Skip to main content

Advertisement

Log in

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

  • Congenital Heart Disease (RA Krasuski, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

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.

Summary

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

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

  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. https://doi.org/10.1056/NEJM199503023320901.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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:https://doi.org/10.1007/s00467-014-2757-z.

  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.

    PubMed  Google Scholar 

  5. Ferry PC. Neurologic sequelae of open-heart surgery in children. An ‘irritating question’. Am J Dis Child. 1990;144(3):369–73.

    Article  CAS  Google Scholar 

  6. Jonas RA. Deep hypothermic circulatory arrest: current status and indications. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2002;5:76–88. https://doi.org/10.1053/pcsu.2002.31493.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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. 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.

    Article  CAS  Google Scholar 

  10. Nelson DP, Andropoulos DB, Fraser CD Jr. Perioperative neuroprotective strategies. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2008;11:49–56. https://doi.org/10.1053/j.pcsu.2008.01.003.

    Article  Google Scholar 

  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. https://doi.org/10.1016/j.athoracsur.2014.02.042.

    Article  PubMed  Google Scholar 

  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. 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. https://doi.org/10.1177/0267659109346661.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.athoracsur.2012.10.029.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1053/j.pcsu.2007.12.004.

    Article  Google Scholar 

  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. https://doi.org/10.1177/2150135113497767.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.jtcvs.2012.03.008.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.jtcvs.2011.08.006.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.athoracsur.2012.04.070.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.jtcvs.2006.11.029.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1093/ejcts/ezv235 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.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1161/CIRCULATIONAHA.113.003312.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1097/IMI.0000000000000211 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.

    Article  Google Scholar 

  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. https://doi.org/10.1097/01.mat.0000235276.77489.bb.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.athoracsur.2013.03.049.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.21037/tp.2016.06.03.

    Article  PubMed  PubMed Central  Google Scholar 

  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. https://doi.org/10.1016/j.athoracsur.2011.03.122 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.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.jtcvs.2010.03.034.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.athoracsur.2017.04.037.

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.athoracsur.2013.06.033.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Andrew J. Lodge.

Ethics declarations

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.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Congenital Heart Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lodge, A.J., Andersen, N.D. & Turek, J.W. Recent Advances in Congenital Heart Surgery: Alternative Perfusion Strategies for Infant Aortic Arch Repair. Curr Cardiol Rep 21, 13 (2019). https://doi.org/10.1007/s11886-019-1098-8

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-019-1098-8

Keywords

Navigation