Isoflurane's Effect on Intraoperative Systolic Left Ventricular Performance in Cardiac Valve Surgery Patients

Ju Deok Kim, Ilsoon Son, Won Kyoung Kwon, Tae Yun Sung, Hanafi Sidik, Karam Kim, Hyun Kang, Jiyon Bang, Gwi Eun Yeo, Dong Kyu Lee, Tae Yop Kim, Ju Deok Kim, Ilsoon Son, Won Kyoung Kwon, Tae Yun Sung, Hanafi Sidik, Karam Kim, Hyun Kang, Jiyon Bang, Gwi Eun Yeo, Dong Kyu Lee, Tae Yop Kim

Abstract

Background: Isoflurane, a common anesthetic for cardiac surgery, reduced myocardial contractility in many experimental studies, few studies have determined isoflurane's direct impact on the left ventricular (LV) contractile function during cardiac surgery. We determined whether isoflurane dose-dependently reduces the peak systolic velocity of the lateral mitral annulus in tissue Doppler imaging (S') in patients undergoing cardiac surgery.

Methods: During isoflurane-supplemented remifentanil-based anesthesia for patients undergoing cardiac surgery with preoperative LV ejection fraction greater than 50% (n = 20), we analyzed the changes of S' at each isoflurane dose increment (1.0, 1.5, and 2.0 minimum alveolar concentration [MAC]: T1, T2, and T3, respectively) with a fixed remifentanil dosage (1.0 μg/min/kg) by using transesophageal echocardiography.

Results: Mean S' values (95% confidence interval [CI]) at T1, T2, and T3 were 10.5 (8.8-12.2), 9.5 (8.3-10.8), and 8.4 (7.3-9.5) cm/s, respectively (P < 0.001 in multivariate analysis of variance test). Their mean differences at T1 vs. T2, T2 vs. T3, and T1 vs. T3 were -1.0 (-1.6, -0.3), -1.1 (-1.7, -0.6), and -2.1 (-3.1, -1.1) cm/s, respectively. Phenylephrine infusion rates were significantly increased (0.26, 0.22, and 0.47 μg/kg/min at T1, T2, and T3, respectively, P < 0.001).

Conclusion: Isoflurane increments (1.0-2.0 MAC) dose-dependently reduced LV systolic long-axis performance during cardiac surgeries with a preserved preoperative systolic function.

Trial registration: ClinicalTrials.gov NCT01819012.

Keywords: Echocardiography; Heart function test; Isoflurane.

Conflict of interest statement

The authors have no potential conflicts of interest to disclose.

© 2018 The Korean Academy of Medical Sciences.

Figures

Fig. 1
Fig. 1
Patient recruitment and analysis diagram. Twenty-one patients were recruited and one was excluded due to the failure to align Doppler beam parallel to the axis of the lateral annular motion during the entire systolic period. LVEF = left ventricular ejection fraction, TTE = transthoracic echocardiography, TEE = transesophageal echocardiography, MAC = minimum alveolar concentration, BIS = Bispectral index, MV = mitral valve, TDI = tissue Doppler imaging, BP = blood pressure, HR = heart rate, bpm = beat per minute.
Fig. 2
Fig. 2
Correlation and agreement of the first and second measurements of TDI parameters. Measure 1: first measurements of each variable. Measure 2: second measurements of each variable. The solid line shows the mean difference and the dash lines show the LOAs (mean difference ± 1.96 standard deviations). TDI = tissue Doppler imaging, S′ = peak velocity of the lateral mitral annulus during systole, e′ = peak velocity of tissue Doppler imaging mitral annulus during early relaxation, a′ = peak velocity of mitral annular TDI during late atrial contraction, LOA = limits of agreement, T1, T2, and T3 = after 10-minute-exposure to isoflurane 1.0, 1.5, and 2.0 MAC, respectively, MAC = minimum alveolar concentration.
Fig. 3
Fig. 3
S′, e′, a′, and BIS during the increments of isoflurane dosage. The boxes show the 25th and 75th percentiles, and horizontal lines within the box show median values. The whiskers show the lowest and highest values in the 25th percentile minus 1.5 IQR and 75th percentile plus 1.5 IQR regions, respectively. The optimal hypnosis level for general anesthesia is a BIS value between 40 and 60. S′ = peak velocity of the lateral mitral annulus during systole, e′ = peak velocity of tissue Doppler imaging mitral annulus during early relaxation, a′ = peak velocity of tissue Doppler imaging mitral annulus during late atrial contraction, BIS = Bispectral index, IQR = interquartile range, T1, T2, and T3 = after 10-minute-exposure to isoflurane 1.0, 1.5, and 2.0 MAC, respectively, MAC = minimum alveolar concentration. aP < 0.05 vs. T1; bP < 0.05 vs. T2.

References

    1. Pagel PS, Kampine JP, Schmeling WT, Warltier DC. Evaluation of myocardial contractility in the chronically instrumented dog with intact autonomic nervous system function: effects of desflurane and isoflurane. Acta Anaesthesiol Scand. 1993;37(2):203–210.
    1. Hannon JD, Cody MJ, Sun DX, Housmans PR. Effects of isoflurane and sevoflurane on intracellular calcium and contractility in pressure-overload hypertrophy. Anesthesiology. 2004;101(3):675–686.
    1. Yang HS, Song BG, Kim JY, Kim SN, Kim TY. Impact of propofol anesthesia induction on cardiac function in low-risk patients as measured by intraoperative Doppler tissue imaging. J Am Soc Echocardiogr. 2013;26(7):727–735.
    1. Yang HS, Kim TY, Bang S, Yu GY, Oh C, Kim SN, et al. Comparison of the impact of the anesthesia induction using thiopental and propofol on cardiac function for non-cardiac surgery. J Cardiovasc Ultrasound. 2014;22(2):58–64.
    1. Kwon WK, Sung TY, Yu GY, Sidik H, Kang WS, Lee Y, et al. Effects of sevoflurane increments on left ventricular systolic long-axis performance during sevoflurane-remifentanil anesthesia for cardiovascular surgery. J Anesth. 2016;30(2):223–231.
    1. Bergquist BD, Leung JM, Bellows WH. Transesophageal echocardiography in myocardial revascularization: I. Accuracy of intraoperative real-time interpretation. Anesth Analg. 1996;82(6):1132–1138.
    1. Isaaz K, Thompson A, Ethevenot G, Cloez JL, Brembilla B, Pernot C. Doppler echocardiographic measurement of low velocity motion of the left ventricular posterior wall. Am J Cardiol. 1989;64(1):66–75.
    1. Skubas N. Intraoperative Doppler tissue imaging is a valuable addition to cardiac anesthesiologists' armamentarium: a core review. Anesth Analg. 2009;108(1):48–66.
    1. Yamada H, Oki T, Tabata T, Iuchi A, Ito S. Assessment of left ventricular systolic wall motion velocity with pulsed tissue Doppler imaging: comparison with peak dP/dt of the left ventricular pressure curve. J Am Soc Echocardiogr. 1998;11(5):442–449.
    1. Tabata T, Cardon LA, Armstrong GP, Fukamach K, Takagaki M, Ochiai Y, et al. An evaluation of the use of new Doppler methods for detecting longitudinal function abnormalities in a pacing-induced heart failure model. J Am Soc Echocardiogr. 2003;16(5):424–431.
    1. Sohn DW, Chai IH, Lee DJ, Kim HC, Kim HS, Oh BH, et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol. 1997;30(2):474–480.
    1. Yu CM, Sanderson JE, Marwick TH, Oh JK. Tissue Doppler imaging a new prognosticator for cardiovascular diseases. J Am Coll Cardiol. 2007;49(19):1903–1914.
    1. Swaminathan M, Nicoara A, Phillips-Bute BG, Aeschlimann N, Milano CA, Mackensen GB, et al. Utility of a simple algorithm to grade diastolic dysfunction and predict outcome after coronary artery bypass graft surgery. Ann Thorac Surg. 2011;91(6):1844–1850.
    1. Reichek N, Wilson J, St John Sutton M, Plappert TA, Goldberg S, Hirshfeld JW. Noninvasive determination of left ventricular end-systolic stress: validation of the method and initial application. Circulation. 1982;65(1):99–108.
    1. Sunagawa K, Maughan WL, Burkhoff D, Sagawa K. Left ventricular interaction with arterial load studied in isolated canine ventricle. Am J Physiol. 1983;245(5 Pt 1):H773–H780.
    1. Chahal NS, Lim TK, Jain P, Chambers JC, Kooner JS, Senior R. Normative reference values for the tissue Doppler imaging parameters of left ventricular function: a population-based study. Eur J Echocardiogr. 2010;11(1):51–56.
    1. Nikitin NP, Witte KK, Thackray SD, de Silva R, Clark AL, Cleland JG. Longitudinal ventricular function: normal values of atrioventricular annular and myocardial velocities measured with quantitative two-dimensional color Doppler tissue imaging. J Am Soc Echocardiogr. 2003;16(9):906–921.
    1. Nickalls RW, Mapleson WW. Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane in man. Br J Anaesth. 2003;91(2):170–174.
    1. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1(8476):307–310.
    1. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8(2):135–160.
    1. Wong GT, Li R, Jiang LL, Irwin MG. Remifentanil post-conditioning attenuates cardiac ischemia-reperfusion injury via κ or δ opioid receptor activation. Acta Anaesthesiol Scand. 2010;54(4):510–518.
    1. Greco M, Landoni G, Biondi-Zoccai G, Cabrini L, Ruggeri L, Pasculli N, et al. Remifentanil in cardiac surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2012;26(1):110–116.
    1. Lison S, Schill M, Conzen P. Fast-track cardiac anesthesia: efficacy and safety of remifentanil versus sufentanil. J Cardiothorac Vasc Anesth. 2007;21(1):35–40.
    1. Bolliger D, Seeberger MD, Kasper J, Skarvan K, Seeberger E, Lurati Buse G, et al. Remifentanil does not impair left ventricular systolic and diastolic function in young healthy patients. Br J Anaesth. 2011;106(4):573–579.
    1. Haluska BA, Short L, Marwick TH. Relationship of ventricular longitudinal function to contractile reserve in patients with mitral regurgitation. Am Heart J. 2003;146(1):183–188.
    1. Katz WE, Gulati VK, Mahler CM, Gorcsan J., 3rd Quantitative evaluation of the segmental left ventricular response to dobutamine stress by tissue Doppler echocardiography. Am J Cardiol. 1997;79(8):1036–1042.
    1. Yamada E, Garcia M, Thomas JD, Marwick TH. Myocardial Doppler velocity imaging--a quantitative technique for interpretation of dobutamine echocardiography. Am J Cardiol. 1998;82(6):806–809.
    1. Nitzschke R, Wilgusch J, Kersten JF, Trepte CJ, Haas SA, Reuter DA, et al. Bispectral index guided titration of sevoflurane in on-pump cardiac surgery reduces plasma sevoflurane concentration and vasopressor requirements: a prospective, controlled, sequential two-arm clinical study. Eur J Anaesthesiol. 2014;31(9):482–490.
    1. Manyam SC, Gupta DK, Johnson KB, White JL, Pace NL, Westenskow DR, et al. When is a bispectral index of 60 too low?: rational processed electroencephalographic targets are dependent on the sedative-opioid ratio. Anesthesiology. 2007;106(3):472–483.
    1. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–1049.
    1. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):e159–e241.
    1. Amà R, Segers P, Roosens C, Claessens T, Verdonck P, Poelaert J. The effects of load on systolic mitral annular velocity by tissue Doppler imaging. Anesth Analg. 2004;99(2):332–338.
    1. Drighil A, Madias JE, Mathewson JW, El Mosalami H, El Badaoui N, Ramdani B, et al. Haemodialysis: effects of acute decrease in preload on tissue Doppler imaging indices of systolic and diastolic function of the left and right ventricles. Eur J Echocardiogr. 2008;9(4):530–535.
    1. Storaa C, Aberg P, Lind B, Brodin LA. Effect of angular error on tissue Doppler velocities and strain. Echocardiography. 2003;20(7):581–587.
    1. Hanekom L, Cho GY, Leano R, Jeffriess L, Marwick TH. Comparison of two-dimensional speckle and tissue Doppler strain measurement during dobutamine stress echocardiography: an angiographic correlation. Eur Heart J. 2007;28(14):1765–1772.
    1. Vinereanu D, Khokhar A, Tweddel AC, Cinteza M, Fraser AG. Estimation of global left ventricular function from the velocity of longitudinal shortening. Echocardiography. 2002;19(3):177–185.
    1. Alam M, Wardell J, Andersson E, Samad BA, Nordlander R. Effects of first myocardial infarction on left ventricular systolic and diastolic function with the use of mitral annular velocity determined by pulsed wave Doppler tissue imaging. J Am Soc Echocardiogr. 2000;13(5):343–352.

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