Cerebral effects of aortic clamping during coarctation repair in children: a transcranial Doppler study.
OBJECTIVE
Haemodynamic changes as a consequence of application and release of aortic clamps for surgical repair of aortic coarctation are compensated by cerebrovascular autoregulation. Transcranial Doppler was used to study the effect of these haemodynamic changes upon brain circulation in children during aortic coarctation repair.


METHODS
A 2-MHz transcranial Doppler system continuously recorded mean cerebral blood flow velocities from the left middle cerebral artery in 13 children (aged from 5 days to 14 years) during repair of their coarctation. Measurements were performed: prior to aortic clamping (baseline); during the first 5 min after clamp application; 1 min before declamping; at 1, 2, 4 and 6 min after the release of both proximal and distal aortic clamps; and at initial chest closure. A contralateral upper-limb non-invasive blood pressure cuff measured systemic blood pressures. Haemodynamic and anaesthetic parameters were monitored. Patients were stratified by age into two groups: age < 6 months (group A) and age > 6 months (group B).


RESULTS
With aortic clamping, systemic blood pressures (range from: -16 to +54%) and cerebral blood flow velocities (range from -40 to +19%) changed slightly (P > 0.05) from initiation to end of aortic clamping. In group A, release of aortic clamps resulted in moderate fluctuations in systemic blood pressures (range from -34 to +15%) (P > 0.05) and a marked reduction in cerebral blood flow velocities (range from -63 to -33%) (P < 0.01). At the time of surgical closure, flow velocities had improved in all infants except one. Group B did not show major reductions in either cerebral blood flow velocity or systemic blood pressures throughout all measurements (P > 0.05). During aortic clamp release, young infants responded with lower brain blood flow velocities as compared to older children (r = 0.68; P < 0.05).


CONCLUSIONS
Transient central nervous system hypotension results as a consequence of flow redistribution during aortic declamping in young infants. Older children usually show a faster autoregulatory compensation to these haemodynamic changes. The observed age-related physiologic differences, suggest that young infants may require higher systemic blood pressures during declamping to prevent the cerebral blood flow reduction. Transcranial Doppler appears to be a valuable monitor of these cerebral haemodynamic changes.
Rodriguez
R A
RA
Department of Surgery, Children's Hospital of Eastern Ontario, Ottawa, Canada. Rodriguez@CHEO.ON.CA
Weerasena
N
N
Cornel
G
G
Splinter
W M
WM
Roberts
D J
DJ
D000293:Adolescent; D001017:Aortic Coarctation / Q000601:surgery*; D001783:Blood Flow Velocity; D001921:Brain / Q000098:blood supply; D002560:Cerebrovascular Circulation; D002648:Child; D002675:Child, Preschool; D003250:Constriction; D004453:Echoencephalography; D006439:Hemodynamics; D006706:Homeostasis; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007432:Intraoperative Period; D012039:Regional Blood Flow