CHICAGO — Antegrade cerebral perfusion offers a survival advantage for high-risk newborns undergoing single-ventricle palliation, Dr. Robert Hannan said at the annual meeting of the Society of Thoracic Surgeons.
He reported on a retrospective analysis of 126 consecutive Rachs-1 category 6 patients who underwent stage 1 palliation of hypoplastic or nonhypoplastic left heart syndrome or a Damus-Kaye-Stansel procedure with either deep hypothermic circulatory arrest or antegrade cerebral perfusion at the Congenital Heart Institute at Miami Children's Hospital from 1995 to 2004.
In early 2001, hospital staff decided to limit the use of deep hypothermic circulatory arrest (DHCA) because of reports on the efficacy and safety of antegrade cerebral perfusion (ACP) and because of what Dr. Hannan called, “persuasive evidence that prolonged periods of deep hypothermic arrest lead to higher short- and long-term morbidity.”
A total of 67 patients were repaired with prolonged DHCA, and 59 with ACP and a short period of DHCA. Dr. Hannan and colleagues further stratified the groups into high-risk (weight less than 2.5 kg or other cardiac diagnosis) and usual-risk groups.
Patients were typically perfused through a shunt at the subclavian-innominate junction during arch reconstruction. Pulmonary artery transection was performed with the body perfused and the heart beating, he said. Circulatory arrest was used for changing the position of the cannulas and the atrial septectomy.
The 30-day survival was significantly higher in the ACP group than the DHCA group (90% vs. 70%). The high-risk ACP patients had a trend toward increased survival, compared with their DHCA counterparts (80% [12/15] vs. 62% [8/13]). But the difference was not significant.
At 1 year, the ACP group continued to have a significant survival advantage over the DHCA group (76% [45/59] vs. 54% [36/67]). But disappointingly, the high-risk groups continued to show a high interim mortality (48% [7/15] vs. 39% [5/13]), he said.
In the DHCA era, there were 32 deaths among 67 patients (48%), compared with 17 deaths in 59 patients in the ACP era (29%).
Cox regression analysis determined that an increase of just 1 kg in the weight of patients below 2.5 kg would lower the risk of death by 47%.
Dr. Hannan acknowledged that multiple changes were made during the study period in the hospital's perfusion strategy, ICU management, and anesthesia practices that confounded the effect of ACP. Perfusion changes included the adoption of a mixed alpha-stat/pH-stat strategy to manage acid base status, increased hematocrit while on bypass, and hyperoxygenation.
At 1 year, the ACP group continued to have a significant survival advantage over the DHCA group (76% vs 54%). DR. HANNAN