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Kuhn JE, Pareja Zabala MC, Chavez MM, Almodóvar M, Mulinari LA, Sainathan S, de Rivero Vaccari JP, Wang KK, Muñoz Pareja JC. Utility of Brain Injury Biomarkers in Children With Congenital Heart Disease Undergoing Cardiac Surgery. Pediatr Neurol 2023; 148:44-53. [PMID: 37657124 DOI: 10.1016/j.pediatrneurol.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Congenital heart disease (CHD) affects roughly 40,000 children annually. Despite advancements, children undergoing surgery for CHD are at an increased risk for adverse neurological outcomes. At present, there is no gold standard for the diagnosis of cerebral injury during the perioperative period. OBJECTIVE To determine the utility of brain injury biomarkers in children undergoing cardiac surgery. METHODS We searched PUBMED, EMBASE, LILACS, EBSCO, ClinicalTrials.gov, Cochrane Databases, and OVID interface to search MEDLINE through July 2021 and assessed the literature following the snowball method. The search terms used were "congenital heart disease," "cardiopulmonary bypass," "biomarkers," "diagnosis," "prognosis," and "children." No language or publication date restrictions were used. Papers studying inflammatory and imaging biomarkers were excluded. The risk of bias, strengths, and limitations of the study were reported. Study was registered in PROSPERO ID: CRD42021258385. RESULTS A total of 1449 articles were retrieved, and 27 were included. Eight neurological biomarkers were examined. Outcomes assessed included prognosis of poor neurological outcome, mortality, readmission, and diagnosis of brain injury. Results from these studies support that significant perioperative elevations in brain injury biomarkers in cerebrospinal fluid and serum, including S100B, GFAP, NSE, and activin A, may be diagnostic of real-time brain injury and serve as an independent predictor of adverse neurological outcomes in patients with CHD undergoing cardiopulmonary bypass. CONCLUSIONS There are limited homogeneous data in the field, limiting the generalizability and comparability of the results. Further large-scale longitudinal studies addressing neurological biomarkers in children undergoing CHD corrective surgery are required to support the routine use of neuronal biomarkers in this population.
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Affiliation(s)
- Jessica E Kuhn
- University of Miami Miller School of Medicine, Miami, Florida
| | | | - Maria Mateo Chavez
- Knowledge and Research Evaluation Unit, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Melvin Almodóvar
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Leonardo A Mulinari
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Sandeep Sainathan
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan Pablo de Rivero Vaccari
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
| | - Kevin K Wang
- Department of Emergency Medicine, Morehouse University, School of Medicine, Atlanta, Georgia; Center for Neurotrauma, Multiomics & Biomarkers (CNMB), Morehouse University, School of Medicine, Atlanta, Georgia
| | - Jennifer C Muñoz Pareja
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida; Division of Pediatric Critical Care, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida.
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Bedir Demirdag T, Gucuyener K, Soysal AS, Guntekin Ergun S, Ozturk Z, Ergun MA, Tunaoğlu S. The effect of apoprotein E gene polymorphism on neurocognitive functions of children with CHD. Cardiol Young 2023; 33:1556-1560. [PMID: 36047305 DOI: 10.1017/s1047951122002621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Studies have demonstrated an association between CHD and neurodevelopmental delay. This delay is associated with many factors like reduced blood flow and oxygen, cardiac catheterisations, and genetic factors. Apo E gene polymorphism is one of these genetic factors. This study aims to show the effect of Apo E gene polymorphism on neurodevelopmental process in children having CHD. A total of 188 children having CHD were admitted to the study. Apo E gene polymorphism of these patients was determined, and psychometric evaluation was performed. The relationship between psychometric test results and gene polymorphism was evaluated. This study shows that, similar to the literature, patients having cyanotic CHD have worse scores than acyanotic patients, and the children with CHD are under risk in terms of neuropsychiatric disorders. Other novel and important findings of this study were the lower verbal scores of ε2 allele carriers than ε4 carriers in Wechsler Intelligence Scale for Children-Revised group and the worse test score of patients having VSD than other acyanotic patients. Besides, some special disorders may be seen in this patient group.
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Affiliation(s)
- Tugba Bedir Demirdag
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Gazi University, Ankara, Turkey
| | - Kivilcim Gucuyener
- Faculty of Medicine, Department of Pediatric Neurology, Gazi University, Ankara, Turkey
| | - A Sebnem Soysal
- Faculty of Medicine, Department of Pediatric Neurology, Gazi University, Ankara, Turkey
| | - Sezen Guntekin Ergun
- Faculty of Medicine, Department of Medical Biology, Hacettepe University, Ankara, Turkey
- Faculty of Medicine, Department of Medical Genetics, Gazi University, Ankara, Turkey
| | - Zeynep Ozturk
- Faculty of Medicine, Department of Pediatrics, Gazi University, Ankara, Turkey
| | - Mehmet Ali Ergun
- Faculty of Medicine, Department of Medical Genetics, Gazi University, Ankara, Turkey
| | - Sedef Tunaoğlu
- Faculty of Medicine, Department of Pediatric Cardiology, Gazi University, Ankara, Turkey
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Memory Problems in Children With Congenital Heart Disease: A Narrative Review. J Neurosurg Anesthesiol 2023; 35:136-141. [PMID: 36745178 DOI: 10.1097/ana.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Care for congenital heart diseases (CHD) has improved significantly over the past several decades, and children with CHD are now surviving into adulthood. Cognitive and behavioral problems affect children with CHD more than healthy peers. A review of performance on neuropsychological memory tasks has not been reported. We aimed to summarize the published literature on memory problems in people with CHD. METHODS We searched Pubmed, Medline, and PsycINFO from January 1, 1986 to March 22, 2022 to reflect modern care for people with CHD. Our inclusion criteria were randomized controlled trials or observational studies that included children with CHD older than age 3 years, which reported the results of at least 1 neuropsychological test of memory in the CHD group. Our exclusion criteria were studies that included heart transplant recipients and studies that included children who required extracorporeal membrane oxygenation. RESULTS Thirty-one studies that met our inclusion criteria and avoided exclusion criteria were included in this review. Several studies reported deficits in the subdomains of short-term and long-term memory and visual and verbal memory, though we found substantial heterogeneity across studies. The most likely subdomain to be affected in children with CHD appears to be short-term visual memory. CONCLUSIONS There is likely an increased risk of memory problems for children and adults with CHD. We were unable to quantify the risk of memory problems due to the heterogeneity of published studies. Future research should make efforts to account for confounding variables and standardize outcome measures.
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Dextro-Transposition of Great Arteries and Neurodevelopmental Outcomes: A Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9040502. [PMID: 35455546 PMCID: PMC9027469 DOI: 10.3390/children9040502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022]
Abstract
Background: Arterial switch operation (ASO) is the gold-standard surgical approach for dextro-transposition of the great arteries (D-TGA). It is performed during the neonatal period and has almost diminished the previously high mortality rate (from 90% if left untreated to <0.5%). Despite the impressively high survival rates, the surgical procedure itself—along with the chronic post-operative complications and the perinatal impaired cerebral oxygen delivery—introduces multiple and cumulative risk factors for neurodevelopmental impairment. Method: This study is a review of English articles, using PUBMED and applying the following search terms, “transposition of the great arteries”, “neurodevelopment”, “autism”, “cerebral palsy”, and “attention-deficit hyperactivity disorder”. Data were extracted by two authors. Results: Even though general IQ is mainly found within the normal range, D-TGA children and adolescents display reduced performance in the assignments of executive functions, fine motor functions, attention, working memory, visual−spatial skills, and higher-order language skills. Moreover, D-TGA survivors may eventually struggle with inferior academic achievements and psychiatric disorders such as depression, anxiety, and ADHD. Conclusions: The existing literature concerning the neurodevelopment of D-TGA patients suggests impairment occurring during their lifespan. These findings underline the importance of close developmental surveillance so that D-TGA patients can better reach their full potential.
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Huisenga D, La Bastide‐Van Gemert S, Van Bergen A, Sweeney J, Hadders‐Algra M. Developmental outcomes after early surgery for complex congenital heart disease: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:29-46. [PMID: 32149404 PMCID: PMC7754445 DOI: 10.1111/dmcn.14512] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
AIM (1) To systematically review the literature on developmental outcomes from infancy to adolescence of children with complex congenital heart disease (CHD) who underwent early surgery; (2) to run a meta-regression analysis on the Bayley Scales of Infant Development, Second Edition Mental Developmental Index and Psychomotor Developmental Index (PDI) of infants up to 24 months and IQs of preschool-aged children to adolescents; (3) to assess associations between perioperative risk factors and outcomes. METHOD We searched pertinent literature (January 1990 to January 2019) in PubMed, Embase, CINAHL, and PsycINFO. Selection criteria included infants with complex CHD who had primary surgery within the first 9 weeks of life. Methodological quality, including risk of bias and internal validity, were assessed. RESULTS In total, 185 papers met the inclusion criteria; the 100 with high to moderate methodological quality were analysed in detail. Substantial heterogeneity in the group with CHD and in methodology existed. The outcome of infants with single-ventricle CHD was inferior to those with two-ventricle CHD (respectively: average scores for PDI 77 and 88; intelligence scores 92 and 98). Perioperative risk factors were inconsistently associated with developmental outcomes. INTERPRETATION The literature on children undergoing surgery in early infancy suggests that infants with a single ventricle are at highest risk of adverse developmental outcomes.
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Affiliation(s)
- Darlene Huisenga
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
| | - Sacha La Bastide‐Van Gemert
- University of GroningenUniversity Medical Center GroningenDepartment of EpidemiologyGroningenthe Netherlands
| | - Andrew Van Bergen
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,Advocate Children’s Heart Institute Division of Pediatric Cardiac Critical CareAdvocate Children’s HospitalOak LawnILUSA
| | - Jane Sweeney
- Pediatric Science Doctoral ProgramRocky Mountain University of Health ProfessionsProvoUTUSA
| | - Mijna Hadders‐Algra
- University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
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Muñoz-López M, Hoskote A, Chadwick MJ, Dzieciol AM, Gadian DG, Chong K, Banks T, de Haan M, Baldeweg T, Mishkin M, Vargha-Khadem F. Hippocampal damage and memory impairment in congenital cyanotic heart disease. Hippocampus 2017; 27:417-424. [PMID: 28032672 PMCID: PMC5363353 DOI: 10.1002/hipo.22700] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/20/2016] [Accepted: 12/20/2016] [Indexed: 11/17/2022]
Abstract
Neonatal hypoxia can lead to hippocampal atrophy, which can lead, in turn, to memory impairment. To test the generalizability of this causal sequence, we examined a cohort of 41 children aged 8‐16, who, having received the arterial switch operation to correct for transposition of the great arteries, had sustained significant neonatal cyanosis but were otherwise neurodevelopmentally normal. As predicted, the cohort had significant bilateral reduction of hippocampal volumes relative to the volumes of 64 normal controls. They also had significant, yet selective, impairment of episodic memory as measured by standard tests of memory, despite relatively normal levels of intelligence, academic attainment, and verbal fluency. Across the cohort, degree of memory impairment was correlated with degree of hippocampal atrophy suggesting that even as early as neonatal life no other structure can fully compensate for hippocampal injury and its special role in serving episodic long term memory. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mónica Muñoz-López
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Aparna Hoskote
- Cardiac Intensive Care Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Martin J Chadwick
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Anna M Dzieciol
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - David G Gadian
- Developmental Imaging and Biophysics Section, UCL Institute of Child Health, London, United Kingdom
| | - Kling Chong
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Tina Banks
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Michelle de Haan
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Torsten Baldeweg
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mortimer Mishkin
- Laboratory of Neuropsychology, National Institute of Mental Health, Bethesda, Maryland
| | - Faraneh Vargha-Khadem
- Cognitive Neuroscience & Neuropsychiatry Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Neuropsychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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Kasmi L, Bonnet D, Montreuil M, Kalfa D, Geronikola N, Bellinger DC, Calderon J. Neuropsychological and Psychiatric Outcomes in Dextro-Transposition of the Great Arteries across the Lifespan: A State-of-the-Art Review. Front Pediatr 2017; 5:59. [PMID: 28393063 PMCID: PMC5364136 DOI: 10.3389/fped.2017.00059] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/10/2017] [Indexed: 11/17/2022] Open
Abstract
Advances in prenatal diagnosis, perioperative management, and postoperative care have dramatically increased the population of survivors of neonatal and infant heart surgery. The high survival rate of these patients into adulthood has exposed the alarming prevalence of long-term neuropsychological and psychiatric morbidities. Dextro-transposition of the great arteries (d-TGA) is one of the most extensively studied cyanotic congenital heart defect (CHD) with regard to neurodevelopmental outcomes. Landmark studies have described a common neurodevelopmental and behavioral phenotype associated with d-TGA. Children with d-TGA display impairments in key neurocognitive areas, including visual-spatial and fine motor abilities, executive functioning, processing speed, and social cognition. As they grow older, they may face additional challenges with a worsening of deficits in higher order cognitive skills, problems in psychosocial adjustment and a higher-than-expected rate of psychiatric disorders, such as attention-deficit hyperactivity disorder, depression, and anxiety. The aim of this review is to summarize the available recent data on neuropsychological and psychiatric outcomes in individuals with d-TGA after the arterial switch operation. We present findings within a life-span perspective, with a particular emphasis on the emerging literature on adolescent and young adult outcomes. Finally, we propose avenues for future research in the CHD adult neuropsychology field. Among these avenues, we explore the potential mechanisms by which pediatric neurodevelopmental impairments may have lifelong adverse effects as well as alternative interventions that could optimize outcomes.
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Affiliation(s)
- Leila Kasmi
- Laboratory of Psychopathology and Neuropsychology, Department of Psychology, University Paris 8, Paris Lumières - CNRS , Saint-Denis , France
| | - Damien Bonnet
- Referral Center for Complex Congenital Cardiac Malformations, Department of Congenital and Pediatric Cardiology, Necker Hospital, University Paris Descartes, Sorbonne Paris Cité , Paris , France
| | - Michèle Montreuil
- Laboratory of Psychopathology and Neuropsychology, Department of Psychology, University Paris 8, Paris Lumières - CNRS , Saint-Denis , France
| | - David Kalfa
- Division of Cardiac, Thoracic, and Vascular Surgery, Section of Pediatric Cardiac Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Irving Medical Center, Columbia University , New York, NY , USA
| | - Nikoletta Geronikola
- Laboratory of Psychopathology and Neuropsychology, Department of Psychology, University Paris 8, Paris Lumières - CNRS , Saint-Denis , France
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Johanna Calderon
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA
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Seghaye MC. Management of children with congenital heart defect: state of the art and future prospects. Future Cardiol 2016; 13:65-79. [PMID: 27936920 DOI: 10.2217/fca-2016-0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The treatment of children with congenital heart defects has evolved in the last 60 years from conservative care to a highly specialized management where advances in imaging, surgical, interventional and support techniques meet together to ensure satisfactory development and good quality of life to the child and to the upcoming grown up. Management of congenital heart defects best begins before birth with the aim, whenever possible, to maintain or establish biventricular physiology or, if this is excluded, to optimize the conditions for univentricular physiology. Current research in the field of genetics, device bioengineering and miniaturization, stem cell therapy, and fusion imaging technology is expected to help to improve further patient outcome. In this review, current management strategies and future prospects are discussed.
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Affiliation(s)
- Marie-Christine Seghaye
- Department of Pediatrics-Pediatric Cardiology, University Hospital Liège, Rue de Gaillarmont 600, B. 4032 Liège, Belgium
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Raja SG, Shauq A, Kaarne M. Outcomes after Arterial Switch Operation for Simple Transposition. Asian Cardiovasc Thorac Ann 2016; 13:190-8. [PMID: 15905355 DOI: 10.1177/021849230501300222] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Without intervention, babies born with transposed great arteries (TGA) are doomed to a rapid death. Jatene and coworkers deserve the credit for performing the first successful arterial switch operation (ASO) in a patient with TGA and ventricular septal defect (VSD) in 1975. Since then ASO has become the procedure of choice in most medical centers. This review article summarizes the historical aspects of arterial switch operation and assesses this procedure's outcomes.
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Affiliation(s)
- Shahzad G Raja
- Department of Pediatric Cardiac Surgery, Alder Hey Hospital, Liverpool, United Kingdom.
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Sterken C, Lemiere J, Vanhorebeek I, Van den Berghe G, Mesotten D. Neurocognition after paediatric heart surgery: a systematic review and meta-analysis. Open Heart 2015; 2:e000255. [PMID: 26568832 PMCID: PMC4636679 DOI: 10.1136/openhrt-2015-000255] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 09/18/2015] [Accepted: 09/29/2015] [Indexed: 11/05/2022] Open
Abstract
Children with congenital heart disease (CHD) often experience difficulties in academic and daily functioning, which have been associated with intelligence and neurocognitive skills, including executive functions (EFs), attention and memory. We report the neurocognitive data of children with CHD who were included in the Leuven glucose control trial (LGC trial). Through a systematic review and meta-analysis, we aimed to find which neurocognitive functions are most consistently and prominently affected. 365 children with CHD and 216 healthy control children underwent extensive neurocognitive testing in the LGC trial. A comprehensive search of electronic databases PubMed, EMBASE and Cochrane was conducted for studies measuring intelligence, EFs, attention and memory in children who underwent heart surgery for CHD. Standardised mean differences (SMDs) between the CHD group and a healthy control group were calculated for these neurocognitive functions. LGC trial data were included in the meta-analysis. Twelve studies with a healthy control group were included in the meta-analysis, involving 647 patients with CHD and 633 controls. The CHD group (median age 7.35 years at testing) had worse scores than healthy control children, for all investigated neurocognitive functions. A medium SMD was found for intelligence (SMD=−0.53 (95% CI −0.68 to −0.38), p<0.00001). Alertness, an attentional function, was also consistently poorer in the CHD group. Memory was less affected, while EF had a medium SMD with large heterogeneity. Children with CHD risk displayed lower performance on intelligence and alertness assessment, which may contribute to difficulties in daily life and school. Heterogeneity in neurocognitive assessment and small sizes in most studies limit the interpretation.
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Affiliation(s)
- Caroline Sterken
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine , KU Leuven , Leuven , Belgium
| | - Jurgen Lemiere
- Child and Adolescent Psychiatry , University Hospitals Leuven , Leuven , Belgium ; Paediatric Haemato-Oncology , University Hospitals Leuven , Leuven , Belgium
| | - Ilse Vanhorebeek
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine , KU Leuven , Leuven , Belgium
| | - Greet Van den Berghe
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine , KU Leuven , Leuven , Belgium
| | - Dieter Mesotten
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine , KU Leuven , Leuven , Belgium
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Neurologic and psycho-intellectual outcome related to structural brain imaging in adolescents and young adults after neonatal arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 2014; 148:2190-9. [DOI: 10.1016/j.jtcvs.2013.10.087] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/23/2013] [Accepted: 10/06/2013] [Indexed: 11/21/2022]
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Glial fibrillary acidic protein in children with congenital heart disease undergoing cardiopulmonary bypass. Cardiol Young 2014; 24:623-31. [PMID: 23845562 DOI: 10.1017/s1047951113000851] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To determine whether blood levels of the brain-specific biomarker glial fibrillary acidic protein rise during cardiopulmonary bypass for repair of congenital heart disease. METHODS This is a prospective observational pilot study to characterise the blood levels of glial fibrillary acidic protein during bypass. Children <21 years of age undergoing bypass for congenital heart disease at Johns Hopkins Hospital and Texas Children's Hospital were enrolled. Blood samples were collected during four phases: pre-bypass, cooling, re-warming, and post-bypass. RESULTS A total of 85 patients were enrolled between October, 2010 and May, 2011. The median age was 0.73 years (range 0.01-17). The median weight was 7.14 kilograms (range 2.2-86.5). Single ventricle anatomy was present in 18 patients (22%). Median glial fibrillary acidic protein values by phase were: pre-bypass: 0 ng/ml (range 0-0.35); cooling: 0.039 (0-0.68); re-warming: 0.165 (0-2.29); and post-bypass: 0.112 (0-0.97). There were significant elevations from pre-bypass to all subsequent stages, with the greatest increase during re-warming (p = 0.0001). Maximal levels were significantly related to younger age (p = 0.03), bypass time (p = 0.03), cross-clamp time (p = 0.047), and temperature nadir (0.04). Peak levels did not vary significantly in those with single ventricle anatomy versus two ventricle repairs. CONCLUSION There are significant increases in glial fibrillary acidic protein levels in children undergoing cardiopulmonary bypass for repair of congenital heart disease. The highest values were seen during the re-warming phase. Elevations are significantly associated with younger age, bypass and cross-clamp times, and temperature nadir. Owing to the fact that glial fibrillary acidic protein is the most brain-specific biomarker identified to date, it may act as a rapid diagnostic marker of brain injury during cardiac surgery.
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Mbuagbaw L, Forlemu-Kamwa D, Chu A, Thabane L, Dillenberg R. Outcomes after corrective surgery for congenital dextro-transposition of the great arteries using the arterial switch technique: a protocol for a scoping systematic review. BMJ Open 2014; 4:e005123. [PMID: 24919640 PMCID: PMC4067827 DOI: 10.1136/bmjopen-2014-005123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Dextro-transposition of the great arteries (d-TGA) is a life-threatening congenital health defect that requires rapid surgery. The most widely used approach is the arterial switch operation (ASO) developed by Jatene in the 1970s. The first set of children who received this intervention are now adults. The objective of this scoping review of the literature was to document the short-term (less than 1 year), medium-term (1-20 years) and long-term (more than 20 years) outcomes in children who underwent the ASO. Our primary income is survival, but we will explore other secondary surgical, cardiovascular, reproductive and quality-of-life outcomes. METHODS AND ANALYSES Using a systematic scoping review approach, we will conduct a systematic search of the published literature for experimental and observational studies published on children who received the ASO intervention for classic d-TGA. We will search MEDLINE, Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Literatura Latino Americana em Ciências da Saúde (LILACS) from 1973 (date of the first successful ASO) to February 2014. Identified articles will be screened in duplicate and full text for selected articles will be retrieved. Data extraction will be carried out in duplicate. Discrepancies will be resolved by consensus or by consulting a third author. Where possible, proportions will be pooled using the inverse variance method. Our findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational studies in Epidemiology (MOOSE) guidelines. ETHICS AND DISSEMINATION The results of this paper will be disseminated as peer-reviewed publications, at conferences and at clinical rounds. Our findings may answer important questions for surgeons who perform the ASO intervention and for clinicians who take care of patients after surgery and throughout their lifespans. TRIAL REGISTRATION NUMBER Prospero/CRD42014007590.
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Affiliation(s)
- Lawrence Mbuagbaw
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | | | - Angela Chu
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicines, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Rejane Dillenberg
- Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, Ontario, Canada
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Oofuvong M, Geater AF, Chongsuvivatwong V, Chanchayanon T, Worachotekamjorn J, Sriyanaluk B, Saefung B, Nuanjun K. Comparison of intelligence, weight and height in children after general anesthesia with and without perioperative desaturation in non-cardiac surgery: a historical and concurrent follow-up study. SPRINGERPLUS 2014; 3:164. [PMID: 25674447 PMCID: PMC4320222 DOI: 10.1186/2193-1801-3-164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 03/21/2014] [Indexed: 11/10/2022]
Abstract
Purpose To determine whether perioperative desaturation (PD) in preschool children undergoing non-cardiac surgery is associated with subsequent impairment of intelligence or subsequent change in age-specific weight and height percentile. Method A historical-concurrent follow-up study was conducted in children aged ≤ 60 months who underwent general anesthesia (GA) for non-cardiac surgery between January 2008 and December 2011 at Songklanagarind Hospital. Children who developed PD (PD group) and children who did not develop perioperative respiratory events (no-PRE group) were matched on sex, age, year of having index GA, type of surgery and choice of anesthesia. The children’s age-specific weight and height percentile and intelligence quotient (IQ) scores by Standford Binet-LM or Wechsler Intelligence Scale for Children, 3rd edition 12–60 months after GA were compared using Student’s t- test and Wilcoxon’s rank sum test. Multivariate linear regression models for standardized IQ and multivariate mixed effects linear regression models for the change of age-specific weight and height percentile from the time of index GA to the time of IQ test were performed to identify independent predictors. The coefficients and 95% confidence intervals (CI) were displayed and considered significant if the F test p-values were < 0.05. Results Of 103 subjects in each group (PD vs no-PRE), there were no statistically significant differences in IQ (94.7 vs 98.3, p = 0.13), standardized IQ (−0.1 vs 0.1, p = 0.14) or age-specific weight percentile (38th vs 63th, p = 0.06). However, age-specific height percentile in the PD group at the time of IQ test was significantly lower (38th vs 50th, p = 0.02). In the multivariate analysis, PD was not a significant predictor for standardized IQ (coefficient: −0.06, 95% CI: −0.3, 0.19, p = 0.57), change in age-specific weight percentile (coefficient: 4.66, 95% CI: −2.63, 11.95, p = 0.21) or change in age-specific height percentile (coefficient: −1.65, 95% CI: −9.74, 6.44, p = 0.69) from the time of index GA to the time of IQ test after adjusting for family and anesthesia characteristics. Conclusion Our study could not demonstrate any serious effect of PD on subsequent intelligence or on the change in age-specific weight and height percentile of children after non-cardiac surgery. Electronic supplementary material The online version of this article (doi:10.1186/2193-1801-3-164) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maliwan Oofuvong
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Alan Frederick Geater
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | | | - Thavat Chanchayanon
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Juthamas Worachotekamjorn
- Division of Child Development, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Bussarin Sriyanaluk
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Boonthida Saefung
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Kanjana Nuanjun
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
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Matos SM, Sarmento S, Moreira S, Pereira MM, Quintas J, Peixoto B, Areias JC, Areias MEG. Impact of fetal development on neurocognitive performance of adolescents with cyanotic and acyanotic congenital heart disease. CONGENIT HEART DIS 2013; 9:373-81. [PMID: 24298977 DOI: 10.1111/chd.12152] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our aims were to evaluate the neurocognitive performance in adolescents with congenital heart disease (CHD) and to determine whether parameters of fetal development evaluated in neonates, such as head circumference, length, weight, and Apgar scores, are somehow related to their neurocognitive performance. METHODS We evaluated 77 CHD patients (43 males) aged from 13 to 18 years old (mean = 15.04 ± 1.86), 46 cyanotic, 23 with tetralogy of Fallot (TF), 23 with transposition of the great arteries (TGA) and 31 acyanotic with ventricular septal defect (VSD) enrolled in this study. The control group included 16 healthy children (11 males) ages ranging from 13 to 18 years old (mean = 15.69 years ± 1.44 years). All assessment measures for CHD patients were once obtained in a tertiary hospital; the control group was evaluated in school. Neuropsychological assessment included Wechsler's Digit Test, direct and reverse (WDD and WDR) and Symbol Search, Rey's Complex Figure (RCF), BADS's Key Searching Test, Color-Word Stroop Test (CWS), Trail Making Test (TMT), and Logical Memory Task (LMT). We evaluated some fetal parameters, such as head circumference, weight and length assessed at birth, and neonatal parameters, such as Apgar scores at 1 and 5 minutes after birth. We also registered some surgical parameters, such as the age at first operation and the number of surgeries. RESULTS CHD patients compared with control group showed lower scores on every test, except for logical memory task. Patients with VSD when compared with patients with TF and TGA showed better results in all neuropsychological tests, although the only significant differences were in RCF, copy (F = 4936; P = .010). Several correlations were apparent between fetal/neonatal parameters and neuropsychological abilities in each type of CHD. However, head circumference at birth stands as the main correlation with cognitive development later on in all kinds of CHD (WDD: rho = .339, P = .011; RCF, copy: rho = 0.297, P = .027; CWS, interference: rho = 0.283, P = .036; TMT-A: rho = -0.321, P = .017). We analyzed the predicting relevance of several variables to cognitive performance of adolescents with CHD and confirmed that "cyanosis" stands as the main predictor (â = -4.758; t = -2.622; P = .011). CONCLUSIONS Adolescents with CHD have worse neuropsychological performance than the control group, mainly the cyanotic patients. Fetal circulation seems to have impact on cerebral and somatic growth, predicting cognitive impairment in adolescents with CHD.
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Affiliation(s)
- Samantha M Matos
- Department of Psychology, Higher Institute for Health Sciences-North (CESPU), Gandra; IINFACTS (CESPU), Gandra
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Risk factors for neurodevelopmental impairments in school-age children after cardiac surgery with full-flow cardiopulmonary bypass. J Thorac Cardiovasc Surg 2012; 144:577-83. [DOI: 10.1016/j.jtcvs.2012.02.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 01/09/2012] [Accepted: 02/03/2012] [Indexed: 11/20/2022]
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17
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Porcayo-Mercado MR, Otero-Ojeda GA, Pliego-Rivero FB, Aguirre-Pérez DM, Ricardo-Garcell J. Neurobehavioral assessment of children presenting diverse congenital cardiopathologies. J Clin Psychol Med Settings 2012; 20:71-8. [PMID: 22886702 DOI: 10.1007/s10880-012-9314-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Brain maturation in 1-36 month old children suffering from congenital cardiopathologies was assessed after a study of psychomotor development. The Rogers' test (Rogers et al., Developmental programming for infants and young children. Volume 2. Early intervention developmental profile, Revised edition, ESL/ELT Michigan, Ann Arbor, 1981) was applied to 65 children, of whom 21 presented with simple cardiopathologies (CpS) and 22 with complex cardiopathologies (CpC). All children were matched by age, sex and socioeconomic status to 22 healthy children in a control group (C). Mean differences between the three groups were established by applying the Kruskal-Wallis test, and mean differences between the C and CpS/CpC groups were determined using the Mann-Whitney test. The proportion of cases evaluated as "low" in each group was calculated by applying the Rogers' test, and a test of proportion differences was applied between the C and CpS/CpC groups. CpS children performed similarly to the C, whereas CpC children scored significantly lower than C children on all variables. It is highly likely that the suboptimal psychomotor performance observed in CpC children was due to compromised hemodynamics and related to subclinical immaturity of cerebral development.
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Abstract
PURPOSE OF REVIEW The present review focuses on neurodevelopmental and neuropsychologic outcomes following neonatal and infant heart surgery for complex congenital heart lesions. The data include recent reports on perioperative MRI and recent results of randomized clinical trials addressing perioperative variables. RECENT FINDINGS Advancements in magnetic resonance techniques have reinforced earlier data that newborns with complex congenital heart lesions are frequently born with brain immaturity. Randomized clinical trials have looked at several important perioperative candidate predictors as potential independent risk factors for worsened neurodevelopmental outcomes: no difference was found between regional cerebral perfusion and deep hypothermic circulatory arrest on 1-year outcomes; no difference was found between the modified Blalock-Taussig shunt and the right ventricular to pulmonary artery shunt as part of the Norwood procedure on 14-month outcomes; at 16-year testing for individuals with transposition of the great arteries following the arterial switch operation, no significant difference was found between low-flow cardiopulmonary bypass and deep hypothermic circulatory arrest. SUMMARY Randomized clinical, cross-sectional, and prospective trials have explored robust analyses looking for independent risk factors for worsened neurodevelopmental outcomes. Most of these risk factors are patient-related or socioeconomic, with only a few potentially modifiable.
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Bhutta AT, Schmitz ML, Swearingen C, James LP, Wardbegnoche WL, Lindquist DM, Glasier CM, Tuzcu V, Prodhan P, Dyamenahalli U, Imamura M, Jaquiss RDB, Anand KJS. Ketamine as a neuroprotective and anti-inflammatory agent in children undergoing surgery on cardiopulmonary bypass: a pilot randomized, double-blind, placebo-controlled trial. Pediatr Crit Care Med 2012; 13:328-37. [PMID: 21926656 DOI: 10.1097/pcc.0b013e31822f18f9] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Infants are potentially more susceptible to cell death mediated via glutamate excitotoxicity attributed to cardiopulmonary bypass. We hypothesized that ketamine, via N-methyl D-aspartate receptor blockade and anti-inflammatory effects, would reduce central nervous system injury during cardiopulmonary bypass. METHODS We randomized 24 infants, without chromosomal abnormalities, to receive ketamine (2 mg/kg, n = 13) or placebo (saline, n = 11) before cardiopulmonary bypass for repair of ventricular septal defects. Plasma markers of inflammation and central nervous system injury were compared at the end of surgery, and 6, 24, and 48 hrs after surgery. Magnetic resonance imaging and spectroscopy before cardiopulmonary bypass and at the time of hospital discharge were performed in a subset of cases and controls (n = 5 in each group). Cerebral hemodynamics were monitored postoperatively using near-infrared spectroscopy, and neurodevelopmental outcomes were assessed using Bayley Scales of Infant Development-II before and 2-3 wks after surgery. RESULTS Statistically significant differences were noted in preoperative inspired oxygen levels, intraoperative cooling and postoperative temperature, respiratory rate, platelet count, and bicarbonate levels. The peak concentration of C-reactive protein was lower in cases compared to controls at 24 hrs (p = .048) and 48 hrs (p = .001). No significant differences were noted in the expression of various cytokines, chemokines, S100, and neuron-specific enolase between the cases and controls. Magnetic resonance imaging with spectroscopy studies showed that ketamine administration led to a significant decrease in choline and glutamate plus glutamine/creatine in frontal white matter. No statistically significant differences occurred between pre- and postoperative Bayley Scales of Infant Development-II scores. CONCLUSIONS We did not find any evidence for neuroprotection or neurotoxicity in our pilot study. A large, adequately powered randomized control trial is needed to discern the central nervous system effect of ketamine on the developing brain. brain. TRIAL REGISTRATION The trial is registered at www.ClinicalTrials.gov, NCT00556361.
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Affiliation(s)
- Adnan T Bhutta
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Karaci AR, Sasmazel A, Aydemir NA, Saritas T, Harmandar B, Tuncel Z, Undar A. Comparison of parameters for detection of splanchnic hypoxia in children undergoing cardiopulmonary bypass with pulsatile versus nonpulsatile normothermia or hypothermia during congenital heart surgeries. Artif Organs 2012; 35:1010-7. [PMID: 22097978 DOI: 10.1111/j.1525-1594.2011.01378.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study is to evaluate gastric mucosal oxygenation together with whole-body oxygen changes in infants undergoing congenital heart surgery with cardiopulmonary bypass (CPB) procedure and the use of either pulsatile or nonpulsatile mode of perfusion with normothermia and pulsatile or nonpulsatile moderate hypothermia. Sixty infants undergoing congenital cardiac surgery were randomized into four groups as: nonpulsatile normothermia CPB (NNCPB, n = 15), pulsatile normothermia CPB (PNCPB, n = 15), nonpulsatile moderate hypothermia CPB (NHCPB, n = 15), and pulsatile moderate hypothermia CPB (PHCPB, n = 15) groups. In NNCPB and PNCPB groups, mild hypothermia was used (35°C), whereas in NHCPB and PHCPB groups, moderate hypothermia (28°C) was used. Gastric intramucosal pH (pHi), whole-body oxygen delivery (DO(2)) and consumption (VO(2)), and whole-body oxygen extraction fraction were measured at sequential time points intraoperatively and up to 2 h postoperatively. The measurement of continuous tonometry data was collected at desired intervals. The values of DO(2), VO(2), and whole-body oxygen extraction fraction were not different between groups before CPB and during CPB, whereas the PNCPB group showed higher values of DO(2), VO(2), and whole-body oxygen extraction fraction compared to the other groups at the measurement levels of 20 and 60 min after aortic cross clamp, end of CPB, and 2 h after CPB (P < 0.0001). Between groups, no difference was observed for pHi, lactate, and cardiac index values (P > 0.05). This study shows that the use of normothermic pulsatile perfusion (35°C) provides better gastric mucosal oxygenation as compared to other perfusion strategies in neonates and infants undergoing congenital heart surgery with CPB procedures.
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Affiliation(s)
- Ali Riza Karaci
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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21
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Mulkey SB, Fontenot EE, Imamura M, Yap VL. Therapeutic Hypothermia in a Neonate with Perinatal Asphyxia and Transposition of the Great Arteries. Ther Hypothermia Temp Manag 2011; 1:205-8. [DOI: 10.1089/ther.2011.0016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sarah B. Mulkey
- Section of Pediatric Neurology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eudice E. Fontenot
- Section of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michiaki Imamura
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Vivien L. Yap
- Section of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Abstract
PURPOSE OF REVIEW Advances in cardiac surgical techniques and intensive care have led to improved survival in babies with congenital heart disease (CHD). Although it is true that the majority of children with CHD today survive, many have impaired neurodevelopmental outcome. Although continuing to improve short-term morbidity and mortality are important goals, recent research has focused on defining the impact of CHD on brain development and brain injury in utero. RECENT FINDINGS The impact of CHD on the developing brain of the fetus and infant will be discussed. Neurologic abnormalities detectable prior to surgery will be described and postnatal progression of abnormalities will be highlighted. Potential causes of these findings will be discussed, including altered cerebral blood flow in utero, and brain development and risk for in-utero and postnatal brain injury. Finally, neurologic and developmental outcome after surgical repair of CHD will be reviewed. SUMMARY Neurodevelopmental evaluation preoperatively and postoperatively in CHD patients should be standard practice, not only to identify those with impairments who would benefit from intervention services but also to identify risk factors and strategies to optimize outcome. Fetal management and intervention strategies for specific defects may ultimately play a role in improving in-utero hemodynamics and increasing cerebral oxygen delivery to enhance brain development.
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Brandlistuen RE, Stene-Larsen K, Holmstrøm H, Landolt MA, Eskedal LT, Vollrath ME. Symptoms of communication and social impairment in toddlers with congenital heart defects. Child Care Health Dev 2011; 37:37-43. [PMID: 20825422 DOI: 10.1111/j.1365-2214.2010.01148.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND With the advances in congenital cardiac surgery and medical management, mortality rates for congenital heart defects (CHD) have declined remarkably. As the number of CHD survivors have increased there is a growing focus on developmental morbidity. The objective of the current study is to compare symptoms of communication and social impairment in 18-month-old children with different severity of CHD with those of controls. METHOD We linked prospective data from the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health, with a nationwide medical CHD registry and identified 198 18-month-olds with CHD in a cohort of 47,692. Three groups of CHD were distinguished: mild/moderate (n= 122), severe (n= 54) and CHD with comorbidity (n= 22). Mothers reported on the child's communication and social skills by completing items from the Ages and Stages Questionnaire as part of the Norwegian Mother and Child Cohort Study. RESULTS Children aged 18 months old with CHD differed significantly from controls in levels of symptoms of communication impairment (P≤ 0.0001) and social impairment (P≤ 0.0001). The largest differences were found in children with CHD and comorbidity. Children with severe CHD also showed higher levels of both symptoms of communication and social impairment. Children with mild/moderate CHD showed a small difference only in symptoms of communication impairment. CONCLUSION Children with severe CHD and CHD with comorbidity show more symptoms of communication and social impairment compared with a large cohort at the age of 18 months. It is important to broaden the scope of inquiry to involve communication and social developmental domains.
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Affiliation(s)
- R E Brandlistuen
- Department of Psychosomatics and Health Behavior, Norwegian Institute of Public Health, Nydalen, Oslo, Norway.
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24
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Impact of congenital heart disease on brain development and neurodevelopmental outcome. Int J Pediatr 2010; 2010. [PMID: 20862365 PMCID: PMC2938447 DOI: 10.1155/2010/359390] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 07/08/2010] [Indexed: 11/17/2022] Open
Abstract
Advances in cardiac surgical techniques and perioperative intensive care have led to improved survival in babies with congenital heart disease (CHD). While it is true that the majority of children with CHD today will survive, many will have impaired neurodevelopmental outcome across a wide spectrum of domains. While continuing to improve short-term morbidity and mortality is an important goal, recent and ongoing research has focused on defining the impact of CHD on brain development, minimizing postnatal brain injury, and improving long-term outcomes. This paper will review the impact that CHD has on the developing brain of the fetus and infant. Neurologic abnormalities detectable prior to surgery will be described. Potential etiologies of these findings will be discussed, including altered fetal intrauterine growth, cerebral blood flow and brain development, associated congenital brain abnormalities, and risk for postnatal brain injury. Finally, reported neurodevelopmental outcomes after surgical repair of CHD will be reviewed.
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Snookes SH, Gunn JK, Eldridge BJ, Donath SM, Hunt RW, Galea MP, Shekerdemian L. A systematic review of motor and cognitive outcomes after early surgery for congenital heart disease. Pediatrics 2010; 125:e818-27. [PMID: 20231182 DOI: 10.1542/peds.2009-1959] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
CONTEXT Brain injury is the most common long-term complication of congenital heart disease requiring surgery during infancy. It is clear that the youngest patients undergoing cardiac surgery, primarily neonates and young infants, are at the greatest risk for brain injury. Developmental anomalies sustained early in life have lifelong repercussions. OBJECTIVE We conducted a systematic review to examine longitudinal studies of cognitive and/or motor outcome after cardiac surgery during early infancy. METHODS Electronic searches were performed in Medline, the Cumulative Index to Nursing and Allied Health Literature (Cinahl), and Embase (1998-2008). The search strategy yielded 327 articles, of which 65 were reviewed. Eight cohorts provided prospective data regarding the cognitive and/or motor outcome of infants who had undergone surgery for congenital heart disease before 6 months of age. Two authors, Ms Snookes and Dr Gunn, independently extracted data and presented results according to 3 subgroups for age of follow-up: early development (1 to <3 years); preschool age (3-5 years); and school age (>5 to 17 years). Weighted analysis was undertaken to pool the results of studies when appropriate. RESULTS All of the identified studies reported results of the Bayley Scales of Infant Development for children younger than the age of 3. Outcome data as reported by the Bayley Scales were combined for infants assessed at 1 year of age, revealing a weighted mean Mental Development Index of 90.3 (95% confidence interval: 88.9-91.6) and Psychomotor Development Index of 78.1 (95% confidence interval: 76.4-79.7). Additional analysis was limited by a lack of data at preschool and school age. CONCLUSIONS With this review we identified a limited number of prospective studies that systematically addressed outcome in patients at the highest risk. These studies consistently revealed cognitive and motor delay in children after cardiac surgery during early infancy. Additional investigation is required to ascertain the consequences of such impairment during later childhood and into adult life.
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Affiliation(s)
- Suzanne H Snookes
- Physiotherapy Department, Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia
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Aortenbogenoperation ohne hypothermen Kreislaufstillstand. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2008. [DOI: 10.1007/s00398-008-0666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Long-term outcome of speech and language in children after corrective surgery for cyanotic or acyanotic cardiac defects in infancy. Eur J Paediatr Neurol 2008; 12:378-86. [PMID: 18221897 DOI: 10.1016/j.ejpn.2007.10.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 10/04/2007] [Accepted: 10/13/2007] [Indexed: 11/21/2022]
Abstract
The purpose of this prospective study was to assess whether outcome of speech and language in children 5-10 years after corrective surgery for tetralogy of Fallot (TOF) or ventricular septal defect (VSD) in infancy was influenced by the preoperative condition of hypoxemia or cardiac insufficiency and whether it was associated with perioperative risk factors and neurodevelopmental outcome. A total of 35 unselected children, 19 with TOF and hypoxemia and 16 with VSD and cardiac insufficiency, operated with combined deep hypothermic circulatory arrest and low-flow cardiopulmonary bypass at mean age 0.7+/-0.3 (mean+/-standard deviation) years, underwent, at mean age 7.4+/-1.6 years, standardized evaluation of speech and language functions. Results were compared between subgroups and related to perioperative factors, sociodemographic and neurodevelopmental status. Age at testing, socioeconomic status and history of speech and language development were not different between the subgroups. In contrast, total scores on oral and speech motor control functions (TFS) as well as on oral and speech apraxia (Mayo Test) were significantly reduced (p<0.02 to <0.05), and scores on anatomical oral structures tended to be lower (p<0.09) in the TOF group as compared to the VSD group. No differences were found for auditory word recognition and phonological awareness as assessed by the Auditory Closure subtest of the Illinois Test of Psycholinguistic Abilities and the test of auditory analysis skills, respectively. In all children, higher age at testing and better socioeconomic status were associated with better results in all domains of assessment (p<0.001 to <0.04). Consistent impairments of all oral and speech motor control functions (TFS and Mayo Test) were present in 29% of all children with a mean age of 6.5 years in contrast to 43% with normal performance and a mean age of 8.3 years. On the receptive speech tasks, only 6% scored below the normal range of their age group. TFS subscores were significantly correlated with age, bypass duration and motor function, but not correlated with socioeconomic status, duration of cardiac arrest, intelligence and academic achievement. Children with preoperative hypoxemia due to cyanotic cardiac defects in infancy are at higher risk for dysfunction in speech and language than those with cardiac insufficiency due to acyanotic heart defects. Age at testing, socioeconomic status, and duration of cardiopulmonary bypass influenced test results. Long-term outcome in speech and language functions can be considered as a sensitive indicator of overall child development after cardiac surgery.
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Factors associated with adverse neurodevelopmental outcomes in infants with congenital heart disease. Brain Dev 2008; 30:437-46. [PMID: 18249516 DOI: 10.1016/j.braindev.2007.12.013] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Revised: 12/07/2007] [Accepted: 12/23/2007] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To review reported neurodevelopmental outcome data for patients with congenital heart disease, identify risk factors for adverse neurodevelopmental sequelae and summarize potential neuromonitoring strategies that have been described. METHODS A Medline search was performed utilizing combinations of the keywords congenital heart, cardiac, neurologic, neurodevelopment, neuromonitoring, quality of life, and outcome. All prospective and longitudinal follow-up studies of patients with congenital heart disease were included. Additionally, studies that examined neuroimaging, neuromonitoring, and clinical factors in relation to outcome were examined. Case reports and editorials were excluded. Additional references were retrieved from selected articles if the abstract described an evaluation of neurodevelopmental outcomes and/or predictors of outcome in patients with congenital heart disease. RESULTS Overall, patients with CHD have increased rates of neurodevelopmental impairments, although intelligence appears to be in the normal range. Preoperative risk stratification, intraoperative techniques, postoperative care, and neuromonitoring strategies may all contribute to ultimate long-term neurodevelopmental outcomes in patients with CHD postsurgical repair. CONCLUSIONS As advances in the medical and surgical management improves survival in patients with CHD, increasing knowledge about neurodevelopmental outcomes and the factors that affect them will provide for strategies to optimize long-term outcome in this high-risk population.
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Wernovsky G. Improving neurologic and quality-of-life outcomes in children with congenital heart disease: Past, present, and future. J Thorac Cardiovasc Surg 2008; 135:240-2, 242.e1-2. [DOI: 10.1016/j.jtcvs.2007.07.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 06/26/2007] [Accepted: 07/05/2007] [Indexed: 11/16/2022]
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Miatton M, De Wolf D, François K, Thiery E, Vingerhoets G. Do parental ratings on cognition reflect neuropsychological outcome in congenital heart disease? Acta Paediatr 2008; 97:41-5. [PMID: 18053001 DOI: 10.1111/j.1651-2227.2007.00530.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To describe the parental view of the cognitive skills of their child with a surgically corrected congenital heart disease (CHD) and compare it to objectified cognitive measures in children with CHD 6-12 years postoperatively. METHODS Parents completed a questionnaire on several cognitive functions of their child. Children with CHD and healthy controls (n=86, aged 8 years 8 months +/- 1 year 6 months) underwent an abbreviated IQ-testing and a neurodevelopmental assessment. RESULTS Parents of the children with CHD more frequently indicated lower sustained attention (p<0.05), lower divided attention (p<0.001), more problems with memory and learning skills (p<0.05), and deficient gross motor functioning (p<0.01) compared to the parents of healthy controls. Intellectual and neuropsychological assessment revealed a lower estimated full-scale IQ (p<0.01), worse sensorimotor functioning (p<0.001), and lower performances on language (p<0.001), attention/executive functioning (p<0.05), and memory (p<0.05) in the CHD-group. Several items of the questionnaire were significant predictors for worse neurodevelopmental outcome. CONCLUSION Overall, the objective and subjective measures on cognitive functioning are in agreement and indicate the presence of neurocognitive deficits in children with CHD. This study endorses the accuracy and usefulness of a parental questionnaire to report on the cognitive functioning of the child and urges the investigation of neurocognitive functioning in children with CHD at follow-up.
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Affiliation(s)
- Marijke Miatton
- Laboratory for Neuropsychology, Department of Internal Medicine, Ghent University, Ghent, Belgium.
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Miatton M, De Wolf D, François K, Thiery E, Vingerhoets G. Neuropsychological performance in school-aged children with surgically corrected congenital heart disease. J Pediatr 2007; 151:73-8, 78.e1. [PMID: 17586194 DOI: 10.1016/j.jpeds.2007.02.020] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Revised: 12/21/2006] [Accepted: 02/05/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE As surgical management of children with congenital heart disease (CHD) advanced, developmental outcome became the main focus of contemporary research. In this study, we specify the cognitive profile of children with CHD, 6 to 12 years postoperatively. STUDY DESIGN Patients with CHD (n = 43, mean age 8 years, 8 months) and healthy controls (n = 43, mean age 8 years, 11 months), were examined with an abbreviated intelligence scale (Wechsler Intelligence Scale for Children-3rd edition, Dutch version) and a developmental neuropsychological assessment battery (NEPSY [a developmental NEuroPSYchological assessment]). RESULTS We identified significantly lower scores for the CHD group on Estimated Full Scale IQ (P < .01). Neuropsychological assessment revealed lower scores for the CHD group on the cognitive domains of Sensorimotor Functioning (P < .001), Language (P < .001), Attention and Executive Functioning (P < .05), and Memory (P < .05). Children with CHD displayed more impulsive test behavior than healthy peers. No differences on IQ or cognitive domains were found between the cyanotic and the acyanotic CHD group. CONCLUSIONS Six to 12 years postoperatively, children with CHD display a neuropsychological profile with mainly mild motor deficits and subtle difficulties with language tasks. Attention/executive functioning and memory also appear involved but to a lesser degree. Long-term follow-up of children with surgically corrected CHD, even when hemodynamically successful, is warranted, as they are at risk for neurodevelopmental delay at school age.
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Affiliation(s)
- Marijke Miatton
- Laboratory for Neuropsychology, Department of Internal Medicine, Ghent University, Ghent, Belgium.
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Miatton M, De Wolf D, François K, Thiery E, Vingerhoets G. Neurocognitive consequences of surgically corrected congenital heart defects: A review. Neuropsychol Rev 2006; 16:65-85. [PMID: 16960756 DOI: 10.1007/s11065-006-9005-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Accepted: 03/31/2006] [Indexed: 10/24/2022]
Abstract
With advances in surgical procedures, neuropsychological assessment after congenital heart defects and pre, peri- and/or postoperative predictors of adverse outcome has become an important focus in research. We aim to summarize neuropsychological sequelae associated with different types of congenital heart defects, critically review the methodology used in more than 20 empirical studies that were retrieved from biomedical electronic search engines, and identify possible directions for future research. Despite the lack of adequate control groups and long-term studies, there seem to be some cognitive deficits. The largest group of children with isolated congenital heart defects present with normal intellectual capacities. However, they tend to show language deficits and motor dysfunction. Although performances on memory tasks are good, unambiguous conclusions concerning their attentional and executive functioning are still lacking. Serious behavioral problems are not an issue. In addition to a detailed description of the (neuro) psychological consequences of pediatric cardiac surgery, an overview of the predictors of the cognitive defects is provided.
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Affiliation(s)
- M Miatton
- Laboratory for Neuropsychology, Department of Internal Medicine, Ghent University, De Pintelaan 185, 4 K 3, B-9000, Ghent, Belgium.
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Park IS, Yoon SY, Min JY, Kim YH, Ko JK, Kim KS, Seo DM, Lee JH. Metabolic alterations and neurodevelopmental outcome of infants with transposition of the great arteries. Pediatr Cardiol 2006; 27:569-76. [PMID: 16897317 DOI: 10.1007/s00246-004-0730-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2003] [Accepted: 09/28/2004] [Indexed: 01/08/2023]
Abstract
Abnormal neurodevelopment has been reported for infants who were born with transposition of the great arteries (TGA) and underwent arterial switch operation (ASO). This study evaluates the cerebral metabolism of TGA infants at birth and before ASO and neurodevelopment 1 year after ASO. Proton magnetic resonance spectroscopy (1H-MRS) was performed on 16 full-term TGA brains before ASO within 3-6 days after birth. The brain metabolite ratios of [NAA/Cr], [Cho/Cr], and [mI/Cr] evaluated measured. Ten infants were evaluated at 1 year using the Bayley Scales of Infants Development II (BSED II). Cerebral metabolism of infants with TGA was altered in parietal white matter (PWM) and occipital gray matter (OGM) at birth before ASO. One year after ASO, [Cho/Cr] in PWM remained altered, but all metabolic ratios in OGM were normal. The results of BSID II at 1 year showed delayed mental and psychomotor development. This delayed neurodevelopmental outcome may reflect consequences of the altered cerebral metabolism in PWM measured by 1H-MRS. It is speculated that the abnormal hemodynamics due to TGA in utero may be responsible for the impaired cerebral metabolism and the subsequent neurodevelopmental deficit.
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Affiliation(s)
- I Sook Park
- Division of Pediatric Cardiology, Asan Medical Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Korea
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Hashmi SF, Hanif M, O'Reilly K. Electrographic seizure after neonatal and infant cardiac surgery. J Thorac Cardiovasc Surg 2006; 132:441; author reply 441-2. [PMID: 16872984 DOI: 10.1016/j.jtcvs.2006.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Accepted: 03/15/2006] [Indexed: 11/15/2022]
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Abstract
Cardiac disease is the most common congenital defect in children, affecting between 3 and 10 in every 1000 live births. While significant advances in medical and surgical management have resulted in increasing numbers of survivors, it is also recognized that there is a growing population of children living with neurological impairment and lowered intellectual function. The aetiology of such impairment is multi-factorial and hypoxia is one of the factors involved. This article provides an overview of the effects of hypoxia on the intellectual development of infants, children and adolescents with congenital heart disease.
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Affiliation(s)
- Jo Wray
- Department of Paediatrics, Royal Brompton and Harefield NHS Trust, UK.
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Hövels-Gürich HH, Konrad K, Skorzenski D, Nacken C, Minkenberg R, Messmer BJ, Seghaye MC. Long-Term Neurodevelopmental Outcome and Exercise Capacity After Corrective Surgery for Tetralogy of Fallot or Ventricular Septal Defect in Infancy. Ann Thorac Surg 2006; 81:958-66. [PMID: 16488701 DOI: 10.1016/j.athoracsur.2005.09.010] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Revised: 09/02/2005] [Accepted: 09/06/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this prospective study was to assess whether neurodevelopmental status and exercise capacity of children 5 to 10 years after corrective surgery for tetralogy of Fallot or ventricular septal defect in infancy was different compared with normal children and influenced by the preoperative condition of hypoxemia or cardiac insufficiency. METHODS Forty unselected children, 20 with tetralogy of Fallot and hypoxemia and 20 with ventricular septal defect and cardiac insufficiency, operated on with combined deep hypothermic circulatory arrest and low flow cardiopulmonary bypass at a mean age of 0.7 +/- 0.3 years (mean +/- SD), underwent, at mean age 7.4 +/- 1.6 years, standardized evaluation of neurologic status, gross motor function, intelligence, academic achievement, language, and exercise capacity. Results were compared between the groups and related to preoperative, perioperative, and postoperative status and management. RESULTS Rate of mild neurologic dysfunction was increased compared with normal children, but not different between the groups. Exercise capacity and socioeconomic status were not different compared with normal children and between the groups. Compared with the normal population, motor function, formal intelligence, academic achievement, and expressive and receptive language were significantly reduced (p < 0.01 to p < 0.001) in the whole group and in the subgroups, except for normal intelligence in ventricular septal defect patients. Motor dysfunction was significantly higher in the Fallot group compared with the ventricular septal defect group (p < 0.01) and correlated with neurologic dysfunction, lower intelligence, and reduced expressive language (p < 0.05 each). Reduced New York Heart Association functional class was correlated with lower exercise capacity and longer duration of cardiopulmonary bypass (p < 0.05 each). Reduced socioeconomic status significantly influenced dysfunction in formal intelligence (p < 0.01) and academic achievement (p < 0.05). Preoperative risk factors such as prenatal hypoxia, perinatal asphyxia, and preterm birth, factors of perioperative management such as cardiac arrest, lowest nasopharyngeal temperature, and age at surgery, and postoperative risk factors as postoperative cardiocirculatory insufficiency and duration of mechanical ventilation were not different between the groups and had no influence on outcome. Degree of hypoxemia in Fallot patients and degree of cardiac insufficiency in ventricular septal defect patients did not influence the outcome within the subgroups. CONCLUSIONS Children with preoperative hypoxemia in infancy are at higher risk for motor dysfunction than children with cardiac insufficiency. Corrective surgery in infancy for tetralogy of Fallot or ventricular septal defect with combined circulatory arrest and low flow bypass is associated with reduced neurodevelopmental outcome, but not with reduced exercise capacity in childhood. In our experience, the general risk of long-term neurodevelopmental impairment is related to unfavorable effects of the global perioperative management. Socioeconomic status influences cognitive capabilities.
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Majnemer A, Limperopoulos C, Shevell M, Rosenblatt B, Rohlicek C, Tchervenkov C. Long-term neuromotor outcome at school entry of infants with congenital heart defects requiring open-heart surgery. J Pediatr 2006; 148:72-7. [PMID: 16423601 DOI: 10.1016/j.jpeds.2005.08.036] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2005] [Revised: 06/30/2005] [Accepted: 08/10/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Increased survival in infants with complex congenital heart defects (CHDs) has resulted in greater focus on morbidity. This prospective study was conducted to investigate whether or not neuromotor impairments evident acutely persist long-term. STUDY DESIGN A total of 94 infants with CHD were reassessed at school entry (age 64.2 +/- 11.3 months) by blinded examiners using the Peabody Developmental Motor Scale and neurologic examination. RESULTS Neurologic abnormalities were noted in 28.4% of the subjects, with hypotonia and developmental delay most commonly observed. Microcephaly was documented in 15.4% of subjects, with head circumference >50th percentile in only 14.1%. Mean gross and fine motor quotients were shifted downward (82.7 +/- 12.3 and 86.2 +/- 16.3, respectively), and gross and fine motor delays were prevalent (49.4% and 39.0%, respectively). Severe disability was rare (<5%). Predictors of neurologic impairment included type of surgery (palliative/corrective), abnormal postoperative neurologic examination, and presence of microcephaly at initial surgery. Gross motor delay was more likely if palliated. Deep hypothermic circulatory arrest time, palliative surgery, microcephaly, and number of hospitalizations were associated with fine motor delay. CONCLUSIONS Neurologic impairments and motor delay are common in survivors of open-heart surgery, persisting to age of school entry. Early indicators of medical complications and acute neurologic compromise are associated with increased risk. Early identification and intervention may optimize performance in those at risk.
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Affiliation(s)
- Annette Majnemer
- School of Physical & Occupational Therapy, Department of Neurology & Neurosurgery, McGill University, Toronto, Ontario, Canada.
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Robertson DR, Justo RN, Burke CJ, Pohlner PG, Graham PL, Colditz PB. Perioperative predictors of developmental outcome following cardiac surgery in infancy. Cardiol Young 2004; 14:389-95. [PMID: 15680045 DOI: 10.1017/s104795110400407x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
At 1 year we assessed the neurodevelopmental outcomes in infants undergoing cardiac surgery, seeking to explore the predictive value of perioperative markers of cerebral injury. We prospectively enrolled 47 neurodevelopmentally normal infants prior to planned cardiac surgery. Postoperative monitoring consisted of 10-channel video synchronised, continuous electroencephalography from 6 to 30 h, Doppler assessment of cerebral blood flow in the anterior cerebral artery at 1, 2, 3 and 5 h, and measurement of serum S-100B at 0 and 24 h. Neurodevelopmental assessments were performed using the second edition of the Bayley Scale of Infant Development. Follow-up at 1 year was available on 35 infants. The mean age of these patients at surgery had been 57 +/- 15 days. We observed clinical seizures in 1 patient, with 3 other patients having electroencephalographic abnormalities. At follow-up of 1 year, neurodevelopmental scores were lower than preoperative scores, with mean mental scores changing from 103 +/- 5 to 94 +/- 13 (p = 0.001), and mean motor scores changing from 99 +/- 8 to 89 +/- 20 (p = 0.004). No association was found between electroencephalographic abnormalities, reduced cerebral blood flow, or elevation of serum S-100B levels and impaired neurodevelopmental outcome at 1 year. Infants with electroencephalographic abnormalities had elevation of the levels of S-100B in the serum (p = 0.02). At 1 year of follow-up, infants undergoing cardiac surgery demonstrated a reduction in the scores achieved using the second edition of the Bayley Scale of Infant Development. They require ongoing assessment of their progress. Electroencephalographic abnormalities, cerebral blood flow, or levels of S-100B in the serum were not useful perioperative markers for predicting a poor neurodevelopmental outcome in the clinical setting.
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Affiliation(s)
- Daphene R Robertson
- Perinatal Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Dibardino DJ, Allison AE, Vaughn WK, McKenzie ED, Fraser CD. Current expectations for newborns undergoing the arterial switch operation. Ann Surg 2004; 239:588-96; discussion 596-8. [PMID: 15082962 PMCID: PMC1356266 DOI: 10.1097/01.sla.0000124293.52814.a7] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The arterial switch operation (ASO) represents a remarkable success story in the surgical treatment of cyanotic congenital heart disease. This study is designed to assess recent outcomes after the ASO in babies presenting with transposition of the great arteries (TGA) and Taussig-Bing anomaly (TBA). METHODS One hundred twenty-five consecutive neonatal and infant ASOs were performed by 2 surgeons at Texas Children's Hospital between July 1, 1995 and October 1, 2003. Patients with TGA and TBA were offered ASO irrespective of patient size and associated cardiac malformations. Primary cardiac diagnoses included TGA with intact ventricular septum (TGA/IVS, n = 79, 63%), TGA with ventricular septal defect (TGA/VSD, n = 37, 30%), and Taussig Bing Anomaly (TBA, n = 9, 7%). RESULTS With complete follow-up, we observed a 30-day mortality rate of 1.6% (n = 2) with 2 late deaths (1.6%), for an overall actuarial survival rate of 96.3% at 7 years. Although there was a significant incidence of complex coronary ostial origin and branching including single coronary (n = 8, 6.4%) and intramural coronary artery (n = 8, 6.4%), this was not associated with increased operative risk. All patients are fully saturated and NYHA functional class I at latest clinic visit (0.3 to 88.4 months postoperatively). There have been no late coronary events. Of 121 survivors, 7 patients (5.8%) have required cardiovascular reoperation at an average of 15.3 +/-11.7 months postoperatively (range, 3.6 to 30.6 months) for an actuarial freedom from reoperation of 90% at 7 years. CONCLUSIONS Using current methodologies, the ASO can be performed safely and with a low incidence of need for reoperation on intermediate follow-up. Recent experience indicates operative survival rates approaching 100%.
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Affiliation(s)
- Daniel J Dibardino
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA
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Wernovsky G, Newburger J. Neurologic and developmental morbidity in children with complex congenital heart disease. J Pediatr 2003; 142:6-8. [PMID: 12520246 DOI: 10.1067/mpd.2003.mpd0354] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Hövels-Gürich HH, Konrad K, Wiesner M, Minkenberg R, Herpertz-Dahlmann B, Messmer BJ, Von Bernuth G. Long term behavioural outcome after neonatal arterial switch operation for transposition of the great arteries. Arch Dis Child 2002; 87:506-10. [PMID: 12456550 PMCID: PMC1755850 DOI: 10.1136/adc.87.6.506] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To evaluate behavioural outcome and quality of life in children aged 8-14 years after neonatal arterial switch operation for transposition of the great arteries. METHODS Sixty children operated as neonates with combined deep hypothermic circulatory arrest and low flow cardiopulmonary bypass were evaluated at age 7.9-14.3 years by the Child Behaviour Checklist (CBCL) and the Inventory for the Assessment of the Quality of Life in Children and Adolescents (IQCL). RESULTS Parent reported behavioural outcome on all CBCL problem and competence scores was worse, whereas quality of life on self reported IQCL scores was not reduced compared to the normal population. On multivariate analysis, severe preoperative hypoxia was related to parent reported social problems; peri- and postoperative cardiocirculatory insufficiency was associated with internalizing, externalizing, attention, and total behavioural problems. Reduced expressive language was associated with total behavioural problems, and poor academic achievement was related to parent reported deficits in school performance. Impaired neurological status and reduced endurance capacity both predicted self reported stress by illness. CONCLUSIONS The neonatal arterial switch operation with combined circulatory arrest and low flow bypass is associated with parent reported long term behavioural impairment, but not with self reported general reduction in quality of life. This discrepancy may be a result of different perception of illness. In our experience, increased risk of long term psychosocial maladjustment after neonatal corrective cardiac surgery is related to the presence of neurological impairment and reduced endurance capacity.
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Affiliation(s)
- H H Hövels-Gürich
- Department of Paediatric Cardiology, Aachen University of Technology, Pauwelsstr. 30, D-52057 Aachen, Germany.
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Hövels-Gürich HH, Seghaye MC, Schnitker R, Wiesner M, Huber W, Minkenberg R, Kotlarek F, Messmer BJ, Von Bernuth G. Long-term neurodevelopmental outcomes in school-aged children after neonatal arterial switch operation. J Thorac Cardiovasc Surg 2002; 124:448-58. [PMID: 12202860 DOI: 10.1067/mtc.2002.122307] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Neurodevelopmental status of children between 8 and 14 years of age after neonatal arterial switch operation for transposition of the great arteries has not previously been systematically evaluated. METHODS Within a longitudinal study, 60 unselected children operated on as neonates with combined deep hypothermic circulatory arrest and low-flow cardiopulmonary bypass were reevaluated at the age of 7.9 to 14.3 years (mean +/- SD 10.5 +/- 1.6 years). Clinical neurologic status and standardized tests to assess gross motor function, intelligence, acquired abilities, language, and speech were carried out, and the results were related to preoperative, perioperative, and postoperative status, to management, and to neurodevelopmental status at a mean age of 5.4 years. RESULTS Neurologic and speech impairments were evidently more frequent (27% and 40%, respectively) than in the general population. Intelligence and socioeconomic status were not different (P =.29 and P =.11), whereas motor function, acquired abilities, and language were reduced (P < or =.04 for each). Overall rate of developmental impairment in one or more domains was 55%, compared with 26% at age 5.4 years. Multivariable analysis showed that severe preoperative acidosis and hypoxia predicted reduced motor function (mean deficit 52.7 points, P <.001), whereas longer bypass duration predicted both neurologic (odds ratio per 10 minutes of bypass duration 1.8, P =.04) and speech (odds ratio per 10 minutes of bypass duration 1.9, P =.02) dysfunction, and perioperative and postoperative cardiocirculatory insufficiency predicted neurologic (odds ratio 6.5, P =.04) and motor (mean deficit 6.8 points, P =.03) dysfunction. CONCLUSIONS The neonatal arterial switch operation with combined circulatory arrest and low-flow bypass is associated increasingly with age, with reduced neurodevelopmental outcome but not with cognitive dysfunction. In our experience, the risk of long-term neurodevelopmental impairment after neonatal corrective cardiac surgery is related to deleterious effects of the global perioperative management and to special adverse effects of prolonged bypass duration. Severe preoperative acidosis and hypoxia and postoperative hemodynamic instability must be considered as important additional risk factors.
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Affiliation(s)
- Hedwig H Hövels-Gürich
- Departments of Pediatric Cardiology, Aachen University of Technology, and the Institute for Medical Research and Information Processing, Repges & Partner, Aachen, Germany.
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Sigler M, Vazquez-Jimenez JF, Grabitz RG, Hövels-Gürich HH, Messmer BJ, von Bernuth G, Seghaye MC. Time course of cranial ultrasound abnormalities after arterial switch operation in neonates. Ann Thorac Surg 2001; 71:877-80. [PMID: 11269468 DOI: 10.1016/s0003-4975(00)02329-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The object of this study was to investigate the time course and fate of abnormal findings in cranial ultrasound after performing an arterial switch operation in neonates with transposition of the great arteries, and to analyze the relationship to cerebral cell damage. METHODS Cranial ultrasound was performed prospectively in 35 neonates with transposition of the great arteries before the operation as well as 4 hours, 1, 2, and 3 days, and 1 and 2 weeks postoperatively. Blood levels of neuron-specific enolase, a marker of cerebral cell damage, were determined before, during, and 4 and 24 hours postoperatively. RESULTS In 17 of 35 neonates (49%), early postoperative cranial ultrasound revealed abnormalities indistinguishable from intraventricular hemorrhage. In 11 neonates findings were transient and were normalized 2 weeks postoperatively, whereas in the remaining 6 neonates there was evidence of resolving hemorrhage. In all neonates there was a rise in neuron-specific enolase blood concentrations during and 4 hours after extracorporal circulation without correlation to sonographic findings. CONCLUSIONS Enhanced echogenicity of the choroid plexus or dilatation of the cerebral ventricular system is a frequent early postoperative finding that may be caused by transient plexus edema rather than intraventricular hemorrhage and is not related to cerebral cell damage.
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Affiliation(s)
- M Sigler
- Department of Pediatric Cardiology, Aachen University of Technology, Germany.
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