Invited Commentary

Abstract

Lim and colleagues [1Lim H.-G. Kim W.-H. Park C.-S. et al.Usefulness of regional cerebral perfusion combined with coronary perfusion during one-stage total repair of aortic arch anomaly.Ann Thorac Surg. 2010; 90: 50-57Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar] are to be congratulated for developing and proving the safety and feasibility of novel pediatric cardiac surgical perfusion strategies. Previous publications from this group have documented that aortic arch reconstruction in neonates and infants using regional cerebral perfusion without circulatory arrest is feasible, safe, and may reduce potential neurologic complications compared with aortic arch reconstruction using circulatory arrest. In this study, they demonstrate that one-stage total arch reconstruction in neonates and infants using a dual perfusion technique with continuous cerebral and cardiac perfusion, and a nonworking beating heart, is feasible, safe, and may reduce neurologic and myocardial complications. The authors are to be congratulated for their excellent results in these challenging patients and for their thoughtful analysis. Although they have demonstrated the safety and feasibility of these novel perfusion strategies, the choice of myocardial perfusion or myocardial arrest during arch reconstruction in their study was selected according to the surgeon's preference. Thus, confounding variables may account for some of the observations. Furthermore, evaluation of the efficacy and safety of continuous regional cerebral perfusion relative to that of hypothermic circulatory arrest requires longer follow-up with formal neurologic testing. Seizures, stroke, and motion disorders such as choreoathetosis represent a small fraction of neurologic complications. This study relied on imaging studies and serial examination by a neurologist, which is important and commendable. However, the assessment of neuroprotective strategies ultimately requires serial comparisons of objective measures of neurodevelopmental outcome in multiple domains. Definitive evaluation of outcomes associated with alternative perfusion strategies requires (1) either a prospective randomized trial or a direct comparison of propensity matched groups, and (2) long-term follow-up. The Single Ventricle Reconstruction trial, supported by the National Heart, Lung, and Blood Institute and coordinated by the Pediatric Heart Network, is a model for how to conduct a prospective randomized trial in pediatric cardiac surgery. The Single Ventricle Reconstruction trial has demonstrated the challenges, including complexity and cost, of approaching the question of comparative effectiveness of treatment strategies for congenital heart disease by means of prospective randomized trials. Multi-institutional registries that track appropriate variables may also be used to facilitate comparisons of propensity matched groups. Transformation of the Society of Thoracic Surgeons Database into a platform for longitudinal follow-up may allow it to be used as a tool to answer questions about the long-term comparative effectiveness of treatment strategies. Usefulness of Regional Cerebral Perfusion Combined With Coronary Perfusion During One-Stage Total Repair of Aortic Arch AnomalyThe Annals of Thoracic SurgeryVol. 90Issue 1PreviewWe assessed whether regional cerebral perfusion is neurologically safe during long-term follow up, and evaluated the effect of our current combined coronary perfusion strategy by comparing outcomes of nonworking beating hearts and arrested hearts under regional cerebral perfusion. Full-Text PDF