Postoperative Cerebral and Somatic Near-Infrared Spectroscopy Saturations and Outcome in Hypoplastic Left Heart Syndrome

doi:10.1016/j.athoracsur.2016.09.100

The Annals of Thoracic Surgery

Volume 103, Issue 5, May 2017, Pages 1527-1535

Presented at the Fifty-second Annual Meeting of The Society of Thoracic Surgeons, Phoenix, AZ, Jan 23–27, 2016.

https://doi.org/10.1016/j.athoracsur.2016.09.100 Get rights and content

Background

Circulatory vulnerability reflected by low systemic venous oxygen saturation after surgical palliation of hypoplastic left heart syndrome predicts adverse neurologic outcome and reduced survival, and targeting venous saturation may improve outcome. We herein test the hypothesis that near-infrared spectroscopy (NIRS)-derived cerebral and somatic/renal regional saturations can predict survival.

Methods

Patient data, from a prospective Institutional Review Board-approved registry of hemodynamic measures after initial palliation of hypoplastic left heart syndrome, were analyzed with logistic and multivariable mixed regression methods to determine relationships between standard hemodynamic measures, direct and NIRS measures of saturation, and outcome. The primary outcome measure was survival through hospital discharge and 30 days.

Results

From the entire cohort of 329 patients, complete data for comparative analysis of physiologic predictors were available from 194 patients. The early survival rate was 92.1%; extracorporeal membrane oxygenation was used in 8.8% of patients. The mean arterial pressure, arterial cerebral, and somatic cerebral NIRS saturation differences were significantly higher for survivors versus nonsurvivors. Multivariable analysis found cerebral and somatic NIRS saturations, heart rate, and arterial pressure as predictors of outcome. Bivariate analysis of mean arterial pressure and somatic saturation allowed early identification of low cardiac output and high mortality risk.

Conclusions

Continuous noninvasive measurement of regional cerebral and somatic NIRS saturations in the early postoperative period can predict outcomes of early mortality and extracorporeal membrane oxygenation use in hypoplastic left heart syndrome. Because outcomes were strongly determined by NIRS measures at 6 hours, early postoperative NIRS measures may be rational targets for goal-directed interventions.

Section snippets

Patients and Methods

A registry of 48-hour hemodynamic measures after stage 1 palliation of neonates with hypoplastic left heart syndrome (HLHS) has been maintained with approval of the Children’s Hospital of Wisconsin Institutional Review Board since May 1996. Standard perioperative monitoring has included heart rate (HR) by electrocardiography, invasive mean arterial pressure (MAP) and right/common atrial pressure (RAP), continuous pulse oximetry (arterial oxygen saturation [Sao₂]), and superior vena cava venous

Population and Monitoring Demographics

The study cohort included 329 patients (mean weight 3.2 ± 0.58 kg, median 3.2 kg [IQR: 0.6], confidence interval: 2.3 to 4.1 kg; mean age 8.8 ± 13 days, median 7 [IQR: 4], confidence interval: 3 to 22) at stage 1 palliation. Overall, 301 patients (91%) had Svo₂ monitoring, 214 (65%) had NIRS monitoring, 321 (98%) had either Svo₂ or NIRS, and 194 (59%) had both Svo₂ and NIRS, comprising the comparison group. Patients with NIRS monitoring were smaller and younger than patients with Svo₂ only (

Comment

This report summarizes our experience with Svo₂ and NIRS monitoring in all patients with HLHS after initial surgical palliation. Our early experience with Svo₂ monitoring led to clarification of clinical physiology in this high-risk population, defining the anerobic threshold, effects of vasodilator strategy on Svo₂, SVR, and pulmonary-systemic flow balance, and validating Svo₂ as a target for goal-directed therapy in this population 4, 30. This report provides similar evidence for the use of

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Original articleCongenital heart surgeryPostoperative Cerebral and Somatic Near-Infrared Spectroscopy Saturations and Outcome in Hypoplastic Left Heart Syndrome

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Population and Monitoring Demographics

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu

J Cardiothorac Vasc Anesth

Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu

J Thorac Cardiovasc Surg

Prog Pediatr Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Pediatr Surg

J Pediatrics

Improved survival of patients undergoing palliation of hypoplastic left heart syndrome: lessons learned from 115 consecutive patients

Circulation

Resuscitation of the patient with the functionally univentricular heart

Curr Pediatr Rev

Near-infrared spectroscopy as a hemodynamic monitor in critical illness

Pediatr Crit Care Med

Near-infrared spectroscopy: exposing the dark (venous) side of the circulation

Paediatr Anaesth

Original article
Congenital heart surgery
Postoperative Cerebral and Somatic Near-Infrared Spectroscopy Saturations and Outcome in Hypoplastic Left Heart Syndrome