Several studies suggest that the mag- nitude of SIRS is greater with on-pump CABG than with Initial studies of preconditioning used mechanical occlusion of arterial inflow followed by reperfusion via aortic cross- clamping immediately on institution of bypass or with coronary artery occlusion proximal to the planned distal anastomosis during off-pump CABG.190,191,214 217 Because of concerns of the potential adverse cerebral effects of aortic manipulation, enthu- siasm for further study of this technique in on-pump CABG patients is limited (Section 5.2.1). Despite intense interest in the physiology of postconditioning, few data are available.197 A small 2008 study in patients undergoing valve surgery, which used repeated manipulation of the ascending aorta, reported a reduction in surrogate markers of inflammation and myo- necrosis.196 In lieu of techniques utilizing mechanical occlusion, pharmacological conditioning agents are likely to be used. An alternative approach that avoids much (but not all) of the safety concerns related to potential vascular injury is remote precondi- tioning of arterial inflow to the leg or (more commonly) the arm via blood pressure cuff occlusion.218 Two studies of patients undergoing on-pump CABG at a single center, the first of which used 2 different myocardial protection strategies and the second of which repeated the study with a standardized cold-blood cardioplegia routine, reported similar amounts of troponin re- lease during the 72 hours postoperatively, with no apparent complications.193,195 A larger trial was unable to confirm any benefits of a similar protocol, casting doubt on the utility of this Volatile halogenated anesthetics and opioids have anti- ischemic or conditioning properties,32,33,219,220 and propofol has antioxidant properties of potential value in subjects with reperfusion injury.221,222 The salutary properties of volatile anesthetics during myocardial ischemia are well known. 