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Lee FT, Sun L, Szabo A, Milligan N, Saini A, Chetan D, Hunt JL, Macgowan CK, Freud L, Jaeggi E, Van Mieghem T, Kingdom J, Miller SP, Seed M. Safety and feasibility pilot study of continuous low-dose maternal supplemental oxygen in fetal single ventricle heart disease. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:493-503. [PMID: 38629477 DOI: 10.1002/uog.27657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/12/2024] [Accepted: 03/16/2024] [Indexed: 10/02/2024]
Abstract
OBJECTIVE Fetuses with single ventricle physiology (SVP) exhibit reductions in fetal cerebral oxygenation, with associated delays in fetal brain growth and neurodevelopmental outcomes. Maternal supplemental oxygen (MSO) has been proposed to improve fetal brain growth, but current evidence on dosing, candidacy and outcomes is limited. In this pilot study, we evaluated the safety and feasibility of continuous low-dose MSO in the setting of SVP. METHODS This single-center, open-label, pilot phase-1 safety and feasibility clinical trial included 25 pregnant individuals with a diagnosis of fetal SVP. Participants self-administered continuous MSO using medical-grade oxygen concentrators for up to 24 h per day from the second half of gestation until delivery. The primary aim was the evaluation of the safety profile and feasibility of MSO. A secondary preliminary analysis was performed to assess the impact of MSO on the fetal circulation using echocardiography and late-gestation cardiovascular magnetic resonance imaging. Early outcomes were assessed, including perinatal growth and preoperative brain injury, and neurodevelopmental outcomes were assessed at 18 months using the Bayley Scales of Infant and Toddler Development 3rd edition, and compared with those of a contemporary fetal SVP cohort (n = 217) that received the normal standard of care (SOC). RESULTS Among the 25 participants, the median maternal age at conception was 35 years, and fetal SVP diagnoses included 16 with right ventricle dominant, eight with left ventricle dominant and one with indeterminate ventricular morphology. Participants started the trial at approximately 29 + 2 weeks' gestation and self-administered MSO for a median of 16.1 h per day for 63 days, accumulating a median of 1029 h of oxygen intake from enrolment until delivery. The only treatment-associated adverse events were nasal complications that were resolved typically by attaching a humidifier unit to the oxygen concentrator. No premature closure of the ductus arteriosus or unexpected fetal demise was observed. In the secondary analysis, MSO was not associated with any changes in fetal growth, middle cerebral artery pulsatility index, cerebroplacental ratio or head-circumference-to-abdominal-circumference ratio Z-scores over gestation compared with SOC. Although MSO was associated with changes in umbilical artery pulsatility index Z-score over the study period compared with SOC (P = 0.02), this was probably due to initial baseline differences in placental resistance. At late-gestation cardiovascular magnetic resonance imaging, MSO was not associated with an increase in fetal cerebral oxygen delivery. Similarly, no differences were observed in neonatal outcomes, including preoperative brain weight Z-score and brain injury, mortality by 18 months of age and neurodevelopmental outcomes at 18 months of age. CONCLUSIONS This pilot phase-1 clinical trial indicates that low-dose MSO therapy is safe and well tolerated in pregnancies diagnosed with fetal SVP. However, our protocol was not associated with an increase in fetal cerebral oxygen delivery or improvements in early neurological or neurodevelopmental outcomes. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F-T Lee
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - L Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - A Szabo
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - N Milligan
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - A Saini
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - D Chetan
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - C K Macgowan
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
- Department of Medical Biophysics, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - L Freud
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - E Jaeggi
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - T Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - J Kingdom
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - S P Miller
- Department of Pediatrics, BC Children's Hospital and University of British Columbia, Vancouver, Canada
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - M Seed
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Hu L, Wu K, Li H, Zhu M, Zhang Y, Fu M, Tang M, Lu F, Cai X, An J, Patel N, Lin Y, Zhang Z, Yang M, Mo X. Association between subcortical nuclei volume changes and cognition in preschool-aged children with tetralogy of Fallot after corrective surgery: a cross-sectional study. Ital J Pediatr 2024; 50:189. [PMID: 39300569 DOI: 10.1186/s13052-024-01764-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 09/08/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Neurocognitive disorders frequently occur in patients with cyanotic congenital heart disease (CCHD) because of the hemodynamic abnormalities induced by preoperative cardiac structural changes. We aimed to evaluate subcortical nuclei volume changes and cognition in postoperative tetralogy of Fallot (TOF) children, and analyze their relationship with preoperative cardiac structural changes. METHODS This case-control study involved thirty-six children with repaired TOF and twenty-nine healthy controls (HCs). We utilized three-dimensional (3D) T1-weighted high-resolution structural images alongside the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition (WPPSI-IV) to evaluate the cognitive differences between the TOF and HC group. RESULTS We observed notable differences in subcortical nuclei volume between the TOF and HC group, specifically in the left amygdala nucleus (LAM, TOF: 1292.60 ± 155.57; HC: 1436.27 ± 140.62, p < 0.001), left thalamus proper nucleus (LTHA, TOF: 6771.54 ± 666.03; HC: 7435.36 ± 532.84, p < 0.001), and right thalamus proper nucleus (RTHA, TOF: 6514.61 ± 715.23; HC: 7162.94 ± 554.60, p < 0.001). Furthermore, a diminished integrity of LAM ( β:-19.828, 95% CI: -36.462, -3.193), which showed an inverse relationship with the size of the preoperative ventricular septal defect (VSD), correlated with lower working memory indices in children with TOF. CONCLUSIONS Our findings indicate that subcortical nuclei structural injuries possibly potentially stemming from cardiac anatomical abnormalities, are associated with impaired working memory in preschool-aged children with TOF. The LAM in particular may serve as a potential biomarker for neurocognitive deficits in TOF, offering predictive value for future neurodevelopmental outcomes, and shedding light on the neurophysiological mechanisms of these cognitive impairments.
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Affiliation(s)
- Liang Hu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Kede Wu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Huijun Li
- Department of Radiology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Meijiao Zhu
- Department of Radiology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Yaqi Zhang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Mingcui Fu
- Department of Radiology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Minghui Tang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Fan Lu
- Department of Radiology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Xinyu Cai
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Jia An
- Medical School of Nanjing University, Nanjing, 210093, China
| | - Nishant Patel
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Ye Lin
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Zhen Zhang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China
| | - Ming Yang
- Department of Radiology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.
- Medical School of Nanjing University, Nanjing, 210093, China.
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Cucerea M, Ognean ML, Pinzariu AC, Simon M, Suciu LM, Ghiga DV, Moldovan E, Moscalu M. Effects of Prostaglandin E1 and Balloon Atrial Septostomy on Cerebral Blood Flow and Oxygenation in Newborns Diagnosed with Transposition of the Great Arteries. Biomedicines 2024; 12:2018. [PMID: 39335532 PMCID: PMC11428714 DOI: 10.3390/biomedicines12092018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Revised: 08/30/2024] [Accepted: 08/31/2024] [Indexed: 09/30/2024] Open
Abstract
Dextro-transposition of the great arteries (D-TGA) is a critical congenital heart defect that can impact neurodevelopment due to cerebral perfusion and oxygenation disorders followed by alterations in synaptogenesis, gyrification, sulcation, and the microstructure. Brain injuries can occur both pre-operatively and postoperatively, especially white matter injuries, neuronal loss, and stroke. Materials and Methods: In a retrospective study conducted at a tertiary center between 2016 and 2023, we investigated the early effects of Prostaglandin E1 (PGE1) administration and balloon atrial septostomy (BAS) on cerebral blood flow and oxygenation in inborn neonates with D-TGA. Cerebral Doppler Ultrasound in the anterior cerebral artery (ACA) was performed to assess the resistive index (RI), Peak Systolic Velocity (PSV), and End-Diastolic Velocity (EVD) before PGE1, before the BAS procedure, and 24 h after birth. Cerebral regional saturations of oxygen (crSO2) and cerebral fractional tissue oxygen extraction (cFTOE) were evaluated. D-TGA patients were divided into the PGE1 group and the PGE1 + BAS group. Age-matched healthy controls were used for comparison. Results: All 83 D-TGA newborns received PGE1 within two hours after delivery, of whom 46 (55.42%) underwent BAS. In addition, 77 newborns composed the control group. PGE1 administration increased crSO2 from 47% to 50% in the PGE1 group, but lower than in controls at 24 h of life, while cFTOE remained elevated. The RI increased 24 h after delivery (0.718 vs. 0.769; p = 0.000002) due to decreased EDV (10.71 vs. 8.74; p < 0.0001) following PGE1 treatment. The BAS procedure resulted in a significant increase in crSO2 from 42% to 51% at 24 h of life in the PGE1 + BAS group. Doppler parameters exhibited a similar trend as observed in the PGE1 group. Conclusions: PGE1 treatment and BAS are lifesaving interventions that may improve cerebral perfusion and oxygenation in newborns with D-TGA during the transition period, as reflected by increasing SpO2 and crSO2.
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Affiliation(s)
- Manuela Cucerea
- Neonatology Department, GEP University of Medicine Pharmacy, Science and Technology of Targu Mures, 540142 Târgu Mureș, Romania
| | - Maria-Livia Ognean
- Dental Medicine and Nursing Department, Faculty of Medicine, Lucian Blaga University of Sibiu, 550169 Sibiu, Romania
| | - Alin-Constantin Pinzariu
- Department of Morpho-Functional Sciences II, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Marta Simon
- Neonatology Department, GEP University of Medicine Pharmacy, Science and Technology of Targu Mures, 540142 Târgu Mureș, Romania
| | - Laura Mihaela Suciu
- Neonatology Department, GEP University of Medicine Pharmacy, Science and Technology of Targu Mures, 540142 Târgu Mureș, Romania
| | - Dana-Valentina Ghiga
- Faculty of Dental Medicine, GEP University of Medicine Pharmacy, Science and Technology of Targu Mures, 540139 Târgu Mureș, Romania
| | - Elena Moldovan
- Pediatric Intensive Care Unit, Cardiovascular and Transplant Emergency Institute, 540136 Târgu Mureș, Romania
| | - Mihaela Moscalu
- Department of Preventive Medicine and Interdisciplinarity, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
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Zhao L, Zhu D, Wang X, Liu X, Li T, Wang B, Yao Z, Zheng W, Hu B. An Attention-Based Hemispheric Relation Inference Network for Perinatal Brain Age Prediction. IEEE J Biomed Health Inform 2024; 28:4483-4493. [PMID: 38857141 DOI: 10.1109/jbhi.2024.3411620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Brain anatomical age is an effective feature to assess the status of the brain, such as atypical development and aging. Although some deep learning models have been developed for estimating infant brain age, the performance of these models was unsatisfactory because few of them considered the developmental characteristics of brain anatomy during the perinatal period-the most rapid and complex developmental stage across the lifespan. The present study proposed an attention-based hemispheric relation inference network (HRINet) that takes advantage of the nature of brain structural lateralization during early development. This model captures the inter-hemispheric relationship using a graph attention mechanism and transmits lateralization information as features to describe the interactive development between bilateral hemispheres. The HRINet was used to estimate the brain age of 531 preterm and full-term neonates from the Developing Human Connectome Project (dHCP) database based on two metrics (mean curvature and sulcal depth) characterizing the folding morphology of the cortex. Our results showed that the HRINet outperformed other benchmark models in fitting the perinatal brain age, with mean absolute error of 0.53 and determination coefficient of 0.89. We also verified the generalizability of the HRINet on an extra independent dataset collected from the Gansu Provincial Maternity and Child-care Hospital. Furthermore, by applying the best-performing model to an independent dataset consisting of 47 scans of preterm infants at term-equivalent age, we showed that the predicted age was significantly lower than the chronological age, suggesting a delayed development of premature brains. Our results demonstrate the effectiveness and generalizability of the HRINet in estimating infant brain age, providing promising clinical applications for assessing neonatal brain maturity.
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Starr JP, Karamlou T, Steele A, Artis AS, Rajeswaran J, Salim Hammoud M, Gates RN. Temperature and Neurologic Outcomes in Neonates Undergoing Cardiac Surgery: A Society of Thoracic Surgeons Study. J Am Coll Cardiol 2024; 84:450-463. [PMID: 39048277 DOI: 10.1016/j.jacc.2024.04.059] [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] [Received: 03/08/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND There is significant variability in postoperative neurological injury rates in patients with congenital heart disease, with early injuries impacting long-term neurodevelopmental outcomes; therefore, there is an urgent need for identifying effective strategies to mitigate such injuries. OBJECTIVES This study aims to assess the association between nadir intraoperative temperature (NIT) and early neurological outcomes in neonates undergoing congenital heart surgery. METHODS Analyzing data from 24,345 neonatal cardiac operations from the Society for Thoracic Surgeons Congenital Heart Surgery Database between 2010 and 2019, NIT was assessed using a mixed-effect logistic regression model, targeting major neurological injury (stroke, seizure, or deficit at discharge) as a primary endpoint. RESULTS The study observed a shift from hypothermic circulatory arrest to cerebral perfusion with an increase in mean nadir temperature from 23.9 °C to 25.6 °C (P < 0.0001). Major neurological injury was noted in 4.9% of the cohort, with variations based on surgical procedure. After adjusting for risk, NIT was not significantly associated with major neurological injuries overall, but a lower NIT showed protective effects in the Norwood subgroup. Factors increasing the risk of major neurological injury included younger age at surgery, the Norwood procedure, longer cardiopulmonary bypass times, younger gestational age, presence of noncardiac abnormalities, and chromosomal anomalies. CONCLUSIONS Whereas neurological injuries are prevalent after neonatal cardiac surgery, current practices lean towards higher core temperatures. This trend is supported by the nonsignificant impact of NIT on neurological outcomes. However, lower NIT in the Norwood subgroup indicates that reduced temperatures may be beneficial amidst specific risk factors.
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Affiliation(s)
- Joanne P Starr
- Department of Surgery, Division of Cardiothoracic Surgery, CHOC Children's Hospital of Orange County, Orange, California, USA.
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Allison Steele
- Department of Quality Risk, CHOC Children's Hospital of Orange County, Orange, California, USA
| | - Amanda S Artis
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Miza Salim Hammoud
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard N Gates
- Department of Surgery, Division of Cardiothoracic Surgery, CHOC Children's Hospital of Orange County, Orange, California, USA
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Pike NA, Roy B, Cabrera-Mino C, Halnon NJ, Lewis AB, Shao X, Wang DJJ, Kumar R. Compromised Cerebral Arterial Perfusion, Altered Brain Tissue Integrity, and Cognitive Impairment in Adolescents with Complex Congenital Heart Disease. J Cardiovasc Dev Dis 2024; 11:236. [PMID: 39195144 PMCID: PMC11354402 DOI: 10.3390/jcdd11080236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/21/2024] [Accepted: 07/25/2024] [Indexed: 08/29/2024] Open
Abstract
(1) Introduction: Adolescents with complex congenital heart disease (CCHD) show brain tissue injuries in regions associated with cognitive deficits. Alteration in cerebral arterial perfusion (CAP), as measured by arterial transit time (ATT), may lead to perfusion deficits and potential injury. Our study aims to compare ATT values between CCHD patients and controls and assess the associations between ATT values, MD values, and cognitive scores in adolescents with CCHD. (2) Methods: 37 CCHD subjects, 14-18 years of age, who had undergone surgical palliation and 30 healthy controls completed cognitive testing and brain MRI assessments using a 3.0-Tesla scanner. ATT values and regional brain mean diffusivity [MD] were assessed for the whole brain using diffusion tensor imaging. (3) Results: The mean MoCA values [23.1 ± 4.1 vs. 28.1 ± 2.3; p < 0.001] and General Memory Index, with a subscore of WRAML2 [86.8 ± 15.4 vs. 110.3 ± 14.5; p < 0.001], showed significant cognitive deficits in CCHD patients compared to controls. The mean global ATT was significantly higher in CCHD patients versus controls (mean ± SD, s, 1.26 ± 0.11 vs. 1.19 ± 0.11, p = 0.03), respectively. The partial correlations between ATT values, MD values, and cognitive scores (p < 0.005) showed significant associations in areas including the hippocampus, prefrontal cortices, cerebellum, caudate, anterior and mid cingulate, insula, thalamus, and lingual gyrus. (4) Conclusions: Adolescents with CCHD had prolonged ATTs and showed correlation with clinical measurements of cognitive impairment and MRI measurements of brain tissue integrity. This suggests that altered CAP may play a role in brain tissue injury and cognitive impairment after surgical palliation.
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Affiliation(s)
- Nancy A. Pike
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA 92697, USA
- The Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Bhaswati Roy
- Departments of Anesthesiology, University of California Los Angeles, Los Angeles, CA 90095, USA;
| | - Cristina Cabrera-Mino
- School of Nursing, University of California Los Angeles, Los Angeles, CA 90095, USA;
| | - Nancy J. Halnon
- Division of Pediatric Cardiology, Mattel Children’s Hospital UCLA, Los Angeles, CA 90095, USA;
| | - Alan B. Lewis
- Division of Pediatric Cardiology, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA;
| | - Xingfeng Shao
- Laboratory of FMRI Technology (LOFT), Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA; (X.S.); (D.J.J.W.)
| | - Danny J. J. Wang
- Laboratory of FMRI Technology (LOFT), Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA; (X.S.); (D.J.J.W.)
| | - Rajesh Kumar
- Departments of Anesthesiology, Radiological Sciences & Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA;
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Yuruk E, Cetinkaya S. The effect of individualized nutrition training of children with congenital heart disease (CHD) on their growth and development a randomized controlled trial. Curr Probl Cardiol 2024; 49:102567. [PMID: 38599555 DOI: 10.1016/j.cpcardiol.2024.102567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVE This study investigated the effectiveness of individualized nutrition training for mothers of children who underwent congenital heart disease (CHD) surgery on their children's growth and development. METHODS The researchers conducted a randomized controlled trial at Çukurova University Medical Faculty Balcalı Hospital in Adana, Turkey, between January 20th, 2021, and June 30th, 2021. They recruited 42 children with CHD and their families. Researchers used a personal information form, growth parameter measurements, and the Ankara Developmental Screening Inventory to assess the children. Participants were randomly divided into three groups. Control group, received standard care. Experimental group 1 (orally fed), received family-centered care and individualized nutrition training focused on age-appropriate food content, preparation methods, and meeting children's caloric needs. Experimental group 2 (orally and nutritionally fed), received the same interventions as group 1. The training programs for the experimental groups included information on strengthening breast milk and additional nutritional nutrition support. The training programs for the experimental groups likely addressed feeding challenges specific to children with CHD. RESULTS The study found a statistically significant difference in weight gain between the first and third follow-ups within the training group (children who received individualized nutrition education). This suggests that the training may have positively impacted weight gain. Additionally, the children in the training groups who were breastfed for longer than 12 months had better growth parameters and developmental scores compared to those with shorter breastfeeding durations. CONCLUSION This study suggests that individualized nutrition training for mothers of children with CHD surgery may support their children's growth and development, particularly when combined with prolonged breastfeeding.
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Affiliation(s)
- Emel Yuruk
- Department of Nursing, Child Health and Diseases Nursing, Çukurova University, Faculty of Health Sciences, Adana, Turkey.
| | - Senay Cetinkaya
- Department of Nursing, Child Health and Diseases Nursing, Çukurova University, Faculty of Health Sciences, Adana, Turkey.
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Agarwal D, Hunt ML, Sridharan A, Larson AC, Rychik J, Licht DJ, Davey MG, Flake AW, Gaynor JW, Didier RA. Unique model of chronic hypoxia in fetal lambs demonstrates abnormal contrast-enhanced ultrasound brain perfusion. Pediatr Res 2024:10.1038/s41390-024-03206-3. [PMID: 38849480 DOI: 10.1038/s41390-024-03206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/28/2024] [Accepted: 03/31/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Children with congenital heart disease (CHD) demonstrate long-term neurodevelopmental impairments. We investigated contrast-enhanced ultrasound (CEUS) cerebral perfusion in a fetal animal model exposed to sub-physiologic oxygen at equivalent levels observed in human fetuses with CHD. METHODS Fifteen fetal lambs [hypoxic animals (n = 9) and normoxic controls (n = 6)] maintained in an extrauterine environment underwent periodic brain CEUS. Perfusion parameters including microvascular flow velocity (MFV), transit time, and microvascular blood flow (MBF) were extrapolated from a standardized plane; regions of interest (ROI) included whole brain, central/thalami, and peripheral parenchymal analyses. Daily echocardiographic parameters and middle cerebral artery (MCA) pulsatility indices (PIs) were obtained. RESULTS Hypoxic lambs demonstrated decreased MFV, increased transit time, and decreased MBF (p = 0.026, p = 0.016, and p < 0.001, respectively) by whole brain analyses. MFV and transit time were relatively preserved in the central/thalami (p = 0.11, p = 0.08, p = 0.012, respectively) with differences in the peripheral parenchyma (all p < 0.001). In general, cardiac variables did not correlate with cerebral CEUS perfusion parameters. Hypoxic animals demonstrated decreased MCA PI compared to controls (0.65 vs. 0.78, respectively; p = 0.027). CONCLUSION Aberrations in CEUS perfusion parameters suggest that in environments of prolonged hypoxia, there are regional microvascular differences incompletely characterized by MCA interrogation offering insights into fetal conditions which may contribute to patient outcomes. IMPACT This work utilizes CEUS to study cerebral microvascular perfusion in a unique fetal animal model subjected to chronic hypoxic conditions equal to fetuses with congenital heart disease. CEUS demonstrates altered parameters with regional differences that are incompletely characterized by MCA Doppler values. These findings show that routine MCA Doppler interrogation may be inadequate in assessing microvascular perfusion differences. To our knowledge, this study is the first to utilize CEUS to assess microvascular perfusion in this model. The results offer insight into underlying conditions and physiological changes which may contribute to known neurodevelopmental impairments in those with congenital heart disease.
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Affiliation(s)
- Divyansh Agarwal
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mallory L Hunt
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abby C Larson
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J William Gaynor
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryne A Didier
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA.
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Maleyeff L, Park HJ, Khazal ZSH, Wypij D, Rollins CK, Yun HJ, Bellinger DC, Watson CG, Roberts AE, Newburger JW, Grant PE, Im K, Morton SU. Meta-regression of sulcal patterns, clinical and environmental factors on neurodevelopmental outcomes in participants with multiple CHD types. Cereb Cortex 2024; 34:bhae224. [PMID: 38836834 DOI: 10.1093/cercor/bhae224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 06/06/2024] Open
Abstract
Congenital heart disease affects 1% of infants and is associated with impaired neurodevelopment. Right- or left-sided sulcal features correlate with executive function among people with Tetralogy of Fallot or single ventricle congenital heart disease. Studies of multiple congenital heart disease types are needed to understand regional differences. Further, sulcal pattern has not been studied in people with d-transposition of the great arteries. Therefore, we assessed the relationship between sulcal pattern and executive function, general memory, and processing speed in a meta-regression of 247 participants with three congenital heart disease types (114 single ventricle, 92 d-transposition of the great arteries, and 41 Tetralogy of Fallot) and 94 participants without congenital heart disease. Higher right hemisphere sulcal pattern similarity was associated with improved executive function (Pearson r = 0.19, false discovery rate-adjusted P = 0.005), general memory (r = 0.15, false discovery rate P = 0.02), and processing speed (r = 0.17, false discovery rate P = 0.01) scores. These positive associations remained significant in for the d-transposition of the great arteries and Tetralogy of Fallot cohorts only in multivariable linear regression (estimated change β = 0.7, false discovery rate P = 0.004; β = 4.1, false discovery rate P = 0.03; and β = 5.4, false discovery rate P = 0.003, respectively). Duration of deep hypothermic circulatory arrest was also associated with outcomes in the multivariate model and regression tree analysis. This suggests that sulcal pattern may provide an early biomarker for prediction of later neurocognitive challenges among people with congenital heart disease.
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Affiliation(s)
- Lara Maleyeff
- Department of Biostatistics, Epidemiology, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Hannah J Park
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
| | - Zahra S H Khazal
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
| | - David Wypij
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Department of Cardiology, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston MA, United States
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital 02115 Boston, MA, United States
- Department of Neurology, Harvard Medical School, Boston MA, United States
| | - Hyuk Jin Yun
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
- Fetal Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston 02115, MA, United States
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital 02115 Boston, MA, United States
- Department of Psychiatry, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston MA, United States
| | - Christopher G Watson
- Department of Neurology, Boston Children's Hospital 02115 Boston, MA, United States
| | - Amy E Roberts
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Department of Cardiology, Boston Children's Hospital, Boston 02115, MA, United States
| | - Jane W Newburger
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Department of Cardiology, Boston Children's Hospital, Boston 02115, MA, United States
| | - P Ellen Grant
- Department of Biostatistics, Epidemiology, and Occupational Health, McGill University, Montreal, QC, Canada
- Fetal Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Radiology, Boston Children's Hospital, Boston 02115, MA, United States
| | - Kiho Im
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Fetal Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston 02115, MA, United States
| | - Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Fetal Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston 02115, MA, United States
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Juergensen S, Liu J, Xu D, Zhao Y, Moon-Grady AJ, Glenn O, McQuillen P, Peyvandi S. Fetal circulatory physiology and brain development in complex congenital heart disease: A multi-modal imaging study. Prenat Diagn 2024; 44:856-864. [PMID: 37817395 PMCID: PMC11004088 DOI: 10.1002/pd.6450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/07/2023] [Accepted: 09/25/2023] [Indexed: 10/12/2023]
Abstract
OBJECTIVE Fetuses with complex congenital heart disease have altered physiology, contributing to abnormal neurodevelopment. The effects of altered physiology on brain development have not been well studied. We used multi-modal imaging to study fetal circulatory physiology and brain development in hypoplastic left heart syndrome (HLHS) and d-transposition of the great arteries (TGA). METHODS This prospective, cross-sectional study investigated individuals with fetal congenital heart disease and controls undergoing fetal echocardiography and fetal brain MRI. MRI measured total brain volume and cerebral oxygenation by the MRI quantification method T2*. Indexed cardiac outputs (CCOi) and vascular impedances were calculated by fetal echocardiography. Descriptive statistics assessed MRI and echocardiogram measurement relationships by physiology. RESULTS Sixty-six participants enrolled (control = 20; HLHS = 25; TGA = 21), mean gestational age 33.8 weeks (95% CI: 33.3-34.2). Total brain volume and T2* were significantly lower in fetuses with cardiac disease. CCOi was lower in HLHS, correlating with total brain volume - for every 10% CCOi increase, volume increased 8 mm3 (95% CI: 1.78-14.1; p = 0.012). Echocardiography parameters and cerebral oxygenation showed no correlation. TGA showed no CCOi or aortic output correlation with MRI measures. CONCLUSIONS In HLHS, lower cardiac output is deleterious to brain development. Our findings provide insight into the role of fetal cardiovascular physiology in brain health.
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Affiliation(s)
- Stephan Juergensen
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
- Department of Pediatrics, Division of Pediatric Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Jing Liu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Duan Xu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Yili Zhao
- Department of Pediatrics, Division of Pediatric Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Anita J Moon-Grady
- Department of Pediatrics, Division of Pediatric Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Orit Glenn
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Patrick McQuillen
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, California, USA
| | - Shabnam Peyvandi
- Department of Pediatrics, Division of Pediatric Cardiology, University of California San Francisco, San Francisco, California, USA
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11
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Lee VK, Ceschin R, Reynolds WT, Meyers B, Wallace J, Landsittel D, Joseph HM, Badaly D, Gaynor JW, Licht D, Greene NH, Brady KM, Hunter JV, Chu ZD, Wilde EA, Easley RB, Andropoulos D, Panigrahy A. Postnatal Brain Trajectories and Maternal Intelligence Predict Childhood Outcomes in Complex CHD. J Clin Med 2024; 13:2922. [PMID: 38792464 PMCID: PMC11121951 DOI: 10.3390/jcm13102922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024] Open
Abstract
Objective: To determine whether early structural brain trajectories predict early childhood neurodevelopmental deficits in complex CHD patients and to assess relative cumulative risk profiles of clinical, genetic, and demographic risk factors across early development. Study Design: Term neonates with complex CHDs were recruited at Texas Children's Hospital from 2005-2011. Ninety-five participants underwent three structural MRI scans and three neurodevelopmental assessments. Brain region volumes and white matter tract fractional anisotropy and radial diffusivity were used to calculate trajectories: perioperative, postsurgical, and overall. Gross cognitive, language, and visuo-motor outcomes were assessed with the Bayley Scales of Infant and Toddler Development and with the Wechsler Preschool and Primary Scale of Intelligence and Beery-Buktenica Developmental Test of Visual-Motor Integration. Multi-variable models incorporated risk factors. Results: Reduced overall period volumetric trajectories predicted poor language outcomes: brainstem ((β, 95% CI) 0.0977, 0.0382-0.1571; p = 0.0022) and white matter (0.0023, 0.0001-0.0046; p = 0.0397) at 5 years; brainstem (0.0711, 0.0157-0.1265; p = 0.0134) and deep grey matter (0.0085, 0.0011-0.0160; p = 0.0258) at 3 years. Maternal IQ was the strongest contributor to language variance, increasing from 37% at 1 year, 62% at 3 years, and 81% at 5 years. Genetic abnormality's contribution to variance decreased from 41% at 1 year to 25% at 3 years and was insignificant at 5 years. Conclusion: Reduced postnatal subcortical-cerebral white matter trajectories predicted poor early childhood neurodevelopmental outcomes, despite high contribution of maternal IQ. Maternal IQ was cumulative over time, exceeding the influence of known cardiac and genetic factors in complex CHD, underscoring the importance of heritable and parent-based environmental factors.
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Affiliation(s)
- Vincent K. Lee
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15260, USA;
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
| | - Rafael Ceschin
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15206, USA
| | - William T. Reynolds
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15206, USA
| | - Benjamin Meyers
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
| | - Julia Wallace
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
| | - Douglas Landsittel
- Department of Biostatistics, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY 14260, USA;
| | - Heather M. Joseph
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Daryaneh Badaly
- Learning and Development Center, Child Mind Institute, New York, NY 10022, USA;
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Daniel Licht
- Perinatal Pediatrics Institute, Children’s National Hospital, Washinton, DC 20010, USA;
| | - Nathaniel H. Greene
- Anesthesiology, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Ken M. Brady
- Department of Pediatrics and Department of Anesthesiology, Lurie Children’s Hospital, Northwestern University, Chicago, IL 60611, USA;
| | - Jill V. Hunter
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA; (J.V.H.); (Z.D.C.); (E.A.W.)
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Zili D. Chu
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA; (J.V.H.); (Z.D.C.); (E.A.W.)
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Elisabeth A. Wilde
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA; (J.V.H.); (Z.D.C.); (E.A.W.)
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - R. Blaine Easley
- Department of Pediatric Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA; (R.B.E.); (D.A.)
| | - Dean Andropoulos
- Department of Pediatric Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA; (R.B.E.); (D.A.)
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Ashok Panigrahy
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15260, USA;
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15206, USA
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12
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Gaynor JW, Moldenhauer JS, Zullo EE, Burnham NB, Gerdes M, Bernbaum JC, D’Agostino JA, Linn RL, Klepczynski B, Randazzo I, Gionet G, Choi GH, Karaj A, Russell WW, Zackai EH, Johnson MP, Gebb JS, Soni S, DeBari SE, Szwast AL, Ahrens-Nicklas RC, Drivas TG, Jacobwitz M, Licht DJ, Vossough A, Nicolson SC, Spray TL, Rychik J, Putt ME. Progesterone for Neurodevelopment in Fetuses With Congenital Heart Defects: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2412291. [PMID: 38805228 PMCID: PMC11134212 DOI: 10.1001/jamanetworkopen.2024.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/08/2024] [Indexed: 05/29/2024] Open
Abstract
Importance Neurodevelopmental outcomes for children with congenital heart defects (CHD) have improved minimally over the past 20 years. Objectives To assess the feasibility and tolerability of maternal progesterone therapy as well as the magnitude of the effect on neurodevelopment for fetuses with CHD. Design, Setting, and Participants This double-blinded individually randomized parallel-group clinical trial of vaginal natural progesterone therapy vs placebo in participants carrying fetuses with CHD was conducted between July 2014 and November 2021 at a quaternary care children's hospital. Participants included maternal-fetal dyads where the fetus had CHD identified before 28 weeks' gestational age and was likely to need surgery with cardiopulmonary bypass in the neonatal period. Exclusion criteria included a major genetic or extracardiac anomaly other than 22q11 deletion syndrome and known contraindication to progesterone. Statistical analysis was performed June 2022 to April 2024. Intervention Participants were 1:1 block-randomized to vaginal progesterone or placebo by diagnosis: hypoplastic left heart syndrome (HLHS), transposition of the great arteries (TGA), and other CHD diagnoses. Treatment was administered twice daily between 28 and up to 39 weeks' gestational age. Main Outcomes and Measures The primary outcome was the motor score of the Bayley Scales of Infant and Toddler Development-III; secondary outcomes included language and cognitive scales. Exploratory prespecified subgroups included cardiac diagnosis, fetal sex, genetic profile, and maternal fetal environment. Results The 102 enrolled fetuses primarily had HLHS (n = 52 [50.9%]) and TGA (n = 38 [37.3%]), were more frequently male (n = 67 [65.7%]), and without genetic anomalies (n = 61 [59.8%]). The mean motor score differed by 2.5 units (90% CI, -1.9 to 6.9 units; P = .34) for progesterone compared with placebo, a value not statistically different from 0. Exploratory subgroup analyses suggested treatment heterogeneity for the motor score for cardiac diagnosis (P for interaction = .03) and fetal sex (P for interaction = .04), but not genetic profile (P for interaction = .16) or maternal-fetal environment (P for interaction = .70). Conclusions and Relevance In this randomized clinical trial of maternal progesterone therapy, the overall effect was not statistically different from 0. Subgroup analyses suggest heterogeneity of the response to progesterone among CHD diagnosis and fetal sex. Trial Registration ClinicalTrials.gov Identifier: NCT02133573.
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Affiliation(s)
- J. William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erin E. Zullo
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nancy B. Burnham
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marsha Gerdes
- Department of Psychology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Judy C. Bernbaum
- Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jo Ann D’Agostino
- Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rebecca L. Linn
- Division of Anatomic Pathology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brenna Klepczynski
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Isabel Randazzo
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gabrielle Gionet
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Grace H. Choi
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Antoneta Karaj
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - William W. Russell
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elaine H. Zackai
- Division of Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mark P. Johnson
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Juliana S. Gebb
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shelly Soni
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Suzanne E. DeBari
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anita L. Szwast
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca C. Ahrens-Nicklas
- Division of Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Theodore G. Drivas
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel J. Licht
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Arastoo Vossough
- Division of Radiology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Susan C. Nicolson
- Division of Cardiac Anesthesia, Department of Anesthesia and Critical Medicine, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas L. Spray
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary E. Putt
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
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13
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Derridj N, Calderon J, Bonnet D, Khoshnood B, Monier I, Guedj R. Neurodevelopmental outcomes of preterm and growth-restricted neonate with congenital heart defect: a systematic review and meta-analysis. Eur J Pediatr 2024; 183:1967-1987. [PMID: 38353800 DOI: 10.1007/s00431-023-05419-w] [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] [Received: 10/31/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 04/23/2024]
Abstract
The purpose of the study is to assess the risks of neurodevelopmental morbidity among preterm and growth restricted youth with congenital heart defects (CHD). This systematic review and meta-analysis included observational studies assessing neurodevelopmental outcomes among children with CHD born preterm (i.e., before 37 weeks of gestation) or growth restricted (small-for-gestational age (SGA) with a birthweight < the 10th percentile or with low birthweight (LBW) < 2500 g). Studies were identified in Medline and Embase databases from inception until May 2022, with data extracted by two blinded reviewers. Risk of bias was assessed using the Critical Appraisal Skills Programme cohort checklist. Meta-analysis involved the use of random-effects models. Main outcome measures were neurodevelopmental outcomes including overall cognitive impairment and intellectual disability, IQ, communication, and motor skills scores. From 3573 reports, we included 19 studies in qualitative synthesis and 6 meta-analysis studies. Risk of bias was low in 8/19 studies. Cognitive impairment and intellectual disability were found in 26% (95% CI 20-32, I2 = 0%) and 19% (95% CI 7-35, I2 = 82%) of preterm children with CHD, respectively. Two studies documented a lower IQ score for SGA children who underwent CHD operations in comparison to non-SGA children who also underwent CHD operations. Two studies have reported lower IQ, communication, and motor skills in children with hypoplastic left heart syndrome (HLHS) and low birth weight compared to those with HLHS and expected birth weight. CONCLUSIONS Based on a low level of evidence, prematurity and/or growth retardation appear to accentuate specific neurodevelopmental outcomes in certain CHD subgroups. Further evidence is needed to confirm these findings. TRIAL REGISTRATION PROSPERO [CRD42020201414]. WHAT IS KNOWN • Children born with CHD, preterm birth, or growth restriction at birth are independently at higher risk for neurodevelopmental impairment. • The additional effect of preterm birth and/or growth restriction on neurodevelopmental outcomes in children with CHD remains unclear. WHAT IS NEW • Prematurity and/or growth retardation appear to accentuate specific neurodevelopmental outcomes in certain CHD subgroups. • Children with CHD, particularly those born preterm or with growth restriction, should undergo lifelong systematic comprehensive neurodevelopmental assessment.
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Affiliation(s)
- Neil Derridj
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Université de Paris, CRESS, INSERM U1153, INRA, 53 avenue de l'Observatoire, 75014, F-75004, Paris, France.
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, AP-HP, Université de Paris Cité, Paris, France.
| | - Johanna Calderon
- UMR 1046 INSERM CNRS PhyMedExp, Université de Montpellier, Montpellier, France
- Department of Psychiatry, Harvard Medical School, Harvard University, Boston, USA
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, AP-HP, Université de Paris Cité, Paris, France
| | - Babak Khoshnood
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Université de Paris, CRESS, INSERM U1153, INRA, 53 avenue de l'Observatoire, 75014, F-75004, Paris, France
| | - Isabelle Monier
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Université de Paris, CRESS, INSERM U1153, INRA, 53 avenue de l'Observatoire, 75014, F-75004, Paris, France
| | - Romain Guedj
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Université de Paris, CRESS, INSERM U1153, INRA, 53 avenue de l'Observatoire, 75014, F-75004, Paris, France
- Pediatric Emergency Department, AP-HP, Armand Trousseau Hospital, Sorbonne Université, Paris, France
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14
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McGetrick ME, Riviello JJ. Neurological injury in pediatric heart disease: A review of developmental and acquired risk factors and management considerations. Semin Pediatr Neurol 2024; 49:101115. [PMID: 38677794 DOI: 10.1016/j.spen.2024.101115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/29/2024]
Abstract
Medical and surgical advancements have improved survival in children with acquired and congenital heart disease (CHD), but the burden of neurological morbidity is high. Brain disorders associated with CHD include white matter injury, stroke, seizure, and neurodevelopmental delays. While genetics and disease-specific factors play a substantial role in early brain injury, therapeutic management of the heart disease intensifies the risk. There is a growing interest in understanding how to reduce brain injury and improve neurodevelopmental outcomes in cardiac diseases. Pediatric neurologists serve a vital role in care teams managing these complex patients, providing interpretation of neuromonitoring and imaging, managing neurologic emergencies, assisting with neuro prognostication, and identifying future research aims.
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Affiliation(s)
- Molly E McGetrick
- Division of Cardiology and Critical Care, Department of Pediatrics, the University of Texas Southwestern, Children's Medical Center, Dallas, Texas, USA.
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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15
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Turner EM, Cassidy AR, Rea KE, Smith-Paine JM, Wolfe KR. [Formula: see text] The multifaceted role of neuropsychology in pediatric solid organ transplant: preliminary guidelines and strategies for clinical practice. Child Neuropsychol 2024; 30:503-537. [PMID: 37291962 DOI: 10.1080/09297049.2023.2221759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/31/2023] [Indexed: 06/10/2023]
Abstract
The incidence of pediatric solid organ transplantation (SOT) has increased in recent decades due to medical and surgical advances as well as improvements in organ procurement. Survival rates for pediatric kidney, liver, and heart transplantation are above 85% but patients continue to experience complex healthcare needs over their lifetime. Long-term developmental and neuropsychological sequelae are becoming increasingly recognized in this population, although preliminary work is limited and deserves further attention. Neuropsychological weaknesses are often present prior to transplantation and may be related to underlying congenital conditions as well as downstream impact of the indicating organ dysfunction on the central nervous system. Neuropsychological difficulties pose risk for functional complications, including disruption to adaptive skill development, social-emotional functioning, quality of life, and transition to adulthood. The impact of cognitive dysfunction on health management activities (e.g., medication adherence, medical decision-making) is also an important consideration given these patients' lifelong medical needs. The primary aim of this paper is to provide preliminary guidelines and clinical strategies for assessment of neuropsychological outcomes across SOT populations for pediatric neuropsychologists and the multidisciplinary medical team, including detailing unique and shared etiologies and risk factors for impairment across organ types, and functional implications. Recommendations for clinical neuropsychological monitoring as well as multidisciplinary collaboration within pediatric SOT teams are also provided.
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Affiliation(s)
- Elise M Turner
- Department of Pediatrics, Section of Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Cassidy
- Departments of Psychiatry & Psychology and Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelly E Rea
- Division of Pediatric Psychology, Department of Pediatrics, C. S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Julia M Smith-Paine
- Division of Developmental-Behavioral Pediatrics & Psychology, Department of Pediatrics, Rainbow Babies & Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kelly R Wolfe
- Department of Pediatrics, Section of Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, CO, USA
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16
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De Silvestro A, Natalucci G, Feldmann M, Hagmann C, Nguyen TD, Coraj S, Jakab A, Kottke R, Latal B, Knirsch W, Tuura R. Effects of hemodynamic alterations and oxygen saturation on cerebral perfusion in congenital heart disease. Pediatr Res 2024:10.1038/s41390-024-03106-6. [PMID: 38438551 DOI: 10.1038/s41390-024-03106-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Patients with severe congenital heart disease (CHD) are at risk for neurodevelopmental impairment. An abnormal cerebral blood supply caused by the altered cardiac physiology may limit optimal brain development. The aim of this study was to evaluate the effect of a systemic-to-pulmonary shunt, aortic arch obstruction and arterial oxygen saturation on cerebral perfusion in patients with severe CHD. METHODS Patients with severe CHD requiring cardiac surgery within the first six weeks of life, who underwent pre- and/or postoperative brain magnetic resonance imaging (MRI), and healthy controls with one postnatal scan were included. Cerebral perfusion in deep and cortical gray matter was assessed by pseudocontinuous arterial spin labeling MRI. RESULTS We included 59 CHD and 23 healthy control scans. The presence of a systemic-to-pulmonary shunt was associated with decreased perfusion in cortical (p = 0.003), but not in deep gray matter (p = 0.031). No evidence for an effect of aortic arch obstruction and arterial oxygen saturation on cerebral perfusion was found. After adjusting for hemodynamic and oxygen saturation parameters, deep (p = 0.018) and cortical (p = 0.012) gray matter perfusion was increased in patients with CHD compared to controls. CONCLUSION We detected regional differences in compensation to the cerebral steal effect in patients with severe CHD. IMPACT Patients with severe congenital heart disease (CHD) have altered postnatal brain hemodynamics. A systemic-to-pulmonary shunt was associated with decreased perfusion in cortical gray matter but preserved perfusion in deep gray matter, pointing towards regional differences in compensation to the cerebral steal effect. No effects of aortic arch obstruction and arterial oxygenation on cerebral perfusion were seen. Cerebral perfusion was increased in patients with CHD compared to healthy controls after adjusting for hemodynamic alterations and oxygen saturation. To improve neuroprotection and neurodevelopmental outcomes, it is important to increase our understanding of the factors influencing cerebral perfusion in neonates with severe CHD.
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Affiliation(s)
- Alexandra De Silvestro
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Center for MR-Research, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Giancarlo Natalucci
- University of Zurich, Zurich, Switzerland
- Larsson-Rosenquist Foundation Center for Neurodevelopment, Growth and Nutrition of the Newborn, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
- Newborn Research Zurich, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Maria Feldmann
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Cornelia Hagmann
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Thi Dao Nguyen
- University of Zurich, Zurich, Switzerland
- Newborn Research Zurich, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Seline Coraj
- University of Zurich, Zurich, Switzerland
- Larsson-Rosenquist Foundation Center for Neurodevelopment, Growth and Nutrition of the Newborn, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
- Newborn Research Zurich, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Andras Jakab
- Center for MR-Research, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Raimund Kottke
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Diagnostic Imaging, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Walter Knirsch
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Ruth Tuura
- Center for MR-Research, University Children's Hospital Zurich, Zurich, Switzerland.
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
- University of Zurich, Zurich, Switzerland.
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17
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Jacobwitz M, Irving SY, Moriarty H, Yost J, Vossough A, Licht DJ, Lynch JM. Predictors of the inability to achieve full oral feeding in postoperative infants with CHD. Cardiol Young 2024; 34:581-587. [PMID: 37608743 DOI: 10.1017/s104795112300313x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Poor oral feeding is a known contributor to growth challenges in neonates with complex CHD who require early surgery. Almost 60% of these infants do not achieve full oral feeding by hospital discharge. This study's objective was to identify predictors of the inability to achieve full oral feeding by discharge in neonates with complex CHD following surgical intervention with cardiopulmonary bypass. STUDY DESIGN A retrospective analysis of a prospective study of 192 full-term neonates with complex CHD was performed. A stepwise selection logistic regression model was developed to predict oral feeding status at hospital discharge. Univariate subgroup analysis was performed with groups determined based on a CHD classification system. RESULTS 58% of neonates (112/192) failed to achieve full oral feeding by hospital discharge. A logistic regression model identified duration of deep hypothermic circulatory arrest and reintubation as predictors of the inability to achieve full oral feeding. Among neonates who achieved full oral feeding by discharge (42%), only 7.5% did so after postoperative day 10. Brain maturation, brain injury, and preoperative oral feeding were not predictors of full postoperative oral feeding. CONCLUSIONS Many infants with CHD fail to achieve full oral feeding by time of hospital discharge. Longer duration of deep hypothermic circulatory arrest and increased number of intubations were predictive of poor feeding after surgery. Prolonging hospitalisation solely to achieve full oral feeding after postoperative day ten is of limited utility; earlier discharge should be promoted to avoid negative impacts on neonatal neurodevelopment as unintended consequences of lengthy hospitalisations.
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Affiliation(s)
- Marin Jacobwitz
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Sharon Y Irving
- Critical Care Nursing, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Helene Moriarty
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Jennifer Yost
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Arastoo Vossough
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer M Lynch
- Division of Cardiothoracic Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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18
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McAlinden B, Pool N, Harnischfeger J, Waak M, Campbell M. 'Baby Liberation' - Developing and implementing an individualised, developmentally-supportive care bundle to critically unwell infants in an Australian Paediatric Intensive Care Unit. Early Hum Dev 2024; 190:105944. [PMID: 38290275 DOI: 10.1016/j.earlhumdev.2024.105944] [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] [Received: 10/30/2023] [Revised: 12/21/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Infants requiring high acuity care within a Paediatric Intensive Care Unit are at multifactorial risk of neurological injury to the immature brain, resulting in long-term developmental difficulties. In 2020, Queensland Children's Hospital implemented an individualised family-centred developmental care program, 'Baby Liberation', to address an identified service gap for critically unwell infants, aimed at optimising early neuroprotective strategies and minimising risk of suboptimal developmental outcomes. AIM To implement Baby Liberation for infants admitted to a quaternary paediatric intensive care referral centre. Secondary aims were to describe environmental changes, enablers and limitations related to implementation. STUDY DESIGN A single-centre, prospective implementation pilot study investigated the feasibility of implementing Baby Liberation. Subjects included infants less than six months of age admitted to Queensland Children's Hospital Paediatric Intensive Care Unit. OUTCOME MEASURES Primary measures comprised data collected during the implementation period, including number of eligible patients and number of developmental care plans provided. Environmental audit data were collected pre and post implementation to inform secondary outcomes. RESULTS Baby Liberation was feasibly implemented into the Queensland Children's Hospital Paediatric Intensive Care Unit. During implementation, 181 individualised care plans were provided to 313 eligible infants (57.8 %). Environmental audits showed improvements in all areas of developmental care, with greatest improvements noted in pain and stress management (+95 %) and staff support and development (+83.3 %). CONCLUSION Implementation of Baby Liberation was feasible within a large quaternary paediatric intensive care unit and has potential to be expanded into other clinical areas providing acute infant care.
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Affiliation(s)
- Bronagh McAlinden
- Physiotherapy Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia; Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia.
| | - Natasha Pool
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Jane Harnischfeger
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Michaela Waak
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Miranda Campbell
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia; Occupational Therapy and Music Therapy Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
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19
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Neukomm A, Claessens NHP, Bonthrone AF, Stegeman R, Feldmann M, Nijman M, Jansen NJG, Nijman J, Groenendaal F, de Vries LS, Benders MJNL, Breur JMPJ, Haas F, Bekker MN, Logeswaran T, Reich B, Kottke R, Dave H, Simpson J, Pushparajah K, Kelly CJ, Arulkumaran S, Rutherford MA, Counsell SJ, Chew A, Knirsch W, Sprong MCA, van Schooneveld MM, Hagmann C, Latal B. Perioperative Brain Injury in Relation to Early Neurodevelopment Among Children with Severe Congenital Heart Disease: Results from a European Collaboration. J Pediatr 2024; 266:113838. [PMID: 37995930 DOI: 10.1016/j.jpeds.2023.113838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/23/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE To examine the relationship between perioperative brain injury and neurodevelopment during early childhood in patients with severe congenital heart disease (CHD). STUDY DESIGN One hundred and seventy children with CHD and born at term who required cardiopulmonary bypass surgery in the first 6 weeks after birth were recruited from 3 European centers and underwent preoperative and postoperative brain MRIs. Uniform description of imaging findings was performed and an overall brain injury score was created, based on the sum of the worst preoperative or postoperative brain injury subscores. Motor and cognitive outcomes were assessed with the Bayley Scales of Infant and Toddler Development Third Edition at 12 to 30 months of age. The relationship between brain injury score and clinical outcome was assessed using multiple linear regression analysis, adjusting for CHD severity, length of hospital stay (LOS), socioeconomic status (SES), and age at follow-up. RESULTS Neither the overall brain injury score nor any of the brain injury subscores correlated with motor or cognitive outcome. The number of preoperative white matter lesions was significantly associated with gross motor outcome after correction for multiple testing (P = .013, β = -0.50). SES was independently associated with cognitive outcome (P < .001, β = 0.26), and LOS with motor outcome (P < .001, β = -0.35). CONCLUSION Preoperative white matter lesions appear to be the most predictive MRI marker for adverse early childhood gross motor outcome in this large European cohort of infants with severe CHD. LOS as a marker of disease severity, and SES influence outcome and future intervention trials need to address these risk factors.
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Affiliation(s)
- Astrid Neukomm
- Child Development Center, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nathalie H P Claessens
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Congenital Cardiothoracic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alexandra F Bonthrone
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Raymond Stegeman
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria Feldmann
- Child Development Center, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Maaike Nijman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Congenital Cardiothoracic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolaas J G Jansen
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Joppe Nijman
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands; Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Johannes M P J Breur
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Felix Haas
- Congenital Cardiothoracic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thushiha Logeswaran
- Pediatric Heart Center, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Bettina Reich
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Raimund Kottke
- Department of Diagnostic Imaging, University Children's Hospital Zurich, Zurich, Switzerland
| | - Hitendu Dave
- Division of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - John Simpson
- Pediatric Cardiology Department, Evelina Children's Hospital London, London, United Kingdom
| | - Kuberan Pushparajah
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Pediatric Cardiology Department, Evelina Children's Hospital London, London, United Kingdom
| | - Christopher J Kelly
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Sophie Arulkumaran
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Mary A Rutherford
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Serena J Counsell
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Andrew Chew
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Walter Knirsch
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, Children's Research Center, University Children's Hospital, University of Zurich, Zurich, Switzerland
| | - Maaike C A Sprong
- Child Development & Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monique M van Schooneveld
- Department of Pediatric Psychology, Neuropsychology Section, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelia Hagmann
- Department of Neonatology and Pediatric Intensive Care, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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20
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Massey SL, Weinerman B, Naim MY. Perioperative Neuromonitoring in Children with Congenital Heart Disease. Neurocrit Care 2024; 40:116-129. [PMID: 37188884 DOI: 10.1007/s12028-023-01737-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
Although neonates and children with congenital heart disease are primarily hospitalized for cardiac and pulmonary diseases, they are also at an increased risk for neurologic injury due to both empiric differences that can exist in their nervous systems and acquired injury from cardiopulmonary pathology and interventions. Although early efforts in care focused on survival after reparative cardiac surgery, as surgical and anesthetic techniques have evolved and survival rates accordingly improved, the focus has now shifted to maximizing outcomes among survivors. Children and neonates with congenital heart disease experience seizures and poor neurodevelopmental outcomes at a higher rate than age-matched counterparts. The aim of neuromonitoring is to help clinicians identify patients at highest risk for these outcomes to implement strategies to mitigate these risks and to also help with neuroprognostication after an injury has occurred. The mainstays of neuromonitoring are (1) electroencephalographic monitoring to evaluate brain activity for abnormal patterns or changes and to identify seizures, (2) neuroimaging to reveal structural changes and evidence of physical injury in and around the brain, and (3) near-infrared spectroscopy to monitor brain tissue oxygenation and detect changes in perfusion. This review will detail the aforementioned techniques and their use in the care of pediatric patients with congenital heart disease.
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Affiliation(s)
- Shavonne L Massey
- Division of Neurology, Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - Bennett Weinerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Maryam Y Naim
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology, Critical Care Medicine, and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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21
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Tanasan A, Eghalian F, Behmanesh H, Khazaei S, Farahani F, Hosseini F. Evaluation of Neurological and Auditory Development in Children with Congenital Heart Disease using Essence Q Questionnaire and Auditory Brainstem Response (ABR) Test. IRANIAN JOURNAL OF CHILD NEUROLOGY 2024; 18:43-50. [PMID: 38375124 PMCID: PMC10874519 DOI: 10.22037/ijcn.v18i.39186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 02/07/2023] [Indexed: 02/21/2024]
Abstract
Objectives The progress of cardiac surgery in children and the increase in the survival of children with Congenital Heart Disease (CHD) has led to consider another issue called a neurodevelopmental disorder. In this study, 53 children with CHD were evaluated in terms of development with the Essence Q questionnaire, Otoacoustic Emission (OAE), and Auditory Brainstem Response (ABR) regarding these patients' hearing and risk factors. The Essence Q scores were also examined. Materials & Methods In this prospective, cross-sectional study, the researchers included 53 children diagnosed with CHD. Initially, each child underwent ABR and OAE tests. Subsequently, data on potential risk factors associated with neurodevelopmental delay were collected. A trained project associate administered the Essence Q questionnaire, using parents' information as a guide. Following data collection, this study proceeded with an in-depth analysis of the information. Results Thirty-six boys (67.92%) and 17 girls (32.08%) with CHD were included in the study. The mean age of children was 26.98± 10.64 months. The mean Essence Q score for boys was 7.48± 2.57. Moreover, the average score for girls was 2.23 ± 8.11. According to this questionnaire, 39 patients (73.58%) had hyperactivity disorder, 46 patients (86.79%) had behavioral disorders, and ten patients (16.98%) had a motor delay. Unlike previous studies, all patients had normal OAE and ABR hearing. Conclusion This study demonstrated that factors such as developmental delay in the first year, a known genetic disease, and a history of seizures significantly impacted the Essence Q score. However, elements like prematurity, the use of ventilation, abnormalities on the dorsum, and the number of days post-surgery did not significantly affect the Essence Q score. Essence Q can be a reliable tool in screening for neurodevelopment in children with CHD.
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Affiliation(s)
- Asadollah Tanasan
- Department of Pediatrices, Hamadan University of Medical Sciences, Hamedan, Iran
| | - Fatemeh Eghalian
- Department of Pediatrices, Hamadan University of Medical Sciences, Hamedan, Iran
| | - Helen Behmanesh
- Departmentof Psycology, Hamadan University of Medical Sciences, Hamedan, Iran
| | - Salman Khazaei
- Research Center for Health Sciences,Hamadan University of Medical Sciences, Hamedan, Iran
| | - Farhad Farahani
- Depatment of Ear, Noise and Throath, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Firozeh Hosseini
- Department of Pediatrices, Hamadan University of Medical Sciences, Hamedan, Iran
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22
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Johng S, Licht DJ, Hedrick HL, Rintoul N, Linn RL, Gebb JS, Xiao R, Massey SL. Prenatal Brain Maturation is Delayed in Neonates with Congenital Diaphragmatic Hernia. J Pediatr 2024; 264:113738. [PMID: 37722557 DOI: 10.1016/j.jpeds.2023.113738] [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] [Received: 05/24/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE To assess brain development in fetuses with congenital diaphragmatic hernia (CDH) using a fetal Total Maturation Score (fTMS). STUDY DESIGN This is a retrospective cohort study using data from a single-center clinical registry. Neonates with an antenatal diagnosis of CDH between 2014 and 2020 and prenatal brain magnetic resonance imaging (MRI) (n = 48) were included. We compared our study sample with historical healthy controls (n = 48). The relationship between fTMS and gestational age (GA), as well as the association between fTMS and key prenatal variables and placental pathologic findings, were evaluated. RESULTS Compared with healthy controls, neonates with CDH had a significant delay in fTMS (P value <.001). Within the CDH cohort, there was no significant difference in fTMS based on CDH severity, intrathoracic liver position, right vs left CDH, sex, presence of abnormal echocardiogram findings, treatment with extracorporeal membrane oxygenation (ECMO), or in-hospital mortality. Placentas of neonates with CDH had a high proportion of fetal vascular malperfusion (56%) and chronic inflammation (67%), and relatively large placentas had a protective effect on prenatal brain maturation (P value = .025). CONCLUSIONS Prenatal brain maturation in neonates with CDH is delayed. Placental pathology may influence fetal brain development. The etiology and clinical impact of prenatal brain immaturity in neonates with CDH warrant further investigation.
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Affiliation(s)
- Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Holly L Hedrick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Natalie Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca L Linn
- Division of Anatomic Pathology, Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Juliana S Gebb
- Richard D Wood, Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Shavonne L Massey
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
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23
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Tang J, Ou J, Chen Y, Li L, Liu H, Sun M, Luo M, Zhong T, Wang T, Wei J, Chen Q, Qin J. The risk of attention-deficit hyperactivity disorder among children with congenital heart disease: A systematic review and meta-analysis. Child Care Health Dev 2024; 50:e13174. [PMID: 37734724 DOI: 10.1111/cch.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/14/2023] [Accepted: 08/31/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Although current treatments are effective in dealing with congenital heart disease (CHD), non-cardiac comorbidities such as attention-deficit hyperactivity disorder (ADHD) have received widespread attention. The purpose of this systematic review and meta-analysis is to assess the risk of ADHD associated with CHD. METHODS The literature search was carried out systematically through eight different databases by the end of September 2022. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. The heterogeneity of the studies was assessed by the Cochran Q test and the I2 statistic. Subgroup and sensitivity analyses were used to explore the potential sources of heterogeneity. RESULTS Eleven studies were included in this study, which involved a total of 296 741 participants. Our study showed that the children with CHD were at a significantly increased risk of ADHD compared with the reference group (OR = 2.98, 95% CI: 2.18-4.08). The results were moderately heterogeneous. These factors including study design, geographic region and study quality were identified as the first three of the most relevant heterogeneity moderators by subgroup analyses. Sensitivity analysis yielded consistent results. There was no evidence of publication bias. CONCLUSIONS The present study suggests that CHD children have a significantly higher risk of ADHD when compared with those without CHD. Early identification and intervention of ADHD is important to reduce its symptoms and adverse effects; therefore, clinicians should increase screening for ADHD in children with CHD and intervene promptly to reduce its effects whenever possible.
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Affiliation(s)
- Jiapeng Tang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jun Ou
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Yige Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Liuxuan Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Hanjun Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Mengting Sun
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Manjun Luo
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Taowei Zhong
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jianhui Wei
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Qian Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
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Andersen KN, Yao S, White BR, Jacobwitz M, Breimann J, Jahnavi J, Schmidt A, Baker WB, Ko TS, Gaynor JW, Vossough A, Xiao R, Licht DJ, Shih EK. Cerebral microhemorrhages in children with congenital heart disease: Prevalence, risk factors, and impact on neurodevelopmental outcomes. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.05.23299539. [PMID: 38105980 PMCID: PMC10723520 DOI: 10.1101/2023.12.05.23299539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Background Infants with complex congenital heart disease (CHD) require life-saving corrective/palliative heart surgery in the first weeks of life. These infants are at risk for brain injury and poor neurodevelopmental outcomes. Cerebral microhemorrhages (CMH) are frequently seen after neonatal bypass heart surgery, but it remains unknown if CMH are a benign finding or constitute injury. Herein, we investigate the risk factors for developing CMH and their clinical significance. Methods 192 infants with CHD undergoing corrective cardiac surgery with cardiopulmonary bypass (CPB) at a single institution were prospectively evaluated with pre-(n = 183) and/or postoperative (n = 162) brain magnetic resonance imaging (MRI). CMH severity was scored based on total number of microhemorrhages. Antenatal, perioperative, and postoperative candidate risk factors for CMH and neurodevelopmental (ND) outcomes were analyzed. Eighteen-month neurodevelopmental outcomes were assessed using the Bayley-III Scales of Infants and Toddler Development in a subset of patients (n = 82). Linear regression was used to analyze associations between risk factors or ND outcomes and presence/number of CMH. Results The most common CHD subtypes were hypoplastic left heart syndrome (HLHS) (37%) and transposition of the great arteries (TGA) (33%). Forty-two infants (23%) had CMH present on MRI before surgery and 137 infants (85%) post-surgery. No parameters evaluated were significant risk factors for preoperative CMH. In multivariate analysis, cardiopulmonary bypass (CPB) duration (p < 0.0001), use of extracorporeal membrane oxygenation (ECMO) support (p < 0.0005), postoperative seizure(s) (p < 0.03), and lower birth weight (p < 0.03) were associated with new or worsened CMH postoperatively. Higher CMH number was associated with lower scores on motor (p < 0.03) testing at 18 months. Conclusion CMH is a common imaging finding in infants with CHD with increased prevalence and severity after CPB and adverse impact on neurodevelopmental outcomes starting at a young age. Longer duration of CPB and need for postoperative ECMO were the most significant risk factors for developing CMH. However, presence of CMH on preoperative scans indicates non-surgical risk factors that are yet to be identified. Neuroprotective strategies to mitigate risk factors for CMH may improve neurodevelopmental outcomes in this vulnerable population.
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Burkhart HM, Nakamura Y, Salkini A, Schwartz RM, Ranallo CD, Makil ES, Campbell M, Daves SM, Henry ED, Mir A. Bilateral pulmonary artery banding in higher risk neonates with hypoplastic left heart syndrome. JTCVS OPEN 2023; 16:689-697. [PMID: 38204678 PMCID: PMC10774943 DOI: 10.1016/j.xjon.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/07/2023] [Accepted: 08/02/2023] [Indexed: 01/12/2024]
Abstract
Objectives Limited data on performing bilateral pulmonary artery banding (BPAB) before stage 1 Norwood procedure suggest that some patients may benefit through the postponement of the major cardiopulmonary bypass procedure. The objective of this study was to evaluate the effectiveness of BPAB in the surgical management of high-risk patients with hypoplastic left heart syndrome (HLHS). Methods A retrospective review of all high-risk neonates with HLHS who underwent BPAB at our institution was performed. No patients, including those with intact or highly restrictive atrial septum (IAS), were excluded. Results Between October 2015 and April 2021, 49 neonates with HLHS (including 6 with IAS) underwent BPAB, 40 of whom progressed to the Norwood procedure. Risk factors for not progressing to the Norwood procedure after BPAP include low birth weight (P = .043), the presence of multiple extracardiac anomalies (P = .005), and the presence of genetic disorders (P = .028). Operative mortality was 7.5% (3/40). IAS was associated with operative mortality (P = .022). Conclusions The strategy of BPAB prestage 1 Norwood procedure was successful in identifying at-risk patients and improving Norwood survival. Although not all patients will need this hybrid approach, a significant number can be expected to benefit from this tactic. These results support the need for a substantial hybrid strategy, in addition to a primary stage 1 Norwood surgical strategy, in the management of HLHS.
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Affiliation(s)
- Harold M. Burkhart
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Yuki Nakamura
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Anas Salkini
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Randall M. Schwartz
- Department of Anesthesia, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Courtney D. Ranallo
- Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Elizabeth S. Makil
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Matthew Campbell
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Suanne M. Daves
- Department of Anesthesia, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Emilie D. Henry
- Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Arshid Mir
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
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26
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Lisanti AJ, Vittner DJ, Peterson J, Van Bergen AH, Miller TA, Gordon EE, Negrin KA, Desai H, Willette S, Jones MB, Caprarola SD, Jones AJ, Helman SM, Smith J, Anton CM, Bear LM, Malik L, Russell SK, Mieczkowski DJ, Hamilton BO, McCoy M, Feldman Y, Steltzer M, Savoca ML, Spatz DL, Butler SC. Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative. Cardiol Young 2023; 33:2521-2538. [PMID: 36994672 PMCID: PMC10544686 DOI: 10.1017/s1047951123000525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.
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Affiliation(s)
- Amy J. Lisanti
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA, Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dorothy J. Vittner
- Egan School of Nursing and Health Studies, Fairfield University Fairfield, CT, USA, Connecticut Children’s, Hartford, CT, USA
| | | | - Andrew H. Van Bergen
- Advocate Children’s Heart Institute, Advocate Children’s Hospital, Oak Lawn, IL, USA
| | - Thomas A. Miller
- Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - Erin E. Gordon
- DO, Inpatient Cardiac Neurodevelopment Program, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karli A Negrin
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, Delaware, USA
| | - Hema Desai
- Rehabilitation Services, CHOC Children’s Hospital, Orange, CA, USA
| | - Suzie Willette
- Department of Speech-Language Pathology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Melissa B Jones
- Cardiac Critical Care, Children’s National Hospital, Washington DC USA
| | - Sherrill D. Caprarola
- Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Anna J. Jones
- Office of Advanced Practice Providers, UT Southwestern Medical Center, Dallas, TX, USA, Heart Center, Children’s Health, Dallas, TX, USA
| | - Stephanie M. Helman
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jodi Smith
- Parent Representative, The Mended Hearts, Inc., Program Director, Richmond, VA, USA
| | - Corinne M. Anton
- Department of Psychology and Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA, Department of Cardiology, Children’s Health, Dallas, Texas, USA
| | - Laurel M. Bear
- Department of Pediatrics, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI, USA
| | - Lauren Malik
- Department of Acute Care Therapy Services, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Sarah K. Russell
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, DE, USA
| | - Dana J. Mieczkowski
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, DE, USA
| | - Bridy O. Hamilton
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, Delaware, USA
| | - Meghan McCoy
- Pediatric and Congenital Heart Center, Duke University Hospital, Durham, NC, USA
| | - Yvette Feldman
- Nursing & Patient Care Center of Excellence, St. Luke’s Health System, Boise, ID, USA
| | - Michelle Steltzer
- Single Ventricle Center of Excellence, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, USA
| | - Melanie L Savoca
- Department of Clinical Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diane L. Spatz
- Department of Family & Community Health, University of Pennsylvania School of Nursing, The Center for Pediatric Nursing Research and Evidence Based Practice, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samantha C. Butler
- Department of Psychiatry (Psychology), Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Provost S, Fourdain S, Vannasing P, Tremblay J, Roger K, García-Puente Y, Doussau A, Vinay MC, Von Siebenthal Z, Paquette N, Poirier N, Gallagher A. Relationship between 4-month functional brain network topology and 24-month neurodevelopmental outcome in children with congenital heart disease. Eur J Paediatr Neurol 2023; 47:47-59. [PMID: 37729706 DOI: 10.1016/j.ejpn.2023.09.005] [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] [Received: 11/10/2022] [Revised: 07/24/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023]
Abstract
Survivors of complex forms of congenital heart disease (CHD)∗ are at high risk of neurodevelopmental disabilities. Neuroimaging studies have pointed to brain anomalies and immature networks in infants with CHD, yet less is known about their functional network topology and associations with neurodevelopment. To characterize the functional network topology in 4-month-old infants with repaired CHD, we compared graph theory metrics measured using resting-state functional near-infrared spectroscopy (rs-fNIRS) between infants with CHD (n = 22) and healthy controls (n = 30). We also investigated the moderating effect of graph theory metrics on the relationship between group (CHD vs. Controls) and developmental outcomes at 24 months. At 4 months, both groups presented similar functional brain network topology. At 24 months, children with CHD had lower scores on the language scale and the expressive communication subscale of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), as well as lower scores on the Grammatical Form scale of the MacArthur-Bates Communicative Development Inventory (MBCDI). The relationship between group and expressive language was moderated by the normalized characteristic path length (λ) and the degree (k). Although infants with CHD have functional brain topology similar to that of healthy controls, our findings suggest that they do not benefit from an optimal functional brain organization in comparison with healthy infants.
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Affiliation(s)
- Sarah Provost
- Department of Psychology, Université de Montréal, Montreal, QC, Canada; Neurodevelopmental Optical Imaging Lab (LIONlab), Sainte-Justine University Hospital Research Center, Montreal, QC, Canada
| | - Solène Fourdain
- Department of Psychology, Université de Montréal, Montreal, QC, Canada; Neurodevelopmental Optical Imaging Lab (LIONlab), Sainte-Justine University Hospital Research Center, Montreal, QC, Canada
| | - Phetsamone Vannasing
- Neurodevelopmental Optical Imaging Lab (LIONlab), Sainte-Justine University Hospital Research Center, Montreal, QC, Canada
| | - Julie Tremblay
- Neurodevelopmental Optical Imaging Lab (LIONlab), Sainte-Justine University Hospital Research Center, Montreal, QC, Canada
| | - Kassandra Roger
- Department of Psychology, Université de Montréal, Montreal, QC, Canada; Neurodevelopmental Optical Imaging Lab (LIONlab), Sainte-Justine University Hospital Research Center, Montreal, QC, Canada
| | | | - Amélie Doussau
- Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | | | - Zorina Von Siebenthal
- Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | - Natacha Paquette
- Neurodevelopmental Optical Imaging Lab (LIONlab), Sainte-Justine University Hospital Research Center, Montreal, QC, Canada
| | - Nancy Poirier
- Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | - Anne Gallagher
- Department of Psychology, Université de Montréal, Montreal, QC, Canada; Neurodevelopmental Optical Imaging Lab (LIONlab), Sainte-Justine University Hospital Research Center, Montreal, QC, Canada.
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28
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Sanz JH, Cox S, Donofrio MT, Ishibashi N, McQuillen P, Peyvandi S, Schlatterer S. [Formula: see text] Trajectories of neurodevelopment and opportunities for intervention across the lifespan in congenital heart disease. Child Neuropsychol 2023; 29:1128-1154. [PMID: 36752083 PMCID: PMC10406974 DOI: 10.1080/09297049.2023.2173162] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
Children with congenital heart disease (CHD) are at increased risk for neurodevelopmental challenges across the lifespan. These are associated with neurological changes and potential acquired brain injury, which occur across a developmental trajectory and which are influenced by an array of medical, sociodemographic, environmental, and personal factors. These alterations to brain development lead to an array of adverse neurodevelopmental outcomes, which impact a characteristic set of skills over the course of development. The current paper reviews existing knowledge of aberrant brain development and brain injury alongside associated neurodevelopmental challenges across the lifespan. These provide a framework for discussion of emerging and potential interventions to improve neurodevelopmental outcomes at each developmental stage.
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Affiliation(s)
- Jacqueline H Sanz
- Division of Neuropsychology, Children's National Hospital, Washington, D.C
- Departments of Psychiatry and Behavioral Sciences & Pediatrics at The George Washington University School of Medicine
| | - Stephany Cox
- Department of Pediatrics, Division of Developmental Medicine, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Mary T Donofrio
- Division of Cardiology, Children's National Health System, Washington, D.C
- Department of Pediatrics at The George Washington University School of Medicine
| | - Nobuyuki Ishibashi
- Department of Pediatrics at The George Washington University School of Medicine
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington D.C
| | - Patrick McQuillen
- Department of Pediatrics, Division of Developmental Medicine, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Shabnam Peyvandi
- Department of Pediatrics, Division of Developmental Medicine, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Sarah Schlatterer
- Department of Pediatrics at The George Washington University School of Medicine
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, D.C
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, D.C
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29
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Hill NM, Malone LA, Sun LR. Stroke in the Developing Brain: Neurophysiologic Implications of Stroke Timing, Location, and Comorbid Factors. Pediatr Neurol 2023; 148:37-43. [PMID: 37651976 DOI: 10.1016/j.pediatrneurol.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Pediatric stroke, which is unique in that it represents a static insult to a developing brain, often leads to long-term neurological disability. Neuroplasticity in infants and children influences neurophysiologic recovery patterns after stroke; therefore outcomes depend on several factors including the timing and location of stroke and the presence of comorbid conditions. METHODS In this review, we discuss the unique implications of stroke occurring in the fetal, perinatal, and childhood/adolescent time periods. First, we highlight the impact of the developmental stage of the brain at the time of insult on the motor, sensory, cognitive, speech, and behavioral domains. Next, we consider the influence of location of stroke on the presence and severity of motor and nonmotor outcomes. Finally, we discuss the impact of associated conditions on long-term outcomes and risk for stroke recurrence. RESULTS Hemiparesis is common after stroke at any age, although the severity of impairment differs by age group. Risk of epilepsy is elevated in all age groups compared with those without stroke. Outcomes in other domains vary by age, although several studies suggest worse cognitive outcomes when stroke occurs in early childhood compared with fetal and later childhood epochs. Conditions such as congenital heart disease, sickle cell disease, and moyamoya increase the risk of stroke and leave patients differentially vulnerable to neurodevelopmental delay, stroke recurrence, silent infarcts, and cognitive impairment. CONCLUSIONS A comprehensive understanding of the interplay of various factors is essential in guiding the clinical care of patients with pediatric stroke.
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Affiliation(s)
- Nayo M Hill
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura A Malone
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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30
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Lynch JM, Gaynor JW, Licht DJ. Commentary on "Brain Injury During Transition in the Newborn With Congenital Heart Disease: Hazards of the Preoperative Period". Semin Pediatr Neurol 2023; 47:101075. [PMID: 37919030 DOI: 10.1016/j.spen.2023.101075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 11/04/2023]
Abstract
BRAIN INJURY DURING TRANSITION IN THE NEWBORN WITH CONGENITAL HEART DISEASE: HAZARDS OF THE PREOPERATIVE PERIOD: Jennifer M. Lynch, J. William Gaynor, Daniel J. Licht Seminars in Pediatric Neurology Volume 28, December 2018, Pages 60-65 Infants born with critical congenital heart disease are at risk for neurodevelopmental morbidities later in life. In-utero differences in fetal circulation lead to vulnerabilities which lead to an increased incidence of stroke, white matter injury, and brain immaturity. Recent work has shown these infants may be most vulnerable to brain injury during the early neonatal period when they are awaiting their cardiac surgeries. Novel imaging and monitoring modalities are being employed to investigate this crucial time period and elucidate the precise timing and cause of brain injury in this population.
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Affiliation(s)
- Jennifer M Lynch
- Division of Cardiothoracic Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Daniel J Licht
- Perinatal Pediatrics Institute, Children's National, Washington, DC
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31
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VanHaltren K, Armstrong RK, Gunn-Charlton JK. Functional measures on PEDI are associated with BSID-3 scales at 2 years, following neonatal surgery. Early Hum Dev 2023; 185:105854. [PMID: 37677891 DOI: 10.1016/j.earlhumdev.2023.105854] [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] [Received: 11/16/2022] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Neonates requiring early surgical intervention for major non-cardiac congenital anomalies are at high risk of adverse neurodevelopmental outcomes. Early recognition of potential neuro-developmental delay is critical to facilitate access to early childhood intervention services and therefore maximise the functional capabilities of these children. AIMS This study aims to compare Bayley's Scales of Infant and Toddler Development (BSID-3) and the Paediatric Evaluation of Disability Inventory (PEDI) as early screening tools in predicting neuro-developmental disability across multiple domains. In addition, it looks at determining which pre, peri and post-operative risk factors lend themselves to more adverse outcomes. STUDY DESIGN Retrospective cohort study. SUBJECTS Neonates requiring surgical intervention at the Royal Children's Hospital from 2012 to 2018 who subsequently underwent neurodevelopmental assessment at 2 years of age. OUTCOME MEASURES The main outcome was the relationship between performance on the PEDI compared with the BSID-3, in 2-year-olds following neonatal surgery. RESULTS Parent -reported functional measures across all domains on PEDI strongly related to the more formal measures of cognition, language, and motor development assessed on BSID-3 (p < 0.05). CONCLUSIONS The questionnaire-based PEDI tool could be considered a reliable replacement to the formal Bayley (BSID-3) scale in low-risk infants and provide a more accessible means of assessment where there are deficiencies in availability of suitably trained clinicians or limited resource centres.
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Affiliation(s)
- Karen VanHaltren
- Department of Neonatal Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, Mercy Hospital for Women, 163 Studley Road, Heidelberg, Victoria 3084, Australia.
| | - Ruth K Armstrong
- Department of Neonatal Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia.
| | - Julia K Gunn-Charlton
- Department of Neonatal Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria 3052, Australia; Neonatal Research Group, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, Mercy Hospital for Women, 163 Studley Road, Heidelberg, Victoria 3084, Australia.
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32
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Meadows JJ, Bauser-Heaton H, Petit CJ, Goldstein BH, Qureshi AM, McCracken CE, Kelleman MS, Nicholson GT, Law MA, Zampi JD, Shahanavaz S, Chai PJ, Romano JC, Batlivala SP, Maskatia SA, Asztalos IB, Eilers L, Kamsheh AM, Healan SJ, Smith JD, Ligon RA, Dailey-Schwartz A, Pettus JA, Pajk AL, Glatz AC, Mascio CE. Comparison of treatment strategies for neonates with tetralogy of Fallot and pulmonary atresia. J Thorac Cardiovasc Surg 2023; 166:916-925.e6. [PMID: 36828672 DOI: 10.1016/j.jtcvs.2023.01.008] [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] [Received: 09/09/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Neonates with tetralogy of Fallot and pulmonary atresia (TOF/PA) but no major aorta-pulmonary collaterals are dependent on the arterial duct for pulmonary blood flow and require early intervention, either by primary (PR) or staged repair (SR) with initial palliation (IP) followed by complete repair (CR). The optimal approach has not been established. METHODS Neonates with TOF/PA who underwent PR or SR were retrospectively reviewed from the Congenital Cardiac Research Collaborative. Outcomes were compared between PR and SR (IP + CR) strategies. Propensity scoring was used to adjust for baseline differences. The primary outcome was mortality. Secondary outcomes included complications, length of stay, cardiopulmonary bypass and anesthesia times, reintervention (RI), and pulmonary artery (PA) growth. RESULTS Of 282 neonates, 106 underwent PR and 176 underwent SR (IP: 144 surgical, 32 transcatheter). Patients who underwent SR were more likely to have DiGeorge syndrome and greater rates of mechanical ventilation before the initial intervention. Mortality was not significantly different. Duration of mechanical ventilation, inotrope use, and complication rates were similar. Cumulative length of stay, cardiopulmonary bypass, and anesthesia times favored PR (P ≤ .001). Early RI was more common in patients who underwent SR (rate ratio, 1.42; P = .003) but was similar after CR (P = .837). Conduit size at the time of CR was larger with SR. Right PA growth was greater with PR. CONCLUSIONS In neonates with TOF/PA, SR is more common in greater-risk patients. Accounting for this, SR and PR strategies have similar mortality. Perioperative morbidities, RI, and right PA growth generally favor PR, whereas SR allows for larger initial conduit implantation.
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Affiliation(s)
- Jeffery J Meadows
- Department of Pediatrics, University of California, San Francisco, San Francisco, Calif; Benioff Children's Hospital, San Francisco, Calif.
| | - Holly Bauser-Heaton
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga; Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Christopher J Petit
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga; Division of Cardiology, Morgan Stanley Children's Hospital of New York, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Bryan H Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati School of Medicine, Cincinnati, Ohio; Department of Pediatrics, Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Athar M Qureshi
- Lillie Frank Abercrombie Section on Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Courtney E McCracken
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Michael S Kelleman
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - George T Nicholson
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Mark A Law
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala
| | - Jeffrey D Zampi
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Mich
| | - Shabana Shahanavaz
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Paul J Chai
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Jennifer C Romano
- Section of Pediatric Cardiothoracic Surgery, Department of Cardiac Surgery, CS Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, Mich
| | - Sarosh P Batlivala
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Shiraz A Maskatia
- Moore Children's Heart Center, Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, Calif
| | - Ivor B Asztalos
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Lindsay Eilers
- Lillie Frank Abercrombie Section on Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Alicia M Kamsheh
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Steven J Healan
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Justin D Smith
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Mich
| | - R Allen Ligon
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Andrew Dailey-Schwartz
- Lillie Frank Abercrombie Section on Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Joelle A Pettus
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Amy L Pajk
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Andrew C Glatz
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Washington University Heart Center at St Louis Children's Hospital, St. Louis, Mo
| | - Christopher E Mascio
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WVa
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Katz JA, Levy PT, Butler SC, Sadhwani A, Lakshminrusimha S, Morton SU, Newburger JW. Preterm congenital heart disease and neurodevelopment: the importance of looking beyond the initial hospitalization. J Perinatol 2023; 43:958-962. [PMID: 37179381 DOI: 10.1038/s41372-023-01687-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
Congenital heart disease (CHD) and prematurity are leading causes of infant mortality in the United States. Infants with CHD born prematurely are often described as facing "double jeopardy" with vulnerability from their underlying heart disease and from organ immaturity. They endure additional complications of developing in the extrauterine environment while healing from interventions for heart disease. While morbidity and mortality for neonates with CHD have declined over the past decade, preterm neonates with CHD remain at higher risk for adverse outcomes. Less is known about their neurodevelopmental and functional outcomes. In this perspective paper, we review the prevalence of preterm birth among infants with CHD, highlight the medical complexity of these infants, and emphasize the importance of exploring outcomes beyond survival. We focus on current knowledge regarding overlaps in the mechanisms of neurodevelopmental impairment associated with CHD and prematurity and discuss future directions for improving neurodevelopmental outcomes.
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Affiliation(s)
- Jenna A Katz
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Samantha C Butler
- Departments of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Anjali Sadhwani
- Departments of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | | | - Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jane W Newburger
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
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Easson K, Gilbert G, Gauthier C, Rohlicek CV, Saint-Martin C, Brossard-Racine M. Sex-Specific Cerebral Blood Flow Alterations in Youth Operated for Congenital Heart Disease. J Am Heart Assoc 2023:e028378. [PMID: 37301764 DOI: 10.1161/jaha.122.028378] [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: 11/03/2022] [Accepted: 03/23/2023] [Indexed: 06/12/2023]
Abstract
Background Lower cerebral blood flow (CBF) has previously been documented preoperatively in neonates with congenital heart disease (CHD). However, it remains unclear if these CBF deficits persist over the life span of CHD survivors following heart surgery. When exploring this question, it is critical to consider the sex differences in CBF that emerge during adolescence. Therefore, this study aimed to compare global and regional CBF between postpubertal youth with CHD and healthy peers and examine if such alterations are related to sex. Methods and Results Youth aged 16 to 24 years who underwent open heart surgery for complex CHD during infancy and age- and sex-matched controls completed brain magnetic resonance imaging, including T1-weighted and pseudo-continuous arterial spin labeling acquisitions. Global gray matter CBF and regional CBF in 9 bilateral gray matter regions were quantified for each participant. Compared with female controls (N=27), female participants with CHD (N=25) presented with lower global and regional CBF. In contrast, there were no differences in CBF between male controls (N=18) and males with CHD (N=17). Concurrently, female controls had higher global and regional CBF compared with male controls, with no differences in CBF between female and male participants with CHD. CBF was lower in individuals with a Fontan circulation. Conclusions This study provides evidence of altered CBF in postpubertal female participants with CHD despite undergoing surgical intervention during infancy. Alterations to CBF could have implications for later cognitive decline, neurodegeneration, and cerebrovascular disease in women with CHD.
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Affiliation(s)
- Kaitlyn Easson
- Advances in Brain & Child Development (ABCD) Research Laboratory Research Institute of the McGill University Health Centre Montreal Quebec Canada
- Department of Neurology & Neurosurgery, Faculty of Medicine & Health Sciences McGill University Quebec Montreal Canada
| | | | - Claudine Gauthier
- Department of Physics Concordia University Montreal Quebec Canada
- Montreal Heart Institute Research Centre Montreal Quebec Canada
| | - Charles V Rohlicek
- Division of Cardiology, Department of Pediatrics Montreal Children's Hospital Montreal Quebec Canada
| | - Christine Saint-Martin
- Division of Pediatric Radiology, Department of Medical Imaging Montreal Children's Hospital Montreal Quebec Canada
| | - Marie Brossard-Racine
- Advances in Brain & Child Development (ABCD) Research Laboratory Research Institute of the McGill University Health Centre Montreal Quebec Canada
- Department of Neurology & Neurosurgery, Faculty of Medicine & Health Sciences McGill University Quebec Montreal Canada
- Division of Neonatology, Department of Pediatrics Montreal Children's Hospital Montreal Quebec Canada
- School of Physical & Occupational Therapy, Faculty of Medicine and Health Sciences McGill University Quebec Montreal Canada
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Feng J, Zhang Y, Zhang J, Liu T, Ma L, Zou M, Chen W, Chen X, Li J. Evaluation of neurodevelopmental impairments and risk factors in children following cardiac surgery: The first cohort from China. JTCVS OPEN 2023; 14:462-471. [PMID: 37425439 PMCID: PMC10328831 DOI: 10.1016/j.xjon.2023.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 07/11/2023]
Abstract
Objective Neurodevelopmental impairment has been realized as the most common complication in children with congenital heart disease undergoing cardiac surgery during the past 30 years. But little attention has been paid to this problem in China. The potential risk factors for adverse outcomes include demographic, perioperative, and socioeconomic factors, which are vastly different in China compared with the developed countries in previous reports. Methods Four hundred twenty-six patients (aged 35.9 ± 18.6 months) at about 1- to 3-year follow-up after cardiac surgery were prospectively enrolled from March 2019 to February 2022. Griffiths Mental Development Scales-Chinese was used to evaluate the quotients of overall development and 5 subscales of the child's locomotor, language, personal-social, eye-hand coordination, and performance skills. Demographic, perioperative, socioeconomic, and feeding type during the first year of life (breastfeeding, mixed, or never breastfeeding) were examined to identify the risk factors for adverse neurodevelopmental outcomes. Results Mean scores were 90.0 ± 15.5 for development quotient, 92.3 ± 19.4 for locomotor, 89.6 ± 19.2 for personal-social, 85.5 ± 21.7 for language, 90.3 ± 17.2 for eye-hand coordination, and 92 ± 17.1 for performance subscales. For the entire cohort, the impairment in at least 1 subscale was found in 76.1% of the cohort (>1 SD below population mean) with 50.1% being severe (>2 SDs below the mean). The significant risk factors included prolonged hospital stay, peak level of postoperative C-reactive protein, socioeconomic status, and never breastfeeding or mixed feeding. Conclusions Neurodevelopmental impairment is substantial in terms of incidence and severity in children with congenital heart disease undergoing cardiac surgery in China. Risk factors contributing to the adverse outcomes included prolonged hospital stay, early postoperative inflammatory response, socioeconomic status, and never breastfeeding or mixed feeding. There is an urgent need for standardized follow-up and neurodevelopmental assessment in this special group of children in China.
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Affiliation(s)
- Jinqing Feng
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Yani Zhang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Jinyuan Zhang
- School of Health Management, Guangzhou Medical University, Guangzhou, China
| | - Techang Liu
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Li Ma
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Minghui Zou
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Wenxiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Xinxin Chen
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Jia Li
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
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36
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Mir M, Moore SS, Wutthigate P, Simoneau J, Villegas Martinez D, Shemie SD, Brossard-Racine M, Dancea A, Bertolizio G, Altit G. Newborns with a Congenital Heart Defect and Diastolic Steal Have an Altered Cerebral Arterial Doppler Profile. J Pediatr 2023; 257:113369. [PMID: 36868306 DOI: 10.1016/j.jpeds.2023.02.015] [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] [Received: 08/18/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVES To compare trends in the anterior cerebral artery (ACA) Doppler markers of vascular flow for neonates with a congenital heart defect (CHD) with and without diastolic systemic steal during the first 7 days of life. METHODS Prospective study recruiting newborns (≥35 weeks of gestation) with a CHD. Doppler ultrasound and echocardiography were performed daily from day 1 to 7. The cohort was divided into the presence/absence of holo-diastolic retrograde flow in the postductal aorta ("retrograde") on the last-available echocardiogram. Data extractors were masked to retrograde status. Mixed effect models (random slope/intercept) were constructed using RStudio. RESULTS We enrolled 38 neonates with CHD. Retrograde aortic flow was present on the last echocardiogram in 23 (61%). Peak systolic velocity and mean velocity increased significantly over time, independent of retrograde status. However, having a "retrograde" flow status conferred a significant decrease over time of their ACA-end-diastolic velocity (β = -5.75 cm/s, 95% CI -8.38 to -3.12, P < .001, when compared with the nonretrograde group), and a significant increase in the ACA resistive (β = 0.16, 95% CI 0.10-0.22, P < .001) and pulsatility (β = 0.49, 95% CI 0.28-0.69, P < .001) indexes. No subject presented retrograde diastolic flow in the ACA. CONCLUSIONS In neonates with CHD in the first week of life, infants with echocardiographic signs of systemic diastolic steal within the pulmonary circulation have Doppler signs of cerebrovascular steal in the ACA.
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Affiliation(s)
- Marina Mir
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada; Division of Pediatrics, Universitat Autonoma de Barcelona, Barcelona, Spain; Institute for Research and Innovation Parc Tauli (I3PT), Barcelona, Spain; Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Shiran Sara Moore
- Division of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Medical Center, Tel-Aviv, Israel
| | - Punnanee Wutthigate
- Division of Neonatology, Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jessica Simoneau
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Daniela Villegas Martinez
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sam D Shemie
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Division of Critical Care Medicine, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Marie Brossard-Racine
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Adrian Dancea
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Division of Pediatric Cardiology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Gianluca Bertolizio
- Department of Pediatric Anesthesia, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Gabriel Altit
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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Ubeda Tikkanen A, Vova J, Holman L, Chrisman M, Clarkson K, Santiago R, Schonberger L, White K, Badaly D, Gauthier N, Pham TDN, Britt JJ, Crouter SE, Giangregorio M, Nathan M, Akamagwuna UO. Core components of a rehabilitation program in pediatric cardiac disease. Front Pediatr 2023; 11:1104794. [PMID: 37334215 PMCID: PMC10275574 DOI: 10.3389/fped.2023.1104794] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 04/17/2023] [Indexed: 06/20/2023] Open
Abstract
There is increasing effort in both the inpatient and outpatient setting to improve care, function, and quality of life for children with congenital heart disease, and to decrease complications. As the mortality rates of surgical procedures for congenital heart disease decrease, improvement in perioperative morbidity and quality of life have become key metrics of quality of care. Quality of life and function in patients with congenital heart disease can be affected by multiple factors: the underlying heart condition, cardiac surgery, complications, and medical treatment. Some of the functional areas affected are motor abilities, exercise capacity, feeding, speech, cognition, and psychosocial adjustment. Rehabilitation interventions aim to enhance and restore functional ability and quality of life for those with physical impairments or disabilities. Interventions such as exercise training have been extensively evaluated in adults with acquired heart disease, and rehabilitation interventions for pediatric patients with congenital heart disease have similar potential to improve perioperative morbidity and quality of life. However, literature regarding the pediatric population is limited. We have gathered a multidisciplinary team of experts from major institutions to create evidence- and practice-based guidelines for pediatric cardiac rehabilitation programs in both inpatient and outpatient settings. To improve the quality of life of pediatric patients with congenital heart disease, we propose the use of individualized multidisciplinary rehabilitation programs that include: medical management; neuropsychology; nursing care; rehabilitation equipment; physical, occupational, speech, and feeding therapies; and exercise training.
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Affiliation(s)
- Ana Ubeda Tikkanen
- Department of Pediatric Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, United States
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, MA, United States
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
| | - Joshua Vova
- Department of Physiatry, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Lainie Holman
- Department Pediatric Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH, United States
| | - Maddie Chrisman
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Kristin Clarkson
- Department of Pediatric Physical Medicine and Rehabilitation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Rachel Santiago
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA, United States
| | - Lisa Schonberger
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA, United States
| | - Kelsey White
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA, United States
| | - Daryaneh Badaly
- Learning and Development Center, Child Mind Institute, New York, NY, United States
| | - Naomi Gauthier
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Tam Dan N. Pham
- Department of Pediatric Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Jolie J. Britt
- Department of Pediatric Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Scott E. Crouter
- Department of Kinesiology, Recreation, and Sport Studies, The University of Tennessee Knoxville, Knoxville, IL, United States
| | - Maeve Giangregorio
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, United States
| | - Unoma O. Akamagwuna
- Department Pediatric Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, TX, United States
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, TX, United States
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Wiafe YA, Amponsah GM, Asafu Adjaye Frimpong G, Owusu IK. Progressive Memory Decline in a Patient With Atrial Septal Defect: Case Report and Literature Review. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231176713. [PMID: 37255701 PMCID: PMC10225960 DOI: 10.1177/11795476231176713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/01/2023] [Indexed: 06/01/2023]
Abstract
Atrial septal defect (ASD) is a common congenital anomaly that increases the risk of heart failure as well as strokes which can lead to cognitive impairment. The risk of stroke is higher when pulmonary hypertension develops and there is reversal of shunt. Stroke in ASD may be due to paradoxical emboli from the right heart or a left ventricular thrombus which develops as a result of atrial fibrillation, a common arrhythmia in ASD. We present a case of a 32-year-old Ghanaian man with history of ASD who presented with progressive memory loss with magnetic resonance imaging scan of the brain showing multiple infarcts, microvascular disease, and cerebral atrophy.
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Affiliation(s)
- Yaw Amo Wiafe
- Department of Medical Diagnostics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Gordon Manu Amponsah
- Department of Physiology, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - George Asafu Adjaye Frimpong
- Department of Radiology, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Isaac Kofi Owusu
- Department of Medicine, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Schmithorst V, Ceschin R, Lee V, Wallace J, Sahel A, Chenevert TL, Parmar H, Berman JI, Vossough A, Qiu D, Kadom N, Grant PE, Gagoski B, LaViolette PS, Maheshwari M, Sleeper LA, Bellinger DC, Ilardi D, O’Neil S, Miller TA, Detterich J, Hill KD, Atz AM, Richmond ME, Cnota J, Mahle WT, Ghanayem NS, Gaynor JW, Goldberg CS, Newburger JW, Panigrahy A. Single Ventricle Reconstruction III: Brain Connectome and Neurodevelopmental Outcomes: Design, Recruitment, and Technical Challenges of a Multicenter, Observational Neuroimaging Study. Diagnostics (Basel) 2023; 13:1604. [PMID: 37174995 PMCID: PMC10178603 DOI: 10.3390/diagnostics13091604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
Patients with hypoplastic left heart syndrome who have been palliated with the Fontan procedure are at risk for adverse neurodevelopmental outcomes, lower quality of life, and reduced employability. We describe the methods (including quality assurance and quality control protocols) and challenges of a multi-center observational ancillary study, SVRIII (Single Ventricle Reconstruction Trial) Brain Connectome. Our original goal was to obtain advanced neuroimaging (Diffusion Tensor Imaging and Resting-BOLD) in 140 SVR III participants and 100 healthy controls for brain connectome analyses. Linear regression and mediation statistical methods will be used to analyze associations of brain connectome measures with neurocognitive measures and clinical risk factors. Initial recruitment challenges occurred that were related to difficulties with: (1) coordinating brain MRI for participants already undergoing extensive testing in the parent study, and (2) recruiting healthy control subjects. The COVID-19 pandemic negatively affected enrollment late in the study. Enrollment challenges were addressed by: (1) adding additional study sites, (2) increasing the frequency of meetings with site coordinators, and (3) developing additional healthy control recruitment strategies, including using research registries and advertising the study to community-based groups. Technical challenges that emerged early in the study were related to the acquisition, harmonization, and transfer of neuroimages. These hurdles were successfully overcome with protocol modifications and frequent site visits that involved human and synthetic phantoms.
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Affiliation(s)
- Vanessa Schmithorst
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Rafael Ceschin
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
- Department of Biomedical Informatics, University of Pittsburgh School, 5607 Baum Blvd., Pittsburgh, PA 15206, USA
| | - Vincent Lee
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Julia Wallace
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Aurelia Sahel
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Thomas L. Chenevert
- Michigan Medicine Department of Radiology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Hemant Parmar
- Michigan Medicine Department of Radiology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Jeffrey I. Berman
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Deqiang Qiu
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322, USA
| | - Patricia Ellen Grant
- Children’s Hospital Boston, Fetal-Neonatal Neuroimaging and Developmental Science Center (FNNDSC), 300 Longwood Avenue, Boston, MA 02115, USA
| | - Borjan Gagoski
- Department of Radiology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Peter S. LaViolette
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Mohit Maheshwari
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - David C. Bellinger
- Cardiac Neurodevelopmental Program, Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA 30329, USA
| | - Sharon O’Neil
- Children’s Hospital Los Angeles, Neuropsychology Core of the Saban Research Institute, 4661 Sunset Blvd., Los Angeles, CA 90027, USA
| | - Thomas A. Miller
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Jon Detterich
- Division of Pediatric Cardiology, Children’s Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027, USA
| | - Kevin D. Hill
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 7506 Hospital North, DUMC Box 3090, Durham, NC 27710, USA
| | - Andrew M. Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, 96 Jonathan Lucas St. Ste. 601, MSC 617, Charleston, SC 29425, USA
| | - Marc E. Richmond
- Program for Pediatric Cardiomyopathy, Heart Failure, and Transplantation, New York-Presbyterian Morgan Stanley Children’s Hospital, 3959 Broadway MSCH North, 2nd Floor, New York, NY 10032, USA
| | - James Cnota
- Fetal Heart Program, Cincinnati Children’s, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - William T. Mahle
- Division of Pediatric Cardiology, Children’s Healthcare of Atlanta, 1400 Tullie Rd NE Suite 630, Atlanta, GA 30329, USA
| | - Nancy S. Ghanayem
- Section of Pediatric Critical Care, Department of Pediatrics, Comer Children’s Hospital, University of Chicago Medicine, 5721 S. Maryland Avenue, Chicago, IL 60637, USA
- Department of Pediatrics, Medical College of Wisconsin Section of Pediatric Critical Care, 9000 W. Wisconsin Avenue MS 681, Milwaukee, WI 53226, USA
| | - J. William Gaynor
- Heart Failure and Transplant Program, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Caren S. Goldberg
- Department of Pediatrics, Division of Cardiology, C.S. Mott Children’s Hospital, 1540 E Hospital Dr #4204, Ann Arbor, MI 48109, USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
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Schmithorst V, Ceschin R, Lee V, Wallace J, Sahel A, Chenevert T, Parmar H, Berman JI, Vossough A, Qiu D, Kadom N, Grant PE, Gagoski B, LaViolette P, Maheshwari M, Sleeper LA, Bellinger D, Ilardi D, O’Neil S, Miller TA, Detterich J, Hill KD, Atz AM, Richmond M, Cnota J, Mahle WT, Ghanayem N, Gaynor W, Goldberg CS, Newburger JW, Panigrahy A. Single Ventricle Reconstruction III: Brain Connectome and Neurodevelopmental Outcomes: Design, Recruitment, and Technical Challenges of a Multicenter, Observational Neuroimaging Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.12.23288433. [PMID: 37131744 PMCID: PMC10153324 DOI: 10.1101/2023.04.12.23288433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Patients with hypoplastic left heart syndrome who have been palliated with the Fontan procedure are at risk for adverse neurodevelopmental outcomes, lower quality of life, and reduced employability. We describe the methods (including quality assurance and quality control protocols) and challenges of a multi-center observational ancillary study, SVRIII (Single Ventricle Reconstruction Trial) Brain Connectome. Our original goal was to obtain advanced neuroimaging (Diffusion Tensor Imaging and Resting-BOLD) in 140 SVR III participants and 100 healthy controls for brain connectome analyses. Linear regression and mediation statistical methods will be used to analyze associations of brain connectome measures with neurocognitive measures and clinical risk factors. Initial recruitment challenges occurred related to difficulties with: 1) coordinating brain MRI for participants already undergoing extensive testing in the parent study, and 2) recruiting healthy control subjects. The COVID-19 pandemic negatively affected enrollment late in the study. Enrollment challenges were addressed by 1) adding additional study sites, 2) increasing the frequency of meetings with site coordinators and 3) developing additional healthy control recruitment strategies, including using research registries and advertising the study to community-based groups. Technical challenges that emerged early in the study were related to the acquisition, harmonization, and transfer of neuroimages. These hurdles were successfully overcome with protocol modifications and frequent site visits that involved human and synthetic phantoms. Trial registration number ClinicalTrials.gov Registration Number: NCT02692443.
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Affiliation(s)
- Vanessa Schmithorst
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
| | - Rafael Ceschin
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
- Department of Biomedical Informatics, University of Pittsburgh School, 5607 Baum Blvd, Pittsburgh, PA 15206-3701 USA
| | - Vince Lee
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
| | - Julia Wallace
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
| | - Aurelia Sahel
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
| | - Thomas Chenevert
- Department of Radiology, Michigan Medicine, University of Michigan, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
| | - Hemant Parmar
- Department of Radiology, Michigan Medicine, University of Michigan, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
| | - Jeffrey I. Berman
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Deqiang Qiu
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322 USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322 USA
| | - Patricia Ellen Grant
- Fetal-Neonatal Neuroimaging and Developmental Science Center (FNNDSC), Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Borjan Gagoski
- Department of Radiology, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115 USA
| | - Peter LaViolette
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
| | - Mohit Maheshwari
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115
- Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - David Bellinger
- Cardiac Neurodevelopmental Program, Department of Neurology, Boston, Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA 30329
| | - Sharon O’Neil
- Neuropsychology Core of the Saban Research Institute, Children’s Hospital Los Angeles, 4661 Sunset Blvd., Los Angeles, CA 90027 USA
| | - Thomas A. Miller
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132 USA
| | - Jon Detterich
- Division of Pediatric Cardiology, Children’s Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027 USA
| | - Kevin D. Hill
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University, School of Medicine, 7506 Hospital North, DUMC Box 3090, Durham, NC 27710 USA
| | - Andrew M. Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, 96 Jonathan Lucas St. Ste. 601, MSC 617, Charleston, SC 29425 USA
| | - Marc Richmond
- Program for Pediatric Cardiomyopathy, Heart Failure, and Transplantation, New York-Presbyterian Morgan Stanley Children’s Hospital, 3959 Broadway MSCH North, 2 Floor, New York, NY 10032 USA
| | - James Cnota
- Fetal Heart Program, Cincinnati Children’s, 3333 Burnet Avenue, Cincinnati, Ohio 45229-3026 USA
| | - William T. Mahle
- Division of Pediatric Cardiology, Children’s Healthcare of Atlanta, 1400 Tullie Rd NE Suite 630, Atlanta, GA 30329
| | - Nancy Ghanayem
- Section of Pediatric Critical Care, Department of Pediatrics, University of Chicago Medicine, Comer Children’s Hospital, 5721 S. Maryland Ave., Chicago, IL 60637 USA
- Section of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, 9000 W. Wisconsin Ave. MS 681, Milwaukee, WI 53226 USA
| | - William Gaynor
- Heart Failure and Transplant Program, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Caren S. Goldberg
- Department of Pediatrics, Division of Cardiology, C.S. Mott Children’s Hospital, 1540 E Hospital Dr #4204, Ann Arbor, MI 48109 USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
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41
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Licht DJ, Jacobwitz M, Lynch JM, Ko T, Boorady T, Devarajan M, Heye KN, Mensah‐Brown K, Newland JJ, Schmidt A, Schwab P, Winters M, Nicolson SC, Montenegro LM, Fuller S, Mascio C, Gaynor JW, Yodh AG, Gebb J, Vossough A, Choi GH, Putt ME. Impaired Maternal-Fetal Environment and Risk for Preoperative Focal White Matter Injury in Neonates With Complex Congenital Heart Disease. J Am Heart Assoc 2023; 12:e025516. [PMID: 36974759 PMCID: PMC10122900 DOI: 10.1161/jaha.122.025516] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
Background Infants with congenital heart disease (CHD) are at risk for white matter injury (WMI) before neonatal heart surgery. Better knowledge of the causes of preoperative WMI may provide insights into interventions that improve neurodevelopmental outcomes in these patients. Methods and Results A prospective single-center study of preoperative WMI in neonates with CHD recorded data on primary cardiac diagnosis, maternal-fetal environment (MFE), delivery type, subject anthropometrics, and preoperative care. Total maturation score and WMI were assessed, and stepwise logistic regression modeling selected risk factors for WMI. Among subjects with severe CHD (n=183) who received a preoperative brain magnetic resonance imaging, WMI occurred in 40 (21.9%) patients. WMI prevalence (21.4%-22.1%) and mean volumes (119.7-160.4 mm3) were similar across CHD diagnoses. Stepwise logistic regression selected impaired MFE (odds ratio [OR], 2.85 [95% CI, 1.29-6.30]), male sex (OR, 2.27 [95% CI, 1.03-5.36]), and older age at surgery/magnetic resonance imaging (OR, 1.20 per day [95% CI, 1.03-1.41]) as risk factors for preoperative WMI and higher total maturation score values (OR, 0.65 per unit increase [95% CI, 0.43-0.95]) as protective. A quarter (24.6%; n=45) of subjects had ≥1 components of impaired MFE (gestational diabetes [n=12; 6.6%], gestational hypertension [n=11; 6.0%], preeclampsia [n=2; 1.1%], tobacco use [n=9; 4.9%], hypothyroidism [n=6; 3.3%], and other [n=16; 8.7%]). In a subset of 138 subjects, an exploratory analysis of additional MFE-related factors disclosed other potential risk factors for WMI. Conclusions This study is the first to identify impaired MFE as an important risk factor for preoperative WMI. Vulnerability to preoperative WMI was shared across CHD diagnoses.
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Affiliation(s)
- Daniel J. Licht
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Marin Jacobwitz
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Jennifer M. Lynch
- Department of Anesthesia and Critical Care, Division of Cardiac AnesthesiaThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Tiffany Ko
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Timothy Boorady
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Mahima Devarajan
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Kristina N. Heye
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Kobina Mensah‐Brown
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - John J. Newland
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Alexander Schmidt
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Peter Schwab
- Department of NeurologyThe University of PennsylvaniaPennsylvaniaPA
| | - Madeline Winters
- Department of Pediatrics, Division of NeurologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Susan C. Nicolson
- Department of Anesthesia and Critical Care, Division of Cardiac AnesthesiaThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Lisa M. Montenegro
- Department of Anesthesia and Critical Care, Division of Cardiac AnesthesiaThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Stephanie Fuller
- Department of Surgery, Division of Cardiothoracic SurgeryThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Christopher Mascio
- Department of Surgery, Division of Cardiothoracic SurgeryThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - J. William Gaynor
- Department of Surgery, Division of Cardiothoracic SurgeryThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Arjun G. Yodh
- Department of Physics and AstronomyUniversity of PennsylvaniaPhiladelphiaPA
| | - Juliana Gebb
- Department of Surgery, Richard D. Wood Jr Center for Fetal Diagnosis & Treatment in the Division of Pediatric General, Thoracic and Fetal SurgeryThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Arastoo Vossough
- Department of RadiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Grace H. Choi
- Department of Biostatistics, Epidemiology and InformaticsUniversity of PennsylvaniaPhiladelphiaPA
- CHOP/Penn Intellectual and Developmental Disabilities Research CenterPhiladelphiaPA
| | - Mary E. Putt
- Department of Biostatistics, Epidemiology and InformaticsUniversity of PennsylvaniaPhiladelphiaPA
- CHOP/Penn Intellectual and Developmental Disabilities Research CenterPhiladelphiaPA
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Abstract
Frameworks of emotional development have tended to focus on how environmental factors shape children's emotion understanding. However, individual experiences of emotion represent a complex interplay between both external environmental inputs and internal somatovisceral signaling. Here, we discuss the importance of afferent signals and coordination between central and peripheral mechanisms in affective response processing. We propose that incorporating somatovisceral theories of emotions into frameworks of emotional development can inform how children understand emotions in themselves and others. We highlight promising directions for future research on emotional development incorporating this perspective, namely afferent cardiac processing and interoception, immune activation, physiological synchrony, and social touch.
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Affiliation(s)
- Kelly E Faig
- Department of Psychology, Hamilton College, 198 College Hill Road, Clinton, NY 13502
| | - Karen E Smith
- Department of Psychology, the University of Wisconsin, 1500 Highland Blvd, Madison, WI, 53705
| | - Stephanie J Dimitroff
- Department of Psychology, Universität Konstanz, Universitätsstraße 10, 78464 Konstanz, Germany
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43
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Moray AA, Robertson CMT, Bond GY, Abeysekera JB, Mohammadian P, Dinu IA, Atallah J, Switzer HN, Hornberger LK. Third Trimester Umbilical Arterial Pulsatility Index is Associated with Neurodevelopmental Outcomes at 2-Years in Major Congenital Heart Disease. Pediatr Cardiol 2023; 44:816-825. [PMID: 36905431 DOI: 10.1007/s00246-022-03062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/21/2022] [Indexed: 03/12/2023]
Abstract
Major congenital heart disease (CHD) is associated with impaired neurodevelopment (ND), partly from prenatal insults. In this study we explore associations between 2nd and 3rd trimester umbilical (UA) and middle cerebral artery (MCA) pulsatility index (PI = systolic-diastolic velocities/mean velocity) in fetuses with major CHD and 2-year ND and growth outcomes. Eligible patients included those with a prenatal diagnosis of CHD from 2007 to 2017 without a genetic syndrome who underwent previously defined cardiac surgeries and 2-year biometric and ND assessments in our program. UA and MCA-PI Z-scores at fetal echocardiography were examined for relationships with 2-year Bayley Scales of Infant and Toddler Development and biometric Z-scores. Data from 147 children was analyzed. Second and 3rd trimester fetal echocardiograms were performed at 22.4 ± 3.7 and 34.7 ± 2.9 weeks (mean ± SD), respectively. Multivariable regression analysis showed an inverse relationship between 3rd trimester UA-PI for all CHD and cognitive - 1.98 (- 3.37, - 0.59), motor - 2.57 (- 4.15, - 0.99), and language - 1.67 (- 3.3, - 0.03) (effect size and 95th confidence interval) ND domains (p < 0.05), with the strongest relationships in the single ventricle and hypoplastic left heart syndrome subgroups. No association was found for 2nd trimester UA-PI or any trimester MCA-PI and ND or between UA or MCA-PI and 2-year growth parameters. Increased 3rd trimester UA-PI, reflecting an altered late gestation fetoplacental circulation, relates to worse 2-year ND in all domains.
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Affiliation(s)
- Amol A Moray
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Pediatric Cardiology, Stollery Children's Hospital 4C2, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, AB, Canada
| | - Gwen Y Bond
- Department of Pediatrics, Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, AB, Canada
| | - Jayani B Abeysekera
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Pediatric Cardiology, Stollery Children's Hospital 4C2, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Parsa Mohammadian
- Institute of Biostatistics and Registry Research, Bradenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Irina A Dinu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Pediatric Cardiology, Stollery Children's Hospital 4C2, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Heather N Switzer
- Wascana Children's Program, Saskatchewan Health Authority, Regina, SK, Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, AB, Canada. .,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada. .,Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada. .,Pediatric Cardiology, Stollery Children's Hospital 4C2, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada.
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44
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Radiographic and histologic characterisation of white matter injury in a sheep model of CHD. Cardiol Young 2023; 33:432-436. [PMID: 35438073 DOI: 10.1017/s104795112200107x] [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] [Indexed: 11/05/2022]
Abstract
Nearly one in five children with CHD is born with white matter injury that can be recognised on postnatal MRI by the presence of T1 hyperintense lesions. This pattern of white matter injury is known to portend poor neurodevelopmental outcomes, but the exact aetiology and histologic characterisation of these lesions have never been described. A fetal sheep was cannulated at gestational age 110 days onto a pumpless extracorporeal oxygenator via the umbilical vessels and supported in a fluid environment for 14.5 days. The fetus was supported under hypoxic conditions (mean oxygen delivery 16 ml/kg/day) to simulate the in utero conditions of CHD. At necropsy, the brain was fixed, imaged with MRI, and then stained to histologically identify areas of injury. Under hypoxemic in utero conditions, the fetus developed a T1 hyperintense lesion in its right frontal lobe. Histologically, this lesion was characterised by microvascular proliferation and astrocytosis without gliosis. These findings may provide valuable insight into the aetiology of white matter injury in neonates with CHD.
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Aguet J, Fakhari N, Nguyen M, Mertens L, Szabo E, Ertl-Wagner B, Crawford L, Haller C, Barron D, Baranger J, Villemain O. Impact of cardiopulmonary bypass on cerebrovascular autoregulation assessed by ultrafast ultrasound imaging. J Physiol 2023; 601:1077-1093. [PMID: 36779673 DOI: 10.1113/jp284070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/03/2023] [Indexed: 02/14/2023] Open
Abstract
Newborns with congenital heart disease undergoing cardiac surgery are at risk of neurodevelopmental impairment with limited understanding of the impact of intra-operative cardiopulmonary bypass (CPB), deep hypothermia and selective cerebral perfusion on the brain. We hypothesized that a novel ultrasound technique, ultrafast power Doppler (UPD), can assess variations of cerebral blood volume (CBV) in neonates undergoing cardiac surgery requiring CPB. UPD was performed before, during and after surgery in newborns with hypoplastic left heart syndrome undergoing a Norwood operation. We found that global CBV was not significantly different between patients and controls (P = 0.98) and between pre- and post-surgery (P = 0.62). UPD was able to monitor changes in CBV throughout surgery, revealing regional differences in CBV during hypothermia during which CBV correlated with CPB flow rate (R2 = 0.52, P = 0.021). Brain injury on post-operative magnetic resonance imaging was observed in patients with higher maximum variation in CBV. Our findings suggest that UPD can quantify global and regional brain perfusion variation during neonatal cardiac surgery with this first intra-operative application demonstrating an association between CBV and CPB flow rate, suggesting loss of autoregulation. Therefore, the measurement of CBV by UPD could enable optimization of cerebral perfusion during cardiac surgery in neonates. KEY POINTS: The impact of cardiopulmonary bypass (CPB) on the neonatal brain undergoing cardiac surgery is poorly understood. Ultrafast power Doppler (UPD) quantifies cerebral blood volume (CBV), a surrogate of brain perfusion. CBV varies throughout CPB surgery and is associated with variation of the bypass pump flow rate during deep hypothermia. Association between CBV and bypass pump flow rate suggests loss of cerebrovascular autoregulatory processes. Quantitative monitoring of cerebral perfusion by UPD could provide a direct parameter to optimize CPB flow rate.
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Affiliation(s)
- Julien Aguet
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Nikan Fakhari
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Minh Nguyen
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Elod Szabo
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Lynn Crawford
- Department of Surgery, Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christoph Haller
- Department of Surgery, Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Barron
- Department of Surgery, Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jérôme Baranger
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Olivier Villemain
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Agha HM, Fathalla A, Isgro G, Cotza M. Predictors of Neurological Complications of Pediatric Post-Cardiotomy Extracorporeal Life Support. J Saudi Heart Assoc 2023; 34:249-256. [PMID: 36816795 PMCID: PMC9930983 DOI: 10.37616/2212-5043.1324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/23/2023] Open
Abstract
Background Post-cardiotomy extracorporeal membrane oxygenation (ECMO) was associated with significant neurological complications affecting the overall outcome. The aim of the work is to determine the incidence and the predictors of neurological events during pediatric extracorporeal life support after cardiac surgery. Patients & Methods This is a retrospective study that encompassed all neonates, infants, and children (<18 years of age) who need extracorporeal life support following cardiac surgery between January 2015 and December 2018 at San Donato Hospital, Italy. Data as regards surgical procedure of congenital heart disease, in-hospital mortality, length of ECMO, hospital stay durations, short-term neurological ECMO complications and outcome were analyzed. Results The sixty-three patients who received post-cardiotomy ECMO, Neurological complications were evident in 31.7% in the form of ischemic stroke in 17.5% and hemorrhagic stroke in 11.1%. By multivariable analysis, the older age of cyanotic cases, the need for a venting cannula, and the rapid CO2 drop in the first 24 h were the most independent risk factors for neurological complications. Prolonged ECMO support and hospital stay duration were associated with neurological sequelae. Conclusion Neurological complications either ischemic or hemorrhagic strokes were common during pediatric post-cardiotomy ECMO and were significantly related to prolonged ECMO support and hospital stay. Predictors of these neurological sequelae are the older cyanotic cases, the need for a venting cannula, the oxygenator thrombosis, and the rapid CO2 drop in the first 24 h of ECMO.
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Affiliation(s)
- Hala M. Agha
- Department of Pediatrics, Pediatric Cardiology Division, Specialized Pediatric Hospital, Cairo University,
Egypt,Corresponding author at: Pediatric Department, Pediatric Cardiology Division, Specialized Pediatric Hospital, Faculty of Medicine, Cairo University. Kasr Al Aini Street, Cairo, 11562, Egypt. E-mail address: (H.M. Agha)
| | - Amr Fathalla
- Department of Pediatrics, Pediatric Cardiology Division, Specialized Pediatric Hospital, Cairo University,
Egypt
| | - Giuseppe Isgro
- Anaesthesia and Intensive Care Department, IRCCS, Policlinico San Donato, Milan,
Italy
| | - Mauro Cotza
- ECMO/ECLS Unit, IRCCS, Policlinico San Donato, Milan,
Italy
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47
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Structural Racism, Social Determinants of Health, and Provider Bias: Impact on Brain Development in Critical Congenital Heart Disease. Can J Cardiol 2023; 39:133-143. [PMID: 36368561 DOI: 10.1016/j.cjca.2022.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/17/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
Critical congenital heart disease (cCHD) has neurodevelopmental sequelae that can carry into adulthood, which may be due to aberrant brain development or brain injury in the prenatal and perinatal/neonatal periods and beyond. Health disparities based on the intersection of sex, geography, race, and ethnicity have been identified for poorer pre- and postnatal outcomes in the general population, as well as those with cCHD. These disparities are likely driven by structural racism, disparities in social determinants of health, and provider bias, which further compound negative brain development outcomes. This review discusses how aberrant brain development in cCHD early in life is affected by reduced access to quality care (ie, prenatal care and testing, postnatal care) due to divestment in non-White neighbourhoods (eg, redlining) and food insecurity, differences in insurance status, location of residence, and perceived interpersonal racism and bias that disproportionately affects pregnant people of colour who have fewer economic resources. Suggestions are discussed for moving forward with implementing strategies in medical education, clinical care, research, and gaining insight into the communities served to combat disparities and bias while promoting cultural humility.
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48
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Peyvandi S, Rollins C. Fetal Brain Development in Congenital Heart Disease. Can J Cardiol 2023; 39:115-122. [PMID: 36174913 PMCID: PMC9905309 DOI: 10.1016/j.cjca.2022.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/08/2022] [Accepted: 09/18/2022] [Indexed: 02/07/2023] Open
Abstract
Neurodevelopmental impairments are the most common extracardiac morbidities among patients with complex congenital heart disease (CHD) across the lifespan. Robust clinical research in this area has revealed several cardiac, medical, and social factors that can contribute to neurodevelopmental outcome in the context of CHD. Studies using brain magnetic resonance imaging (MRI) have been instrumental in identifying quantitative and qualitative difference in brain structure and maturation in this patient population. Full-term newborns with complex CHD are known to have abnormal microstructural and metabolic brain development with patterns similar to those seen in premature infants at approximately 34 to 36 weeks' gestation. With the advent of fetal brain MRI, these brain abnormalities are now documented as they begin in utero, as early as the third trimester. Importantly, disturbed brain development in utero is now known to be independently associated with neurodevelopmental outcome in early childhood, making the prenatal period an important timeframe for potential interventions. Advances in fetal brain MRI provide a robust imaging tool to use in future neuroprotective clinical trials. The causes of abnormal fetal brain development are multifactorial and include cardiovascular physiology, genetic abnormalities, placental impairment, and other environmental and social factors. This review provides an overview of current knowledge of brain development in the context of CHD, common prenatal imaging tools to evaluate the developing fetal brain in CHD, and known risk factors contributing to brain immaturity.
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Affiliation(s)
- Shabnam Peyvandi
- University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA.
| | - Caitlin Rollins
- Boston Children's Hospital and Harvard University Departments of Neurology, Boston, Massachusetts, USA
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Reducing Perioperative Brain Injury in Congenital Heart Disease: A Ray of Hope. J Am Coll Cardiol 2023; 81:267-269. [PMID: 36653094 DOI: 10.1016/j.jacc.2022.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/28/2022] [Indexed: 01/18/2023]
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Omann C, Kristensen R, Tabor A, Gaynor JW, Hjortdal VE, Nyboe C. School performance is impaired in children with both simple and complex congenital heart disease. Front Pediatr 2023; 11:1073046. [PMID: 36911031 PMCID: PMC9995927 DOI: 10.3389/fped.2023.1073046] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/01/2023] [Indexed: 02/25/2023] Open
Abstract
Background We do not know if children born with a simple or uncorrected congenital heart disease (CHD) have school performance issues and an increased need for special education compared to healthy peers. With this study we examine the school performance and the need for special education in children with both simple and complex CHD. Further, we evaluate if exposure to preeclampsia or smoking affects the need for special education. Methods In this nation-wide population based registry study, we included all Danish children with CHD born 1994-2012. In addition ten age and gender matched control per CHD child were included. Non-singletons and children born with a syndrome were excluded. Exposure was defined as having a CHD and the outcome was defined as needing special education service in the Danish primary and lower secondary school. Results The population consisted of 7,559 CHD children and 77,046 non-CHD children (controls). CHD children had a higher need for special education compared to non-CHD children, OR: 2.14 (95% CI: 2.00; 2.28), p < 0.001. The odds ratio was also increased when comparing children with a minor CHD to non-CHD children, OR: 1.99 (95% CI: 1.86; 2.14), p < 0.001. CHD children exposed to preeclampsia or smoking had a higher risk of receiving special education compared to unexposed CHD children. Conclusion We find that school performance is impaired in children born with CHD. This applies to both simple and complex CHD. If a child with CHD was exposed to preeclampsia or maternal smoking this further increased the need for special education.
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Affiliation(s)
- Camilla Omann
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rasmus Kristensen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ann Tabor
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Vibeke E Hjortdal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Camilla Nyboe
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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