Journal: J Cardiothorac Vasc Anesth 21(5):664-671, 2007. 26 References
Reprint: Dept of Anesthesia and Intensive Care, Aarhus University Hospital-Skejby, DK-8200 Aarhus N, Denmark (CJ Jakobsen, MD)
Faculty Disclosure: Abstracted by L. Easley, who has nothing to disclose.
Because of progressive cost containment in health care, providers are expected to produce reliable information regarding the cost-effectiveness of their procedures and are now obligated to regularly monitor their results. The purpose of this retrospective study was to evaluate whether there is an overall difference in the effect on mortality between sevoflurane and propofol anesthesia in cardiac surgery. Between 1999 and 2005 there were 10,535 single cardiac procedures from three major cardiac centers available for cross-section analysis. The propofol group (cardiac center A) was given standard total IV anesthesia using propofol, 40 to 80 mcg/kg/min, sufentanil, 3 to 5 mcg/kg, and pancuronium. The sevoflurane group (cardiac centers B and C) was given anesthesia inductions with midazolam or pentobarbital together with fentanyl, 10 to 25 mcg/kg, or sufentanil, 3 to 5 mcg/kg, and rocuronium/cisatracurium.
The primary predictor for comparing patient epidemiologic data was the EuroSCORE. In the database, myocardial infarction (MI) was defined by relatively indiscriminate criteria, the options being: no infarction, infarction, or possible infarction. Patients with a history of an MI within 90 days before cardiac surgery had a significantly higher 30-day mortality rate than all other patients. In patients without a recent MI, there was a tendency toward a lower mortality rate after sevoflurane. Patients with unstable angina had a significantly higher mortality compared with patients without angina. In patients without unstable angina, there was a significantly lower 30-day mortality in the sevoflurane group. When combining causes of death other than cerebrovascular or cardiovascular, the patients in the propofol group had a significantly lower mortality, both overall and for coronary artery bypass graft (CABG) procedures only. The mortality was significantly higher in patients suffering a postoperative MI, for both non-CABG and CABG procedures. For non-CABG procedures, propofol anesthesia had a nonsignificant influence on the incidence of postoperative MI. According to anesthetic group; 69.7% of patients had no postoperative arrhythmias after sevoflurane compared with 71.6% after propofol.
This observational study shows differences in mortality rate between cardiac surgical patients grouped according to their primary anesthetic agent. The conclusion that sevoflurane possesses cardioprotective properties and thus indirectly reduces mortality was suggested by the fact that there was no apparent difference in mortality related to anesthetic technique for patients with recent preoperative MI or for patients with preoperative unstable angina, whereas patients not suffering these complications did have a statistically significant lower mortality after sevoflurane. Another interesting finding in the present study was the lower incidence of postoperative MI after CABG surgery compared with non-CABG surgery after sevoflurane anesthesia, a difference that was not seen in patients receiving propofol. The observed difference in mortality rates between anesthetic groups can be partly explained by the difference in the incidence of postoperative arrhythmias because a higher mortality was found in patients with arrhythmias other than atrial fibrillation.
In conclusion, sevoflurane appears to be superior to propofol in patients with little or no ischemic heart disease, such as those undergoing non-CABG surgery and CABG surgery without severe preoperative ischemia. Propofol may be a better choice for patients with severe ischemia, cardiovascular instability, or undergoing urgent surgery. |
