Normothermic regional cerebro-myocardial perfusion in newborns undergoing aortic arch repair

Abstract

Introduction: Regardin the data of Andropoulos et al. perfusion volume speed should be individually chosen based on deep oxymetria and transcranial dopplerography [1]. Luciani et al. showed advantages of cerebral and myocardial perfusion under moderate hypothermia in comparison to standard perfusion [2]. They showed that standard perfusion and low cerebro-myocardial flow are predictors of myocardial dysfunction. We eventually have come to a decision to abstain from cardioplegia and hypothermia that way, first, removing myocardial dysfunction risk factors; second, shortening perfusion time, and third, preserving brain flow self-regulation. Method(s): After obtaining the ethics committee approval we prospectively analyzed results of neonatal aortic arch reconstruction in our clinic since July 2015. In this period of time we performed 36 operations for hypoplastic aortic arch in newborn. All the procedures were performed in normothermic (above 34 C) antegrade regional cerebral perfusion and coronary perfusion. We used transcranial doppler, deep cerebral oximetry and ECG to assess perfusion efficacy. Result(s): Mean age was 12.3 (6-23) days, weight - 3.2 (2.4-4.4) kg. Perfusion time was 70 (61.5;83.5) minutes, selective perfusion (antegrade regional cerebral and coronary) time was 28 (24;33.5) minutes. Perfusion flow was 118.5 (106;131.5) ml/kg/minute. Middle cerebral artery flow was 28 (22.5;33.25) cm/s on the right and 24 (18;27) cm/s on the left. ECG and deep cerebral oxygenation was stable through whole perfusion. Four (13.8%) patients required delayed sternal closure. In 6 hours after the operation vasoactive inotropic score was 10 (5;14.5), in 48 hours after the operation it was 5 (3;10). Lactate level was 3.2 (2.8;4.3) mmol/L in 6 hours after the procedure and 2.2 (1.85-3) mmol/L in 48 hours. Creatine phosphokinase (CPK) and creatine phosphokinase myocardial band (CPKMB) levels were 445.5 (302.75;632.5) U/L and 64 (51.25;96.5) U/L, respectively, in 6 hours and decreased to 126 (97;233) U/L and 50 (23;96) U/L in 48 hours after the operation. Troponin I level in 6 hours was 1.35 (0.95;1.5) ng/ml and in 48 hours - 0.62 (0.55;0.76) ng/ml. All patients regained consciousness in 24-48 hours after the operation with no neurologic deficiency. Mean ventilation time was 4.4 (1-11) days, mean ICU stay time was 5.9 (2-22) days. Hospital mortality was 2.8% (1 patient). Discussion(s): Normothermic antegrade regional cerebral perfusion with coronary perfusion is a safe and decent technique in neonatal aortic arch reconstruction. It allows to avoid such detrimental risk factors as circulatory arrest, hypothermia, extensive perfusion and cardioplegia.Copyright © 2020