Targeting Normoxia in Neonates With Cyanotic Congenital Heart Disease in the Intra-operative and Immediate Post-operative Period (T-NOX)
Phase: NA
Conditions: Hypoplastic Left Heart Syndrome, Total Anomalous Pulmonary Venous Return, Truncus Arteriosus, Pulmonary Atresia With Ventricular Septal Defect, Transposition of the Great Arteries, Double Outlet Right Ventricle, Subpulmonary VSD, Tetralogy of Fallot, Double Outlet Right Ventricle With Subaortic Ventricular Septal Defect and Pulmonary Stenosis, Cardiopulmonary Bypass
Sponsor: University of Michigan

TargeƟng Normoxia in Neonates With CyanoƟc 
Congenital Heart Disease in the Intra-operaƟve and 
Immediate Post-operaƟve Period (T-NOX) 
 
NCT04452188 
 
IRB Approval Date: April 14, 2021 

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Title:  Targeting Normoxia in Neonates with Cyanotic Congenital Heart Disease in the Intra-
operative and Immediate Post-operative Period (T-NOX) 
 
Background: 
Infants who undergo cardiac surgery with cardiopulmonary bypass (CPB) are at significant risk of 
morbidity and mortality associated with end-organ injury and dysfunction.  The etiology for end-organ 
injury and dysfunction after heart surgery is multi-factorial and likely related to intraoperative techniques, 
residual cardiac lesions, a systemic inflammatory response, and several patient-specific factors such as age, 
weight, level of preoperative support, genetic abnormalities, cardiac diagnosis and type of surgical 
procedure.  Not surprisingly, there is wide institutional variation in outcomes after cardiac surgery in infants 
and young children.   
During open heart surgery with CPB, the myocardium is exposed to a period of ischemia and 
reperfusion, which is associated with mitochondrial dysfunction and oxidant stress.  Despite the well-
described role of oxidant stress in ischemia-reperfusion injury, the current practice at many centers is to 
administer supra-physiologic oxygen levels (hyperoxia) to infants through the cardiopulmonary bypass 
circuit and mechanical ventilator, which could theoretically exacerbate oxidant stress and reperfusion 
injury.  These detrimental effects of hyperoxia may be more pronounced in neonates and infants who are 
known to have immature anti-oxidant defenses compared to older children and adults[1], and further 
influenced by preoperative cyanosis. 
There is mounting experimental evidence and several clinical studies that support the concept that 
hyperoxia (versus normoxia) is associated with adverse outcomes after ischemia.  Animal models of CPB 
and cardioplegic arrest show that hyperoxic myocardial reperfusion is associated with increased oxidant 
stress, inflammation, and organ injury compared with normoxic reperfusion[2].  Furthermore, hyperoxia 
during and after cardiopulmonary resuscitation has been associated with an increased risk of mortality in 
both children and adults[3-6].  Lastly, in pediatric patients requiring veno-arterial extracorporeal membrane 
oxygenation, hyperoxia was associated with worse clinical outcomes[7, 8]. 

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There are a few comparative trials of hyperoxic versus controlled normoxic reperfusion following 
CPB in adults and children with mixed results.  In two adult studies, there were no observed clinical 
differences between the different reperfusion strategies [9, 10], however Ihnken and colleagues showed a 
significant increase in pulmonary function and evidence for decreased oxidant stress biomarkers in patients 
exposed to normoxia compared to hyperoxia [11].   In older children undergoing cardiac surgery, exposure 
to lower oxygen levels during cardiopulmonary bypass produced a significant reduction in oxidant stress 
biomarkers [12-14], biomarkers of brain injury [13, 15], and length of mechanical ventilation [14, 16].  In 
single ventricle patients, normoxic reperfusion during CPB also improved long-term survival, systemic 
ventricular function, and heart failure classification [17].  A summary of the studies in adults and children 
is shown in Table 1. 
 
 
 
 
 
 
 
 
 
 
 
 

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Table 1: Summary of studies in adults and children comparing hyperoxic vs normoxic reperfusion 
following cardiopulmonary bypass.  
 
Authors 
Date 
Age 
Sample 
Size 
Trial Type 
Description 
Results 
Smit et al 
2016 
Adult (median 
67 (IQR 63-
71) 
57 
Randomized controlled trial 
of normoxia (PaO2 130-150) 
vs Hyperoxia (PaO2 200-
220) in patients undergoing 
coronary artery bypass 
grafting 
No adverse events 
or mortality 
reported 
No difference in biomarkers of 
myocardial injury, oxidative stress, end-
organ function.  No difference measured 
cardiac index or systemic vascular 
resistance 
McGuiness et al 
2016 
Adult (20-90 
years) 
298 
Randomized controlled trial 
of normoxia on CPB (PaO2 
75-90) vs standard of care 
(PaO2 170-200) 
No adverse events 
or side effects 
reported.  9 deaths 
total (4 in control 
group and 5 in 
intervention group) 
No difference in occurrence of renal 
dysfunction (primary outcome).  No 
differences in biomarkers or other clinical 
outcomes (ICU stay, ventilator time, 
mortality) 
Caputo et al 
2014 
Pediatric (29 
days to 17 
years) 
69 
Cyanotic patients 
randomized to normoxia (50-
100) vs standard of care 
(160-170) 
No adverse events 
and no deaths <30 
days after surgery 
reported 
No difference in clinical outcomes (length 
of stay, ventilator time).  There was a 
significant decrease in heart failure 
symptoms (mean follow-up time of 7 
years) in patients exposed to normoxia 
compared to hyperoxia.  Cardiac function 
as measured by echo was also 
significantly different in the normoxia 
group (more patients with EF>50%).  
Statistically significant decrease in 
biomarkers for oxidative stress, 
myocardial, cerebral, hepatic dysfunction, 
stress/inflammatory response. 
Babu et al 
2012 
Pediatric (9 
months – 5 
years) 
29 
Randomized controlled trial 
of cyanotic patients 
(sat<85%) comparing 
initiating CPB with FiO2 of 
21% (with titration up to 
60% after 5 minutes) vs 
FiO2 of 60%  
No major adverse 
events reported.  
Two deaths in each 
group.   
Ventilation time was significantly lower 
in the normoxia group with no other 
clinical differences seen.  Statistically 
significant decrease in myocardial injury 
as measured by CK-MB in the normoxia 
group.   
Caputo et al 
2009 
Pediatric (6-49 
months) 
67 
Cyanotic patients were 
randomized to hyperoxia 
(150-180) vs normoxia (50-
80) on CPB 
No adverse events 
reported and no 
deaths reported 
No difference in clinical outcomes 
(ventilator times or ICU stay).  
Statistically significant decrease in 
biomarkers for oxidative stress, 
myocardial damage, cerebral and hepatic 
injury in the normoxia group compared to 
hyperoxia.   
Bulutcu et al 
2002 
Pediatric (3 
months – 5 
years) 
14 
Cyanotic patients (sat<85%) 
were randomly allocated to 
PaO2 of 300-350 or PaO2 of 
90-110  
No safety issues 
reported and no 
deaths.   
No difference in intubation times or ICU 
stay. Statistically significant decrease in 
oxidative stress biomarker (MDA) from a 
myocardial tissue biopsy and decrease in 
pro-inflammatory cytokines (TNF-a and 
IL-6) in the normoxia group compared to 
hyperoxia group 
Matheis et al 
2000 
Pediatric (5 
days to 15 
years) 
21 
Cyanotic patients allocated 
(non-randomized) to 
normoxia on CPB 
(PaO2<150) vs hyperoxia 
(PaO2>150) 
No adverse events 
reported.  Two 
deaths reported 
(<30 days of 
surgery) both in 
hyperoxia group.  
One death in an 
infant in the 
normoxia group 
was reported at 34 
days after surgery 
Increased release of S100 biomarker 
(neurologic injury) in cyanotic patients 
exposed to hyperoxia compared to 
normoxia  
Ihnken et al 
1998 
Adult (mean 
61 years) 
40 
Randomized to hyperoxia on 
CPB (PaO2 400) vs 
normoxia (PaO2 140) 
No adverse events 
reported 
Statistically significant increase in 
oxidative stress biomarkers and 
myocardial damage in hyperoxic group 
compared to normoxia.  No differences in 
clinical outcomes of ICU/hospital stay.  
Statistically significant decrease in lung 
function measured by PFTs in hyperoxia 
group 5 days post-operatively 
 

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Overall, pediatric clinical and pre-clinical experimental studies suggest that there is a likely benefit 
to normoxic and controlled re-oxygenation during cardiac surgery.  However, there are several limitations 
to the published data including single center studies enrolling a wide age range, heterogeneous patient 
populations encompassing a wide variety of cardiac diagnoses and surgical procedures, and an inconsistent 
approach to preventing early exposure to supra-physiologic oxygen levels.  Furthermore, results from an 
informal survey of other large pediatric cardiac surgery centers (Table 2) and survey data from 39 centers 
from a large multi-institutional registry (NPC-QIC) (Figure 1) indicates that most centers utilize a supra-
physiologic oxygen management strategy and that there is significant practice variation with regards to goal 
oxygen levels during cardiopulmonary bypass.  Therefore, the goal of this proposed study is to investigate 
the use of normoxia or near-physiologic oxygen levels before, during, and after cardiopulmonary bypass in 
a well-defined, high-risk cyanotic neonatal population undergoing a select number of surgeries.  The study 
will be a pilot single center study to show efficacy and safety with the eventual goal of a larger multi-center 
study that will be powered to show a true difference in clinical outcomes. 
 
 
 
 
 
 
 
 
 

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Table 2: Survey results from large pediatric cardiac surgery centers reporting PaO2 management on 
bypass practice.  
PHN Center 
Practice with regards to PaO2 management on Bypass 
Michigan 
All patients: 200-300 
MUSC 
Cyanotic patients at baseline: Initiate at 70-100 and 150 during 
rewarming.   
 
All other patients: 150-250 
Emory 
All patients:  250-300 
Boston Children’s 
All patients: >500 
CHOP 
All patients:  200-250 
Texas Children’s 
All patients:  Goal 150-250 
Sick Kids Toronto 
All patients:  Goal 120-150 on bypass 
Cyanotic patients: Initiate bypass with PaO2<100 and then increase 
to goal 
Cincinnati Children’s 
Cyanotic patients at baseline: Initiate bypass at 21% FiO2 and then 
increase to 200-250.  Decrease to 80-120 prior to cross clamp 
removal and then goal of 200-250 
 
All other patients: Maintain >200, decrease to 80-120 just prior to 
cross clamp removal and then 200-250 afterwards 

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Figure 1: Survey Data results of NPC-QIC Perfusion Practices: Goal PaO2 while on 
cardiopulmonary bypass. 
 
Specific Aims:  
1. To assess oxidative stress and end organ injury in the normoxia versus supra-physiologic oxygen groups.  
Hypothesis 1a:  Normoxia will be associated with reduced oxidative stress as measured by 
thiobarbituric acid reactive substances (TBARS), a marker of lipid peroxidation. We also anticipate 
reductions in other measures including protein carbonyl, 8-isoprostane, and whole blood reduction-
oxidation potential. 
Hypothesis 1b: End organ injury will be reduced as assessed by biomarkers of renal (Neutrophil 
gelatinase-associated lipocalin), neurologic (Glial fibrillary acidic protein, Tau), liver (Intestinal fatty-
acid binding protein), vascular (Angiopoietin 2), and myocardial injury (Troponin I) as well as 
immune system activation (IL-6, IL-10). 
2. To evaluate the safety profile of a strategy of normoxia versus supra-physiologic oxygen. 
Hypothesis:  Observed major adverse events including in-hospital mortality, cardiac arrest, need for 
mechanical circulatory support, seizures, and dialysis will be similar or lower in the normoxia group.   
 
3. To investigate optimal endpoints in the study of the clinical impact of normoxia. 
 

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We will assess clinical endpoints that may be reflective of a reduction in oxidative stress to understand 
effect sizes and inform the design of subsequent trials. These endpoints will include post-operative 
length of stay, days alive and out of the intensive care unit (ICU) at 30 days after surgery, a composite 
outcome of major adverse events as described above, and a global rank score. 
 
Study Design: 
 
Participants: 
Single center (University of Michigan) randomized pilot study in infants less than 30 days of age 
undergoing heart surgery with cardiopulmonary bypass. The trial will be unblinded with respect to 
knowledge of treatment assignment as the majority of clinical personnel will have knowledge of the 
cardiopulmonary bypass strategy based on blood gases and operative documents. 
Inclusion Criteria:   
• 
Age less than 30 days of age at time of surgery with need for cardiopulmonary bypass with 
cardioplegic arrest (with or without deep hypothermic circulatory arrest) 
• 
Diagnosis with cyanosis at baseline (pre-operative PaO2 of less than 50mmHG) due to: 
o Complete admixture lesion (example: hypoplastic left heart syndrome, total anomalous 
pulmonary venous return, truncus arteriosus, pulmonary atresia with VSD) 
o Transposition physiology (example: D-Transposition of the great arteries or Double 
outlet right ventricle with subpulmonary VSD) 
o Right-to-left shunt (example: Tetralogy of Fallot, double outlet right ventricle with 
suboaortic VSD and pulmonary stenosis) 
 
Exclusion Criteria: 
• 
Corrected gestation at time of surgery less than 37 weeks 
• 
Prior cardiac arrest 
• 
Current or prior history of ECMO support 
• 
Current or prior history of needing renal replacement therapy with dialysis 
• 
Prior cardiac surgery requiring cardiopulmonary bypass 
• 
Diagnosis of Ebstein’s Anomaly 
• 
Known genetic syndrome other than Trisomy 21 or DiGeorge Syndrome 

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Subject Availability: 
Based on historical data, the number of patients that fit the inclusion criteria would be about 40-50 patients 
per year in this single center study. A sample size of 21 patients per treatment group (42 total patients) will 
be enrolled. With a 50-67% consent rate, the study duration will be approximately 24 months. 
 
Trial Enrollment and Randomization: 
 
Infants will be randomized into two groups: 
1. Normoxia Group (with controlled re-oxygenation): 
a. Goal PaO2 on cardiopulmonary bypass of 60-100 mm Hg using lower FiO2 (blended 
sweep gas) via oxygenator 
b. Post-bypass, goal of PaO2 <100 mm Hg by anesthesia and in ICU via oxygen titration via 
mechanical ventilator for 24 hours post-op. 
2. Standard of Care Group:  Current standard of care  
 
Randomization will be performed in random permuted block sizes of 2 or 4 and stratified by “Stage I 
Palliation” (Norwood arch reconstruction with shunt placement [Right ventricle-to-pulmonary artery shunt, 
modified Blalock-Taussig shunt, or central aortopulmonary shunt]) in each treatment group.  Patients 
undergoing Stage I palliation are known to have higher rates of complications and mortality at baseline and 
therefore the stratification will be done to control for this in the randomization. 
 
Study Protocol: 
Please see Figure 2 for a summary of the study protocol. 
1. Preoperative: 
Patients that meet the defined inclusion and exclusion criteria will be identified and the families will be 
approached for consent prior to the scheduled surgery.   
Patients that are enrolled in the study will have the following pre-operative studies: 

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• 
Head ultrasound (not currently standard of care but will be used to evaluate for any brain injury 
in each group) 
• 
Renal function and liver function panel (within 24 hours prior to surgery) 
 
2. Operating Room: 
Patients will be brought to the operating room in a standard fashion.  Anesthesia will induce general 
anesthesia per protocol and secure an airway (if needed) and place invasive lines.  Patients will have labs 
drawn (baseline biomarkers of oxidative stress, troponin level, and Redox potential) and an arterial blood 
gas.   
All patients will have a median sternotomy and be cannulated onto cardiopulmonary bypass via standard 
procedures at the discretion of the surgery team.   
 
3. Initiation of Cardiopulmonary Bypass: 
 The cardiopulmonary bypass circuits will be set up and primed per standard institutional protocols.   
“Normoxia” Group:  Prior to cannulation, a blood gas will be drawn from the cardiopulmonary bypass 
circuit and correlated to the CDI (in-line PaO2 monitor).  The FiO2 of the oxygenator will then be titrated 
to achieve a PaO2 of the circuit and CDI of 60-100 mm Hg.  After cannulation, frequent blood gases will 
be checked per protocol and correlated with the CDI to maintain a PaO2 of 60-100 mm Hg. 
“Standard of Care” Group:  After cannulation, frequent blood gases will be checked per protocol on bypass 
and correlated with the CDI to maintain a PaO2 of 200-300 per standard practice. 
 
4. Weaning of Cardiopulmonary Bypass: 
At the end of re-warming, a blood sample will be obtained for appropriate studies. 
“Normoxia” Group:  As cardiopulmonary bypass is being weaned, anesthesia will initiate mechanical 
ventilation with an FiO2 of 50% or less (unless clinically necessary) to achieve oxygen saturation and PaO2 
goals that fit within the expected range for the patient’s physiology: 
1. Single ventricle patients (PaO2:35-45 and oxygen saturation 75%-85%) 
2. Two ventricle patients (PaO2: 60-100 and oxygen saturation >92%) 

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Measures of oxygen delivery such as NIRS monitoring, mixed venous oxygen saturations, and 
lactate measurements will be used to verify appropriate oxygen delivery. 
 
“Standard of Care” Group:  As cardiopulmonary bypass is being weaned, anesthesia will initiate mechanical 
ventilation per standard protocols.  Ventilation will be continued in the ICU and adjusted per standard goals 
per the intensivist.   
 
5. Post-Operative Course: 
After transfer to the PCTU from the OR, the goals as stated above based on the patient’s physiology will 
be maintained for 24 hours after the surgery per the goals per group and physiology. 
After cardiac surgery, the following tests and evaluation will be performed: 
1.  At 2, 6, and 24 hours after surgery (time marked as decannulation from cardiopulmonary 
bypass):  biomarkers for oxidative stress, inflammation, vascular injury, neurologic, 
myocardial, and renal injury will be drawn. 
2. At 24, 48, and 72 hours after surgery: renal function and liver function panels will be obtained 
3. A head ultrasound will be performed at 24 and 72 hours after surgery 
4. EEG monitoring may be connected to each infant after arrival to the ICU as part of the standard 
of care.  
 
6. Adverse Event Assessment 
Assessment of Serious Adverse Events will be performed 1month post surgery. A chart review will be 
performed by the study team. If a chart review can’t be accomplished, the study team will contact the patient 
via phone call for an assessment. See Serious Adverse Event section of the protocol for specific definitions. 
 
 
 
 
 

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Figure 2: Study protocol flow chart 
 
Outcomes and Analysis: 
Analysis will be performed on the basis of the intent-to-treat principle. Baseline characteristics will be 
compared between the treatment groups using standard univariate tests.  
Specific Aim 1: The primary outcome for this aim will be systemic oxidative stress based on thiobarbituric 
acid reactive substances (TBARS), a measurement of lipid peroxidation, assessed at three separate time 
points in the first 24 hours after surgery. An analysis of co-variance will be used incorporating all available 
data to model the outcome with an adjustment for pre-operative baseline (although we anticipate no 
differences in baseline values by treatment arm due to randomization). The model will compare the mean 
values (and 95% confidence intervals) between the two groups at each time-point.  In this model, we will 
assume missing data are missing at random, i.e., missing values may depend on observed but not 
unobserved data.  Analysis will be performed on the basis of the intent-to-treat principle and will include 
an interim analysis after 24 patients are enrolled.  In secondary analyses, we will use propensity scores to 

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account for any characteristics that were not balanced by treatment arm after randomization. We plan to 
analyze other biomarkers of oxidative stress and organ injury using analogous analysis of variance models.   
Specific Aim 2: To evaluate safety, we will assess the rate of observed adverse events between groups using 
Chi-square test or Fisher’s exact test as appropriate. Safety will also closely be monitored on a routine basis 
by the Data Safety and Monitoring Board (DSMB). .   
Specific Aim 3: To investigate optimal endpoints in the study of the clinical impact of normoxia. We will 
assess clinical endpoints that may be reflective of a reduction in oxidative stress, including post-operative 
length of stay, days alive and out of the intensive care unit (ICU) at 30 days after surgery, a composite 
outcome of major adverse events as described above, and a global rank score. For all endpoints, data on 
distribution within our study population and between the two groups will be calculated to understand effect 
sizes and aid in planning subsequent studies.  
1. Post-operative length of stay: Calculated as number of days in the hospital after surgery. May be an 
attractive outcome as it can incorporate many of the morbidities that would be influenced by strategies to 
reduce oxidative stress as most would lead to prolonged length of stay. The disadvantages are that it does 
not incorporate mortality, and may be influenced by other center care processes and practices. 
2. Days alive and out of the ICU or hospital at 30 days after surgery: This endpoint has been used to measure 
outcomes in other adult trials and a limited number of pediatric trials.  It can incorporate both mortality and 
various morbidities that may be influenced by strategies to reduce oxidative stress as most significant 
complications or end-organ injury can extend stay in the ICU or hospital. As a continuous variable, it is 
also statistically expedient allowing for smaller sample sizes to detect significant differences in treatment 
groups. 
3. Composite outcome: A composite endpoint can combine multiple relevant morbidities or adverse events 
such as those described above. Disadvantages are that all are inherently assumed to be of equal severity. 

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4. Global rank score: The rank score has the advantage of allowing for the combination of various endpoints 
into a single quantifiable endpoint like a composite outcome, however also allows weighting of the severity 
of the component endpoints, as opposed to a traditional composite endpoint where all endpoints are treated 
equally. It has been utilized increasingly in other trial settings. In this study, scores will be calculated based 
on a pre-specified ranking of outcomes:  mortality, cardiac arrest, ECMO, seizures, and dialysis. We will 
also explore the inclusion of other clinical endpoints in both the global rank score and composite outcome, 
as well as different ranking strategies.   
Other secondary exploratory outcomes of general morbidity and end-organ dysfunction will be 
measured and compared between the two treatment groups.  Please see Table 3 for a description of the 
biomarkers and other tests that will be collected or performed. 
Other Secondary Exploratory Outcomes: 
1. Neurologic:  
a. Post-operative intracranial hemorrhage and stroke as measured by Head ultrasound 
i. Alternatively, the diagnosis can be made via Head CT or MRI if clinically 
indicated by the treatment team 
b. Biomarkers for neurologic injury (GFAP, Tau) 
c. Incidence of seizures (clinical or sub-clinical by EEG) 
2. Respiratory:  
a. Mechanical ventilation time (total during hospital stay) 
b. Time from surgery to first extubation attempt 
c. The T3 Etiometry system will be used to calculate indices of lung compliance (Tidal 
volumes, mean airway pressures) on admission, 2, 6, and 24 hours after surgery (or 
until extubation) 
3. Heart/Circulatory system:  
a. Incidence of arrhythmias requiring medical therapy 

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b. VIS score on admission, 2, 6, and 24 hours post-operatively 
c. Measurement of arteriovenous saturation difference: 
i. Regional venous saturation measurements (NIRS), which are routinely 
collected in all patients (measurements will be recorded at 2, 6 and 24 hours 
after surgery) 
ii. Pulse oximetry measurements and arterial oxygen saturation (via arterial blood 
gas) at 2, 6, and 24 hours after surgery 
d. Lactic acid production (highest and lowest value in 12-hour increments in the first 48 
hours after surgery). Arterial blood gases are routinely obtained in the post-operative 
period 
e. Need for stress dose hydrocortisone in the post-operative setting 
f. Biomarkers: troponin release, vascular injury (ANGPT2) and inflammatory balance 
(IL-6, IL-10) 
4. Kidneys:  
a. % above dry-weight daily for the first 5 post-operative days (Dry weight will be 
defined as dosing weight which will likely be the birth weight of the infant) 
b. Days to dry weight 
c. Serum creatinine levels (comparison of pre-op, daily trends in the first 3 days including 
identification of peak level) 
d. Biomarkers: NGAL (urine) 
5. Oxidative stress: 
a. Whole blood redox potential 
b. Biomarkers (protein carbonyls, total antioxidant capacity (TAC), and 8-isoprostanes) 
6. GI:  
a. Liver function tests and intestinal fatty acid binding protein (I-FABP (pre-operatively, 
24, 48, and 72 hours post-operatively) 

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b. Time to goal feeds 
Table 3: Schedule of Evaluations 
* SOC: test performed as part of Standard of Care. R: Test performed as part of research 
** Note: blood volume is extra amount that is needed for research purposes only. 
*** Can be run with already collected samples per SOC 
Test 
Pre-op 
(within 
24hrs 
prior to 
surgery) 
Baseline 
(in OR 
prior to 
bypass) 
End 
Rewarming 
2 
hour 
post 
6 
hour 
post 
24 
hour 
post 
Morning 
of POD 
1 
Morning 
of POD 
2 
Morning 
of POD3 
General 
Post-Op 
for 48 
hours 
1 
month 
Post-
op 
Blood ** 
0 mL 
2.75 mL 
2.25 mL 
2.75 
mL 
2.75 
mL 
2.75 
mL 
0 mL 
0 mL 
0 mL 
 
 
Renal Function 
Panel 
X 
SOC 
 
 
 
 
 
X 
SOC 
X 
SOC 
X 
SOC 
 
 
Liver Function 
Panel *** 
X 
R 
 
 
 
 
 
X 
R 
X 
R 
X 
R 
 
 
TBARS 
 
X 
R 
X 
R 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
Protein 
Carbonyl 
 
X 
R 
X 
R 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
8-isoprostane 
 
X 
R 
X 
R 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
Total 
Antioxidant 
Capacity 
 
X 
R 
X 
R 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
Redox Potential 
 
X 
R 
X 
R 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
i-FABP 
 
X 
R 
 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
Troponin 
 
X 
R 
 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
GFAP 
 
X 
R 
X 
R 
 
 
X 
R 
 
 
 
 
 
Tau 
 
X 
R 
 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
ANGPT-2 
 
X 
R 
 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
IL-6 
 
X 
R 
 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
Il-10 
 
X 
R 
 
X 
R 
X 
R 
X 
R 
 
 
 
 
 
Urine 
 
 
 
 
 
 
 
 
 
 
 
Urine: NGAL 
 
X 
R 
 
X 
R 
 
 
 
 
 
 
 
Neuroimaging 
and Testing 
 
 
 
 
 
 
 
 
 
 
 
Head 
Ultrasound 
X 
R 
 
 
 
 
 
X 
R 
 
X 
R 
 
 
EEG 
 
 
 
 
 
 
 
 
 
X 
SOC 
 
Miscellaneous 
(Collected or 
Measured as 
SOC or Based 
on Clinical Care 
Team 
 
 
 
 
 
 
 
 
 
 
 
NIRS (Cerebral 
and Renal) 
 
 
 
X 
SOC 
X 
SOC 
X 
SOC 
 
 
 
X 
SOC 
 
Arterial Blood 
Gas with 
Lactate 
 
 
 
X 
SOC 
X 
SOC 
X 
SOC 
 
 
 
X 
SOC 
 
Adverse Events 
 
 
 
 
 
 
 
 
 
 
 
Assessment of 
Serious Adverse 
Events 
 
 
 
 
 
 
 
 
 
 
X 
R 

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Description of Risks/Benefits and Monitoring Strategy 
Benefits: 
The possible benefits of the study will be that the patient’s family and care team will receive extra 
information regarding their cardiovascular and health status.  The evaluation of organ function and injury 
after surgery may provide valuable information to the family and the clinical team that would not otherwise 
be available, and this may lead to early intervention if abnormalities are detected.  Although an individual 
patient may not directly benefit from the study participation, the results will help to further the 
understanding of oxidative stress and organ injury after cardiopulmonary bypass and will hopefully allow 
for further future studies that enroll a larger number of patients.   
If parents decline to participate, their child’s medical care will not be affected in any way.  Furthermore, if 
they agree to participate, they are free to withdraw at any time. 
Risks: 
 
Definition of Serious Adverse Event: 
An extensive review of the literature and survey results from other centers with cardiopulmonary bypass 
strategies similar to what is proposed indicate that there is a low probability of additional risk to the patients.  
In this trial, due to the risks of cardiac surgery itself, assessment of relationship of the intervention to any 
adverse event is challenging.  
Consistent with standard clinical trials practice, a Serious Adverse Event is defined generally as any event 
that:  

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(a) Is fatal; or 
(b) Is life-threatening (the subject was, in the view of the Principal Investigator, in immediate danger of 
death from the event as it occurred); or 
(c) Is severely or permanently disabling; or 
(d) Necessitates significant intervention, such as major surgery, to prevent permanent impairment of a 
body function or permanent damage to a body structure; or 
(e) Necessitates or prolongs hospital admission; or 
(f) The Principal Investigator, medical monitor, or DSMB considers a serious adverse event.  
Because many normal post-operative outcomes in this study would meet these criteria, only the following 
six events have been identified as specific Serious Adverse Events for the purposes of this study:  
(a) Death 
(b) Cardiac arrest requiring CPR and medications 
(c) Cardiopulmonary insufficiency requiring ECMO 
(d) Seizures 
(e) Need for dialysis 
In addition, any other event that in the opinion of the study investigator is considered to be a Serious 
Adverse Event may be classified as such and will then adhere to the rules for expedited reported. 
If a clinical event or finding does not meet the definition of “serious” per above, these non- serious events 
will be classified and will be reported as a complication rather than as a serious adverse event.  
 
Classification of Serious Adverse Event 
All Serious Adverse Events will be classified based on whether the event was expected, the relationship to 
the intervention, and the clinical outcome.  Specific definitions and classifications are described below. 

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All Serious Adverse Events will be evaluated as to whether their occurrence was expected or whether it 
was not expected to occur.  
A).  “Expected”: An event is considered expected if it is known to be associated with the underlying 
cardiovascular anomaly or with congenital heart surgery, and is mentioned in the protocol, 
informed consent, or other study documents. An event may be expected despite the study subject’s 
clinical state immediately prior to the event. For this protocol, expected events include:  
(a)  Sudden cardiac death  
(b)  Arrhythmias  
(c)  Tamponade  
(d)  Postoperative bleeding  
(e)  Postoperative open chest  
(f)  Postoperative chest re-exploration  
(g)  Postoperative electrolyte abnormalities  
(h)  Postoperative fever  
(i)  Postoperative renal dysfunction  
(j)  Postoperative liver dysfunction  
(k)  Shunt thrombosis  
(l)  Aortic coarctation with or without associated ventricular dysfunction  
(m)  Ventricular dysfunction not associated with coarctation  

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(n)  Pericardial effusion  
(o)  Wound infection  
(p)  Reintubation after extubation following surgery  
(q)  Hypoxia  
(r)  Respiratory distress  
(s)  Pleural effusions  
(t)  Seizures  
(u)  Renal dysfunction associated with ventricular dysfunction  
(v)  Liver dysfunction associated with ventricular dysfunction   
B).  “Unexpected”. An event is considered unexpected if there are no prior data linking this 
event with either the condition or intervention under study.  
In terms of relation to the intervention, the Serious Adverse Event will be classified as:  
a)  definitely related to the intervention 
b) probably related to the intervention 
c) possibly related to the intervention 
d) unlikely to be related to the intervention 
e) definitely not related to the intervention 
 
The clinical outcome of the Serious Adverse Event will be characterized as follows:  

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(a) Death 
(b) Recovered: the patient returned to baseline status 
(c) Symptoms continue  
Data Safety Monitoring Board (DSMB) 
A Data and Safety Monitoring Board will be established. The DSMB will meet 4 times a year to review 
study conduct, adverse events, and any interim data.  
After each DSMB meeting, a Summary Report of Adverse Events will be prepared within 30 days and will 
be distributed to the Principal Investigator with instructions that the Principal Investigator forward the 
Summary Report to the IRB. The Summary Report will contain the following information:  
• 
A statement that a DSMB review of outcome data, adverse events, and information relating to study 
performance took place on a given date  
• 
A statement as to whether or not the frequency of adverse events exceeded what was expected and 
indicated in the informed consent  
• 
A statement that a review of recent literature relevant to the research took place  
• 
The DSMB’s recommendation with respect to progress or need for modification of the protocol or 
informed consent. If the DSMB recommends changes to the protocols or informed consent, the 
rationale for such changes and any relevant data will be provided  
Reporting of Adverse Events/Serious Adverse Events 
Reports of Adverse Events/Serious Adverse Events will be submitted to the local Institutional Review 
Board (IRB) per institutional guidelines. The PI will report any serious adverse event to the DSMB Chair 
as soon as possible and no later than 7 calendar days after the event.  

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All events/complications and all events reported as serious adverse events will be tabulated and reviewed 
by the DSMB at their regularly-scheduled meetings, at least 4 times per year. 
Data Collection Procedures for Adverse Events/Serious Adverse Events 
 
1.  The five events specified as Serious Adverse Events are to be reported in an expedited fashion. Any 
other event that in the opinion of the study investigator is considered to meet the definition of a Serious 
Adverse Event should also be reported in an expedited fashion.  
Significant peri-operative and other in-hospital adverse events will be collected and be reported as 
“complications” versus adverse events.  
2. Any medical condition or abnormal laboratory value present at enrollment that remains unchanged or 
improves will not be reported as a serious adverse event or complication. However, worsening of a medical 
condition that was present at enrollment will be considered a new event and reported according to the plan 
outlined above.  
3. The onset of an event/complication will be recorded according to the date of the first presenting symptom.  
4. Serious adverse events will be reviewed by the Principal Investigator and the DSMB.  
 
 
 
 

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References: 
 
1. 
Saugstad, O.D., Oxidative stress in the newborn--a 30-year perspective. Biol Neonate, 2005. 88(3): 
p. 228-36. 
2. 
Peng, Y.W., et al., Differential Effects of Normoxic and Hyperoxic Reperfusion on Global 
Myocardial Ischemia-Reperfusion Injury. Semin Thorac Cardiovasc Surg, 2018. 
3. 
Del Castillo, J., et al., Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac 
arrest in children. Resuscitation, 2012. 83(12): p. 1456-61. 
4. 
Elmer, J., et al., The association between hyperoxia and patient outcomes after cardiac arrest: 
analysis of a high-resolution database. Intensive Care Med, 2015. 41(1): p. 49-57. 
5. 
Guerra-Wallace, M.M., et al., Hyperoxia and hypoxia in children resuscitated from cardiac arrest. 
Pediatr Crit Care Med, 2013. 14(3): p. e143-8. 
6. 
Kilgannon, J.H., et al., Relationship between supranormal oxygen tension and outcome after 
resuscitation from cardiac arrest. Circulation, 2011. 123(23): p. 2717-22. 
7. 
Cashen, K., et al., Hyperoxia and Hypocapnia During Pediatric Extracorporeal Membrane 
Oxygenation: Associations With Complications, Mortality, and Functional Status Among 
Survivors. Pediatr Crit Care Med, 2018. 19(3): p. 245-253. 
8. 
Sznycer-Taub, N.R., et al., Hyperoxia Is Associated With Poor Outcomes in Pediatric Cardiac 
Patients Supported on Venoarterial Extracorporeal Membrane Oxygenation. Pediatr Crit Care 
Med, 2016. 17(4): p. 350-8. 
9. 
McGuinness, S.P., et al., A Multicenter, Randomized, Controlled Phase IIb Trial of Avoidance of 
Hyperoxemia during Cardiopulmonary Bypass. Anesthesiology, 2016. 125(3): p. 465-73. 
10. 
Smit, B., et al., Moderate hyperoxic versus near-physiological oxygen targets during and after 
coronary artery bypass surgery: a randomised controlled trial. Crit Care, 2016. 20: p. 55. 
11. 
Ihnken, K., et al., Normoxic cardiopulmonary bypass reduces oxidative myocardial damage and 
nitric oxide during cardiac operations in the adult. J Thorac Cardiovasc Surg, 1998. 116(2): p. 
327-34. 
12. 
Bulutcu, F.S., et al., Does normoxemic cardiopulmonary bypass prevent myocardial reoxygenation 
injury in cyanotic children? J Cardiothorac Vasc Anesth, 2002. 16(3): p. 330-3. 
13. 
Caputo, M., et al., The effects of normoxic versus hyperoxic cardiopulmonary bypass on oxidative 
stress and inflammatory response in cyanotic pediatric patients undergoing open cardiac surgery: 
a randomized controlled trial. J Thorac Cardiovasc Surg, 2009. 138(1): p. 206-14. 
14. 
Ghorbel, M.T., et al., Controlled reoxygenation cardiopulmonary bypass is associated with 
reduced transcriptomic changes in cyanotic tetralogy of Fallot patients undergoing surgery. 
Physiol Genomics, 2012. 44(22): p. 1098-106. 
15. 
Matheis, G., et al., Uncontrolled reoxygenation by initiating cardiopulmonary bypass is associated 
with higher protein S100 in cyanotic versus acyanotic patients. Thorac Cardiovasc Surg, 2000. 
48(5): p. 263-8. 
16. 
Babu, B., et al., Controlling oxygenation during initiation of cardiopulmonary bypass: can it 
improve immediate postoperative outcomes in cyanotic children undergoing cardiac surgery? A 
prospective randomized study. World J Pediatr Congenit Heart Surg, 2012. 3(3): p. 310-6. 
17. 
Caputo, M., et al., Controlled reoxygenation during cardiopulmonary bypass decreases markers of 
organ damage, inflammation, and oxidative stress in single-ventricle patients undergoing pediatric 
heart surgery. J Thorac Cardiovasc Surg, 2014. 148(3): p. 792-801 e8; discussion 800-1. 
 
 

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APPENDIX A: Acronym List 
 
ANGPT2: Angiopoietin2 
CPB: Cardio-Pulmonary Bypass 
CT: Computed Tomography 
ECMO: Extracorporeal membrane oxygenation 
EEG: Electroencephalogram  
EF: Ejection Fraction 
FiO2: Fraction of Inspired Oxygen 
GFAP: Glial fibrillary acidic protein 
GI: Gastro-Intestinal 
ICU: Intensive Care Unit 
I-FABP: Intestinal fatty-acid binding protein 
IL: Interleukin 
IQR: Interval Quartile Range 
MRI: Magnetic Resonance Imaging 
NIRS: Near-infrared spectroscopy 
PaO2: Partial Pressure of Oxygen 
PCTU: Pediatric Cardiothoracic Intensive Care  
PFT: Pulmonary Function Test 
POD: Post-Operative Day 

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TBARS: Thiobarbituric Acid Reactive Substance 
VIS: Vasoactive-Inotropic Score 
VSD: Ventricular Septal Defect