Discussion
The use of DHCA to repair the aortic arch in newborns and infants is
decreasing as surgeons’ experience and available technology increases
(13), and brain, heart, and even lower-body perfusion applications have
become more common (9,14). We reviewed 173 newborn and infant patients
who underwent BH one-stage aortic arch reconstruction in a single‐center
serial study of a pediatric patient cohort, which to the best of our
knowledge is the largest such study to date. In this report, we
evaluated the short- and mid-term results of 113 newborns and infants
who underwent BHAS with the aim of eliminating concerns about the
applicability and safety of the technique. We also wanted to evaluate
whether this technique had a positive effect on short and mid-term
results by comparing the results of 60 newborns and infants who
underwent arch reconstruction under ACP-CA at different time intervals
(2011–2014).
Theoretically, this technique is expected to have a positive effect on
surgical results without increasing the difficulty of the procedure
(9,14). Because this technique can be used without needing to induce CA
in the patient, better postoperative results are expected. Some studies
have reported better postoperative results in BHAS patients (15). Lim et
al. compared patients undergoing arch reconstruction under BHAS and
under ACP-CA and found that the BHAS patients experienced fewer inotrope
requirements, fewer delayed sternal closures, less mechanichal
ventilation time, and required less time in intensive care (16). They
also argued that this technique can minimize myocardial complications
and related morbidities, and claimed that it could be used in patients
with single-ventricle physiology (16). Turek et al. compared patients
underwent Norwood procedure (which renders patients more susceptible to
ischemia) in combination with both the ACP-CA and BHAS techniques (9).
They observed better postoperative cardiac function in the patients,
less need for ECMO, and a lower mortality rate in the BHAS group, which
contributed to the popularization of this technique (9). In a more
recent study, Gil-Jaurena et al. reported that this technique can be
used safely and has positive effects on patient outcomes (17). We showed
that this technique reduced myocardial ischemic time and did not
increase descending aortic clamp time or CPB time. Although there are no
definitive data to show that coronary perfusion significantly improves
outcomes, there is a theoretical benefit to operating without inducing
cardioplegic arrest. Greater knowledge of this BHAS technique for arch
reconstruction repair could save valuable arrest time when concomitant
intracardiac procedures are required. Although the preoperative data of
the groups were similar, ARF and delayed sternal closure were observed
to occur more often in the CA group. There was no difference between the
groups in terms of mortality or incidence of MAE. Even though there was
no statistically significant difference between the groups, there was
higher recurrent nerve paralysis incidence in the BHAS group. This
result may be related due to poor visualization.
A modification of this technique is the selective ACP-CP method, wherein
coronary and cerebral flows are supplied with two separate pump heads.
Luciani et al. compared BHAS with the selective BHAS method and found
that cardiac morbidity was higher in the non-selective group, although
they found no significant differences between the groups in terms of
long-term survival or need for reintervention (18). Luciani et al.’s
study was a multicenter, retrospective, and highly heterogeneous and
their results were to an extent speculative (19). Although it supports
our finding that coronary perfusion is beneficial, we did not find
convincing evidence that it should be done selectively. We found that
the non-selective CP procedure is easier to prepare, apply, and follow.
Reoperation and reintervention after arch reconstruction due to
restenosis surgery is another concern. In the literature, restenosis and
reintervention are reported to occur in 4–28% of cases (20-23). Gray
et al. reported the freedom from reintervention rate to be 87% at 1, 3,
and 5 years (20). There are several factors reported in the literature
that are thought to cause restenosis. The effect of the surgical
technique, patch material, and perfusion strategies on restenosis has
been investigated by various authors (10,23,24). However, there is
insufficient data about the effect of the perfusion strategy used on
surgical quality and long-term mortality and reintervention. Fuchigami
et al. compared the results of arch surgery patients with conventional
arch surgery and procedures done using BHAS, and found no difference
between the groups in terms of long-term survival and reintervention
(10). In our study, the restenosis rate was found to be 9% (11
reoperations, 5 reinterventions). There were no statistically
significant differences between the BHAS and CA groups in terms of
reoperation or reintervention.
The results of this study indicate that coronary perfusion as a surgical
strategy is comperable to the standard technique for protecting the
heart while performing aortic arch repair (9, 16-18). Moreover, we found
that simultaneous brain and heart perfusion by the same arterial line is
an easy, reproducible technique that does not create surgical
difficulties. As the duration of cardiac ischemia is shorter during
BHAS, in theory it should reduce the likelihood of cardiac morbidity.
However, there are also theoretical disadvantages such as performing the
operation on a BH complicates the procedure, affects the quality of
anastomosis, and leads to increased incidences of reoperation and
reintervention in the short term. However, we found that there is no
increase in the incidence of reoperation and reintervention in the
mid-term. Although it does not fully meet our expectations of low
cardiac morbidity, we have been performing BHAS routinely since 2014
because the procedure is not as complicated as thought and due to its
theoretical advantages.