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.