Recent Advances in Congenital Heart Surgery: Alternative Perfusion Strategies for Infant Aortic Arch Repair

  • Andrew J. LodgeEmail author
  • Nicholas D. Andersen
  • Joseph W. Turek
Congenital Heart Disease (RA Krasuski, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Congenital Heart Disease


Purpose of Review

This paper will discuss current cannulation strategies for infant aortic arch repair and compare them to more traditionally used techniques.

Recent Findings

Aortic arch reconstruction in infants has traditionally involved deep hypothermic circulatory arrest which results in total body ischemia. This has been associated with an increased risk of morbidity including bleeding, renal dysfunction, and neurologic injury. Advances in perfusion techniques have allowed for preserved perfusion to the brain during arch repair. Current techniques have further evolved that allow for continuous perfusion of the heart and even the lower body during arch reconstruction.


With current techniques, aortic arch reconstruction in infants can be performed with continuous perfusion to the brain, heart, and lower body. Further technical refinements will be helpful, and study is necessary to evaluate the benefit of these strategies.


Aortic arch Perfusion Cardiopulmonary bypass Infant Congenital heart surgery 


Compliance with Ethical Standards

Conflict of Interest

Andrew J. Lodge, Nicholas D. Andersen, and Joseph W. Turek declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

All cited studies performed by the authors have been approved by the appropriate institutional and/or national research ethics committee and have been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Bellinger DC, Jonas RA, Rappaport LA, Wypij D, Wernovsky G, Kuban KC, et al. Developmental and neurologic status of children after heart surgery with hypothermic circulatory arrest or low-flow cardiopulmonary bypass. N Engl J Med. 1995;332(9):549–55. Scholar
  2. 2.
    Clancy RR, McGaurn SA, Wernovsky G, Gaynor JW, Spray TL, Norwood WI, et al. Risk of seizures in survivors of newborn heart surgery using deep hypothermic circulatory arrest. Pediatrics. 2003;111(3):592–601.CrossRefGoogle Scholar
  3. 3.
    Gil-Ruiz Gil-Esparza MA, Alcaraz Romero AJ, Romero Otero A, Gil Villanueva N, Sanavia Moran E, Rodriguez Sanchez de la Blanca A et al. Prognostic relevance of early AKI according to pRIFLE criteria in children undergoing cardiac surgery. Pediatr Nephrol 2014;29(7):1265–1272. doi:
  4. 4.
    du Plessis AJ, Treves ST, Hickey PR, O'Tuama L, Barlow CF, Costello J, et al. Regional cerebral perfusion abnormalities after cardiac operations. Single photon emission computed tomography (SPECT) findings in children with postoperative movement disorders. J Thorac Cardiovasc Surg. 1994;107(4):1036–43.PubMedGoogle Scholar
  5. 5.
    Ferry PC. Neurologic sequelae of open-heart surgery in children. An ‘irritating question’. Am J Dis Child. 1990;144(3):369–73.CrossRefGoogle Scholar
  6. 6.
    Jonas RA. Deep hypothermic circulatory arrest: current status and indications. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2002;5:76–88. Scholar
  7. 7.
    Langley SM, Chai PJ, Miller SE, Mault JR, Jaggers JJ, Tsui SS, et al. Intermittent perfusion protects the brain during deep hypothermic circulatory arrest. Ann Thorac Surg. 1999;68(1):4–12 discussion −3.CrossRefGoogle Scholar
  8. 8.
    Mault JR, Whitaker EG, Heinle JS, Lodge AJ, Greeley WJ, Ungerleider RM. Intermittent perfusion during hypothermic circulatory arrest: a new and effective technique for cerebral protection. Surg Forum. 1992;44:314.Google Scholar
  9. 9.
    Mault JR, Whitaker EG, Heinle JS, Lodge AJ, Greeley WJ, Ungerleider RM. Cerebral metabolic effects of sequential periods of hypothermic circulatory arrest. Ann Thorac Surg. 1994;57(1):96–100 discussion −1.CrossRefGoogle Scholar
  10. 10.
    Nelson DP, Andropoulos DB, Fraser CD Jr. Perioperative neuroprotective strategies. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2008;11:49–56. Scholar
  11. 11.
    Pizarro C, Sood ED, Kerins P, Duncan D, Davies RR, Woodford E. Neurodevelopmental outcomes after infant cardiac surgery with circulatory arrest and intermittent perfusion. Ann Thorac Surg. 2014;98(1):119–24. Scholar
  12. 12.
    Whitaker EG, Mault JR, Heinle JS, Lodge AJ, Greeley WJ, Jobsis-VanderVliet FF, et al. Near-infrared spectroscopy for non-invasive cerebral metabolic monitoring during congenital heart repair. Surg Forum. 1993;45:211–2.Google Scholar
  13. 13.
    Zhang H, Cheng P, Hou J, Li L, Liu H, Liu R, et al. Regional cerebral perfusion for surgical correction of neonatal aortic arch obstruction. Perfusion. 2009;24(3):185–9. Scholar
  14. 14.
    Amir G, Frenkel G, Shukrun G, Gogia O, Bachar O, Bruckheimer E, et al. Direct innominate artery cannulation for antegrade cerebral perfusion in neonates undergoing arch reconstruction. Ann Thorac Surg. 2013;95(3):956–61. Scholar
  15. 15.
    Malhotra SP, Hanley FL. Routine continuous perfusion for aortic arch reconstruction in the neonate. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2008;11:57–60. Scholar
  16. 16.
    Nasirov T, Mainwaring RD, Reddy VM, Sleasman J, Margetson T, Hanley FL. Innominate artery cannulation and antegrade cerebral perfusion for aortic arch reconstruction in infants and children. World J Pediatr Congenit Heart Surg. 2013;4(4):356–61. Scholar
  17. 17.
    Algra SO, Schouten AN, van Oeveren W, van der Tweel I, Schoof PH, Jansen NJ, et al. Low-flow antegrade cerebral perfusion attenuates early renal and intestinal injury during neonatal aortic arch reconstruction. J Thorac Cardiovasc Surg. 2012;144(6):1323–8, 8 e1–2. Scholar
  18. 18.
    Algra SO, Kornmann VN, van der Tweel I, Schouten AN, Jansen NJ, Haas F. Increasing duration of circulatory arrest, but not antegrade cerebral perfusion, prolongs postoperative recovery after neonatal cardiac surgery. J Thorac Cardiovasc Surg. 2012;143(2):375–82. Scholar
  19. 19.
    Andropoulos DB, Easley RB, Brady K, McKenzie ED, Heinle JS, Dickerson HA, et al. Neurodevelopmental outcomes after regional cerebral perfusion with neuromonitoring for neonatal aortic arch reconstruction. Ann Thorac Surg. 2013;95(2):648–54; discussion 54–5. Scholar
  20. 20.
    Goldberg CS, Bove EL, Devaney EJ, Mollen E, Schwartz E, Tindall S, et al. A randomized clinical trial of regional cerebral perfusion versus deep hypothermic circulatory arrest: outcomes for infants with functional single ventricle. J Thorac Cardiovasc Surg. 2007;133(4):880–7. Scholar
  21. 21.
    • Kornilov IA, Sinelnikov YS, Soinov IA, Ponomarev DN, Kshanovskaya MS, Krivoshapkina AA, et al. Outcomes after aortic arch reconstruction for infants: deep hypothermic circulatory arrest versus moderate hypothermia with selective antegrade cerebral perfusion. Eur J Cardiothorac Surg. 2015;48(3):e45–50. This study is important because it provided evidence that RCP provides protection from neurolgic injury compared to DHCA. Interestingly, however, it showed a higher incidence of renal insufficiency in the RCP patients indicating the attention to flow rate, temperature, and adequate distal perfusion is necessary.CrossRefPubMedGoogle Scholar
  22. 22.
    Algra SO, Jansen NJ, van der Tweel I, Schouten AN, Groenendaal F, Toet M, et al. Neurological injury after neonatal cardiac surgery: a randomized, controlled trial of 2 perfusion techniques. Circulation. 2014;129(2):224–33. Scholar
  23. 23.
    • Carlson AM, Tcheng JW, Holgren SE, Turek JW. Beating-heart sliding arch aortoplasty for arch hypoplasia beyond infancy. Innovations (Phila). 2015;10(6):441–3. This report is important in that it illustrates the successful use of a beating heart technique with continuous coronary perfusion for complex aortic arch reconstruction in children.CrossRefGoogle Scholar
  24. 24.
    Kotani Y, Ishino K, Kasahara S, Yoshizumi K, Honjo O, Kawada M, et al. Continuous cerebral and myocardial perfusion during aortic arch repair in neonates and infants. ASAIO J. 2006;52(5):536–8. Scholar
  25. 25.
    Turek JW, Hanfland RA, Davenport TL, Torres JE, Duffey DA, Patel SS, et al. Norwood reconstruction using continuous coronary perfusion: a safe and translatable technique. Ann Thorac Surg. 2013;96(1):219–23: discussion 23-4. Scholar
  26. 26.
    Gupta B, Dodge-Khatami A, Tucker J, Taylor MB, Maposa D, Urencio M, et al. Antegrade cerebral perfusion at 25 °C for arch reconstruction in newborns and children preserves perioperative cerebral oxygenation and serum creatinine. Transl Pediatr. 2016;5(3):114–24. Scholar
  27. 27.
    • Karavas AN, Deschner BW, Scott JW, Mettler BA, Bichell DP. Three-region perfusion strategy for aortic arch reconstruction in the Norwood. Ann Thorac Surg. 2011;92(3):1138–40. This is a report of the successful use of three region perfusion (simultaneous perfusion of the heart, brain, and lower body during the Norwood procedure. The Norwood procedure is a complex operation performed in a neonate involving reconstruction of the aortic arch.CrossRefPubMedGoogle Scholar
  28. 28.
    Rajagopal SK, Emani SM, Roy N, Westgate L, Bacha EA. Acute kidney injury and regional abdominal perfusion during neonatal aortic arch reconstruction. J Thorac Cardiovasc Surg. 2010;140(2):453–8. Scholar
  29. 29.
    Raees MA, Morgan CD, Pinto VL, Westrick AC, Shannon CN, Christian KG, et al. Neonatal aortic arch reconstruction with direct splanchnic perfusion avoids deep hypothermia. Ann Thorac Surg. 2017;104(6):2054–63. Scholar
  30. 30.
    Hammel JM, Deptula JJ, Karamlou T, Wedemeyer E, Abdullah I, Duncan KF. Newborn aortic arch reconstruction with descending aortic cannulation improves postoperative renal function. Ann Thorac Surg. 2013;96(5):1721–6; discussion 6. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Andrew J. Lodge
    • 1
    Email author
  • Nicholas D. Andersen
    • 2
  • Joseph W. Turek
    • 2
  1. 1.Duke University Medical Center, Pediatric and Congenital Heart Center, Division of Cardiovascular and Thoracic SurgeryDurhamUSA
  2. 2.Pediatric and Congenital Heart CenterDuke University Medical CenterDurhamUSA

Personalised recommendations