1  2007 European Association for Cardio-thoracic Surgery doi:10.1510/mmcts.2006.002345 Neonatal aortic arch surgery Gaetano Gargiulo*, Guido Oppido, Emanuela Angeli, Carlo Pace Napoleone Pediatric Cardiac Surgery Unit, S. Orsola-Malpighi Hospital, University of Bologna Medical School, Via Massarenti 9, 40138 Bologna, Italy Surgical repair of the aortic arch is entailed in the neonatal period of patients with: hypo- plastic left heart syndrome, interrupted aortic arch, hypoplastic aortic arch and complex aortic coarctation. Aortic arch surgery requires a period of circulatory arrest and deep hypo- thermia. Cerebral selective perfusion has recently been introduced as an alternative to cir- culatory arrest with the aim of reducing mortality and neurological complications. Moreover, the arch reconstruction phase can be safely performed under moderate hypothermia and with cerebral and myocardial perfusion (on beating heart), thus, completely avoiding cerebral ischemia and completely avoiding or drastically reducing myocardial ischemia. Keywords: Antegrade selective cerebral perfusion; Aortic arch hypoplasia; Circulatory arrest; Interrupted aortic arch Introduction Aortic coarctation without associated intracardiac lesions, with or without posterior arch hypoplasia, is safely and effectively repaired via left posterolateral thoracotomy. On the contrary, median sternotomy and cardiopul- monary bypass are necessary for aortic arch recon- struction in the following conditions: hypoplastic left heart syndrome (which is not the object of the present section), interrupted aortic arch (IAA), complete aortic arch hypoplasia (AAH), complex aortic arch hypopla- sia (very short proximal arch associated with hypo- plastic and long distal arch and isthmus: ‘bovine truncus’ pattern of the arch branches) or coarctation with posterior arch hypoplasia associated with other cardiac lesions w1–4x. Proximal arch, distal arch, and isthmus are considered hypoplastic when sized -60, 50, and 40% of the ascending aorta, respectively, according to Moulaert w5x, or the anterior arch is smaller than 1 mm/per kg of body weight plus 1, according to Karl w6x. * Corresponding author: Pediatric Cardiac Surgery Unit Director, Tel.: q39-051-6363156; fax: q39-051-6363157. E-mail: gargiulo@aosp.bo.it Although deep hypothermic circulatory arrest has been extensively used in neonates for aortic arch surgery w7, 8x, the incidence of seizures and choreoathetosis and the high impact on the neuro- developmental outcome of such a technique w9, 10x, has prompted surgeons to explore safer cerebral pro- tection strategies. Intermittent cerebral perfusion combined with deep hypothermia, proposed by Kimura and colleagues w11x in 1994, was the first successful attempt to pro- vide a longer uneventful ischemic period for the brain. Since then many different techniques and strategies have been developed and proposed in order to achieve a satisfactory continuous cerebral perfusion during the entire procedure w4, 12–18x. Surgical technique Aortic arch hypoplasia: end-to-end extended anastomosis (Schematic 1A–F) A central venous line is positioned either in the right jugular or right subclavian vein; it is advisable to avoid left central venous access because the presence of