brain protection in pediatric aortic arch repair
DESCRIPTION
Brain Protection in Pediatric Aortic Arch Repair: Deep Hypothermic Circulatory Arrest, Selective Cerebral Perfusion or Combined TechniqueTRANSCRIPT
Hisar Intercontinental Hospital
Brain Protection in Pediatric Aortic Arch
Repair: Deep Hypothermic
Circulatory Arrest, Selective Cerebral
Perfusion or Combined Technique
No Disclosures
DHCA has been widely employed DHCA has been widely employed since 1970s in complex CHD in since 1970s in complex CHD in neonatesneonatesReduction in CPB time Elimination of the need for multiple
cannulaeBloodless operative field
History of DHCAHistory of DHCA
First SCP for arch replacement First SCP for arch replacement DeBakey at al 1962
SCP from axilllary artery SCP from axilllary artery Panday et al 1974Panday et al 1974
Hypothermic (25-28C) SCPHypothermic (25-28C) SCPFirst et al 1986First et al 1986
Early successful hypothermic SCPEarly successful hypothermic SCPMatsuda et al 1989Matsuda et al 1989Kazui et al 1989 Kazui et al 1989
First SCP for aortic arch repair in First SCP for aortic arch repair in neonates neonates Asou et al 1996Asou et al 1996
History of SCP for History of SCP for AdultsAdults
The circle of Willis (CoW)The circle of Willis (CoW)%17 incomplete CoW %17 incomplete CoW 11
Collateral vessels 2
Ophthalmic arteryLeptomeningeal vesselsExternal carotid artery
Anatomy Anatomy
1. Merkkola et al. Ann Thorac surg;2006:82:74.2. Eur J Cardiothorac Surg 2010:37:1332
Pathophysiology of Pathophysiology of Neonatal Brain InjuryNeonatal Brain Injury
The brain utilizes up to 20% of The brain utilizes up to 20% of total body Ototal body O22 consumption consumption
Mechanisms of Cell Death Necrosis Apoptosis
DHCA Excitatory amino acids: glutamateExcitatory amino acids: glutamate
Selective Vulnerability of the Developing Brain (DHCA)
Adult : generalized Jacksonian type seizures
Neonatal: focal seizures Infant: choreoathetosis
Motor and Cognitive Outcomes After Surgery
for CHD NNeonateseonates and young infantsand young infants have have
greatest risk for brain injurygreatest risk for brain injury Duration of DHCADuration of DHCA Seemingly normal 1-year-old after Seemingly normal 1-year-old after
surgerysurgery Significant abnormalities of Significant abnormalities of
neurodevelopment at 4 or 8 years of neurodevelopment at 4 or 8 years of agesages
Neonatal Brain Protection
Hypothermia Hypothermia pH stat blood management pH stat blood management Pharmacologic agents Pharmacologic agents
Volatile anaesthetics Volatile anaesthetics Thiopental Thiopental SteroidsSteroids
TechniquesTechniques DHCADHCA Intermittent cerebral perfusionIntermittent cerebral perfusion SCPSCP
Hypothermia
EEG silence and EEG silence and disappearance of the disappearance of the SSER occur at 17°CSSER occur at 17°C
Deep brain cools faster than the Deep brain cools faster than the subcortical areassubcortical areas
2°C-to 3°C between deep brain and 2°C-to 3°C between deep brain and superficial brain superficial brain
Blood temperature should not exceed Blood temperature should not exceed 37°C during rewarming 37°C during rewarming
Arterial Blood Gas Management
pH Stat & Alpha Stat The impact of The impact of arterial blood gas arterial blood gas
management duringmanagement during DHCA in children DHCA in children is still unclearis still unclear
pH statpH stat improveimprovess cerebral blood flow cerebral blood flow and cerebraland cerebral
ooxygenationxygenation and effectively cools the brain and effectively cools the brain but has a greater risk of microembolismbut has a greater risk of microembolism
Experimental Experimental studies suggestedstudies suggested that that pHpH stat arterial blood gas stat arterial blood gas management provides improvedmanagement provides improved brain brain protection during DHCA. protection during DHCA.
However, clinical studies have shown However, clinical studies have shown no significant differance in the no significant differance in the longterm results between the pH stat longterm results between the pH stat and the alpha stat and the alpha stat
Pharmacologic Agents Pharmacologic Agents
Methylprednisolone* Barbiturates Volatile anesthetics
Lidocain MannitolMannitol AnticonvulsantsAnticonvulsants Benzodiazepines PropofolPropofol Aprotinin Ca++ channel blockers Leukocyte filtration Diazoxide Thromboxane A2 blokers Glutamate Receptor Glutamate Receptor
BlockersBlockers Nitric Oxide Synthase Nitric Oxide Synthase
InhibitorsInhibitors Free Radical ScavengersFree Radical Scavengers
Techniques1-DHCA
The advanteges of DHCA includes the The advanteges of DHCA includes the reduction ofreduction of
Cellular metabolic rate Cellular metabolic rate Vascular permeabilityVascular permeability Blood-brain barrier disruption Blood-brain barrier disruption Postischemic cerebral edema Postischemic cerebral edema
Disadventages of DHCADisadventages of DHCA Longer myocardial ischemia Longer myocardial ischemia Autoregulation is lost (below 22°C)Autoregulation is lost (below 22°C)
Coagulative, renal and pulmonary Coagulative, renal and pulmonary complicationscomplications
NNeurodevelopmental morbiditieseurodevelopmental morbidities
Techniques1-DHCA
Neurologic sequelae depends onNeurologic sequelae depends on Arrest periodArrest period Variations in perfusion technique during Variations in perfusion technique during
cooling and rewarming cooling and rewarming Safe DHCA period Safe DHCA period
35<min35<min Beyond this period neurologic Beyond this period neurologic
sequelae may increase sequelae may increase Late neurologic abnormal Late neurologic abnormal
develepment develepment
1. Oates, et al. J Thorac Cardiovasc Surg. 1995;110:7862. Newburger et al. N Engl J Med. 1993;329:10573. Bellinger et al. Circulation. 1999;100:526
Techniques2-Intermittent Cerebral
Perfusion ICP has been used routinly in ICP has been used routinly in
pulmonary thromboendarterectomy pulmonary thromboendarterectomy for adult patientsfor adult patients
Experimental studies Experimental studies 1,21,2 using neonatal using neonatal piglets have shown that ICP has better piglets have shown that ICP has better brain protection than DHCA brain protection than DHCA
However, there is not an adequate However, there is not an adequate clinical study supporting the clinical study supporting the advantages of ICP in pediatric advantages of ICP in pediatric patients .patients .
1. Kimura T, et al. Demmy TL, et al. JCS 1994;108:6582. Langley SM, et al. Ann Thorac Surg 1999;68:4
Techniques3-Selective elective CCerebral erebral
PPerfusion erfusion Technical issues relating toTechnical issues relating to SCP, SCP, such such
as theas the perfusate temperatureperfusate temperature,, the flow the flow raterate,, and pressure and pressure , are still unsolved , are still unsolved
Lowering perfusion pressure gradually from Lowering perfusion pressure gradually from 90 mmHg to 40 mm Hg 90 mmHg to 40 mm Hg doesdoes not change not change cerebral blood flow orcerebral blood flow or CMROCMRO22 (1)(1)
BBelow 40 mmelow 40 mm Hg, cerebral blood flow Hg, cerebral blood flow declinedecliness abruptly abruptly 11
AA reduction of 45% reduction of 45% to 70% in pump flow at to 70% in pump flow at 18°C significantly reduce18°C significantly reduces s cerebral blood cerebral blood flow and CMROflow and CMRO22 (2)(2)
1. Tanaka , et al. J Thorac Cardiovasc Surg 1988;95:124 2. Kern , et al. Ann Thorac Surg 1993;56:1366
Which one ? DHCA or SCP
Some surgeons have moved away Some surgeons have moved away from DHCAfrom DHCA
There are many risksThere are many risks
Some surgeons Some surgeons still prefer DHCA prefer DHCA becausebecause
The neurodevelopmental outcomes are The neurodevelopmental outcomes are not different ! not different !
TTechnical surgical reconstruction can beechnical surgical reconstruction can be performed with greater precisionperformed with greater precision than than by using SCPby using SCP
The differences between DHCA & SCP
In a piglet model, In a piglet model, SCP SCP was found superior was found superior toto DHCADHCA11
The The resultsresults from from clinical studies clinical studies comparing comparing SSCP with DHCA haveCP with DHCA have not shown not shown a similar benefita similar benefit
A A random trial demonstrated no clearrandom trial demonstrated no clear difference difference between between SCPSCP and DHCA and DHCA after after 1 year 1 year of of Norwood Norwood surgerysurgery 22
Two additional clinical studies also Two additional clinical studies also demonstrated no cleardemonstrated no clear differencedifferencess between between SSCP CP and DHCAand DHCA 3,43,4
Neurodevelopmental outcomes after 1 Neurodevelopmental outcomes after 1 yearyear of of Norwood Norwood operationsoperations with with SCPSCP werewere significantlysignificantly below population norms below population norms 2,42,41. Myung, et al. J Thorac Cardiovasc Surg. 2004;127:1051
2. Goldberg, et al. J Thorac Cardiovasc Surg. 2007;133:8803. Dent, et al. J Thorac Cardiovasc Surg. 2006;131:1904. Visconti ,et al. Ann Thorac Surg. 2006;82:2207
Neurodevelopmental Neurodevelopmental Outcomes After Regional Outcomes After Regional
Cerebral PerfusionCerebral Perfusion
MRI Brain Injury Preoperative,
Postoperative and Premature 20-40 % preoperative MRI brain 20-40 % preoperative MRI brain
injury injury 11
35-75 % postoperative MRI brain 35-75 % postoperative MRI brain injuryinjury 1 1
Brain injury in premature newborns Brain injury in premature newborns detected with MRI is 37 %detected with MRI is 37 % 2 2
1. Andropoulos, et al. Ann Thorac Surg 2013;95:6482. Miller, et al J Pediatr 2005;147:609
RReconstructioneconstruction of A of Aortic ortic AArch and rch and Isthmus
Hypoplasia in Our Clinic BB
etween Jan 2007 etween Jan 2007 -- Sep 2012 Sep 201233
7 cases with aortic arch and 7 cases with aortic arch and isthmus hypoplasia accompanisthmus hypoplasia accompaning ing other other cardiac defects cardiac defects
This technique was not used in technique was not used in patients who had patients who had HLHSHLHS
Additional Additional PProcedures rocedures
Patients (n)
VSD 23
Interruption repair 3
Subaortic resection 2
Arterial switch operation 8
CAVSD repair 2
Pulmonary arterial banding 3
Septectomy 1
Cardiopulmonary bypass time, min 154±61
Cross-clamp time, min 64.7±36
Selective cerebral and myocardial perfusion time, min
22.4±8
Descending aorta ischemia time, min 26.1±6.7
Total circulatory arrest time, min 7.1±2.7 (minimum: 4, maximum: 10)
Extubation time, hour 159±180
Length of ICU stay time, hour 219± 249
Hospital length of stay time, day 13±11
Postoperative CoursePostoperative Course
All VSD-CoAAH patients were extubated within 1. POD
Prolonged extubation patients had single ventricle physiology or complex cardiac anomalies
None of the patients had neurological defects
Perfusion Techniques in Neonatal Arch Reconstruction
Ohne RG. J Thorac Cardiovasc Surg 2009;137:803
1. Result 1. Result
SCP is theoreticalSCP is theoreticallyly advantageous advantageous inin preventpreventinging ischemia of the brain ischemia of the brain
It should not be relied on totally as a It should not be relied on totally as a safe method safe method
AAn inapn inapppropriately applied ropriately applied SCPSCP may may cause more damage than cause more damage than TCATCA
High or High or low low flow and pressure during flow and pressure during SCPSCP may cause brain damage.may cause brain damage.
Surgical Surgical procedureproceduress may take may take a a longer longer timetime when performed with when performed with SCP SCP
2. Result 2. Result
NeuromonitorizationNeuromonitorization is highly necessary is highly necessary during SCP compared to TCAduring SCP compared to TCA
We know that short term We know that short term TCATCA is a safe is a safe methodmethod
The The SCPSCP technique technique doesndoesn’’t effect thet effect the surgeon's comfort and speedsurgeon's comfort and speed
In our clinical experiance combining In our clinical experiance combining SCP and shortSCP and short period of period of TTCCA (under 10 A (under 10 minutes) minutes) isis safe and practical in safe and practical in pediatric pediatric aortic aortic arch arch reconstructioreconstructionn
Thank You!