Protection Effect of Epidural Anesthesia combined with General Anesthesia in Patients Underwent Cardiac Surgery: A Meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

 HANBao-yi , ZHANGYue ,  ZHENGHong

The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830011, China;

Corresponding author：

ZHENGHong, Email: xjzhenghong@aliyun.com

Keywords：

Epidural anesthesia; General anesthesia; Cardiac surgery; Systematic review; Meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.20150231

Video：

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Objective To systematically review the protection effect of epidural anesthesia combined with general anesthesia versus general anesthesia alone in patients underwent cardiac surgery, so as to provide evidence for reducing complications of cardiac surgery. Methods Databases including PubMed, EMbase, The Cochrane Library (Issue 2, 2015), WanFang Data, CBM, and CNKI were searched to collect randomized controlled trials (RCTs) about epidural anesthesia combined with general anesthesia versus general anesthesia alone for patients underwent cardiac surgery from inception to February 2015. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed by RevMan 5.3 software. Results A total of 35 RCTs involving 3 311 patients were included. The results of meta-analysis showed that, compared with the general anesthesia group, the combination anesthesia group had lower incidence of supraventricular tachycardias (RR=0.63, 95%CI 0.48 to 0.83, P=0.001) and shorter ICU stay time (SMD=-0.57, 95%CI -1.02 to-0.12, P=0.01), but there were no significant differences in the incidences of respiratory complications, myocardial infarction, stroke and mortality between the two groups (all P values >0.05). Conclusion Current evidence shows that the combination of epidural anesthesia and general anesthesia has better protection effect than general anesthesia alone in cardiac surgery, but the influence on long-term prognosis still needs to be assessed. Due to the limited quality of included studies, the above conclusion still needs to be verified by more high quality studies．

Citation： HANBao-yi, ZHANGYue, ZHENGHong. Protection Effect of Epidural Anesthesia combined with General Anesthesia in Patients Underwent Cardiac Surgery: A Meta-analysis. Chinese Journal of Evidence-Based Medicine, 2015, 15(12): 1413-1423. doi: 10.7507/1672-2531.20150231 Copy

1.	Mangano DT. Assessment of the patient with cardiac disease:an anesthesiologist's paradigm. Anesthesiology, 1999, 91(5):1521-1526.
2.	Coriat P, Beaussier M. Fast-tracking after coronary artery bypass graft surgery. Anesth Analg, 2001, 92(5):1081-1083.
3.	Kolek MJ, Muehlschlegel JD, Bush WS, et al. Genetic and clinical risk prediction model for postoperative atrial fibrillation. Circ Arrhythm Electrophysiol, 2015, 8(1):25-31.
4.	Crestanello JA, Higgins RSD, He X, et al. The association of chronic lung disease with early mortality and respiratory adverse events after aortic valve replacement. Ann Thorac Surg, 2014, 98(6):2068-2077.
5.	Podgoreanu MV, White WD, Morris RW, et al. Inflammatory gene polymorphisms and risk of postoperative myocardial infarction after cardiac surgery. Circulation, 2006, 114(1 suppl):I²75-I²81.
6.	Nygård E, Kofoed KF, Freiberg J, et al. Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation, 2005, 111(17):2165-2170.
7.	Beattie WS, Badner NH, Choi PTL. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg, 2003, 97(3):919-920.
8.	Ballantyne JC, Carr DB, Suarez T, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg, 1998, 86(3):598-612.
9.	Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0[updated March 2011]. The Cochrane Collaboration. 2011. Available at:www.cochranehandbook.org.
10.	Bach F, Grundmann U, Bauer M, et al. Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia. Acta Anaesthesiol Scand, 2002, 46(10): 1227-1235.
11.	Bakhtiary F, Therapidis P, Dzemali O, et al. Impact of high thoracic epidural anesthesia on incidence of perioperative atrial fibrillation in off-pump coronary bypass grafting:a prospective randomized study. J Thorac Cardiovasc Surg, 2007, 134(2):460-464.
12.	Barrington MJ, Kluger R, Watson R, et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg, 2005, 100(4):921-928.
13.	Berendes E, Schmidt C, Van Aken H, et al. Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting:a randomized trial. Arch Surg, 2003, 138(12): 1283-1290.
14.	Brix-Christensen V, Tønnesen E, Sørensen IJ, et al. Effects of anaesthesia based on high versus low doses of opioids on the cytokine and acute-phase protein responses in patients undergoing cardiac surgery. Acta Anaesthesiol Scand, 1998, 42(1):63-70.
15.	Caputo M, Alwair H, Rogers CA, et al. Myocardial, inflammatory, and stress responses in off-pump coronary artery bypass graft surgery with thoracic epidural anesthesia. Ann Thorac Surg, 2009, 87(4):1119-1126.
16.	Caputo M, Alwair H, Rogers CA, et al. Thoracic epidural anesthesia improves early outcomes in patients undergoing off-pump coronary artery bypass surgery:a prospective, randomized, controlled trial. Anesthesiology, 2011, 114(2):380-390.
17.	de Vries AJ, Mariani MA, van der Maaten JMAA, et al. To ventilate or not after minimally invasive direct coronary artery bypass surgery:the role of epidural anesthesia. J Cardiothorac Vasc Anesth, 2002, 16(1):21-26.
18.	El-Morsy GZ, El-Deeb A. The outcome of thoracic epidural anesthesia in elderly patients undergoing coronary artery bypass graft surgery. Saudi J Anaesth, 2012, 6(1):16-21.
19.	Fillinger MP, Yeager MP, Dodds TM, et al. Epidural anesthesia and analgesia:effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth, 2002, 16(1):15-20.
20.	Gurses E, Berk D, Sungurtekin H, et al. Effects of high thoracic epidural anesthesia on mixed venous oxygen saturation in coronary artery bypass grafting surgery. Med Sci Monit, 2013, 19:222-229.
21.	Hansdottir V, Philip J, Olsen MF, et al. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery:a randomized controlled trial on length of hospital stay and patientperceived quality of recovery. Anesthesiology, 2006, 104(1):142-151.
22.	Heijmans J, Fransen E, Buurman W, et al. Comparison of the modulatory effects of four different fast-track anesthetic techniques on the inflammatory response to cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth, 2007, 21(4): 512-518.
23.	Kendall JB, Russell GN, Scawn NDA, et al. A prospective, randomised, single-blind pilot study to determine the effect of anaesthetic technique on troponin T release after off-pump coronary artery surgery. Anaesthesia, 2004, 59(6):545-549.
24.	Kiliçkan L, Gonca S, Dalçik C, et al. General anesthesia with thoracic epidural anesthesia in the cardiopulmonary bypass surgery reduces apoptosis by upregulating antiapoptotic protein Bcl-2. J Cardiovasc Surg (Torino), 2006, 47(3):315-322.
25.	Kirnö K, Friberg P, Grzegorczyk A, et al. Thoracic epidural anesthesia during coronary artery bypass surgery:effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg, 1994, 79(6):1075-1081.
26.	Lagunilla J, García-Bengochea JB, Fernandez AL, et al. High thoracic epidural blockade increases myocardial oxygen availability in coronary surgery patients. Acta Anaesthesiol Scand, 2006, 50(7): 780-786.
27.	Liem TH, Hasenbos MAWM, Booij LHDJ, et al. Coronary artery bypass grafting using two different anesthetic techniques:Part 2: Postoperative outcome. J Cardiothorac Vasc Anesth, 1992, 6(2):156-161.
28.	Loick HM, Schmidt C, Van Aken H, et al. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg, 1999, 88(4):701-709.
29.	Lundstrøm LH, Nygard E, Hviid LB, et al. The effect of thoracic epidural analgesia on the occurrence of late postoperative hypoxemia in patients undergoing elective coronary bypass surgery: a randomized controlled trial. CHEST, 2005, 128(3):1564-1570.
30.	Moore CM, Cross MH, Desborough JP, et al. Hormonal effects of thoracic extradural analgesia for cardiac surgery. Br J Anaesth, 1995, 75(4):387-393.
31.	Nielsen DV, Bhavsar R, Greisen J, et al. High Thoracic Epidural Analgesia in Cardiac Surgery:Part 2-High Thoracic Epidural Analgesia Does Not Reduce Time in or Improve Quality of Recovery in the Intensive Care Unit. J Cardiothorac Vasc Anesth, 2012, 26(6): 1048-1054.
32.	Nygård E, Sørensen LH, Hviid LB, et al. Effects of amiodarone and thoracic epidural analgesia on atrial fibrillation after coronary artery bypass grafting. J Cardiothorac Vasc Anesth, 2004, 18(6):709-714.
33.	Onan IS, Onan B, Korkmaz AA, et al. Effects of thoracic epidural anesthesia on flow and endothelium of internal thoracic artery in coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth, 2011, 25(6):1063-1070.
34.	Onan B, Onan IS, Kilickan L, et al. Effects of epidural anesthesia on acute and chronic pain after coronary artery bypass grafting. J Card Surg, 2013, 28(3):248-253.
35.	Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery:the effects on tracheal intubation time and length of hospital stay. Anesth Analg, 2002, 94(2):275-282.
36.	Rajakaruna C, Rogers C, Pike K, et al. Superior haemodynamic stability during off-pump coronary surgery with thoracic epidural anaesthesia:results from a prospective randomized controlled trial. Interact Cardiovasc Thorac Surg, 2013, 16(5):602-607.
37.	Rein KA, Stenseth R, Myhre HO, et al. The influence of thoracic epidural analgesia on transcapillary fluid balance in subcutaneous tissue. Acta Anaesthesiol Scand, 1989, 33(1):79-83.
38.	Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg, 2003, 75(1):93-100.
39.	Scott NB, Turfrey DJ, Ray DAA, et al. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg, 2001, 93(3):528-535.
40.	Sharma M, Mehta Y, Sawhney R, et al. Thoracic epidural analgesia in obese patients with body mass index of more than 30 kg/m² for off pump coronaryartery bypass surgery. Ann Card Anaesth, 2010, 13(1):28-33.
41.	Stenseth R, Bjella L, Berg EM, et al. Thoracic epidural analgesia in aortocoronary bypass surgery I:Haemodynamic effects. Acta Anaesthesiol Scand, 1994, 38(8):826-833.
42.	Levang OW, Gisvold SE. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardio-thorac Surg, 1996, 10(10):859-865.
43.	Svircevic V, Nierich AP, Moons KG, et al. Thoracic epidural anesthesia for cardiac surgery:a randomized trial. Anesthesiology, 2011, 114(2):262-270.
44.	Tenling A, Joachimsson PO, Tydén H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth, 1999, 13(3):258-264.
45.	Du XJ, Cox HS, Dart AM, et al. Sympathetic activation triggers ventricular arrhythmias in rat heart with chronic infarction and failure. Cardiovasc Res, 1999, 43(4):919-929.
46.	Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg, 1997, 84(6):1211-1221.
47.	Hoar PF, Hickey RF, Ullyot DJ. Systemic hypertension following myocardial revascularization. A method of treatment using epidural anesthesia. J Thorac Cardiovasc Surg, 1976, 71(6):859-864.
48.	Beattie WS, Badner NH, Choi PT. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg, 2003, 97(3):919-920.

1. Mangano DT. Assessment of the patient with cardiac disease:an anesthesiologist's paradigm. Anesthesiology, 1999, 91(5):1521-1526.
2. Coriat P, Beaussier M. Fast-tracking after coronary artery bypass graft surgery. Anesth Analg, 2001, 92(5):1081-1083.
3. Kolek MJ, Muehlschlegel JD, Bush WS, et al. Genetic and clinical risk prediction model for postoperative atrial fibrillation. Circ Arrhythm Electrophysiol, 2015, 8(1):25-31.
4. Crestanello JA, Higgins RSD, He X, et al. The association of chronic lung disease with early mortality and respiratory adverse events after aortic valve replacement. Ann Thorac Surg, 2014, 98(6):2068-2077.
5. Podgoreanu MV, White WD, Morris RW, et al. Inflammatory gene polymorphisms and risk of postoperative myocardial infarction after cardiac surgery. Circulation, 2006, 114(1 suppl):I²75-I²81.
6. Nygård E, Kofoed KF, Freiberg J, et al. Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation, 2005, 111(17):2165-2170.
7. Beattie WS, Badner NH, Choi PTL. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg, 2003, 97(3):919-920.
8. Ballantyne JC, Carr DB, Suarez T, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg, 1998, 86(3):598-612.
9. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0[updated March 2011]. The Cochrane Collaboration. 2011. Available at:www.cochranehandbook.org.
10. Bach F, Grundmann U, Bauer M, et al. Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia. Acta Anaesthesiol Scand, 2002, 46(10): 1227-1235.
11. Bakhtiary F, Therapidis P, Dzemali O, et al. Impact of high thoracic epidural anesthesia on incidence of perioperative atrial fibrillation in off-pump coronary bypass grafting:a prospective randomized study. J Thorac Cardiovasc Surg, 2007, 134(2):460-464.
12. Barrington MJ, Kluger R, Watson R, et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg, 2005, 100(4):921-928.
13. Berendes E, Schmidt C, Van Aken H, et al. Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting:a randomized trial. Arch Surg, 2003, 138(12): 1283-1290.
14. Brix-Christensen V, Tønnesen E, Sørensen IJ, et al. Effects of anaesthesia based on high versus low doses of opioids on the cytokine and acute-phase protein responses in patients undergoing cardiac surgery. Acta Anaesthesiol Scand, 1998, 42(1):63-70.
15. Caputo M, Alwair H, Rogers CA, et al. Myocardial, inflammatory, and stress responses in off-pump coronary artery bypass graft surgery with thoracic epidural anesthesia. Ann Thorac Surg, 2009, 87(4):1119-1126.
16. Caputo M, Alwair H, Rogers CA, et al. Thoracic epidural anesthesia improves early outcomes in patients undergoing off-pump coronary artery bypass surgery:a prospective, randomized, controlled trial. Anesthesiology, 2011, 114(2):380-390.
17. de Vries AJ, Mariani MA, van der Maaten JMAA, et al. To ventilate or not after minimally invasive direct coronary artery bypass surgery:the role of epidural anesthesia. J Cardiothorac Vasc Anesth, 2002, 16(1):21-26.
18. El-Morsy GZ, El-Deeb A. The outcome of thoracic epidural anesthesia in elderly patients undergoing coronary artery bypass graft surgery. Saudi J Anaesth, 2012, 6(1):16-21.
19. Fillinger MP, Yeager MP, Dodds TM, et al. Epidural anesthesia and analgesia:effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth, 2002, 16(1):15-20.
20. Gurses E, Berk D, Sungurtekin H, et al. Effects of high thoracic epidural anesthesia on mixed venous oxygen saturation in coronary artery bypass grafting surgery. Med Sci Monit, 2013, 19:222-229.
21. Hansdottir V, Philip J, Olsen MF, et al. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery:a randomized controlled trial on length of hospital stay and patientperceived quality of recovery. Anesthesiology, 2006, 104(1):142-151.
22. Heijmans J, Fransen E, Buurman W, et al. Comparison of the modulatory effects of four different fast-track anesthetic techniques on the inflammatory response to cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth, 2007, 21(4): 512-518.
23. Kendall JB, Russell GN, Scawn NDA, et al. A prospective, randomised, single-blind pilot study to determine the effect of anaesthetic technique on troponin T release after off-pump coronary artery surgery. Anaesthesia, 2004, 59(6):545-549.
24. Kiliçkan L, Gonca S, Dalçik C, et al. General anesthesia with thoracic epidural anesthesia in the cardiopulmonary bypass surgery reduces apoptosis by upregulating antiapoptotic protein Bcl-2. J Cardiovasc Surg (Torino), 2006, 47(3):315-322.
25. Kirnö K, Friberg P, Grzegorczyk A, et al. Thoracic epidural anesthesia during coronary artery bypass surgery:effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg, 1994, 79(6):1075-1081.
26. Lagunilla J, García-Bengochea JB, Fernandez AL, et al. High thoracic epidural blockade increases myocardial oxygen availability in coronary surgery patients. Acta Anaesthesiol Scand, 2006, 50(7): 780-786.
27. Liem TH, Hasenbos MAWM, Booij LHDJ, et al. Coronary artery bypass grafting using two different anesthetic techniques:Part 2: Postoperative outcome. J Cardiothorac Vasc Anesth, 1992, 6(2):156-161.
28. Loick HM, Schmidt C, Van Aken H, et al. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg, 1999, 88(4):701-709.
29. Lundstrøm LH, Nygard E, Hviid LB, et al. The effect of thoracic epidural analgesia on the occurrence of late postoperative hypoxemia in patients undergoing elective coronary bypass surgery: a randomized controlled trial. CHEST, 2005, 128(3):1564-1570.
30. Moore CM, Cross MH, Desborough JP, et al. Hormonal effects of thoracic extradural analgesia for cardiac surgery. Br J Anaesth, 1995, 75(4):387-393.
31. Nielsen DV, Bhavsar R, Greisen J, et al. High Thoracic Epidural Analgesia in Cardiac Surgery:Part 2-High Thoracic Epidural Analgesia Does Not Reduce Time in or Improve Quality of Recovery in the Intensive Care Unit. J Cardiothorac Vasc Anesth, 2012, 26(6): 1048-1054.
32. Nygård E, Sørensen LH, Hviid LB, et al. Effects of amiodarone and thoracic epidural analgesia on atrial fibrillation after coronary artery bypass grafting. J Cardiothorac Vasc Anesth, 2004, 18(6):709-714.
33. Onan IS, Onan B, Korkmaz AA, et al. Effects of thoracic epidural anesthesia on flow and endothelium of internal thoracic artery in coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth, 2011, 25(6):1063-1070.
34. Onan B, Onan IS, Kilickan L, et al. Effects of epidural anesthesia on acute and chronic pain after coronary artery bypass grafting. J Card Surg, 2013, 28(3):248-253.
35. Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery:the effects on tracheal intubation time and length of hospital stay. Anesth Analg, 2002, 94(2):275-282.
36. Rajakaruna C, Rogers C, Pike K, et al. Superior haemodynamic stability during off-pump coronary surgery with thoracic epidural anaesthesia:results from a prospective randomized controlled trial. Interact Cardiovasc Thorac Surg, 2013, 16(5):602-607.
37. Rein KA, Stenseth R, Myhre HO, et al. The influence of thoracic epidural analgesia on transcapillary fluid balance in subcutaneous tissue. Acta Anaesthesiol Scand, 1989, 33(1):79-83.
38. Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg, 2003, 75(1):93-100.
39. Scott NB, Turfrey DJ, Ray DAA, et al. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg, 2001, 93(3):528-535.
40. Sharma M, Mehta Y, Sawhney R, et al. Thoracic epidural analgesia in obese patients with body mass index of more than 30 kg/m² for off pump coronaryartery bypass surgery. Ann Card Anaesth, 2010, 13(1):28-33.
41. Stenseth R, Bjella L, Berg EM, et al. Thoracic epidural analgesia in aortocoronary bypass surgery I:Haemodynamic effects. Acta Anaesthesiol Scand, 1994, 38(8):826-833.
42. Levang OW, Gisvold SE. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardio-thorac Surg, 1996, 10(10):859-865.
43. Svircevic V, Nierich AP, Moons KG, et al. Thoracic epidural anesthesia for cardiac surgery:a randomized trial. Anesthesiology, 2011, 114(2):262-270.
44. Tenling A, Joachimsson PO, Tydén H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth, 1999, 13(3):258-264.
45. Du XJ, Cox HS, Dart AM, et al. Sympathetic activation triggers ventricular arrhythmias in rat heart with chronic infarction and failure. Cardiovasc Res, 1999, 43(4):919-929.
46. Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg, 1997, 84(6):1211-1221.
47. Hoar PF, Hickey RF, Ullyot DJ. Systemic hypertension following myocardial revascularization. A method of treatment using epidural anesthesia. J Thorac Cardiovasc Surg, 1976, 71(6):859-864.
48. Beattie WS, Badner NH, Choi PT. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg, 2003, 97(3):919-920.

Chinese Journal of Evidence-Based Medicine

Protection Effect of Epidural Anesthesia combined with General Anesthesia in Patients Underwent Cardiac Surgery: A Meta-analysis

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