Regional Low-Flow Perfusion Versus Circulatory Arrest in Neonates: One-Year Neurodevelopmental Outcome

Visconti, Karen J.; Rimmer, David W.; Gauvreau, Kimberlee; Nido, Pedro J. del; Mayer, John E.; Hagino, Ikou; Pigula, Frank A.

doi:10.1016/j.athoracsur.2006.06.069

Cited by 115 publications

(89 citation statements)

References 23 publications

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“…Despite the theoretical advantage of ACP in providing cerebral blood flow and oxygenation during aortic arch reconstruction at a time when DHCA would traditionally be utilized, the recent outcome studies comparing neurodevelopmental outcomes at 1 year with DHCA vs. ACP have revealed no differences (11,12). Lack of standardization in cannulation, ACP flow rates, and cerebral physiological monitoring have, in our view, prevented meaningful comparisons of these techniques.…”

Section: Introductionmentioning

confidence: 93%

“…Visconti et al (12) retrospectively reviewed 29 patients undergoing the Norwood Stage I Palliation, 9 of whom received ACP, and 20 DHCA, in a non-randomized assignment at the surgeon's discretion. ACP flow rates were 30-40 ml/kg/min, and monitored with left radial artery pressure kept at 20-25 mm Hg.…”

Section: Review Of Acp Publicationsmentioning

confidence: 99%

“…Strategy for Achieving Antegrade Cerebral Perfusion -Cannulation Technique). ACP bypass flow rates in published papers have varied from 20-94 ml/kg/min (8)(9)(10)(11)(12). Monitoring techniques during ACP have varied from none (11), to arterial pressure only (12), to near infrared spectroscopy (NIRS) for cerebral oxygenation (3), and also transcranial Doppler ultrasound (TCD) (8,9).…”

Section: Introductionmentioning

confidence: 99%

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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: Introductionmentioning

confidence: 93%

Section: Review Of Acp Publicationsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

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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“…Regional cerebral perfusion was used, however, in all patients in the RVPA era and thus could not be analyzed as a predictor. A recent retrospective study 43 and a recent randomized clinical trial 44 compared the neurodevelopmental outcome of patients undergoing the Norwood procedure with and without lowflow regional cerebral perfusion and showed no difference in the Bayley Scales of Infant Development-II scores when assessed at 1 year of age.…”

Section: Mental and Psychomotor Outcomesmentioning

confidence: 99%

Two-Year Survival and Mental and Psychomotor Outcomes After the Norwood Procedure

Atallah

Dinu²,

Joffe³

et al. 2008

Circulation

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Background-The Norwood procedure for stage 1 palliation of hypoplastic left heart syndrome is performed with either the modified Blalock-Taussig (MBTS) or the right ventricle-to-pulmonary artery (RVPA) shunt. In our institution, surgical practice changed from use of the MBTS to use of the RVPA shunt in 2002. We analyzed survival and mental and psychomotor outcomes of the 2 consecutive surgical eras. Methods and Results-Between September 1996 and July 2005, 94 neonates with hypoplastic left heart syndrome underwent the Norwood procedure. Patients were recruited as neonates and followed up prospectively. Health, mental, and psychomotor outcomes (Bayley Scales of Infant Development-II) were assessed at 2 years. The study subjects were from the Norwood-MBTS era (nϭ62; 1996 to 2002) or the Norwood-RVPA era (nϭ32; 2002 to 2005). In the MBTS era, early and 2-year mortality rates were 23% (14/62) and 52% (32/62); the mean (SD) mental and psychomotor developmental indices were 79 (18) and 67 (19). In the RVPA era, early and 2-year mortality rates were 6% (2/32) and 19% (6/32); the mean (SD) mental and psychomotor developmental indices were 85 (18) and 78 (18). The 2-year mortality rate (Pϭ0.002) and the psychomotor developmental index (Pϭ0.029) were improved in the more recent surgical era. On multivariable Cox regression analysis, postoperative highest serum lactate independently predicted 2-year mortality in the MBTS and RVPA eras. Conclusions-Analysis of 2 consecutive surgical eras of hypoplastic left heart syndrome patients undergoing the Norwood procedure showed a significant improvement in 2-year survival and psychomotor development in the more recent era.

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“…28,29 Regional cerebral perfusion has been investigated as an alternative to deep hypothermic circulatory arrest. Some authors report no statistically significant differences in neurodevelopmental outcomes with this technique [32][33][34] ; however, a high incidence of stroke has been reported. 35 Other factors that have been associated with adverse neurodevelopmental outcomes include low gestational age, low birth weight, presence of a genetic syndrome, and high pre-and post-operative lactate.…”

Section: Opportunities For Intervention: Etiology Of Neurodevelopmentmentioning

confidence: 99%

Preventing Brain Injury in Newborns With Congenital Heart Disease

Sherlock

McQuillen

Miller

2009

Stroke

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Miller, MDCM, MAS; on behalf of aCCENTBackground and Purpose-Newborns with congenital heart disease are at high risk for brain injury and adverse neurodevelopmental outcomes. MRI enables the objective determination of the severity of brain injury in critically ill newborns with congenital heart disease. We will rationalize the use of MRI as a surrogate for neurodevelopmental outcome and describe novel randomization techniques that can be used in trials in this population. Methods-This article describes the evidence for the use of MRI and the link with neurodevelopmental outcome established in newborns. We also discuss the use of adaptive randomization techniques for future clinical trials in newborns with congenital heart disease. These strategies will be highlighted using an example. Results-Brain injuries occur with high frequency in newborns with congenital heart disease. It is not until school age that the full extent of neurological sequelae becomes apparent and the rapid pace of innovation in neonatal cardiac surgery prevents timely evaluation of changes in care. MRI provides a timely, safe, and reliable outcome measure and has been extensively studied in newborns with other conditions in which the link between brain injury and neurodevelopmental outcome has been established. Clinical trials using MRI as an outcome measure as well as adaptive randomization can improve the efficiency of such trials. Conclusions-Clinical trials of brain protection are urgently needed in newborns with congenital heart disease given the unacceptable frequency of brain injury in this population; MRI provides an early surrogate marker of long-term neurodevelopmental outcome and adaptive randomization can be used to improve the efficiency of these clinical trials. Key Words: brain injury Ⅲ congenital heart disease Ⅲ MRI Ⅲ neurodevelopment Ⅲ randomized, controlled trials E xperts have called for large clinical trials in the prevention of pediatric strokes based on the example set by pediatric oncology groups; oncology clinical trials have vastly improved the survival and outcomes of pediatric oncology survivors. 1 The incidence of stroke in the newborn is 20 per 100 000 live births and leads to a high risk of significant long-term neurological impairments for survivors, 2 including cerebral palsy, 3 cognitive deficits, visual disturbances, and epilepsy. 4 MRI is increasingly being used to detect stroke in the newborn. A number of imaging features of stroke are now recognized as predictors of adverse neurodevelopmental outcome. 3,5 Newborns with congenital heart disease (CHD) are at increased risk for brain injury and adverse neurodevelopmental outcomes. High-resolution MRI and diffusion tensor imaging enable us to objectively determine the severity of brain injury in these newborns. Periventricular leukomalacia and neonatal strokes have both been reported to be the most significant lesions in terms of severity and incidence in infants that undergo CHD repair 6,7 ; modifiable risk factors have been identified for both giving the ho...

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Regional Low-Flow Perfusion Versus Circulatory Arrest in Neonates: One-Year Neurodevelopmental Outcome

Cited by 115 publications

References 23 publications

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

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

Two-Year Survival and Mental and Psychomotor Outcomes After the Norwood Procedure

Preventing Brain Injury in Newborns With Congenital Heart Disease

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