Echocardiographic evaluation and comparison of the effects of isoflurane, sevoflurane and desflurane on left ventricular relaxation indices in patients with diastolic dysfunction

Abstract

This prospective randomized study aims to evaluate and compare the effects of isoflurane, sevoflurane and desflurane (study drugs) on left ventricular (LV) diastolic function in patients with impaired LV relaxation due to ischemic heart disease using transesophageal Doppler echocardiography. After approval of the local ethics committee and informed consent, 45 patients scheduled for coronary artery bypass grafting surgery were enrolled in the study. Patients were selected by a preoperative Transthoracic Echocardiographic diagnosis of impaired relaxation or Grade 1 Diastolic Dysfunction. They randomly received fentanyl and midazolam anesthesia with 1 MAC of isoflurane (n=16), sevoflurane (n=14) or desflurane (n=15). Hemodynamic parameters and TEE derived ventricular diastolic relaxation indices before and after the study drug administration were compared. LV filling pressures were kept constant throughout the study period to exclude the effect of the loading conditions on diastolic function. Four patients in the sevoflurane group and three in the desflurane group were excluded from the study, after baseline TEE examination revealed normal diastolic filling pattern. All the three study drugs significantly reduced the systemic vascular resistance index with a significant increase in cardiac index. Mean arterial pressure was reduced by all the drugs, although the decrease was not statistically significant. Hemodynamic changes were comparable between all the three groups. In terms of LV relaxation indices, all three agents led to a significant improvement in diastolic function. Transmitral and Tissue Doppler E/A and Em/Am ratios improved significantly Transmitral and Tissue Doppler E/A and Em/Am ratios improved significantly accompanied by a significant decrease in deceleration time and isovolumetric relaxation time. The effect of all three agents on diastolic relaxation parameters was comparable. In conclusion , Isoflurane, sevoflurane and desflurane, do not appear to have a detrimental effect in patients with early diastolic dysfunction. On the contrary, these inhalational agents actually improve the LV relaxation. A significant reduction in afterload produced by these vapors can be a possible reason for these findings. The positive effect of these inhalational agents on LV relaxation can have a profound effect on the perioperative anesthetic management of patients with diastolic dysfunction.

Perioperative management of left ventricular diastolic dysfunction and heart failure: an anesthesiologist's perspective

“…Sevoflurane during spontaneous ventilation preserves diastolic relaxation better than propofol, but there are no differences between them regarding diastolic function during positive pressure ventilation through balanced anesthesia [ 75 ]. The common volatile agents (sevoflurane, desflurane, isoflurane), IV anesthetics (propofol, midazolam), and opioids (morphine, remifentanil) have no significant effects on diastolic performance in healthy people, unlike some animal models [ 76 77 ]. However, in high-risk DHF patients, anesthesiologists should avoid acute changes in hemodynamic load conditions, heart rate, and myocardial oxygen balance.…”

TAPB and RSB protects cardiac diastolic function in elderly patients undergoing abdominopelvic surgery: a retrospective cohort study

“…In patients without diastolic dysfunction before operation, inhaled anesthetics could impair left ventricular diastolic function (Sarkar, GuhaBiswas & Rupert, 2010). However, many clinical studies have shown that patients with left ventricular diastolic dysfunction before anesthesia could be improved by using isoflurane, desflurane, or sevoflurane owing to reducing the after-load of the left ventricle to achieve a normal filling pattern (Sarkar, GuhaBiswas & Rupert, 2010). Ammar, A. reported that isoflurane was favourable over propofol on diastolic dysfunction (Ammar et al, 2016).…”

“…Different anesthetics cause various degrees of inhibition of diastolic function (Sarkar, GuhaBiswas & Rupert, 2010;Ammar et al, 2016;Lee et al, 2016). Thus, for patients with cardiovascular disease, it is vital to implement appropriate anesthesia maintenance strategies to substantially reduce the impact on heart function as much as possible.…”

Heart failure with preserved ejection fraction (HFpEF): Implications for the anesthesiologists

“…A comparison among isoflurane, desflurane, and sevoflurane found no significant effect on diastolic function in healthy volunteers as well as in those with diastolic dysfunction. [ 18 ] Among intravenous anesthetic agents, barbiturates, and ketamine exert similar effects on diastolic function by inhibiting sarcolemmal transport of calcium ions, and ketamine, in addition can reduce chamber compliance. Etomidate, propofol, morphine, midazolam, and remifentanil do not appear to have any effect on diastolic performance.…”