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J Thorac Cardiovasc Surg 2009;137:803-806
© 2009 The American Association for Thoracic Surgery

Editorial

The quest to optimize neurodevelopmental outcomes in neonatal arch reconstruction: The perfusion techniques we use and why we believe in them

^a Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
^b Department of Pediatrics and Communicable Disease, University of Michigan Medical School, Ann Arbor, Michigan
^c Department of Cardiothoracic Surgery, Drexel University, College of Medicine, Philadelphia, Pennsylvania

Received for publication October 8, 2008; accepted for publication October 31, 2008.

^_* Address for reprints: Richard G. Ohye, MD, 5144 CVC/SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5864. (Email: ohye@umich.edu).

The first 300 words of the full text of this article appear below.

Major advances in surgical techniques and medical care have brought exciting change to the outcomes of children treated for complex congenital heart disease. Hypoplastic left heart syndrome, for example, was uniformly fatal only 30 years ago, but now has a 5-year survival of approximately 70%.^1-4 Although the survival for those with surgically repaired complex congenital heart defects has markedly improved, associated morbidities remain high. The neurodevelopmental outcomes of infants and children requiring multiple cardiac operations in childhood are among the major concerns of those who care for patients with congenital heart disease.

Deep hypothermic circulatory arrest (DHCA), an adjunctive surgical technique that requires cooling the patient to 18°C and ceasing all blood flow to the entire body including the brain, has until recently been the standard intraoperative procedure used to perform aortic arch reconstruction in infants and young children. The development of DHCA in the early 1970s was a breakthrough that allowed for the operative treatment of many lesions previously not amenable to repair in neonates. Unfortunately, although still a mainstay in congenital heart surgery, DHCA is associated with the potential for poor neurodevelopmental outcomes.^5-7

Alternative Perfusion Techniques

Regional cerebral perfusion (RCP), a recently described alternative to DHCA, involves directing blood flow to the central nervous system throughout aortic arch reconstruction. RCP, first described by Asou and colleagues⁸ in 1996 as an alternative to DHCA, is hypothesized to be potentially neuroprotective relative to DHC. Since 2000, multiple case series of patients managed with RCP have been published.^9,10 In a piglet model, RCP was found superior to DHCA on neurobehavioral and histopathologic scores, albeit at a long period of DHCA (90 minutes).¹¹ However, results from human trials comparing RCP with DHCA have not shown a similar benefit. Data from a single institution randomized trial that we conducted demonstrated no clear difference between RCP and . . . [Full Text of this Article]

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