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J Thorac Cardiovasc Surg 2001;121:0003-0009
© 2001 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Effect of Trendelenburg head position during cardiac deairing on cerebral microemboli in children: A randomized controlled trial

From the Division of Cardiovascular Surgery, the Departments of Surgery,^a Biostatistics,^b and Anaesthesia,^c Children's Hospital of Eastern Ontario, CHEO Research Institute and University of Ottawa, Ottawa, Ontario, Canada.

This work was partially funded by a grant-in-aid from the Children's Hospital of Eastern Ontario Foundation.

Portions of this study were presented at the International Neurosonology meeting, Winston Salem, NC, 1997, and at the Canadian Cardiovascular Society meeting, Winnipeg, MB, Canada, 1997.

Received for publication April 4, 2000. Revisions requested July 18, 2000; revisions received July 29, 2000. Accepted for publication August 30, 2000. Address for reprints: Rosendo A. Rodriguez, MD, PhD, Division of Cardiovascular Surgery, Department of Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1, Canada (E-mail: Rodriguez{at}CHEO.ON.CA).

Objectives: We prospectively evaluated the effects of head position during cardiac deairing on the Doppler ultrasonography–detected cerebral microemboli in children and the association between the embolic counts and the clinical assessment of deairing.
Methods: Children requiring exposure of the systemic ventricle under cardiopulmonary bypass were randomized to Trendelenburg (–15°) and horizontal (0°) head positions during and after standard surgical deairing. Complexity of repair was categorized as follows: group I consisted of single simple lesions, and group II consisted of multiple complex lesions. Transcranial Doppler ultrasonography identified high-intensity transient signals in the right middle cerebral artery within the first 5 minutes after aortic declamping (release) and from this ending period until cardiopulmonary bypass termination (residual). Electrocardiographic alterations after deairing were documented. A predefined 5-point scale was used by the surgeon for blinded assessment of deairing.
Results: High-intensity transient signals were identified in 97% of 128 patients (aged 5 days to 17 years). The median total high-intensity transient signal count was 60 (25th-75th quartiles, 14-189). Head position or surgeon did not affect the rate of high-intensity transient signals (P > .20). During the residual interval, occurrence of HITS in group I was less than that in group II (P < .05), but there was no difference at release. The incidence of high-intensity transient signals and electrocardiographic alterations correlated with the clinical assessment of deairing (P < .01).
Conclusions: Trendelenburg head position as a complement of cardiac deairing in children does not decrease the cerebral microembolic load compared with the horizontal head position. The cerebral microembolic count and the occurrence of electrocardiographic alterations usually increases when the surgeon is less confident in the efficacy of deairing.