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Reversible Cardiac Sympathectomy by High Thoracic Epidural Anesthesia Improves Regional Left Ventricular Function in Patients Undergoing Coronary Artery Bypass Grafting
A Randomized Trial
Elmar Berendes, MD;
Christoph Schmidt, MD;
Hugo Van Aken, MD, PhD;
Maike Grosse Hartlage, MD;
Stefan Wirtz, MD;
Holger Reinecke, MD;
Markus Rothenburger, MD;
Hans Heinrich Scheld, MD;
Bernhard Schlüter, MD;
Gerhard Brodner, MD;
Michael Walter, MD
Arch Surg. 2003;138:1283-1290.
Hypothesis To evaluate the effects of high thoracic epidural anesthesia (TEA) on global and regional myocardial function and on perioperative coronary risk in patients undergoing coronary artery bypass grafting.
Design, Setting, and Patients Prospective and randomized clinical trial blinded for the primary outcome measure of 73 patients scheduled for coronary artery bypass grafting who had a left ventricular ejection fraction of 50% or more conducted from February 1, 2000, through August 31, 2000, at University Hospital, Münster, Germany.
Interventions Of 73 randomized patients, 37 were control subjects (who received general anesthesia only) and 36 were in the group who received general anesthesia and high TEA.
Main Outcome Measures The primary outcome measure was regional left ventricular function after myocardial revascularization, assessed by transesophageal echocardiography. We further determined the plasma concentrations of cardiac troponin I and atrial and brain natriuretic peptides. Secondary outcome measures were postoperative complications recorded to 14 days and mortality recorded to 720 days.
Results High TEA was effective in all patients of this group, the somatosensory block extended from T1 through T7 vertebrae. Regional left ventricular function was significantly improved (mean [SD] global wall motion index, 0.74 [0.18] vs 0.38 [0.16]; P<.05), and cardiac troponin I concentrations were reduced by 72% (mean [SD], 5.7 [1.5] vs 1.6 [0.7] ng/mL, P<.05) in patients with high TEA. Natriuretic peptide concentrations peaked during reperfusion (atrial natriuretic peptide) and 24 hours after reperfusion (brain natriuretic peptide). High TEA reduced the mean (SD) peak concentrations of atrial natriuretic peptide by 54% (211 [63] vs 98 [33] ng/mL, P = .03) and brain natriuretic peptide by 43% (189 [39] vs 108 [21] ng/mL, P = .01). One of 36 patients who received high TEA and 3 of 37 controls died.
Conclusions Reversible cardiac sympathectomy by high TEA improves regional left ventricular function and reduces postoperative ischemia after coronary artery bypass grafting. These effects of high TEA may improve the long-term outcome after myocardial revascularization.
From the Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin (Drs Berendes, Schmidt, Van Aken, Gross Hartlage, Wirtz, and Brodner), the Medizinische Klinik und Poliklinik C (Dr Reinecke), the Klinik und Poliklinik für Herz-, Thorax- und Gefässchirurgie (Drs Rothenburger and Scheld), the Institut für Klinische Chemie und Laboratoriumsmedizin (Dr Schlüter), Universitätsklinikum, Münster, Germany; and the Department of Biochemistry, Southwestern Medical Center at Dallas, Dallas, Tex (Dr Walter).
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