Monitoring of selective antegrade cerebral perfusion using near infrared spectroscopy in neonatal aortic arch surgery

Hofer, Anna; Haizinger, Bettina; Geiselseder, Gertraud; Mair, Rudolf; Rehak, Peter; Gombotz, Hans

doi:10.1017/s0265021505000499

Cited by 40 publications

(19 citation statements)

References 31 publications

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“…The animal and human data reviewed above suggest that ACP flows, with the technique described by Pigula et al (2), should be at least 40 ml/kg/min or more for most patients, again guided by neuromonitoring (18,19,21,23). Flows less than this are consistently associated with the development of low cerebral oxygen tensions, placing the patient at risk, which may be silent in the absence of monitoring.…”

Section: Discussionmentioning

confidence: 99%

Principles of Antegrade Cerebral Perfusion During Arch Reconstruction in Newborns/Infants

Fraser

Andropoulos

2008

Seminars in Thoracic and Cardiovascular Surgery: Pediatric Card

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Antegrade cerebral perfusion (ACP) is a cardiopulmonary bypass technique that uses special cannulation procedures to perfuse only the brain during neonatal and infant aortic arch reconstruction. It is used in lieu of deep hypothermic circulatory arrest (DHCA), and thus has the theoretical advantage of protecting the brain from hypoxic ischemic injury. Despite this, recent comparative studies have demonstrated no difference in neurodevelopmental outcomes with ACP vs. DHCA for neonatal arch repair. This article presents animal and human data demonstrating that ACP flows less than 30 ml/kg/min are inadequate for many patients, and may be the explanation for lack of outcome difference vs. DHCA. A technique for ACP, its physiologic basis, and a neuromonitoring strategy are presented, and then the results of an outcome study are reviewed demonstrating that with ACP technique at higher flows of 50-80 ml/kg/min guided by neuromonitoring, periventricular leukomalacia (PVL) is eliminated on postoperative brain MRI after neonatal cardiac surgery.

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Section: Discussionmentioning

confidence: 99%

Principles of Antegrade Cerebral Perfusion During Arch Reconstruction in Newborns/Infants

Fraser

Andropoulos

2008

Seminars in Thoracic and Cardiovascular Surgery: Pediatric Card

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“…The cerebral protection methods currently used for aortic surgery and complex open heart surgery are profound hypothermic circulatory arrest with or without retrograde cerebral perfusion, and antegrade RCP (Hofer et al, 2005;Lee et al, 2011;Algra et al, 2012;Pacini et al, 2012;Senanayake et al, 2012). Each technique has its own advantages and disadvantages.…”

Section: Discussionmentioning

confidence: 99%

“…The animal and human data reviewed above suggest that RCP flows, with the technique described by Pigula et al (2000), should be at least 40 mL/(kg$minute) or more for most patients, again guided by neuromonitoring (Hofer et al, 2005;Amir et al, 2006;Chock et al, 2006;Schears et al, 2006). Flows less than this are consistently associated with the development of low cerebral oxygen tensions, placing the patient at risk, which may be dangerous in the absence of monitoring.…”

Section: Guo Et Almentioning

confidence: 99%

“…Various strategies, including antegrade and retrograde cerebral perfusion are used for preventing neurological problems and allowing the surgeons more time for optimal repair and hemostasis has been developed (Griepp, 2001;Lee et al, 2011;Pacini et al, 2012;Senanayake et al, 2012). Regional cerebral perfusion (RCP), also called antegrade cerebral perfusion is one of the most promising cerebral protection techniques and is dominantly used in children (Hofer et al, 2005;Algra et al, 2012;Pacini et al, 2012;Senanayake et al, 2012). RCP has been the cerebral protection method of choice in the Shanghai Children's Medical Center since 2004.…”

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confidence: 99%

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Usefulness of Deep Hypothermic Circulatory Arrest and Regional Cerebral Perfusion in Children

Guo

Zhang

et al. 2013

Therapeutic Hypothermia and Temperature Management

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To compare the safety and usefulness of deep hypothermic circulatory arrest (DHCA) and regional cerebral perfusion (RCP) during pediatric open heart surgery. Between January 1, 2004 and September 30, 2012, 1250 children with congenital cardiac defect underwent corrective operation with the DHCA or RCP technique in the Shanghai Children's Medical Center. Of them, 947 cases underwent the operation with the aid of DHCA (DHCA group), and 303 cases with RCP (RCP group). The mean DHCA time was 30.64 -15.81 (7-63) minutes and mean RCP time was 36.18 -12.86 (10-82) minutes. The mortality rate was 7.18% (68/947) and 6.60% (20/30) in two groups, respectively. The postoperative incidences of temporary and permanent neurological dysfunction were 6.23% (59/947) in the DHCA group and 2.64% (8/303) in the RCP group ( p < 0.01). The incidence of other complications such as low cardiac output, renal dysfunction, and lung issues are similar in both groups. RCP is a reliable technique for cerebral protection and it facilitates time-consuming corrected procedures for complex congenital cardiac defect repair procedures.

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“…Older studies stated that perfusion pressures of 40 mm Hg and flow rates of 20 mL/kg/min were acceptable for the maintenance of baseline cerebral saturations. More recently, by recording the Doppler velocity in left middle cerebral artery and alpha‐stat strategy, Hofer et al were not able to detect cerebral blood flow in 3 of 10 patients at an SACP flow rate of 20 mL/kg/min and in 4 of 10 patients at 10 mL/kg/min, suggesting that SACP at these flow rates may produce ischemia in some patients, similar to DHCA. Andropoulos et al proposed a physiological monitoring strategy to guide SACP: cerebral regional saturation (rSO 2 ) and Doppler velocity were measured after cooling to 17‐22°C during full‐flow bypass and using pH‐stat strategy, then regional low‐flow perfusion was instituted and CPB flow rate was adjusted so as to maintain cerebral rSO 2 and Doppler velocities within 10% of baseline .…”

Section: Hypothermiamentioning

confidence: 99%

Recent achievements and future developments in neonatal cardiopulmonary bypass

Bojan

2019

Pediatric Anesthesia

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Summary A primary goal of improving neonatal cardiopulmonary bypass has been making the circuit smaller and reduce the blood contacting surfaces. As bypass circuit size has decreased, bloodless surgery has become possible even in neonates. Since transfusion guidelines are difficult to construct based on existing literature, these technical advances should be taken advantage of in conjunction with an individualized transfusion scheme, based on monitoring of oxygen availability to the tissues. For the majority of neonatal heart operations, several centers have shifted toward normothermic bypass even for complex neonatal surgeries, in order to avoid the adverse effects of hypothermia. Deep hypothermic circulatory arrest is no longer a necessity but an option, and selective antegrade cerebral perfusion has become common practice; however, technical uncertainties with regard to this technique have to be addressed, based on reliable neurologic monitoring. Maintenance of patient‐specific heparin concentrations during bypass is another key goal, since neonates have lower baseline antithrombin concentrations and, therefore, a higher risk for inadequate thrombin inhibition and postoperative bleeding. Due to the immaturity of their hemostatic system, the standard coagulation tests alone are inappropriate to guide hemostatic therapy in neonates. The use of indirect heparin concentration assays and global viscoelastic assays in the operating room is likely to represent the optimal strategy, and requires validation in neonates. Monitoring of global and regional indexes of oxygen availability and consumption on bypass have become possible; however, their use in neonates still has outstanding technical issues which should be addressed and hence needs further validation. Due to the immaturity of the neonatal myocardium, single‐shot cold cardioplegia solutions are thought to confer the best myocardial protection; their superiority when compared to more conventional modalities, however, remains to be demonstrated.

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Monitoring of selective antegrade cerebral perfusion using near infrared spectroscopy in neonatal aortic arch surgery

Abstract: Near infrared spectroscopy reliably detects flow alterations during ACP with profound hypothermia.

Cited by 40 publications

References 31 publications

Principles of Antegrade Cerebral Perfusion During Arch Reconstruction in Newborns/Infants

Principles of Antegrade Cerebral Perfusion During Arch Reconstruction in Newborns/Infants

Usefulness of Deep Hypothermic Circulatory Arrest and Regional Cerebral Perfusion in Children

Recent achievements and future developments in neonatal cardiopulmonary bypass

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