OBJECTIVE: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN: A post hoc analysis of a randomized trial. SETTING: Cardiac surgical operating rooms. PARTICIPANTS: Patients undergoing elective, isolated CABG. INTERVENTIONS: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. MEASUREMENTS AND MAIN RESULTS: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.

5 Negovsky Reanimatology Research Institute Moscow Russia

Anesthesia Section Department of Cardiovascular Surgery Dante Pazzanese Institute of Cardiology São Paulo Brazil

Cardiothoracic Anesthesiology and Intensive Care Medicine Department of Anesthesiology and Intensive Care Medicine Institute for Clinical and Experimental Medicine Prague Czech Republic

Cardiothoracic ICU and Anesthesia Department Mohammed Bin Khalifa Cardiac Center Riffa Bahrain

Center for Anesthesiology Beijing Anzhen Hospital Capital Medical University Beijing China

Department of Anaesthesia and Intensive Care Cardiovascular Institute Dedinje Belgrade Serbia

Department of Anaesthesiology and Intensive Care Hospital Pulau Pinang Pulau Pinang Malaysia

Department of Anaesthesiology Faculty of Medicine University of Malaya Kuala Lumpur Malaysia

Department of Anaesthesiology Hospital de Santa Maria Lisboa Portugal

Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy

Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy; School of Medicine Vita Salute San Raffaele University Milan Italy

Department of Anesthesia and Intensive Care Ural Institute of Cardiology Ekaterinburg Russia

Department of Anesthesiology and Intensive Care 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Department of Anesthesiology and Intensive Care 1st Moscow State Medical University Moscow Russia; 5 Negovsky Reanimatology Research Institute Moscow Russia

Department of Anesthesiology and Intensive Care E Meshalkin National Medical Research Center Novosibirsk Russia

Department of Anesthesiology and Intensive Care E Meshalkin National Medical Research Center Novosibirsk Russia; Department of Anesthesiology and Intensive Care Novosibirsk State University Novosibirsk Russia

Department of Anesthesiology and Intensive Care Federal Center for Cardiovascular Surgery Astrakhan Astrakhan Russia

Department of Anesthesiology and Perioperative Medicine Xijing Hospital Xi'an Shaanxi China

Department of Anesthesiology College of Medicine Imam Abdulrahman Bin Faisal University Dammam Saudi Arabia

Department of Anesthesiology The 2nd Xiangya Hospital of Central South University Changsha China

Department of Cardiac Surgery Federal Center for Cardiovascular Surgery Astrakhan Astrakhan Russian Federation

Department of Cardiopneumology Instituto do Coração Universidade de São Paulo São Paulo Brazil; Intensive Care Unit Hospital SirioLibanes São Paulo Brazil

Department of Cardiovascular Anesthesiology and Intensive Care Medicine Clinical Department of Anesthesiology Resuscitation and Intensive Care Medicine University Hospital Dubrava Zagreb Croatia; Department of Biomedical Sciences University North Varazdin Croatia

Department of Medicine University of Udine Udine Italy; Department of Anesthesia and Intensive Care Medicine ASUFC University Hospital of Central Friuli Udine Italy

Federal Research and Clinical Center of Resuscitation and Rehabilitation Moscow Russia

Institute of Anesthesia and Intensive Care Padua University Hospital Padua Italy

Institute of Anesthesia and Intensive Care Padua University Hospital Padua Italy; Department of Medicine University of Padua Padua Italy

Intensive Care Unit Scientific Research Institute for Complex Issues of Cardiovascular Diseases Kemerovo Russia

Laboratory for Anesthesiology and Intensive Care Almazov National Medical Research Center Saint Petersburg Russia

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