“Goal-Directed Perfusion” during Biventricular Repair of Congenital Aortic Arch Anomalies—Technical Challenge or Easy to Achieve?

Objectives: The refinement of cardiopulmonary bypass techniques has led to an improvement of organ protective methods during aortic arch surgery. Using three separate roller pumps, individual management of simultaneous cerebral, myocardial, and descending aortic perfusion, hence “goal directed perfusion”, is feasible. The aim of the present retrospective study was to assess short-term and mid-term results of patients with biventricular morphology who underwent regional cerebral and distal aortic perfusion during aortic arch repair for congenital lesions.

Methods: From December 2013 to November 2017, 21 patients with biventricular morphology underwent aortic arch surgery under regional cerebral and distal aortic perfusions. Twelve of them (57%) had an additional period of selective myocardial perfusion. Median weight was 3.6 kg (range: 2.2–89 kg). Age spectrum included 12 neonates, 2 toddlers, 2 children (2 and 6 years), and 5 adults (range: 18–42 years). Two neonates, one with Taussig–Bing anomaly and one with common arterial trunk type A4, underwent staged repair. Data of near-infrared spectroscopy (NIRS) and lactate levels were collected during the procedure.

Results: The median cardiopulmonary bypass time was 195 minutes (37–427 minutes). The median regional oximetry levels measured by NIRS during regional cerebral and distal aortic perfusions at the left and right hemispheres, and renal region were 71% (range: 61–87%), 75% (range: 56–82%), and 79% (range: 69–92%), respectively (p = n.s.). Level of median peak perioperative lactate until first postoperative day was 6.1 mmol/L (range: 2.3–12.8 mmol/L). Hospital mortality was 4.8% (n = 1) for the whole cohort. One patient with hypoplastic left heart complex died early due to failed biventricular repair after secondary Norwood procedure. One patient after primary repair of common arterial trunk with hypoplastic aortic arch died late abroad of noncardiac course. One and 5-year survival was 91 ± 6%, respectively.

Conclusion: Selective regional cerebral and distal aortic perfusions enable an adequate management of end-organ perfusion during aortic arch repair as expressed by levels of regional saturations. Particularly for patients with biventricular morphology, outcomes after arch repair with “goal-directed perfusion” techniques meet the claim of procedural safety.

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