The Dilemma of Hypertension During Cardiopulmonary Bypass: Clevidipine May be the Answer

To the Esteemed Editor: We read with great interest the 2024 EACTS/EACTAIC/EBCP guidelines on cardiopulmonary bypass (CPB) in adult cardiac surgery, recently published jointly in European Journal of Cardio-Thoracic Surgery, Interdisciplinary CardioVascular and Thoracic Surgery, and British Journal of Anaesthesia,1 which provide an in-depth focus on the management of hypertension during CPB—a potential challenge for the practicing cardiac anaesthesiologist.1 As pointed out in the guidelines, hypertension does not affect all patients undergoing CPB, and the routine use of vasodilators during CPB cannot be recommended.1 Nevertheless, the use of intravenous vasodilators is suggested to correct elevated mean arterial pressure during CPB that persists despite correction of potential contributing factors (eg, inadequate depth of anaesthesia). Among possible agents, calcium channel blockers are noted to be among the most frequently used; however, definitive recommendations for choice of agent were not made due to the paucity of supporting evidence. We would like to take this occasion to highlight clevidipine as a potential option by providing an overview of the current evidence on its use for the management of hypertension during on-pump cardiac surgery. Clevidipine is an arteriolar selective vasodilator characterized by an ultra-short half-life, rapid onset and offset, and plasmatic metabolism that is completely independent from end-organ function.2 Moreover, it is easily titratable and its dosing is independent of patient body weight, contributing to the ease-of-use and appeal of this drug.2 Empirical evidence suggests that clevidipine is feasible and pharmacologically plausible for arterial blood pressure control and afterload reduction during cardiac surgery.2 Additionally, when compared to nitroglycerin in vitro, clevidipine is effective both in the presence and absence of endothelial damage, a desirable characteristic as CPB is known to induce endothelial dysfunction.2 Clinical studies demonstrate that clevidipine provides tighter blood pressure control compared to nicardipine or nitroglycerin in patients undergoing cardiac surgery, and the large ECLIPSE trial confirmed its favourable profile, showing lower mortality than sodium nitroprusside and better blood pressure control when stricter pressure targets are applied.3–5 Nevertheless, some important considerations on clevidipine major drawbacks are warranted. Despite the potential occurrence of adverse events (eg, tachycardia, hypoxia), their reported rates across the literature are low, and its discontinuation often leads to a prompt resolution due to the drug’s high clearance rate.2 Additionally, the impact on heart rate does not seem to differ from that of other calcium channel blockers or nitroglycerin. However, in vivo studies reported a significant reduction in clevidipine clearance during CPB, mainly influenced by reduced body temperature, which constitutes an aspect worthy of further investigation.6 In summation, while we agree that the available body of evidence cannot fully support the use of one antihypertensive agent over another in the setting of CPB, we sought to provide readers with an additional and concise overview of the potentialities of clevidipine. Therefore, we call for the need to perform additional research aimed at providing a more comprehensive and definitive evaluation of clevidipine specifically in the context of CPB, to better understand its potential advantages and disadvantages compared to other antihypertensive drugs. The authors would like to thank Kate Gralton for English language editing. Alice Bottussi (Conceptualization, Supervision, Investigation, Data Curation, and Writing—original draft), Jacopo D’Andria Ursoleo (Conceptualization, Supervision, Investigation, Methodology and Writing—review & editing), Myriam Aprile (Methodology, Data Curation and Writing—original draft), Patrick M. Wieruszewski (Data Curation and Writing—review & editing), Fabrizio Monaco (Supervision, Investigation, Data Curation and Writing—review & editing). All authors read and approved the final manuscript. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. P.M.W. serves as a consultant for Wolters Kluwer/UpToDate. The other authors declare that they have no conflict of interest. No new data were generated or analysed in support of this research.