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Total circulatory arrest as a support modality in congenital heart surgery: review and current evidence

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Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

The use of total circulatory arrest (TCA)/deep hypothermic circulatory arrest (DHCA) as a support modality in congenital heart surgery is a time-tested strategy. However, with technological advances, the widespread use of this technique has decreased. Adjunctive cerebral perfusion with continuous cardiopulmonary bypass (CPB) gradually has become more popular with a view to reduce the complications related to DHCA. In addition, better neuromonitoring and neuroprotective strategies have made DHCA much safer. However, the level of evidence to support the best way to protect the brain during congenital heart surgery is insufficient. This review analyzes the history, physiology, techniques of DHCA, as well as other alternative strategies like selective cerebral perfusion and presents the current available evidence.

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References

  1. Rimmer L, Fok M, Bashir M. The history of deep hypothermic circulatory arrest in thoracic aortic surgery. Aorta. 2014;2:129–34.

    Article  Google Scholar 

  2. Lewis FJ, Taufic M, Varco RL, Niazi S. The surgical anatomy of atrial septal defects: experiences with repair under direct vision. Ann Surg. 1955;142:401–17.

    Article  CAS  Google Scholar 

  3. Cooley DA, Mahaffey DE, De Bakey ME. Total excision of the aortic arch for aneurysm. Surg Gynecol Obstet. 1955;101:667–72.

    CAS  PubMed  Google Scholar 

  4. Drew CE, Keen G, Benazon DB. Profound hypothermia. Lancet. 1959;1:745–7.

    Article  CAS  Google Scholar 

  5. Ungerleider RM, Gaynor JW. The Boston circulatory arrest study: an analysis. J Thorac Cardiovasc Surg. 2004;127:1256–61.

    Article  Google Scholar 

  6. Asou T, Kado H, Imoto Y, et al. Selective cerebral perfusion technique during aortic arch repair in neonates. Ann Thorac Surg.1996;61:1546–8.

  7. Algra SO, Schouten AN, van Oeveren W, et al. Low-flow antegrade cerebral perfusion attenuates early renal and intestinal injury during neonatal aortic arch reconstruction. J Thorac Cardiovasc Surg. 2012;144:1323–8.

    Article  Google Scholar 

  8. Hofer A, Haizinger B, Geiselseder G, Mair R, Rehak P, Gombotz H. Monitoring of selective antegrade cerebral perfusion using near infrared spectroscopy in neonatal aortic arch surgery. Eur J Anaesthesiol. 2005;22:293–8.

    Article  CAS  Google Scholar 

  9. Haverich A, Hagl C. Organ protection during hypothermic circulatory arrest. J Thorac Cardiovasc Surg. 2003;125:460–2.

    Article  Google Scholar 

  10. Boyle EM, Pohlman TH, Cornejo CJ, Verrier ED. Endothelial cell injury in cardiovascular surgery: ischemia-reperfusion. Ann Thorac Surg. 1996;62:1868–75.

  11. Imota Y, Kado H, Shiokawa Y, Minami K, Yasui H. Experience with Norwood procedure without circulatory arrest. J Thorac Cardiovasc Surg. 2001;122:879–82.

    Article  Google Scholar 

  12. Barratt-Boyes BG, Simpson MM, Neutze JM. Intracardiac surgery in neonates and infants using deep hypothermia. Circulation 1970;62:III-73.

  13. Ehrlich MP, McCullough JN, Zhang N, et al. Effect of hypothermia on cerebral blood flow and metabolism in the pig. Ann Thorac Surg.2002;73:191–197.

  14. Kornilov IA, Sinelnikov YS, Soinov AI, et al. Outcomes after aortic arch reconstruction for infants: deep hypothermic circulatory arrest versus moderate hypothermia with selective antegrade cerebral perfusion. Eur J Cardiothorac Surg. 2015;48:e45–50.

    Article  Google Scholar 

  15. Hanley FL. Religion, politics…….. deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg. 2005;130:1236.

  16. Gaynor JW, Nicolson SC, Jarvic GP, et al. Increasing duration of deep hypothermic circulatory arrest is associated with an increased incidence of postoperative electroencephalographic seizures. J Thorac Cardiovasc Surg. 2005;130:1278–86.

    Article  Google Scholar 

  17. Wypij D, Newburger JW, Rappaport LA, et al. The effect of duration of deep hypothermic circulatory arrest in infant heart surgery on late neurodevelopment: the Boston Circulatory Arrest trial. J Thorac Cardiovasc Surg.2003;126:1397–403.

  18. Elmistekawy EM, Rubens FD. Deep hypothermic circulatory arrest: alternative strategies for cerebral perfusion. A review article. Perfusion.2011;26:27–34.

  19. Guo Z, Hu RJ, Zhu DM, Zhu ZQ, Zhang HB, Wang W. Usefulness of deep hypothermic circulatory arrest and regional cerebral perfusion in children. Ther Hypothermia Temp Manag.2013;3:126–131.

  20. Hammel JM, Deptula JJ, Karamlou T, Wedemeyer E, Abdullah I, Duncan KF. Newborn aortic arch reconstruction with descending aortic cannulation improves postoperative renal function. Ann Thorac Surg. 2013;96:1721–6.

  21. Andropoulos DB, Easley RB, Brady K et. al. Neurodevelopmental outcomes after regional cerebral perfusion with neuromonitoring for neonatal aortic arch reconstruction. Ann Thorac Surg 2013;95:648–655.

  22. Barnard J, Dunning J, Grossbner M, Bittar MN. In aortic arch surgery is there any benefit in using antegrade cerebral perfusion or retrograde cerebral perfusion as an adjunct to hypothermic circulatory arrest? Interact Cardiovasc Thorac Surg. 2004;3:621–630.

  23. Tian DH, Wan B1, Bannon PG, et al. A meta-analysis of deep hypothermic circulatory arrest alone versus with adjunctive selective antegrade cerebral perfusion. Ann Cardiothorac Surg. 2013;2:261–70.

    PubMed  PubMed Central  Google Scholar 

  24. Meyer D B , Jacobs J P, Hill K, Wallace AS, Bateson B, Jacobs ML. Variation in perfusion strategies for neonatal and infant aortic arch repair: contemporary practice in the STS congenital heart surgery database. World J Pediatr Congenit Heart Surg. 2016;7:638–644.

  25. Dewhurst AT, Moore SJ, Libian JB. Pharmacological agents as cerebral protectants during deep hypothermic circulatory arrest in adult thoracic aortic surgery. A survey of current practice. Anaesthesia. 2002;57:1016–21.

    Article  CAS  Google Scholar 

  26. Loepke AW, Soriano SG. An assessment of the effects of general anaesthetics on developing brain structure and neurocognitive function. Anesth Analg. 2008;106:1681–707.

    Article  Google Scholar 

  27. McAuliffe JJ, Loepke AW, Miles L, Joseph B, Hughes E, Vorhees CV. Desflurane, isoflurane and sevoflurane provide limited neuroprotection against neonatal hypoxia-ischemia in a delayed preconditioning paradigm. Anesthesiology. 2009;111:533–46.

  28. Medscape. FDA Warns on Anesthetic, Sedative Use in Pregnant Women, Kids. 2016. http://www.medscape.com/viewarticle/873310_print.

  29. Brain resuscitation clinical trial I study group. A randomised clinical study of thiopental loading in comatose survivors of cardiac arrest. N Engl J Med. 1986;314:397–403.

    Article  Google Scholar 

  30. Zaidan JR, Klochany A, Martin WM, Ziegler JS, Harless DM, Andrews RB. Effect of thiopental on neurologic outcome following coronary artery bypass grafting. Anesthesiology. 1991;74:406–11.

    Article  CAS  Google Scholar 

  31. Jolkkonen J, Puurunen K, Koistinaho J, et al. Neuroprotection by the alpha 2 –adrenoceptor agonist, dexmedetomidine, in rat focal cerebral ischemia. Eur J Pharmacol.1999;372:31–36.

  32. Agus MS, Asaro LA, Steil GM, et al. Tight glycemic control after pediatric cardiac surgery in high-risk patient populations: a secondary analysis of the safe pediatric euglycemia after cardiac surgery trial. Circulation. 2014;129:2297–304.

  33. Beardsall K, Vanhaesebrouck S, Ogilvy-Stuart AL, et al. A Randomised controlled trial of early insulin therapy in very low birth weight infants, “NIRTURE” (Neonatal Insulin Replacement Therapy in Europe.) BMC Pediatr. 2007;7:29.

  34. Langley SM, Chai PJ, JaggersJJ, Ungerleider RM. Preoperative high dose methylprednisolone attenuates the cerebral response to deep hypothermic circulatory arrest. Eur J Cardiothorac Surg. 2000;17:279–286.

  35. Stegeman R, Lamur KD, van den Hoogen A, et al. Neuroprotective drugs in infants with severe congenital heart disease: A systematic review. Front Neurol. 2018;9:521.

  36. Malan A. The evolution of mammalian hibernation: lessons from comparative acid-base physiology. Integr Comp Biol. 2014;54:484–96.

    Article  CAS  Google Scholar 

  37. Wypij D, Jonas RA, Bellinger DC, et al. The effect of hematocrit during hypothermic cardiopulmonary bypass in infant heart surgery: results from the combined boston hematocrit trials. J Thorac Cardiovasc Surg. 2008;135:355–360.

  38. Hirsch JC, Jacobs ML, Andropoulos D, et al. Protecting the infant brain during cardiac surgery: a systematic review. Ann Thorac Surg. 2012;94:1365–73.

  39. Conolly S, Arrowsmith J E, Klein A A. Deep hypothermic circulatory arrest. Continuing education in Anaesthesia, Critical Care Pain 2010;10:138–142.

  40. Newburger JW, Jonas RA, Wernovsky G, et al. A comparison of the perioperative neurologic effects of hypothermic circulatory arrest versus low-flow cardiopulmonary bypass in infant heart surgery. N Engl J Med. 1993;329:1057–1064.

  41. Bellinger DC, Wypij D, Kuban KC, et al. Developmental and neurological status of children at 4 years of age after heart surgery with hypothermic circulatory arrest or low-flow cardiopulmonary bypass. Circulation. 1999;100:526–532.

  42. Fuller S, Rajagopalan R, Jarvik G P et.al. Deep hypothermic circulatory arrest does not impair neurodevelopmental outcome in school-age children after infant cardiac surgery. Ann Thorac Surg 2010;90:1985–1995.

  43. Schechter MA, Shah AA, Englum BR et. al. Prolonged postoperative respiratory support after proximal thoracic aortic surgery: is deep hypothermic circulatory arrest a risk factor? J Crit Care 2016; 31:125–129.

  44. Andropoulos DB, Hunter JV, Nelson DP, et al. Brain immaturity is associated with brain injury before and after neonatal cardiac surgery with high-flow bypass and cerebral oxygenation monitoring. J Thorac Cardiovasc Surg. 2010;139:543–56.

  45. Bellinger DC, Wypij D, duPlessis AJ, et al. Neurodevelopmental status at eight years in children with dextro-position of great arteries: The Boston circulatory arrest trial. J Thorac Cardiovasc Surg. 2003;126:1385–96.

  46. Galli KK, Zimmerman RA, Jarvik GP, et al. Periventricular leukomalacia is common after neonatal cardiac surgery. J Thorac Cardiovasc Surg. 2004;127:692–704.

  47. Schlunt ML, Brauer SD. Anesthetic management for the pediatric patient undergoing deep hypothermic circulatory arrest. Semin Cardiothorac Vasc Anesth. 2007;11:16–22.

    Article  Google Scholar 

  48. de Ferranti S, Gauvreau K, Hickey PR, et al. Intraoperative hyperglycemia during infant cardiac surgery is not associated with adverse neurodevelopmental outcomes at 1, 4 and 8 years. Anesthesiology. 2004;100:1345–1352.

  49. Tu LN, Timms AE, Kibiryeva N ,et al. Transcriptome profiling reveals activation of inflammation and apoptosis in the neonatal striatum after deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg.2019;158:882–890.

  50. Jaggers J. Commentary: this is your brain, and this is your brain on deep hypothermic cardiac arrest. J Thorac Cardiovasc Surg. 2019;158:893–4.

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Cardiac Surgery, Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah, 711103, India

    Debasis Das & Nilanjan Dutta

  2. Department of Cardiac Surgery, BM Birla Heart Research Centre, 1, National Library Avenue, Alipore, Kolkata, 700027, India

    Kuntal Roy Chowdhuri

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  1. Debasis Das
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  2. Nilanjan Dutta
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  3. Kuntal Roy Chowdhuri
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Correspondence to Debasis Das.

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Key points

• Continuous CPB along with adjunct antegrade cerebral perfusion has gained substantial popularity in recent times.

• TCA (total circulatory arrest)/DHCA remains a time-tested strategy for complex aortic arch surgery as well as for achieving a bloodless, clutter-free surgical space for neonatal and infant cardiac surgeries.

• Newer neuromonitoring and neuroprotective methods have improved the safety margin of DHCA.

• There seems to be consensus that 45 min is the upper limit of safe duration of DHCA; however, limiting the duration of DHCA should always be a part of surgical plan.

• Neurodevelopmental outcomes of children operated with DHCA are better in contemporary series.

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Das, D., Dutta, N. & Roy Chowdhuri, K. Total circulatory arrest as a support modality in congenital heart surgery: review and current evidence. Indian J Thorac Cardiovasc Surg 37 (Suppl 1), 165–173 (2021). https://doi.org/10.1007/s12055-020-00930-3

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  • DOI: https://doi.org/10.1007/s12055-020-00930-3

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