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Remote Ischemic Preconditioning for Cardiac Surgery
Study Questions:
What is the impact of remote ischemic preconditioning (RIPC) on clinical outcomes in patients undergoing cardiac surgery?
Methods:
The investigators conducted a prospective, double-blind, multicenter, randomized, controlled trial involving adults who were scheduled for elective cardiac surgery requiring cardiopulmonary bypass under total anesthesia with intravenous propofol. The trial compared upper-limb RIPC with a sham intervention. The primary endpoint was a composite of death, myocardial infarction, stroke, or acute renal failure up to the time of hospital discharge. Secondary endpoints included the occurrence of any individual component of the primary endpoint by day 90.
Results:
A total of 1,403 patients underwent randomization. The full analysis set comprised 1,385 patients (692 in the RIPC group and 693 in the sham-RIPC group). There was no significant between-group difference in the rate of the composite primary endpoint (99 patients [14.3%] in the RIPC group and 101 [14.6%] in the sham-RIPC group, p = 0.89), or of any of the individual components: death (9 patients [1.3%] and 4 [0.6%], respectively; p = 0.21), myocardial infarction (47 [6.8%] and 63 [9.1%], p = 0.12), stroke (14 [2.0%] and 15 [2.2%], p = 0.79), and acute renal failure (42 [6.1%] and 35 [5.1%], p = 0.45). The results were similar in the per-protocol analysis. No treatment effect was found in any subgroup analysis. No significant differences between the RIPC group and the sham-RIPC group were seen in the level of troponin release, the duration of mechanical ventilation, the length of stay in the intensive care unit or the hospital, new onset of atrial fibrillation, and the incidence of postoperative delirium. No RIPC-related adverse events were observed.
Conclusions:
The authors concluded that upper-limb RIPC performed while patients were under propofol-induced anesthesia did not show a relevant benefit among patients undergoing elective cardiac surgery.
Perspective:
This study reports that there was no significant difference between upper-limb RIPC and a sham intervention with respect to the rate of postoperative myocardial infarction, stroke, renal failure, and death within 90 days after elective cardiac surgery. These findings, along with the results of the ERICCA trial, suggest lack of any significant benefit with RIPC.
Keywords: Acute Kidney Injury, Anesthesia, Atrial Fibrillation, Cardiac Surgical Procedures, Cardiopulmonary Bypass, Ischemic Preconditioning, Myocardial Infarction, Propofol, Stroke, Troponin
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