提示: 手机请竖屏浏览!

挥发性麻醉药与全静脉麻醉用于心脏手术的比较
Volatile Anesthetics versus Total Intravenous Anesthesia for Cardiac Surgery


Giovanni Landoni ... 心脑血管疾病 • 2019.03.28

摘要


背景

挥发性(吸入)麻醉药具有心肌保护作用,可能改善接受冠状动脉旁路移植术(CABG)患者的临床结局。

 

方法

我们在13个国家36个研究中心开展了一项实用性、多中心、单盲、对照试验。计划接受择期CABG的患者被随机分组,分别采用包括一种挥发性麻醉药(地氟醚、异氟醚或七氟醚)的术中麻醉方案或采用全静脉麻醉。主要结局是1年时的全因死亡。

 

结果

共有5,400例患者被随机分组:2,709例被分配至挥发性麻醉药组,2,691例被分配至全静脉麻醉组。64%的患者接受了停跳CABG,体外循环的平均持续时间为79分钟。两组的基线人口统计学和临床特征、体外循环持续时间和桥血管数量相似。第二次期中分析时,由于无效(futility),数据和安全监察委员会建议终止试验。两组1年(有5,353例患者[99.1%]的数据可用;挥发性麻醉药组的全因死亡率2.8%,全静脉麻醉组3.0%;相对危险度,0.94;95%置信区间[CI],0.69~1.29;P=0.71)和30日(有5,398例患者[99.9%]的数据可用;全因死亡率分别为1.4%和1.3%;相对危险度,1.11;95% CI,0.70~1.76)时的全因死亡率无显著差异。两组的次要结局或预设不良事件(包括心肌梗死)发生率均无显著差异。

 

结论

在接受择期CABG的患者中,与全静脉麻醉相比,采用挥发性麻醉药未显著减少1年时的患者死亡数量(由意大利卫生部[Italian Ministry of Health]资助;MYRIAD在ClinicalTrials.gov注册号为NCT02105610)。 





作者信息

Giovanni Landoni, M.D., Vladimir V. Lomivorotov, M.D., Ph.D., Caetano Nigro Neto, M.D., Ph.D., Fabrizio Monaco, M.D., Vadim V. Pasyuga, M.D., Nikola Bradic, M.D., Rosalba Lembo, M.Sc., Gordana Gazivoda, M.D., Valery V. Likhvantsev, M.D., Ph.D., Chong Lei, M.D., Ph.D., Andrey Lozovskiy, M.D., Nora Di Tomasso, M.D., Nazar A.R. Bukamal, M.B., B.Ch., Fernanda S. Silva, M.D., Andrey E. Bautin, M.D., Ph.D., Jun Ma, M.D., Martina Crivellari, M.D., Ahmed M.G.A. Farag, M.D., Nikolay S. Uvaliev, M.D., Cristiana Carollo, M.D., Marina Pieri, M.D., Jan Kunstýř, M.D., Ph.D., Chew Yin Wang, M.B., Ch.B., Alessandro Belletti, M.D., Ludhmila A. Hajjar, Ph.D., Evgeny V. Grigoryev, M.D., Ph.D., Felice E. Agrò, M.D., Hynek Riha, M.D., Ph.D., Mohamed R. El-Tahan, M.D., A. Mara Scandroglio, M.D., Abeer M. Elnakera, M.D., Massimo Baiocchi, M.D., Paolo Navalesi, M.D., Vladimir A. Shmyrev, M.D., Ph.D., Luca Severi, M.D., Mohammed A. Hegazy, M.D., Giuseppe Crescenzi, M.D., Dmitry N. Ponomarev, M.D., Ph.D., Luca Brazzi, M.D., Ph.D., Renato Arnoni, M.D., Ph.D., Dmitry G. Tarasov, M.D., Ph.D., Miomir Jovic, M.D., Ph.D., Maria G. Calabrò, M.D., Tiziana Bove, M.D., Rinaldo Bellomo, M.D., Ph.D., and Alberto Zangrillo, M.D. for the MYRIAD Study Group*
From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute (G.L., F.M., R.L., N.D.T., M.C., M.P., A.B., A.M.S., M.G.C., A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, Istituto di Anestesia e Rianimazione, Azienda Ospedaliera di Padova, Padua (C.C.), Anesthesia and Intensive Care Department, University Campus Bio-Medico of Rome (F.E.A.), and Anestesia e Rianimazione, Dipartimento Cardiovascolare, Azienda Ospedaliera San Camillo Forlanini (L.S.), Rome, the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.), Dipartimento di Scienze Mediche e Chirurgiche, Università Magna Graecia di Catanzaro, Catanzaro (P.N.), Anestesia e Terapia Intensiva Cardiochirurgica, Istituto Clinico Humanitas, Rozzano (G.C.), the Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, and the Department of Surgical Sciences, University of Turin, Turin (L.B.), and the Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine (T.B.) — all in Italy; the Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk (V.V. Lomivorotov, V.A.S., D.N.P.), the Departments of Anesthesiology and Intensive Care (V.V.P.) and Cardiac Surgery (D.G.T.), Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, the Department of Anesthesia and Intensive Care, First Moscow State Medical University (V.V.P., V.V. Likhvantsev), and the Department of Intensive Care, Moscow Regional Clinical and Research Institute (V.V. Likhvantsev), Moscow, the Department of Anesthesia and Intensive Care, Ural Institute of Cardiology, Ekaterinburg (A.L.), the Laboratory for Anesthesiology and Intensive Care, Almazov National Medical Research Center, Saint Petersburg (A.E.B.), and the Intensive Care Unit, Scientific Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo (E.V.G.) — all in Russia; the Anesthesia Section, Department of Surgery, Dante Pazzanese Institute of Cardiology (C.N.N.), the Department of Cardiopneumology, Instituto do Coração, Universidade de São Paulo, and the Intensive Care Unit, Hospital SirioLibanes (L.A.H.), and the Cardiac Surgery Section, Department of Surgery, Dante Pazzanese Institute of Cardiology (R.A.), São Paulo, Brazil; the Department of Cardiovascular Anesthesiology and Intensive Care Medicine, and the Clinical Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Dubrava, Zagreb (N.B.), and the Department of Biomedical Sciences, University North, Varaždin (N.B.) — both in Croatia; the Department of Anesthesia and Intensive Care, Cardiovascular Institute Dedinje (G.G., M.J.), and the School of Medicine, University of Belgrade (M.J.), Belgrade, Serbia; the Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi (C.L.), and the Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing (J.M.) — both in China; the Cardiothoracic Intensive Care Unit and Anesthesia Department, Mohammed Bin Khalifa Cardiac Center, Riffa, Bahrain (N.A.R.B.); the Department of Anesthesiology, Hospital de Santa Maria, Lisbon, Portugal (F.S.S.); the Department of Anesthesia, King Abdullah Medical City–Holy Capital, Makkah (A.M.G.A.F.), and the Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam (M.R.E.-T.) — both in Saudi Arabia; Anesthesia and Intensive Care, Acibadem City Clinic–Cardiac Surgery Center, Burgas, Bulgaria (N.S.U.); the Department of Anesthesiology, Resuscitation and Intensive Medicine, Charles University in Prague, First Faculty of Medicine and General Teaching Hospital (J.K.), and the Cardiothoracic Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine (H.R.), Prague, Czech Republic; the Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (C.Y.W.); the Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Zagazig University Hospitals, Zagazig (A.M.E.), and the Department of Anesthesia and Surgical Intensive Care, Mansoura University, Mansoura (M.A.H.) — both in Egypt; and the School of Medicine, University of Melbourne, Melbourne, VIC, Australia (R.B.). Address reprint requests to Dr. Landoni at the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy, or at landoni.giovanni@hsr.it. *A complete list of investigators in the MYRIAD Study Group is provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Head SJ, Kieser TM, Falk V, Huysmans HA, Kappetein AP. Coronary artery bypass grafting. 1. The evolution over the first 50 years. Eur Heart J 2013;34:2862-2872.

2. Alexander JH, Smith PK. Coronary-artery bypass grafting. N Engl J Med 2016;374:1954-1964.

3. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics — 2018 update: a report from the American Heart Association. Circulation 2018;137(12):e67-e492.

4. Moazzami K, Dolmatova E, Maher J, et al. In-hospital outcomes and complications of coronary artery bypass grafting in the United States between 2008 and 2012. J Cardiothorac Vasc Anesth 2017;31:19-25.

5. Seccareccia F, Perucci CA, D’Errigo P, et al. The Italian CABG Outcome Study: short-term outcomes in patients with coronary artery bypass graft surgery. Eur J Cardiothorac Surg 2006;29:56-62.

6. Pagel PS. Myocardial protection by volatile anesthetics in patients undergoing cardiac surgery: a critical review of the laboratory and clinical evidence. J Cardiothorac Vasc Anesth 2013;27:972-982.

7. Pagel PS, Crystal GJ. The discovery of myocardial preconditioning using volatile anesthetics: a history and contemporary clinical perspective. J Cardiothorac Vasc Anesth 2018;32:1112-1134.

8. Kunst G, Klein AA. Peri-operative anaesthetic myocardial preconditioning and protection — cellular mechanisms and clinical relevance in cardiac anaesthesia. Anaesthesia 2015;70:467-482.

9. Meco M, Cirri S, Gallazzi C, Magnani G, Cosseta D. Desflurane preconditioning in coronary artery bypass graft surgery: a double-blinded, randomised and placebo-controlled study. Eur J Cardiothorac Surg 2007;32:319-325.

10. Landoni G, Biondi-Zoccai GG, Zangrillo A, et al. Desflurane and sevoflurane in cardiac surgery: a meta-analysis of randomized clinical trials. J Cardiothorac Vasc Anesth 2007;21:502-511.

11. Uhlig C, Bluth T, Schwarz K, et al. Effects of volatile anesthetics on mortality and postoperative pulmonary and other complications in patients undergoing surgery: a systematic review and meta-analysis. Anesthesiology 2016;124:1230-1245.

12. Landoni G, Greco T, Biondi-Zoccai G, et al. Anaesthetic drugs and survival: a Bayesian network meta-analysis of randomized trials in cardiac surgery. Br J Anaesth 2013;111:886-896.

13. Garcia C, Julier K, Bestmann L, et al. Preconditioning with sevoflurane decreases PECAM-1 expression and improves one-year cardiovascular outcome in coronary artery bypass graft surgery. Br J Anaesth 2005;94:159-165.

14. De Hert S, Vlasselaers D, Barbé R, et al. A comparison of volatile and non volatile agents for cardioprotection during on-pump coronary surgery. Anaesthesia 2009;64:953-960.

15. Likhvantsev VV, Landoni G, Levikov DI, Grebenchikov OA, Skripkin YV, Cherpakov RA. Sevoflurane versus total intravenous anesthesia for isolated coronary artery bypass surgery with cardiopulmonary bypass: a randomized trial. J Cardiothorac Vasc Anesth 2016;30:1221-1227.

16. Landoni G, Rodseth RN, Santini F, et al. Randomized evidence for reduction of perioperative mortality. J Cardiothorac Vasc Anesth 2012;26:764-772.

17. Landoni G, Pisano A, Lomivorotov V, et al. Randomized evidence for reduction of perioperative mortality: an updated consensus process. J Cardiothorac Vasc Anesth 2017;31:719-730.

18. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008;372:139-144.

19. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;124(23):e652-e735.

20. Sousa-Uva M, Head SJ, Milojevic M, et al. 2017 EACTS guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2018;53:5-33.

21. Symons JA, Myles PS. Myocardial protection with volatile anaesthetic agents during coronary artery bypass surgery: a meta-analysis. Br J Anaesth 2006;97:127-136.

22. Yu CH, Beattie WS. The effects of volatile anesthetics on cardiac ischemic complications and mortality in CABG: a meta-analysis. Can J Anaesth 2006;53:906-918.

23. Landoni G, Lomivorotov V, Pisano A, et al. Mortality in cardiac surgery (MYRIAD): a randomized controlled trial of volatile anesthetics — rationale and design. Contemp Clin Trials 2017;59:38-43.

24. Muntean DM, Ordodi V, Ferrera R, Angoulvant D. Volatile anaesthetics and cardioprotection: lessons from animal studies. Fundam Clin Pharmacol 2013;27:21-34.

25. Ridgeon E, Bellomo R, Myburgh J, et al. Validation of a classification system for causes of death in critical care: an assessment of inter-rater reliability. Crit Care Resusc 2016;18:50-54.

26. Serruys PW, Morice M-C, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961-972.

27. Park S-J, Ahn J-M, Kim Y-H, et al. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med 2015;372:1204-1212.

28. Kapur A, Hall RJ, Malik IS, et al. Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial. J Am Coll Cardiol 2010;55:432-440.

29. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012;367:2375-2384.

30. Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med 2009;361:1827-1837.

31. Jakobsen CJ, Berg H, Hindsholm KB, Faddy N, Sloth E. The influence of propofol versus sevoflurane anesthesia on outcome in 10,535 cardiac surgical procedures. J Cardiothorac Vasc Anesth 2007;21:664-671.

32. DeMets DL, Pocock SJ, Julian DG. The agonising negative trend in monitoring of clinical trials. Lancet 1999;354:1983-1988.

33. Newcombe RG. Interval estimation for the difference between independent proportions: comparison of eleven methods. Stat Med 1998;17:873-890.

34. Conzen PF, Fischer S, Detter C, Peter K. Sevoflurane provides greater protection of the myocardium than propofol in patients undergoing off-pump coronary artery bypass surgery. Anesthesiology 2003;99:826-833.

35. Guarracino F, Landoni G, Tritapepe L, et al. Myocardial damage prevented by volatile anesthetics: a multicenter randomized controlled study. J Cardiothorac Vasc Anesth 2006;20:477-483.

36. Wang J, Zheng H, Chen CL, Lu W, Zhang YQ. Sevoflurane at 1 MAC provides optimal myocardial protection during off-pump CABG. Scand Cardiovasc J 2013;47:175-184.

37. Tempe DK, Dutta D, Garg M, Minhas H, Tomar A, Virmani S. Myocardial protection with isoflurane during off-pump coronary artery bypass grafting: a randomized trial. J Cardiothorac Vasc Anesth 2011;25:59-65.

38. Ovize M, Thibault H, Przyklenk K. Myocardial conditioning: opportunities for clinical translation. Circ Res 2013;113:439-450.

39. Lee MC, Chen CH, Kuo MC, Kang PL, Lo A, Liu K. Isoflurane preconditioning-induced cardio-protection in patients undergoing coronary artery bypass grafting. Eur J Anaesthesiol 2006;23:841-847.

40. Landoni G, Guarracino F, Cariello C, et al. Volatile compared with total intravenous anaesthesia in patients undergoing high-risk cardiac surgery: a randomized multicentre study. Br J Anaesth 2014;113:955-963.

服务条款 | 隐私政策 | 联系我们