Neonatal aortic arch reconstruction avoiding circulatory arrest and direct arch vessel cannulation

Abstract

Background. Aortic arch reconstruction in neonates routinely requires deep hypothermic circulatory arrest. We reviewed our experience with techniques of continuous low-flow cerebral perfusion (LFCP) avoiding direct arch vessel cannulation. Methods. Eighteen patients, with a median age of 11 days (range 1 to 85 days) and a mean weight of 3.2 ± 0.8 kg, underwent aortic arch reconstruction with LFCP. Seven had biventricular repairs with arch reconstruction, 9 underwent the Norwood operation and 2 had isolated arch repairs. In 1 Norwood and 7 biventricular repair patients, LFCP was maintained by advancing the cannula from the distal ascending aorta into the innominate artery. In 8 of 9 Norwood patients, LFCP was maintained by directing the arterial cannula into the pulmonary artery confluence and perfusing the innominate artery through the right modified Blalock–Taussig shunt fully constructed before cannulation for cardiopulmonary bypass. In 2 patients requiring isolated arch reconstruction, the ascending aorta was cannulated and the cross-clamp was applied just distal to the innominate artery. Results. LFCP was maintained at 0.6 ± 0.2 L · min −1 · m −2 for 41.0 ± 13.9 minutes at 18.5°C ± 1.1°C. In 10 of the 18 patients, blood pressure during LFCP was 15 ± 8 mm Hg remote from the innominate artery (left radial, umbilical or femoral arteries). In 8 of the 18 patients, right radial pressure during LFCP was 24 ± 10 mm Hg. The mean mixed-venous saturation was 79.8% ± 10% during LFCP. Two patients had preoperative seizures, whereas none had seizures postoperatively. One patient died. Conclusions. Neonatal aortic arch reconstruction is possible without circulatory arrest or direct arch vessel cannulation. These techniques maintained adequate mixed-venous oxygen saturations with no associated adverse neurologic outcomes.