Principles of antegrade cerebral perfusion during arch reconstruction in newborns/infants

Abstract

Antegrade cerebral perfusion (ACP) is a cardiopulmonary bypass technique that uses special cannulation procedures to perfuse only the brain during neonatal and infant aortic arch reconstruction. It is used in lieu of deep hypothermic circulatory arrest (DHCA), and thus has the theoretical advantage of protecting the brain from hypoxic ischemic injury. Despite this, recent comparative studies have shown no difference in neurodevelopmental outcomes with ACP versus DHCA for neonatal arch repair. This article presents animal and human data demonstrating that ACP flows less than 30 mL/kg/min are inadequate for many patients, and may be the explanation for lack of outcome difference versus DHCA. A technique for ACP, its physiologic basis, and a neuromonitoring strategy are presented, and then the results of an outcome study are reviewed, showing that with ACP technique at higher flows of 50 to 80 mL/kg/min guided by neuromonitoring, periventricular leukomalacia is eliminated on postoperative brain magnetic resonance imaging after neonatal cardiac surgery.

Figure 1

Depiction of the operative field during aortic arch reconstruction with antegrade cerebral perfusion (ACP). Arterial inflow is through the cannulated 3.5 mm polytetrafluoroethylene (PTFE) graft after the anastomosis to the innominate artery. Exposure is maintained by the brachiocephalic snares and a snare or clamp on the descending aorta, and the right atrial cannula. The PTFE graft will admit an 8 or 10 french aortic cannula. Reproduced with permission from Pigula et al. (3)

Figure 2

Flow related changes in superficial and deep brain saturations during regional low flow perfusion (RLFP). Values are plotted as means ± standard error of the mean. A significant difference was found between the deep and superficial brain during RLFP after a period of deep hypothermic circulatory arrest. RLFP is synonymous with antegrade cerebral perfusion. Reproduced with permission from Amir et al. (23)

Figure 3

Figure 3A (left): Normal preoperative T2 weighted sagittal MRI scan in patient with hypoplastic left heart syndrome. Figure 3B (right): The same patient with normal postoperative scan after Norwood Stage I palliation using antegrade cerebral perfusion.

Figure 4

Figure 4A (left): Normal preoperative T1 weighted sagittal MRI scan in patient with interuupted aortic arch, ventricular septal defect. Figure 4B (right) : Same patient with normal postoperative scan after complete repair using antegrade cerebral perfusion.