Individualized mean arterial pressure during cardiac surgery The OPTIPAM Randomized Clinical Trial

Background: Whether targeting an individualized mean arterial pressure (MAP) during cardiac surgery improves outcomes remains uncertain. The balance between improved perfusion and vasopressor-driven blood pressure augmentation is unclear. Methods: In this single-blind, multicenter randomized clinical trial conducted in 10 tertiary centers in France, adult patients undergoing elective cardiac surgery with cardiopulmonary bypass were assigned to either individualized MAP management (target within ±10% of preoperative baseline during surgery and for 24 h postoperatively) or standard management (target MAP ≥65 mm Hg). The primary outcome was a composite of all-cause death, acute kidney injury, or prespecified neurologic complications within 7 days. Safety outcomes included hemorrhagic complications and transfusion requirements. Results: A total of 172 patients were enrolled before the trial was stopped early by the data and safety monitoring board because of increased bleeding in the individualized group. Mean intraoperative MAP was higher with individualized management (80.6 vs 75.6 mm Hg; P<0.001), despite limited target adherence (33% of intraoperative time) and greater vasopressor use. The primary outcome occurred in 27 of 85 patients (32%) in the individualized group and 25 of 87 (29%) in the standard group (relative risk, 1.1; 95% CI, 0.7 to 1.8; P=0.76). Hemorrhagic complications occurred more frequently in the individualized group (18% vs 3%; P=0.003). Conclusions: In patients undergoing cardiac surgery, it was not possible to determine whether an individualized MAP strategy reduced major postoperative complications. More bleeding complications were observed in the individualized group. Future studies should further investigate this safety signal when evaluating individualized blood pressure targets.