J Thorac Cardiovasc Surg 2006;131:252-253
© 2006 The American Association for Thoracic Surgery
Anesthetic preconditioning as the alternative to ischemic preconditioning
Markus Lange, MD,
Norbert Roewer, MD, PhD,
Franz Kehl, MD, PhD, DEAA
Department of Anesthesiology, University of Würzburg, Würzburg, Germany
To the Editor:
We read with interest the article by Canyon and Dobson
1
presenting a combination of the adenosine A1 agonist 2-chloro-N6-cyclopentyladenosine (CCPA) and lidocaine as a possibly useful alternative to ischemic preconditioning in the clinical setting. As Canyon and Dobson
1
state, "A goal for more than 2 decades has been to develop a pharmacologic mimetic of IPC [ischemic preconditioning] to protect the heart during acute regional ischemia." Canyon and Dobson
1
unfortunately did not mention that volatile anesthetics are potent triggers of preconditioning, especially in the perioperative setting. Volatile anesthetic-induced preconditioning leads to a profound infarct size reduction, as effectively as does ischemic preconditioning,
2
and follows a dose-response relationship.
3
Desflurane, enflurane, halothane, isoflurane, and sevoflurane induce anesthetic preconditioning.
4,5
Apart from these experimental data, there is clear evidence for preconditioning by volatile anesthetics in human beings. Recent clinical studies indicate that volatile anesthetics confer cardioprotective effects in high-risk patients undergoing coronary surgery.
6-8
Sevoflurane-induced preconditioning has been seen to preserve myocardial function and decrease troponin I levels after cardiopulmonary bypass
7
and even to reduce the incidence of late adverse cardiac events during the first year after surgery.
8
Canyon and Dobson
1
emphasized that coadministration of lidocaine and CCPA was able to prevent life-threatening arrhythmias during ischemia and reperfusion. Again, volatile anesthetics show similar qualities: anesthetic preconditioning significantly reduces arrhythmias after ischemic periods.
9
Stimulation of adenosine A1 receptors, among other membrane receptors, is part of the signal transduction pathway of anesthetic preconditioning.
10
Therefore, it is unlikely that the administration of a selective adenosine A1 agonist in addition to a volatile anesthetic would further enhance cardioprotection. Canyon and Dobson
1
suggest intracoronary administration of CCPA and lidocaine for percutaneous interventions, off-pump and on-pump heart surgery, and perioperative applications. Apart from percutaneous coronary interventions, patients are anesthetized throughout these procedures. An inhalational anesthetic regimen would therefore appear to be the method of choice for patients at risk for perioperative ischemia because it would confer profound cardioprotection without the need for potentially deleterious additional intracoronary medication. Patients undergoing percutaneous coronary interventions might benefit from emulsified volatile anesthetics, administered intravenously at subanesthetic doses, in the near future.
11
In conclusion, there is a large body of evidence demonstrating that volatile anesthetics effectively induce cardioprotection, to the benefit of high-risk cardiac patients. Therefore, the need for adjuvant CCPA or lidocaine administered additionally to a patient already being protected by volatile anesthetics is questionable and remains to be proven.
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References
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- Garcia C, Julier K, Bestmann L, Zollinger A, von Segesser LK, Pasch T, et al. Preconditioning with sevoflurane decreases PECAM-1 expression and improves one-year cardiovascular outcome in coronary artery bypass graft surgery. Br J Anaesth 2005;94:159-165.[Abstract/Free Full Text]
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- Kersten JR, Orth KG, Pagel PS, Mei DA, Gross GJ, Warltier DC. Role of adenosine in isoflurane-induced cardioprotection. Anesthesiology 1997;86:1128-1139.[Medline]
- Chiari PC, Pagel PS, Tanaka K, Krolikowski JG, Ludwig LM, Trillo Jr RA, et al. Intravenous emulsified halogenated anesthetics produce acute and delayed preconditioning against myocardial infarction in rabbits. Anesthesiology 2004;101:1160-1166.[Medline]
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References