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Ann Thorac Surg 2004;78:1658
© 2004 The Society of Thoracic Surgeons

INVITED COMMENTARY

Department of Surgery, Ulleval University Hospital, Oslo, Norway 0407

i.j.vaage{at}ioks.uio.no

The role of insulin, glucose-insulin, and glucose-insulin-potassium therapy as an adjunct to protection in relation to myocardial ischemia, cardioplegia, and so forth, has been controversial, although there have been several proponents of this as an important part of myocardial protection. The studies performed all have their weaknesses, in particular the number of patients included has been too low.

The present meta-analysis is a huge work and an interesting attempt to get a perspective on this controversy: what role glucose-insulin therapy may have in cardiac surgery. One may have several views on the methodology used by the authors, how they include and exclude, how they handle the heterogeneities of the studies, but the criteria used by the authors are probably as good as any other.

The investigators have concentrated on myocardial contractile power as the primary endpoint, and for this purpose they have included cardiac index. That is a serious oversimplification as cardiac index also depends strongly on preload and afterload, which are not reported. However, the authors have also discussed this weakness.

Another major difficulty for such an analysis is the completely different regimens of glucose-insulin used. Again, the views how to handle this problem may be different, and possibly no view is absolutely correct.

From the present meta-analysis arise many questions and comments, including its limitations, most of which the authors present themselves. First, perioperative hyperglycemia per se is an important risk factor for complications and mortality, including noncardiac morbidity such as stroke. This is the case both in diabetic and nondiabetic patients. More information concerning blood glucose in the studies performed might be important. Surprisingly, detailed glucose data were not generally available. Second, diabetic patients should be analyzed as a subgroup. Third, the generalized heterogeneity of patients and regimens of the studies are major problems. Fourth, most studies on glucose-insulin therapy are more than 10 years old and may not necessarily reflect today's treatment. Finally, the timing of the treatment in relation to cardioplegic arrest as well as the length of treatment may be very important.

From the data the authors conclude that glucose-insulin treatment improves postoperative cardiovascular performance. Furthermore, they reach the obvious conclusion: there is a need for a large, prospective multicenter study. If they take the initiative for such a study, they have taken an important step forward.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jarle Vaage Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Vaage, J. Search for Related Content PubMed PubMed Citation Articles by Vaage, J. Related Collections Myocardial protection