We read with great interest the systematic review and meta-analysis by Bonanni et al., recently published in Anesthesiology,in which the authors investigated how different anesthetic agents (volatile vs. propofol) affected outcomes in patients who had undergone cardiac surgery with cardiopulmonary bypass. The main finding—that volatile anesthetics were superior to propofol with regard to long-term mortality as well as cardioprotective effects—is clinically valuable information. Some methodologic issues should be further discussed and clarified, however, and there is a need for data validation, for three main reasons which we describe below.

First, we are skeptical about the authors’ assertion that the majority of the studies were at low risk of bias (Supplemental Digital Content 2, http://links.lww.com/ALN/C280, in Bonanni et al.). It is almost impossible for anesthesiologists to perform either total intravenous anesthesia or...

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