High-Target Versus Low-Target Blood Pressure Management During Cardiopulmonary Bypass to Prevent Cerebral Injury in Cardiac Surgery Patients

• DOI: 10.1161/circulationaha.117.030308
• Publication Date: 2018-01-16T10:25:16Z
• Authors: Anne G. Vedel; Frederik Holmgaard; Lars S. Rasmussen; Annika Langkilde; Olaf B. Paulson; Theis Lange; Carsten Thomsen; Peter Skov Olsen; Hanne Berg Ravn; Jens C. Nilsson
• Keywords: Male; Time Factors; Denmark; Norepinephrine; 03 medical and health sciences; 0302 clinical medicine; Risk Factors; Humans; Vasoconstrictor Agents; Arterial Pressure; Cardiac Surgical Procedures; Aged; Cardiopulmonary Bypass; Intraoperative Care; blood pressure; Cerebral Infarction; Middle Aged; cerebral infarction; coronary artery bypass; 3. Good health; Diffusion Magnetic Resonance Imaging; Treatment Outcome; neuroprotection; Female; cardiopulmonary bypass; heart valves

Background: Cerebral injury is an important complication after cardiac surgery with the use of cardiopulmonary bypass. The rate of overt stroke after cardiac surgery is 1% to 2%, whereas silent strokes, detected by diffusion-weighted magnetic resonance imaging, are found in up to 50% of patients. It is unclear whether a higher versus a lower blood pressure during cardiopulmonary bypass reduces cerebral infarction in these patients.

Methods:

In a patient- and assessor-blinded randomized trial, we allocated patients to a higher (70–80 mm Hg) or lower (40–50 mm Hg) target for mean arterial pressure by the titration of norepinephrine during cardiopulmonary bypass. Pump flow was fixed at 2.4 L·min −1 ·m −2 . The primary outcome was the total volume of new ischemic cerebral lesions (summed in millimeters cubed), expressed as the difference between diffusion-weighted imaging conducted preoperatively and again postoperatively between days 3 and 6. Secondary outcomes included diffusion-weighted imaging–evaluated total number of new ischemic lesions.

Results:

Among the 197 enrolled patients, mean (SD) age was 65.0 (10.7) years in the low-target group (n=99) and 69.4 (8.9) years in the high-target group (n=98). Procedural risk scores were comparable between groups. Overall, diffusion-weighted imaging revealed new cerebral lesions in 52.8% of patients in the low-target group versus 55.7% in the high-target group ( P =0.76). The primary outcome of volume of new cerebral lesions was comparable between groups, 25 mm 3 (interquartile range, 0–118 mm 3 ; range, 0–25 261 mm 3 ) in the low-target group versus 29 mm 3 (interquartile range, 0–143 mm 3 ; range, 0–22 116 mm 3 ) in the high-target group (median difference estimate, 0; 95% confidence interval, −25 to 0.028; P =0.99), as was the secondary outcome of number of new lesions (1 [interquartile range, 0–2; range, 0–24] versus 1 [interquartile range, 0–2; range, 0–29] respectively; median difference estimate, 0; 95% confidence interval, 0–0; P =0.71). No significant difference was observed in frequency of severe adverse events.

Conclusions: Among patients undergoing on-pump cardiac surgery, targeting a higher versus a lower mean arterial pressure during cardiopulmonary bypass did not seem to affect the volume or number of new cerebral infarcts.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02185885.