title: Low-flow antegrade cerebral perfusion attenuates early renal and intestinal injury during neonatal aortic arch reconstruction.
abstract: OBJECTIVE
  Deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP) are 2 cardiopulmonary bypass strategies mainly used in aortic arch reconstructions. It has been suggested that during ACP, abdominal organs are better protected than during DHCA owing to partial perfusion via collaterals. We tested this hypothesis using intraoperative near-infrared spectroscopy (NIRS), lactate measurements, and biomarkers for early abdominal injury in neonates undergoing complex aortic arch repair.
  
  
  METHODS
  Neonates scheduled for aortic arch reconstruction via median sternotomy between 2009 and 2011 were randomized to either DHCA or ACP. During surgery, regional oxygen saturations of the abdomen were monitored using NIRS. Immediately aafter DHCA or ACP, lactate concentrations from the inferior vena cava were compared with those from the arterial cannula. Postoperatively, biomarkers for early abdominal organ injury were measured in urine.
  
  
  RESULTS
  Twenty-five neonates were analyzed (DHCA, n = 12; ACP, n = 13). Procedures were performed at 18°C, and ACP flow was set at 35 to 50 mL · kg(-1) · min(-1). Median abdominal NIRS value during DHCA was 31% (IQR, 28%-41%) whereas during ACP it was 56% (IQR, 34%-64%; P < .01 between groups). Immediately after DHCA, median lactate from the inferior vena cava was 4.2 mmol/L (IQR, 3.3-5.3 mmol/L) compared with 3.1 mmol/L (IQR, 2.9-4.4 mmol/L) after ACP (P = .03). Postoperatively, biomarkers for renal and intestinal damage (gluthatione s-transferase and intestinal fatty acid binding protein, respectively) were higher in the DHCA group than for the ACP group (P = .03, P = .04, respectively).
  
  
  CONCLUSIONS
  These results substantiate earlier suggestions that ACP provides more abdominal organ protection than DHCA in neonates undergoing aortic arch reconstruction.
authors.affiliation: Department of Pediatric Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. s.o.algra@umcutrecht.nl
authors.forename: Selma O
authors.initials: SO
authors.lastname: Algra
authors.forename: Antonius N J
authors.initials: AN
authors.lastname: Schouten
authors.forename: Wim
authors.initials: W
authors.lastname: van Oeveren
authors.forename: Ingeborg
authors.initials: I
authors.lastname: van der Tweel
authors.forename: Paul H
authors.initials: PH
authors.lastname: Schoof
authors.forename: Nicolaas J G
authors.initials: NJ
authors.lastname: Jansen
authors.forename: Felix
authors.initials: F
authors.lastname: Haas
mesh_terms: D001013:Aorta, Thoracic / Q000002:abnormalities / Q000503:physiopathology / Q000601:surgery*; D015415:Biomarkers / Q000097:blood; D002560:Cerebrovascular Circulation; D050792:Circulatory Arrest, Deep Hypothermia Induced / Q000009:adverse effects; D050556:Fatty Acid-Binding Proteins / Q000097:blood; D005982:Glutathione Transferase / Q000097:blood; D006330:Heart Defects, Congenital / Q000097:blood / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007231:Infant, Newborn; D007422:Intestines / Q000098:blood supply*; D007511:Ischemia / Q000209:etiology / Q000517:prevention & control*; D007668:Kidney / Q000098:blood supply*; D019344:Lactic Acid / Q000097:blood; D016343:Monitoring, Intraoperative / Q000379:methods; D009426:Netherlands; D010477:Perfusion / Q000009:adverse effects; D019265:Spectroscopy, Near-Infrared; D056346:Sternotomy; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects
chemical_list: D015415:Biomarkers; D050556:Fatty Acid-Binding Proteins; D019344:Lactic Acid; D005982:Glutathione Transferase