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Eur J Cardiothorac Surg 2007;31:757. doi:10.1016/j.ejcts.2007.01.008
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Letters to the Editor |
Departments of Anesthesiology and Pediadric Cardiac Surgery, Hopital Necker-Enfant Malades, 49 rue de Sevres, 75007 Paris, France
Received 4 January 2007; accepted 8 January 2007.
* Corresponding author. Tel.: +33144381903; fax: +33144381906. (Email: ppouard.laennec{at}invivo.edu).
Key Words: Cardiopulmonary bypass • Congenital heart disease • Pediatric • Perfusion • Surgery
We appreciate the interest showed by Dr Corno in our article [1] and we agree with most of his comments. In his letter [2], Corno lists different factors to be considered when using normothermic CPB. Most of them are key factors to avoid oxygen demand/delivery imbalance, especially the flow level (3.5 l/min/m2), and so called ‘high’ hematocrit (always maintained above 30%). Jonas et al. [3] have already shown that higher hematocrit was better in neonates even at lower temperature. In addition, 40% hematocrit at the end of CPB, could be still considered as an anemia compared with normal range for this age! When listing the arguments against normothermia, Corno point out high flow and high hematocrit that could enhance the insult of CPB, it is a real and important question. However, it is difficult to claim that physiological features could be deleterious. Admittedly, CBP itself is not physiologic. In addition, it has never been really shown that by decreasing temperature, flow, hematocrit or pressure, we were improving the CPB tolerance. CPB has been run at normothermia in adult and children for years particularly in simple congenital heart diseases or in difficult setting like in developing countries without intensive case unit. The new challenge of normothermic neonatal CPB found naturally its place in the range of measures to improve the neonatal CPB, besides ultrafiltration, aprotinin, closed system, coating, low priming volume, NIRS and appropriate anesthesia. Corno proposes prospective randomized clinical trials between normothermic and hypothermic technique and highlights five important and very accurate difficulties to perform them. We think that both techniques have to be used. In cases with aortic repair (interrupted aortic arch, TGA with VSD and aortic coarctation, Norwood procedure) normothermic CPB can be performed [4] but is more complex. For these kind of repair, hypothermic CPB with circulatory arrest and selective cerebral perfusion seems easier and perhaps safer. However, is it really necessary to decrease the temperature in the other repairs? In conclusion, in our routine practise, normothermic CPB can be applied in 95% of the pediatric and neonatal cases. Dr Corno himself was at the origin of the question [5] in pediatric cardiac surgery and we try to contribute to the answer.
References
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