Efficacy of electroacupuncture on myocardial protection and postoperative rehabilitation in patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and Meta-analysis

doi:10.19852/j.cnki.jtcm.20230904.003

Abstract

Abstract:

OBJECTIVE: To evaluate the efficacy of electroacupuncture (EA) intervention on myocardial protection and postoperative rehabilitation in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).

METHODS: Eight databases, including PubMed, Embase, the Cochrane Library, Web of Science, Chinese BioMedical Literature Database, China National Knowledge Infrastructure Database, Wanfang Data, China Science and Technology Journal Database, and two clinical trial registries, were searched. All randomized controlled trials (RCTs) related to EA intervention in cardiac surgery with CPB were collected. Based on the inclusion and exclusion criteria, two researchers independently screened articles and extracted data. After the quality evaluation, RevMan 5.3 software was used for analysis.

RESULTS: Fourteen RCTs involving 836 patients were included. Compared with the control treatment, EA significantly increased the incidence of cardiac automatic rebeat after aortic unclamping [relative risk (RR) = 1.15, 95% confidence interval (CI) (1.01, 1.31), P < 0.05; moderate]. Twenty-four hours after aortic unclamping, EA significantly increased the superoxide dismutase [standardized mean difference (SMD) = 0.96, 95% CI(0.32, 1.61), P < 0.05; low], and interleukin (IL)-2 [SMD = 1.33, 95% CI(0.19, 2.47), P < 0.05; very low] expression levels and decreased the malondialdehyde [SMD =－1.62, 95% CI(－2.15, －1.09), P < 0.05; moderate], tumour necrosis factor-α [SMD = －1.28, 95% CI(－2.37, －0.19), P < 0.05; moderate], and cardiac troponin I [SMD = －1.09, 95% CI(－1.85, －0.32), P < 0.05; low] expression levels as well as the inotrope scores [SMD = －0.77, 95% CI(－1.22, －0.31), P < 0.05; high]. There was no difference in IL-6 and IL-10 expression levels. The amount of intraoperative sedative [SMD = -0.31, 95% CI(－0.54, －0.09), P < 0.05; moderate] and opioid analgesic [SMD = -0.96, 95% CI(－1.53, －0.38), P < 0.05; low] medication was significantly lower in the EA group than in the control group. Moreover, the postoperative tracheal intubation time [SMD = －0.92, 95% CI(－1.40, －0.45), P < 0.05; low] and intensive care unit stay [SMD = －1.71, 95% CI(－3.06, －0.36), P < 0.05; low] were significantly shorter in the EA group than in the control group. There were no differences in the time to get out of bed for the first time, total days of antibiotic use after surgery, or postoperative hospital stay. No adverse reactions related to EA were reported in any of the included studies.

CONCLUSIONS: In cardiac surgery with CPB, EA may be a safe and effective strategy to reduce myocardial ischaemia-reperfusion injury and speed up the recovery of patients after surgery. These findings must be interpreted with caution, as most of the evidence was of low or moderate quality. More RCTs with larger sample sizes and higher quality are needed to provide more convincing evidence.

Key words: electroacupuncture, cardiopulmonary bypass, thoracic surgery, myocardial ischaemia-reperfusion injury, myocardial protection, postoperative rehabilitation, Meta-analysis, randomized controlled trial

QIN Xiaoyu, WANG Chunai, XUE Jianjun, ZHANG Jie, LU Xiaoting, DING Shengshuang, GE Long, WANG Minzhen. Efficacy of electroacupuncture on myocardial protection and postoperative rehabilitation in patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and Meta-analysis[J]. Journal of Traditional Chinese Medicine, 2024, 44(1): 1-15.

Figures/Tables 6

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Study	Number of patients	Age (years)			Heart function degree	Operation type	EA parameter	Acupoint	Outcome
Study	Number of patients	EA		Control	Heart function degree	Operation type	EA parameter	Acupoint	Outcome
Ma FG et al 2015²⁹	50	45±16		46±15	Ⅱ-Ⅲ	Valve replacement	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 2.34-6.24 mA, adjusted according to the patient's tolerance.	PC6	Incidence of cardiac automatic rebeat, SOD, MDA, cTnI
Ni XL et al 2012³⁰	70	3.95		3.45	Unreported	Repair of congenital heart disease	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 14±3 mA.	PC6	IL-6, IL-10, TNF-α, cTnI, Sedative drug usage, analgesic usage, tracheal intubation time, length of ICU stay, length of hospital stay
Shan JG 2009;³¹ Shan JG et al 2010³²	30	31.1±15.7		32.5±13.6	Unreported	Valve replacement, septal defect repair, incision of pulmonary stenosis	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is adjusted according to the patient's tolerance.	PC6, LU7, LU2	Incidence of cardiac automatic rebeat, IL-2, IL-10, TNF-α, total days of antibiotic use, Length of ICU stay, length of hospital stay
Tao YY 2009³³	23	31.8±13.6		35.9±8.5	Ⅱ-Ⅲ	Valve replacement, septal defect repair, septal defect repair and valvuloplasty	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 1-3 mA.	PC6, LU7, LU2	Incidence of cardiac automatic rebeat, cTnI, sedative drug usage, analgesic usage, Tracheal intubation time, length of ICU stay
Wang XR et al 1999³⁴	28	27.4±8.9		28.9±10.1	Ⅰ-Ⅱ	Septal defect repair	The frequency is 3-4 Hz and the intensity is 0.5-1 mA.	PC6, LU7, LU2	Incidence of cardiac automatic rebeat
Wang YQ et al 2012³⁵	40	42.5 ± 6.5		43.3±6.8	Ⅱ-Ⅲ	Valve replacement	The frequency is 3-4 Hz and the intensity is adjusted according to the patient's tolerance.	PC6, LU7, LU2	SOD, MDA
Wang Y et al 2019³⁶	60	44±4		45±5	Ⅱ-Ⅲ	Valve replacement	Sparse-dense wave at a frequency of 2/15 Hz. the intensity is 1 mA.	GV20, EX-HN3, GV26	IL-6, IL-10, TNF-α, length of ICU stay, length of hospital stay
Wu DQ et al 2018;³⁷ Wu DQ et al 2019³⁸	40	48±10.4		47.4±10.4	Unreported	Valve replacement	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 1-24 mA, adjusted according to the patient's tolerance.	LI4, LI11, ST36, SP9	Sedative drug usage, analgesic usage, tracheal intubation time, length of ICU stay
Yang QG et al 2006³⁹	20	31.3±7.6		31.8±11.5	Unreported	Septal defect repair	The frequency is 3-4 Hz and the intensity is adjusted according to the patient's tolerance.	PC6, LU7, LU2	IL-2, IL-6, IL-10
Yang LF et al 2009⁴⁰	75	50±4		51±6	Ⅱ-Ⅲ	Valve replacement, coronary artery bypass grafting	Sparse-dense wave at a frequency of 5-6/25-30 Hz. The intensity is 2.34-6.24 mA, adjusted according to the patient's tolerance.	PC6, LU7, LU2	Incidence of cardiac automatic rebeat, Sedative drug usage, analgesic usage, length of hospital stay
Yang YL et al 2020⁴²	100	6.9±2.4	7.3±2.2		Unreported	Repair of tetralogy of fallot	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 6 mA,	GV20, PC6, LI4, PC4	IL-6, TNF-α, analgesic usage, tracheal intubation time, length of ICU stay, hospital stay
Zhang FX et al 2017;⁴³ Xiao H et al 2018⁴⁴	40	44±6	47±5		Ⅱ-Ⅲ	Valve replacement	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 0.5-1.2 mA, adjusted according to the patient's tolerance.	PC6, PC4, GV24, GV20	Incidence of cardiac automatic rebeat, MDA, cTnI, inotrope scores, sedative drug usage, analgesic usage, tracheal intubation time, time to get out of bed for the first time, length of ICU stay, length of hospital stay
Zhou J et al 2011⁴⁵	200	51.3	53.8		Ⅰ-Ⅲ	Repair of congenital heart disease, valve replacement, valvuloplasty	The frequency is 3-4 Hz and the intensity is adjusted according to the patient's tolerance.	LU1, LU7, PC4	Time to get out of bed for the first time, total days of antibiotic use, length of ICU stay, length of hospital stay

Study	Number of patients	Age (years)			Heart function degree	Operation type	EA parameter	Acupoint	Outcome
Study	Number of patients	EA		Control	Heart function degree	Operation type	EA parameter	Acupoint	Outcome
Ma FG et al 2015²⁹	50	45±16		46±15	Ⅱ-Ⅲ	Valve replacement	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 2.34-6.24 mA, adjusted according to the patient's tolerance.	PC6	Incidence of cardiac automatic rebeat, SOD, MDA, cTnI
Ni XL et al 2012³⁰	70	3.95		3.45	Unreported	Repair of congenital heart disease	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 14±3 mA.	PC6	IL-6, IL-10, TNF-α, cTnI, Sedative drug usage, analgesic usage, tracheal intubation time, length of ICU stay, length of hospital stay
Shan JG 2009;³¹ Shan JG et al 2010³²	30	31.1±15.7		32.5±13.6	Unreported	Valve replacement, septal defect repair, incision of pulmonary stenosis	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is adjusted according to the patient's tolerance.	PC6, LU7, LU2	Incidence of cardiac automatic rebeat, IL-2, IL-10, TNF-α, total days of antibiotic use, Length of ICU stay, length of hospital stay
Tao YY 2009³³	23	31.8±13.6		35.9±8.5	Ⅱ-Ⅲ	Valve replacement, septal defect repair, septal defect repair and valvuloplasty	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 1-3 mA.	PC6, LU7, LU2	Incidence of cardiac automatic rebeat, cTnI, sedative drug usage, analgesic usage, Tracheal intubation time, length of ICU stay
Wang XR et al 1999³⁴	28	27.4±8.9		28.9±10.1	Ⅰ-Ⅱ	Septal defect repair	The frequency is 3-4 Hz and the intensity is 0.5-1 mA.	PC6, LU7, LU2	Incidence of cardiac automatic rebeat
Wang YQ et al 2012³⁵	40	42.5 ± 6.5		43.3±6.8	Ⅱ-Ⅲ	Valve replacement	The frequency is 3-4 Hz and the intensity is adjusted according to the patient's tolerance.	PC6, LU7, LU2	SOD, MDA
Wang Y et al 2019³⁶	60	44±4		45±5	Ⅱ-Ⅲ	Valve replacement	Sparse-dense wave at a frequency of 2/15 Hz. the intensity is 1 mA.	GV20, EX-HN3, GV26	IL-6, IL-10, TNF-α, length of ICU stay, length of hospital stay
Wu DQ et al 2018;³⁷ Wu DQ et al 2019³⁸	40	48±10.4		47.4±10.4	Unreported	Valve replacement	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 1-24 mA, adjusted according to the patient's tolerance.	LI4, LI11, ST36, SP9	Sedative drug usage, analgesic usage, tracheal intubation time, length of ICU stay
Yang QG et al 2006³⁹	20	31.3±7.6		31.8±11.5	Unreported	Septal defect repair	The frequency is 3-4 Hz and the intensity is adjusted according to the patient's tolerance.	PC6, LU7, LU2	IL-2, IL-6, IL-10
Yang LF et al 2009⁴⁰	75	50±4		51±6	Ⅱ-Ⅲ	Valve replacement, coronary artery bypass grafting	Sparse-dense wave at a frequency of 5-6/25-30 Hz. The intensity is 2.34-6.24 mA, adjusted according to the patient's tolerance.	PC6, LU7, LU2	Incidence of cardiac automatic rebeat, Sedative drug usage, analgesic usage, length of hospital stay
Yang YL et al 2020⁴²	100	6.9±2.4	7.3±2.2		Unreported	Repair of tetralogy of fallot	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 6 mA,	GV20, PC6, LI4, PC4	IL-6, TNF-α, analgesic usage, tracheal intubation time, length of ICU stay, hospital stay
Zhang FX et al 2017;⁴³ Xiao H et al 2018⁴⁴	40	44±6	47±5		Ⅱ-Ⅲ	Valve replacement	Sparse-dense wave at a frequency of 2/100 Hz. The intensity is 0.5-1.2 mA, adjusted according to the patient's tolerance.	PC6, PC4, GV24, GV20	Incidence of cardiac automatic rebeat, MDA, cTnI, inotrope scores, sedative drug usage, analgesic usage, tracheal intubation time, time to get out of bed for the first time, length of ICU stay, length of hospital stay
Zhou J et al 2011⁴⁵	200	51.3	53.8		Ⅰ-Ⅲ	Repair of congenital heart disease, valve replacement, valvuloplasty	The frequency is 3-4 Hz and the intensity is adjusted according to the patient's tolerance.	LU1, LU7, PC4	Time to get out of bed for the first time, total days of antibiotic use, length of ICU stay, length of hospital stay

Outcome	No. of studies	No. of patients	Quality assessment					Relative effect (95% CI)	Quality
Outcome	No. of studies	No. of patients	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Relative effect (95% CI)	Quality
Incidence of cardiac automatic rebeat	7	306	Serious^a	None	None	None	None	RR 1.15 (1.01, 1.31)	Moderate
Oxidative stress indicators (SOD)	2	90	Serious^a	Serious^b	None	None	None	SMD 0.96 (0.32, 1.61)	Low
Oxidative stress indicators (MDA)	3	130	Serious^a	None	None	None	None	SMD －1.62 (－2.15, －1.09)	Moderate
Inflammatory factor indicators (IL-2)	2	50	Serious^a	Serious^b	None	Serious^c	None	SMD 1.33 (0.19, 2.47)	Very low
Inflammatory factor indicators (IL-6)	4	250	None	Serious^b	None	None	None	SMD －0.69 (－1.43, 0.05)	Moderate
Inflammatory factor indicators (IL-10)	4	180	Serious^a	Serious^b	None	Serious^c	None	SMD 0.65 (－0.01, 1.32)	Very low
Inflammatory factor indicators (TNF-α)	4	260	None	Serious^b	None	None	None	SMD －1.28 (－2.37, －0.19)	Moderate
Myocardial injury markers (cTnI)	5	243	Serious^a	Serious^b	None	None	None	SMD －1.09 (－1.85, －0.32)	Low
Inotrope scores	2	100	None	None	None	None	None	SMD －0.77 (－1.22, －0.31)	High
Sedative drug usage	12	586	Serious^a	None	None	None	None	SMD －0.31 (－0.54, －0.09)	Moderate
Sedative drug usage (propofol)	5	238	Serious^a	Serious^b	None	None	None	SMD －0.28 (－0.78, 0.23)	Low
Sedative drug usage (midazolam)	6	308	Serious^a	None	None	None	None	SMD －0.33 (－0.57, －0.09)	Moderate
Sedative drug usage (etomidate)	1	40	Serious^a	None	None	Serious^c	None	SMD －0.36 (－0.99, 0.27)	Low
Analgesic usage	8	448	Serious^a	Serious^b	None	None	None	SMD －0.96 (－1.53, －0.38)	Low
Analgesic usage (fentanyl)	4	228	Serious^a	Serious^b	None	None	None	SMD －0.78 (－1.72, 0.15)	Low
Analgesic usage (sufentanil)	3	180	Serious^a	None	None	None	None	SMD －0.98 (－1.29, －0.67)	Moderate
Analgesic usage (remifentanil)	1	40	Serious^a	None	None	Serious^c	None	SMD －1.91 (－2.67, －1.15)	Low
Tracheal intubation time	6	333	Serious^a	Serious^b	None	None	None	SMD －0.92 (－1.40, －0.45)	Low
Time to get out of bed for the first time	2	240	Serious^a	Serious^b	None	Serious^c	None	SMD －6.58 (－18.70, 5.53)	Very low
Total days of antibiotic use	2	230	Serious^a	Serious^b	None	Serious^c	None	SMD －3.13 (－6.89, 0.63)	Very low
Length of ICU stay	9	623	Serious^a	Serious^b	None	None	None	SMD －1.71 (－3.06, －0.36)	Low
Length of hospital stay	8	635	Serious^a	Serious^b	None	Serious^c	None	SMD －0.71 (－1.56, 0.14)	Very low

Outcome	No. of studies	No. of patients	Quality assessment					Relative effect (95% CI)	Quality
Outcome	No. of studies	No. of patients	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Relative effect (95% CI)	Quality
Incidence of cardiac automatic rebeat	7	306	Serious^a	None	None	None	None	RR 1.15 (1.01, 1.31)	Moderate
Oxidative stress indicators (SOD)	2	90	Serious^a	Serious^b	None	None	None	SMD 0.96 (0.32, 1.61)	Low
Oxidative stress indicators (MDA)	3	130	Serious^a	None	None	None	None	SMD －1.62 (－2.15, －1.09)	Moderate
Inflammatory factor indicators (IL-2)	2	50	Serious^a	Serious^b	None	Serious^c	None	SMD 1.33 (0.19, 2.47)	Very low
Inflammatory factor indicators (IL-6)	4	250	None	Serious^b	None	None	None	SMD －0.69 (－1.43, 0.05)	Moderate
Inflammatory factor indicators (IL-10)	4	180	Serious^a	Serious^b	None	Serious^c	None	SMD 0.65 (－0.01, 1.32)	Very low
Inflammatory factor indicators (TNF-α)	4	260	None	Serious^b	None	None	None	SMD －1.28 (－2.37, －0.19)	Moderate
Myocardial injury markers (cTnI)	5	243	Serious^a	Serious^b	None	None	None	SMD －1.09 (－1.85, －0.32)	Low
Inotrope scores	2	100	None	None	None	None	None	SMD －0.77 (－1.22, －0.31)	High
Sedative drug usage	12	586	Serious^a	None	None	None	None	SMD －0.31 (－0.54, －0.09)	Moderate
Sedative drug usage (propofol)	5	238	Serious^a	Serious^b	None	None	None	SMD －0.28 (－0.78, 0.23)	Low
Sedative drug usage (midazolam)	6	308	Serious^a	None	None	None	None	SMD －0.33 (－0.57, －0.09)	Moderate
Sedative drug usage (etomidate)	1	40	Serious^a	None	None	Serious^c	None	SMD －0.36 (－0.99, 0.27)	Low
Analgesic usage	8	448	Serious^a	Serious^b	None	None	None	SMD －0.96 (－1.53, －0.38)	Low
Analgesic usage (fentanyl)	4	228	Serious^a	Serious^b	None	None	None	SMD －0.78 (－1.72, 0.15)	Low
Analgesic usage (sufentanil)	3	180	Serious^a	None	None	None	None	SMD －0.98 (－1.29, －0.67)	Moderate
Analgesic usage (remifentanil)	1	40	Serious^a	None	None	Serious^c	None	SMD －1.91 (－2.67, －1.15)	Low
Tracheal intubation time	6	333	Serious^a	Serious^b	None	None	None	SMD －0.92 (－1.40, －0.45)	Low
Time to get out of bed for the first time	2	240	Serious^a	Serious^b	None	Serious^c	None	SMD －6.58 (－18.70, 5.53)	Very low
Total days of antibiotic use	2	230	Serious^a	Serious^b	None	Serious^c	None	SMD －3.13 (－6.89, 0.63)	Very low
Length of ICU stay	9	623	Serious^a	Serious^b	None	None	None	SMD －1.71 (－3.06, －0.36)	Low
Length of hospital stay	8	635	Serious^a	Serious^b	None	Serious^c	None	SMD －0.71 (－1.56, 0.14)	Very low

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