Abstract
Many known risk factors for adverse cardiovascular and neurological outcomes in children with congenital heart defects (CHD) are not modifiable; however, the temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered in an attempt to improve long-term neurological outcomes. Deep hypothermic circulatory arrest, traditionally used for aortic arch repair, has been associated with short-term and long-term neurologic sequelae. Therefore, there is a rising interest in using moderate hypothermia with selective antegrade cerebral blood flow on CPB during aortic arch repair. Rewarming from moderate-to-deep hypothermia has been shown to be associated with neuronal injury, neuroinflammation, and loss of cerebrovascular autoregulation. A significantly lesser degree of rewarming is required following mild (33–35°C) hypothermia as compared with moderate (28–32°C), deep (21–27°C), and profound (less than 20°C) hypothermia. Therefore, we believe that mild hypothermia is associated with a lower risk of rewarming-induced neurologic injury. We hypothesize that mild hypothermia with selective antegrade cerebral perfusion during CPB for neonatal aortic arch repair would be associated with improved neurologic outcome.
Highlights
Congenital heart disease (CHD) is a common cause of morbidity and mortality in children
Cardiopulmonary bypass (CPB) surgery is a potential risk factor, which is known to contribute to the neurologic injury in this patient population
In a study where neonates were randomly assigned to either deep hypothermic (18°C) circulatory arrest (DHCA) or deep hypothermic low blood flow on CPB during aortic arch repair, both strategies were associated with increased risk of neurodevelopmental disabilities [6]
Summary
Congenital heart disease (CHD) is a common cause of morbidity and mortality in children. Long-term neurocognitive outcomes in children with congenital heart disease are determined by variety of prenatal, perinatal, and postnatal factors, and some of them are not related to the surgical strategy. Many children’s centers continue to advocate deep hypothermia at 18°C with selective antegrade cerebral blood flow, during neonatal aortic arch repair. Rewarming from moderate-to-deep hypothermia is associated with loss of cerebrovascular autoregulation and neuronal injury [10–15]. The underlying mechanism of increased vulnerability to neurologic injury during rewarming from hypothermia is unknown, but it may be related to inadvertent cerebral hyperthermia [18]. Some centers have adopted mild hypothermia with SACP as a standard of care during aortic arch repair in children. There is no study of short-term and long-term outcomes following mild hypothermia (32–35°C) with SACP in children undergoing aortic arch repair
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