Does additional descending aorta perfusion in neonates undergoing arch reconstruction with antegrade cerebral perfusion lead to better patient outcome?

Introduction: Many congenital cardiac surgeons use selective antegrade cerebral perfusion (ACP) during aortic arch reconstruction. However, with ACP there is uncertainty how much of cardiopulmonary bypass (CPB) flow reaches the lower body. We compared the outcome of HLHS patients with three different perfusion strategies.

Methods: A total of 51 neonates who underwent arch repair from January 2012-2014 were included. In group I (min. body temperature: 18°C, n=13) a lower ACP flow rate was applied compared to the flow rate in group II (28°C, n=16). In group III (32°C, n=13) 30% of CPB flow was directed to the lower and 70% to the upper body body.

Results: Group III demonstrated significantly lower serum lactate at the end of reperfusion (2.8±1.5 vs. 5.0±1.5 mmol/l) relative to group I. In all groups there was a slight temporary postoperative increase in serum creatinine to 134% of baseline levels (p=ns). In hospital mortality and duration of postoperative open chest and ventilation was not significantly different between the groups. In none of the groups were obvious neurologic events.

Conclusions: Direct cannulation of the descending aorta is surgically feasible in neonates with a low complication rate. The additional flow via descending aorta allows safe complex arch repairs at higher temperatures (32°C). In patients undergoing arch repair with lower body perfusion the post CPB serum lactate levels were significantly lower compared to ACP only. Further investigations are needed to determine optimal flow rates, flow distribution and temperature during arch reconstructions.