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      Selective lower body perfusion during aortic arch surgery in neonates and small children

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          Abstract

          Introduction:

          Aortic arch reconstruction surgery represents a challenge for the medical personnel involved in treatment. Along the years, the perfusion strategies for aortic arch reconstruction have evolved from deep hypothermic cardiac arrest to antegrade cerebral perfusion with moderate hypothermia, and recently to a combined cerebral and lower body perfusion with moderate hypothermia. To achieve a lower body perfusion, several cannulation strategies have been described. In this study, we investigated the feasibility of utilizing an arterial sheath introduced in the femoral artery to achieve an effective lower body perfusion.

          Methods:

          We included patients who underwent an aortic arch reconstruction surgery with a lower body perfusion, from January 2017 to June 2019. To achieve a lower body perfusion, a three-way stopcock was connected to the arterial line, where one end was connected to the central cannulation for cerebral perfusion and the other to an arterial sheath that was introduced through the femoral artery. A total of 25 patients were included. Peri- and postoperative lactate and creatinine levels and signs of malperfusion were recorded.

          Results:

          During the reperfusion phase, after selective perfusion ended none of the patients showed a significant increase in lactate, creatinine, and liver enzyme levels. After 24 hours, there were no signs of an acute kidney injury, femoral vessel injury, or limb malperfusion.

          Conclusion:

          These findings show that a sufficient lower body perfusion through an arterial sheath placed in the femoral artery for aortic arch reconstruction can be achieved. This approach caused no complications related to the arterial sheath during the early postoperative period and is an easy way to maintain perfusion of systemic organs.

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          Most cited references10

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          Independent association between acute renal failure and mortality following cardiac surgery.

          To determine whether there is an independent association of acute renal failure requiring dialysis with operative mortality after cardiac surgery. The 42,773 patients who underwent coronary artery bypass or valvular heart surgery at 43 Department of Veterans Affairs Medical Centers between 1987 and 1994 were evaluated to determine the association between acute renal failure sufficient to require dialysis and operative mortality, with and without adjustment for comorbidity and postoperative complications. Crude and adjusted odds ratios (OR) and 95% confidence intervals (95% CI) were derived from logistic regression analysis. Acute renal failure occurred in 460 (1.1%) patients. Overall operative mortality was 63.7% in these patients, compared with 4.3% in patients without this complication. The unadjusted OR for death was 39 (95% CI 32 to 48). After adjustment for comorbid factors related to the development of acute renal failure (surgery type, baseline renal function, preoperative intraaortic balloon pump, prior heart surgery, NYHA class IV status, peripheral vascular disease, pulmonary rales, left ventricular ejection fraction below 35%, chronic obstructive pulmonary disease, systolic blood pressure, and the cross-product of systolic blood pressure and surgery type), the OR was 27 (95% CI 22 to 34). Further adjustment was made for seven postoperative complications (low cardiac output, cardiac arrest, perioperative myocardial infarction, prolonged mechanical ventilation, reoperation for bleeding or repeat cardiopulmonary bypass, stroke or coma, and mediastinitis), that were independently associated with operative mortality. The OR adjusted for comorbidity and postoperative complications associated with acute renal failure was 7.9 (95% CI 6 to 10). Acute renal failure was independently associated with early mortality following cardiac surgery, even after adjustment for comorbidity and postoperative complications. Interventions to prevent or improve treatment of this condition are urgently needed.
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            Regional low-flow perfusion provides cerebral circulatory support during neonatal aortic arch reconstruction.

            Because of concerns regarding the effects of deep hypothermia and circulatory arrest on the neonatal brain, we have developed a technique of regional low-flow perfusion that provides cerebral circulatory support during neonatal aortic arch reconstruction. We studied the effects of regional low-flow perfusion on cerebral oxygen saturation and blood volume as measured by near-infrared spectroscopy in 6 neonates who underwent aortic arch reconstruction and compared these effects with 6 children who underwent cardiac repair with deep hypothermia and circulatory arrest. All the children survived with no observed neurologic sequelae. Near-infrared spectroscopy documented significant decreases in both cerebral blood volume and oxygen saturations in children who underwent repair with deep hypothermia and circulatory arrest as compared with children with regional low-flow perfusion. Reacquisition of baseline cerebral blood volume and cerebral oxygen saturations were accomplished with a regional low-flow perfusion rate of 20 mL x kg(-1) x min(-1). Regional low-flow perfusion is a safe and simple bypass management technique that provides cerebral circulatory support during neonatal aortic arch reconstruction. The reduction of deep hypothermia and circulatory arrest time required may reduce the risk of cognitive and psychomotor deficits.
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              Newborn aortic arch reconstruction with descending aortic cannulation improves postoperative renal function.

              A clinically driven transition in perfusion technique occurred at Children's Hospital and Medical Center, Omaha, Nebraska, from primarily selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest to a technique of dual arterial perfusion including innominate artery and descending aortic cannulation (DAC), with continuous mildly hypothermic (>30 °C) full-flow cardiopulmonary bypass to the entire body. This study retrospectively compared outcomes in a recent cohort of neonates undergoing aortic arch reconstruction with the two techniques.
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                Author and article information

                Journal
                Perfusion
                Perfusion
                PRF
                spprf
                Perfusion
                SAGE Publications (Sage UK: London, England )
                0267-6591
                1477-111X
                21 January 2020
                October 2020
                : 35
                : 7
                : 621-625
                Affiliations
                [1 ]Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
                [2 ]Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
                Author notes
                [*]Christian Schlensak, Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany. Email: Christian.schlensak@ 123456med.uni-tuebingen.de
                Author information
                https://orcid.org/0000-0002-4907-7020
                Article
                10.1177_0267659119896890
                10.1177/0267659119896890
                7536511
                31960747
                5dedcaab-a6e0-496e-8aa9-b254d7b76304
                © The Author(s) 2020

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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                congenital cardiac surgery,perfusion,organ protection

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