Remimazolam Effects on Hemodynamics and Perioperative Recovery in Cardiac Surgery

Background: Hemodynamic instability during invasive cardiac surgery, particularly cardiopulmonary bypass (CPB) procedures, is a common and clinically significant problem associated with increased perioperative morbidity and mortality. Although anesthetic agents such as propofol and etomidate are widely used, their limitations in maintaining stable hemodynamics have led to interest in alternative strategies. Remimazolam, a novel ultra-short-acting benzodiazepine, has been proposed as a safer alternative due to its favorable cardiovascular profile. Objective: This systematic review and meta-analysis evaluated the effects of remimazolam on hemodynamic stability, vasopressors, extubation time and recovery after cardiac surgery in comparison to the conventional types of anesthetics. Methods: A meta-analysis of seven randomized controlled trials (RCTs) involving a total of 557 patients compared remimazolam with other anesthetic agents during cardiac surgery. Relevant studies reporting hemodynamic outcomes, extubation time, postoperative nausea and vomiting (PONV), and vasopressor use were identified through systematic searches of PubMed, Scopus, and Cochrane CENTRAL. Two independent reviewers performed study selection and data extraction, with risk of bias assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. Statistical analyses were conducted using Review Manager (RevMan) version 5.4, and the certainty of evidence was evaluated using the GRADE approach. Results: The analysis demonstrated no significant differences between remimazolam and control groups in operative time (mean difference [MD]: 1.91 minutes; p=0.53) or mean arterial pressure (MAP) (MD: –0.90 mmHg; p=0.80). For intraoperative hypotension, remimazolam was associated with a non-significant 25% increased risk (risk ratio [RR]: 1.25; p=0.57). However, sensitivity analysis excluding one trial (Yim et al., 2024) revealed a statistically significant 64% increased risk of hypotension (RR: 1.64; p=0.005). In contrast, remimazolam significantly reduced extubation time (MD: –27.98 minutes; p=0.04). No significant differences were observed in secondary outcomes, including hospital length of stay and vasopressor use. Postoperative nausea and vomiting (PONV) showed a non-significant 31% reduction in risk with remimazolam (RR: 0.69; p=0.72). Conclusion: Remimazolam did not demonstrate a significant effect on hemodynamic stability during cardiac surgery; however, it was associated with a significant reduction in extubation time. These findings suggest a potential advantage in terms of faster postoperative recovery, while its role in maintaining intraoperative hemodynamic stability remains inconclusive. Further large-scale, adequately powered randomized controlled trials are warranted to better define its efficacy and safety profile in this setting.