Ischaemic preconditioning during cardiac surgery: systematic review and meta-analysis of perioperative outcomes in randomised clinical trials

Numerous small trials have been conducted to confirm the existence of the ischaemic preconditioning (IP) mechanism in the human heart and to clarify whether it can be induced in a clinical situation. The effect on clinical end-points remains unclear. Most of the available trials reported some clinical outcomes. We performed a systematic review and meta-analysis in order to determine whether IP produces any clinical benefit in cardiac surgery. The systematic review identified 22 eligible trials containing 933 patients. All patients undergoing on-pump surgery also received cardioplegia or intermittent cross-clamp fibrillation (ICCF) with or without adjunctive cooling. IP was mainly performed after initiation of cardiopulmonary bypass, before any additional myocardial protection was initiated. Overall, IP was associated with significant reductions in ventricular arrhythmias (pooled odds ratio 0.11; 95% CI 0.04-0.29; p=0.001), inotrope requirements (pooled odds ratio 0.34; 95% CI 0.17-0.68; p=0.002) and intensive care unit stay (weighted mean difference -3h; 95% CI -4.6 to -1.5h; p=0.001). These effects persisted when the analyses were restricted to those patients receiving cardioplegia. The effect disappeared when the analyses were restricted to patients receiving ICCF. IP may provide additional myocardial protection over cardioplegia alone, but a large-scale clinical trial may be required to determine the role of IP with any certainty.