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J Thorac Cardiovasc Surg 1997;114:991-1001
© 1997 Mosby, Inc.

SURGERY FOR CONGENITAL HEART DISEASE

PERIOPERATIVE EFFECTS OF ALPHA-STAT VERSUS pH-STAT STRATEGIES FOR DEEP HYPOTHERMIC CARDIOPULMONARY BYPASS IN INFANTS

Adre J. du Plessis , MBChB, MPH, Richard A. Jonas , MD, David Wypij , PhD, Paul R. Hickey , MD, James Riviello , MD, David L. Wessel , MD, Stephen J. Roth , MD, MPH, Frederick A. Burrows , MD, Gene Walter , REEGT, David M. Farrell , MA, CCP, Amy Z. Walsh , RN, Christine A. Plumb , RN, MSN, Pedro del Nido , MD, Redmond P. Burke , MD, Aldo R. Castaneda , MD, John E. Mayer , Jr. , MD, Jane W. Newburger , MD, MPH

Supported by grants NS32570, RR02172, and K08-MNS01721 from the National Institutes of Health, the Kobren Fund, and the William Randolph Hearst Foundation.

Received for publication May 7, 1997 Revisions requested June 16, 1997 Revisions received July 30, 1997 Accepted for publication July 31, 1997 Address for reprints: Richard A. Jonas, MD, Department of Cardiovascular Surgery, Children's Hospital, 300 Longwood Ave., Boston, MA 02115.

Abstract

Objectives: In a randomized, single-center trial, we compared perioperative outcomes in infants undergoing cardiac operations after use of the alpha-stat versus pH-stat strategy during deep hypothermic cardiopulmonary bypass. Methods: Admission criteria included reparative cardiac surgery, age less than 9 months, birth weight 2.25 kg or more, and absence of associated congenital or acquired extracardiac disorders. Results: Among the 182 infants in the study, diagnoses included D-transposition of the great arteries ( n = 92), tetralogy of Fallot ( n = 50), tetralogy of Fallot with pulmonary atresia ( n = 6), ventricular septal defect ( n = 20), truncus arteriosus ( n = 8), complete atrioventricular canal ( n = 4), and total anomalous pulmonary venous return ( n = 2). Ninety patients were assigned to alpha-stat and 92 to pH-stat strategy. Early death occurred in four infants (2%), all in the alpha-stat group ( p = 0.058). Postoperative electroencephalographic seizures occurred in five of 57 patients (9%) assigned to alpha-stat and one of 59 patients (2%) assigned to pH-stat strategy ( p = 0.11). Clinical seizures occurred in four infants in the alpha-stat group (4%) and two infants in the pH-stat group (2%) ( p = 0.44). First electroencephalographic activity returned sooner among infants randomized to pH-stat strategy ( p = 0.03). Within the homogeneous D-transposition subgroup, those assigned to pH-stat tended to have a higher cardiac index despite a lower requirement for inotropic agents; less frequent postoperative acidosis ( p = 0.02) and hypotension ( p = 0.05); and shorter duration of mechanical ventilation ( p = 0.01) and intensive care unit stay ( p = 0.01). Conclusions: Use of the pH-stat strategy in infants undergoing deep hypothermic cardiopulmonary bypass was associated with lower postoperative morbidity, shorter recovery time to first electroencephalographic activity, and, in patients with D-transposition, shorter duration of intubation and intensive care unit stay. These data challenge the notion that alpha-stat management is a superior strategy for organ protection during reparative operations in infants using deep hypothermic cardiopulmonary bypass.




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