Keep Ventilating the Lungs While the Heart is Still Ejecting on Femoro-femoral Cardiopulmonary Bypass

Femoro-femoral cardiopulmonary bypass (CPB) followed by deep hypothermic circulatory arrest is one of the modalities used for ascending aortic pseudoaneurysm repair to achieve cardiac unloading and to avoid severe hemorrhage due to the risk of rupture during the sternal entry. However, due to the limited size of the cannulas, it can be challenging to achieve total cardiopulmonary support. Therefore, despite the achievement of total cardiopulmonary support, the heart may still be able to eject antegrade blood flow that meets the retrograde blood flow from the arterial side of the CPB. The point where the blood flow meets in the aorta is called the watershed area. If the antegrade blood flow is large due to a left ventricular ejection, the watershed area will be located in the descending aorta. Therefore, if ventilation is stopped, deoxygenated blood will be ejected to the cerebral circulation. Cerebral near-infrared spectroscopy (NIRS) may be used as a noninvasive and continuous measurement of regional brain oxygen saturation (rSO2). This case demonstrates that cerebral desaturation due to discontinued mechanical ventilation, when the heart was still ejecting during the initial phase of femoro-femoral CPB, immediately was detected by a pronounced drop bilaterally: In the left frontal lobe, rSO2 fell from 56% to 21%, and in the right frontal lobe it fell from 47% to 25%. The authors recommend monitoring cerebral saturation using NIRS in the case of femoro-femoral CPB.