Studies of hypothermic circulatory arrest and low flow bypass as used for congenital heart surgery

Objective Increased survival in children with critical congenital heart disease (CHD) has raised interest in the neurodevelopmental sequelae of these lesions. This investigation is part of an institutional effort to examine the neurodevelopment of 5-year-old children following repair or palliation of CHD. Methods We performed a battery of neuropsychological tests on a sample of 243 children between 1998 and 2001. Results In the sample as a whole, mean full-scale (FSIQ), verbal (VIQ), and performance (PIQ) IQ scores were in the normal range (96.8±15.9, 97.8±14.6, and 96.3±17.1, respectively). Anatomic, demographic, and perioperative factors were assessed for impact on neurodevelopment. In multiple regression analysis, lower socioeconomic status (SES) and the diagnosis of velocardiofacial syndrome (VCFS) predicted a lower FSIQ ( P =0.01, and P =0.001, respectively). A single ventricle diagnosis ( P =0.06), longer postoperative ICU stay ( P =0.08), and cumulative duration of hypothermic circulatory arrest (HCA) ( P =0.09) approached significance as predictors of lower FSIQ. Conclusion Children with CHD, on the whole, appear to be performing within the average range in terms of intellectual abilities. Lower SES and VCFS are associated with lower IQ scores. Trends toward worse outcomes were observed in single ventricle patients, biventricular patients with longer postrepair ICU stays, and patients subjected to longer periods of HCA.

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A vulnerable interval for cerebral injury—comparison of hypothermic circulatory arrest and low flow cardiopulmonary bypass

Cardiology in the Young ◽

10.1017/s1047951100001694 ◽

1993 ◽

Vol 3 (3) ◽

pp. 287-298 ◽

Cited By ~ 11

Author(s):

Craig K. Mezrow ◽

Peter S. Midulla ◽

Ali M. Sadeghi ◽

Otto Dapunt ◽

Alejandro Gandsas ◽

...

Keyword(s):

Congenital Heart Disease ◽

Heart Disease ◽

Cardiopulmonary Bypass ◽

Congenital Heart ◽

Circulatory Arrest ◽

Hypothermic Circulatory Arrest ◽

Cerebral Injury ◽

Low Flow ◽

Increasing Risk ◽

Hypothermic Arrest

Over the past two decades, advances in equipment used for cardiopulmonary bypass and in operative techniques have resulted in a tremendous decrease in the mortality of patients undergoing surgical repair of congenital heart disease utilizing hypothermic circulatory arrest. Despite the widespread use of hypothermic arrest, opinion is not unanimous with regard to its safety. Previous studies which have examined neurological outcome following repair of congenital heart disease in infancy have generally agreed that when the period of arrest exceeds 60 minutes, there is increasing risk of cerebral injury.

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A comparison of the perioperative neurologic effects of hypothermic circulatory arrest versus low-flow cardiopulmonary bypass in infant heart surgery.

Journal of Neurosurgical Anesthesiology ◽

10.1097/00008506-199401000-00017 ◽

1994 ◽

Vol 6 (1) ◽

pp. 61-62

Author(s):

David S. Smith

Keyword(s):

Cardiopulmonary Bypass ◽

Heart Surgery ◽

Circulatory Arrest ◽

Hypothermic Circulatory Arrest ◽

Low Flow

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Developmental and Neurologic Status of Children after Heart Surgery with Hypothermic Circulatory Arrest or Low-Flow Cardiopulmonary Bypass

New England Journal of Medicine ◽

10.1056/nejm199503023320901 ◽

1995 ◽

Vol 332 (9) ◽

pp. 549-555 ◽

Cited By ~ 473

Author(s):

David C. Bellinger ◽

Richard A. Jonas ◽

Leonard A. Rappaport ◽

David Wypij ◽

Gil Wernovsky ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Heart Surgery ◽

Circulatory Arrest ◽

Hypothermic Circulatory Arrest ◽

Low Flow ◽

Neurologic Status

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Glycoprotein IIb/IIIa inhibition reduces prothrombotic events under conditions of deep hypothermic circulatory arrest

Thrombosis and Haemostasis ◽

10.1160/th04-10-0641 ◽

2005 ◽

Vol 94 (07) ◽

pp. 115-122 ◽

Cited By ~ 8

Author(s):

Ruben Azevedo ◽

Wolfram Beierlein ◽

Hans P. Wendel ◽

Klaus Dietz ◽

Gerhard Ziemer ◽

...

Keyword(s):

Platelet Aggregation ◽

Platelet Activation ◽

Heart Surgery ◽

Circulatory Arrest ◽

Organ Damage ◽

Congenital Heart Surgery ◽

Deep Hypothermic Circulatory Arrest ◽

Hypothermic Circulatory Arrest ◽

Short Acting

SummaryDeep Hypothermic Circulatory Arrest (DHCA) is employed during thoracic aortic and congenital heart surgery, and can induce postoperative neurological damage probably caused by microthrombembolism. Hypothermia has been reported to induce platelet activation and aggregation. The platelet activation marker P-selectin mediates binding of platelets to leukocytes. Tirofiban and eptifibatide, short-acting inhibitors of the platelet fibrinogen receptor GP IIb/IIIa, have recently been shown to protect platelet function without increasing bleeding during heart surgery using cardiopulmonary bypass. The aim of this study was to investigate the effect of tirofiban and eptifibatide on platelets and platelet-leukocyte interaction under DHCA conditions in vitro.Platelet aggregation, binding of the GP IIb/IIIa activation specific antibody PAC-1, P-selectin expression as well as monocyte and granulocyte content of aggregates were investigated in un-stimulated and ADP-stimulated samples using flow cytometry. Tirofiban and eptifibatide inhibited massive platelet aggregation and PAC-1 binding which were induced by DHCA conditions. P-selectin expression was inhibited by tirofiban but increased by eptifibatide at hypothermia. Platelet-bound leukocytes were present in all samples. Eptifibatide increased granulocyte content of aggregates at hypothermia in ADP-stimulated samples. We conclude that under conditions of DHCA both tirofiban and eptifibatide inhibit platelet aggregation but have different effects on platelet P-selectin expression and platelet-leukocyte interaction. Application of a short-acting and non-activating GP IIb/IIIa inhibitor should be considered during DHCA in vivo to prevent occlusion of the microvasculature and subsequent organ damage.

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