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Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in
Elmar Berendes1, Christoph Schmidt, Hugo Van Aken
1Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum, Münster, Germany. berenel@uni-muenster.de
Insights
High thoracic epidural anesthesia (TEA) improved heart function and reduced cardiac injury markers in patients undergoing coronary artery bypass grafting. This anesthesia technique may enhance long-term outcomes after myocardial revascularization.
Area of Science:
- Cardiology
- Anesthesiology
- Cardiac Surgery
Background:
- Coronary artery bypass grafting (CABG) is a major surgical procedure.
- Maintaining myocardial function and reducing perioperative ischemia are critical for patient outcomes.
- Thoracic epidural anesthesia (TEA) has been explored for its potential cardioprotective effects.
Purpose of the Study:
- To evaluate the impact of high thoracic epidural anesthesia (TEA) on global and regional myocardial function.
- To assess the effect of high TEA on perioperative coronary risk in patients undergoing CABG.
- To determine if TEA improves postoperative outcomes and reduces myocardial damage.
Main Methods:
- A prospective, randomized clinical trial involving 73 patients with left ventricular ejection fraction ≥50% scheduled for CABG.
- Patients received either general anesthesia alone (control) or general anesthesia combined with high TEA (T1-T7 block).
- Regional left ventricular function was assessed using transesophageal echocardiography; plasma levels of cardiac troponin I and natriuretic peptides were measured. Postoperative complications and mortality were recorded.
Main Results:
- High TEA significantly improved regional left ventricular function (global wall motion index).
- Cardiac troponin I concentrations were reduced by 72% in the high TEA group.
- Peak concentrations of atrial and brain natriuretic peptides were significantly lower in the high TEA group, indicating reduced myocardial stress and ischemia.
Conclusions:
- High thoracic epidural anesthesia acts as a reversible cardiac sympathectomy, enhancing regional left ventricular function post-CABG.
- TEA effectively reduces postoperative myocardial ischemia and associated biomarkers.
- These findings suggest that high TEA may lead to improved long-term outcomes following myocardial revascularization.
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.
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