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Kunst G, Klein AA. Peri-operative anaesthetic myocardial preconditioning and protection - cellular mechanisms and clinical relevance in cardiac anaesthesia. Anaesthesia 2015; 70:467-82. [PMID: 25764404 PMCID: PMC4402000 DOI: 10.1111/anae.12975] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2014] [Indexed: 12/11/2022]
Abstract
Preconditioning has been shown to reduce myocardial damage caused by ischaemia–reperfusion injury peri-operatively. Volatile anaesthetic agents have the potential to provide myocardial protection by anaesthetic preconditioning and, in addition, they also mediate renal and cerebral protection. A number of proof-of-concept trials have confirmed that the experimental evidence can be translated into clinical practice with regard to postoperative markers of myocardial injury; however, this effect has not been ubiquitous. The clinical trials published to date have also been too small to investigate clinical outcome and mortality. Data from recent meta-analyses in cardiac anaesthesia are also not conclusive regarding intra-operative volatile anaesthesia. These inconclusive clinical results have led to great variability currently in the type of anaesthetic agent used during cardiac surgery. This review summarises experimentally proposed mechanisms of anaesthetic preconditioning, and assesses randomised controlled clinical trials in cardiac anaesthesia that have been aimed at translating experimental results into the clinical setting.
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Affiliation(s)
- G Kunst
- Department of Anaesthetics, King's College Hospital NHS Foundation Trust, London, UK
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56
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Potočnik I, Novak Janković V, Šostarič M, Jerin A, Štupnik T, Skitek M, Markovič-Božič J, Klokočovnik T. Antiinflammatory effect of sevoflurane in open lung surgery with one-lung ventilation. Croat Med J 2015; 55:628-37. [PMID: 25559834 PMCID: PMC4295075 DOI: 10.3325/cmj.2014.55.628] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim To prospectively assess the antiinflammatory effect of volatile anesthetic sevoflurane in patients undergoing open lung surgery with one lung ventilation (OLV). Methods This prospective, randomized study included 40 patients undergoing thoracic surgery with OLV (NCT02188407). The patients were randomly allocated into two equal groups that received either propofol or sevoflurane. Four patients were excluded from the study because after surgery they received blood transfusion or non-steroid antiinflammatory drugs. Inflammatory mediators (interleukins 6, 8, and 10, C-reactive protein [CRP], and procalcitonin) were measured perioperatively. The infiltration of the nonoperated lung was assessed on chest x-rays and the oxygenation index was calculated. The major postoperative complications were counted. Results Interleukin 6 levels were significantly higher in propofol than in sevoflurane group (P = 0.014). Preoperative CRP levels did not differ between the groups (P = 0.351) and in all patients they were lower than 20 mg/L, but postoperative CRP was significantly higher in propofol group (31 ± 6 vs 15 ± 7 ng/L; P = 0.035); Pre- and postoperative procalcitonin was within the reference range (<0.04 µg/L) in both groups. The oxygenation index was significantly lower in propofol group (339 ± 139 vs 465 ± 140; P = 0.021). There was no significant difference between the groups in lung infiltrates (P = 0.5849). The number of postoperative adverse events was higher in propofol group, but the difference was not-significant (5 vs 1; P = 0.115). Conclusion The study suggests an antiinflammatory effect of sevoflurane in patients undergoing thoracotomy with OLV.
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Affiliation(s)
- Iztok Potočnik
- Iztok Potocnik, University Medical Centre Ljubljana, Clinical Department of Anesthesiology and Intensive Therapy, Zaloska 7, SI-1000 Ljubljana, Slovenia,
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Vercueil A. Ischaemic conditioning: intervening to protect; before, after, and at a distance. Anaesthesia 2015; 70:379-83. [PMID: 25764400 DOI: 10.1111/anae.13054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A Vercueil
- King's College Hospital, NHS Foundation Trust, King's Health Partners, London, UK.
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Moscarelli M, Punjabi PP, Miroslav GI, Del Sarto P, Fiorentino F, Angelini GD. Myocardial conditioning techniques in off-pump coronary artery bypass grafting. J Cardiothorac Surg 2015; 10:7. [PMID: 25599579 PMCID: PMC4304196 DOI: 10.1186/s13019-014-0204-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/26/2014] [Indexed: 11/24/2022] Open
Abstract
Off-pump coronary artery bypass surgery by avoiding cardioplegic arrest seems to reduce the risk of ischemic myocardial injury. However, even short-term regional ischemic periods, hemodynamic instability and arrhythmias associated with the procedure can be responsible for myocardial damage. Conditioning, a potential cardio-protective tool during on-pump cardiac surgery, has hardly been investigated in the context of off-pump surgery. There are virtually no large trials on remote ischemic preconditioning and the majority of reports have focused on central ischemic conditioning. Similarly, volatile anesthetic agents with conditioning effect like ischemic preconditioning have been shown to reduce cardiac injury during on-pump procedures but have not been validated in the off-pump scenario. Here, we review the available evidence on myocardial conditioning, either with ischemia/reperfusion or volatile anesthetic agents in patients undergoing off-pump coronary artery surgery.
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Affiliation(s)
- Marco Moscarelli
- NHLI, Hammersmith Hospital, Imperial College London, London, UK. .,Fondazione Monasterio, Ospedale Pasquinucci, Massa, Italy.
| | | | - Gamov I Miroslav
- NHLI, Hammersmith Hospital, Imperial College London, London, UK.
| | | | | | - Gianni D Angelini
- NHLI, Hammersmith Hospital, Imperial College London, London, UK. .,Bristol Heart Institute, University of Bristol, Bristol, UK.
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Landoni G, Guarracino F, Cariello C, Franco A, Baldassarri R, Borghi G, Covello R, Gerli C, Crivellari M, Zangrillo A. Volatile compared with total intravenous anaesthesia in patients undergoing high-risk cardiac surgery: a randomized multicentre study. Br J Anaesth 2014; 113:955-963. [DOI: 10.1093/bja/aeu290] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Bettex DA, Wanner PM, Bosshart M, Balmer C, Knirsch W, Dave H, Dillier C, Bürki C, Hug M, Seifert B, Spahn DR, Beck-Schimmer B. Role of sevoflurane in organ protection during cardiac surgery in children: a randomized controlled trial. Interact Cardiovasc Thorac Surg 2014; 20:157-65. [DOI: 10.1093/icvts/ivu381] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Lavi S, Bainbridge D, D'Alfonso S, Diamantouros P, Syed J, Jablonsky G, Lavi R. Sevoflurane in acute myocardial infarction: a pilot randomized study. Am Heart J 2014; 168:776-83. [PMID: 25440807 DOI: 10.1016/j.ahj.2014.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 07/16/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Experimental evidence suggests that the inhalational anesthetic sevoflurane has a cardioprotective effect. Our objective was to determine if sedation with sevoflurane will reduce infarct size in patients with acute myocardial infarction (MI) who are treated with primary percutaneous coronary intervention (PCI). METHODS We randomized 50 patients presenting with a first acute ST-elevation MI treated by primary PCI within 6 hours from symptom onset to sedation with sevoflurane inhalation or standard sedation (control). Coronary flow at the end of PCI was assessed by corrected Thrombolysis In Myocardial Infarction frame count. Myocardial reperfusion was assessed by ST-segment resolution 60 minutes post-PCI. Infarct size was assessed by release of creatinine kinase (CK) and troponin T. RESULTS There was no difference in the primary end point: troponin T or CK release adjusted to the area at risk, between groups. However, among patients with anterior MI, there was a trend toward lower CK (P = .05) and nonsignificant decrease in troponin (P = .11) levels in the sevoflurane group. Corrected Thrombolysis In Myocardial Infarction frame count was 12.3 ± 1.5 in the sevoflurane group and 15.6 ± 9.1 in the control group (P = .16). There was more ST resolution in patients treated by sevoflurane 80.7% ± 25.8% versus 56.6% ± 35.7% (P = .01). Sevoflurane had no significant adverse effect during administration. CONCLUSIONS Sevoflurane administration during primary PCI did not reduce infarct size. There was a trend toward a reduction in infarct size among patients with anterior MI. Sevoflurane administration was associated with improvement in ST-segment resolution.
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Fechner J, Ihmsen H, Schüttler J, Jeleazcov C. A randomized open-label phase I pilot study of the safety and efficacy of total intravenous anesthesia with fospropofol for coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2014; 27:908-15. [PMID: 24054187 DOI: 10.1053/j.jvca.2013.01.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine safety and efficacy of the water-soluble prodrug fospropofol for anesthesia in cardiac surgery and to compare the pharmacodynamic profiles of fospropofol and propofol. DESIGN Pilot study and a prospective, phase I, open-label, single-center, randomized clinical trial. SETTING University hospital; single institution. PARTICIPANTS Sixteen patients undergoing elective first-time coronary artery bypass surgery. INTERVENTIONS Patients were randomized to receive total intravenous anesthesia with fospropofol (n = 8) or propofol (n = 8) combined with alfentanil as total intravenous anesthesia. Bispectral index, arterial blood pressure, and heart rate were recorded continuously, and pulmonary artery catheter measurements were obtained. Plasma concentrations of formate, phosphate, and Ca(2+) were monitored closely. Safety and tolerability were assessed by adverse events, neurologic examinations, clinical laboratory tests, and vital signs. MEASUREMENTS AND MAIN RESULTS The total doses of fospropofol and propofol during anesthesia were 11.3±2.5 and 4.4±1.0 mg/kg/h, respectively. According to the achieved bispectral index (BIS) values, fospropofol was as effective as propofol in providing general anesthesia and sedation. There were no clinical signs of formate toxicity in the fospropofol group. The only treatment-related adverse event after administration of fospropofol was a transient burning sensation in the perineal and perianal region during induction of sedation or anesthesia. CONCLUSIONS Fospropofol could be used to provide general anesthesia in patients undergoing coronary artery bypass graft surgery. Further larger studies are needed to prove the safety of fospropofol when given to provide general anesthesia for major cardiac surgical procedures.
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Affiliation(s)
- Jörg Fechner
- Department of Anesthesiology, University of Erlangen-Nuremberg, Erlangen, Germany.
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Sevoflurane- Compared with Propofol-based Anesthesia Reduces the Need for Inotropic Support in Patients Undergoing Abdominal Aortic Aneurysm Repair: Evidence of Cardioprotection by Volatile Anesthetics in Noncardiac Surgery. Anesthesiology 2014; 120:1289-90. [DOI: 10.1097/aln.0000000000000186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Takeuchi J, Sakamoto A, Takizawa T. Sevoflurane anesthesia persistently downregulates muscle-specific microRNAs in rat plasma. Int J Mol Med 2014; 34:291-8. [PMID: 24718700 DOI: 10.3892/ijmm.2014.1739] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/31/2014] [Indexed: 11/06/2022] Open
Abstract
The volatile anesthetic, sevoflurane, is widely used in surgery. Over the years, there has been a growing interest in the biological effects of sevoflurane on tissue and organ systems and the molecular mechanisms involved. MicroRNAs (miRNAs or miRs) acting as pivotal post‑transcriptional regulators for fine-tuning gene networks are not only expressed intracellularly, but are also secreted into the plasma. However, the sevoflurane‑associated dynamics of circulating miRNAs and the effects of sevoflurane on tissues remain unknown. Thus, the aim of this study was to perform a comprehensive analysis of circulating miRNA levels and compositions in sevoflurane‑anesthetized rats. The rats were allowed to breathe spontaneously under 2% sevoflurane anesthesia for 6 h, and we performed a quantitative polymerase chain reaction (PCR)‑based array analysis of the time-dependent changes in plasma miRNA levels and compositions. Subsequently, we validated the levels of muscle‑specific miRNAs (also known as myomiRNAs; miR-1, miR‑133a, miR-133b and miR-206) of the plasma, heart and skeletal muscle by quantitative PCR following 3 and 6 h of anesthesia, as well as at 1, 3, 7 and 14 days post-anesthesia. Of the 210 miRNAs detected in the rat plasma from the control group (no anesthesia), 161 plasma miRNAs (77%) were transiently downregulated as a result of sevoflurane anesthesia. Although the downregulation of the plasma miRNAs (148 out of the 161 plasma mRNAs; 92%) recovered immediately after anesthesia, the plasma levels of 4 muscle-specific miRNAs were persistently downregulated until 14 days post-anesthesia. In the cardiac and skeletal muscles, the expression levels of the muscle-specific miRNAs were upregulated within 2 weeks post-anesthesia, indicating that the expression levels of the muscle-specific miRNAs in the cardiac and skeletal muscles and their plasma levels are substantially inversely correlated following anesthesia. Our data suggest that sevoflurane predominantly affects cardiac and skeletal muscles and suppresses the release of miRNA from these tissues into the circulation. This new information provides novel insight into the molecular mechanisms of action of the anesthetic, sevoflurane.
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Affiliation(s)
- Jumpei Takeuchi
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8602, Japan
| | - Atsuhiro Sakamoto
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8602, Japan
| | - Toshihiro Takizawa
- Department of Molecular Medicine and Anatomy, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8602, Japan
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Nigro Neto C, Landoni G, Cassarà, L, De Simone F, Zangrillo A, Tardelli MA. Use of Volatile Anesthetics During Cardiopulmonary Bypass: A Systematic Review of Adverse Events. J Cardiothorac Vasc Anesth 2014; 28:84-89. [DOI: 10.1053/j.jvca.2013.05.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Indexed: 11/11/2022]
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The anesthesia in abdominal aortic surgery (ABSENT) study: a prospective, randomized, controlled trial comparing troponin T release with fentanyl-sevoflurane and propofol-remifentanil anesthesia in major vascular surgery. Anesthesiology 2014; 119:802-12. [PMID: 23838709 DOI: 10.1097/aln.0b013e31829bd883] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND On the basis of data indicating that volatile anesthetics induce cardioprotection in cardiac surgery, current guidelines recommend volatile anesthetics for maintenance of general anesthesia during noncardiac surgery in hemodynamic stable patients at risk for perioperative myocardial ischemia. The aim of the current study was to compare increased troponin T (TnT) values in patients receiving sevoflurane-based anesthesia or total intravenous anesthesia in elective abdominal aortic surgery. METHODS A prospective, randomized, open, parallel-group trial comparing sevoflurane-based anesthesia (group S) and total intravenous anesthesia (group T) with regard to cardioprotection in 193 patients scheduled for elective abdominal aortic surgery. Increased TnT level on the first postoperative day was the primary endpoint. Secondary endpoints were postoperative complications, nonfatal coronary events and mortality. RESULTS On the first postoperative day increased TnT values (>13 ng/l) were found in 43 (44%) patients in group S versus 41 (43%) in group T (P = 0.999), with no significant differences in TnT levels between the groups at any time point. Although underpowered, the authors found no differences in postoperative complications, nonfatal coronary events or mortality between the groups. CONCLUSIONS In elective abdominal aortic surgery sevoflurane-based anesthesia did not reduce myocardial injury, evaluated by TnT release, compared with total intravenous anesthesia. These data indicate that potential cardioprotective effects of volatile anesthetics found in cardiac surgery are less obvious in major vascular surgery.
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67
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Landoni G, Greco T, Biondi-Zoccai G, Nigro Neto C, Febres D, Pintaudi M, Pasin L, Cabrini L, Finco G, Zangrillo A. Anaesthetic drugs and survival: a Bayesian network meta-analysis of randomized trials in cardiac surgery. Br J Anaesth 2013; 111:886-96. [PMID: 23852263 DOI: 10.1093/bja/aet231] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- G Landoni
- Anesthesia and Intensive Care Department, San Raffaele Scientific Institute, Milan, Italy
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68
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Pagel PS. Myocardial Protection by Volatile Anesthetics in Patients Undergoing Cardiac Surgery: A Critical Review of the Laboratory and Clinical Evidence. J Cardiothorac Vasc Anesth 2013; 27:972-82. [DOI: 10.1053/j.jvca.2012.10.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Indexed: 11/11/2022]
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69
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Neto CN, Arnoni R, Rida BS, Landoni G, Tardelli MA. Randomized Trial on the Effect of Sevoflurane on Polypropylene Membrane Oxygenator Performance. J Cardiothorac Vasc Anesth 2013; 27:903-7. [DOI: 10.1053/j.jvca.2012.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Indexed: 11/11/2022]
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CERVIGÓN RAQUEL, MORENO JAVIER, PÉREZ-VILLACASTÍN JULIÁN, CASTELLS FRANCISCO. Profound Sedation with Propofol Modifies Atrial Fibrillation Dynamics. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:1176-88. [DOI: 10.1111/pace.12137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 01/17/2013] [Accepted: 02/14/2013] [Indexed: 11/27/2022]
Affiliation(s)
- RAQUEL CERVIGÓN
- Universidad de Castilla7#x02010;La Mancha, DIEEAC, UCLM; Bioengineering Innovation Research Group (GIBI); Cuenca Spain
| | - JAVIER MORENO
- Unidad de Arritmias; Hospital Clínico San Carlos; Madrid Spain
| | | | - FRANCISCO CASTELLS
- Universidad Politécnica de Valencia; Bioengineering Electronic Telemedicine (BET); DIE; Valencia Spain
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71
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Cardioprotective effect of sevoflurane and propofol during anaesthesia and the postoperative period in coronary bypass graft surgery. Eur J Anaesthesiol 2012; 29:561-9. [DOI: 10.1097/eja.0b013e3283560aea] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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72
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Van Allen NR, Krafft PR, Leitzke AS, Applegate RL, Tang J, Zhang JH. The role of Volatile Anesthetics in Cardioprotection: a systematic review. Med Gas Res 2012; 2:22. [PMID: 22929111 PMCID: PMC3598931 DOI: 10.1186/2045-9912-2-22] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 08/10/2012] [Indexed: 02/06/2023] Open
Abstract
This review evaluates the mechanism of volatile anesthetics as cardioprotective agents in both clinical and laboratory research and furthermore assesses possible cardiac side effects upon usage. Cardiac as well as non-cardiac surgery may evoke perioperative adverse events including: ischemia, diverse arrhythmias and reperfusion injury. As volatile anesthetics have cardiovascular effects that can lead to hypotension, clinicians may choose to administer alternative anesthetics to patients with coronary artery disease, particularly if the patient has severe preoperative ischemia or cardiovascular instability. Increasing preclinical evidence demonstrated that administration of inhaled anesthetics - before and during surgery - reduces the degree of ischemia and reperfusion injury to the heart. Recently, this preclinical data has been implemented clinically, and beneficial effects have been found in some studies of patients undergoing coronary artery bypass graft surgery. Administration of volatile anesthetic gases was protective for patients undergoing cardiac surgery through manipulation of the potassium ATP (KATP) channel, mitochondrial permeability transition pore (mPTP), reactive oxygen species (ROS) production, as well as through cytoprotective Akt and extracellular-signal kinases (ERK) pathways. However, as not all studies have demonstrated improved outcomes, the risks for undesirable hemodynamic effects must be weighed against the possible benefits of using volatile anesthetics as a means to provide cardiac protection in patients with coronary artery disease who are undergoing surgery.
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Affiliation(s)
- Nicole R Van Allen
- Department of Physiology, Loma Linda University School of Medicine, Risley Hall, Room 223, Loma Linda, CA 92354, USA.
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BIGNAMI E, LANDONI G, GERLI C, TESTA V, MIZZI A, FANO G, NUZZI M, FRANCO A, ZANGRILLO A. Sevoflurane vs. propofol in patients with coronary disease undergoing mitral surgery: a randomised study. Acta Anaesthesiol Scand 2012; 56:482-90. [PMID: 22103571 DOI: 10.1111/j.1399-6576.2011.02570.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Myocardial ischemic damage is reduced by volatile anaesthetics in patients undergoing low-risk coronary artery bypass graft surgery; few and discordant results exist in other settings. We therefore performed a randomised controlled trial (sevoflurane vs. propofol) to compare cardiac troponin release in patients with coronary disease undergoing mitral surgery. METHODS Patients with coronary artery disease undergoing mitral surgery were randomly allocated to receive either sevoflurane (50 patients) or propofol (50 patients) as main hypnotic. The primary endpoint of the study was peak post-operative cardiac troponin release defined as the maximum value among the post-operative values measured at intensive care unit arrival, 4 h later, on the first and second post-operative day. RESULTS There was no significant difference in post-operative peak troponin release, the median (25th-75th percentiles) values being 14.9 (10.1-22.1) ng/ml and 14.5 (8.8-17.6) ng/ml in the sevoflurane and propofol groups, respectively (P = 0.4). Fentanyl administration was different between the two groups: 1347 ± 447 μg in patients receiving sevoflurane and 1670 ± 469 μg in those receiving propofol, P = 0.002. The 1-year follow-up identified two patients who died in the propofol group (one myocardial infarction and one low cardiac output syndrome) and one in the sevoflurane group (myocardial infarction). CONCLUSION In this study, patients with coronary artery disease undergoing mitral surgery did not benefit from the cardioprotective properties of halogenated anaesthetics. Sevoflurane anaesthesia was not associated to lower cardiac troponin release when compared with propofol anaesthesia.
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Affiliation(s)
- E. BIGNAMI
- Department of Anesthesia and Intensive Care; Università Vita-Salute San Raffaele; Milan; Italy
| | | | - C. GERLI
- Department of Anesthesia and Intensive Care; Università Vita-Salute San Raffaele; Milan; Italy
| | - V. TESTA
- Department of Anesthesia and Intensive Care; Università Vita-Salute San Raffaele; Milan; Italy
| | - A. MIZZI
- Department of Anesthesia and Intensive Care; Università Vita-Salute San Raffaele; Milan; Italy
| | - G. FANO
- Department of Anesthesia and Intensive Care; Università Vita-Salute San Raffaele; Milan; Italy
| | - M. NUZZI
- Department of Anesthesia and Intensive Care; Università Vita-Salute San Raffaele; Milan; Italy
| | - A. FRANCO
- Department of Anesthesia and Intensive Care; Università Vita-Salute San Raffaele; Milan; Italy
| | - A. ZANGRILLO
- Department of Anesthesia and Intensive Care; Università Vita-Salute San Raffaele; Milan; Italy
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JAKOBSSON J. Desflurane: a clinical update of a third-generation inhaled anaesthetic. Acta Anaesthesiol Scand 2012; 56:420-32. [PMID: 22188283 DOI: 10.1111/j.1399-6576.2011.02600.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2011] [Indexed: 12/30/2022]
Abstract
Available volatile anaesthetics are safe and efficacious; however, their varying pharmacology provides small but potentially clinically important differences. Desflurane is one of the third-generation inhaled anaesthetics. It is the halogenated inhaled anaesthetic with the lowest blood and tissue solubilities, which promotes its rapid equilibration and its rapid elimination following cessation of administration at the end of anaesthesia. The low fat solubility of desflurane provides pharmacological benefits, especially in overweight patients and in longer procedures by reducing slow compartment accumulation. A decade of clinical use has provided evidence for desflurane's safe and efficacious use as a general anaesthetic. Its benefits include rapid and predictable emergence, and early recovery. In addition, the use of desflurane promotes early and predictable extubation, and the ability to rapidly transfer patients from the operating theatre to the recovery area, which has a positive impact on patient turnover. Desflurane also increases the likelihood of patients, including obese patients, recovering their protective airway reflexes and awakening to a degree sufficient to minimise the stay in the high dependency recovery area. The potential impact of the rapid early recovery from desflurane anaesthesia on intermediate and late recovery and resumption of activities of daily living requires further study.
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Affiliation(s)
- J. JAKOBSSON
- Department of Anaesthesia and Intensive Care; Institution for Physiology and Pharmacology; Karolinska Institute; Danderyds University Hospital; Stockholm; Sweden
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Andrews DT, Royse C, Royse AG. The mitochondrial permeability transition pore and its role in anaesthesia-triggered cellular protection during ischaemia-reperfusion injury. Anaesth Intensive Care 2012; 40:46-70. [PMID: 22313063 DOI: 10.1177/0310057x1204000106] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This review summarises the most recent data in support of the role of the mitochondrial permeability transition pore (mPTP) in ischaemia-reperfusion injury, how anaesthetic agents interact with this molecular channel, and the relevance this holds for current anaesthetic practice. Ischaemia results in damage to the electron transport chain of enzymes and sets into play the assembly of a non-specific mega-channel (the mPTP) that transgresses the inner mitochondrial membrane. During reperfusion, uncontrolled opening of the mPTP causes widespread depolarisation of the inner mitochondrial membrane, hydrolysis of ATP, mitochondrial rupture and eventual necrotic cell death. Similarly, transient opening of the mPTP during less substantial ischaemia leads to differential swelling of the intermembrane space compared to the mitochondrial matrix, rupture of the outer mitochondrial membrane and release of pro-apoptotic factors into the cytosol. Recent data suggests that cellular protection from volatile anaesthetic agents follows specific downstream interactions with this molecular channel that are initiated early during anaesthesia. Intravenous anaesthetic agents also prevent the opening of the mPTP during reperfusion. Although by dissimilar mechanisms, both volatiles and propofol promote cell survival by preventing uncontrolled opening of the mPTP after ischaemia. It is now considered that anaesthetic-induced closure of the mPTP is the underlying effector mechanism that is responsible for the cytoprotection previously demonstrated in clinical studies investigating anaesthetic-mediated cardiac and neuroprotection. Manipulation of mPTP function offers a novel means of preventing ischaemic cell injury. Anaesthetic agents occupy a unique niche in the pharmacological armamentarium available for use in preventing cell death following ischaemia-reperfusion injury.
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Affiliation(s)
- David T Andrews
- Department of Anaesthesia, Mater Misericordiae Health Services, Brisbane, Queensland, Australia.
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76
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Jovic M, Stancic A, Nenadic D, Cekic O, Nezic D, Milojevic P, Micovic S, Buzadzic B, Korac A, Otasevic V, Jankovic A, Vucetic M, Velickovic K, Golic I, Korac B. Mitochondrial Molecular Basis of Sevoflurane and Propofol Cardioprotection in Patients Undergoing Aortic Valve Replacement with Cardiopulmonary Bypass. Cell Physiol Biochem 2012; 29:131-42. [DOI: 10.1159/000337594] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2011] [Indexed: 12/21/2022] Open
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Clinical application of the cardioprotective effects of volatile anaesthetics: CON--total intravenous anaesthesia or not total intravenous anaesthesia to anaesthetise a cardiac patient? Eur J Anaesthesiol 2011; 28:623-7. [PMID: 21743333 DOI: 10.1097/eja.0b013e328349aca4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Although volatile anaesthetics show strong and easily reproducible cardioprotective effects in animal experiments, these effects are less obvious in clinical settings. Indeed, more than a decade after the first human clinical study, the number of publications has increased extensively, but the encouraging results from previous studies in terms of myocardial protection have failed to translate into an improvement in survival or a decrease the incidence of myocardial infarction. No consensus on the modalities of administration of volatile anaesthetics has been agreed and when the experimental protocols are transposed into daily clinical practice, their cardioprotective effects are still weak. The reasons for the disparities between experimental and clinical studies will be reviewed here, especially the role of patients' co-morbidities and medications as well as the limitations of the main positive clinical trials. Recent data showing anti-inflammatory properties of propofol will also be explained. One of the most important clinical benefits of propofol is that it can be used by target-controlled or continuous infusion for anaesthesia and sedation throughout the surgical and critical care periods without the risk of a transition failure. Further large multi-centre clinical investigations are still required.
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78
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Is anaesthetic cardioprotection clinically relevant? Another futile search for a magic bullet? Eur J Anaesthesiol 2011; 28:616-7. [PMID: 21822075 DOI: 10.1097/eja.0b013e3283497d00] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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79
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Cardioprotective effects of inhalational and intravenous anesthetics. COR ET VASA 2011. [DOI: 10.33678/cor.2011.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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80
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Raedschelders K, Ansley DM, Chen DDY. The cellular and molecular origin of reactive oxygen species generation during myocardial ischemia and reperfusion. Pharmacol Ther 2011; 133:230-55. [PMID: 22138603 DOI: 10.1016/j.pharmthera.2011.11.004] [Citation(s) in RCA: 256] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 11/04/2011] [Indexed: 02/07/2023]
Abstract
Myocardial ischemia-reperfusion injury is an important cause of impaired heart function in the early postoperative period subsequent to cardiac surgery. Reactive oxygen species (ROS) generation increases during both ischemia and reperfusion and it plays a central role in the pathophysiology of intraoperative myocardial injury. Unfortunately, the cellular source of these ROS during ischemia and reperfusion is often poorly defined. Similarly, individual ROS members tend to be grouped together as free radicals with a uniform reactivity towards biomolecules and with deleterious effects collectively ascribed under the vague umbrella of oxidative stress. This review aims to clarify the identity, origin, and progression of ROS during myocardial ischemia and reperfusion. Additionally, this review aims to describe the biochemical reactions and cellular processes that are initiated by specific ROS that work in concert to ultimately yield the clinical manifestations of myocardial ischemia-reperfusion. Lastly, this review provides an overview of several key cardioprotective strategies that target myocardial ischemia-reperfusion injury from the perspective of ROS generation. This overview is illustrated with example clinical studies that have attempted to translate these strategies to reduce the severity of ischemia-reperfusion injury during coronary artery bypass grafting surgery.
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Affiliation(s)
- Koen Raedschelders
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine. The University of British Columbia, Vancouver, BC, Canada.
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81
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Abstract
The demographic change is associated with an increasing number of elderly patients with serious comorbidities. The prevalence of coronary heart disease in particular increases with age and raises the risk of perioperative myocardial ischemia. In the last few years various interventions have been evaluated to lower the perioperative risk for serious cardiovascular events. This includes cardioprotective medical interventions, for example with β-receptor blockers and statins. Current guidelines recommend that patients who are on β-receptor blockers or statins for chronic treatment of cardiovascular diseases should continue this medication throughout the perioperative period. Myocardial conditioning has been assessed to be effective under numerous experimental conditions and clinical trials have also provided evidence for myocardial protection by conditioning. Besides ischemic and anesthetic-induced preconditioning the noninvasive technique of remote preconditioning offers interesting possibilities, especially for patients with serious comorbidities; however, large scale randomized clinical multicentre trials are still needed. Regarding cardioprotective effectiveness, the clinical data for regional anesthesia are very heterogeneous; nevertheless regional anesthesia is very effective in postoperative pain therapy. Therefore regional anesthesia should be used as a part of multimodal therapy concepts to lower the risk of perioperative cardiovascular events.
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Affiliation(s)
- M Damm
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstrasse 74, Dresden, Germany.
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Zangrillo A, Testa V, Aldrovandi V, Tuoro A, Casiraghi G, Cavenago F, Messina M, Bignami E, Landoni G. Volatile agents for cardiac protection in noncardiac surgery: a randomized controlled study. J Cardiothorac Vasc Anesth 2011; 25:902-7. [PMID: 21872490 DOI: 10.1053/j.jvca.2011.06.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Volatile anesthetics reduce the risk of myocardial infarction and mortality in coronary artery surgery. Recently, the American College of Cardiology/American Heart Association Guidelines suggested the use of volatile anesthetic agents for the maintenance of general anesthesia during noncardiac surgery in patients at risk for perioperative myocardial ischemia, but no randomized experience to document the cardioprotective effects of these agents exists in this setting. Therefore, the authors performed a prospective, randomized, controlled trial to compare the effects of sevoflurane versus total intravenous anesthesia, in terms of postoperative cardiac troponin I release in patients undergoing noncardiac surgery. DESIGN A randomized, controlled trial. SETTING A teaching hospital. PARTICIPANTS Eighty-eight consecutive patients undergoing noncardiac surgery. INTERVENTIONS Patients were allocated randomly to receive either volatile anesthetic (44 patients) as the main anesthetic agent or total intravenous anesthesia (TIVA) (44 patients). MEASUREMENTS Postoperative cardiac troponin I release was measured as a marker of myocardial necrosis. Patients with detectable postoperative troponin I in the sevoflurane group (12/44, 27.3%) were similar to those in the propofol group (9/44, 20.5%; p = 0.6). There was no significant reduction of postoperative median peak cTnI release (0.16 ± 0.71 ng/mL in the sevoflurane group compared with the TIVA group, 0.03 ± 0.08 ng/mL; p = 0.4). Three patients died at the 1-year follow-up for noncardiac causes (2 in the TIVA group). CONCLUSIONS In the authors' experience, patients undergoing noncardiac surgery did not benefit from anesthesia based on halogenated anesthetics. Further studies are necessary to evaluate the cardioprotective effects of volatile agents in noncardiac surgery.
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Affiliation(s)
- Alberto Zangrillo
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milan, Italy
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83
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Bignami E, Landoni G, Biondi-Zoccai G, Greco T, Zangrillo A. Clinically Relevant Outcomes and Long-term Follow-up in Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2011. [DOI: 10.1053/j.jvca.2011.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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84
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Karuppasamy P, Chaubey S, Dew T, Musto R, Sherwood R, Desai J, John L, Shah AM, Marber MS, Kunst G. Remote intermittent ischemia before coronary artery bypass graft surgery: a strategy to reduce injury and inflammation? Basic Res Cardiol 2011; 106:511-9. [PMID: 21544683 DOI: 10.1007/s00395-011-0185-9] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 03/28/2011] [Accepted: 04/20/2011] [Indexed: 12/11/2022]
Abstract
Perioperative myocardial ischemia contributes to postoperative morbidity and mortality. Remote intermittent ischemia (RI) has been shown to benefit patients undergoing coronary artery bypass graft (CABG) surgery by decreasing postoperative cardiac troponin levels. In addition, there is evidence that volatile anesthetics may provide myocardial protection. In this prospective randomized controlled trial we tested the hypothesis that RI is cardioprotective under a strict anesthetic regime with volatile anesthesia until cardiopulmonary bypass (CPB). We also assessed whether RI modulates postoperative cytokine and growth factor concentrations. Fifty-four patients referred for elective CABG surgery without concomitant valve or aortic surgery were randomized to three 5-min cycles of left upper limb ischemia by cuff inflation (RI) or placebo without cuff inflation (Plac). All patients received the volatile anesthetic isoflurane (1.15-1.5 vol%) before CPB and the intravenous anesthetic propofol (3-4 mg/kg/h) thereafter until the end of surgery. Cardiac arrest during CPB was induced by intermittent cross-clamp fibrillation, or by blood cardioplegia. We excluded patients older than 85 years, with unstable angina, significant renal disease, and those taking sulfonylureas. Troponin I (cTnI) was measured preoperatively and after 6, 12, 24 and 48 h. In addition, brain natriuretic peptide (BNP), creatine kinase (CKMB) and a panel of cytokines and growth factors were analyzed perioperatively. Although cTnI, BNP and CKMB all increased post-CABG, there were no significant differences between RI and Plac groups; area under the curve for cTnI 189.4 (183.6) ng/mL/48 h and 183.0 (155.2) ng/mL/48 h mean (SD), p = 0.90, respectively, despite a tendency to a shorter (p < 0.07) cross-clamp time in the treatment group. Similarly, there were no differences between groups in the central venous concentrations of numerous cytokines and growth factors. In patients undergoing CABG surgery RI does not provide myocardial protection under a strict anesthetic regime with volatile anesthesia until CPB, and RI was not associated with changes in cytokines.
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Affiliation(s)
- Partheeban Karuppasamy
- Department of Anaesthetics, Intensive Care Medicine and Pain Therapy, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
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85
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Smul TM, Stumpner J, Blomeyer C, Lotz C, Redel A, Lange M, Roewer N, Kehl F. Propofol Inhibits Desflurane-Induced Preconditioning in Rabbits. J Cardiothorac Vasc Anesth 2011; 25:276-81. [DOI: 10.1053/j.jvca.2010.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Indexed: 11/11/2022]
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86
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Lavi S, Lavi R. Conditioning of the heart: From pharmacological interventions to local and remote protection. Int J Cardiol 2011; 146:311-8. [DOI: 10.1016/j.ijcard.2010.08.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 07/14/2010] [Accepted: 08/07/2010] [Indexed: 01/08/2023]
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87
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Schmidt M, Maeng M, Jakobsen CJ, Madsen M, Thuesen L, Nielsen PH, Bøtker HE, Sørensen HT. Existing data sources for clinical epidemiology: The Western Denmark Heart Registry. Clin Epidemiol 2010; 2:137-44. [PMID: 20865111 PMCID: PMC2943184 DOI: 10.2147/clep.s10190] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The Western Denmark Heart Registry (WDHR) has not previously been described as a research tool in clinical epidemiology. OBJECTIVES We examined the setting, organization, content, data quality, and research potential of the WDHR. METHOD We collected information from members of the WDHR organization, including the committee of representatives, the board, the data management group, and physicians reporting to the database. We retrieved 2008 data from the WDHR to illustrate database variables. RESULTS The WDHR is a clinical database within a population-based health care system. It was launched on 1 January 1999 to monitor and improve the quality of cardiac intervention in Western Denmark (population: 3.3 million) and to allow for clinical and health-service research. More than 200,000 interventions, with 50-150 variables each, have been registered. The data quality is ensured by automatic validation rules at data entry combined with systematic validation procedures and random spot-checks after entry. CONCLUSIONS The WDHR is a valuable research tool because it provides ongoing longitudinal registration of detailed patient and procedural data. The Danish national health care system enables this research because it allows complete follow-up for medical events after cardiac intervention by linkage with multiple medical databases.
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Flier S, Post J, Concepcion A, Kappen T, Kalkman C, Buhre W. Influence of propofol–opioid vs isoflurane–opioid anaesthesia on postoperative troponin release in patients undergoing coronary artery bypass grafting † †A preliminary account of the results of this study has been presented at the 23rd Annual Meeting of the European Association of Cardiothoracic Anaesthesiologists in Antalya, Turkey. Br J Anaesth 2010; 105:122-30. [DOI: 10.1093/bja/aeq111] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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89
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Mebazaa A, Pitsis AA, Rudiger A, Toller W, Longrois D, Ricksten SE, Bobek I, De Hert S, Wieselthaler G, Schirmer U, von Segesser LK, Sander M, Poldermans D, Ranucci M, Karpati PCJ, Wouters P, Seeberger M, Schmid ER, Weder W, Follath F. Clinical review: practical recommendations on the management of perioperative heart failure in cardiac surgery. Crit Care 2010; 14:201. [PMID: 20497611 PMCID: PMC2887098 DOI: 10.1186/cc8153] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery.
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Affiliation(s)
- Alexandre Mebazaa
- Department of Anaesthesia and Intensive care, INSERM UMR 942, Lariboisière Hospital, University of Paris 7 - Diderot, 2 rue Ambroise Paré, Paris, France.
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Abstract
The occurrence of myocardial ischaemia will result in either reversible or irreversible myocardial dysfunction. Even when revascularization is successful, some reperfusion injury may occur that transiently impairs myocardial function. Therefore, treatment should not only be directed towards prompt restoration of myocardial blood flow but measures should also be taken to prevent or alleviate the consequences of myocardial reperfusion injury. Over the years, various strategies have been developed. The present contribution reviews a number of these strategies focusing on pharmacological treatments that have been developed to address myocardial reperfusion injury.
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92
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Kirkebøen KA, Lindholm E, Raeder J. [Choice of anaesthetic approach and anaesthetic drugs]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:388-91. [PMID: 20220866 DOI: 10.4045/tidsskr.08.0370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND All types of anaesthesia should ensure absence of pain, inhibit autonomic responses and provide optimal conditions for surgery. Choice of anaesthetic approach (local, regional or general anaesthesia or a combination of methods) depends on type of surgery and the patients' health and preferences. MATERIAL AND METHODS The review is based on literature identified through non-systematic searches in PubMed and own research and experience. RESULTS When selecting anaesthetic approach and anaesthetic drugs one has to consider not only the perioperative period, but also postoperative aspects such as pain relief, awakeness, functional ability and absence of nausea. After major surgery, regional anaesthesia (especially epidural anaesthesia) and postoperative analgesia have been shown to reduce pulmonary complications and chronic pain. General anaesthesia can be administered either by volatile agents for inhalation, intravenous hypnotics, potent opioids or a combination (often used). Volatile agents, shown to be cardioprotective during cardiac surgery, are recommended for major non-cardiac surgery in patients with heart disease (even though clinical documentation is limited). INTERPRETATION An appropriate anaesthetic approach, taking into account patient characteristics and type of surgery, is important for safety and potential complications. In some situations, the anaesthetic approach and anaesthetic drugs may have an impact on outcome.
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Veel T, Bugge J, Kirkebøen K, Pleym H. Anestesi ved åpen hjertekirurgi hos voksne. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:618-22. [DOI: 10.4045/tidsskr.08.0371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Krzych LJ, Szurlej D, Bochenek A. Rationale for Propofol Use in Cardiac Surgery. J Cardiothorac Vasc Anesth 2009; 23:878-85. [DOI: 10.1053/j.jvca.2009.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Indexed: 11/11/2022]
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Landoni G, Turi S, Bignami E, Zangrillo A. Organ protection by volatile anesthetics in non-coronary artery bypass grafting surgery. Future Cardiol 2009; 5:589-603. [DOI: 10.2217/fca.09.52] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The cardioprotective properties of volatile anesthetics have been widely demonstrated by numerous randomized studies and meta-analyses in the setting of cardiac surgery, above of all during coronary artery bypass grafting procedures. Recently, conflicting results have been presented in cardiac non-coronary artery bypass grafting surgery. Unfortunately, despite the existence of a great number of studies comparing a total intravenous anesthetic regimen with an inhalational regimen, at present there are no randomized studies presenting data regarding mortality and important outcomes, such as myocardial infarction, in non-cardiac surgery. In this review we analyze and present the results of the most recent and important studies regarding anesthetic preconditioning in cardiac and in noncardiac surgery. Furthermore, we focus on the emerging data from animal experiments, discussing in particular the molecular mechanisms underlying anesthetic preconditioning.
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Affiliation(s)
- Giovanni Landoni
- Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Via Olgettina 60, Milano, Italy
| | - Stefano Turi
- Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Via Olgettina 60, Milano, Italy
| | - Elena Bignami
- Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Via Olgettina 60, Milano, Italy
| | - Alberto Zangrillo
- Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Via Olgettina 60, Milano, Italy
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Comparison of Isoflurane-, Sevoflurane-, and Desflurane-Induced Pre- and Postconditioning Against Myocardial Infarction in Mice In Vivo. Exp Biol Med (Maywood) 2009; 234:1186-91. [DOI: 10.3181/0902-rm-58] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The murine in vivo model of acute myocardial infarction is increasingly used to investigate anesthetic-induced preconditioning (APC) and postconditioning (APOST). However, in mice the potency of different volatile anesthetics to reduce myocardial infarct size (IS) has never been investigated systematically nor in a head to head comparison with regard to ischemic preconditioning (IPC) and postconditioning (IPOST). Male C57BL/6 mice were subjected to 45 min of coronary artery occlusion (CAO) and 180 min of reperfusion. To induce APC, 1.0 MAC isoflurane (ISO), sevoflurane (SEVO) or desflurane (DES) was administered 30 min prior to CAO for 15 min. In an additional group, ISO was administered 45 min prior to CAO for 30 min. To induce APOST, 1.0 MAC ISO, SEVO or DES was administered for 18 min starting 3 min prior to the end of CAO. IPC was induced by 3 or 6 cycles of 5 min ischemia/reperfusion, 40 or 60 min prior to CAO, respectively. IPOST was induced by 3 cycles of 30 sec reperfusion/ischemia at the beginning of reperfusion. Area at risk (AAR) and IS were determined with Evans Blue and TTC staining, respectively. IS (IS/AAR) was 50 ± 4% (mean ± SEM) in the control group and was significantly (* P < 0.05) reduced by 3×5 IPC (26 ± 3%*), 6×5 IPC (26 ± 4%*), IPOST (20 ± 2%*), ISO APOST (19 ± 1%*), SEVO APOST (15 ± 1%*), DES APOST (14 ± 2%*) and SEVO APC (27 ± 6%*). ISO APC significantly reduced IS compared to control when administered 30 min (33 ± 4%*), but not when administered 15 min (48 ± 6%). DES APC significantly reduced IS compared to control and to SEVO APC (7 ± 1%*). Within the paradigm of preconditioning, the potency of volatile anesthetics to reduce myocardial infarct size in mice significantly increases from ISO over SEVO to DES, whereas within the paradigm of postconditioning the potency of these volatile anesthetics to reduce myocardial infarct size in mice is similar.
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Pagel PS. Cardioprotection by Volatile Anesthetics: Established Scientific Principle or Lingering Clinical Uncertainty? J Cardiothorac Vasc Anesth 2009; 23:589-93. [DOI: 10.1053/j.jvca.2009.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Indexed: 01/12/2023]
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98
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Bignami E, Biondi-Zoccai G, Landoni G, Fochi O, Testa V, Sheiban I, Giunta F, Zangrillo A. Volatile Anesthetics Reduce Mortality in Cardiac Surgery. J Cardiothorac Vasc Anesth 2009; 23:594-9. [PMID: 19303327 DOI: 10.1053/j.jvca.2009.01.022] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Indexed: 02/08/2023]
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Yao YT, Li LH. Sevoflurane Versus Propofol for Myocardial Protection in Patients Undergoing Coronary Artery Bypass Grafting Surgery: a Meta-analysis of Randomized Controlled Trials. ACTA ACUST UNITED AC 2009; 24:133-41. [DOI: 10.1016/s1001-9294(09)60077-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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