The influence of pH strategy on cerebral and collateral circulation during hypothermic cardiopulmonary bypass in cyanotic patients with heart disease: results of a randomized trial and real-time monitoring.
OBJECTIVE
The optimal pH strategy during hypothermic cardiopulmonary bypass remains controversial. Systemic pulmonary collateral circulation may develop in patients with cyanotic anomalies. The purpose of this study was to evaluate the effect of pH strategies on cerebral oxygenation and systemic pulmonary collateral circulation during hypothermic cardiopulmonary bypass in cyanotic patients with heart disease.


METHODS
Forty cyanotic patients (age > 1 year) with heart disease were prospectively randomized into 2 groups. Group 1 (n = 19, 14.3 +/- 1.5 kg) underwent hypothermic cardiopulmonary bypass with alpha-stat strategy and group 2 (n = 21, 12.5 +/- 0.9 kg) with pH-stat. Cardiopulmonary bypass was established with pump-assisted drainage. Cerebral oxygenation was assessed by near-infrared spectroscopy and the systemic pulmonary collateral circulation was calculated by pump flows [% systemic pulmonary collateral circulation = perfusion flow - drainage flow)/perfusion flow x 100]. Lactate was measured as an index of systemic anaerobic metabolism.


RESULTS
There were no significant differences in preoperative hematocrit, oxygen saturation, Qp/Qs, cardiopulmonary bypass duration, minimum temperatures, perfusion flow and pressure, urine output, and depth of anesthesia between the groups. Oxyhemoglobin signal and tissue oxygenation index of near-infrared spectroscopy monitoring were significantly lower in group 1 compared with group 2 (P =.008 and P <.0001, respectively), suggesting inadequate cerebral oxygenation with alpha-stat. Deoxygenated hemoglobin signal was significantly higher in group 1 relative to group 2 (P <.0001). The % systemic pulmonary collateral circulation was significantly lower in group 2 compared with group 1, suggesting a reduced pulmonary collateral circulation with pH-stat (P <.0001, average; group 1, 20.1% +/- 1.2%; group 2; 7.7% +/- 0.7%). Serum lactate was significantly lower in group 2 (P <.0001).


CONCLUSIONS
The pH-stat strategy results in an improved environment, including sufficient cerebral oxygenation, decreased systemic pulmonary collateral circulation, and lower lactate level during hypothermic cardiopulmonary bypass in cyanotic patients with heart disease. Future studies should investigate the long-term neurological outcome.
Sakamoto
Takahiko
T
Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, Japan. takasakamoto@yahoo.co.jp
Kurosawa
Hiromi
H
Shin'oka
Toshiharu
T
Aoki
Mitsuru
M
Isomatsu
Yukihisa
Y
D000704:Analysis of Variance; D002315:Cardiopulmonary Bypass / Q000379:methods*; D002560:Cerebrovascular Circulation / Q000502:physiology*; D002648:Child; D002675:Child, Preschool; D003097:Collateral Circulation / Q000502:physiology; D003490:Cyanosis / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D005260:Female; D006323:Heart Arrest / Q000517:prevention & control; D006331:Heart Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007036:Hypothermia, Induced / Q000379:methods; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods*; D010092:Oximetry; D010100:Oxygen / Q000097:blood*; D011379:Prognosis; D011446:Prospective Studies; D011659:Pulmonary Gas Exchange; D018570:Risk Assessment; D012680:Sensitivity and Specificity
D010100:Oxygen