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

ABSTRACT

Objective

To investigate the effect of volatile anesthetics on rate of postoperative myocardial infarction (MI) and cardiac death following coronary artery bypass graft (CABG).

Design

Post-hoc analysis of a randomized trial.

Setting

Cardiac surgery theaters.

Participants

Patients undergoing elective, isolated CABG.

Interventions

Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane or sevoflurane) or total intravenous anesthesia (TIVA). Primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48h from surgery. Secondary outcome was 1-year death due to cardiac causes.

Measurements and Main Results

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). Mean age was 62±8.4 years, and median baseline ejection fraction was 57 (50-67)%, without differences between the two groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14/2,530 [0.6%] versus 27/2,501 [1.1%] in the TIVA group; p=0.038) and as-treated analyses (16/2,708 [0.6%] versus 29/2,617 [1.1%] in the TIVA group; p=0.039), but not in the intention-to-treat analysis (17/2,663 (0.6%) versus 28/2,667 (1.0%) in the TIVA group; p=0.10). Overall, death due to cardiac causes was lower in the volatile group (23/2,685 [0.9%] versus 40/2,668 [1.5%] 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.

Study registration

ClinicalTrials.gov, NCT02105610, Registered 7 April 2014, https://clinicaltrials.gov/ct2/show/NCT02105610.