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CARDIOVASCULAR ANESTHESIA

Strict Thermoregulation Attenuates Myocardial Injury During Coronary Artery Bypass Graft Surgery as Reflected by Reduced Levels of Cardiac-Specific Troponin I

Nahum Nesher, MD^*, Eli Zisman, MD, Tamir Wolf, PhD^*, Ram Sharony, MD^*, Gil Bolotin, MD^*, Miriam David, DSc, Gideon Uretzky, MD^*, and Reuven Pizov, MD

*Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and Department of Anesthesiology and General Hospital Laboratories, Lady Davis Carmel Medical Center, Israel Technion, Haifa, Israel

Address correspondence and reprint requests to Nahum Nesher, MD, The Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, 6 Weitzman St., Tel Aviv 64269, Israel. Address e-mail to nnesher{at}netvision.net.il

We assessed the cardioprotective effects of perioperative maintenance of normothermia by determining the perioperative profile of troponin I, a highly cardiac-specific protein important in risk stratification of patients with acute ischemic events. Candidates for their primary coronary artery bypass grafting (CABG) were randomized into a new thermoregulation system group, Allon^TM thermoregulation (AT; n = 30), and a routine thermal care (RTC; n = 30) group. Anesthetic and operative techniques were similar in both groups. Intraoperative warming was applied before and after cardiopulmonary bypass (CPB) and up to 4 h after surgery. Perioperative temperature and hemodynamic data were recorded. Blood samples for creatine kinase (CK) and its isoform, MB (CK-MB), and for cardiac-specific troponin I (cTnI) were obtained at predetermined intervals throughout the entire operation. Core and skin temperatures were higher in the AT group at all time points. The systemic vascular resistance was lower and the cardiac index higher in the AT group at all intra- and postoperative time points. Increases in CK, CK-MB, and cTnI levels indicated intraoperative ischemic insult in all patients. The respective CK levels for the AT and RTC groups were 53.3 ± 22.7 IU/L and 47.9 ± 17.86 IU/L at the time of anesthesia and 64.7 ± 45.6 IU/L and 47.8 ± 19.4 IU/L 30 min after the onset of surgery, demonstrating thereafter a steep increase before the discontinuation of CPB. CK-MB mass concentrations in both groups behaved almost identically. Pre-CPB cTnI levels at anesthesia induction were 0.3 ± 0 ng/mL in both groups, followed by a distinctive profile observed after separation from CPB: 28.1 ± 11.4 ng/mL, 26.05 ± 9.20 ng/mL, and 22.3 ± 8.9 ng/mL at discontinuation from CPB, chest closure, and 2 h after surgery, respectively, in the RTC group, versus 0.6 ± 4.6 ng/mL, 6.6 ± 5.5 ng/mL, and 7.9 ± 4.76 ng/mL at these three time points, respectively, in the AT group (P < 0.01 between groups at the specified time points). Contrary to conventional thinking about the benefits of hypothermia, maintenance of normothermia throughout the non-CPB phases during CABG was demonstrated to be important in attenuating myocardial ischemic injury. Insofar as troponin I was more sensitive than other tested markers, it may provide important data on possible protection from myocardial insult and on other cardioprotective measures.

IMPLICATIONS: Maintenance of normothermia throughout the nonbypass phases of coronary artery bypass graft surgery is important in the attenuation of myocardial ischemic injury as assessed by intraoperative cardiac-specific troponin I measurements. It may also provide a method of assessing the efficacy of current cardioprotective strategies, as well as of future pharmacological and mechanical approaches.

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