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Letter by Ge and Kong Regarding Article, "High-Target Versus Low-Target Blood Pressure Management During Cardiopulmonary Bypass to Prevent Cerebral Injury in Cardiac Surgery Patients: A Randomized Controlled Trial".

November 20, 2018 2445 Hong-Wei Ge, MD Fei-Juan Kong, MD To the Editor: We congratulate Vedel et al1 for their significant work recently published in Circulation. The authors conducted a single-center, controlled trial to investigate whether a higher (70–80 mm Hg) versus a lower (40–50 mm Hg) blood pressure during cardiopulmonary bypass reduces cerebral infarction in patients. However, the findings of this randomized trial indicating that targeting a higher versus a lower blood pressure during cardiopulmonary bypass did not seem to reduce cerebral infarction in patients undergoing on-pump cardiac surgery deserve further improvement in trial conduct and patient selection. We are concerned that the methodological approach to control for confounding fails to account for surgical intensity. The high-target group appeared to have much greater surgical intensity, evidenced by greater cardiopulmonary bypass times, which may have meant a more complex procedure, greater cerebral lesions, and worse outcomes.2 Moreover, angiotensin-converting enzyme inhibitor therapy early after cardiac surgery is associated with improved in-hospital outcomes,3 which was not specially stated in this study. We wonder whether the results would change if adjusted for these variables. In addition, detailed information about anesthesia management in the present study is missing, which makes determining the extent to which interventions by anesthesiologists might have affected outcomes elusive. Furthermore, it has been shown that the risk of major complications and mortality was markedly increased after perioperative transfusion in patients undergoing on-pump cardiac surgery.4 Therefore, the lack of detailed information about perioperative treatment and difference in surgical intensity makes it confusing to understand whether the negative outcomes are attributable to the ineffectiveness of high-target blood pressure treatment or the disturbance from confounding factors.