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  • Title: Newborn aortic arch reconstruction with descending aortic cannulation improves postoperative renal function.
    Author: Hammel JM, Deptula JJ, Karamlou T, Wedemeyer E, Abdullah I, Duncan KF.
    Journal: Ann Thorac Surg; 2013 Nov; 96(5):1721-6; discussion 1726. PubMed ID: 23998412.
    Abstract:
    BACKGROUND: A clinically driven transition in perfusion technique occurred at Children's Hospital and Medical Center, Omaha, Nebraska, from primarily selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest to a technique of dual arterial perfusion including innominate artery and descending aortic cannulation (DAC), with continuous mildly hypothermic (>30 °C) full-flow cardiopulmonary bypass to the entire body. This study retrospectively compared outcomes in a recent cohort of neonates undergoing aortic arch reconstruction with the two techniques. METHODS: The clinical records of 142 consecutive neonates undergoing operations involving aortic arch reconstruction at a single institution between April 2004 and September 2012 were reviewed. Renal function changes were graded according to the pediatric RIFLE score (based on risk, injury, failure, loss, and end-stage kidney disease). Sixteen patients, 8 supported with selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest and 8 with DAC, required immediate postoperative extracorporeal membrane oxygenation and were excluded from renal function analysis. Multivariable regression models evaluated predictors of pediatric RIFLE score. RESULTS: Patients with DAC had shorter median bypass support (113 versus 172 minutes; p < 0.001) and myocardial ischemic time (43 versus 81 minutes; p < 0.001). Patients with DAC had less median fluid gain at 24 hours (37 versus 69 mL/kg; p < 0.001), and lower incidence of acute kidney injury (5% versus 31%; p < 0.001). Fewer patients with DAC (31% versus 58%; p = 0.001) required open chest. Use of selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest, single-ventricular physiology, and aortic cross-clamp time were found to be multivariable predictors of serious kidney dysfunction. CONCLUSIONS: Multisite arterial perfusion, including DAC, and maintenance of continuous mildly hypothermic full-flow cardiopulmonary bypass may offer advantages as a perfusion strategy for neonatal arch reconstruction. Prospective investigation of this technique is warranted.
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