In cardiac surgery, the association between hypotension during specific intraoperative phases or vasopressor-inotropes with adverse outcomes remains unclear. This study’s hypothesis was that intraoperative hypotension duration throughout the surgery or when separated into hypotension during and outside cardiopulmonary bypass may be associated with postoperative major adverse events.


This retrospective observational cohort study included data for adults who had cardiac surgery between 2008 and 2016 in a tertiary hospital. Intraoperative hypotension was defined as mean arterial pressure of less than 65 mmHg. The total duration of hypotension was divided into three categories based on the fraction of overall hypotension duration that occurred during cardiopulmonary bypass (more than 80%, 80 to 60%, and less than 60%). The primary outcome was a composite of stroke, acute kidney injury, or mortality during the index hospitalization. The association with the composite outcome was evaluated for duration of hypotension during the entire surgery, outside cardiopulmonary bypass, and during cardiopulmonary bypass and the fraction of hypotension during cardiopulmonary bypass adjusting for vasopressor-inotrope dose, milrinone dose, patient, and surgical factors.


The composite outcome occurred in 256 (5.1%) of 4,984 included patient records; 66 (1.3%) patients suffered stroke, 125 (2.5%) had acute kidney injury, and 109 (2.2%) died. The primary outcome was associated with total duration of hypotension (adjusted odds ratio, 1.05; 95% CI, 1.02 to 1.08; P = 0.032), hypotension outside cardiopulmonary bypass (adjusted odds ratio, 1.06; 95% CI, 1.03 to 1.10; P = 0.001) per 10-min exposure to mean arterial pressure of less than 65 mmHg, and fraction of hypotension duration during cardiopulmonary bypass of less than 60% (reference greater than 80%; adjusted odds ratio, 1.67; 95% CI, 1.10 to 2.60; P = 0.019) but not with each 10-min period hypotension during cardiopulmonary bypass (adjusted odds ratio, 1.04; 95% CI, 0.99 to 1.09; P = 0.118), fraction of hypotension during cardiopulmonary bypass of 60 to 80% (adjusted odds ratio, 1.45; 95% CI, 0.97 to 2.23; P = 0.082), or total vasopressor-inotrope dose (adjusted odds ratio, 1.00; 95% CI, 1.00 to 1.00; P = 0.247).


This study confirms previous single-center findings that intraoperative hypotension throughout cardiac surgery is associated with an increased risk of acute kidney injury, mortality, or stroke.

Editor’s Perspective
What We Already Know about This Topic
  • Single-center data demonstrate that intraoperative hypotension during cardiac surgery is independently associated with stroke and acute kidney injury
  • The reproducibility of this observation and whether the timing of hypotension during cardiac surgery (within vs. outside the cardiopulmonary bypass period) modifies the association remain unclear
What This Article Tells Us That Is New
  • Among 4,984 patients undergoing cardiac surgery at a single tertiary care center between 2008 and 2016, 256 (5.1%) experienced the primary outcome of stroke (66, 1.3%), acute kidney injury (125, 2.5%), or mortality (109, 2.2%)
  • Each 10 min of hypotension (mean arterial pressure of less than 65 mmHg) during, before, or after cardiopulmonary bypass was associated with an increased odds ratio of 1.06 (95% CI, 1.03 to 1.10; P = 0.001)
  • Intraoperative hypotension, even if it occurs outside of cardiopulmonary bypass, is independently associated with stroke, acute kidney injury, or death after cardiac surgery