Brain Protection in Pediatric Aortic Arch Repair
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Brain Protection in Pediatric Aortic Arch Repair: Deep Hypothermic Circulatory Arrest, Selective Cerebral Perfusion or Combined Technique
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Brain Protection in Pediatric Aortic Arch Repair
- 1. Hisar Intercontinental Hospital Brain Protection in Pediatric Aortic Arch Repair: Deep Hypothermic Circulatory Arrest, Selective Cerebral Perfusion or Combined Technique
- 3. DHCA has been widely employedDHCA has been widely employed since 1970s in complex CHD insince 1970s in complex CHD in neonatesneonates Reduction in CPB time Elimination of the need for multiple cannulae Bloodless operative field History of DHCAHistory of DHCA
- 4. First SCP for arch replacementFirst SCP for arch replacement DeBakey at al 1962 SCP from axilllary arterySCP from axilllary artery Panday et al 1974Panday et al 1974 Hypothermic (25-28C) SCPHypothermic (25-28C) SCP First et al 1986First et al 1986 Early successful hypothermic SCPEarly successful hypothermic SCP Matsuda et al 1989Matsuda et al 1989 Kazui et al 1989Kazui et al 1989 First SCP for aortic arch repair inFirst SCP for aortic arch repair in neonatesneonates History of SCP for AdultsHistory of SCP for Adults
- 5. The circle of Willis (CoW)The circle of Willis (CoW) %17 incomplete CoW%17 incomplete CoW 11 Collateral vessels 2 Ophthalmic artery Leptomeningeal vessels External carotid artery AnatomyAnatomy 1. Merkkola et al. Ann Thorac surg;2006:82:74. 2. Eur J Cardiothorac Surg 2010:37:1332
- 7. Pathophysiology of NeonatalPathophysiology of Neonatal Brain InjuryBrain Injury The brain utilizes up to 20% of totalThe brain utilizes up to 20% of total body Obody O22 consumptionconsumption Mechanisms of Cell Death Necrosis Apoptosis DHCA Excitatory amino acids: glutamateExcitatory amino acids: glutamate Selective Vulnerability of the Developing Brain (DHCA) Adult : generalized Jacksonian type seizures Neonatal: focal seizures Infant: choreoathetosis
- 8. Motor and Cognitive Outcomes After Surgery for CHD NNeonateseonates and young infantsand young infants havehave greatest risk for brain injurygreatest risk for brain injury Duration of DHCADuration of DHCA Seemingly normal 1-year-old afterSeemingly normal 1-year-old after surgerysurgery Significant abnormalities ofSignificant abnormalities of neurodevelopment at 4 or 8 years ofneurodevelopment at 4 or 8 years of agesages
- 9. Neonatal Brain Protection HypothermiaHypothermia pH stat blood managementpH stat blood management Pharmacologic agentsPharmacologic agents Volatile anaestheticsVolatile anaesthetics ThiopentalThiopental SteroidsSteroids TechniquesTechniques DHCADHCA Intermittent cerebral perfusionIntermittent cerebral perfusion SCPSCP
- 10. Hypothermia EEG silence andEEG silence and disappearance of thedisappearance of the SSER occur at 17°CSSER occur at 17°C Deep brain cools faster than theDeep brain cools faster than the subcortical areassubcortical areas 2°C-to 3°C between deep brain and2°C-to 3°C between deep brain and superficial brainsuperficial brain Blood temperature should not exceedBlood temperature should not exceed 37°C during rewarming37°C during rewarming
- 11. Arterial Blood Gas Management pH Stat & Alpha Stat The impact ofThe impact of arterial blood gasarterial blood gas management duringmanagement during DHCA in children isDHCA in children is still unclearstill unclear pH statpH stat improveimprovess cerebral blood flowcerebral blood flow and cerebraland cerebral ooxygenationxygenation and effectively cools the brainand effectively cools the brain but has a greater risk of microembolismbut has a greater risk of microembolism ExperimentalExperimental studies suggestedstudies suggested that pHthat pH stat arterial blood gas managementstat arterial blood gas management provides improvedprovides improved brain protection duringbrain protection during DHCA.DHCA. However, clinical studies have shown noHowever, clinical studies have shown no significant differance in the longtermsignificant differance in the longterm results between the pH stat and the alpharesults between the pH stat and the alpha statstat
- 12. Pharmacologic AgentsPharmacologic Agents Methylprednisolone* Barbiturates Volatile anesthetics Lidocain MannitolMannitol AnticonvulsantsAnticonvulsants Benzodiazepines PropofolPropofol Aprotinin Ca++ channel blockers Leukocyte filtration Diazoxide Thromboxane A2 blokers Glutamate ReceptorGlutamate Receptor BlockersBlockers Nitric Oxide SynthaseNitric Oxide Synthase InhibitorsInhibitors Free Radical ScavengersFree Radical Scavengers
- 13. Techniques 1-DHCA The advanteges of DHCA includes theThe advanteges of DHCA includes the reduction ofreduction of Cellular metabolic rateCellular metabolic rate Vascular permeabilityVascular permeability Blood-brain barrier disruptionBlood-brain barrier disruption Postischemic cerebral edemaPostischemic cerebral edema Disadventages of DHCADisadventages of DHCA Longer myocardial ischemiaLonger myocardial ischemia Autoregulation is lost (below 22°C)Autoregulation is lost (below 22°C) Coagulative, renal and pulmonaryCoagulative, renal and pulmonary complicationscomplications NNeurodevelopmental morbiditieseurodevelopmental morbidities
- 14. Techniques 1-DHCA Neurologic sequelae depends onNeurologic sequelae depends on Arrest periodArrest period Variations in perfusion technique duringVariations in perfusion technique during cooling and rewarmingcooling and rewarming Safe DHCA periodSafe DHCA period 35<min35<min Beyond this period neurologic sequelaeBeyond this period neurologic sequelae may increasemay increase Late neurologic abnormal develepmentLate neurologic abnormal develepment 1. Oates, et al. J Thorac Cardiovasc Surg. 1995;110:786 2. Newburger et al. N Engl J Med. 1993;329:1057 3. Bellinger et al. Circulation. 1999;100:526
- 15. Techniques 2-Intermittent Cerebral Perfusion ICP has been used routinly in pulmonaryICP has been used routinly in pulmonary thromboendarterectomy for adult patientsthromboendarterectomy for adult patients Experimental studiesExperimental studies 1,21,2 using neonatalusing neonatal piglets have shown that ICP has betterpiglets have shown that ICP has better brain protection than DHCAbrain protection than DHCA However, there is not an adequate clinicalHowever, there is not an adequate clinical study supporting the advantages of ICP instudy supporting the advantages of ICP in pediatric patients .pediatric patients . 1. Kimura T, et al. Demmy TL, et al. JCS 1994;108:658 2. Langley SM, et al. Ann Thorac Surg 1999;68:4
- 16. Techniques 3-Selectiveelective CCerebralerebral PPerfusionerfusion Technical issues relating toTechnical issues relating to SCP,SCP, such assuch as thethe perfusate temperatureperfusate temperature,, the flow ratethe flow rate,, and pressureand pressure , are still unsolved, are still unsolved Lowering perfusion pressure gradually from 90Lowering perfusion pressure gradually from 90 mmHg to 40 mm HgmmHg to 40 mm Hg doesdoes not change cerebralnot change cerebral blood flow orblood flow or CMROCMRO22 (1)(1) BBelow 40 mmelow 40 mm Hg, cerebral blood flow declineHg, cerebral blood flow decline ss abruptlyabruptly 11 AA reduction of 45%reduction of 45% to 70% in pump flow atto 70% in pump flow at 18°C significantly reduce18°C significantly reduce ss cerebral blood flowcerebral blood flow and CMROand CMRO22 (2)(2) 1. Tanaka , et al. J Thorac Cardiovasc Surg 1988;95:124 2. Kern , et al. Ann Thorac Surg 1993;56:1366
- 17. Which one ? DHCA or SCP Some surgeons have moved away fromSome surgeons have moved away from DHCADHCA There are many risksThere are many risks Some surgeonsSome surgeons still prefer DHCAprefer DHCA becausebecause The neurodevelopmental outcomes are notThe neurodevelopmental outcomes are not different !different ! TTechnical surgical reconstruction can beechnical surgical reconstruction can be performed with greater precisionperformed with greater precision than bythan by using SCPusing SCP
- 18. The differences between DHCA & SCP In a piglet model,In a piglet model, SCPSCP was found superior towas found superior to DHCADHCA11 TheThe resultsresults fromfrom clinical studiesclinical studies comparingcomparing SSCP with DHCA haveCP with DHCA have not shown a similarnot shown a similar benefitbenefit AA random trial demonstrated no clearrandom trial demonstrated no clear differencedifference betweenbetween SCPSCP and DHCAand DHCA afterafter 1 year1 year ofof NorwoodNorwood surgerysurgery 22 Two additional clinical studies alsoTwo additional clinical studies also demonstrated nodemonstrated no clearclear differencedifferencess betweenbetween SSCP and DHCACP and DHCA 3,43,4 Neurodevelopmental outcomes after 1 yearNeurodevelopmental outcomes after 1 year ofof NorwoodNorwood operationsoperations withwith SCPSCP werewere significantlysignificantly below population normsbelow population norms 2,42,4 1. Myung, et al. J Thorac Cardiovasc Surg. 2004;127:1051 2. Goldberg, et al. J Thorac Cardiovasc Surg. 2007;133:880 3. Dent, et al. J Thorac Cardiovasc Surg. 2006;131:190 4. Visconti ,et al. Ann Thorac Surg. 2006;82:2207
- 19. Neurodevelopmental OutcomesNeurodevelopmental Outcomes After Regional Cerebral PerfusionAfter Regional Cerebral Perfusion
- 20. MRI Brain Injury Preoperative, Postoperative and Premature 20-40 % preoperative MRI brain injury20-40 % preoperative MRI brain injury 11 35-75 % postoperative MRI brain injury35-75 % postoperative MRI brain injury 11 Brain injury in premature newbornsBrain injury in premature newborns detected with MRI is 37 %detected with MRI is 37 % 22 1. Andropoulos, et al. Ann Thorac Surg 2013;95:648 2. Miller, et al J Pediatr 2005;147:609
- 21. RReconstructioneconstruction of Aof Aorticortic AArch andrch and Isthmus Hypoplasia in Our Clinic etween Jan 2007etween Jan 2007 -- Sep 2012Sep 2012 7 cases with aortic arch and7 cases with aortic arch and isthmus hypoplasia accompanisthmus hypoplasia accompan inging otherother cardiac defectscardiac defects This technique was not used intechnique was not used in patients who hadpatients who had HLHSHLHS
- 22. AdditionalAdditional PProceduresrocedures Patients (n) VSD 23 Interruption repair 3 Subaortic resection 2 Arterial switch operation 8 CAVSD repair 2 Pulmonary arterial banding 3 Septectomy 1
- 25. Cardiopulmonary bypass time, min 154±61 Cross-clamp time, min 64.7±36 Selective cerebral and myocardial perfusion time, min 22.4±8 Descending aorta ischemia time, min 26.1±6.7 Total circulatory arrest time, min 7.1±2.7 (minimum: 4, maximum: 10) Extubation time, hour 159±180 Length of ICU stay time, hour 219± 249 Hospital length of stay time, day 13±11
- 26. Postoperative CoursePostoperative Course All VSD-CoAAH patients were extubated within 1. POD Prolonged extubation patients had single ventricle physiology or complex cardiac anomalies None of the patients had neurological defects
- 28. Perfusion Techniques in Neonatal Arch Reconstruction Ohne RG. J Thorac Cardiovasc Surg 2009;137:803
- 29. 1. Result1. Result SCP is theoreticalSCP is theoreticallyly advantageousadvantageous inin preventpreventinging ischemia of the brainischemia of the brain It should not be relied on totally as a safeIt should not be relied on totally as a safe methodmethod AAn inapn inapppropriately appliedropriately applied SCPSCP maymay cause more damage thancause more damage than TCATCA High orHigh or lowlow flow and pressure duringflow and pressure during SCPSCP may cause brain damage.may cause brain damage. SurgicalSurgical procedureproceduress may takemay take aa longerlonger timetime when performed withwhen performed with SCPSCP
- 30. 2. Result2. Result NeuromonitorizationNeuromonitorization is highly necessaryis highly necessary during SCP compared to TCAduring SCP compared to TCA We know that short termWe know that short term TCATCA is a safeis a safe methodmethod TheThe SCPSCP techniquetechnique doesndoesn’t effect the’t effect the surgeon's comfort and speedsurgeon's comfort and speed In our clinical experiance combiningIn our clinical experiance combining SCPSCP and shortand short period ofperiod of TTCCA (under 10 minutes)A (under 10 minutes) isis safe and practical insafe and practical in pediatricpediatric aorticaortic archarch reconstructioreconstructionn
- 31. Thank You!
Editor's Notes
- I will present Brain Protection in Pediatric Aortic Arch Repair : Deep Hypothermic Circulatory Arrest, Selective Cerebral Perfusion or Combined Technique
- ( SLAYD)
- SLAYD:::::::::::::::::the 1970 During the 1970s it was very important for SLAYD
- SLAYD……was used by DeBakey in 1962 First SCP from AA was used in 1974 First description of hypothermic SCP was reported by First and colleagues Early successfull hypothermic SCP was performed by 2 JapanESE surgeons in 1989 The SCP for neonates and infants started much later. in 1996 it was first used by Asou
- Anatomic variation of cerebral circulation is important for the repair of complex CHD during unilateral SCP The Circle of Willis is an arterial circle at the base of the brain The Circle of Willis has been found incomplEte in 17% of human brain autopsies. However, these anatomic studies underestimated the importance of collateral vessels which are.. SLAYD
- Circle of Willis variations are present in a significant number of patients
- T he brain utilizes up to 20% of total body oxygen consumption Neuronal cell death occurs by two distinct mechanisms, necrosis and apoptosis apoptosis, or the other term programmed cell death, lead to cell death despite adequate cellular energetics. The role of glutamate in the pathogenesis of ischemic brain injury after DHCA has been demostreted in animal models . D HCA inflicts a global and diffuse ischemic insult to the brain; nevertheless, damage is most likely to occur in s elect groups of structures in the immature brain . Clinically, in adults, generalized Jacksonian type seizures (sijırs) follow severe (si vir) hypoxic ischemic insults, whereas in neonates focal seizures are more common. In Infants , choreoathetosis can be a manifestation of ischemic neurologic postoperative insult, usually s econdary to basal ganglia damage.
- The mechanisms of brain injury remain multifactorial and studies have shown that up to 25% of children had resİdual neurological sequelae after surgery P rimarily neonates and young infants undergoing cardiac surgery, are at the greatest risk of brain (brein) injury. It is important to note that a seemingly normal 1-year-old , who had cardiac surgery in early infancy may display significant abnormalities of neurodevelopment at 4 o r 8 years of age
- To protect the neonatal brain from injury d uring aortic arch surgery, several surgical and anesthetic techniques have been developed.These include the use of ( SLAYD) ……………
- Electrocerebral silence and the disappearance of the somatosensory evoked response occur at approximately nasopharyngeal temperature of 17°C. In experimental study, there is a temperature gradient of 2C-to 3C between the deep brain and the superficial brain during cooling and rewarming. The Arterial blood temperatures should not exceed 37°C during rewarming, and nasopharyngeal temperatures should be monitored closely.
- The impact of arterial blood gas management during DHCA in children is still unclear. pH stat improve s cerebral blood flow and cerebral o xygenation and effectively cools the brain but has a greater risk of microembolism Experimental data suggest ed that pH stat arterial blood gas management provides improved brain protection during DHCA. However, clinical studies have shown no significant differance in the longterm results between the pH stat (stat)and the alpha stat
- Barbiturates(BARBİTÜREYTS DİYE OKUNUYOR) (barbicuits), Methylprednisolone, Volatile anesthetics have been used to protect the brain during periods of ischemia in clinical practise Most of all a high dose of preoperative MP has a protective effect during brain ischemi Many other substrates (sabstraits)and techniques including…… ( SLAYD) ………. have been used in experimental studies. However most of them were not used in clinical practice to protect the brain
- DHCA has until recently been the standard intraoperative procedure used to perform aortic arch reconstruction in infants and young children. DHCA is a double-edged (eçd)sword (sord) The advantages of DHCA includes the reduction of cel….……Slayd:::::: However, there are some disadventages which are longer myocardial ischemia, loss of autoregulation. Deep hypothermia also has coagulative, renal and pulmonary complications and N eurodevelopmental morbidities
- After DHCA, Neurologic sequelae (SEKÜELİ)( sekvıeli ) depends on Arrest period and also variations in the perfusion techniques Safe DHCA period is under 35 minutes Beyond this duration , the incidence of perminant or transient neurologic sequelae may increase. In the long term, DHCA also has the potential for abnormal neurologic develepment including lower motor scores and greater speech abnormalities .
- SLAYD
- The other technique for cerebral protection is SCP Technical issues relating to SCP , such as the perfusate temperature , the flow rate , and pressure ,are still unresolved. Lowering perfusion pressure gradually from 90 mmHg to 40 mm Hg does not change cerebral blood flow or CMRO 2 (1) cerebral oxygen consumption (CMRO2), B elow 40 mm Hg, cerebral blood flow decline s abruptly (EBRABTLİ)(abrabtli) A reduction of 45% to 70% in pump flow at 18°C significantly reduce s cerebral blood flow and CMRO 2 cerebral oxygen consumption (CMRO2), cerebral metabolic rates of oxygen consumption = [CMRO2],
- Today this is an important question SLAYD ………………..
- SLAY (hümın) Below(be-lo)(BİLOV) D:::::::::::
- Studies have been made at the Texas Childrens Hospital on Neurodevelopmental Outcomes After Regional Cerebral Perfusion With Neuromonitoring for Neonatal Aortic Arch Reconstruction. The results of the study show language and motor development (dıv ı lopment)is slightly lower than reference population norm The technique has been found to be effective and safe
- The preoperative diagnosis (Dayagnosis)of brain Injury is important The prevalence at autopsy of recognized cerebral dysgenesis in infants with CHD ranges from 10 to 29 % . Most studies report a 20% to 40% incidence of preoperative MRI brain injury in neonatal cardiac surgical patients and a 35% to 75% incidence of new postoperative brain injury in neonatal cardiac surgical patients
- 37 cases with aortic arch and isthmus hypoplasia accompan ing (EKAMPANİYİNG) (akompaning) other cardiac defects were operated with SCMP and short TSA The technique was not used in patients who had hypoplastic left heart syndrome.
- Additional (EDİŞINIL)(adişinal) P rocedures are …………..
- Regional oxygen saturation was monitored Aorta was cannulated in the middle of the ascending aorta in all cases. The cross-clamp was applied to the aortic arch at distal to the innominate artery . In addition, a side clamp was applied to the descending aorta.
- The aorta is reconstructed with glt treated autogeneous pericardium The proximal aorta reconstruction is carried out under short TCA. Following the aortic reconstruction and de-airing, full flow CPB is reinstituted The Cross clamp is applied to the ascending aorta and cardioplegia is applied for intracardiac repair.
- The mean cardiopulmonary bypass and cross-clamp times were 154±61 and 64.7±36 minutes, respectively. The mean SCMP and descending aorta ischemia times were 22.4±8 and 26.1±6.7minutes, respectively. Mean TCA time 7.1±2.7 minutes (min: 4, max 10 min). The extubation and the length of ICU stay times were 159±180 hours and 219± 249 hours, respectively. The hospital length of stay time was 13±11 days. The mortality rate was 2.7% (1 patient).
- All VSD- coarctation with aortic arch hypoplasia ( CoAAH ) p atients without complex cardiac anomalies were extubated on the day of surgery or on the first morning following surgery. The cases who had prolonged extubation and ICU stay duration were the ones who had single ventricle physiology or complex cardiac anomalies. None of the cases operated with this technique had neurological defects or needed cranial imaging.
- This case is an example of this technique During SCP Cerebral oxygen saturations were above 60 % . During TCA, Cerebral oxygen saturation dec reased rapidly from 60 % to 25 % . This time period was only 8 min and then Cerebral oxygen saturation increased rapidly after staring CPB
- Perfusion Techniques in Neonatal Arch Reconstruction This was taken from Richard Ohne ’s study This study shows that today, most North American pediatric cardiac surgeons prefer SCP instead of DHCA during Neonatal Arch Reconstruction Most surgeons think that DHCA is to be avoided when possible
- ( SLAYD) (thioretikli) (totıli) The same surgical procedure may take a longer time when performed with SCP compared with TCA “ SURGİCAL PROCEDURES MAY TAKE LONGER... ” OLACAK
- ( SLAYD) Nöromoniterizasyona SCP da TCA den daha fazla ihtiyaç vardır. TCA kısa bir period içersinde güvenli olduğunu biliyoruz. Uygulanılacak SCP tekniği cerrahın konforunu ve hızını kesmeyecek şekilde olmalıdır. Cerrahın alışmış olduğu yöntemi ve hızı kesmeden kombine olarak kullanılmasıda iyi bir alternatiftir.
- Which one is safer, staying on the ıce DHCA or jumping from the ice SCP
- 1. What is your SCP flow , perfusion detail, and temparature ? At 24ºC, SCMP is initiated at a rate of 30-40 ml/kg/min while the right radial artery pressure is measured to ensure adequate flow (between 30-45 mmHg). 2. Do you excise istmus tottally No, we excise tottally all ductal tissue. All ductal tissue is excised from the under surface of the aortic arch . Distal descending aortic incision is extended 2 cm distally into the descending aorta 3. Why do you prefer extention of augmentetion to the ascending aorta We prefer the extention of augmentation to the ascending aorta if the aortic arch has completly hyplastic 4. Why do you use innominate artery cannulation instaed of asc aort cannulation for SCMP All VSD and coarctation with aortic arch hypoplasia patients were extubeted within the first postoperative day without neroulogical complication The management of a hypoplastic aortic arch is difficult through the left thoracotomy in patients with hypoplastic segment extending to proximal aortic arch and ascending aorta.