Comparison Between the Protective Effect of Isoflurane and Propofol on Myocardium During Coronary Artery Bypass Grafting: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Bao, Qi; Lei, Min; Xiao, Dongju; Xie, Junran

doi:10.21470/1678-9741-2021-0424

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Brazilian Journal of Cardiovascular Surgery

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REVIEW ARTICLE • Braz. J. Cardiovasc. Surg. 39 (3) • 2024 • https://doi.org/10.21470/1678-9741-2021-0424 copy

Comparison Between the Protective Effect of Isoflurane and Propofol on Myocardium During Coronary Artery Bypass Grafting: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Intravenous non-volatile anaesthetics like propofol are commonly used in cardiac surgeries across several countries. Volatile anaesthetics like isoflurane may help in protecting the myocardium and minimize ischaemia-reperfusion injury. Hence, we did this review to compare the cardioprotective effect of isoflurane and propofol among patients undergoing coronary artery bypass grafting (CABG).

Methods:

We conducted a search in the databases Medical Literature Analysis and Retrieval System Online (or MEDLINE), Embase, PubMed Central®, ScienceDirect, Google Scholar, and Cochrane Library from inception until April 2021. We carried out a meta-analysis with random-effects model and reported pooled risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI) depending on the type of outcome.

Results:

We analysed 13 studies including 808 participants. Almost all were low-quality studies. For cardiac index, the pooled SMD was 0.14 (95% CI: -0.22 to 0.50); for cardiac troponin I, pooled SMD was 0.10 (95% CI: -0.28 to 0.48). For mortality, the RR was 3.00 (95% CI: 0.32 to 28.43); for MI, pooled RR was 1.58 (95% CI: 0.59 to 4.20); and for inotropic drug use, pooled RR was 1.04 (95% CI: 0.90 to 1.21). For length of intensive care unit stay, the pooled SMD was 0.13 (95% CI: -0.29 to 0.55), while pooled SMD for mechanical ventilation time was -0.02 (95% CI: -0.54 to 0.51).

Conclusion:

Isoflurane did not have significant cardioprotective effect compared to propofol following CABG. Hence, the anaesthetists need to check some viable alternatives to manage these patients and reduce the rate of postoperative complications.

Keywords:
Cardiac Surgery; Isoflurane; Meta-Analysis; Propofol; Troponin I

Abbreviations, Acronyms & Symbols
CABG	= Coronary artery bypass grafting
CI	= Confidence interval
EIC	= Elective isolated coronary artery bypass grafting
I	= Isoflurane
ICU	= Intensive care unit
MI	= Myocardial infarction
NR	= Not reported
P	= Propofol
RCTs	= Randomized controlled trials
RoB 2	= Cochrane risk-of-bias tool for randomized controlled trials
RR	= Risk ratio
SD	= Standard deviation
SE	= Standard error
SMD	= Standardized mean difference

Study nº	First author and year	Country	Study design	Sample size (I vs. P)	Type of surgery	Aortic cross-clamping	Mean age (years)	Outcomes assessed
1	El-Shobaki et al., 2002	Egypt	RCT	I=25	EIC	NR	NR	Cardiac index, length of ICU stay, mechanical ventilation time
1	El-Shobaki et al., 2002	Egypt	RCT	P=25	EIC	NR	NR
2	Engoren et al., 1998	United States of America	RCT	I=35	EIC	NR	61	In-hospital mortality, MI, length of ICU stay, mechanical ventilation time
2	Engoren et al., 1998	United States of America	RCT	P=35	EIC	NR	61
3	Flier et al., 2010	Netherlands	RCT	I=41	EIC	53	67	Cardiac index, cardiac troponin, in-hospital mortality, MI, inotropic drug use, length of ICU stay, mechanical ventilation time
3	Flier et al., 2010	Netherlands	RCT	P=43	EIC	53	67
4	Huang et al., 2011	Italy	RCT	I=30	EIC	NR	61	Cardiac index, cardiac troponin, in-hospital mortality, MI, inotropic drug use, length of ICU stay, mechanical ventilation time
4	Huang et al., 2011	Italy	RCT	P=30	EIC	NR	61
5	Imantalab et al., 2012	Iran	RCT	I=20	EIC	41	NR	Cardiac troponin, mechanical ventilation time
5	Imantalab et al., 2012	Iran	RCT	P=20	EIC	41	NR	Cardiac troponin, mechanical ventilation time
6	Kendall et al., 2004	United Kingdom	RCT	I=10	EIC	NR	I=58.1	Cardiac troponin, MI, inotropic drug use, mechanical ventilation time
6	Kendall et al., 2004	United Kingdom	RCT	P=10	EIC	NR	P=68.1
7	Kottenberg et al., 2011	Germany	RCT	I=19	EIC	72	65	Cardiac troponin, in-hospital mortality
7	Kottenberg et al., 2011	Germany	RCT	P=19	EIC	72	65	Cardiac troponin, in-hospital mortality
8	Parker et al., 2004	Australia	RCT	I=118	EIC	NR	66	Cardiac index, in-hospital mortality, MI, inotropic drug use, length of ICU stay, mechanical ventilation time
8	Parker et al., 2004	Australia	RCT	P=118	EIC	NR	66
9	Phillips et al., 1994	Ireland	RCT	I=31	EIC	NR	60	Cardiac index
9	Phillips et al., 1994	Ireland	RCT	P=33	EIC	NR	60	Cardiac index
10	Sorbara et al., 1995	Italy	RCT	I=15	EIC	67	60	Cardiac index, mechanical ventilation time
10	Sorbara et al., 1995	Italy	RCT	P=15	EIC	67	60	Cardiac index, mechanical ventilation time
11	Tempe et al., 2011	India	RCT	I=20	EIC	NR	I=53	Cardiac index, in-hospital mortality, MI, inotropic drug use, mechanical ventilation time
11	Tempe et al., 2011	India	RCT	P=20	EIC	NR	P=54
12	Xia et al., 2006	China	RCT	I=18	EIC	84	64	Cardiac index, cardiac troponin, MI, inotropic drug use, length of ICU stay, mechanical ventilation time
12	Xia et al., 2006	China	RCT	P=18	EIC	84	64
13	Yildrim et al., 2009	Turkey	RCT	I=20	EIC	2	68	Cardiac index, cardiac troponin, in-hospital mortality, MI, length of ICU stay, mechanical ventilation time
13	Yildrim et al., 2009	Turkey	RCT	P=20	EIC	2	68

Study nº	Author and year	Randomization process	Deviation from intended intervention	Missing outcome data	Measurement of the outcome	Selection of the reported results	Overall
1	El-Shobaki et al., 2002	Low	High	Low	High	High	High
2	Engoren et al., 1998	Low	Some concerns	High	High	High	High
3	Flier et al., 2010	Low	Some concerns	Low	Low	Low	Some concerns
4	Huang et al., 2011	Some concerns	High	Low	Low	Low	High
5	Imantalab et al., 2012	Some concerns	Some concerns	High	Low	Low	High
6	Kendall et al., 2004	Low	High	High	Low	Low	High
7	Kottenberg et al., 2011	Low	High	Some concerns	High	Low	High
8	Parker et al., 2004	Low	Low	High	High	High	High
9	Phillips et al., 1994	Low	Some concerns	High	High	Low	High
10	Sorbara et al., 1995	Low	High	Low	Low	Low	High
11	Tempe et al., 2011	Some concerns	Low	Low	Low	Low	Some concerns
12	Xia et al., 2006	Low	Low	High	High	Low	High
13	Yildrim et al., 2009	Some concerns	High	High	High	Low	High

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[1] Correspondence Address: Junran Xie, https://orcid.org/0000-0003-0853-8123, Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, People’s Republic of China, Zip Code: 310016, E-mail: xiejunran@zju.edu.cn