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Association of Ongoing Cerebral Oxygen Extraction During Deep Hypothermic Circulatory Arrest With Postoperative Brain Injury

Published:September 08, 2021DOI:https://doi.org/10.1053/j.semtcvs.2021.08.026
      Cardiac surgery utilizing circulatory arrest is most commonly performed under deep hypothermia (∼18°C) to suppress tissue oxygen demand and provide neuroprotection during operative circulatory arrest. Studies investigating the effects of deep hypothermic circulatory arrest (DHCA) on neurodevelopmental outcomes of patients with congenital heart disease give conflicting results. Here, we address these issues by quantifying changes in cerebral oxygen saturation, blood flow, and oxygen metabolism in neonates during DHCA and investigating the association of these changes with postoperative brain injury. Neonates with critical congenital heart disease undergoing DHCA were recruited for continuous intraoperative monitoring of cerebral oxygen saturation (ScO2) and an index of cerebral blood flow (CBFi) using 2 noninvasive optical techniques, diffuse optical spectroscopy (DOS) and diffuse correlation spectroscopy (DCS). Pre- and postoperative brain magnetic resonance imaging (MRI) was performed to detect white matter injury (WMI). Fifteen neonates were studied, and 11/15 underwent brain MRI. During DHCA, ScO2 decreased exponentially in time with a median decay rate of -0.04 min−1. This decay rate was highly variable between subjects. Subjects who had larger decreases in ScO2 during DHCA were more likely to have postoperative WMI (P = 0.02). Cerebral oxygen extraction persists during DHCA and varies widely from patient-to-patient. Patients with a higher degree of oxygen extraction during DHCA were more likely to show new WMI in postoperative MRI. These findings suggest cerebral oxygen extraction should be monitored during DHCA to identify patients at risk for hypoxic-ischemic injury, and that current commercial cerebral oximeters may underestimate cerebral oxygen extraction.

      Graphical Abstract

      Keywords

      Abbreviations:

      CBFi (cerebral blood flow index), CBF (cerebral blood flow), CBV (cerebral blood volume), CHD (congenital heart disease/defect), CICU (cardiac intensive care unit), CHOP (The Children's Hospital of Philadelphia), CMRO2 (cerebral metabolic rate of oxygen), CW-NIRS (continuous-wave near infrared spectroscopy), DCS (diffuse correlation spectroscopy), FD-DOS (frequency-domain diffuse optical spectroscopy), FD-NIRS (frequency-domain near infrared spectroscopy), Hb (deoxyhemoglobin, measured with DOS), HbO2 (oxyhemoglobin, measured with DOS), Hct (hematocrit, measured from blood gas), Hgb (hemoglobin, measured from blood gas), HLHS (hypoplastic left heart syndrome), IQR (interquartile range), OEF (cerebral oxygen extraction fraction), SpO2 (peripheral capillary oxygen saturation), ScO2 (cerebral tissue oxygen saturation), WMI (white matter injury)
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