Let's talk about ultra fast track in off pump coronary artery bypass grafting: is there any place for desflurane and remifentanil?

Nowadays, patients undergoing Off-pump Coronary Artery Bypass Grafting (OPCAB) and Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) could be extubated in the operating room (OR) immediately after surgery reducing peri-operative morbidity and costs. This management is defined as "Ultra-Fast-Track"(UTF). The combination of desflurane and remifentanil may be an excellent option for UTF because of their pharmacokinetics properties. Moreover, both drugs provides cardio-protection against ischaemia/reperfusion by Ischemic-Preconditioning (I-Pre) and Ischemic-Post-conditioning (I-Post) mechanisms by activation of Protein Kinase-C (PKC), generation of reactive oxygen species (ROS), uncoupling effects of mitochondrial ATP-sensitive potassium channels (K+ATP), and over-expression of Pim-1 kinase among others, preserving mitochondrial integrity after ischemia/reperfusion via an anti-apoptotic effect and reducing the perioperative levels of necrosis myocardial markers after cardiac surgery.
This review article tries to summarize the cardio-protective mechanisms of desflurane and remifentanil and the advantage of UTF-OPCAB and UTF-MIDCAB in term of reduction of morbility, UCI -length of stay and cost. We also mention the potential benefits of the use of desflurane/remifentanil combination for UTF-OPCAB and MIDCAB due to its pharmacokinetics (Pk) and important cardioprotection properties.