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Published on: August 19, 2020
Cerebral regional oxygenation during aortic coarctation repair in pediatric population
Ahmed Farouk1, Mohsen Karimi, Mark Henderson
1Department of Pediatric Cardiothoracic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH 44106, USA.
Insights
During aortic coarctation repair, clamping the aorta near the left carotid artery significantly reduced cerebral oxygen saturation. Monitoring cerebral saturation is recommended to detect potential hypoperfusion during surgery.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Neuroscience
Background:
- Aortic coarctation repair involves clamping the transverse aortic arch, potentially compromising cerebral blood flow.
- The left common carotid and vertebral arteries may experience reduced perfusion when the clamp is placed proximal to the left common carotid artery.
Purpose of the Study:
- To assess if blood flow through the right carotid and vertebral arteries adequately perfuses the brain during aortic cross-clamping.
- To determine the impact of aortic cross-clamp position on regional cerebral oxygen saturation (cSO2) using near-infrared spectroscopy.
Main Methods:
- Near-infrared spectroscopy was used to measure cSO2 in 11 children undergoing aortic coarctation repair.
- Patients were divided into two groups: extended repair (clamp between innominate and left common carotid arteries) and standard repair (clamp between left common carotid and subclavian arteries).
Main Results:
- The extended repair group showed a significant decrease in cSO2 after clamping (-9.2+/-12.2%), while the standard repair group exhibited an increase (6.0+/-5.1%).
- The position of the aortic cross-clamp was the only significant factor affecting cSO2 changes; age and clamp duration were not significant.
- No postoperative neurological impairments were observed in either group.
Conclusions:
- Aortic cross-clamping proximal to the left carotid artery during coarctation repair is linked to decreased cerebral oxygen saturation.
- Cerebral saturation monitoring is advised to identify potential cerebral hypoperfusion.
- Long-term follow-up in a larger cohort is necessary to evaluate the clinical significance of these findings.
Objective:
During repair of aortic coarctation, clamping of the transverse aortic arch proximal to the left common carotid artery occludes blood flow to the left carotid and vertebral arteries. The objective of the present study is to determine whether blood flow through the right carotid and vertebral arteries provides adequate cerebral blood flow during aortic cross-clamping, as assessed by near-infrared spectroscopy.
Methods:
In 11 consecutive children undergoing aortic coarctation repair through a standard posterolateral thoracotomy, regional cerebral oxygen saturation (cSO(2)) was measured using near-infrared spectroscopy. Six patients underwent an extended end-to-end repair, in which the aortic cross-clamp was placed in between the innominate and left common carotid arteries (extended repair group). Five patients underwent a standard end-to-end repair in which the cross-clamp was clamp placed between the left common carotid and subclavian arteries (standard repair group).
Results:
After aortic clamping, there was a significant decrease in cSO(2) in the extended repair group, whereas the cSO(2) increased in the standard repair group (-9.2+/-12.2 vs 6.0+/-5.1%, extended vs standard repair groups, p=0.03). In the extended repair group, the cSO(2) decreased linearly during the aortic cross-clamping period (r(S)=-0.842, p<0.001), while in the standard repair group, the cSO(2) increased during the same time period (r(S)=0.786, p<0.001). Regression analysis identified the site of aortic cross-clamping as the sole independently significant variable explaining changes in the cSO(2) during aortic cross-clamping (p<0.03), whereas neither age nor duration of aortic cross-clamping was statistically significant. There were no postoperative neurological impairments in either group of patients.
Conclusion:
During aortic coarctation repair, aortic cross-clamping proximal, as compared to distal, to the left carotid artery is associated with significantly decreased regional cerebral oxygen saturation, as measured by near-infrared spectroscopy. Although no short-term clinical impairments were identified, long-term follow-up in a larger cohort is needed to study the effects of unbalanced cerebral oxygenation during clamping of the transverse arch. These data suggest that cerebral saturation monitoring is warranted, and may be indicative of cerebral hypoperfusion.
