The limits of detectable cerebral perfusion by transcranial Doppler sonography in neonates undergoing deep hypothermic low-flow cardiopulmonary bypass

Abstract

Objective: Neurologic morbidity including seizures, abnormal neurologic function, and delayed psychomotor development continue to be significant problems for some patients undergoing operations for congenital heart disease, particularly for those subjected to deep hypothermic circulatory arrest. The technique of low-flow cardiopulmonary bypass has been advocated to decrease the incidence of neurologic sequelae. Our study examined the limits of detectable blood flow in the middle cerebral artery during low-flow cardiopulmonary bypass in 28 neonates undergoing the arterial switch procedure.

Methods: Cerebral blood flow velocity was measured noninvasively in the M1 segment of the middle cerebral artery with a 2 MHz range-gated pulsed-wave transcranial Doppler sonographic probe that was placed over the left temporal window. As part of the initiation of a planned period of deep hypothermic circulatory arrest, the cardiopulmonary bypass flow rate was decreased in stages to five low-flow rates (50, 40, 30, 20, and 10 ml/kg per minute). After a period of stabilization, cerebral blood flow velocities were recorded at each of the five low-flow rates and reported as a percentage of baseline.

Results: All 28 neonates had detectable perfusion in the middle cerebral artery at flow rates of 30 ml/kg per minute or higher. At flows of 20 and 10 ml/kg per minute, one and eight, respectively, of the 28 neonates had no detectable perfusion in the middle cerebral artery.

Conclusions: Our data show that cerebral perfusion can be detected by transcranial Doppler sonography in the middle cerebral artery in some neonates at bypass pump flows as low as 10 ml/kg per minute. However, when transcranial Doppler sonography was used in our patient population, a minimum bypass flow rate of 30 ml/kg per minute was needed to detect cerebral perfusion in all neonates.