Esmolol in Cardiac Surgery: A Randomized Controlled Trial

A review of recent advances in anesthetic drugs for patients undergoing cardiac surgery

Inducing and maintaining general anesthesia requires a diverse set of medications. Currently, heart surgery anesthetic management does not adhere to any one standard protocol or set of drugs. To ensure steady circulatory function while providing sufficient sedation, anesthetic medications are carefully selected for cardiovascular operations. Among the opioids used most often in cardiac surgery are fentanyl, sufentanil, and remifentanil. As a cardiac anesthesiologist, your key responsibilities will be to maintain your patient's blood pressure (BP) and oxygen levels, reduce the frequency and intensity of ischemia events, and make it easy for them to get off of cardiopulmonary bypass (CPB) and supplemental oxygen fast. Additionally, new knowledge gaps have been identified as a result of developments in cardiac anesthetics, which must be addressed. The goal of the most recent developments in cardiac anesthesia has been to decrease risks and increase accuracy in patient outcomes during cardiac surgeries. Furthermore, new methods and tools are contributing to the evolution of cardiovascular anesthesia toward a more dynamic, patient-centered approach, with an eye on boosting safety, decreasing complications, and facilitating better recovery for patients. New medications and methods have emerged in the field of anesthetic pharmacology, aiming to improve anesthesia management, particularly for patients who have cardiovascular disease. Optimal cardiovascular stability, fewer side effects, and enhanced surgical recovery are achieved by use of these medications. We have reviewed all the different kinds of cardiac anesthetic techniques and medications in this research. We have also examined the many new anesthetic medicines that have been produced and used for individuals with cardiovascular issues. Next, we covered prospects in the realm of cardiovascular anesthesia and novel cardiac anesthetic drugs.

Comparison of the efficacy and safety of Landiolol and Esmolol in critically ill patients: a propensity score-matched study

BACKGROUND

Excessive tachycardia is associated with impaired hemodynamics and worse outcome in critically ill patients. Previous studies suggested beneficial effect of β-blockers administration in ICU patients, including those with septic shock. However, comparisons in ICU settings are lacking. Our study aims to compare Landiolol and Esmolol regarding heart rate control and hemodynamic variables in general ICU patients.

METHODS

This retrospective, observational study was conducted in a 56-bed ICU at a university hospital. A propensity score matching (PSM) was employed to balance baseline differences. Generalized estimating equations (GEE) were used to compare heart rate between two drugs. The primary outcome was heart rate control, while secondary outcomes included hemodynamic response, hospital length of stay (HLOS) and ICU length of stay (ICULOS).

RESULTS

From June 2016 to December 2022, 438 patients were included after PSM, (292 in the Esmolol group and 146 the in Landiolol group). Baseline heart rate was similar between groups (Landiolol:120.0 [110.2, 131.0] bpm vs. Esmolol:120.0 [111.0, 129.0] bpm, p = 0.925). During 72 h. of β-blocker infusion, Landiolol reduced heart rate by 4.7 (1.3, 8.1) bpm, more than Esmolol (p = 0.007), while preserving a comparable proportion of patients able to stabilize vasopressor doses within the first 24 h. (82.9 vs. 80.8%, respectively, p = 0.596). Norepinephrine doses and lactate levels were similar between groups over 72 h., while the Landiolol group exhibited notably higher minimal ScvO2 levels (72% [63%, 78%] vs 68% [55%, 73%], respectively, p = 0.006) and a lower maximal PCO2 gap compared to the Esmolol group (7.0 [6.0, 9.0] vs. 8.0 [6.0, 10.0] mmHg, respectively, p = 0.040). Patients in the Landiolol group were observed to experience shorter HLOS than patients in the Esmolol group (26.5 [13.0, 42.0] vs 30.0 [17.0, 47.2] days, respectively, p = 0.044) and ICULOS (4.9 [2.8, 10.0] vs.6.7 [3.4, 13.1] days, respectively, p = 0.011).

CONCLUSION

Landiolol provides superior heart rate control in critically ill patients with tachycardia compared to Esmolol, without increasing vasopressor requirements during the first 24 h. Findings from ScvO2 levels and PCO2 gap suggest that Landiolol may exert less impact on cardiac output than Esmolol. Further studies, incorporating comprehensive hemodynamic monitoring, are warranted to clarify the clinical implications of heart rate control with β-blockers in ICU patients with tachycardia.

Normothermic Crystalloid Polarizing Cardioplegia Improves Systolic and Diastolic Function in a Porcine Model of Cardiopulmonary Bypass

BACKGROUND/OBJECTIVES

Previously, we showed that blood-based polarizing cardioplegia exerted beneficial cardioprotection during hypothermic ischemia; however, these positive effects of blood-based polarizing cardioplegia were reduced during normothermic ischemia compared to blood-based hyperkalemic (depolarizing) cardioplegia. This study compares crystalloid polarizing cardioplegia to crystalloid depolarizing cardioplegia in a normothermic porcine model of cardiopulmonary bypass; Methods: Twelve pigs were randomized to receive either normothermic polarizing (n = 7) or depolarizing (n = 5) crystalloid cardioplegia. After the initiation of cardiopulmonary bypass, normothermic arrest (34 °C, 60 min) was followed by 60 min of on-pump and 90 min of off-pump reperfusion. Myocardial injury (arterial CK-MB), hemodynamic function, and the energy status of the hearts were measured; Results: The arterial release of CK-MB was comparable between groups (p = 0.78) during reperfusion. During 150 min of reperfusion, systolic left ventricular pressure (p = 0.01) and coronary flow (p = 0.009) were increased, and wedge pressure (p = 0.04) was decreased in the polarized group. Further hemodynamic parameters (cardiac output, stroke volume) and high-energy phosphate levels were similar between groups. The requirement for noradrenaline administration during reperfusion was significantly higher (p = 0.013) in the polarized group; Conclusions: Under normothermic conditions and despite a similar increase in levels of cardiac CK-MB, crystalloid polarizing cardioplegia protected systolic and diastolic cardiac function after 60 min of cardiac arrest. These results suggest beneficial effects for polarizing cardioplegia; clinical studies are required to confirm these effects.

Efficacy and Safety of Esmolol in Neonatal Cardiac Surgery with Cardiopulmonary Bypass (CPB) for d-Transposition of the Great Arteries (d-TGA)

OBJECTIVE

D-Transposition of the great arteries (d-TGA) is the most common congenital heart disease requiring surgical correction within the neonatal period. Sinus tachycardia often persists postoperatively, potentially affecting cardiac function. This study aimed to investigate the efficacy and safety of the short-acting beta-1-selective beta-blocker esmolol in controlling heart rate in neonatal cardiac surgery with cardiopulmonary bypass (CPB).

METHODS

A retrospective cohort study was conducted on neonates undergoing surgery for d-TGA. The study cohort included 112 patients, divided into an esmolol intervention group (n = 57) and a control group (n = 55). Baseline characteristics, hemodynamic parameters and outcome measures were assessed.

RESULTS

In the esmolol group, median heart rate at ICU admission was significantly higher compared to the control group (155 vs. 147 bpm, p = 0.018). After a median time of 11 h, heart rate was lower among the esmolol patients (135 vs. 144 bpm, p < 0.001). There were no differences in other hemodynamic parameters between the two groups. Patients treated with esmolol required longer catecholamine support while no difference regarding survival, duration of invasive ventilation and ICU stay were noticed.

CONCLUSION

No relevant hemodynamic difference was seen between neonates treated with perioperative esmolol and the control group and outcome did not differ. This indicates non-inferiority of perioperative betablocker therapy in young age. Prospective and placebo-controlled assessment of perioperative esmolol therapy in neonates is needed.

Left Ventricular Diastolic Dysfunction in Cardiac Surgery: A Narrative Review

Cardiac relaxation is a complex process that involves various interconnected characteristics and, along with contractile properties, determines stroke volume. Perioperative ischemia-reperfusion injury and left ventricular diastolic dysfunction (DD) are characterized by the left ventricle's inability to receive a sufficient blood volume under adequate preload. Baseline DD and perioperative DD have an impact on postoperative complications, length of hospital stay, and major clinical outcomes in a variety of cardiac pathologies. Several baseline and perioperative factors, such as age, female sex, hypertension, left ventricle hypertrophy, diabetes, and perioperative ischemia-reperfusion injury, contribute to the risk of DD. The recommended diagnostic criteria available in guidelines have not been validated in the perioperative settings and still need clarification. Timely diagnosis of DD might be crucial for effectively treating postoperative low cardiac output syndrome. This implies the need for an individualized approach to fluid infusion strategy, cardiac rate and rhythm control, identification of extrinsic causes, and administration of drugs with lusitropic effects. The purpose of this review is to consolidate scattered information on various aspects of diastolic dysfunction in cardiac surgery and provide readers with well-organized and clinically applicable information.

Clinical Effect of Norepinephrine Combined with Esmolol Treatment in Patients with Septic Shock and Its Impact on Prognosis

Objective

To unveil the influence of norepinephrine (NE) combined with esmolol treatment on cardiac function, hemodynamics, inflammatory factor levels, and prognosis in patients with septic shock.

Methods

Ninety-six patients with septic shock admitted to our hospital from January 2021 to June 2023 were retrospectively analyzed and divided into the control and observation groups according to the different treatment methods. The control group was treated with standard anti-infection and fluid resuscitation, followed by NE administration [with an infusion rate of 0.1-0.5 μg/(kg-min)]. The observation group was treated with esmolol [starting pumping rate of 50 μg/(kg-min) and adjusting the pumping rate according to the target heart rate] in combination with the control group. Changes in hemodynamic parameters, including heart rate, mean arterial pressure, central venous pressure, cardiac index, stroke volume index, and systemic vascular resistance index, were monitored by pulse-indicating continuous cardiac output monitors before treatment (T0), 24h after treatment (T1), and 72h after treatment (T2); changes in cardiac function before and after 72h of treatment, indicators of inflammatory factors before and after treatment, and indicators of oxygenation metabolism were assessed; and adverse drug reactions during treatment were recorded in both groups.

Results

NE combined with esmolol treatment improved the efficacy of patients with septic shock; was beneficial for the enhancement of blood perfusion in patients; improved the patient's cardiac function, reduced myocardial injury, and suppressed the inflammatory response in patients; improved the oxygenation metabolism and the prognosis of patients; did not significantly increase the adverse drug reactions of patients and had a better safety profile.

Conclusion

NE combined with esmolol treatment can improve the efficacy of patients with septic shock, improve their cardiac function and hemodynamic indices, reduce myocardial injury and inflammatory response, and have a better safety profile, which is conducive to improving patient prognosis and reducing mortality.

The role of esmolol in sepsis: a meta-analysis based on randomized controlled trials

BACKGROUND

Sepsis is associated with a high incidence and mortality and poses a significant challenge to the treatment. Although esmolol has shown promise in sepsis treatment, its efficacy and safety remain contentious. This meta-analysis aims to clarify the role of esmolol in sepsis management.

METHODS

PubMed, Embase, Web of Science, Cochrane library, clinicaltrials.gov and the Chinese Clinical Trial Registry were searched and references of relevant reviews and meta-analysis were also screened for appropriate studies. Keywords and free words of 'sepsis', 'esmolol' and 'randomized controlled trials' were used for search. Meta-analysis was performed using RevMan 5.3 software.

RESULTS

Fifteen studies involving 1100 patients were included. Compared with the control group, patients receiving esmolol exhibited significantly decreased 28-day mortality (RR, 0.69; 95% CI, 0.60 to 0.81; P < 0.0001), heart rate (HR) (SMD, -1.15; 95% CI, -1.34 to -0.96; P < 0.0001), cardiac troponin I levels (cTnI) (SMD, -0.88; 95% CI, -1.13 to -0.64; P < 0.0001), length of intensive care unit (ICU) stay (SMD, -0.46; 95% CI, -0.62 to -0.3; P < 0.0001) and duration of mechanical ventilation (SMD, -0.28; 95% CI, -0.48 to -0.09; P = 0.004) and significantly increased central venous oxygen saturation (ScvO2) (SMD, 0.66; 95% CI, 0.44 to 0.88; P < 0.0001).While, esmolol had no significant influence on norepinephrine dosage (SMD, 0.08; 95% CI, -0.13 to 0.29; P = 0.46), mean arterial pressure (MAP) (SMD, 0.17; 95% CI, -0.07 to 0.4; P = 0.16), central venous pressure (CVP) (SMD, 0.16; 95% CI, -0.04 to 0.35; P = 0.11) and left ventricular ejection fraction (LVEF) (SMD, 0.21; 95% CI, -2.9 to 0.7; P = 0.41).

CONCLUSION

Esmolol reduces 28-day mortality, length of ICU stay and duration of mechanical ventilation in sepsis patients. Furthermore, esmolol improves oxygen metabolism, mitigates myocardial injury and decreases heart rate without significantly affecting hemodynamic parameters.

TRIAL REGISTRATION

This study was registered on the PROSPERO website (registration number: CRD42023484884).

Effect of Esmolol on Clinical Outcomes in Critically Ill Patients: Data from the MIMIC-IV Database

BACKGROUND AND AIMS

Esmolol is a common short-acting drug to control ventricular rate. This study aimed to evaluate the association between use of esmolol and mortality in critically ill patients.

METHODS

This is a retrospective cohort study from MIMIC-IV database containing adult patients with a heart rate of over 100 beats/min during the intensive care unit (ICU) stay. Multivariable Cox proportional hazard models and logistic regression were used to explore the association between esmolol and mortality and adjust confounders. A 1:1 nearest neighbor propensity score matching (PSM) was performed to minimize potential cofounding bias. The comparison for secondary outcomes was performed at different points of time using an independent t-test.

RESULTS

A total of 30,332 patients were reviewed and identified as critically ill. There was no significant difference in 28-day mortality between two groups before (HR = 0.90, 95% CI = 0.73-1.12, p = 0.343) and after PSM (HR = 0.84, 95% CI = 0.65-1.08, p = 0.167). Similar results were shown in 90-day mortality before (HR = 0.93, 95% CI = 0.75-1.14, p = 0.484) and after PSM (HR = 0.85, 95% CI = 0.67-1.09, p = 0.193). However, esmolol treatment was associated with higher requirement of vasopressor use before (HR = 2.89, 95% CI = 2.18-3.82, p < 0.001) and after PSM (HR = 2.66, 95% CI = 2.06-3.45, p < 0.001). Esmolol treatment statistically reduced diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (all p < 0.001) and increased fluid balance at 24 hours (p < 0.05) but did not significantly lower SBP (p = 0.721). Patients in esmolol group showed no significant difference in lactate levels and daily urine output when compared with those in non-esmolol group when adjusted for confounders (all p > 0.05).

CONCLUSION

Esmolol treatment was associated with reduced heart rate and lowered DBP and MAP, which may increase vasopressor use and fluid balance at the timepoint of 24 hours in critically ill patients during ICU stay. However, after adjusting for confounders, esmolol treatment was not associated with 28-day and 90-day mortality.

Esmolol inhibits cognitive impairment and neuronal inflammation in mice with sepsis-induced brain injury

Sepsis is a potentially fatal organ failure resulting from a dysregulated host response to infection. It can be a substantial financial burden on families and society due to the high cost of medical care. The study aims to investigate the protective roles of Esmolol in mice with sepsis-induced brain injuries against cognitive dysfunction and neuronal inflammation. Male C57BL/6J mice were intraperitoneally injected with LPS (10 mg/kg, L2630, Sigma) to establish a septic encephalopathy model. Esmolol (15 mg/kg/h, HY-B1392, MedChemExpress) was subcutaneously infused using osmotic mini-pumps for 6 h before LPS injection. Morris water maze and novel object recognition tests evaluated LPS-induced cognitive impairment and behavioral phenotypes. Cytokines and protein expression were assessed using ELISA assay and RT-qPCR. Esmolol treatment potentially improved cognitive impairment in septic mice. Esmolol administration markedly diminished the abnormal hippocampal neuronal structure, and the expression of interleukin (IL)-1β, IL-6, and tumor necrosis factor-α was significantly downregulated in the hippocampal tissue. Esmolol treatment significantly reduced apoptotic TUNEL-positive cells and reversed the related gene expression (BAX and BCL-2). The effects of esmolol on the reactive oxidative species and oxidative stress markedly reduce malondialdehyde MDA content and increase superoxide dismutase and catalase in hippocampal tissues. In addition, esmolol significantly reduced the percentage and density of Iba-1 + microglia in septic mice. Our results demonstrated that esmolol potentially improved cognitive impairment and neuronal inflammation in mice with sepsis-induced brain injury.

Maintenance over Time of the Effect Produced by Esmolol on the Structure and Function of Coronary Arteries in Hypertensive Heart Diseases

We previously observed that esmolol treatment for 48 h reduced vascular lesions in spontaneously hypertensive rats (SHRs). Therefore, we investigated whether this beneficial effect is persistent after withdrawal. Fourteen-month-old SHRs (SHR-Es) were treated with esmolol (300 μg/kg/min) or a vehicle for 48 h. Two separate groups were also given identical treatment, but they were then monitored for a further 1 week and 1 month after drug withdrawal. We analyzed the geometry and composition of the coronary artery, vascular reactivity and plasma redox status. Esmolol significantly decreased wall thickness (medial layer thickness and cell count), external diameter and cross-sectional area of the artery, and this effect persisted 1 month after drug withdrawal. Esmolol significantly improved endothelium-dependent relaxation by ACh (10⁻⁹–10⁻⁴ mol/L); this effect persisted 1 week (10⁻⁹–10⁻⁴ mol/L) and 1 month (10⁻⁶–10⁻⁴ mol/L) after withdrawal. Esmolol reduced the contraction induced by 5-HT (3 × 10⁻⁸–3 × 10⁻⁵ mol/L), and this effect persisted 1 week after withdrawal (10⁻⁶–3 × 10⁻⁵ mol/L). Esmolol increased nitrates and reduced glutathione, and it decreased malondialdehyde and carbonyls; this enhancement was maintained 1 month after withdrawal. This study shows that the effect of esmolol on coronary remodeling is persistent after treatment withdrawal in SHRs, and the improvement in plasma oxidative status can be implicated in this effect.

Cardioplegia between Evolution and Revolution: From Depolarized to Polarized Cardiac Arrest in Adult Cardiac Surgery

Despite current advances in perioperative care, intraoperative myocardial protection during cardiac surgery has not kept the same pace. High potassium cardioplegic solutions were introduced in the 1950s, and in the early 1960s they were soon recognized as harmful. Since that time, surgeons have minimized many of the adverse effects by lowering the temperature of the heart, lowering K⁺ concentration, reducing contact K⁺ time, changing the vehicle from a crystalloid solution to whole-blood, adding many pharmacological protectants and modifying reperfusion conditions. Despite these attempts, high potassium remains a suboptimalway to arrest the heart. We briefly review the historical advances and failures of finding alternatives to high potassium, the drawbacks of a prolonged depolarized membrane, altered Ca²⁺ intracellular circuits and heterogeneity in atrial-ventricular K⁺ repolarization during reanimation. Many of these untoward effects may be alleviated by a polarized membrane, and we will discuss the basic science and clinical experience from a number of institutions trialling different alternatives, and our institution with a non-depolarizing adenosine, lidocaine and magnesium (ALM) cardioplegia. The future of polarized arrest is an exciting one and may play an important role in treating the next generation of patients who are older, and sicker with multiple comorbidities and require more complex operations with prolonged cross-clamping times.

The Efficacy and Safety of Esmolol for Septic Shock: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Purpose: The meta-analysis aims to identify whether septic shock patients can benefit from esmolol.

Materials and Methods: The relevant studies from MEDLINE, Cochrane Library, Embase were searched by two independent investigators using a variety of keywords. Stata software (version 12.0, Stata Corp LP, College Station, TX, United States)was used for statistical analysis.

Results: A total of 14 studies were identified and incorporated into the meta-analysis. For overall analysis, the treatment of esmolol was associated with decreased 28-day mortality (RR = 0.66, 95% CI = 0.56–0.77, p < 0.001). Meanwhile, our analysis found that, esmolol could decrease HR (SMD: −1.70; 95% CI: [−2.24−(−1.17)], cTnI (SMD: −1.61; 95% CI: [−2.06−(−1.16)] compared with standard treatment. No significant differences between the two groups were found in MAP, Lac, CI, and SVI.

Conclusion: The findings of this meta-analysis intend to demonstrate that septic shock patients with high heart beats rate might be benefit from esmolol treatment despite enough fluid resuscitation. While, dependent on the study published, with the further development of septic shock, the positive impact of esmolol varies. The appropriate heart rate change interval cannot be confirmed, further high-quality and large-scale RCTs should be performed to verify it and screening more suitable heart rate levels.

Systematic Review Registration: CRD42021239513