Straarup Therese S, Hausenloy Derek J, Rolighed Larsen Jens K
From the Department of Anaesthesia, Aarhus University Hospital, Viborg, Denmark (TSS); The Hatter Cardiovascular Institute, University College London, London, UK (DJH); and Institute of Clinical Medicine, Aarhus University Hospital and Department of Anaesthesia, Viborg and Silkeborg, Denmark (JKRL).
Eur J Anaesthesiol. 2016 Jun;33(6):396-407. doi: 10.1097/EJA.0000000000000397.
Reports from animal studies indicate that volatile anaesthetics protect the myocardium against the effects of acute ischaemia-reperfusion injury by reducing infarct size. This cardioprotective effect in the clinical setting of coronary artery bypass graft (CABG) surgery, where the heart is subjected to global ischaemia-reperfusion injury, remains controversial.
The objective was to demonstrate that clinical studies investigating the cardioprotective effect of volatile anaesthetics on cardiac troponins in CABG are no longer warranted. We also investigated the effect of volatile anaesthetics on cardiac enzymes in off-pump cardiac surgery.
Systematic review of randomised clinical trials, meta-analyses and trial sequential analysis (TSA).
Trials between January 1985 and March 2015 were obtained from electronic databases (Medline, Excerpta Medica Database (EMBASE), Cochrane Controlled Trial Register, abstracts from major anaesthesiology and cardiology journals and reference lists of relevant randomised trials and review articles.
Relevant randomised clinical trials were included. We investigated the effect of volatile anaesthetics in both off-pump and on-pump CABG surgery with respect to troponin release [peak postoperative cardiac troponin I (cTnI) and cardiac troponin T (cTnT), cTnI/cTnT] and performed two separate meta-analyses. TSA was used to overcome the weakness of a type-1 error associated with repeated meta-analyses.
From 30 studies, 2578 patients were pooled for the meta-analysis. The outcome significantly favours the use of peroperative volatile over non-volatile anaesthetics during on-pump CABG surgery with regard to peak postoperative cTnI (0.995 mg l; standard mean difference, 95% confidence interval, -1.316 to -0.673; P < 0.001). Meta-analysis of 11 off-pump studies showed no difference in peak postoperative cTnI (0.385 mg l; standard mean difference, 95% confidence interval, -0.857 to 0.087; P = 0.11). TSA indicated that the required information size for on-pump surgery was 1072 patients, and for off-pump surgery it was 1442; this latter figure has not yet been reached.
Studies investigating the cardioprotective effect of volatile anaesthetics on cardiac troponins in on-pump CABG surgery are no longer warranted. This is not yet the case for off-pump surgery.
动物研究报告表明，挥发性麻醉剂可通过减小梗死面积来保护心肌免受急性缺血 - 再灌注损伤的影响。在冠状动脉旁路移植术（CABG）手术的临床环境中，心脏会受到整体缺血 - 再灌注损伤，这种心脏保护作用仍存在争议。
目的是证明不再需要进行临床研究来调查挥发性麻醉剂对CABG手术中心肌肌钙蛋白的心脏保护作用。我们还研究了挥发性麻醉剂对非体外循环心脏手术中心脏酶的影响。
对随机临床试验、荟萃分析和试验序贯分析（TSA）进行系统评价。
1985年1月至2015年3月期间的试验来自电子数据库（Medline、医学文摘数据库（EMBASE）、Cochrane对照试验注册库、主要麻醉学和心脏病学杂志的摘要以及相关随机试验和综述文章的参考文献列表）。
纳入相关随机临床试验。我们研究了挥发性麻醉剂在非体外循环和体外循环CABG手术中对肌钙蛋白释放的影响[术后心肌肌钙蛋白I（cTnI）和心肌肌钙蛋白T（cTnT）峰值、cTnI/cTnT]，并进行了两项单独的荟萃分析。TSA用于克服与重复荟萃分析相关的I型错误的弱点。
从30项研究中，共纳入2578例患者进行荟萃分析。在体外循环CABG手术中，关于术后cTnI峰值，使用术中挥发性麻醉剂比使用非挥发性麻醉剂的结果明显更有利（0.995mg/l；标准均差，95%置信区间，-1.316至-0.673；P<0.001）。对11项非体外循环研究的荟萃分析显示，术后cTnI峰值无差异（0.385mg/l；标准均差，95%置信区间，-0.857至0.087；P = 0.11）。TSA表明，体外循环手术所需的信息量为1072例患者，非体外循环手术为1442例；后者尚未达到。
不再需要进行研究来调查挥发性麻醉剂对体外循环CABG手术中心肌肌钙蛋白的心脏保护作用。非体外循环手术的情况并非如此。
