Sevoflurane Versus Total Intravenous Anesthesia for Isolated Coronary Artery Bypass Surgery With Cardiopulmonary Bypass: A Randomized Trial


      Several studies have suggested that the cardioprotective effects of halogenated anesthetics in cardiac surgery result in reduced cardiac biomarker release compared with total intravenous anesthesia (TIVA). These findings came from relatively small randomized clinical trials and meta-analyses. The authors of this study hypothesized that the beneficial effects of volatile anesthetics translate into a reduced length of hospital stay after coronary artery bypass grafting surgery (CABG) with cardiopulmonary bypass.


      A randomized controlled trial.


      Two university hospitals.


      Adult patients undergoing elective CABG surgery with cardiopulmonary bypass.


      Patients were assigned randomly to 2 following groups: propofol-based TIVA group (n = 431) and sevoflurane group (n = 437).

      Measurements and Main Results

      The primary endpoint was hospital length of stay, and the secondary endpoint included postoperative troponin T and N-terminal pro-brain natriuretic peptide release and mortality. In the sevoflurane group, a reduced length of hospital stay was observed compared with the propofol-based TIVA group (10 [9–11] days v 14 [10–16], p<0.001) as were reductions in cardiac troponin T release (0.18 ng/mL v 0.57 ng/mL at 24 hours, p<0.001), in N-terminal pro-brain natriuretic peptide release (633 pg/mL v 878 pg/mL at 24 hours, p<0.001; 482 pg/mL v 1,036 pg/mL at 48 hours, p<0.001), and in mortality at 1-year follow up (17.8% v 24.8%, p = 0.03).


      Anesthesia with sevoflurane reduced cardiac biomarker release and length of hospital stay after CABG with cardiopulmonary bypass surgery compared with propofol-based TIVA with a possible reduction in 1-year mortality.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Herbertson M.
        Recombinant activated factor VII in cardiac surgery.
        Blood Coagul Fibrinolysis. 2004; : S31-S32
        • Ferguson Jr, T.B.
        • Hammill B.G.
        • Peterson E.D.
        • et al.
        A decade of change—risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990-1999: A report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons.
        Ann Thorac Surg. 2002; 73: 480-489
        • Landoni G.
        • Rodseth R.N.
        • Santini F.
        • et al.
        Randomized evidence for reduction of perioperative mortality.
        J Cardiothorac Vasc Anesth. 2012; 26: 764-772
        • Oliveira M.A.
        • Brandi A.C.
        • Santos C.A.
        • et al.
        Modes of induced cardiac arrest: Hyperkalemia and hypocalcemia—literature review.
        Rev Bras Cir Cardiovasc. 2014; 29: 432-436
        • DiNardo J.A.
        • Zvara D.A.
        Myocardial preservation during cardiopulmonary bypass.
        in: DiNardo J.A. Zvara D.A. Anesthesia for cardiac surgery. Blackwell Publishing, Oxford, UK2008: 409-424
        • Warltier D.C.
        • Pagel P.S.
        • Kersten J.R.
        Approaches to the prevention of perioperative myocardial ischemia.
        Anesthesiology. 2000; 92: 253-259
        • Cason B.A.
        • Gamperl A.K.
        • Slocum R.E.
        • et al.
        Anesthetic-induced preconditioning: Previous administration of isoflurane decreases myocardial infarct size in rabbits.
        Anesthesiology. 1997; 87: 1182-1190
        • Landoni G.
        • Fochi O.
        • Bignami E.
        • et al.
        Cardiac protection by volatile anesthetics in non-cardiac surgery? A meta-analysis of randomized controlled studies on clinically relevant endpoints.
        HSR Proc Intensive Care Cardiovasc Anesth. 2009; 1: 34-43
        • Soro M.
        • Gallego L.
        • Silva V.
        • et al.
        Cardioprotective effect of sevoflurane and propofol during anaesthesia and the postoperative period in coronary bypass graft surgery: A double-blind randomised study.
        Eur J Anaesthesiol. 2012; 29: 561-569
        • Bein B.
        • Renner J.
        • Caliebe D.
        • et al.
        Sevoflurane but not propofol preserves myocardial function during minimally invasive direct coronary artery bypass surgery.
        Anesth Analg. 2005; 100: 610-616
        • De Hert S.G.
        • Van der Linden P.J.
        • Cromheecke S.
        • et al.
        Choice of primary anesthetic regimen can influence intensive care unit length of stay after coronary surgery with cardiopulmonary bypass.
        Anesthesiology. 2004; 101: 9-20
        • Julier K.
        • da Silva R.
        • Garcia C.
        • et al.
        Preconditioning by sevoflurane decreases biochemical markers for myocardial and renal dysfunction in coronary artery bypass graft surgery: A double-blinded, placebo-controlled, multicenter study.
        Anesthesiology. 2003; 98: 1315-1327
        • De Hert S.G.
        • Cromheecke S.
        • ten Broecke P.W.
        • et al.
        Effects of propofol, desflurane, and sevoflurane on recovery of myocardial function after coronary surgery in elderly high-risk patients.
        Anesthesiology. 2003; 99: 314-323
        • Cromheecke S.
        • Pepermans V.
        • Hendrickx E.
        • et al.
        Cardioprotective properties of sevoflurane in patients undergoing aortic valve replacement with cardiopulmonary bypass.
        Anesth Analg. 2006; 103: 289-296
        • De Hert S.G.
        • Van der Linden P.J.
        • Cromheecke S.
        • et al.
        Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with cardiopulmonary bypass are related to the modalities of its administration.
        Anesthesiology. 2004; 101: 299-310
        • Guarracino F.
        • Landoni G.
        • Tritapepe L.
        • et al.
        Myocardial damage prevented by volatile anesthetics: A multicenter randomized controlled study.
        J Cardiothorac Vasc Anesth. 2006; 20: 477-483
        • Pagel P.S.
        Myocardial protection by volatile anesthetics in patients undergoing cardiac surgery: a critical review of the laboratory and clinical evidence.
        J Cardiothorac Vasc Anesth. 2013; 27: 972-982
        • Kunst G.
        • Klein A.A.
        Peri-operative anaesthetic myocardial preconditioning and protection - cellular mechanisms and clinical relevance in cardiac anaesthesia.
        Anaesthesia. 2015; 70: 467-482
        • Bignami E.
        • Landoni G.
        • Gerli C.
        • et al.
        Sevoflurane vs. propofol in patients with coronary disease undergoing mitral surgery: A randomised study.
        Acta Anaesthesiol Scand. 2012; 56: 482-490
        • De Hert S.
        • Vlasselaers D.
        • Barbé R.
        • et al.
        A comparison of volatile and non volatile agents for cardioprotection during on-pump coronary surgery.
        Anaesthesia. 2009; 64: 953-960
        • Jakobsen C.J.
        • Berg H.
        • Hindsholm K.B.
        • et al.
        The influence of propofol versus sevoflurane anesthesia on outcome in 10,535 cardiac surgical procedures.
        J Cardiothorac Vasc Anesth. 2007; 21: 664-671
        • Yao Y.T.
        • Li L.H.
        Sevoflurane versus propofol for myocardial protection in patients undergoing coronary artery bypass grafting surgery: A meta-analysis of randomized controlled trials.
        Chin Med Sci J. 2009; 24: 133-141
        • Landoni G.
        • Greco T.
        • Biondi-Zoccai G.
        • et al.
        Anaesthetic drugs and survival: A Bayesian network meta-analysis of randomized trials in cardiac surgery.
        Br J Anaesth. 2013; 111: 886-896
        • Landoni G.
        • Biondi-Zoccai G.G.
        • Zangrillo A.
        • et al.
        Desflurane and sevoflurane in cardiac surgery: A meta-analysis of randomized clinical trials.
        J Cardiothorac Vasc Anesth. 2007; 21: 502-511
        • Kohro S.
        • Hogan Q.H.
        • Nakae Y.
        • et al.
        Anesthetic effects on mitochondrial ATP-sensitive K channel.
        Anesthesiology. 2001; 95 (1435-340): 1435-1440
        • Borisov K.Y.
        • Moroz V.V.
        • Grebenchikov O.A.
        • et al.
        Effect of propofol on sevoflurane-induced myocardial preconditioning in the experiment.
        Gen Reanimatol IX. 2013; : 30-35
        • Pasin L.
        • Landoni G.
        • Cabrini L.
        • et al.
        Propofol and survival: A meta-analysis of randomized clinical trials.
        Acta Anaesthesiol Scand. 2015; 59: 17-24
        • Tritapepe L.
        • Landoni G.
        • Guarracino F.
        • et al.
        Cardiac protection by volatile anaesthetics: A multicentre randomized controlled study in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.
        Eur J Anaesthesiol. 2007; 24: 323-331
        • Garcia C.
        • Julier K.
        • Bestmann L.
        • 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
        • Nozohoor S.
        • Nilsson J.
        • Algotsson L.
        • et al.
        Postoperative increase in B-type natriuretic peptide levels predicts adverse outcome after cardiac surgery.
        J Cardiothorac Vasc Anesth. 2011; 25: 469-475
        • Nigro Neto C.
        • Costa E.
        • Rossi R.
        • et al.
        Inhalation induction with sevoflurane in adult cardiac surgery patients. A case series.
        Heart Lung Vessel. 2014; 6: 8-12
        • Thielmann M.
        • Kottenberg E.
        • Kleinbongard P.
        • et al.
        Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery: A single-centre randomised, double-blind, controlled trial.
        Lancet. 2013; 382: 597-604
        • Zarbock A.
        • Schmidt C.
        • Van Aken H.
        • et al.
        Effect of remote ischemic preconditioning on kidney injury among high-risk patients undergoing cardiac surgery: A randomized clinical trial.
        JAMA. 2015; 313: 2133-2141
        • Zangrillo A.
        • Musu M.
        • Greco T.
        • et al.
        Additive effect on survival of anaesthetic cardiac protection and remote ischemic preconditioning in cardiac surgery: A Bayesian network meta-analysis of randomized trials.
        PLoS One. 2015; 10: e0134264
        • Hausenloy D.J.
        • Candilio L.
        • Evans R.
        • et al.
        Remote ischemic preconditioning and outcomes of cardiac surgery.
        N Engl J Med. 2015; 373: 1408-1417
        • Meybohm P.
        • Bein B.
        • Brosteanu O.
        • et al.
        A multicenter trial of remote ischemic preconditioning for heart surgery.
        N Engl J Med. 2015; 373: 1397-1407
        • Landoni G.
        • Baiardo Redaelli M.
        • Votta C.D.
        Remote ischemic preconditioning and cardiac surgery.
        N Engl J Med. 2016; 374: 489
        • Bein B.
        • Renner J.
        • Caliebe D.
        • et al.
        The effects of interrupted or continuous administration of sevoflurane on preconditioning before cardio-pulmonary bypass in coronary artery surgery: Comparison with continuous propofol.
        Anaesthesia. 2008; 63: 1046-1055
        • Jovic M.
        • Stancic A.
        • Nenadic D.
        • et al.
        Mitochondrial molecular basis of sevoflurane and propofol cardioprotection in patients undergoing aortic valve replacement with cardiopulmonary bypass.
        Cell Physiol Biochem. 2012; 29: 131-142
        • Huang Z.
        • Zhong X.
        • Irwin M.G.
        • et al.
        Synergy of isoflurane preconditioning and propofol postconditioning reduces myocardial reperfusion injury in patients.
        ClinSci (Lond). 2011; 121: 57-69