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Pediatric Cardiac Surgery Department, Denver Children's Hospital, University of Colorado, 1056 E 19th Ave, Denver, CO 80218
(Email: lacour-gayet.francois{at}tchden.org).
This article by Durandy and colleagues [1] demonstrates that normothermic cardiopulmonary bypass (CPB) with warm blood cardioplegia is safe even for prolonged, cross-clamp times. The excellent results in mortality and morbidity reported in this series of 234 patients weighing less than 10 kg is remarkable and indicates the excellence of the surgeons.
The optimal CPB method for congenital heart operations is characterized today by lack of evidence. The most prominent teams report excellent outcomes when using diametrically different techniques, such as total deep hypothermic circulatory arrest (DHCA) or full flow normothermic perfusion. This lack of evidence is confounding, and of necessity, expert opinion, experience, or intuition guides clinical practice.
There is a trend to keep some distance from DHCA due to consistently higher risks of neurocognitive impairments after long DHCA times. Selective antegrade cerebral perfusion is progressively gaining more support in sparing the surgeon from the need for very fast surgical repairs.
Nevertheless, a few teams, essentially in Europe, have switched to normothermic perfusion. Marc de Leval in his editorial "Because we can, should we ...?" stated, "After reflection, however, one has to remember that CPB is a highly unphysiological state and the question arises whether normothermic continuous perfusion for neonatal cardiac surgery is the best strategy to alleviate or prevent the consequences of those physiological perturbations" [2].
The question raised is whether normothermic perfusion is more likely to limit systemic inflammatory reactions that account for important morbidity in infant cardiac surgery. The analogy with normothermic extracorporeal membrane oxygenation (ECMO) is not valid in this regard because there is no exposure of the blood to the air during ECMO and the inflammatory response is greater when blood is exposed to air.
The inflammatory process is complex and can be considered a balance between proinflammatory factors such as interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor-
(TNF-), intercellular adhesion molecule, and others, and antiinflammatory factors such as IL-10, IL-1ra, and TNF-sr) [3]. No reports clearly show that normothermic perfusion is superior for establishing a stable state between proinflammatory and antiinflammatory components. This article, however, tends to prove that observed very short ventilation times and hospital stays produce better stability of the inflammatory system with normothermia.
A growing number of European teams are convinced of the superiority of normothermia vs hypothermia, but their choice is based on empirical experience. The multiinstitutional randomized clinical trial announced in the article of Durandy and colleagues is clearly needed. In the absence of such evidence in congenital heart surgery, surgeons will base their CPB technique on impressions, as is done for "religion and politics," as stated by Frank Hanley [4].
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  Y. Durandy Warm Pediatric Cardiac Surgery: European Experience Asian Cardiovasc Thorac Ann, August 1, 2010; 18(4): 386 - 395. [Abstract] [Full Text] [PDF]
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