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Impact of the superior cavopulmonary anastomosis on cerebral oxygenation
Nikhil Thatte1,2, Lingyu Zhou1,2, John N Kheir1,2
1Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
Insights
Following superior cavopulmonary anastomosis surgery, infant cerebral autoregulation remains intact despite increased venous pressure. Cerebral venous oxygen saturation is mainly influenced by arterial oxygen levels, not surgical pressure changes.
Area of Science:
- Pediatric Cardiology
- Neurosurgery
- Critical Care Medicine
Background:
- Univentricular heart disease patients may undergo superior cavopulmonary anastomosis (SCPA).
- SCPA increases cerebral venous pressure and impedes venous return.
- Infantile cerebral autoregulation's response to SCPA is not well understood.
Purpose of the Study:
- To evaluate infantile cerebral autoregulation following SCPA.
- To determine factors influencing cerebral oxygenation post-SCPA.
Main Methods:
- Compared SCPA patients (cases) with controls (tetralogy of Fallot repair or arterial switch operation).
- Measured cerebral venous oxyhemoglobin saturation via internal jugular venous catheter.
- Analyzed predictors including arterial oxygen saturation, mean arterial blood pressure, and superior caval pressure.
Main Results:
- SCPA cases had lower post-operative cerebral venous and arterial oxyhemoglobin saturation than controls.
- Cerebral venous oxyhemoglobin saturation poorly correlated with superior caval pressure.
- Arterial oxyhemoglobin saturation was the primary determinant of central venous oxyhemoglobin saturation (β = 0.79, p < 0.001).
Conclusions:
- Cerebral autoregulation appears intact despite acute cerebral venous hypertension post-SCPA.
- Arterial oxyhemoglobin saturation is the main driver of cerebral venous oxygenation after SCPA.
Background:
Patients with univentricular heart disease may undergo a superior cavopulmonary anastomosis, an operative intervention that raises cerebral venous pressure and impedance to cerebral venous return. The ability of infantile cerebral autoregulation to compensate for this is not well understood.
Materials And Methods:
We identified all patients undergoing a superior cavopulmonary anastomosis (cases) and compared metrics of cerebral oxygenation upon admission to the ICU with patients following repair of tetralogy of Fallot or arterial switch operation (controls). The primary endpoint was cerebral venous oxyhaemoglobin saturation measured from an internal jugular venous catheter. Other predictor variables included case-control assignment, age, weight, sex, ischemic times, arterial oxyhaemoglobin saturation, mean arterial blood pressure, and superior caval pressure.
Results:
A total of 151 cases and 350 controls were identified. The first post-operative cerebral venous oxyhaemoglobin saturation was significantly lower following superior cavopulmonary anastomosis than in controls (44 ± 12 versus 59 ± 15%, p < 0.001), as was arterial oxyhaemoglobin saturation (81 ± 9 versus 98 ± 5%, p < 0.001). Cerebral venous oxyhaemoglobin saturation correlated poorly with superior caval pressure in both groups. When estimated by linear mixed effects model, arterial oxyhaemoglobin saturation was the primary determinant of central venous oxyhaemoglobin saturation in both groups (β = 0.79, p = 3 × 10-14); for every 1% point increase in arterial oxyhaemoglobin saturation, there was a 0.79% point increase in venous oxyhaemoglobin saturation. In this model, no other predictors were significant, including superior caval pressure and case-control assignment.
Conclusion:
Cerebral autoregulation appears to remain intact despite acute imposition of cerebral venous hypertension following superior cavopulmonary anastomosis. Following superior cavopulmonary anastomosis, cerebral venous oxyhaemoglobin saturation is primarily determined by arterial oxyhaemoglobin saturation.
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