In the present meta-analysis, we have reviewed the literature regarding the efficacy of TEA in preventing POAF in adult patients undergoing CABG. The pooled results from meta-analysis of five RCTs using a random-effects model suggest that TEA shows no beneficial efficacy in preventing POAF in adult patients undergoing CABG. Also, substantial heterogeneity across the studies was observed.
The main finding of our meta-analysis seems to contradict a previous review on the topic, which assessed the effects of TEA on the clinical outcomes in patients undergoing cardiac surgery. In detail, in a meta-analysis by Svircevic et al. [26
], it was noted that “the use of TEA in patients undergoing cardiac surgery reduces the risk of postoperative supraventricular arrhythmias.” In fact, the contribution may not be conclusive. As their authors clearly emphasized, the included studies were heterogeneous and the study by Scott et al. [27
] in 420 patients mainly contributed to this result. In this study, all patients discontinued β-blockers therapy during the study period. Moreover, the patients in TEA
GA group received clonidine, while the patients in GA group were not given this cardioprotective drug [28
]. The above factors may result in the beneficial efficacy of TEA on supraventricular arrhythmias.
For the current meta-analysis, we evaluated the efficacy of TEA in preventing POAF in adult patients undergoing CABG. In an attempt to produce robust results, we pre-stated rigorous inclusion criteria and included only RCTs that provided definition and monitoring of POAF. We found that there was no significant difference in the incidence of POAF between the two groups, but significant heterogeneity was observed among these studies. Our sensitivity analyses suggest that 2 studies conducted in patients undergoing CABG with OPCAB technique probably contributed to the heterogeneity [17
]. In addition, sensitivity analyses based other various exclusion criteria did not materially alter the pooled results, which added robustness to our main finding.
Our study provides additional interesting clues that may be useful for future research on the topic. Two RCTs included in our meta-analysis were conducted in patients undergoing CABG with OPCAB technique instead of CPB [17
]. These two studies consistently suggest that TEA
GA significantly reduced the incidence of POAF. Thus, a new question arise, does TEA really reduce the incidence of POAF in patients undergoing CABG with OPCAB technique? However, a recent meta-analysis indicated that OPCAB technique was associated with lower incidence of POAF when compared with CPB technique in the population undergoing CABG [29
]. Besides, in one study [17
], the patients in the TEA group received ropivacaine which has a substantial anti-inflammatory effect [30
]. In the other study [19
], the epidural infusion protocol used was similar to the one used by Scott and colleagues [27
] and clonidine was administered only to the patients in TEA group. These may make the isolated effects of TEA on the incidence of POAF become less clear and raise additional concerns on the interpretation of the positive results.
One could expect that use of TEA may cause potential complications in patients undergoing CABG. TEA may give rise to the following possible hazardous complications, such as the appearance of epidural hematoma. Systematic anticoagulation needed during cardiopulmonary bypass could increase the incidence of epidural hematoma related to the use of an epidural catheter [31
]. In addition, the intense sympathycolysis may lead to systemic hypotension, which can be difficult to correct. In the included studies, no cases of epidural hematoma were reported because this devastating complication is too rare to evaluate in randomized studies. Additional studies or data regarding the potential complications related to TEA are warranted.
There are several potential limitations that should be taken into account. First, substantial heterogeneity among studies was observed. Nevertheless, we were able to detect the major source of heterogeneity through the sensitivity analyses. Second, our analysis was based on only five RCTs and all of them were carried out in only western countries and just enrolled older age patients undergoing elective surgery. Thus, the results of the RCTs need to be reproduced in other populations. Morever, we only included the trial providing definition and monitoring of POAF. Because the end-point of our study was less POAF, the monitoring needs to specificied clearly for the various studies. Since identification of POAF is critical to the conclusion, the monitoring has to be standardized or at least specified. Otherwise the conclusions are hard to justify. Exclusion of the studies lacking a clear definition of POAF may have potential influence on the final analysis. Finally, these studies lack homogeneity in both the method of postoperative monitoring and in their definition of POAF. This may lead to potential underestimation and/or overestimation of the true incidence of POAF.