Cerebral and myocardial perfusion strategies in neonatal aortic arch repair_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

TONG Yuanyuan ,  LIU Jinping

Department of Pediatric Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P.R.China;

Corresponding author：

LIU Jinping, Email: jinpingfw@hotmail.com

Keywords：

Neonates; aortic arch repair; cerebral perfusion; myocardial perfusion

DOI：

10.7507/1007-4848.201711033

Video：

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Myocardial and cerebral protection are always the major concerns in neonatal aortic arch surgery. From the application of deep hypothermic circulatory arrest technology to continuous cardio-cerebral perfusion strategy adopted in many cardiac centers recently, each perfusion method has its own pros and cons, so there is no consensus on which one is the most suitable. This review aims to summarize the development and research progress of various perfusion methods, so that to provide a foundation for further development.

Citation： TONG Yuanyuan, LIU Jinping. Cerebral and myocardial perfusion strategies in neonatal aortic arch repair. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2018, 25(9): 809-813. doi: 10.7507/1007-4848.201711033 Copy

1.	Law MA, Bhimji SS. Aortic, Coarctation. Treasure Island (FL): StatPearls Publishing LLC, 2017.
2.	Desai J, Aggarwal S, Lipshultz S, et al. Surgical interventions in infants born preterm with congenital heart defects: An analysis of the kids' inpatient database. J Pediatr, 2017, 191: 103-109.
3.	Fudulu D, Angelini G. Oxidative stress after surgery on the immature heart. Oxid Med Cell Longev, 2016, 2016: 1971452.
4.	Bellinger DC, Wypij D, Rivkin MJ, et al. Adolescents with d-transposition of the great arteries corrected with the arterial switch procedure: neuropsychological assessment and structural brain imaging. Circulation, 2011, 124(12): 1361-1369.
5.	Creighton DE, Robertson CM, Sauve RS, et al. Neurocognitive, functional, and health outcomes at 5 years of age for children after complex cardiac surgery at 6 weeks of age or younger. Pediatrics, 2007, 120(3): e478-e486.
6.	Bergeron EJ, Mosca MS, Aftab M, et al. Neuroprotection strategies in aortic surgery. Cardiol Clin, 2017, 35(3): 453-465.
7.	Barratt-Boyes BG, Simpson M, Neutze JM. Intracardiac surgery in neonates and infants using deep hypothermia with surface cooling and limited cardiopulmonary bypass. Circulation, 1971, 43(5 Suppl): I25-I30.
8.	Haldenwang PL, Bechtel M, Moustafine V, et al. State of the art in neuroprotection during acute type A aortic dissection repair. Perfusion, 2012, 27(2): 119-126.
9.	Pizarro C, Sood ED, Kerins P, et al. Neurodevelopmental outcomes after infant cardiac surgery with circulatory arrest and intermittent perfusion. Ann Thorac Surg, 2014, 98(1): 119-124.
10.	Yoo JS, Kim JB, Joo Y, et al. Deep hypothermic circulatory arrest versus non-deep hypothermic beating heart strategy in descending thoracic or thoracoabdominal aortic surgery. Eur J Cardiothorac Surg, 2014, 46(4): 678-684.
11.	Algra SO, Jansen NJ, van der Tweel I, et al. Neurological injury after neonatal cardiac surgery: a randomized, controlled trial of 2 perfusion techniques. Circulation, 2014, 129(2): 224-233.
12.	Hagl C, Khaladj N, Karck M, et al. Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of different cerebral perfusion techniques and other methods of cerebral protection. Eur J Cardiothorac Surg, 2003, 24(3): 371-378.
13.	Zierer A, Aybek T, Risteski P, et al. Moderate hypothermia (30 degrees C) for surgery of acute type A aortic dissection. Thorac Cardiovasc Surg, 2005, 53(2): 74-79.
14.	Guo Z, Li X. 2016 survey about temperature management during extracorporeal circulation in China. Perfusion, 2018, 33(3): 219-227.
15.	Gupta B, Dodge-Khatami A, Tucker J, et al. Antegrade cerebral perfusion at 25℃ for arch reconstruction in newborns and children preserves perioperative cerebral oxygenation and serum creatinine. Transl Pediatr, 2016, 5(3): 114-124.
16.	Garg V, Tsirigotis DN, Dickson J, et al. Direct innominate artery cannulation for selective antegrade cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery. J Thorac Cardiovasc Surg, 2014, 148(6): 2920-2924.
17.	Nasirov T, Mainwaring RD, Reddy VM, et al. Innominate artery cannulation and antegrade cerebral perfusion for aortic arch reconstruction in infants and children. World J Pediatr Congenit Heart Surg, 2013, 4(4): 356-361.
18.	De Paulis R, Czerny M, Weltert L, et al. Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe. Eur J Cardiothorac Surg, 2015, 47(5): 917-923.
19.	Garg V, Peterson MD, Chu MW, et al. Axillary versus innominate artery cannulation for antegrade cerebral perfusion in aortic surgery: design of the Aortic Surgery Cerebral Protection Evaluation (ACE) CardioLink-3 randomised trial. BMJ Open, 2017, 7(6): e014491.
20.	Hagl C, Ergin MA, Galla JD, et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg, 2001, 121(6): 1107-1121.
21.	Rüffer A, Tischer P, Münch F, et al. Comparable cerebral blood flow in both hemispheres during regional cerebral perfusion in infant aortic arch surgery. Ann Thorac Surg, 2017, 103(1): 178-185.
22.	Aytekin B, Ünal EU, Demir A, et al. Unilateral antegrade cerebral perfusion and moderate hypothermia: Assessing safety with novel biomarkers. Heart Lung Circ, 2017, 26(5): 495-503.
23.	Meyer DB, Jacobs JP, Hill K, et al. Variation in perfusion strategies for neonatal and infant aortic arch repair: Contemporary practice in the STS Congenital Heart Surgery Database. World J Pediatr Congenit Heart Surg, 2016, 7(5): 638-644.
24.	Masuda Z, Ishino K, Kato G, et al. Isolated cerebral and myocardial perfusion during aortic arch repair in neonates. J Cardiol, 2001, 38(3): 163-168.
25.	Lim HG, Kim WH, Park CS, et al. Usefulness of regional cerebral perfusion combined with coronary perfusion during one-stage total repair of aortic arch anomaly. Ann Thorac Surg, 2010, 90(1): 50-57.
26.	De Rita F, Lucchese G, Barozzi L, et al. Selective cerebro-myocardial perfusion in complex congenital aortic arch pathology: a novel technique. Artif Organs, 2011, 35(11): 1029-1035.
27.	Asou T, Kado H, Imoto Y, et al. Selective cerebral perfusion technique during aortic arch repair in neonates. Ann Thorac Surg, 1996, 61(5): 1546-1548.
28.	Lim HG, Kim WH, Jang WS, et al. One-stage total repair of aortic arch anomaly using regional perfusion. Eur J Cardiothorac Surg, 2007, 31(2): 242-248.
29.	Turkoz R, Saritas B, Ozker E, et al. Selective cerebral perfusion with aortic cannulation and short-term hypothermic circulatory arrest in aortic arch reconstruction. Perfusion, 2014, 29(1): 70-74.
30.	Martens A, Koigeldiyev N, Beckmann E, et al. Do not leave the heart arrested. Non-cardioplegic continuous myocardial perfusion during complex aortic arch repair improves cardiac outcome. Eur J Cardiothorac Surg, 2016, 49(1): 141-148.
31.	Ishino K, Sano S. Aortic arch repair with a working beating heart in premature infants. J Thorac Cardiovasc Surg, 2003, 126(5): 1653-1654.
32.	Kostelka M, Walther T, Geerdts I, et al. Primary repair for aortic arch obstruction associated with ventricular septal defect. Ann Thorac Surg, 2004, 78(6): 1989-1993.
33.	Martens A, Beckmann E, Kaufeld T, et al. Total aortic arch repair: risk factor analysis and follow-up in 199 patients. Eur J Cardiothorac Surg, 2016, 50(5): 940-948.
34.	Carlson AM, Tcheng JW, Holgren SE, et al. Beating-heart sliding arch aortoplasty for arch hypoplasia beyond infancy. Innovations (Phila), 2015, 10(6): 441-443.
35.	Chen H, Zhang H, Hong H, et al. Outcome of continuous cerebral and myocardial perfusion under mild hypothermia for aortic coarctation with ventricular septal defect repair. J Card Surg, 2013, 28(1): 64-69.
36.	Janssen C, Kellermann S, Münch F, et al. Myocardial protection during aortic arch repair in a piglet model: beating heart technique compared with crystalloid cardioplegia. Ann Thorac Surg, 2015, 100(5): 1758-1766.
37.	Turek JW, Hanfland RA, Davenport TL, et al. Norwood reconstruction using continuous coronary perfusion: a safe and translatable technique. Ann Thorac Surg, 2013, 96(1): 219-223.
38.	Malec E, Schmidt C, Lehner A, et al. Results of the Fontan operation with no early mortality in 248 consecutive patients. Kardiol Pol, 2017, 75(3): 255-260.
39.	Kotani Y, Ishino K, Kasahara S, et al. Continuous cerebral and myocardial perfusion during aortic arch repair in neonates and infants. ASAIO J, 2006, 52(5): 536-538.

1. Law MA, Bhimji SS. Aortic, Coarctation. Treasure Island (FL): StatPearls Publishing LLC, 2017.
2. Desai J, Aggarwal S, Lipshultz S, et al. Surgical interventions in infants born preterm with congenital heart defects: An analysis of the kids' inpatient database. J Pediatr, 2017, 191: 103-109.
3. Fudulu D, Angelini G. Oxidative stress after surgery on the immature heart. Oxid Med Cell Longev, 2016, 2016: 1971452.
4. Bellinger DC, Wypij D, Rivkin MJ, et al. Adolescents with d-transposition of the great arteries corrected with the arterial switch procedure: neuropsychological assessment and structural brain imaging. Circulation, 2011, 124(12): 1361-1369.
5. Creighton DE, Robertson CM, Sauve RS, et al. Neurocognitive, functional, and health outcomes at 5 years of age for children after complex cardiac surgery at 6 weeks of age or younger. Pediatrics, 2007, 120(3): e478-e486.
6. Bergeron EJ, Mosca MS, Aftab M, et al. Neuroprotection strategies in aortic surgery. Cardiol Clin, 2017, 35(3): 453-465.
7. Barratt-Boyes BG, Simpson M, Neutze JM. Intracardiac surgery in neonates and infants using deep hypothermia with surface cooling and limited cardiopulmonary bypass. Circulation, 1971, 43(5 Suppl): I25-I30.
8. Haldenwang PL, Bechtel M, Moustafine V, et al. State of the art in neuroprotection during acute type A aortic dissection repair. Perfusion, 2012, 27(2): 119-126.
9. Pizarro C, Sood ED, Kerins P, et al. Neurodevelopmental outcomes after infant cardiac surgery with circulatory arrest and intermittent perfusion. Ann Thorac Surg, 2014, 98(1): 119-124.
10. Yoo JS, Kim JB, Joo Y, et al. Deep hypothermic circulatory arrest versus non-deep hypothermic beating heart strategy in descending thoracic or thoracoabdominal aortic surgery. Eur J Cardiothorac Surg, 2014, 46(4): 678-684.
11. Algra SO, Jansen NJ, van der Tweel I, et al. Neurological injury after neonatal cardiac surgery: a randomized, controlled trial of 2 perfusion techniques. Circulation, 2014, 129(2): 224-233.
12. Hagl C, Khaladj N, Karck M, et al. Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of different cerebral perfusion techniques and other methods of cerebral protection. Eur J Cardiothorac Surg, 2003, 24(3): 371-378.
13. Zierer A, Aybek T, Risteski P, et al. Moderate hypothermia (30 degrees C) for surgery of acute type A aortic dissection. Thorac Cardiovasc Surg, 2005, 53(2): 74-79.
14. Guo Z, Li X. 2016 survey about temperature management during extracorporeal circulation in China. Perfusion, 2018, 33(3): 219-227.
15. Gupta B, Dodge-Khatami A, Tucker J, et al. Antegrade cerebral perfusion at 25℃ for arch reconstruction in newborns and children preserves perioperative cerebral oxygenation and serum creatinine. Transl Pediatr, 2016, 5(3): 114-124.
16. Garg V, Tsirigotis DN, Dickson J, et al. Direct innominate artery cannulation for selective antegrade cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery. J Thorac Cardiovasc Surg, 2014, 148(6): 2920-2924.
17. Nasirov T, Mainwaring RD, Reddy VM, et al. Innominate artery cannulation and antegrade cerebral perfusion for aortic arch reconstruction in infants and children. World J Pediatr Congenit Heart Surg, 2013, 4(4): 356-361.
18. De Paulis R, Czerny M, Weltert L, et al. Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe. Eur J Cardiothorac Surg, 2015, 47(5): 917-923.
19. Garg V, Peterson MD, Chu MW, et al. Axillary versus innominate artery cannulation for antegrade cerebral perfusion in aortic surgery: design of the Aortic Surgery Cerebral Protection Evaluation (ACE) CardioLink-3 randomised trial. BMJ Open, 2017, 7(6): e014491.
20. Hagl C, Ergin MA, Galla JD, et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg, 2001, 121(6): 1107-1121.
21. Rüffer A, Tischer P, Münch F, et al. Comparable cerebral blood flow in both hemispheres during regional cerebral perfusion in infant aortic arch surgery. Ann Thorac Surg, 2017, 103(1): 178-185.
22. Aytekin B, Ünal EU, Demir A, et al. Unilateral antegrade cerebral perfusion and moderate hypothermia: Assessing safety with novel biomarkers. Heart Lung Circ, 2017, 26(5): 495-503.
23. Meyer DB, Jacobs JP, Hill K, et al. Variation in perfusion strategies for neonatal and infant aortic arch repair: Contemporary practice in the STS Congenital Heart Surgery Database. World J Pediatr Congenit Heart Surg, 2016, 7(5): 638-644.
24. Masuda Z, Ishino K, Kato G, et al. Isolated cerebral and myocardial perfusion during aortic arch repair in neonates. J Cardiol, 2001, 38(3): 163-168.
25. Lim HG, Kim WH, Park CS, et al. Usefulness of regional cerebral perfusion combined with coronary perfusion during one-stage total repair of aortic arch anomaly. Ann Thorac Surg, 2010, 90(1): 50-57.
26. De Rita F, Lucchese G, Barozzi L, et al. Selective cerebro-myocardial perfusion in complex congenital aortic arch pathology: a novel technique. Artif Organs, 2011, 35(11): 1029-1035.
27. Asou T, Kado H, Imoto Y, et al. Selective cerebral perfusion technique during aortic arch repair in neonates. Ann Thorac Surg, 1996, 61(5): 1546-1548.
28. Lim HG, Kim WH, Jang WS, et al. One-stage total repair of aortic arch anomaly using regional perfusion. Eur J Cardiothorac Surg, 2007, 31(2): 242-248.
29. Turkoz R, Saritas B, Ozker E, et al. Selective cerebral perfusion with aortic cannulation and short-term hypothermic circulatory arrest in aortic arch reconstruction. Perfusion, 2014, 29(1): 70-74.
30. Martens A, Koigeldiyev N, Beckmann E, et al. Do not leave the heart arrested. Non-cardioplegic continuous myocardial perfusion during complex aortic arch repair improves cardiac outcome. Eur J Cardiothorac Surg, 2016, 49(1): 141-148.
31. Ishino K, Sano S. Aortic arch repair with a working beating heart in premature infants. J Thorac Cardiovasc Surg, 2003, 126(5): 1653-1654.
32. Kostelka M, Walther T, Geerdts I, et al. Primary repair for aortic arch obstruction associated with ventricular septal defect. Ann Thorac Surg, 2004, 78(6): 1989-1993.
33. Martens A, Beckmann E, Kaufeld T, et al. Total aortic arch repair: risk factor analysis and follow-up in 199 patients. Eur J Cardiothorac Surg, 2016, 50(5): 940-948.
34. Carlson AM, Tcheng JW, Holgren SE, et al. Beating-heart sliding arch aortoplasty for arch hypoplasia beyond infancy. Innovations (Phila), 2015, 10(6): 441-443.
35. Chen H, Zhang H, Hong H, et al. Outcome of continuous cerebral and myocardial perfusion under mild hypothermia for aortic coarctation with ventricular septal defect repair. J Card Surg, 2013, 28(1): 64-69.
36. Janssen C, Kellermann S, Münch F, et al. Myocardial protection during aortic arch repair in a piglet model: beating heart technique compared with crystalloid cardioplegia. Ann Thorac Surg, 2015, 100(5): 1758-1766.
37. Turek JW, Hanfland RA, Davenport TL, et al. Norwood reconstruction using continuous coronary perfusion: a safe and translatable technique. Ann Thorac Surg, 2013, 96(1): 219-223.
38. Malec E, Schmidt C, Lehner A, et al. Results of the Fontan operation with no early mortality in 248 consecutive patients. Kardiol Pol, 2017, 75(3): 255-260.
39. Kotani Y, Ishino K, Kasahara S, et al. Continuous cerebral and myocardial perfusion during aortic arch repair in neonates and infants. ASAIO J, 2006, 52(5): 536-538.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Cerebral and myocardial perfusion strategies in neonatal aortic arch repair

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