Neurological Injury after Neonatal Cardiac Surgery: A Randomized Controlled Trial of Two Perfusion Techniques

BACKGROUND:

Complex neonatal cardiac surgery is associated with cerebral injury. Especially aortic arch repair, requiring either deep hypothermic circulatory arrest(DHCA) or antegrade cerebral perfusion(ACP), entail a high risk of peri-operative injury. It is unknown, whether ACP results in less cerebral injury than DHCA.

METHODS AND RESULTS:

Thirty-seven neonates with an aortic arch obstruction presenting for uni- or biventricular repair, were randomized to either DHCA or ACP. Pre-operatively and one week after surgery, magnetic resonance imaging(MRI) was performed in 36 patients(one patient died during hospital stay). The presence of new postoperative cerebral injury was scored, and results were entered into a sequential analysis, which allows for immediate data analysis. After the 36th patient, it was clear that there was no difference between DHCA and ACP in terms of new cerebral injury. Pre-operatively, 50% of patients had evidence of cerebral injury. Postoperatively, 14/18(78%) of DHCA patients had new injury, versus 13/18(72%) of ACP(p=0.66). White matter injury(WMI) was the most common type of injury in both groups, but central infarctions occurred exclusively after ACP(0 vs. 6/18[33%];p=0.02). Early motor and cognitive outcome at 24 months was assessed and was similar between groups(p=0.28 and p=0.25,respectively). Additional analysis revealed lower postoperative arterial pCO2 as risk factor for new WMI(p=0.04).

CONCLUSIONS:

In this group of neonates undergoing complex cardiac surgery, we were unable to demonstrate a difference in the incidence of peri-operative cerebral injury after ACP compared to DHCA. Both techniques resulted in a high incidence of new WMI, with central infarctions occurring exclusively following ACP.