Ann Thorac Surg 2001;72:1969
© 2001 The Society of Thoracic Surgeons
Invited commentary
Gus J. Vlahakes, MD, Associate Professor of Surgerya
a Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114–2696, USA
e-mail: vlahakes.gus{at}mgh.harvard.edu
Contemporary myocardial preservation has permitted cardiac surgeons to perform complex procedures on ill patients, including individuals with depressed ventricular function. Surgeons’ efforts have been directed toward using contemporary myocardial protection to prevent loss of function from perioperative myocardial infarction. Modern surgical techniques and refined surgical decision making have made acute perioperative infarction and major decrements in cardiac function a much less common occurrence in our field; nonetheless surgeons are often presented patients with infarctions in evolution, largely as a result of misadventures during interventional catheterization. Thus, although the authors have made their findings in an experimental model, this study should serve as a stimulus for surgeons to consider using the short-acting ß-blocker esmolol during reperfusion, particularly in patients who require urgent surgical procedures with evolving ischemia.
Esmolol has proven to be of value in management of cardiac surgical patients. Because the agent is short-acting, it can be used empirically with the opportunity to discontinue administration if the desired effect is not achieved or if significant side effects occur. Furthermore, when patients have undergone cardiac operation in the setting of poor ventricular function or with ongoing ischemia, esmolol has been useful as an effective antiarrhythmic agent for patients who have been difficult to defibrillate following reperfusion. The authors’ findings in this experimental study, in addition to the findings of Hekmat and coworkers (reference 21 in the article) should form the basis for using this particular agent in the management of patients who may have evolving infarction at the time of urgent operation.
The authors have indicated that esmolol may produce its observed effects in this model through more than one mechanism. It is particularly interesting that high-dose ß-blockade with esmolol enhanced myocardial salvage in this experimental protocol even when it was administered after the ischemic period. Whether its effect is through minimizing oxygen consumption during reperfusion or some other mechanism is not important to the decision to use this agent clinically. On a risk versus benefit basis, the short effective half-life of esmolol should support its initial use on bypass for the management of the consequences of acute ischemia in the perioperative setting.
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Ann. Thorac. Surg. 2001 72: 1964-1969.
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