Comparison of sevoflurane and propofol anaesthetic regimes in respect to the release of troponin I and cystatin C in off-pump myocardial revascularisation: a randomised controlled trial

Objective. Sevoflurane has been used in cardiac surgery because of its protective ef-fects on the myocardium from ischaemic injury. We wanted to test the hypothesis that sevoflurane has beneficial effects on the heart and kidneys in comparison to propofol.

Methods. We conducted a randomised controlled study, with balanced randomi-zation blocked by sex. The participants were 62 patients undergoing off-pump myocardial revascularization (44 men and 18 women), who did not have a myocardi-al infarction less than 24 hours before the start of the operation and who had normal serum values of troponin I preoperatively. The surgery and the measurements were conducted according to the same protocol for both groups. Propofol was used for the induction of anaesthesia in both groups; anaesthesia was continued with either propofol or sevoflurane. Troponin I and cystatin C plasma concentrations were de-termined in eight consecutive blood sam-ples, starting before induction of anaesthe-sia and ending 48 hours after admission to the intensive care unit (ICU). The data were log-transformed and analysed using analysis of variance.

Results. We observed a clear and highly statistically significant effect of time for troponin I (p<0.001) without statistically significant differences between the groups (either main or interaction effects). For the majority of patients, the measurements rose quickly upon reperfusion and reached a peak 12 hours after admission to the ICU, descending approximately back to the rep-erfusion level 48 hours after admission to the ICU. Similar inferences were reached for cystatin C, for which the time-course was approximately bath-shaped.

Conclusion. We observed no clear superi-ority of either sevoflurane or propofol an-aesthetic regime in off-pump myocardial revascularisation.

anaesthetic regime, cardiopro-tection, kidney function, heart surgery

1. De Hert SG, Turani F, Mathur S, Stowe D. Cardioprotection with volatile anesthetics: mechanisms and clinical implications. Anesth Analg 2005;100(6):1584-93.

2. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circula-tion 1986;74(5):1124-36.

3. Toller WG, Kersten JR, Pagel PS, Hettrick DA, Warltier DC. Sevoflurane reduces myocardial infarct size and decreases the time tre-shold for ischemic preconditioning in dogs. Anesthesiology 1999;91(5):1437-46.

4. Varadarajan S, An J, Novalija E, Stowe DF. Sevoflurane before or after ischemia improves contractile and metabolic function while reducing myoplasmic Ca(2+) loading in intact hearts. Anesthesiology 2002;96(1):125-33.

5. Müllenheim J, Ebel D, Bauer M, Otto F, Heinen A, Preckel B, Schlack W. Sevoflurane confers additional cardioprotection after is-chemic late preconditioning in rabits. Anesthesiology 2003;99(3):624-31.

6. Riess M, Eels J, Kevin L, Camara A, Henry MM, Stowe DF. Attenuation of mitochondrial respiration by sevoflurane in isolated car-diac mitochondria is mediated in part by reactive oxygen species. Anesthesiology 2004;100(3):498-505.

7. Bouwmann RA, Musters RJP, van Beek-Harmsen, de Lange JJ, Boer C. Reactive oxygen species precede protein kinase C-δ activation independent of adenosine triphosphate-sensitive mitochondrial channel opening in sevoflurane-induced cardioprotection. Anesthe-siology 2004;100(3):506-14.

8. De Hert SG, Van der Linden PJ, Cromheecke S, Meeus R, Nelis A, Van Reeth V, et al. Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with cardiopulmonary bypass are related to the modalities of its administration. Anesthesiol-ogy 2004;101(2):299-310.

9. De Hert S, ten Broecke PW, Mertens E, Van Sommeren EW, De Blier IG, Stockman BA, Rodrigus IE. Sevoflurane but not propofol preserves myocardial function in coronary surgery patients. Anesthesiology 2002;97(1):42-9.

10. De Hert S, Vlasselaers D, Barbe´ R, Ory J-P, Dekegel D, Donnadonni R, et al. A comparison of volatile and non volatile agents for cardioprotection during on-pump coronary surgery. Anaesthesia 2009;64(9):953-60.

11. Landoni G, Fochi O, Tritapepe L, Guarracino F, Belloni I, Bignami E, Zangrillo A. Cardiac protection by volatile anesthetics. A re-view. Minerva Anestesiol 2009;75(5):269-73.

12. Vives M. Peri-operative renal protective strategies in cardiac surgery. OA Nephrology 2013;1(1):9.

13. Julier K, daSilva R, Garcia C, Bestmann L, Frascarolo P, Zollinger A, et al. Preconditioning by sevoflurane decreases biochemical markers for myocardial and renal dysfunction in coronary artery bypass graft surgery: a double-blinded, placebo-controlled, multi-center study. Anesthesiology 2003;98(6):1315-27.

14. Butterworth J, James R, Prielipp R, Cerese J, Livir J. Female gender associates with increased duration of intubation and length of stay after coronary artery surgery. CABG Clinical Benchmarking Database Participants. Anesthesiology 2000;92(2):414-24.

15. Nathoe HM, Moons KGM, van Dijk D, Jansen EWL, Borst C, de Jaegere PPT, Grobbee DE. Risk and determinants of myocardial injury during off-pump coronary artery bypass grafting. Am J Cardiol 2006;97(10):1482-86.

16. Schwarzenberger JC, Sun LS, Pesce MA, Heyer EJ, Delphin E, Almedia GM, Wood M. Sex-based differences in serum cardiac tro-ponin I, a specific marker for myocardial injury, after cardiac surgery. Crit Care Med 2003;31(3):689-93.

17. Buchanan FF, Myles PS, Cicuttini F. Patient sex and its influence on general anaesthesia. Anaesth Intensive Care 2009;37(2):207-18.

18. De Hert SG. Is anaesthetic cardioprotection clinically relevant? Another futile search for a magic bullet? Eur J Anaesthesiol 2011;28(9):616-7.

19. Van Allen NR, Krafft PR, Leitzke AS, Applegate RL 2nd, Tang J, Zhang JH. The role of volatile anesthetics in cardioprotection: a systematic review. Med Gas Res 2012;2(1):22.

20. Conzen P, Fischer S, Detter C, Peter K. Sevoflurane provides greater protection of the myocardium than propofol in patients under-going off-pump coronary artery bypass surgery. Anesthesiology 2003;99(4):826-33.

21. Hix JK, Thakar CV, Katz EM, Yared J-P, Sabik J, Paganini EP. Effect of off-pump coronary artery bypass graft surgery on postoperative acute kidney injury and mortality. Crit Care Med 2006;34(12):2979-83.

22. Palevsky P. Off-pump cardiac surgery and acute kidney injury. Crit Care Med 2006;34(12):3052-3.

23. Murty MSN, Sharma UK, Pandey VB, Kankare SB. Serum cystatin C as a marker of renal function in detection of early acute kidney injury. Indian J Nephrol 2013;23(3):180-3.

24. Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function – measured and estimated glomerular filtration rate. N Engl J Med 2006;354(23):2473-83.

25. Stevens LA, Coresh J, Schmid CH, Feldman HI, Froissart M, Kusek J, et al. Estimating GFR using serum cystatin C alone and in combination with serum creatinine: a pooled analysis of 3,418 individuals with CKD. Am J Kidney Dis 2008;51(3):395-406.

26. Seabra VF, Alobaidi S, Balk EM, Poon AH, Jaber BL. Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized controlled trials. Clin J Am Soc Nephrol 2010;5(10):1734-44.