Cardioprotective Effects of Sevoflurane, Isoflurane, and Propofol in Coronary Surgery Patients: A Randomized Controlled Study

Authors

  • Vedat Yildirim
  • Suat Doganci
  • Ahmet Aydin
  • Cengiz Bolcal
  • Ufuk Demirkilic
  • Ahmet Cosar

DOI:

https://doi.org/10.1532/HSF98.20081137

Abstract

Background: This study was undertaken to compare the in vivo effects of isoflurane, sevoflurane, and propofol anesthesia on ischemia- and reperfusion-mediated free-radical injury and oxidative stress during coronary arety bypass graft surgery. We also compared the effects of these anesthetic agents on levels of end products of lipid peroxidation and nitric oxide (NO) in human right atrial tissue and blood.

Methods: Sixty patients scheduled to undergo elective coronary surgery with cardiopulmonary bypass (CPB) were enrolled. Patients were randomly allocated to receive 1 of 3 different anesthetic protocols: propofol (group A), isoflurane (group B), or sevoflurane (group C). We recorded global hemodynamic data (mean arterial pressure, mean pulmonary artery pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac output, cardiac index, and systemic vascular resistance index) just before the start of surgery, before the start of CPB, 15 minutes after the end of CPB, at the end of the operation, 6 hours after installation in the intensive care unit, and 12 and 24 hours later. Samples of the right atrial appendage were harvested before and after exposure of the heart to blood cardioplegia and short-term reperfusion under conditions of CPB. Biochemical and oxidative stress parameters were analyzed in both blood and tissue.

Results: Hemodynamic parameters were kept stable throughout in all groups. Troponin I increased transiently with all used anesthetic regimens, but this increase was significantly lower in groups B and C. After clamp removal, lipid peroxidation in patients who received propofol (group A) was less than in patients who received isoflurane (group B) or sevoflurane (group C) (P = .001, P = .005, respectively). Although the 3 groups showed no statistically significant differences in tissue levels of thiobarbituric acid-reactive substances and superoxide dismutase, propofol significantly lowered NO production in atrial tissue after clamp removal and induced less NO production than sevoflurane (P < .05).

Conclusion: Inhalation anesthetics such as isoflurane and sevoflurane preserved cardiac function in coronary surgery patients after CPB with less evidence for myocardial damage than propofol. Furthermore, propofol induced lower blood levels of lipid peroxidation than isoflurane and sevoflurane. Propofol also increased glutathione peroxidase activity but induced less NO production compared to sevoflurane. These findings also support the cardioprotective properties that are demonstrated by hemodynamic parameters.

References

Allaouchiche B, Debon R, Goudable J, et al. 2001. Oxidative stress status during exposure to propofol, sevoflurane and desflurane. Anesth Analg 93:981-5.nAnsley DM, Sun J, Visser WA, et al. 1999. High dose propofol enhances red cell antioxidant capacity during CPB in humans. Can J Anaesth 46:641-8.nAydin A, Orhan H, Sayal A, Ozata M, Sahin G, Isimer A. 2001. Oxidative stress and nitric oxide related parameters in type II diabetes mellitus: effects of glycemic control. Clin Biochem 34:65-70.nBaines CP, Goto M, Downey JM. 1997. Oxygen radicals released during ischemic preconditioning contribute to cardioprotection in the rabbit myocardium. J Mol Cell Cardiol 29:207-16.nBecker LB. 2004. New concepts in reactive oxygen species and cardiovascular reperfusion physiology. Cardiovasc Res 61:461-70.nBerger RL, Davis KB, Kaiser GC, et al. 1981. Preservation of the myocardium during coronary artery bypass grafting. Circulation 64:II61-6nBolcal C, Yildirim V, Doganci S, et al. 2007. Protective effects of antioxidant medications on limb ischemia reperfusion injury. J Surg Res 139:274-9.nDe Hert SG, ten Broecke PW, Mertens E, et al. 2002. Sevoflurane but not propofol preserves myocardial function in coronary surgery patients. Anesthesiology 97:42-9.nDe Hert SG, Cromheecke S, ten Broecke PW, et al. 2003. Effects of propofol, desflurane, and sevoflurane on recovery of myocardial function after coronary surgery in elderly high-risk patients. Anesthesiology 99:314-23.nDe Hert SG, Van der Linden PJ, Cromheecke S, et al. 2004. Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with cardiopulmonary bypass are related to the modalities of its administration. Anesthesiology 101:299-310.nDe Hert SG, Van der Linden PJ, Cromheecke S, et al. 2004. Choice of primary anesthetic regimen can influence intensive care unit length of stay after coronary surgery with cardiopulmonary bypass. Anesthesiology 101:9-20.nDe Ruijter W, Musters RJ, Boer C, et al. 2003. The cardioprotective effect of sevoflurane depends on protein kinase C activation, opening of mitochondrial K(+)(ATP) channels, and the production of reactive oxygen species. Anesth Analg 97:1370-6.nDing HL, Zhu HF, Dong JW, et al. 2005. Inducible nitric oxide synthase contributes to intermittent hypoxia against ischemia/reperfusion injury. Acta Pharmacol Sin 26:315-22.nEtievent JP, Chocron S, Toubin G, et al. 1995. Use of cardiac troponin I as a marker of perioperative myocardial ischemia. Ann Thorac Surg May 59:1192-4.nGuarracino F, Landoni G, Tritapepe L, et al. 2006. Myocardial damage prevented by volatile anesthetics: a multicenter randomized controlled study. J Cardiothorac Vasc Anesth 20:477-83.nHanouz JL, Yvon A, Massetti M, et al. 2002. Mechanisms of desflurane-induced preconditioning in isolated human right atria in vitro. Anesthesiology 97:33-41.nJacquet L, Noirhomme P, El Khoury G, et al. 1998. Cardiac troponin I as an early marker of myocardial damage after coronary bypass surgery. Eur J Cardiothorac Surg 13:378-84.nJakobsen CJ, Berg H, Hindsholm KB, Faddy N, Sloth E. 2007. The influence of propofol versus sevoflurane anesthesia on outcome in 10,535 cardiac surgical procedures. J Cardiothorac Vasc Anesth 21:664-71.nKersten JR, Schmeling TJ, Hettrick DA, Pagel PS, Gross GJ, Warltier DC. 1996. Mechanism of myocardial protection by isoflurane. Role of adenosine triphosphate-regulated potassium (KATP) channels. Anesthesiology 85:794-807.nKevin LG. 2003. Propofol and myocardial lipid peroxidation. Br J Anaesth 253:253-4.nKokita N, Hara A. 1996. Propofol attenuates hydrogen peroxide-induced mechanical and metabolic derangements in the isolated rat heart. Anesthesiology 84:117-27.nLandoni G, Biondi-Zoccai GGL, Zangrillo A, et al. 2007. Desflurane and sevoflurane in cardiac surgery: a meta-analysis of randomised clinical trials. J Cardiothorac Vasc Anesth 21:502-11.nLefevre G, Beljean-Leymarie M, et al. 1998. Evaluation of lipid peroxidation by measuring thiobarbituric acid reactive substances Ann Biol Ann Biol Clin (Paris) 56:305-19.nMangano DT. 1985. Biventricular function after myocardial revascularization in humans: deterioration and recovery patterns during the first 24 hours. Anesthesiology 62:571-7.nMullenheim J, Ebel D, Frabetadorf J, et al. 2002. Isoflurane preconditions myocardium against infarction via release of free radicals. Anesthesiology 96:934-40.nMurphy PG, Myers DS, Davies MJ, et al. 1992. The antioxidant potential of propofol (2,6-diisopropylphenol). Br J Anaesth 68:613-8.nSadony V, Korber M, Albes G, et al. 1998. Cardiac troponin I plasma levels for diagnosis and quantitation of perioperative myocardial damage in patients undergoing coronary artery bypass surgery. Eur J Cardiothorac Surg 13:57-65.nSayin MM, Ozatamer O, Tasoz R, et al. 2002. Propofol attenuates myocardial lipid peroxidation during coronary artery bypass grafting surgery. Br J Anaesth 89: 242-6.nSommerschild HT, Kirkeboen KA. 2002. Preconditioning-endogenous defence mechanisms of the heart. Acta Anaesthesiol Scand 46:123-37.nTritapepe L, Landoni G, Guarracino F, et al. 2007. Cardiac protection by volatile anaesthetics: a multicentre randomized controlled study in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. Eur J Anaesthesiol 24:323-31.nYtrehus K, Hegstad AC. 1991. Lipid peroxidation and membrane damage of the heart. Acta Physiol Scand Suppl 599:81-91.nZaugg M, Lucchinetti E, Spahn DR, Pasch T, Garcia C, Schaub MC. 2002. Differential effects of anesthetics on mitochondrial K(ATP) channel activity and cardiomyocyte protection. Anesthesiology 97:15-23.n

Published

2009-02-20

How to Cite

Yildirim, V., Doganci, S., Aydin, A., Bolcal, C., Demirkilic, U., & Cosar, A. (2009). Cardioprotective Effects of Sevoflurane, Isoflurane, and Propofol in Coronary Surgery Patients: A Randomized Controlled Study. The Heart Surgery Forum, 12(1), E1-E9. https://doi.org/10.1532/HSF98.20081137

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