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J Thorac Cardiovasc Surg 2002;123:1221
© 2002 The American Association for Thoracic Surgery

Letters to the Editor

Aortic arch reconstruction in neonates without hypothermic circulatory arrest

Stanford University School of Medicine, Falk CVRB, Stanford, CA 94305

To the Editor:

We read with interest the article by Imoto and coworkers ¹ titled "Experience With the Norwood Procedure Without Circulatory Arrest," published in the November 2001 issue of the Journal. The authors describe a new approach, which allows for one of the most complex neonatal aortic arch procedures to be completed with moderate hypothermia. The technique uses aortic crossclamping distal to the ductus arteriosus and retrograde perfusion of the descending aorta with a right-angled cannula through an opening in the posterior pericardium. An expanded polytetrafluoroethylene graft is anastomosed to the innominate artery and cannulated directly for selective antegrade cerebral perfusion.

Over the past 3 years, we have used a somewhat simpler technique, which allowed us to complete aortic arch reconstruction in 15 neonates drifting only to mild hypothermia (32°C-34°C). We cannulate the proximal innominate artery directly with a 6- or 8-mm arterial cannula and temporarily occlude the left common carotid and subclavian arteries with neurosurgical aneurysm clips. A clip is placed across the proximal aortic arch, between the innominate and left common carotid arteries. The distal arch and isthmus can therefore be opened while the innominate and coronary arteries are being perfused. We do not perfuse the descending aorta, and we complete the distal aortoplasty around a cardiotomy sucker placed in the thoracic aorta.

The ascending aorta is then augmented by repositioning the arch clip proximal to the innominate artery and removing the clips on the arch vessels. The ascending aorta can then be approached while the arch vessels and descending aorta are being perfused in an antegrade fashion. When we are approaching the aortic root, coronary perfusion with warm blood can be continued with aortic crossclamping above the sinotubular junction; a brief period of cardioplegic arrest (for atrial septectomy or for repair of the aortic root) may then be required.

Blood flow is approximately 60 mL · kg^-1 · min^-1 during the period of selective antegrade cerebral and coronary perfusion and is adjusted according to mean right radial arterial pressure; after completion of the arch anastomosis, the flow is increased to 150 to 200 mL · kg^-1 · min^-1. We have seen no untoward neurologic sequelae, such as seizures or paraplegia. In all patients, we have observed copious bleeding from the open descending aorta from abundant collateral flow.

12/8/123522

doi:10.1067/mtc.2002.123522

Reference

1. Imoto Y, Kado H, Shiokawa Y, Minami K, Yasui H. Experience with the Norwood procedure without circulatory arrest. J Thorac Cardiovasc Surg. 2001;122:879-82.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Luca A. Vricella Michael D. Black Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Vricella, L. A. Articles by Black, M. D. Search for Related Content PubMed PubMed Citation Articles by Vricella, L. A. Articles by Black, M. D.