Esmolol as cardioplegia adjuvant reduces the need for catecholaminergic support: a randomized trial

Background. Esmolol, a ultra- short- acting β-blocker, has been proved beneficial in reducing the incidence of myocardial ischemia and arrhythmias in cardiac surgery. To improve myocardial protection during cardiopulmonary bypass, we hypothesized that the administration of esmolol as cardioplegia adjuvant might have a beneficial effect, reducing myocardial activity and, therefore, oxygen consumption. Methods: We performed a single-center, double-blind, placebo-controlled, parallel-group phase IV trial. Patients undergoing elective cardiac surgery with preoperative evidence of left ventricular end diastolic diameter > 60 mm and/or left ventricular ejection fraction <50% were randomized to receive either esmolol or placebo in a 1:1 allocation ratio. The study drug was administered before aortic cross clamping (1 mg/kg) and within the cardioplegia solution (2 mg/kg). Results: A total of 200 patients was randomized in the study. Patients were mostly male (73%) undergoing valve surgery (95%). No difference was observed in the primary endpoint of prolonged ICU stay and mortality, (36% in the placebo group versus 27% in the esmolol group, p = 0.13). Maximum inotropic score during the first 24 postoperative hours was significantly lower in the esmolol group (10 [5 – 15] versus 7 [5 – 10.5]; p=0.04) Conclusions: Intraoperative esmolol administration enhances cardiac protection during cardiac surgery, reducing the need for postoperative catecholaminergic support, although it did not reduce the incidence of a composite outcome of prolonged ICU stay and mortality in the present study.