Effects of Volatile versus Total Intravenous Anesthesia on Occurrence of Myocardial Injury after Non-Cardiac Surgery.

Kwon Kwon,Oh Oh,Min Min,Lee Lee,Park Park

doi:10.3390/jcm8111999

Abstract

The cardioprotective effects of volatile anesthetics versus total intravenous anesthesia (TIVA) are controversial, especially in patients undergoing non-cardiac surgery. Using current generation high-sensitivity cardiac troponin (hs-cTn), we aimed to evaluate the effect of anesthetics on the occurrence of myocardial injury after non-cardiac surgery (MINS). From February 2010 to December 2016, 3555 patients without preoperative hs-cTn elevation underwent non-cardiac surgery under general anesthesia. Patients were grouped according to anesthetic agent; 659 patients were classified into a propofol-remifentanil total intravenous anesthesia (TIVA) group, and 2896 patients were classified into a volatile group. To balance the use of remifentanil between groups, a balanced group (n = 1622) was generated with patients who received remifentanil infusion in the volatile group, and two separate comparisons were performed (TIVA vs. volatile and TIVA vs. balanced). The primary outcome was occurrence of MINS, defined as rise of hs-cTn I ≥ 0.04 ng/mL within postoperative 48 hours. The secondary outcomes were 30-day mortality, postoperative acute kidney injury (AKI), and adverse events during hospital stay (mortality, type I myocardial infarction (MI), and new-onset arrhythmia). In propensity-matched analyses, the occurrence of MINS was lower in the TIVA group compared to the volatile group (OR 0.642; 95% CI 0.450–0.914; p = 0.014). However, after balancing the use of remifentanil, there was no difference between groups in the risk of MINS (OR 0.832; 95% CI 0.554–1.251; p-value = 0.377). There were no significant associations between the two groups in type 1 MI, new-onset atrial fibrillation, in-hospital and 30-day mortality before and after balancing the use of remifentanil. However, the incidence of postoperative AKI was lower in the TIVA group (OR 0.362; 95% CI 0.194–0.675; p-value = 0.001). After balancing the use of remifentanil, volatile anesthesia and TIVA showed comparable effects on MINS in patients undergoing non-cardiac surgery without preoperative myocardial injury. Further studies are needed on the benefit of remifentanil infusion.

Highlights

Myocardial injury after non-cardiac surgery (MINS) is independently associated with an increased risk of mortality and major cardiac complications at 30 days and up to two years after surgery [1,2,3,4,5].Current generation high-sensitivity cardiac troponin enables early detection of MINS; perioperative measures to prevent or minimize injury have not been determined [6].Both volatile anesthetics and total intravenous anesthesia (TIVA) have cardioprotective effects through different mechanisms [7], and studies have extensively compared the protective effects of the two techniques [8]
After propensity score matching between the TIVA and volatile groups, 564 patients were grouped into the TIVA group, and 978 patients were grouped into the volatile group
After propensity score matching between the TIVA and volatile groups, the overall incidence of MINS was 13.0% (200/1542), with 10.1% (57/564) in the TIVA group and 15.0% (147/978) in the volatile group

Summary

Introduction

Myocardial injury after non-cardiac surgery (MINS) is independently associated with an increased risk of mortality and major cardiac complications at 30 days and up to two years after surgery [1,2,3,4,5].Current generation high-sensitivity cardiac troponin (hs-cTn) enables early detection of MINS; perioperative measures to prevent or minimize injury have not been determined [6].Both volatile anesthetics and total intravenous anesthesia (TIVA) have cardioprotective effects through different mechanisms [7], and studies have extensively compared the protective effects of the two techniques [8]. Myocardial injury after non-cardiac surgery (MINS) is independently associated with an increased risk of mortality and major cardiac complications at 30 days and up to two years after surgery [1,2,3,4,5]. Current generation high-sensitivity cardiac troponin (hs-cTn) enables early detection of MINS; perioperative measures to prevent or minimize injury have not been determined [6]. Both volatile anesthetics and total intravenous anesthesia (TIVA) have cardioprotective effects through different mechanisms [7], and studies have extensively compared the protective effects of the two techniques [8].

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