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Improvement of outcomes after coronary artery bypass. A randomized trial comparing intraoperative high versus low
J P Gold1, M E Charlson, P Williams-Russo
1Cornell Coronary Artery Bypass Outcomes Trial (CCABOT) Group, Cornell University Medical College, New York, N.Y., USA.
Insights
Maintaining higher mean arterial pressure during cardiopulmonary bypass significantly reduces postoperative complications in coronary artery bypass grafting patients. This strategy improves cardiac and neurologic outcomes, enhancing patient recovery.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Neurosurgery
Background:
- Investigating intraoperative mean arterial pressure (MAP) during coronary artery bypass grafting (CABG).
- Assessing if MAP below autoregulatory limits impacts postoperative complications.
- Comparing hemodynamic management strategies during cardiopulmonary bypass (CPB).
Purpose of the Study:
- To determine if intraoperative MAP influences postoperative complications in CABG patients.
- To compare outcomes between low MAP (50-60 mm Hg) and high MAP (80-100 mm Hg) during CPB.
- To evaluate the safety and efficacy of different MAP targets during CPB.
Main Methods:
- Randomized clinical trial with 248 patients undergoing primary, non-emergency CABG.
- Patients randomized to low MAP (n=124) or high MAP (n=124) during CPB.
- Prospective observation to 6 months, assessing mortality, cardiac/neurologic morbidity, cognitive, and quality of life outcomes.
Main Results:
- Combined cardiac and neurologic complications were significantly lower in the high MAP group (4.8%) vs. low MAP group (12.9%).
- High MAP group showed trends favoring lower mortality (1.6% vs. 4.0%), stroke (2.4% vs. 7.2%), and cardiac complications (2.4% vs. 4.8%).
- No significant differences observed in cognitive or functional status outcomes between groups.
Conclusions:
- Higher MAP during CPB is achievable safely.
- Elevating MAP during CPB effectively improves postoperative outcomes in CABG patients.
- MAP management during CPB is a critical factor for reducing complications.
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.
Methods:
A 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.
Results:
The 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.
Conclusion:
Higher mean arterial pressures during cardiopulmonary bypass can be achieved in a technically safe manner and effectively improve outcomes after coronary bypass.