Contemporary Use of Circulatory Arrest and Selective Antegrade Cerebral Perfusion During Neonatal Aortic Arch Surgery—International Survey

BACKGROUND: Selective antegrade cerebral perfusion (SACP) is increasingly used during neonatal aortic arch surgery, yet practices remain inconsistent across surgeons and institutions due to limited evidence and lack of consensus. This study aimed to characterize deep hypothermic circulatory arrest (DHCA) and SACP practices among congenital heart surgeons internationally, including temperature, flow rate, and monitoring. METHODS: A 124-question electronic survey was distributed to congenital heart surgeons worldwide through the World Society for Pediatric and Congenital Heart Surgery from November 2024 to February 2025. Responses were limited to currently practicing or recently retired surgeons. RESULTS: The survey was completed by 104 surgeons (95.2% active, 4.8% retired). Respondents were predominantly men (93.3%) with a median age of 53 years and 19 years in practice. SACP was used exclusively by 69.2% and DHCA by 9.6%, whereas 21.2% selected between techniques based on anatomy or anticipated arrest duration. A change in individual practice was reported by 41% of the respondents, most transitioning from DHCA to SACP-particularly among older surgeons (median age 60 vs 48 years, P < .001). Among those using SACP, 78.3% used it alone and 21.7% combined it with lower body perfusion. Target SACP temperature ranged widely from <20 °C to 35 °C, with lower targets for longer procedures. Flow determination also varied: 59.6% used weight-based calculations, whereas others adjusted by pressure or near-infrared spectroscopy. After initiation, flow was titrated to right radial artery pressure (38.0%) or near-infrared spectroscopy (55.4%). CONCLUSIONS: Substantial variability persists in neuroprotective strategies during neonatal aortic arch repair, emphasizing the need for evidence-based standardization and high-fidelity neuromonitoring strategies.