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CARDIOVASCULAR ANESTHESIA

The Effect of Insulin Cardioplegia on Atrial Fibrillation After High-Risk Coronary Bypass Surgery: A Double-Blinded, Randomized, Controlled Trial

Marja Hynninen, MD^*, Michael A. Borger, MD, Vivek Rao, MD, PhD, Richard D. Weisel, MD, George T. Christakis, MD^§, Jo-Ann Carroll, RN^*, and Davy C. H. Cheng, MD^*

*Division of Cardiac Anesthesia and Intensive Care, and Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; and §Division of Cardiovascular Surgery, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada

Address correspondence and reprint requests to Davy Cheng, MD, Division of Cardiac Anesthesia and Intensive Care, Toronto General Hospital, University Health Network, 200 Elizabeth Street, EN3-464, Toronto, Ontario, Canada M5G 2C4. Address e-mail to davy.cheng{at}uhn.on.ca

Atrial fibrillation after coronary bypass (CABG) surgery is an important cause of morbidity and increased resource utilization. Insulin-enhanced cardioplegia may reduce postoperative arrhythmias by improving aerobic myocardial metabolism and mitigating the deleterious effects of ischemia. We performed a double-blinded, randomized, controlled clinical trial to determine if insulin-enhanced cardioplegia decreases the risk of post-CABG atrial fibrillation in a high-risk patient population. We randomized 501 patients undergoing urgent CABG to receive insulin-enhanced (Humulin R 10 IU/L, Insulin group, n = 243) or standard (Control group, n = 258) blood cardioplegia during cardiopulmonary bypass. Patients were monitored by using continuous electrocardiography for a minimum of 3 days postoperatively. All standard cardiac medications, including ß-adrenergic blockers, were continued postoperatively. Insulin-enhanced cardioplegia did not result in a significant reduction in postoperative atrial fibrillation. Furthermore, we failed to detect a difference in the incidence of conduction defects, ventricular tachycardia, or pacemaker requirements between insulin and placebo patients. Atrial fibrillation was the most common arrhythmia, occurring in 31% of all patients. Independent predictors of atrial fibrillation were elderly age, preoperative atrial fibrillation, and renal insufficiency. Right bundle branch block was the most common conduction abnormality. Predictors of right bundle branch block were elderly age, female sex, and circumflex coronary artery disease. The incidence of postoperative ventricular tachycardia, left bundle branch block, and permanent pacemaker requirement was small. We conclude that insulin-enhanced cardioplegia does not reduce the incidence of postoperative atrial fibrillation in high-risk CABG patients.

Implications: We conducted a double-blinded, randomized, placebo-controlled trial of insulin-enhanced cardioplegia in 501 patients undergoing urgent coronary bypass surgery. Insulin did not decrease the incidence of postoperative atrial fibrillation when compared with placebo. We also failed to demonstrate a difference in the incidence of other postoperative arrhythmias between the two groups of patients.

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999