Impact of Perfusion Modalities on Cerebral Hemodynamics and Clinical Outcomes in Risk-Stratified Congenital Heart Surgery Patients
Krishna Patel, Yongwook Dan, Lilly Su, Allen Kunselman, Joseph B. Clark, John Myers, Akif Undar
Pediatrics, Surgery, and Biomedical Eng., Penn State College of Medicine, Hershey, Pennsylvania, United States
Objective: While pulsatile flow during cardiopulmonary bypass (CPB) may offer more physiologic perfusion to the systemic circulation, conclusive evidence is lacking to support its superiority over non-pulsatile flow for improved postoperative outcomes in patients undergoing cardiac surgery. The objective of this retrospective review was to evaluate the effects of perfusion modalities on cerebral hemodynamics and clinical outcomes in pediatric congenital cardiac surgery patients stratified by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality categories.
Methods: This study included 284 pediatric patients undergoing congenital cardiac surgery with CPB support utilizing only 8/10/12 Fr arterial cannulae. Patients were divided by mortality category into low/middle-risk (1-3) and high-risk (4-5) groups, and then further subdivided based on non-pulsatile versus pulsatile perfusion. Intraoperative cerebral gaseous microemboli (GME) counts, pulsatility index, and mean flow velocity at the right middle cerebral artery were assessed using transcranial Doppler ultrasound. Clinical outcomes were also compared between the groups. Unpaired t-tests, or Wilcoxon rank-sum tests if parametric assumptions were not met, and chi-square tests were used to compare the groups for continuous and categorical variables, respectively.
Results: In the high-risk group, patients using non-pulsatile perfusion had higher baseline mortality score, aortic cross-clamp time, and CPB time (Table 1). GME counts were similar between non-pulsatile and pulsatile groups. Pulsatility index during aortic cross-clamp was consistently higher in the pulsatile group (Figure 1A). However, no differences in mean flow velocity were noted between the groups (Figure 1B). Clinical outcomes revealed significantly longer intubation time, and intensive care unit and hospital length of stay in high-risk patients using non-pulsatile perfusion compared to pulsatile perfusion. No differences in clinical outcomes were identified between the perfusion groups in low/middle-risk patients (Table 1). Additionally, no differences in mortality were observed between pulsatile and non-pulsatile perfusion in both risk groups.
Conclusions: Among high-risk patients, better clinical outcomes were observed in the pulsatile group, but these findings may be attributable to dissimilar characteristics between groups, with pulsatile patients having lower baseline mortality score, aortic cross-clamp time, and CPB time. Among low/middle-risk patients, where characteristics were similar between the perfusion groups, no improvement in clinical outcomes was observed for the pulsatile patients. These findings suggest that while pulsatile perfusion represents a safe modality for CPB support, its use may not translate into demonstrably superior clinical outcomes.
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