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

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.