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Di Pumpo et al. Vessel Plus 2018;2:41 I http://dx.doi.org/10.20517/2574-1209.2018.38 Page 5 of 8

nates in valve surgery is controversial [46,47] . A 2006 study showed that the use of sevoflurane leads to better
preservation of myocardial function and less postoperative release of troponin I in patients undergoing aor-
[48]
[47]
tic valve replacement . In contrast, the study of Pinaud et al. in 2015, demonstrated that preconditioning
does not have cardioprotective effects in patients undergoing valve surgery without CABG.
There are no clear advantages of the use of volatiles in valve surgery. A first reason is that myocardial infarc-
[49]
tion can simulate a preconditioned state by improving the effect of halogenated agents . In fact, as dem-
[2]
onstrated by Murry et al. , short periods of transient myocardial ischemia protect the heart from extensive
damage in longer periods of ischemia. Furthermore, valvular surgery causes an increase in troponin due to
higher surgical injuries and anatomical changes that modify the geometry and function of the left ventricle,
[50]
with acute increase in the afterload, especially in mitral valve surgery .

We must remember that when using TIVA in cardiac surgery we do not have remote ischemic precondition-
[34]
ing . This led to the demonstration that TIVA leads to an increase in mortality, while there is no study
showing that it increases survival [32,36,37] .

[51]
However, TIVA remains widely used for rapid interventions. As demonstrated by Çaparlar et al. , patients
eligible for the preferential ward were older and the time for rapid suitability was shorter in the TIVA group
compared to sevoflurane (82.1% vs. 57.5% and 8 min vs. 12 min, P < 0.05).

At the same time, it must be stated that volatile agents, such as desfuorane, are proving to be an excellent
alternative to propofol for fast-track interventions [52,53] .

Thus we obtain two results: the cardiac preconditioning given by the volatile agent and rapid extubation
times.

CONCLUSION
[54]
Volatile anesthetics are among the few drugs that affect survival in the perioperative period . In addition,
they can be administered in other areas other than cardiac surgery due to their cardioprotective effects,
which may add future perspectives in their use.

Notwithstanding the numerous studies in favor of volatile anesthetics, it is necessary to give a definitive an-
swer regarding the greater survival of patients with the simple use of volatile anesthetics, with randomized
trials provided with a very large sample. The largest study currently underway is recruiting 10,600 partici-
pants and has the task of conclusively demonstrating how the simple use of a halogenated agent improves
one-year survival in patients undergoing CABG.

DECLARATIONS
Authors’ contributions
Data collection, manuscript revision: Di Pumpo A
Study design, literature analysis, manuscript drafting: Di Pumpo A, Candela C
Literature analysis, manuscript critical revision: Cucciniello F, Sarubbi D
Study design, manuscript critical revision: Agrò FE

Availability of data and materials
Literature search (Pubmed, Scopus).