Newborn Aortic Arch Reconstruction With Descending Aortic Cannulation Improves Postoperative Renal Function

摘要

Patients and GroupsSurgical TechniqueSelective cerebral perfusion with brief deep hypothermic circulatory arrestDual arterial perfusion with continuous cardiopulmonary bypassStatistical AnalysisLimitationsConclusionsDiscussionReferencesA clinically driven transition in perfusion technique occurred at Children's Hospital and Medical Center, Omaha, Nebraska, from primarily selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest to a technique of dual arterial perfusion including innominate artery and descending aortic cannulation (DAC), with continuous mildly hypothermic (>30°C) full-flow cardiopulmonary bypass to the entire body. This study retrospectively compared outcomes in a recent cohort of neonates undergoing aortic arch reconstruction with the two techniques.MethodsThe clinical records of 142 consecutive neonates undergoing operations involving aortic arch reconstruction at a single institution between April 2004 and September 2012 were reviewed. Renal function changes were graded according to the pediatric RIFLE score (based on risk, injury, failure, loss, and end-stage kidney disease). Sixteen patients, 8 supported with selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest and 8 with DAC, required immediate postoperative extracorporeal membrane oxygenation and were excluded from renal function analysis. Multivariable regression models evaluated predictors of pediatric RIFLE score.ResultsPatients with DAC had shorter median bypass support (113 versus 172 minutes; p < 0.001) and myocardial ischemic time (43 versus 81 minutes; p < 0.001). Patients with DAC had less median fluid gain at 24 hours (37 versus 69 mL/kg; p < 0.001), and lower incidence of acute kidney injury (5% versus 31%; p < 0.001). Fewer patients with DAC (31% versus 58%; p?= 0.001) required open chest. Use of selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest, single-ventricular physiology, and aortic cross-clamp time were found to be multivariable predictors of serious kidney dysfunction.ConclusionsMultisite arterial perfusion, including DAC, and maintenance of continuous mildly hypothermic full-flow cardiopulmonary bypass may offer advantages as a perfusion strategy for neonatal arch reconstruction. Prospective investigation of this technique is warranted.CTSNet classification:23Deep hypothermia with low-flow cardiopulmonary bypass or periods of complete circulatory arrest was instrumental in the earliest era of infant and pediatric cardiac surgery in that it allowed reduced exposure to the injurious effects of cardiopulmonary bypass, and permitted intracardiac and extracardiac repairs to be performed in a still, bloodless field free of obstructive perfusion cannulas. With the evolution of less damaging cardiopulmonary bypass techniques and systems, the availability of smaller and less obtrusive cannulas, refined surgical instrumentation, and visualization, and the increasing proficiency of cardiac surgical teams, the use of deep hypothermia and circulatory arrest for operations apart from reconstruction of the aortic arch has mostly disappeared, although for aortic arch reconstruction it remains the standard of care.Although survival after arch reconstruction has improved considerably, there remains important morbidity and mortality. The desire to improve both perioperative and longer-term outcomes requires consideration of intraoperative strategies that may lessen the impact of the operation on already compromised organ system functions. Techniques to augment perfusion of the lower body during aortic arch reconstruction have begun to attract interest.This retrospective study examines outcomes in neonates undergoing arch reconstruction for the full spectrum of anatomic diagnoses. Descending aortic cannulation (DAC) was initially applied at the Children's Hospital and Medical Center, Omaha, Nebraska, when it was believed to