Volatile Anesthesia Versus Total Intravenous Anesthesia During Cardiopulmonary Bypass: A Narrative Review on the Technical Challenges and Considerations

The pragmatic, multicenter MYRIAD trial that compared volatile anesthesia and total intravenous anesthesia (TIVA) in 5,400 patients undergoing elective coronary artery bypass grafting (CABG) demonstrated that intraoperative anesthesia with a volatile anesthetic did not result in a significantly lower number of deaths at 1 year than did TIVA. There also were no significant differences in the following aspects: perioperative nonfatal myocardial infarction; adverse cerebral outcome (a composite of stroke, delirium, or postoperative cognitive impairment); acute kidney injury; and requirement for renal replacement therapy, surgical revision for bleeding, high-dose inotropic support, and mechanical circulatory support. The trial was stopped at the time of the second interim analysis because of futility in demonstrating the hypothesized effects at 30 days and at 1 year. With no demonstrable benefit of volatile anesthetics over TIVA for CABG, this narrative review focuses on the technical challenges and considerations regarding the administration of volatile anesthesia versus TIVA during CPB.