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Published on: December 10, 2020
Continuous cerebral and myocardial perfusion during one-stage repair for aortic coarctation with ventricular septal
Huiwen Chen1, Haifa Hong, Zhongqun Zhu
1Heart Center, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Dongfang Road 1678, Shanghai, China. hwhwc@hotmail.com
Insights
Continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia offers a safer alternative to deep hypothermic circulatory arrest (DHCA) for aortic coarctation (CoA) with ventricular septal defect (VSD) repair, improving recovery without neurological events.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Thoracic Surgery
Background:
- Surgical repair of aortic coarctation (CoA) with ventricular septal defect (VSD) remains complex.
- Debate exists regarding optimal perfusion strategies, specifically comparing deep hypothermic circulatory arrest (DHCA) with selective antegrade cerebral perfusion (SACP) against continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia.
Purpose of the Study:
- To compare the outcomes of surgical repair for CoA with VSD using CCMP under mild hypothermia versus DHCA with SACP.
- To evaluate the safety and efficacy of CCMP in this patient population.
Main Methods:
- Retrospective analysis of 110 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011.
- Group A (n=60) underwent repair with CCMP (mild hypothermia, 32°C).
- Group B (n=50) underwent repair with DHCA (18°C) and SACP.
Main Results:
- Group A experienced no hospital mortalities, compared to 4% in Group B.
- Group A demonstrated shorter myocardial ischemic and cardiopulmonary times, reduced need for extracorporeal membrane oxygenation, and fewer instances of multiorgan failure.
- Both groups had similar long-term survival and freedom from reintervention, with no neurologic events reported in either group.
Conclusions:
- CCMP with mild hypothermia is a feasible and safe perfusion strategy for CoA with VSD repair.
- This technique is associated with improved postoperative recovery and may be the preferred method.
Abstract:
Controversy still exists concerning the use of deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (SACP) for repair of aortic coarctation (CoA) with ventricular septal defect (VSD). This report therefore describes outcomes of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia compared with DHCA and SACP. Retrospective analysis was performed for 110 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Patients repaired under CCMP with mild hypothermia (32 °C) (group A, n = 60) were compared with those repaired under DHCA (18 °C) and SACP (group B, n = 50). In group A, the single arterial cannula perfusion technique was used for 15 patients (25 %), and the dual arterial cannula perfusion technique was used for 45 patients (75 %). The preoperative data were similar in the two groups. Group A had no hospital mortalities, compared with two mortalities (4 %) in group B. Group A had shorter myocardial ischemic and cardiopulmonary times, fewer delayed sternal closures, a shorter time to extubation, lower postoperative lactate levels, and fewer patients with low cardiac output requiring extracorporeal membrane oxygenation or with multiorgan failure than group B. During the postoperative course, no clinical or electrical neurologic events occurred in either group. The mean follow-up period was 5.2 ± 3.2 years for group A and 7.5 ± 3.1 years for group B (P = 0.048). One late death occurred in group B and no late deaths in group A. The actuarial survival for the two groups was similar (100 % for group A vs 96 % for group B; P = 0.264). The freedom from all types of cardiac reintervention was 96.7 % in group A and 89.6 % in group B (P = 0.688). All the patients were free of neurologic symptoms. The authors' perfusion strategy using CCMP with mild hypothermia for repair of CoA with VSD is feasible, safe, and associated with improved postoperative recovery and should be the method of choice.
