Developmental progress after cardiac surgery in infancy using hypothermia and circulatory arrest.

Clarkson, P. M.; Macarthur, Barton A.; Barratt‐Boyes, B. G.; Whitlock, R. M. L.; Neutze, John M.

doi:10.1161/01.cir.62.4.855

Cited by 105 publications

(20 citation statements)

References 11 publications

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“…De spite the use of total circulatory arrest clini cally for over 25 years and a number of clin ical and experimental studies [6][7][8], there continues to be controversy regarding the presence of neurologic damage associated with its use and relationship to its duration. Treasure et al [9] indirectly examined the safe period of total circulatory arrest during cardiac surgery by studying the effects of periods of 0-180 min of profoundly hypo thermic (20 °C) cerebral circulatory arrest in the gerbil produced by bilateral carotid ar tery occlusion.…”

Section: Alterations In Organ Perfusion and Metabolismmentioning

confidence: 99%

Cardiopulmonary Bypass: Studies on Its Damaging Effects

1987

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Despite the widespread safe application of cardiopulmonary bypass (CPB) for cardiac surgery, it is inherently a pathologic state. CPB produces a generalized inflammatory reaction involving at least the complement, coagulation, kallikrein, and fibrinolytic cascades.Marked alterations in organ perfusion and metabolism occur during CPB which are further affected by the perfusion flow rate. During hypothermic CPB at 20 °C, there is a progressive decrease in perfusion of the microcirculation at flow rates less than 1.2 liters/min/m2. Experimental studies suggest that brain oxygen consumption and resistance remain relatively constant as flow rates are reduced during hypothermia, and the brain becomes the passive recipient of proportionally more blood flow.Recent ultrafïltration studies have demonstrated a specific increase in microvascular permeability to proteins after 2 h of normo thermic CPB. This provides experimental support to the well-known clinical observation of increased interstitial fluid following CPB. The development of uniformly safe CPB depends upon prevention of the abnormalities of the micro-circulation and upon neutralization of the deleterious effects of inflammatory mediators.

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Section: Alterations In Organ Perfusion and Metabolismmentioning

confidence: 99%

Cardiopulmonary Bypass: Studies on Its Damaging Effects

1987

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“…Although it is not clear yet whether or not CPB impairs future brain function and developmental outcome, recent experimental and clinical data strongly suggest that deep hypothermic CPB and espe cially circulatory arrest longer than 60 min may be detrimental [5][6][7], In previous studies, we and others showed that especially at deep hypothermic CPB, brain perfusion is very low and cerebral autoregulation seems to be easily disturbed [2,4], Moreover, Greely et al [8] found that the intracellular brain oxygenation of pediatric patients decreased significantly during circulatory arrest and remained im paired after rewarming and CPB despite nor malization of the oxygen availability.…”

Section: Introductionmentioning

confidence: 99%

Changes in Cerebral Hemodynamics and Oxygenation during Hypothermic Cardiopulmonary Bypass in Neonates and Infants

et al. 1996

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Delay in development after open-heart surgery in infants has frequently been reported. Inadequate brain perfusion and oxygenation during deep hypothermic cardiopulmonary bypass (CPB) may play an important role. We investigated the effect of CPB on cerebral perfusion and oxygenation in 12 neonates and infants (age 0–11 months) undergoing open-heart surgery. Changes in cerebral blood volume (ΔCBV; in ml/100 g brain tissue) and oxidation level of the intracerebral mitochondrial enzyme cytochrome aa₃ (ΔCytaa₃; in µmol/l) were measured with near infrared spectroscopy. Nasopharyngeal temperature (T_nas) for assessment of changes in brain temperature, and mean arterial blood pressure (MAP) were monitored continuously. CBV lowered during cooling and increased during rewarming. These changes were only related with changes in Tnas (p < 0.001; 0.07 ml·100 g^-1/°C). No relation was found with changes in MAP or pump flow rate of the heart-lung machine. During steady-state hypothermic CPB, changes in CBV were only related to changes in MAP (p < 0.001). The individual regression lines between ΔCBV and MAP became steeper at lower absolute T_nas. Cytaa₃ showed an increase shortly after the initiation of CPB in 9 patients, with a sustained decrease to baseline values in 8 patients towards the end of the CPB period. Two patients who had a circulatory arrest during CPB had a sharp decrease in Δcytaa₃ after cessation of the heart-lung pump and showed no complete recovery of ΔCytaa₃ to baseline at the end of the CPB period. We conclude that changes in CBV during CPB are related to changes in T_nas. During deep hypothermic steady-state CPB, changes in CBV and MAP were related to each other, suggesting lack of cerebral autoregulation. The large decrease in Cytaa₃ in 2 patients with circulatory arrest suggests that this procedure compromises energy metabolism of the brain cell.

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“…These studies have reported low-average to average developmental or IQ scores. [1][2][3][4] More recent studies have reported low-average long-term developmental outcomes in children with hypoplastic left heart syndrome (HLHS) who have undergone staged reconstructive surgery. 5,6 In 1993, Baum et al 7 published developmental outcome data on infant recipients of heart transplantation.…”

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confidence: 99%