From the Guidelines
The Mean Arterial Pressure (MAP) goal for right heart failure is greater than 65 mm Hg.
Rationale
- The goal of MAP >65 mm Hg is to improve RV supply/demand balance and optimize ventricular interdependence, as stated in the study published in the Journal of the American College of Cardiology 1.
- This is part of the postoperative management strategies and therapeutic targets to address right-sided heart failure, which also includes preload optimization, afterload reduction, and inotrope use.
- Specifically, the study suggests that afterload reduction with a MAP >65 mm Hg can help recouple the RV to the PA and improve ejection, highlighting the importance of maintaining adequate blood pressure in right heart failure.
- Additionally, the use of inotropes with a cardiac index >2.0 and pacing strategies with a heart rate of 90-110 beats/min can also help improve RV function and overall cardiac output.
From the Research
Mean Arterial Pressure (MAP) Goal for Right Heart Failure
- The optimal MAP target for patients with right ventricular failure (RVF) secondary to pre-capillary pulmonary hypertension (PH) remains unknown 2.
- A retrospective analysis of 60 patients with decompensated RVF secondary to pre-capillary PH found that a dynamic MAP goal determined by invasively obtained central venous pressure or right atrial pressure was associated with a statistically significant decrease in in-hospital mortality and incidence of acute kidney injury compared to a static MAP goal of 65 or 70 mmHg 2.
- A meta-analysis of randomized controlled trials found that a higher MAP goal (> 70 mmHg) was associated with similar risk of mortality, duration of mechanical ventilation, and ICU length of stay compared to a standard MAP goal (60-70 mmHg) in critically ill patients 3.
- A study of patients with heart failure found that a higher MAP was associated with a lower risk of all-cause mortality and readmission, with a threshold analysis indicating that a MAP of ≤ 93 mmHg was associated with improved outcomes 4.
- The ratio of MAP to right atrial pressure (RAP) has been identified as a predictor of outcome after successful percutaneous edge-to-edge repair for severe mitral valve regurgitation, with a MAP/RAP ratio threshold of 7.13 associated with improved event-free survival 5.
- A multicentre, randomized, controlled trial is currently underway to compare three different strategies of MAP management during cardiopulmonary bypass, including a "standard MAP" (50-60 mmHg), a "high MAP" (70-80 mmHg), and a "patient-tailored MAP" (comparable to the patient's preoperative MAP) 6.