WHOLE BODY PERFUSION STRATEGY FOR AORTIC ARCH REPAIR UNDER NORMOTERMIA AND BEATING HEART TECHNIQUE IN PEDIATRIC PATIENTS. THREE CLINICAL CASES

Abstract

Introduction The incidence of aortic arch pathology in older children is rare. Most often this occurs as a result of a previous aortic arch operation and less often it could be detected primarily. Previously, we successfully used normothermic perfusion during neonatal aortic arch repair. In this paper we evaluate the effectiveness of the method of selective whole body perfusion with coronary perfusion on the beating heart during aortic arch reconstruction in older children. Methods Between October 2019 and February 2021, 3 children underwent aortic arch surgery at our institution using the defined protocol. During the cardiopulmonary bypass (CPB), antegrade cerebral perfusion (ACP), antegrade coronary perfusion on beating heart and distal retrograde femoral aortic perfusion at a constant blood temperature 36 C were used. During the surgery, cerebral and visceral perfusion were monitored using near-infrared spectroscopy (NIRS) and transcranial dopplerography, electrocardiography and arterial blood gases. The data was collected prospectively. Results Patient one. Male, 6 years old, 27 kg. Elective admission. Diagnosis: Aortic arch hypoplasia. Surgery: Aortic arch reconstruction. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 2,5 l/min. CPB time – 78 min, ACP – 44 min. BCA cannula – 14 fr, coronary cannula – 4fr, femoral artery cannula – 10 fr. Ultrafiltration during CPB. Mechanical ventilation - 18 hours post/op. Blood lactate 6 hours post/op – 1,8 mmol/l. ICU admission – 24 hours. Hospital discharge 12 days. Patient two, 17 y.o., 38 kg. Elective admission. Diagnosis: Aortic arch hypoplasia. The history of coarctation of the aorta surgery. Surgery: Aortic arch reconstruction. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 2,5 l/min. CPB time – 136 min, ACP time – 54 min. BCA cannula – 14 fr, coronary cannula – 4fr, femoral artery cannula – 15 fr. Ultrafiltration during CPB. Mechanical ventilation – 4 hours post/op. Blood lactate 6 hours post/op – 2,6 mmol/l. ICU admission – 16 hours. Hospital discharge 17 days. Patient three. Female, 4 years old, 15 kg. Admitted urgently. Diagnosis: Critical aortic arch stenosis. Brachiocephalic artery (BCA) and left common carotid artery (LCCA) stenosis. The history of coarctation of the aorta surgery. Low ejection fraction. Surgery: Aortic arch, BCA and LCCA repair. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 3 l/min. CPB time – 107 min, ACP – 68 min. BCA cannula – 12 fr, coronary cannula – 4fr, femoral artery cannula – 12 fr. Ultrafiltration during CPB. Mechanical ventilation - 44 hours post/op. Blood lactate 6 hours post/op – 1,6 mmol/l. ICU admission – 5 days. Hospital discharge 26 days. During surgery, laboratory and instrumental parameters were within reference values. Patients had no neurological deficiency during hospital stage. Discussion These clinical cases show that the whole-body perfusion with coronary perfusion on beating heart provide safe conditions during aortic arch surgery in children using normothermia. Using this protocol, we were able to eliminate risk factors: circulatory arrest, hypothermia, cardioplegia, extended