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J Thorac Cardiovasc Surg 1995;110:1302-1314
© 1995 Mosby, Inc.

SURGERY FOR ACQUIRED HEART DISEASE

IMPROVEMENT OF OUTCOMES AFTER CORONARY ARTERY BYPASS: A randomized trial comparing intraoperative high versus low mean arterial pressure

Jeffrey P. Gold, MD (by invitation), Mary E. Charlson, MD (by invitation), Pamela Williams-Russo, MD, MPH (by invitation), Ted P. Szatrowski, MD (by invitation), Janey C. Peterson, MA, RN (by invitation), Paul A. Pirraglia, BA (by invitation), Gregg S. Hartman, MD (by invitation), Fun Sun F. Yao, MD (by invitation), James P. Hollenberg, MD (by invitation), Denise Barbut, MD (by invitation), Joseph G. Hayes, MD (by invitation), Stephen J. Thomas, MD (by invitation), Mary Helen Purcell, BA, RN (by invitation), Steven Mattis, PhD (by invitation), Larry Gorkin, PhD (by invitation), Martin Post, MD (by invitation), Karl H. Krieger, MD, O. Wayne Isom, MD


New York, N.Y., and Alexandria, Va.

Supported by grant HL44719 from the National Institutes of Health, National Heart, Lung, and Blood Institute.

Address for reprints: Jeffrey P. Gold, MD, Department of Cardiothoracic Surgery, The New York Hospital–Cornell Medical Center, Suite F2114, 525 E. 68th St., New York, NY 10021.

Abstract

Background The objective of this randomized clinical trial of elective coronary artery bypass grafting was to investigate whether intraoperative mean arterial pressure below autoregulatory limits of the coronary and cerebral circulations was a principal determinant of postoperative complications. The trial compared the impact of two strategies of hemodynamic management during cardiopulmonary bypass on outcome. Patients were randomized to a low mean arterial pressure of 50 to 60 mm Hg or a high mean arterial pressure of 80 to 100 mm Hg during cardiopulmonary bypass. MethodsA total of 248 patients undergoing primary, nonemergency coronary bypass were randomized to either low (n = 124) or high (n = 124) mean arterial pressure during cardiopulmonary bypass. The impact of the mean arterial pressure strategies on the following outcomes was assessed: mortality, cardiac morbidity, neurologic morbidity, cognitive deterioration, and changes in quality of life. All patients were observed prospectively to 6 months after the operation. ResultsThe overall incidence of combined cardiac and neurologic complications was significantly lower in the high pressure group at 4.8% than in the low pressure group at 12.9% (p= 0.026). For each of the individual outcomes, the trend favored the high pressure group. At 6 months after coronary bypass for the high and low pressure groups, respectively, total mortality rate was 1.6% versus 4.0%, stroke rate 2.4% versus 7.2%, and cardiac complication rate 2.4% versus 4.8%. Cognitive and functional status outcomes did not differ between the groups. ConclusionHigher mean arterial pressures during cardiopulmonary bypass can be achieved in a technically safe manner and effectively improve outcomes after coronary bypass. (J THORAC CARDIOVASC SURG 1995;110:1302-14)




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