ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Asou, T.
Right arrow Articles by Yasui, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Asou, T.
Right arrow Articles by Yasui, H.

Ann Thorac Surg 1996;61:1546-1548
© 1996 The Society of Thoracic Surgeons

How to Do It

Selective Cerebral Perfusion Technique During Aortic Arch Repair in Neonates

Toshihide Asou, MD, Hideaki Kado, MD, Yutaka Imoto, MD, Yuichi Shiokawa, MD, Ryuji Tominaga, MD, Yoshito Kawachi, MD, Hisataka Yasui, MD

Department of Cardiovascular Surgery, Fukuoka Children's Hospital, and Division of Cardiac Surgery, Research Institute of Angiocardiology, Kyushu University, Fukuoka, Japan

Accepted for publication December 16, 1995.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Techniques
 Comment
 References
 
We describe selective cerebral perfusion techniques for repair of the aortic arch in neonates. These techniques may help protect the brain from ischemic injury caused by a cessation of cerebral perfusion for aortic arch reconstruction in patients with hypoplastic left heart syndrome or interrupted aortic arch.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Techniques
 Comment
 References
 
Although hypothermic circulatory arrest has been a widely used procedure for the surgical repair of arch anomalies in neonates and infants, it has been suggested that this procedure sometimes produces neurologic injury [1]. Because the long-term outcomes of cerebral function such as intellectual function and development after hypothermic circulatory arrest still remain to be determined [2], it seems worthwhile to protect the brain from ischemic injury as much as possible in neonatal open heart operations. We herein present some selective cerebral perfusion techniques in which the cerebral blood flow can be better maintained during the reconstruction of the aortic arch in the Norwood operation for neonates with hypoplastic left heart syndrome.


   Techniques
Top
 Footnotes
 Abstract
 Introduction
 Techniques
Comment
 References
 
Technique 1
Cardiopulmonary bypass is commenced by inserting an arterial cannula into the main pulmonary artery and snaring both pulmonary arteries. A right atrial cannula is used for venous drainage. During cooling a 4-mm polytetrafluoroethylene graft is anastomosed to the innominate artery and then is connected to the arterial infusion circuit of cardiopulmonary bypass with a Y-shaped connector (Fig 1Go). When the patient reaches a rectal temperature of 22°C the arterial cannula to the main pulmonary artery is clamped and removed. The innominate artery just proximal to the graft is then also clamped to direct perfusion to the brain. The brain is perfused at the rate of 50 mL•kg-1•min-1 through the polytetrafluoroethylene graft. The arterial pressure is monitored in the left temporal artery. After arch reconstruction with an equine pericardial roll, the roll is clamped at its proximal end with both the innominate artery and the descending aorta unclamped. The perfusion rate returns to 150 mL•kg-1•min-1 to perfuse the upper and the lower part of the body via the graft of the innominate artery. The pericardial roll is anastomosed to the proximal end of the main pulmonary artery conjoined with the ascending aorta to create a systemic outflow tract. After the atrial septal defect is enlarged, another arterial cannula is then inserted into the pericardial roll to perfuse the whole body while the cannula inserted into the polytetrafluoroethylene graft is removed. Finally, the graft is trimmed and anastomosed to the pulmonary artery as a systemic--pulmonary arterial shunt.



View larger version (34K):
[in this window]
[in a new window]
  		Fig 1. . A polytetrafluoroethylene (PTFE) graft is anastomosed to the innominate artery and the brain is perfused through it.

 
Technique 2
Another source of cerebral perfusion during aortic arch reconstruction in neonates is a specially designed thin-walled, metal-tipped arterial cannula (Japan Medical Supply Co, Ltd, Hiroshima, Japan) (Fig 2Go). Its external diameter is 2.1 mm and its internal diameter is 1.7 mm. A water test showed that it could deliver water at the rate of 500 mL/min with a pressure loss of less than 100 mm Hg. The line pressure in the circuit has never exceeded 300 mm Hg in any case at a maximum flow rate of 458 ± 61 mL/min when this cannula was used for systemic perfusion in 36 neonates and infants less than 3 kg of body weight in our institute. It is inserted into the innominate artery to perfuse the brain during aortic arch reconstruction in cases where the ascending aorta is large enough to be used as a systemic--pulmonary arterial shunt (Fig 3Go). Because it is flexible and light, it does not cause any excessive tension on the innominate artery, which thus facilitates perfusion of the brain and arch reconstruction. Using this method aortic arch reconstruction can be accomplished without any cessation of the blood supply to both the brain and the myocardium by clamping the aortic arch just distal to the innominate artery. After cardioplegic arrest the ascending aorta is then amputated 1 cm above the aortic commissure. The proximal end of the main pulmonary artery is conjoined with the proximal end of the ascending aorta and is anastomosed to the pericardial roll the same as in technique 1. Finally, the distal end of the ascending aorta is anastomosed to the pulmonary artery to create a systemic--pulmonary shunt.



View larger version (76K):
[in this window]
[in a new window]
  		Fig 2. . Specially designed thin-walled arterial cannula. Its external diameter is 2.1 mm and its internal diameter is 1.7 mm. It is flexible and light so as not to cause any excessive tension on the innominate artery.

 


View larger version (40K):
[in this window]
[in a new window]
  		Fig 3. . A thin-walled, metal-tipped arterial cannula is inserted into the innominate artery for cerebral perfusion. With a clamp placed on the aortic arch just distal to the innominate artery, both the brain and the myocardium are perfused during the reconstruction of the aortic arch.

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Techniques
 Comment
References
 
Postoperative cerebral damage has been one of the major concerns in neonates and infants who have required hypothermic circulatory arrest for operation. We have developed two selective cerebral perfusion techniques to repair the aortic arch in patients with hypoplastic left heart syndrome without interfering with the cerebral blood flow. We used two different ways to perfuse the brain through the innominate artery during arch repair. First, a polytetrafluoroethylene tube graft was used, which served as a systemic--pulmonary shunt after weaning from the bypass. Second, we inserted a specially designed thin-walled, metal-tipped aortic cannula, which we have routinely used for systemic perfusion in open heart operations for patients who weigh less than 3.0 kg. We consider that the selective cerebral perfusion techniques presented herein may protect the brain from ischemic injury caused by cessation of cerebral perfusion in neonates with hypoplastic left heart syndrome. These techniques may also be useful for repairing the interrupted aortic arch [3]. We have applied the present technique in 8 neonates with hypoplastic left heart syndrome, with 5 survivors, and in 6 with interrupted aortic arch with no mortality.

The appropriate perfusion rate for the brain in the neonate during selective cerebral perfusion is still controversial. As shown in Figure 4Go, we measured arterial pressures of the right radial artery and the left superficial temporal artery during Norwood operation (technique 1) in a patient with hypoplastic left heart syndrome. During selective cerebral perfusion at the flow rate of 50 mL•kg-1•min-1 the right radial arterial pressure was around 28 mm Hg and the left temporal pressure was 20 mm Hg, with a pressure difference of only 8 mm Hg between them. This may show the existence of reasonable communication between the right and left hemispheres of the brain via the circle of Willis. The right radial arterial pressure during selective cerebral perfusion was even lower than that just before and after selective cerebral perfusion. Consequently, the flow rate (50 mL•kg-1•min-1) that we have selected during selective cerebral perfusion in the neonate may not be excessive, although it is much higher than that used in the adult. In the neonate the brain represents about one-seventh to one-tenth of the body weight, whereas it represents one-fiftieth of the total body weight of the adult [4]. Because of the remarkable difference in the ratio of the brain to the total body weight between the neonate and the adult, the optimal cerebral flow rate during selective cerebral perfusion in the neonate must differ from and could be much higher than that of the adult.



View larger version (22K):
[in this window]
[in a new window]
  		Fig 4. . Mean arterial pressures were monitored on the right radial artery and the left superficial temporal artery during Norwood operation in a patient with hypoplastic left heart syndrome. The gradient between the pressures was only 8 mm Hg during selective cerebral perfusion. On the other hand, a significant difference in arterial pressure between them was found while clamping the innominate artery to anastomose the graft and after weaning from bypass. Especially, they were widely separated after commencement of the aortopulmonary shunt flow. (SCP = selective cerebral perfusion.)

 
A remarkable difference between right radial and left superficial temporal arterial pressures was found after weaning from bypass as shown in Figure 4Go. Accordingly, arterial pressure measurement of the ipsilateral side of aortopulmonary shunt should not be reliable as an index of systemic perfusion after coming off bypass because of the pressure gradient in the innominate artery between the graft and the aorta attributable to the increase in blood flow of the innominate artery. Therefore, in the present technique we monitored the cerebral arterial pressure contralateral to the perfusion site.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Techniques
 Comment
 References
 
Address reprint requests to Dr Asou, Department of Cardiovascular Surgery, Fukuoka Children's Hospital, 2-5-1 Tojin-machi, Chuo-ku, Fukuoka 810, Japan.


   References
Top
 Footnotes
 Abstract
 Introduction
 Techniques
 Comment
 References
 

  1. Du Plessis AJ, Treves ST, Hickey PR, et al. Regional cerebral perfusion abnormalities after cardiac operations: single photon emission computed tomography (SPECT) findings in children with postoperative movement disorders. J Thorac Cardiovasc Surg 1994;107:1036–43.[Abstract/Free Full Text]
  2. Ferry PC. Neurologic sequelae of open-heart surgery in children: an irritating question. Am J Dis Child 1990;144: 369–78.[Abstract/Free Full Text]
  3. Yasui H, Kado H, Yonenaga K, et al. Revised techniques of cardiopulmonary bypass in one-stage repair of interrupted aortic arch complex. Ann Thorac Surg 1993;55:1166–71.[Abstract]
  4. Amiel-Tison C, Larroche JC. Brain development and neurological survey during the neonatal period. In: Stern L, Vert P, eds. Neonatal medicine. New York: Masson Publishing, 1987:245.



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
J. D. Salazar, R. D. Coleman, S. Griffith, J. D. McNeil, M. Steigelman, H. Young, B. Hensler, P. Dixon, J. Calhoon, F. Serrano, et al.
Selective cerebral perfusion: real-time evidence of brain oxygen and energy metabolism preservation.
Ann. Thorac. Surg., July 1, 2009; 88(1): 162 - 169.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
R. G. Ohye, C. S. Goldberg, J. Donohue, J. C. Hirsch, M. Gaies, M. L. Jacobs, J. G. Gurney, and Michigan Congenital Heart Outcomes Research and Di
The quest to optimize neurodevelopmental outcomes in neonatal arch reconstruction: The perfusion techniques we use and why we believe in them
J. Thorac. Cardiovasc. Surg., April 1, 2009; 137(4): 803 - 806.
[Full Text] [PDF]

Home page
 Anesth. Analg.Home page
P. Meybohm, G. Hoffmann, J. Renner, A. Boening, E. Cavus, M. Steinfath, J. Scholz, and B. Bein
Measurement of Blood Flow Index During Antegrade Selective Cerebral Perfusion with Near-Infrared Spectroscopy in Newborn Piglets
Anesth. Analg., March 1, 2008; 106(3): 795 - 803.
[Abstract] [Full Text] [PDF]

Home page
 Asian Cardiovasc. Thorac. Ann.Home page
A. F Corno and M. Pozzi
Safe Innominate Artery Cannulation for Cardiopulmonary Bypass in Neonates
Asian Cardiovasc Thorac Ann, December 1, 2007; 15(6): 528 - 530.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
J. G. Kwak, W.-H. Kim, A. Y. Oh, T. G. Yoon, H.-S. Kim, J. H. Chae, and S. Y. Park
Is unilateral brain regional perfusion neurologically safe during congenital aortic arch surgery?
Eur. J. Cardiothorac. Surg., November 1, 2007; 32(5): 751 - 755.
[Abstract] [Full Text] [PDF]

Home page
 MMCTSHome page
G. Gargiulo, G. Oppido, E. Angeli, and C. P. Napoleone
Neonatal aortic arch surgery
MMCTS, July 23, 2007; 2007(0723): 2345.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
C. S. Goldberg, E. L. Bove, E. J. Devaney, E. Mollen, E. Schwartz, S. Tindall, C. Nowak, J. Charpie, M. B. Brown, T. J. Kulik, et al.
A randomized clinical trial of regional cerebral perfusion versus deep hypothermic circulatory arrest: Outcomes for infants with functional single ventricle
J. Thorac. Cardiovasc. Surg., April 1, 2007; 133(4): 880 - 887.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
G. Oppido, C. P. Napoleone, S. Turci, B. Davies, G. Frascaroli, S. Martin-Suarez, A. Giardini, and G. Gargiulo
Moderately Hypothermic Cardiopulmonary Bypass and Low-Flow Antegrade Selective Cerebral Perfusion for Neonatal Aortic Arch Surgery
Ann. Thorac. Surg., December 1, 2006; 82(6): 2233 - 2239.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
G. Amir, C. Ramamoorthy, R. K. Riemer, C. R. Davis, F. L. Hanley, and V. M. Reddy
Visual light spectroscopy reflects flow-related changes in brain oxygenation during regional low-flow perfusion and deep hypothermic circulatory arrest
J. Thorac. Cardiovasc. Surg., December 1, 2006; 132(6): 1307 - 1312.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
R. L. Hannan, M. A. Ybarra, J. W. Ojito, F. A. Alonso, A. F. Rossi, and R. P. Burke
Complex Neonatal Single Ventricle Palliation Using Antegrade Cerebral Perfusion.
Ann. Thorac. Surg., October 1, 2006; 82(4): 1278 - 1285.
[Abstract] [Full Text] [PDF]

Home page
 Asian Cardiovasc. Thorac. Ann.Home page
Y. Takeda, T. Asou, N. Yamamoto, K. Ohara, H. Yoshimura, and H. Okamoto
Arch Reconstruction without Circulatory Arrest in Neonates
Asian Cardiovasc Thorac Ann, December 1, 2005; 13(4): 337 - 340.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
T. Tlaskal, B. Hucin, V. Kucera, P. Vojtovic, R. Gebauer, V. Chaloupecky, and J. Skovranek
Repair of persistent truncus arteriosus with interrupted aortic arch
Eur. J. Cardiothorac. Surg., November 1, 2005; 28(5): 736 - 741.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
G. Amir, C. Ramamoorthy, R. K. Riemer, V. M. Reddy, and F. L. Hanley
Neonatal Brain Protection and Deep Hypothermic Circulatory Arrest: Pathophysiology of Ischemic Neuronal Injury and Protective Strategies
Ann. Thorac. Surg., November 1, 2005; 80(5): 1955 - 1964.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
Y. Tanoue, H. Kado, Y. Shiokawa, N. Fusazaki, and S. Ishikawa
Midterm Ventricular Performance After Norwood Procedure With Right Ventricular-Pulmonary Artery Conduit
Ann. Thorac. Surg., December 1, 2004; 78(6): 1965 - 1971.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
T. Oosterhof, A. Azakie, R. M. Freedom, W. G. Williams, and B. W. McCrindle
Associated Factors and Trends in Outcomes of Interrupted Aortic Arch
Ann. Thorac. Surg., November 1, 2004; 78(5): 1696 - 1702.
[Abstract] [Full Text] [PDF]

Home page
 Anesth. Analg.Home page
D. B. Andropoulos, L. K. Diaz, C. D. Fraser Jr., E. D. McKenzie, and S. A. Stayer
Is Bilateral Monitoring of Cerebral Oxygen Saturation Necessary During Neonatal Aortic Arch Reconstruction?
Anesth. Analg., May 1, 2004; 98(5): 1267 - 1272.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
R. J. Myung, M. Petko, A. R. Judkins, G. Schears, R. F. Ittenbach, R. J. Waibel, and W. M. DeCampli
Regional low-flow perfusion improves neurologic outcome compared with deep hypothermic circulatory arrest in neonatal piglets
J. Thorac. Cardiovasc. Surg., April 1, 2004; 127(4): 1051 - 1057.
[Abstract] [Full Text] [PDF]

Home page
 Asian Cardiovasc. Thorac. Ann.Home page
K. S. Murthy, R. Coelho, C. Roy, S. Kulkarni, B. Ninan, and K. M. Cherian
One-Stage Repair of Cardiac and Arch Anomalies Without Circulatory Arrest
Asian Cardiovasc Thorac Ann, September 1, 2003; 11(3): 250 - 254.
[Abstract] [Full Text]

Home page
 Ann. Thorac. Surg.Home page
M. Ricci, G. A. Cohen, D. Roebuck, and M. J. Elliott
Management of complex tracheo-aortic fistula following neonatal tracheal reconstruction
Ann. Thorac. Surg., April 1, 2003; 75(4): 1325 - 1328.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
W. M. DeCampli, G. Schears, R. Myung, S. Schultz, J. Creed, A. Pastuszko, and D. F. Wilson
Tissue oxygen tension during regional low-flow perfusion in neonates
J. Thorac. Cardiovasc. Surg., March 1, 2003; 125(3): 472 - 480.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
D. B. Andropoulos, S. A. Stayer, E. D. McKenzie, and C. D. Fraser Jr
Novel cerebral physiologic monitoring to guide low-flow cerebral perfusion during neonatal aortic arch reconstruction
J. Thorac. Cardiovasc. Surg., March 1, 2003; 125(3): 491 - 499.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
C. Lim, W.-H. Kim, S.-C. Kim, J.-W. Rhyu, M.-J. Baek, S.-S. Oh, C.-Y. Na, and C. W. Kim
Aortic arch reconstruction using regional perfusion without circulatory arrest
Eur. J. Cardiothorac. Surg., February 1, 2003; 23(2): 149 - 155.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
C. I. Tchervenkov, S. J. Korkola, D. Shum-Tim, C. Calaritis, E. Laliberte, T. U. Reyes, and J. Lavoie
Neonatal aortic arch reconstruction avoiding circulatory arrest and direct arch vessel cannulation
Ann. Thorac. Surg., November 1, 2001; 72(5): 1615 - 1620.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
A. Azakie, S. L. Merklinger, B. W. McCrindle, G. S. Van Arsdell, K.-J. Lee, L. N. Benson, J. G. Coles, and W. G. Williams
Evolving strategies and improving outcomes of the modified Norwood procedure: a 10-year single-institution experience
Ann. Thorac. Surg., October 1, 2001; 72(4): 1349 - 1353.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
H. Uemura, T. Yagihara, Y. Kawahira, Y. Yoshikawa, and S. Kitamura
Continuous systemic perfusion improves outcome in one stage repair of obstructed aortic arch and associated cardiac malformation
Eur. J. Cardiothorac. Surg., September 1, 2001; 20(3): 603 - 608.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
Y. Isomatsu, Y. Imai, T. Shin'oka, M. Aoki, and K. Sato
Coarctation of the aorta and ventricular septal defect: Should we perform a single-stage repair?
J. Thorac. Cardiovasc. Surg., September 1, 2001; 122(3): 524 - 528.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
C.I. Tchervenkov, S.J. Korkola, and D. Shum-Tim
Surgical technique to avoid circulatory arrest and direct arch vessel cannulation during neonatal aortic arch reconstruction
Eur. J. Cardiothorac. Surg., May 1, 2001; 19(5): 708 - 710.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
C. I. Tchervenkov, V. F. Chu, D. Shum-Tim, E. Laliberte, and T. U. Reyes
Norwood operation without circulatory arrest: a new surgical technique
Ann. Thorac. Surg., November 1, 2000; 70(5): 1730 - 1733.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
K. Ishino, M. Kawada, H. Irie, K. Kino, and S. Sano
Single-stage repair of aortic coarctation with ventricular septal defect using isolated cerebral and myocardial perfusion
Eur. J. Cardiothorac. Surg., May 1, 2000; 17(5): 538 - 542.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
F. A. Pigula, E. M. Nemoto, B. P. Griffith, and R. D. Siewers
REGIONAL LOW-FLOW PERFUSION PROVIDES CEREBRAL CIRCULATORY SUPPORT DURING NEONATAL AORTIC ARCH RECONSTRUCTION
J. Thorac. Cardiovasc. Surg., February 1, 2000; 119(2): 331 - 339.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
Y. Imoto, H. Kado, Y. Shiokawa, K. Fukae, and H. Yasui
Norwood procedure without circulatory arrest
Ann. Thorac. Surg., August 1, 1999; 68(2): 559 - 561.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Asou, T.
Right arrow Articles by Yasui, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Asou, T.
Right arrow Articles by Yasui, H.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS