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Wray J, Ryde M, Butler CR, Hewitt RJ. Quality of life can be good after slide tracheoplasty for long-segment tracheal stenosis. Interact Cardiovasc Thorac Surg 2020; 29:876-882. [PMID: 31435669 DOI: 10.1093/icvts/ivz194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/24/2019] [Accepted: 07/10/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The objectives of this study were to measure 'health-related quality of life' (HRQoL) in children following slide tracheoplasty for long-segment tracheal stenosis (LSTS) and to explore the relationship of comorbidities and parental mental health with HRQoL outcomes. METHODS A cross-sectional study was undertaken with children who had undergone slide tracheoplasty. Participants included parents and children (age 5-15 years) recruited over a 13-month period, who were asked to complete validated measures of HRQoL, development and behaviour. Scores were compared to published norms. RESULTS Forty-two children (male 69%; n = 29) were included; mean age was 5.3 (standard deviation 3.5) years and mean follow-up was 45 (range 4-179) months. Mean total HRQoL scores for children with repaired LSTS did not differ from those of healthy norms other than for children aged 13-23 months, but 10 children (24%) had scores >2 SD below the mean for healthy children. HRQoL was poorer in children with non-cardiac congenital comorbidities than in those with isolated LSTS (mean scores 60.34 ± 17.19 and 85.52 ± 12.19, respectively, P = 0.01). There was good agreement between children's and parents' scores, although children rated their HRQoL as better than their parents did. Anxious parents rated their children's HRQoL as significantly worse than non-anxious parents (P<0.001). CONCLUSIONS Older children with isolated LSTS can have excellent HRQoL after surgery. Younger children, at an earlier time point postoperatively, and those with non-cardiac congenital comorbidities have poorer HRQoL. Further longitudinal evaluation is required to identify psycho-social (including parental) predictors of outcome which may inform, or be amenable to, intervention.
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Affiliation(s)
- Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Matthew Ryde
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Colin R Butler
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Richard J Hewitt
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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102
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Lisanti AJ, Vittner D, Medoff-Cooper B, Fogel J, Wernovsky G, Butler S. Individualized Family-Centered Developmental Care: An Essential Model to Address the Unique Needs of Infants With Congenital Heart Disease. J Cardiovasc Nurs 2020; 34:85-93. [PMID: 30303895 PMCID: PMC6283700 DOI: 10.1097/jcn.0000000000000546] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infants born with critical congenital heart disease (cCHD) who require surgical intervention in the newborn period are often hospitalized in a cardiac intensive care unit (CICU). Cardiac surgery and the CICU environment are traumatic to infants and their families. Infants are exposed to overwhelming stress, which can result in increased pain, physiologic instability, behavioral disorganization, disrupted attachment, and altered brain development. Individualized Family-centered Developmental Care (IFDC) is a model that can address the unique needs and developmental challenges of infants with cCHD. PURPOSE The purpose of this article is to (1) clearly describe the uniqueness of the infant with cCHD, including the medical, neurological, and parental challenges, and (2) propose methods to apply IFDC to support recovery of infants with cCHD in the CICU. CONCLUSIONS The experiences in the CICU shape the developing brain and alter recovery and healing, thus adversely impacting development. Individualized Family-centered Developmental Care is a promising model of care that nurses can integrate into the CICU to promote neuroprotection and development. Nurses can effectively integrate IFDC into the CICU by understanding the unique characteristics of infants with cCHD and applying IFDC interventions that include both maturity and recovery perspectives. CLINICAL IMPLICATIONS The incorporation of IFDC interventions is essential for the infant with cCHD and should be a standard of care. Applying IFDC with a recovery perspective in all aspects of caregiving will provide opportunities for individualization of care and parent engagement, allowing infants in the CICU to recover from surgery while supporting both short- and long-term neurodevelopment.
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Affiliation(s)
- Amy Jo Lisanti
- Amy Lisanti, PhD, RN, CCNS, CCRN-K NRSA Postdoctoral Fellow, University of Pennsylvania School of Nursing; and Clinical Nurse Specialist/Nurse Scientist, Cardiac Nursing at Children's Hospital of Philadelphia, Pennsylvania. Dorothy Vittner, PhD, RN Nurse Scientist, Connecticut Children's Medical Center, Hartford; and Faculty, School of Nursing and an Assistant Professor, University of Connecticut School of Nursing, Storrs. Barbara Medoff-Cooper, PhD, RN Professor, Univeristy of Pennsylvania School of Nursing, Philadelphia. Jennifer Fogel, M.S.CCC-SLP/L Pediatric Speech Language Pathologist, Advocate Children's Hospital, Oak Lawn, Illinois. Gil Wernovsky, MD Senior Consultant in Cardiac Critical Care and Pediatric Cardiology, Children's National Health System, Washington, District of Columbia. Samantha Butler, PhD Developmental and Clinical Psychologist Director, Boston Children's; and Assistant Professor in Psychiatry, Harvard Medical School, Boston, Massachusetts
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103
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Karamlou T, Najm HK. Evolution of care pathways for babies with hypoplastic left heart syndrome: integrating mechanistic and clinical process investigation, standardization, and collaborative study. J Thorac Dis 2020; 12:1174-1183. [PMID: 32274198 PMCID: PMC7139006 DOI: 10.21037/jtd.2019.10.75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since initial descriptions of staged palliation for hypoplastic left heart syndrome (HLHS) in the 1980’s, much has been learned about the pathophysiology of the single ventricle circulation. New therapies that leverage systems biology and clinical derivatives have been developed. While in-hospital mortality and morbidity for babies with HLHS have continued to improve, there remains a long (and daresay winding) road ahead to achieve ideal outcomes. Important variation in even these abbreviated in-hospital metrics persists among institutions and currently utilized prediction models explain only a small amount of this variation. Moreover, long-term survival and neurodevelopmental health for patients with HLHS are infrequently reported and remain suboptimal despite improved in-hospital outcomes. This focused review will describe the evolution of national outcomes for HLHS over time and the potential factors motivating improved time-related mortality. Emerging modifiable risk-factors that hold promise in terms of moving the needle for long-term success, including social determinants of health and the delineation of genetic profiles, will be discussed. Specifically, this review will integrate contemporary data based on the first murine HLHS models that suggest a genetically elicited modular phenotype with environmental factors known to impact the initial durability of surgical therapies. A comprehensive approach to the management of HLHS, which leverages both proactive transplantation and hybrid palliation, in addition to traditional Norwood palliation, will be emphasized to extend and match management to the complete spectrum of patient risk-profiles. Finally, we will explore the critical role that national collaboratives and quality reporting initiatives have played in improving outcomes and shifting the focus to more meaningful long-term survival and neurodevelopment.
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Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
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104
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Goldberg CS. Commentary: No Child Left Behind: Toddler Evaluations Correlate With School Age Evaluations But Still Plan Early Intervention for All. Semin Thorac Cardiovasc Surg 2020; 32:311-312. [PMID: 32068128 DOI: 10.1053/j.semtcvs.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/03/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Caren S Goldberg
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan.
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105
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Early Neurodevelopmental Outcomes in Children with Hypoplastic Left Heart Syndrome and Related Anomalies After Hybrid Procedure. Pediatr Cardiol 2019; 40:1591-1598. [PMID: 31471627 DOI: 10.1007/s00246-019-02191-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
The hybrid strategy is one approach to single ventricle palliation. In this study, we reported neurodevelopment at 12 months for two cohorts of children managed with the hybrid and clinical factors associated with neurodevelopment in the entire sample. We performed a retrospective study of children with single ventricle who had undergone a neonatal hybrid procedure. One group included infants with hypoplastic left heart syndrome (HLHS); another group included infants with non-HLHS single ventricle. Neurodevelopment was assessed with 12-month Bayley III. Parametric and non-parametric statistics were used for analysis. Nine infants with HLHS and 15 with non-HLHS were identified. Abnormal neurodevelopment was identified in 11 of 24 (46%), primarily motor (46%). Development did not differ between groups. In the whole sample, higher lactate levels were associated with lower cognitive scores (p = 0.04). Fewer mechanical ventilation days were associated with higher cognitive scores (p = 0.05) after Stage 1 and higher motor scores after Stage 2. Shorter ICU length of stay (p = 0.01), shorter hospital length of stay (p = 0.01), and fewer complications (p = 0.01) after stage 2 were associated with higher motor scores. Higher cognitive (p = 0.02) and language (p = 0.002) scores were associated with higher weight at 12 months. In the largest cohort of single ventricle children treated with neonatal hybrid palliation yet reported, significant neurodevelopmental impairment was identified. No differences in neurodevelopment were found between children with HLHS and those with non-HLHS variants. A multicenter trial is needed to test differences in neurodevelopment between hybrid and Norwood approaches.
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106
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Abstract
Neurodevelopmental outcomes after neonatal congenital heart surgery are significantly influenced by brain injury detectable by MRI imaging techniques. This brain injury can occur in the prenatal and postnatal periods even before cardiac surgery. Given the significant incidence of new MRI brain injury after cardiac surgery, much work is yet to be done on strategies to detect, prevent, and treat brain injury in the neonatal period in order to optimize longer-term neurodevelopmental outcomes.
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107
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Zaidi AH, Newburger JW, Wypij D, Stopp C, Watson CG, Friedman KG, Rivkin MJ, Rollins CK. Ascending Aorta Size at Birth Predicts White Matter Microstructure in Adolescents Who Underwent Fontan Palliation. J Am Heart Assoc 2019; 7:e010395. [PMID: 30561261 PMCID: PMC6405606 DOI: 10.1161/jaha.118.010395] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background In neonates with single ventricle, smaller ascending aorta diameter is associated with cerebral white matter ( WM ) microstructural abnormalities. We sought to determine whether this association persists into adolescence. Methods and Results Ascending aorta Z scores were obtained from first postnatal echocardiogram. Brain magnetic resonance imaging with diffusion tensor imaging was acquired in adolescence and used to obtain fractional anisotropy, axial diffusivity, radial diffusivity, and mean diffusivity in 33 WM tract regions of interest. Partial Pearson correlation coefficients were evaluated for associations between ascending aorta Z scores and WM microstructure measures, adjusting for sex, age at magnetic resonance imaging, scanner field strength, and Norwood status. Among 42 single ventricle patients aged 10 to 19 years, 31 had undergone the Norwood procedure as neonates. Lower ascending aorta Z scores were associated with lower fractional anisotropy in bilateral pontine crossing tracts ( P=0.02), inferior fronto-occipital fasciculus ( P=0.02), and inferior longitudinal fasciculus ( P=0.01); left cingulum-cingulate bundle ( P=0.01), superior longitudinal fasciculus ( P=0.04), and superior longitudinal fasciculus-temporal component ( P=0.01); and right cingulum-hippocampal bundle (P=0.009) and inferior cerebellar peduncle ( P=0.01). Lower ascending aorta Z scores were associated with higher radial diffusivity and mean diffusivity in a similar regional pattern but not with axial diffusivity. Conclusions In adolescents with single ventricle, smaller aorta diameter at birth is associated with abnormalities of WM microstructure in a subset of WM tracts, mostly those located in deeper brain regions. Our findings suggest that despite multiple intervening medical or surgical procedures, prenatal cerebral blood flow may have a lasting influence on WM microstructure in single-ventricle patients.
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Affiliation(s)
- Abbas H Zaidi
- 1 Department of Cardiology Boston Children's Hospital Boston MA.,5 Department of Pediatrics Harvard Medical School Boston MA
| | - Jane W Newburger
- 1 Department of Cardiology Boston Children's Hospital Boston MA.,5 Department of Pediatrics Harvard Medical School Boston MA
| | - David Wypij
- 1 Department of Cardiology Boston Children's Hospital Boston MA.,5 Department of Pediatrics Harvard Medical School Boston MA.,7 Department of Biostatistics Harvard T.H. Chan School of Public Health Boston MA
| | - Christian Stopp
- 1 Department of Cardiology Boston Children's Hospital Boston MA
| | | | - Kevin G Friedman
- 1 Department of Cardiology Boston Children's Hospital Boston MA.,5 Department of Pediatrics Harvard Medical School Boston MA
| | - Michael J Rivkin
- 2 Department of Neurology Boston Children's Hospital Boston MA.,3 Department of Psychiatry Boston Children's Hospital Boston MA.,4 Department of Radiology Boston Children's Hospital Boston MA.,6 Department of Neurology Harvard Medical School Boston MA
| | - Caitlin K Rollins
- 2 Department of Neurology Boston Children's Hospital Boston MA.,6 Department of Neurology Harvard Medical School Boston MA
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108
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Sigmon ER, Kelleman M, Susi A, Nylund CM, Oster ME. Congenital Heart Disease and Autism: A Case-Control Study. Pediatrics 2019; 144:peds.2018-4114. [PMID: 31601611 DOI: 10.1542/peds.2018-4114] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES There has long been an association between congenital heart disease (CHD) and general neurodevelopmental delays. However, the association between CHD and autism spectrum disorders (AuSDs) is less well understood. Using administrative data, we sought to determine the association between CHD and AuSD and identify specific CHD lesions with higher odds of developing AuSD. METHODS We performed a 1:3 case-control study of children enrolled in the US Military Health System from 2001 to 2013. Children with International Classification of Disease, Ninth Revision, Clinical Modification codes for AuSD were identified as cases and matched with controls on the basis of date of birth, sex, and enrollment time frame. Each child's records were reviewed for CHD lesions and associated procedures. Conditional logistic regression determined odds ratios (ORs) and 95% confidence intervals (CIs) for comparative associations. RESULTS There were 8760 cases with AuSD and 26 280 controls included in the study. After adjustment for genetic syndrome, maternal age, gestational diabetes, short gestation, newborn epilepsy, birth asphyxia, and low birth weight, there were increased odds of AuSD in patients with CHD (OR 1.32; 95% CI 1.10-1.59). Specific lesions with significant OR included atrial septal defects (n = 82; OR 1.72; 95% CI 1.07-2.74) and ventricular septal defects (n = 193; OR 1.65; 95% CI 1.21-2.25). CONCLUSIONS Children with CHD have increased odds of developing AuSD. Specific lesions associated with increased risk include atrial septal defects and ventricular septal defects. These findings will be useful for counseling parents of children with CHD.
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Affiliation(s)
- Eric R Sigmon
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta and.,Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia; and
| | - Michael Kelleman
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia; and
| | - Apryl Susi
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Cade M Nylund
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Matthew E Oster
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta and .,Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia; and
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109
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Fang A, Allen KY, Marino BS, Brady KM. Neurologic outcomes after heart surgery. Paediatr Anaesth 2019; 29:1086-1093. [PMID: 31532867 DOI: 10.1111/pan.13744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 09/05/2019] [Accepted: 09/14/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Amy Fang
- Anesthesia, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Kiona Y Allen
- Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago, Chicago, IL, USA
| | - Bradley S Marino
- Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago, Chicago, IL, USA
| | - Ken M Brady
- Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago, Chicago, IL, USA
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110
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du Plessis K, d’Udekem Y. The Neurodevelopmental Outcomes of Patients With Single Ventricles Across the Lifespan. Ann Thorac Surg 2019; 108:1565-1572. [DOI: 10.1016/j.athoracsur.2019.05.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/08/2019] [Accepted: 05/10/2019] [Indexed: 12/27/2022]
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111
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Haxel C, Glickstein J, Parravicini E. Neonatal Palliative Care for Complicated Cardiac Anomalies: A 10-Year Experience of an Interdisciplinary Program at a Large Tertiary Cardiac Center. J Pediatr 2019; 214:79-88. [PMID: 31655705 DOI: 10.1016/j.jpeds.2019.07.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/18/2019] [Accepted: 07/18/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To report the outcomes of a Neonatal Palliative Care (NPC) Program at a large tertiary cardiac center caring for a subset of fetuses and neonates with life-limiting cardiac diagnoses or cardiac diagnoses with medical comorbidities leading to adverse prognoses. STUDY DESIGN The Neonatal Comfort Care Program at New York-Presbyterian Morgan Stanley Children's Hospital/Columbia University Medical Center is an interdisciplinary team that offers the option of NPC to neonates prenatally diagnosed with life-limiting conditions, including single ventricle (SV) congenital heart disease (CHD) or less severe forms of CHD complicated by multiorgan dysfunction or genetic syndromes. RESULTS From 2008 to 2017, the Neonatal Comfort Care Program cared for 75 fetuses or neonates including 29 with isolated SV CHD, 36 with CHD and multiorgan dysfunction and/or severe genetic abnormalities, and 10 neonates with a prenatal diagnosis of isolated CHD and postnatal diagnoses of severe conditions who were initially in intensive care before transitioning to NPC because of a poor prognosis. CONCLUSIONS At New York-Presbyterian Morgan Stanley Children's Hospital/Columbia University Medical Center, a large tertiary cardiac center, 13.5% of parents of fetuses or neonates with isolated SV CHD opted for NPC. Twenty-six of 29 newborns with SV CHD treated with NPC died. Of the remaining, 2 neonates with mixing lesions are alive at 3 and 5 years of age, and 1 neonate was initially treated with NPC and then pursued surgical palliation. These results suggest that NPC is a reasonable choice for neonates with SV CHD.
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Affiliation(s)
- Caitlin Haxel
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO; Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY.
| | - Julie Glickstein
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Elvira Parravicini
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
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112
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Goldberg CS, Hu C, Brosig C, Gaynor JW, Mahle WT, Miller T, Mussatto KA, Sananes R, Uzark K, Trachtenberg F, Pizarro C, Pemberton VL, Lewis AB, Li JS, Jacobs JP, Cnota J, Atz AM, Lai WW, Bellinger D, Newburger JW. Behavior and Quality of Life at 6 Years for Children With Hypoplastic Left Heart Syndrome. Pediatrics 2019; 144:e20191010. [PMID: 31628208 PMCID: PMC6856798 DOI: 10.1542/peds.2019-1010] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We measured behavioral, quality of life (QoL), and functional status outcomes for 6-year-old children with hypoplastic left heart syndrome enrolled in the Single Ventricle Reconstruction Trial. We sought to compare these outcomes with those in the normative population and to analyze risk factors for worse outcomes within the single-ventricle group. METHODS Parent-response instruments included the Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) (primary outcome), Behavior Assessment System for Children 2, Pediatric Quality of Life Inventory 4.0, and other measures of QoL and functional status. We compared subjects with those in the normative sample using 1-sample Wilcoxon rank tests and assessed outcome predictors using multivariable regression. RESULTS Of 325 eligible patients, 250 (77%) participated. Compared with population norms, participants had lower scores on the Vineland-II motor skills domain (90 ± 17 vs 100 ± 15; P < .001), with 11% scoring >2 SDs below the normative mean. On nearly all major domains, more study subjects (3.3%-19.7%) scored outside the normal range than anticipated for the general population. Independent risk factors for lower Vineland-II scores included perioperative extracorporeal membrane oxygenation, male sex, use of regional cerebral perfusion, catheterization after stage 2 operation, visual problems, seizure history, and more complications after 2 years (R 2 = 0.32). Independent predictors of worse Behavior Assessment System for Children 2 (R 2 = 0.07-0.20) and Pediatric Quality of Life Inventory 4.0 (R 2 = 0.17-0.25) domain scores also included sociodemographic factors and measures of morbidity and/or greater course complexity. CONCLUSIONS At 6 years, children with hypoplastic left heart syndrome had difficulty in areas of adaptive behavior, behavioral symptoms, QoL, and functional status. Principal risks for adverse outcomes include sociodemographic factors and measures of greater course complexity. However, models reveal less than one-third of outcome variance.
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Affiliation(s)
- Caren S Goldberg
- Department of Pediatrics, Medical School, University of Michigan and Michigan Medicine, Ann Arbor, Michigan;
| | - Chenwei Hu
- New England Research Institutes, Watertown, Massachusetts
| | - Cheryl Brosig
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - J William Gaynor
- Pediatric Cardiothoracic Surgery, School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William T Mahle
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Thomas Miller
- Department of Pediatrics, and The University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Kathleen A Mussatto
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Renee Sananes
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Canada
| | - Karen Uzark
- Department of Pediatrics, Medical School, University of Michigan and Michigan Medicine, Ann Arbor, Michigan
| | | | - Christian Pizarro
- Department of Surgery, Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Victoria L Pemberton
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Alan B Lewis
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Jennifer S Li
- Department of Pediatrics, Duke University, Durham, North Carolina
- Department of Pediatrics, East Carolina University, Greenville, North Carolina
- Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina
| | | | - James Cnota
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Wyman W Lai
- Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - David Bellinger
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and
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113
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Brown KL, Ridout D, Pagel C, Wray J, Anderson D, Barron DJ, Cassidy J, Davis PJ, Rodrigues W, Stoica S, Tibby S, Utley M, Tsang VT. Incidence and risk factors for important early morbidities associated with pediatric cardiac surgery in a UK population. J Thorac Cardiovasc Surg 2019; 158:1185-1196.e7. [DOI: 10.1016/j.jtcvs.2019.03.139] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 11/29/2022]
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114
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Migally K, Rettiganti M, Gossett JM, Reemtsen B, Gupta P. Impact of Regional Cerebral Perfusion on Outcomes Among Neonates Undergoing Norwood Operation. World J Pediatr Congenit Heart Surg 2019; 10:261-267. [PMID: 31084315 DOI: 10.1177/2150135118825274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate the impact of regional cerebral perfusion (RCP) during heart operation on outcomes in neonates undergoing Norwood operation. METHODS We performed a retrospective cohort study using data from the Single Ventricle Reconstruction trial data set. The adjusted effect of RCP use on each outcome was studied using a penalized logistic regression model with bootstrap validation. RESULTS Of 549 patients included in the study, 252 patients (45.9%) received RCP during their heart operation. In univariate comparisons, the majority of the baseline characteristics and preoperative risk factors were similar in the RCP and No RCP group. The total cardiopulmonary bypass (CPB) time and the total cross-clamp (CC) time were longer in the RCP group (RCP vs No RCP, median CPB time: 161 minutes vs 109 minutes; median CC time: 63 minutes vs 43 minutes). In adjusted models, the use of RCP was not associated with decreased mortality and/or need for heart transplant at hospital discharge (odds ratio [OR]: 0.73; 95% confidence interval [CI]: 0.43-1.25) or prolonged mechanical ventilation (OR: 1.20, 95% CI: 0.62-2.28) or prolonged hospital length of stay (OR: 1.30, 95% CI: 0.73-2.30). We demonstrated that use of RCP was associated with longer CPB times, increased use of ultrafiltration, and higher probability of open chest after Norwood operation. CONCLUSIONS This study did not demonstrate any impact of RCP on in-hospital mortality and/or heart transplantation, prolonged mechanical ventilation, and prolonged hospital length of stay among neonates undergoing Norwood operation.
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Affiliation(s)
- Karl Migally
- 1 Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,2 Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Mallikarjuna Rettiganti
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Jeffrey M Gossett
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA.,3 Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Brian Reemtsen
- 4 Division of Pediatric Cardiac Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Punkaj Gupta
- 1 Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,5 Section of Cardiac Critical Care, Methodist Children's Hospital, San Antonio, TX, USA
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Romanowicz J, Leonetti C, Dhari Z, Korotcova L, Ramachandra SD, Saric N, Morton PD, Bansal S, Cheema A, Gallo V, Jonas RA, Ishibashi N. Treatment With Tetrahydrobiopterin Improves White Matter Maturation in a Mouse Model for Prenatal Hypoxia in Congenital Heart Disease. J Am Heart Assoc 2019; 8:e012711. [PMID: 31331224 PMCID: PMC6761654 DOI: 10.1161/jaha.119.012711] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/24/2019] [Indexed: 01/05/2023]
Abstract
Background Reduced oxygen delivery in congenital heart disease causes delayed brain maturation and white matter abnormalities in utero. No treatment currently exists. Tetrahydrobiopterin (BH4) is a cofactor for neuronal nitric oxide synthase. BH4 availability is reduced upon NOS activation, such as during hypoxic conditions, and leads to toxin production. We hypothesize that BH4 levels are depleted in the hypoxic brain and that BH4 replacement therapy mitigates the toxic effects of hypoxia on white matter. Methods and Results Transgenic mice were used to visualize oligodendrocytes. Hypoxia was introduced during a period of white matter development equivalent to the human third trimester. BH4 was administered during hypoxia. BH4 levels were depleted in the hypoxic brain by direct quantification (n=7-12). The proliferation (n=3-6), apoptosis (n=3-6), and developmental stage (n=5-8) of oligodendrocytes were determined immunohistologically. Total oligodendrocytes increased after hypoxia, consistent with hypoxia-induced proliferation seen previously; however, mature oligodendrocytes were less prevalent in hypoxia, and there was accumulation of immature oligodendrocytes. BH4 treatment improved the mature oligodendrocyte number such that it did not differ from normoxia, and accumulation of immature oligodendrocytes was not observed. These results persisted beyond the initial period of hypoxia (n=3-4). Apoptosis increased with hypoxia but decreased with BH4 treatment to normoxic levels. White matter myelin levels decreased following hypoxia by western blot. BH4 treatment normalized myelination (n=6-10). Hypoxia worsened sensory-motor coordination on balance beam tasks, and BH4 therapy normalized performance (n=5-9). Conclusions Suboptimal BH4 levels influence hypoxic white matter abnormalities. Repurposing BH4 for use during fetal brain development may limit white matter dysmaturation in congenital heart disease.
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Affiliation(s)
- Jennifer Romanowicz
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
| | - Camille Leonetti
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Zaenab Dhari
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Ludmila Korotcova
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Shruti D. Ramachandra
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Nemanja Saric
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Paul D. Morton
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Shivani Bansal
- Lombardi Comprehensive Cancer CenterGeorgetown University Medical CenterWashingtonDC
| | - Amrita Cheema
- Lombardi Comprehensive Cancer CenterGeorgetown University Medical CenterWashingtonDC
| | - Vittorio Gallo
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Richard A. Jonas
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Nobuyuki Ishibashi
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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Wolfe KR, Brinton J, Di Maria MV, Meier M, Liptzin DR. Oxygen saturations and neurodevelopmental outcomes in single ventricle heart disease. Pediatr Pulmonol 2019; 54:922-927. [PMID: 30919581 DOI: 10.1002/ppul.24275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/20/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To evaluate whether the degree of hypoxemia following stage-I and stage-II palliative surgeries predicts neurodevelopmental outcomes at 14 months of age in children with single ventricle congenital heart disease (SVCHD). DESIGN We analyzed longitudinal data from two Pediatric Heart Network (PHN) randomized controlled trials, with a total of 328 subjects. Oxygen saturations, measured via pulse oximetry, at time of discharge from stage-I and stage-II surgeries were the primary predictors of interest, and Bayley Scales of Infant Development-II (BSID-II) scores at 14 months old were the primary outcome measure. Relevant covariates from previously-published PHN studies were also included in regression models. RESULTS Oxygen saturations at time of discharge from stage-I and stage-II surgeries were not related to BSID-II scores. Having one or more oxygen saturation measurements below 80% was also not associated with BSID-II scores, and neither was change in oxygen saturations over time. These relationships were not altered by inclusion of relevant covariates. CONCLUSIONS In this large cohort of children with SVCHD, oxygen saturations post-stage-I and post-stage-II palliation surgeries as measured via pulse oximetry were not associated with neurodevelopmental outcomes at 14 months of age. The relationship between oxygen saturations and neurodevelopment in SVCHD is likely complex, and neurodevelopment is known to be affected by a number of factors. Pulse oximetry may also be an insufficient proxy for cerebral oxygen delivery. Clinically, pulse oximetry readings during the interstage and post-stage-II surgery periods are not a reliable predictor of future neurodevelopmental risk.
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Affiliation(s)
- Kelly R Wolfe
- Pediatric Neurology, University of Colorado School of Medicine and Children's Hospital, Aurora, Colorado
| | - John Brinton
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Michael V Di Maria
- Heart Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Maxene Meier
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Deborah R Liptzin
- Pediatric Pulmonary Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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Morell E, Moynihan K, Wolfe J, Blume ED. Palliative care and paediatric cardiology: current evidence and future directions. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:502-510. [PMID: 31126897 DOI: 10.1016/s2352-4642(19)30121-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/20/2019] [Accepted: 02/27/2019] [Indexed: 12/24/2022]
Abstract
Although outcomes for children with heart disease have improved substantially over the past several decades, heart disease remains one of the leading causes of paediatric mortality. For children who progress to advanced heart disease, disease morbidity is high, with many children requiring multiple surgical interventions and long-term intensive care hospitalisations. Care for children with advanced heart disease requires a multidisciplinary approach, and opportunities for earlier integration of palliative care are being explored. This Viewpoint summarises the relevant literature over the past decade. We also identify gaps in parent and provider understanding of prognosis and communication, propose indications for palliative care consultation in paediatric advanced heart disease, and summarise attitudes and perceived barriers to palliative care consultation. Areas for additional research that we identify include paediatric cardiologist education, parental distress, socioeconomic disparities, and patient-reported outcomes. Interdisciplinary clinical and research efforts are required to further advance the field and improve integration of palliative care in the care of children with heart disease.
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Affiliation(s)
- Emily Morell
- Division of Pediatric Critical Care, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Pediatric Palliative Care, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
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119
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Affiliation(s)
- David Bichell
- 1 Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, USA
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120
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Goldstone AB, Baiocchi M, Wypij D, Stopp C, Andropoulos DB, Atallah J, Atz AM, Beca J, Donofrio MT, Duncan K, Ghanayem NS, Goldberg CS, Hövels-Gürich H, Ichida F, Jacobs JP, Justo R, Latal B, Li JS, Mahle WT, McQuillen PS, Menon SC, Pike NA, Pizarro C, Shekerdemian LS, Synnes A, Williams IA, Bellinger DC, Newburger J, Gaynor JW. The Bayley-III scale may underestimate neurodevelopmental disability after cardiac surgery in infants. Eur J Cardiothorac Surg 2019; 57:63-71. [DOI: 10.1093/ejcts/ezz123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/17/2019] [Accepted: 03/20/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Neurodevelopmental disability is the most common complication among congenital heart surgery survivors. The Bayley scales are standardized instruments to assess neurodevelopment. The most recent edition (Bayley Scales of Infant and Toddler Development 3rd Edition, Bayley-III) yields better-than-expected scores in typically developing and high-risk infants than the second edition (Bayley Scales of Infant Development 2nd Edition, BSID-II). We compared BSID-II and Bayley-III scores in infants undergoing cardiac surgery.
METHODS
We evaluated 2198 infants who underwent operations with cardiopulmonary bypass between 1996 and 2009 at 26 institutions. We used propensity score matching to limit confounding by indication in a subset of patients (n = 705).
RESULTS
Overall, unadjusted Bayley-III motor scores were higher than BSID-II Psychomotor Development Index scores (90.7 ± 17.2 vs 77.6 ± 18.8, P < 0.001), and unadjusted Bayley-III composite cognitive and language scores were higher than BSID-II Mental Development Index scores (92.0 ± 15.4 vs 88.2 ± 16.7, P < 0.001). In the propensity-matched analysis, Bayley-III motor scores were higher than BSID-II Psychomotor Development Index scores [absolute difference 14.1, 95% confidence interval (CI) 11.7–17.6; P < 0.001] and the Bayley-III classified fewer children as having severe [odds ratio (OR) 0.24; 95% CI 0.14–0.42] or mild-to-moderate impairment (OR 0.21; 95% CI 0.14–0.32). The composite of Bayley-III cognitive and language scores was higher than BSID-II Mental Development Index scores (absolute difference 4.0, 95% CI 1.4–6.7; P = 0.003), but there was no difference between Bayley editions in the proportion of children classified as having severe cognitive and language impairment.
CONCLUSIONS
The Bayley-III yielded higher scores than the BSID-II and classified fewer children as severely impaired. The systematic bias towards higher scores with the Bayley-III precludes valid comparisons between early and contemporary cardiac surgery cohorts.
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Affiliation(s)
- Andrew B Goldstone
- Department of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | | | | | - Joseph Atallah
- Stollery Children’s Hospital, Western Canadian Complex Pediatric Therapies Follow-up Program, Edmonton, AB, Canada
| | - Andrew M Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - John Beca
- Starship Children’s Hospital, Auckland, New Zealand
| | | | - Kim Duncan
- Children’s Hospital and Medical Center, Omaha, NE, USA
| | - Nancy S Ghanayem
- Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | | | | | | | - Jeffrey P Jacobs
- Johns Hopkins All Children’s Heart Institute, St. Petersburg, FL, USA
| | | | - Beatrice Latal
- University Children’s Hospital Zurich, Zurich, Switzerland
| | | | | | | | - Shaji C Menon
- Primary Children’s Medical Center, Salt Lake City, UT, USA
| | - Nancy A Pike
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | | | | | - Anne Synnes
- University of British Columbia, Vancouver, BC, Canada
| | - Ismée A Williams
- New York-Presbyterian Morgan Stanley Children’s Hospital of New York, New York, NY, USA
| | | | | | - J William Gaynor
- Department of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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121
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Reich B, Heye KN, Wetterling K, Logeswaran T, Hahn A, Akintürk H, Jux C, Schranz D. Neurodevelopmental outcome in hypoplastic left heart syndrome after hybrid procedure. Transl Pediatr 2019; 8:94-106. [PMID: 31161076 PMCID: PMC6514277 DOI: 10.21037/tp.2019.04.05] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Little is known about the mid-term outcome and brain development in patients following the hybrid approach for hypoplastic left heart syndrome (HLHS). This study investigates neurodevelopmental outcome, quality of life (QoL) and brain MRI findings in HLHS preschoolers treated with the hybrid approach. METHODS Twenty HLHS patients (60% males) have been examined after neonatal hybrid Stage I and comprehensive stage II operation at the Pediatric Heart Center Giessen, Germany, between 2012 and 2016. Patients were evaluated with the Bayley Scales of Infant and Toddler Development III (Bayley-III), neurological examination, the Preschool Children Quality of Life Questionnaire (TAPQOL) at age 26.5±3.6 months, and again at 39.7±3.9 months with the Pediatric Cardiac Quality of Life Inventory (PCQLI). Furthermore, brain volumetric measurements and conventional brain MRI findings (27.3±4.5 months) were analyzed and compared with six healthy controls (29.2±11.1 months, P=0.53). Children with verified genetic comorbidities were excluded. RESULTS Mean cognitive, language, and motor composite scores on the Bayley-III were not different from healthy norms (100±15), and were 101±9.3 (P=0.48), 100±13 (P=0.93), and 98±11.7 (P=0.45), respectively. Status post stroke was the most common brain MRI abnormality, and was found in 3/19 (16%) patients, most common affecting the middle cerebral artery territory. In comparison to controls, total white matter volumes were reduced (P=0.014), and cerebrospinal fluid (CSF) volumes were increased (P=0.042) in patients. Overall health-related QoL in 2 to 3 years aged children HLHS was good, but inferior scores in the motor subscale were noted compared to healthy norms (P=0.007). However, at 3 to 4 years, parents reported comparable QoL for their children in the PCQLI to children with biventricular heart lesion. CONCLUSIONS HLHS patients followed by hybrid approach without major complications show a favorable neurodevelopment at 2-3 years of age. Despite extensive health-related burden, the vast majority of Fontan preschoolers with HLHS showed a good health-related QoL. Nevertheless, comprehensive care and establishing routine follow-up examinations are important to recognize long-term challenges and further improve neurodevelopmental outcome of this high-risk patient population.
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Affiliation(s)
- Bettina Reich
- Pediatric Heart Center, University Hospital Giessen, Justus-Liebig-University, Giessen, Germany
| | - Kristina N Heye
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Thushiha Logeswaran
- Pediatric Heart Center, University Hospital Giessen, Justus-Liebig-University, Giessen, Germany
| | - Andreas Hahn
- Pediatric Neurology, University Hospital Giessen, Justus-Liebig-University, Giessen, Germany
| | - Hakan Akintürk
- Pediatric Heart Center, University Hospital Giessen, Justus-Liebig-University, Giessen, Germany
| | - Christian Jux
- Pediatric Heart Center, University Hospital Giessen, Justus-Liebig-University, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center Hesse, Johann-Wolfgang-Goethe University Hospital Frankfurt, Frankfurt/Main, Germany
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122
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Leonetti C, Back SA, Gallo V, Ishibashi N. Cortical Dysmaturation in Congenital Heart Disease. Trends Neurosci 2019; 42:192-204. [PMID: 30616953 PMCID: PMC6397700 DOI: 10.1016/j.tins.2018.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/28/2018] [Accepted: 12/11/2018] [Indexed: 01/09/2023]
Abstract
Congenital heart disease (CHD) is among the most common birth defects. Children with CHD frequently display long-term intellectual and behavioral disability. Emerging evidence indicates that cardiac anomalies lead to a reduction in cerebral oxygenation, which appears to profoundly impact on the maturation of cerebral regions responsible for higher-order cognitive functions. In this review we focus on the potential mechanisms by which dysregulation of cortical neuronal development during early life may lead to the significant cognitive impairments that commonly occur in children with CHD. Further understanding of the mechanisms underlying cortical dysmaturation due to CHD will be necessary to identify strategies for neonatal neuroprotection and for mitigating developmental delays in this patient population.
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Affiliation(s)
- Camille Leonetti
- Center for Neuroscience Research, Children's National Health System, Washington, DC 20010, USA; Children's National Heart Institute, Children's National Health System, Washington, DC 20010, USA
| | - Stephen A Back
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA; Department of Neurology, Oregon Health and Science University, Portland, OR 97239, USA
| | - Vittorio Gallo
- Center for Neuroscience Research, Children's National Health System, Washington, DC 20010, USA.
| | - Nobuyuki Ishibashi
- Center for Neuroscience Research, Children's National Health System, Washington, DC 20010, USA; Children's National Heart Institute, Children's National Health System, Washington, DC 20010, USA.
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123
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Calderon J, Bellinger DC, Hartigan C, Lord A, Stopp C, Wypij D, Newburger JW. Improving neurodevelopmental outcomes in children with congenital heart disease: protocol for a randomised controlled trial of working memory training. BMJ Open 2019; 9:e023304. [PMID: 30782877 PMCID: PMC6377570 DOI: 10.1136/bmjopen-2018-023304] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 10/22/2018] [Accepted: 12/20/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Executive function (EF) impairments are among the most prevalent neurodevelopmental morbidities in youth with congenital heart disease (CHD). To date, no studies have investigated the efficacy of cognitive interventions to improve EF outcomes in children with CHD. METHODS AND ANALYSIS This is a single-centre, single-blinded, two-arm randomised controlled trial to test the efficacy of Cogmed Working Memory Training (Cogmed) versus standard of care in children with CHD after open-heart surgery in infancy. Participants will consist of 100 children with CHD aged 7-12 years who underwent open-heart surgery before the age of 12 months. Participants are randomly allocated to either an intervention group including training on the home-based Cogmed intervention for a duration of approximately 5 weeks or a control group who receive the standard of care. We will evaluate the efficacy of Cogmed at post-treatment and 3 months after completion of the intervention. Baseline, post-treatment and 3-month follow-up assessments will include specific measures of EF, cognitive and social functioning, and attention deficit hyperactivity disorder (ADHD) symptoms. The primary outcome of this study is the change in standardised mean score on the List Sorting Working Memory test from the National Institutes of Health Toolbox for the Assessment of Neurological and Behavioral Function. Secondary outcomes include measures of social skills, inhibitory control, cognitive flexibility and behavioural EF as well as ADHD symptoms as measured by the Behavior Rating Inventory of Executive Function, Second Edition, and the Conners Third Edition. The efficacy of the intervention will be evaluated by comparing within-subject differences (baseline to post-treatment, baseline to 3-month follow-up) between the two groups using an intention-to-treat analysis. ETHICS AND DISSEMINATION This study has received Institutional Review Board (IRB) approval from Boston's Children's Hospital IRB (P00022440) and the Human Protection Agency from the US Department of Defense. TRIAL REGISTRATION NUMBER NCT03023644; Pre-results.
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Affiliation(s)
- Johanna Calderon
- Boston Children’s Hospital, Department of Psychiatry, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - David C Bellinger
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine Hartigan
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Alison Lord
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Christian Stopp
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - David Wypij
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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124
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Demianczyk AC, Behere SP, Thacker D, Noeder M, Delaplane EA, Pizarro C, Sood E. Social Risk Factors Impact Hospital Readmission and Outpatient Appointment Adherence for Children with Congenital Heart Disease. J Pediatr 2019; 205:35-40.e1. [PMID: 30366772 PMCID: PMC6527093 DOI: 10.1016/j.jpeds.2018.09.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/16/2018] [Accepted: 09/12/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To examine the relations of individual and cumulative social risk factors to hospitalization outcomes and adherence to outpatient cardiology appointments within the first 2 years of life for congenital heart disease survivors. STUDY DESIGN Data were extracted for 219 patients who underwent infant cardiac surgery with cardiopulmonary bypass. Cumulative social risk was dichotomized into high social risk (≥2 risk factors; n = 103) versus low social risk (≤1 risk factor; n = 116). The risk of morbidity by procedure was assigned from 1 to 5 (Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery Morbidity Scores and Categories). Two-way ANOVAs examined the effects of social risk and morbidity risk on length of first surgical hospitalization, number of readmissions and readmission days, subsequent cardiac surgical interventions, and adherence to outpatient cardiology appointments. RESULTS An interaction between social risk and morbidity risk was identified for number of readmission days, F(4, 209) = 3.07, P = .02, η2 = .06. Pairwise comparisons demonstrated that, among those patients with the lowest risk of morbidity by procedure (morbidity scores of 1 and 2), patients at high social risk had more readmission days than patients at low social risk (morbidity score 1: 16.63 ± 34.41 days vs 3.02 ± 7.13 days; morbidity score 2: 27.68 ± 52.11 days vs 2.20 ± 4.43 days). High social risk also predicted significantly worse adherence to cardiology appointments. CONCLUSIONS Cumulative social risk impacts readmission days for patients with congenital heart disease with a low risk of morbidity by procedure. Social risk assessment can identify families who may benefit from social/behavioral interventions to optimize discharge readiness, congenital heart disease home management, and long-term outcomes.
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Affiliation(s)
- Abigail C. Demianczyk
- Division of Behavioral Health, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Shashank P. Behere
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Deepika Thacker
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Maia Noeder
- Division of Behavioral Health, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Emily A. Delaplane
- Department of Patient and Family Services, Nemours/Alfred I. duPont Hospital for Children, Wilmington,
DE
| | - Christian Pizarro
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Erica Sood
- Division of Behavioral Health, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Neuromotor performance in infants before and after early open-heart surgery and risk factors for delayed development at 6 months of age. Cardiol Young 2019; 29:100-109. [PMID: 30352635 DOI: 10.1017/s1047951118001622] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Early identification of infants with CHD at heightened risk of developmental delays can inform surveillance priorities. This study investigated pre-operative and post-operative neuromotor performance in infants undergoing open-heart surgery, and their developmental status at 6 months of age, to identify risk factors and inform care pathways. METHODS Infants undergoing open-heart surgery before 4 months of age were recruited into a prospective cohort study. Neuromotor performance was assessed pre-operatively and post-operatively using the Test of Infant Motor Performance and Prechtl's Assessment of General Movements. Development was assessed at 6 months of age using the Ages and Stages Questionnaire third edition. Pre-operative and post-operative General Movements performance was compared using McNemar's test and test of infant motor performance z-scores using Wilcoxon's signed rank test. Risk factors for delayed development at 6 months were explored using logistic regression. RESULTS Sixty infants were included in this study. In the 23 (38%) infants. A total of 60 infants were recruited. In the 23 (38%) infants assessed pre-operatively, there was no significant difference between pre- and post-operative performance on the GMs (p=0.63) or TIMP (p=0.28). At discharge, 15 (26%) infants presented with abnormal GMs, and the median TIMP z-score was -0.93 (IQR: -1.4 to -0.69). At 6 months, 28 (52.8%) infants presented with gross motor delay on the ASQ-3, significantly negatively associated with gestational age (p=0.03), length of hospital stay (p=0.04) and discharge TIMP score (p=0.01). CONCLUSIONS Post-operative assessment using the GMs and TIMP may be useful to identify infants requiring individualised care and targeted developmental follow-up. Long-term developmental surveillance beyond 6 months of age is recommended.
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Graham EM, Martin RH, Atz AM, Hamlin-Smith K, Kavarana MN, Bradley SM, Alsoufi B, Mahle WT, Everett AD. Association of intraoperative circulating-brain injury biomarker and neurodevelopmental outcomes at 1 year among neonates who have undergone cardiac surgery. J Thorac Cardiovasc Surg 2019; 157:1996-2002. [PMID: 30797587 DOI: 10.1016/j.jtcvs.2019.01.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/19/2018] [Accepted: 01/12/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Neurodevelopmental disability is the most significant complication for survivors of infant surgery for congenital heart disease. In this study we sought to determine if perioperative circulating brain injury biomarker levels are associated with neurodevelopmental outcomes at 12 months. METHODS A secondary analysis of a randomized controlled trial of neonates who underwent cardiac surgery was performed. Glial fibrillary acidic protein (GFAP) was measured: (1) before skin incision; (2) immediately after bypass; (3) 4 and (4) 24 hours postoperatively. Linear regression models were used to determine an association with the highest levels of GFAP and Bayley Scales of Infant and Toddler Development third edition (BSID) composite scores. RESULTS There were 97 subjects who had cardiac surgery at a mean age of 9 ± 6 days and completed a BSID at 12.5 ± 0.6 months of age. Median (25th-75th percentile) levels of GFAP were 0.01 (0.01-0.02), 0.85 (0.40-1.55), 0.07 (0.05-0.11), and 0.03 (0.02-0.04) ng/mL at the 4 time points, respectively. In univariate analysis GFAP was negatively associated with cognitive, language, and motor composite scores. GFAP levels immediately after bypass differed between institutions; 1.57 (0.92-2.48) versus 0.77 (0.36-1.21) ng/mL (P = .01). After adjusting for center and potential confounders, GFAP was independently associated with BSID motor score (P = .04). CONCLUSIONS Higher GFAP levels at the time of neonatal cardiac operations were independently associated with decreased BSID motor scores at 12 months. GFAP might serve as a diagnostic means to acutely identify perioperative brain-specific injury and serve as a benchmark of therapeutic efficacy for investigational treatments, discriminate center-specific effects, and provide early prognostic information for intervention.
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Affiliation(s)
- Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC.
| | - Renee' H Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Andrew M Atz
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Kasey Hamlin-Smith
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Minoo N Kavarana
- Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Scott M Bradley
- Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, Children's Healthcare of Atlanta and Emory University, Atlanta, Ga
| | - William T Mahle
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, Ga
| | - Allen D Everett
- Division of Cardiology, Department of Pediatrics, Johns Hopkins University, Baltimore, Md
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127
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Sánchez O, Ruiz-Romero A, Domínguez C, Ferrer Q, Ribera I, Rodríguez-Sureda V, Alijotas J, Arévalo S, Carreras E, Cabero L, Llurba E. Brain angiogenic gene expression in fetuses with congenital heart disease. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:734-738. [PMID: 29205570 DOI: 10.1002/uog.18977] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 10/09/2017] [Accepted: 11/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To assess potential differences in the expression of antiangiogenic and angiogenic factors and of genes associated with chronic hypoxia in cerebral tissue of euploid fetuses with congenital heart disease (CHD) vs those without. METHODS Cerebral tissue was obtained from 15 fetuses with CHD and 12 control fetuses that had undergone termination of pregnancy. Expression profiles of the antiangiogenic factor soluble fms-like tyrosine kinase-1 (sFlt-1), the angiogenic vascular endothelial growth factor-A (VEGF-A) and placental growth factor (PlGF), and of genes associated with chronic hypoxia were determined by real-time polymerase chain reaction in tissue from the frontal cortex and the basal ganglia of the fetuses. RESULTS Expression of sFlt-1 was 48% higher in the frontal cortex (P = 0.0431) and 72% higher in the basal ganglia (P = 0.0369) of CHD fetuses compared with controls. The expression of VEGF-A was 60% higher (P = 0.0432) and that of hypoxia-inducible factor 2-alpha was 98% higher (P = 0.0456) in the basal ganglia of CHD fetuses compared with controls. No significant differences were observed between the two groups in the expression of PlGF and hypoxia-inducible factor 1-alpha. CONCLUSION An overall dysregulation of angiogenesis with a net balance towards an antiangiogenic environment was observed in the cerebral tissue of fetuses with CHD, suggesting that these fetuses may have an intrinsic angiogenic impairment that could contribute to impaired brain perfusion and abnormal neurological development later in life. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- O Sánchez
- Maternal and Child Health and Development Network (SAMID), RD16/0022/0015, Instituto de Salud Carlos III, Barcelona, Spain
- Biochemistry and Molecular Biology Research Centre for Nanomedicine, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - A Ruiz-Romero
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Research Institute (VHIR), SAMID Network, Vall d'Hebron University Hospital, Barcelona, Spain
| | - C Domínguez
- Biochemistry and Molecular Biology Research Centre for Nanomedicine, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
- Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Q Ferrer
- Pediatric Cardiology Unit, Department of Pediatrics, Vall d'Hebron University Hospital, Barcelona, Spain
| | - I Ribera
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Research Institute (VHIR), SAMID Network, Vall d'Hebron University Hospital, Barcelona, Spain
| | - V Rodríguez-Sureda
- Biochemistry and Molecular Biology Research Centre for Nanomedicine, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
- Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - J Alijotas
- Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - S Arévalo
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Research Institute (VHIR), SAMID Network, Vall d'Hebron University Hospital, Barcelona, Spain
| | - E Carreras
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Research Institute (VHIR), SAMID Network, Vall d'Hebron University Hospital, Barcelona, Spain
| | - L Cabero
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Research Institute (VHIR), SAMID Network, Vall d'Hebron University Hospital, Barcelona, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - E Llurba
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Research Institute (VHIR), SAMID Network, Vall d'Hebron University Hospital, Barcelona, Spain
- School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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Abstract
BACKGROUND Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection. METHODS We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure. RESULTS During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment. CONCLUSION When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.
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129
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Peyvandi S, Donofrio MT. Circulatory Changes and Cerebral Blood Flow and Oxygenation During Transition in Newborns With Congenital Heart Disease. Semin Pediatr Neurol 2018; 28:38-47. [PMID: 30522727 DOI: 10.1016/j.spen.2018.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
This review aims to describe how the complex events of cardiovascular transition may affect the brain of infants with congenital heart disease (CHD). In particular, we describe the vulnerabilities of the neonatal brain in the transitional period during and immediately after delivery and propose management strategies that can potentially influence neurodevelopmental outcomes in this patient population. Delayed brain development has been identified in the third trimester fetus with certain forms of CHD. Neonates with critical CHD are at risk for brain injury even before their neonatal operation. The transitional period from fetal to neonatal life is marked with hemodynamic changes that can affect cerebral blood flow and oxygenation and may exacerbate injury and influence outcome. We propose specific perinatal management strategies tailored to maternal-fetal pairs aimed at optimizing hemodynamic stability, especially cerebral blood flow and oxygenation, to maximize the neurodevelopmental potential of infants with CHD.
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Affiliation(s)
- Shabnam Peyvandi
- Division of Pediatric Cardiology, University of California San Francisco, Pediatric Heart Center, Benioff Children's Hospital, San Francisco, CA
| | - Mary T Donofrio
- Division of Cardiology, George Washington University, Children's National Health System, Washington, DC.
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130
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Dagenais L, Materassi M, Desnous B, Vinay MC, Doussau A, Sabeh P, Prud'homme J, BSc KG, Lenoir M, Charron MA, Nuyt AM, Poirier N, Beaulieu-Genest L, Carmant L, Birca A. Superior Performance in Prone in Infants With Congenital Heart Disease Predicts an Earlier Onset of Walking. J Child Neurol 2018; 33:894-900. [PMID: 30226082 DOI: 10.1177/0883073818798194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Infants with congenital heart disease are at risk of impaired neurodevelopment, which frequently manifests as motor delay during their first years of life. This delay is multifactorial in origin and environmental factors, such as a limited experience in prone, may play a role. In this study, we evaluated the motor development of a prospective cohort of 71 infants (37 males) with congenital heart disease at 4 months of age using the Alberta Infant Motor Scales (AIMS). We used regression analyses to determine whether the 4-month AIMS scores predict the ability to walk by 18 months. The influence of demographic and clinical variables was also assessed. Fifty-one infants (71.8%) were able to maintain the prone prop position (AIMS score of ≥3 in prone) at 4 months. Of those, 47 (92.2%) were able to walk by 18 months compared to only 12/20 (60%) of those who did not maintain the position. Higher AIMS scores were predictive of a greater likelihood of walking by 18 months ( P < .001), with the scores in prone having a higher predictive ability compared to those in other positions (Exp(B) 15.2 vs 4.0). Shorter hospital stays and female gender were also associated with an earlier onset of walking. In conclusion, our study demonstrates that early ventral performance in infants with congenital heart disease impacts the age of acquisition of walking and could be used to guide referral to rehabilitation.
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Affiliation(s)
- Lynn Dagenais
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada
| | - Manuela Materassi
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada
| | - Beatrice Desnous
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada.,2 Division of Neurology, Department of Neuroscience, CHU Sainte-Justine and the University of Montréal, Montréal, Québec, Canada
| | - Marie-Claude Vinay
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada
| | - Amélie Doussau
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada
| | - Pascale Sabeh
- 3 CHU Sainte-Justine Research Centre, University of Montréal, Montréal, Québec, Canada
| | - Joelle Prud'homme
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada
| | - Karine Gagnon BSc
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada
| | - Marien Lenoir
- 4 Division of Cardiac Surgery, Department of Surgery, University of Montréal, Montréal, Québec, Canada
| | - Marc-Antoine Charron
- 3 CHU Sainte-Justine Research Centre, University of Montréal, Montréal, Québec, Canada
| | - Anne Monique Nuyt
- 3 CHU Sainte-Justine Research Centre, University of Montréal, Montréal, Québec, Canada.,5 Department of Pediatrics, CHU Sainte-Justine and the University of Montréal, Montréal, Québec, Canada
| | - Nancy Poirier
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada.,4 Division of Cardiac Surgery, Department of Surgery, University of Montréal, Montréal, Québec, Canada
| | - Laurence Beaulieu-Genest
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada.,5 Department of Pediatrics, CHU Sainte-Justine and the University of Montréal, Montréal, Québec, Canada
| | - Lionel Carmant
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada.,2 Division of Neurology, Department of Neuroscience, CHU Sainte-Justine and the University of Montréal, Montréal, Québec, Canada.,3 CHU Sainte-Justine Research Centre, University of Montréal, Montréal, Québec, Canada.,5 Department of Pediatrics, CHU Sainte-Justine and the University of Montréal, Montréal, Québec, Canada.,These authors contributed equally to this work
| | - Ala Birca
- 1 Clinique d'Investigation Neuro-Cardiaque (CINC), CHU Sainte-Justine, Montréal, Québec, Canada.,2 Division of Neurology, Department of Neuroscience, CHU Sainte-Justine and the University of Montréal, Montréal, Québec, Canada.,3 CHU Sainte-Justine Research Centre, University of Montréal, Montréal, Québec, Canada.,5 Department of Pediatrics, CHU Sainte-Justine and the University of Montréal, Montréal, Québec, Canada.,These authors contributed equally to this work
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131
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Butler SC, Sadhwani A, Stopp C, Singer J, Wypij D, Dunbar-Masterson C, Ware J, Newburger JW. Neurodevelopmental assessment of infants with congenital heart disease in the early postoperative period. CONGENIT HEART DIS 2018; 14:236-245. [PMID: 30324749 DOI: 10.1111/chd.12686] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/07/2018] [Accepted: 09/12/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Mortality rates for children with congenital heart disease (CHD) have significantly declined, resulting in a growing population with associated neurodevelopmental disabilities. American Heart Association guidelines recommend systematic developmental screening for children with CHD. The present study describes results of inpatient newborn neurodevelopmental assessment of infants after open heart surgery. OUTCOME MEASURES We evaluated the neurodevelopment of a convenience sample of high-risk infants following cardiac surgery but before hospital discharge using an adaptation of the Newborn Behavioral Observation. Factor analysis examined relationships among assessment items and consolidated them into domains of development. RESULTS We assessed 237 infants at a median of 11 days (interquartile range [IQR]: 7-19 days) after cardiac surgery and median corrected age of 21 days (IQR: 13-33 days). Autonomic regulation was minimally stressed or well organized in 14% of infants. Upper and lower muscle tone was appropriate in 33% and 35%, respectively. Appropriate response to social stimulation ranged between 7% and 12% depending on task, and state regulation was well organized in 14%. The vast majority (87%) required enhanced examiner facilitation for participation. Factor analyses of assessment items aligned into four domains of development (autonomic, motor, oral motor, and attention organization). CONCLUSION At discharge, postoperative infants with CHD had impairments in autonomic, motor, attention, and state regulation following cardiac surgery. Findings highlight the challenges faced by children with CHD relative to healthy peers, suggesting that neurodevelopmental follow-up and intervention should begin early in infancy.
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Affiliation(s)
- Samantha C Butler
- Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Anjali Sadhwani
- Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Jayne Singer
- Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts.,Developmental Medicine Center, Boston Children's Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Janice Ware
- Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts.,Developmental Medicine Center, Boston Children's Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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132
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Szwast A, Putt M, Gaynor JW, Licht DJ, Rychik J. Cerebrovascular response to maternal hyperoxygenation in fetuses with hypoplastic left heart syndrome depends on gestational age and baseline cerebrovascular resistance. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:473-478. [PMID: 28976608 PMCID: PMC6719779 DOI: 10.1002/uog.18919] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/26/2017] [Accepted: 09/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Compared with normal fetuses, fetuses with hypoplastic left heart syndrome (HLHS) have smaller brain volumes and are at higher risk of brain injury, possibly due to diminished cerebral blood flow and oxygen content. By increasing cerebral oxygen delivery, maternal hyperoxygenation (MH) might improve brain development and reduce the risk of brain injury in these fetuses. This study investigated whether gestational age and baseline cerebrovascular resistance affect the response to MH in fetuses with HLHS. METHODS The study population comprised 43 fetuses with HLHS or HLHS variant referred for fetal echocardiography between January 2004 and September 2008. Middle cerebral artery (MCA) pulsatility index (PI), a surrogate measure of cerebrovascular resistance, was assessed between 20 and 41 weeks' gestation at baseline in room air (RA) and after 10 min of MH. Z-scores of MCA-PI were generated. A mixed-effects model was used to determine whether change in MCA-PI depends upon gestational age and baseline MCA-PI. RESULTS In RA and following MH, MCA-PI demonstrated a curvilinear relationship with gestational age in fetuses with HLHS, peaking at around 28 weeks and then falling more steeply near term. MCA-PI Z-score declined in a linear manner, such that it was 1.4 SD below that in normal fetuses at 38 weeks. Increase in MCA-PI Z-score after MH was first seen at ≥ 28 weeks. A baseline MCA-PI Z-score ≤ -0.96 was predictive of an increase in cerebrovascular resistance in response to MH. CONCLUSION In fetuses with HLHS, MCA-PI first increases in response to MH at ≥ 28 weeks' gestation. A baseline MCA-PI Z-score ≤ -0.96 predicts an increase in cerebrovascular resistance in response to MH. These results may have implications for clinical trials utilizing MH as a neuroprotective agent. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Szwast
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Putt
- Division of Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - J W Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - D J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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133
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Saef J, Sodhi S, Tecson KM, Al Rashida V, Mi Ko J, White KS, Ludbrook PA, Cedars AM. Contributors to disease-specific health knowledge in adults with congenital heart disease: A correlational study. CONGENIT HEART DIS 2018; 13:967-977. [PMID: 30259669 DOI: 10.1111/chd.12668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 06/27/2018] [Accepted: 08/07/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Growth in the adults with congenital heart disease (ACHD) population represents a challenge to the health care infrastructure. As patients with chronic disease are increasingly held accountable for their own care, contributors to disease-specific health knowledge, which are known to correlate with patients' participation in care, merit investigation to design patient-focused interventions. DESIGN We conducted a single-site, cross-sectional study of ACHD patients. Investigators retrospectively gathered clinical data as well as psychometric and health status assessments completed at the time of enrollment. OUTCOME MEASURES We investigated the impact of clinical and psychological variables on Leuven Knowledge Questionnaire for Congenital Heart Diseases health knowledge composite scores (HKCS). Variables with significant associations were considered in a stepwise multivariable regression model to determine which combination of variables jointly explained variability in HKCS. RESULTS Overall HKCS was associated with the number of prior cardiac surgeries (r = 0.273; 95% CI: 0.050-0.467; P = .016), perceived stress (r = 0.260; 95% CI: 0.033-0.458; P = .024), SF-36 emotional well-being (r = -0.251; 95% CI: -0.451, -0.024; P = .030), history of noncardiac surgery (P = .037), cirrhosis (P = .048), and presence of implantable cardioverter-defibrillator (P = .028). On multivariable modeling, only the number of cardiac surgeries was found to correlate with HKCS. CONCLUSIONS While univariate correlations were found between HCKS and several other clinical and psychological variables, only number of prior cardiac surgeries independently correlated with disease-specific health knowledge in ACHD patients. These results suggest that clinical and psychological variables are not impediments to disease-specific health knowledge.
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Affiliation(s)
- Joshua Saef
- Department of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Sandeep Sodhi
- Department of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Kristen M Tecson
- Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, Texas
| | - Vanessa Al Rashida
- Department of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Jong Mi Ko
- Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, Texas
| | - Kamila S White
- Department of Psychology, University of Missouri, St Louis, Missouri
| | - Philip A Ludbrook
- Department of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Ari M Cedars
- Department of Cardiology, Baylor Scott & White Health Care, Dallas, Texas
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134
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Tran NN, Kumar SR, Hodge FS, Macey PM. Cerebral Autoregulation in Neonates With and Without Congenital Heart Disease. Am J Crit Care 2018; 27:410-416. [PMID: 30173174 DOI: 10.4037/ajcc2018672] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Congenital heart disease (CHD) is a leading birth defect in the United States, affecting about 40 000 neonates each year. Despite efforts to prevent developmental delays, many children with CHD have neurological deficits that last into adulthood, influencing employability, self-care, and quality of life. OBJECTIVE To determine if neonates with CHD have impaired cerebral autoregulation and poorer neurodevelopmental outcomes compared with healthy controls. METHODS A total of 44 full-term neonates, 28 with CHD and 16 without, were enrolled in the study. Inclusion criteria included confirmed diagnosis of CHD, stable hemodynamic status, and being no more than 12 days old. Exclusion criteria included intraventricular hemorrhage and intubation. Cerebral autoregulation was determined by measuring regional cerebral oxygenation during a postural change. The Einstein Neonatal Neurobehavioral Assessment Scale was used to measure overall neurodevelopmental outcomes (motor, visual, and auditory functions). RESULTS Of the 28 neonates with CHD, 8 had single-ventricle physiology. A χ2 analysis indicated no significant difference in impaired cerebral autoregulation between neonates with CHD and controls (P = .38). Neonates with CHD had lower regional cerebral oxygenation than did neonates without CHD (P < .001). Regression analyses with adjustments for cerebral autoregulation indicated that neonates with CHD had poorer total neurodevelopmental outcomes scores (β = 9.3; P = .02) and motor scores (β = 7.6; P = .04). CONCLUSION Preoperative neonates with CHD have poorer developmental outcomes and more hypoxemia than do controls.
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Affiliation(s)
- Nhu N. Tran
- Nhu N. Tran is a clinical research nurse III, Department of Cardiothoracic Surgery, Children’s Hospital Los Angeles, Los Angeles, California. Ram Kumar is an assistant professor of surgery, Keck School of Medicine, University of Southern California, Los Angeles, California. Felicia S. Hodge is a professor and Paul M. Macey is an associate professor, School of Nursing, University of California, Los Angeles
| | - S. Ram Kumar
- Nhu N. Tran is a clinical research nurse III, Department of Cardiothoracic Surgery, Children’s Hospital Los Angeles, Los Angeles, California. Ram Kumar is an assistant professor of surgery, Keck School of Medicine, University of Southern California, Los Angeles, California. Felicia S. Hodge is a professor and Paul M. Macey is an associate professor, School of Nursing, University of California, Los Angeles
| | - Felicia S. Hodge
- Nhu N. Tran is a clinical research nurse III, Department of Cardiothoracic Surgery, Children’s Hospital Los Angeles, Los Angeles, California. Ram Kumar is an assistant professor of surgery, Keck School of Medicine, University of Southern California, Los Angeles, California. Felicia S. Hodge is a professor and Paul M. Macey is an associate professor, School of Nursing, University of California, Los Angeles
| | - Paul M. Macey
- Nhu N. Tran is a clinical research nurse III, Department of Cardiothoracic Surgery, Children’s Hospital Los Angeles, Los Angeles, California. Ram Kumar is an assistant professor of surgery, Keck School of Medicine, University of Southern California, Los Angeles, California. Felicia S. Hodge is a professor and Paul M. Macey is an associate professor, School of Nursing, University of California, Los Angeles
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135
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Cooper DKC, Hara H, Iwase H, Banks CA, Cleveland DC. An approach to induction of tolerance to pig cardiac xenografts in neonates. Xenotransplantation 2018; 25:e12454. [PMID: 30125392 PMCID: PMC10124770 DOI: 10.1111/xen.12454] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/04/2018] [Accepted: 07/20/2018] [Indexed: 02/06/2023]
Abstract
There is a continuing need for donor hearts for infants with complex congenital heart defects. The transplantation of hearts from neonatal pigs would be an alternative to human organs, particularly if donor-specific immunological tolerance could be achieved. The great majority of infant humans do not make natural (preformed) antibodies against triple-knockout (TKO) pigs (that do not express any of the three known pig antigens against which humans have natural anti-pig antibodies). The transplantation of a heart from a TKO pig into an infant would therefore minimize any risk of early antibody-mediated rejection, and, with adequate immunosuppressive therapy, prolonged graft survival may well be achieved. Total host thymectomy (commonly carried out at the time of orthotopic heart transplantation in this age group) ± residual T-cell depletion and donor-specific pig thymus tissue transplantation might induce T-cell tolerance and allow immunosuppressive therapy to be discontinued (if there is in vitro evidence of T-cell and B-cell nonresponsiveness to donor-specific pig cells). Even if tolerance were not achieved, with continuing immunosuppressive therapy, the graft would likely "bridge" the patient until a suitable allograft became available or be associated with prolonged xenograft function.
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Affiliation(s)
- David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charles Adam Banks
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - David C Cleveland
- Department of Pediatric Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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136
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Prediction of Periventricular Leukomalacia in Neonates after Cardiac Surgery Using Machine Learning Algorithms. J Med Syst 2018; 42:177. [DOI: 10.1007/s10916-018-1029-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
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137
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Schmithorst VJ, Votava-Smith JK, Tran N, Kim R, Lee V, Ceschin R, Lai H, Johnson JA, De Toledo JS, Blüml S, Paquette L, Panigrahy A. Structural network topology correlates of microstructural brain dysmaturation in term infants with congenital heart disease. Hum Brain Mapp 2018; 39:4593-4610. [PMID: 30076775 DOI: 10.1002/hbm.24308] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 12/22/2022] Open
Abstract
Neonates with complex congenital heart disease (CHD) demonstrate microstructural brain dysmaturation, but the relationship with structural network topology is unknown. We performed diffusion tensor imaging (DTI) in term neonates with CHD preoperatively (N = 61) and postoperatively (N = 50) compared with healthy term controls (N = 91). We used network topology (graph) analyses incorporating different weighted and unweighted approaches and subject-specific white matter segmentation to investigate structural topology differences, as well as a voxel-based analysis (VBA) to confirm the presence of microstructural dysmaturation. We demonstrate cost-dependent network inefficiencies in neonatal CHD in the pre- and postoperative period compared with controls, related to microstructural differences. Controlling for cost, we show the presence of increased small-worldness (hierarchical fiber organization) in CHD infants preoperatively, that persists in the postoperative period compared with controls, suggesting the early presence of brain reorganization. Taken together, topological microstructural dysmaturation in CHD infants is accompanied by hierarchical fiber organization during a protracted critical period of early brain development. Our methodology also provides a pipeline for quantitation of network topology changes in neonates and infants with microstructural brain dysmaturation at risk for perinatal brain injury.
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Affiliation(s)
- Vincent J Schmithorst
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jodie K Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Nhu Tran
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Richard Kim
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Vince Lee
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rafael Ceschin
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hollie Lai
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California
| | - Jennifer A Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joan Sanchez De Toledo
- Pediatric Cardiac Intensive Care Division, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stefan Blüml
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California
| | - Lisa Paquette
- Department of Pediatrics, Division of Neonatology, Children's Hospital Los Angeles, Los Angeles, California
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California
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138
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Solomon RS, Sasi T, Sudhakar A, Kumar RK, Vaidyanathan B. Early Neurodevelopmental Outcomes After Corrective Cardiac Surgery In Infants. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1281-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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139
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Mothers and Fathers Experience Stress of Congenital Heart Disease Differently: Recommendations for Pediatric Critical Care. Pediatr Crit Care Med 2018; 19. [PMID: 29533356 PMCID: PMC6037564 DOI: 10.1097/pcc.0000000000001528] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To inform pediatric critical care practice by examining how mothers and fathers experience the stress of caring for a young child with congenital heart disease and use hospital and community supports. DESIGN Qualitative study of mothers and fathers of young children with congenital heart disease. SETTING Tertiary care pediatric hospital in the Mid-Atlantic region of the United States. SUBJECTS Thirty-four parents (20 mothers, 14 fathers) from diverse backgrounds whose child previously underwent cardiac surgery during infancy. INTERVENTIONS Subjects participated in semi-structured, individual interviews about their experiences and psychosocial needs at the time of congenital heart disease diagnosis, surgical admission, and discharge to home after surgery. Qualitative interview data were coded, and consistent themes related to emotional states, stressors, and supports were identified. MEASUREMENTS AND MAIN RESULTS Fathers experience and respond to the stressors and demands of congenital heart disease in unique ways. Fathers often described stress from not being able to protect their child from congenital heart disease and the associated surgeries/pain and from difficulties balancing employment with support for their partner and care of their congenital heart disease child in the hospital. Fathers were more likely than mothers to discuss support from the work environment (coworkers/managers, flexible scheduling, helpful distraction) and were less likely to describe the use of hospital-based resources or congenital heart disease peer-to-peer supports. CONCLUSIONS This study highlights the importance of understanding the paternal experience and tailoring interventions to the unique needs of both mothers and fathers. Opportunities for critical care practice change to promote the mental health of mothers and fathers following a diagnosis of congenital heart disease are discussed.
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140
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Rotermann I, Logoteta J, Falta J, Wegner P, Jung O, Dütschke P, Scheewe J, Kramer HH, Hansen JH. Neuro-developmental outcome in single-ventricle patients: is the Norwood procedure a risk factor? Eur J Cardiothorac Surg 2018; 52:558-564. [PMID: 28472306 DOI: 10.1093/ejcts/ezx119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/19/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Complex neonatal surgery is considered a risk factor for neuro-developmental impairment in single-ventricle patients. Neuro-developmental outcome was compared between preschool-aged Fontan patients who underwent a Norwood procedure and single-ventricle patients not requiring neonatal surgery with cardiopulmonary bypass. METHODS Verbal, performance and full-scale intelligence quotient (IQ) were evaluated with the Wechsler Preschool and Primary Scale of Intelligence. Cognitive functions were assessed with the German 'Kognitiver Entwicklungstest für das Kindergartenalter' (KET-KID). Risk factors for impaired neuro-development were evaluated. RESULTS Neuro-developmental assessment was completed in 95 patients (Norwood: n = 69; non-Norwood: n = 26). Median (interquartile range) IQ and KET-KID scores were in the normal range. Except for verbal KET-KID, scores did not differ between Norwood and non-Norwood patients (verbal IQ: 98 (86-105) vs 93 (85-102), P = 0.312; performance IQ: 91 (86-100) vs 96 (86-100), P = 0.932; full-scale IQ: 93 (86-101) vs 89 (84-98), P = 0.314; KET-KID verbal: 48 (17-72) vs 25 (2-54), P = 0.020; KET-KID non-verbal: 33 (18-62) vs 45 (15-54), P = 0.771; KET-KID global: 42 (14-65) vs 28 (6-63), P = 0.208). Full-scale IQ was below average (<85 points) in 14 (20%) Norwood and 9 (35%) non-Norwood cases (P = 0.181). Global KET-KID was below average (<16th percentile) in 19 (28%) and 10 (38%) patients (P = 0.326). Smaller head circumference z-score and complications before neonatal surgery were independently associated with lower scores. CONCLUSIONS Neuro-developmental outcome of preschool-aged Fontan patients was in the normal range. The Norwood procedure was not a risk factor for neuro-developmental impairment. Preoperative condition and patient-related factors were more important determinants than variables related to surgical palliation.
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Affiliation(s)
- Ina Rotermann
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jana Logoteta
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Janine Falta
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Philip Wegner
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Olaf Jung
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Peter Dütschke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jens Scheewe
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Hans-Heiner Kramer
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
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141
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Ubeda Tikkanen A, Nathan M, Sleeper LA, Flavin M, Lewis A, Nimec D, Mayer JE, Del Nido P. Predictors of Postoperative Rehabilitation Therapy Following Congenital Heart Surgery. J Am Heart Assoc 2018; 7:JAHA.117.008094. [PMID: 29754124 PMCID: PMC6015299 DOI: 10.1161/jaha.117.008094] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Patients with congenital heart disease are at risk of motor, cognitive, speech, and feeding difficulties after cardiac surgery. Rehabilitation therapy could improve functional outcomes in this population if applied in the acute postcardiac surgical in‐hospital stay. However, information on the types of acute postcardiac surgery therapy needs in children is scarce. Our goal was to describe rehabilitation therapy following congenital heart surgery and pre/intraoperative factors associated with need for therapy. Methods and Results This is a retrospective cohort study of patients <18 years undergoing heart surgery at our center from January 1, 2013 to January 31, 2015. Demographic, and pre‐, intra‐, and postoperative clinical and rehabilitation therapy (physical, occupational, speech, feeding therapy, and neurodevelopment intervention) data were collected. Need for rehabilitation therapy in the acute postoperative period, particularly following palliative repair, was the outcome variable in a multivariable logistic regression model to identify independent pre‐ and intraoperative factors associated with therapy. A total of 586 out of 1415 (41%) subjects received rehabilitation therapy postsurgery. Certain subgroups had increased rehabilitation therapy use such as neonates (80%). On multivariable analysis, palliative repair, prematurity, genetic syndrome, presurgical hospital stay of more than 1 day, and prolonged cardiopulmonary bypass time were independently associated with rehabilitation therapy. Conclusions Nearly half of patients who underwent post–congenital heart surgery received rehabilitation therapy. Frequency of use and types of therapy vary according to patient characteristics; however, certain pre‐ and intraoperative factors are associated with need for rehabilitation therapy, and may aid decision‐making for appropriate resource allocation.
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Affiliation(s)
- Ana Ubeda Tikkanen
- Department of Pediatric Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA .,Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Lynn A Sleeper
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Marisa Flavin
- Department of Pediatric Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA
| | - Ana Lewis
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Donna Nimec
- Department of Pediatric Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Pedro Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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142
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Peyvandi S, Chau V, Guo T, Xu D, Glass HC, Synnes A, Poskitt K, Barkovich AJ, Miller SP, McQuillen PS. Neonatal Brain Injury and Timing of Neurodevelopmental Assessment in Patients With Congenital Heart Disease. J Am Coll Cardiol 2018; 71:1986-1996. [PMID: 29724352 PMCID: PMC5940013 DOI: 10.1016/j.jacc.2018.02.068] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Brain injury (BI) is reported in 60% of newborns with critical congenital heart disease as white matter injury (WMI) or stroke. Neurodevelopmental (ND) impairments are reported in these patients. The relationship between neonatal BI and ND outcome has not been established. OBJECTIVES This study sought to determine the association between peri-operative BI and ND outcomes in infants with single ventricle physiology (SVP) and d-transposition of the great arteries (d-TGA). METHODS Term newborns with d-TGA and SVP had pre-operative and post-operative brain magnetic resonance imaging and ND outcomes assessed at 12 and 30 months with the Bayley Scales of Infant Development-II. BI was categorized by the brain injury severity score and WMI was quantified by volumetric analysis. RESULTS A total of 104 infants had follow-up at 12 months and 70 had follow-up at 30 months. At 12 months, only clinical variables were associated with ND outcome. At 30 months, subjects with moderate-to-severe WMI had significantly lower Psychomotor Development Index (PDI) scores (13 points lower) as compared with those with none or minimal WMI for d-TGA and SVP (p = 0.03 and p = 0.05, respectively) after adjusting for various factors. Quantitative WMI volume was likewise associated. Stroke was not associated with outcome. The Bland-Altman limits of agreement for PDI scores at 12 and 30 months were wide (-40.3 to 31.2) across the range of mean PDI values. CONCLUSIONS Increasing burden of WMI is associated with worse motor outcomes at 30 months for infants with critical congenital heart disease, whereas no adverse association was seen between small strokes and outcome. These results support the utility of neonatal brain magnetic resonance imaging in this population to aid in predicting later outcomes and the importance of ND follow-up beyond 1 year of age.
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Affiliation(s)
- Shabnam Peyvandi
- Department of Pediatrics, Division of Cardiology, Benioff Children's Hospital, University of California-San Francisco, San Francisco, California
| | - Vann Chau
- Department of Neurology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ting Guo
- Neurosciences and Mental Health, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Duan Xu
- Department of Radiology, University of California-San Francisco, San Francisco, California
| | - Hannah C Glass
- Department of Neurology, Benioff Children's Hospital, University of California-San Francisco, San Francisco, California; Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, Benioff Children's Hospital, University of California-San Francisco, San Francisco, California
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kenneth Poskitt
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - A James Barkovich
- Department of Radiology, University of California-San Francisco, San Francisco, California
| | - Steven P Miller
- Department of Neurology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Patrick S McQuillen
- Department of Pediatrics, Division of Critical Care, Benioff Children's Hospital, University of California-San Francisco, San Francisco, California.
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143
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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144
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Cheatham SL, Chisolm JL, O'Brien N. Cerebral Blood Flow Following Hybrid Stage I Palliation in Infants with Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2018; 39:837-843. [PMID: 29497771 DOI: 10.1007/s00246-018-1836-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/21/2018] [Indexed: 12/26/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) palliation may result in altered cerebral blood flow with subsequent neurodevelopmental implications. The purpose of the study was to assess blood flow in the middle cerebral artery (MCA) and investigate the relationship with early neurodevelopmental outcomes in infants with HLHS after hybrid stage I. Transcranial Doppler (TCD) was performed to obtain peak systolic, end-diastolic, and mean velocities, as well as pulsatility index of the MCA in infants with HLHS (n = 18) at baseline and at 2, 4, and 6 months of age. Developmental assessment was performed at 6 months of age. Results of TCD and development were compared to healthy control subjects (n = 6) and normative data. Overall, peak systolic velocity (p = 0.0031), end-diastolic velocity (p < 0.0001), and mean velocity (p < 0.0001) were significantly lower and pulsatility index (p = 0.0011) significantly higher in the HLHS group compared to the control group. A significant increase in change over time was noted for peak systolic velocity (p < 0.0016) and mean velocity (p < 0.0046). There was no significant correlation between TCD variables and development scores. TCD values in 5-6 months old infants with HLHS who undergo hybrid stage I palliation had consistently lower blood flow velocities than control infants; however, pulsatility index was slightly higher. No correlation between TCD measurements and measures of cognitive, language, and motor skills were noted.
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Affiliation(s)
- Sharon L Cheatham
- The Heart Center, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA. .,The Ohio State University, Columbus, OH, USA.
| | - Joanne L Chisolm
- The Heart Center, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Nicole O'Brien
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University, Columbus, OH, USA
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145
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Russell MW, Chung WK, Kaltman JR, Miller TA. Advances in the Understanding of the Genetic Determinants of Congenital Heart Disease and Their Impact on Clinical Outcomes. J Am Heart Assoc 2018; 7:e006906. [PMID: 29523523 PMCID: PMC5907537 DOI: 10.1161/jaha.117.006906] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mark W Russell
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, NY
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Thomas A Miller
- Department of Pediatrics, University of Utah, Salt Lake City, UT
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146
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Klin A, Jones W. An agenda for 21st century neurodevelopmental medicine: lessons from autism. Rev Neurol 2018; 66:S3-S15. [PMID: 29516447 PMCID: PMC6606044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
The future of neurodevelopmental medicine has the potential of situating child neurology at the forefront of a broad-based public health effort to optimize neurodevelopmental outcomes of children born with high-prevalence and diverse genetic, pre- and peri-natal, and environmental burdens compromising early brain development and leading to lifetime disabilities. Building on advancements in developmental social neuroscience and in implementation science, this shift is already occurring in the case of emblematic neurodevelopmental disorders such as autism. Capitalizing on early neuroplasticity and on quantification of trajectories of social-communicative development, new technologies are emerging for high-throughput and cost-effective diagnosis and for community-viable delivery of powerful treatments, in seamless integration across previously fragmented systems of healthcare delivery. These solutions could be deployed in the case of other groups of children at greater risk for autism and communication delays, such as those born extremely premature or with congenital heart disease. The galvanizing concept in this aspirational future is a public health focus on promoting optimal conditions for early brain development, not unlike current campaigns promoting pre-natal care, nutrition or vaccination.
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Affiliation(s)
- A Klin
- Children's Healthcare of Atlanta and Emory University School of Medicine. Atlanta, Georgia, EE.UU
| | - W Jones
- Children's Healthcare of Atlanta and Emory University School of Medicine. Atlanta, Georgia, EE.UU
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147
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Beke DM. Norwood Procedure for Palliation of Hypoplastic Left Heart Syndrome: Right Ventricle to Pulmonary Artery Conduit vs Modified Blalock-Taussig Shunt. Crit Care Nurse 2018; 36:42-51. [PMID: 27908945 DOI: 10.4037/ccn2016861] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Patients with hypoplastic left heart syndrome undergo a series of operations to separate the pulmonary and systemic circulations. The first of at least 3 operations occurs in the newborn period, with a stage I palliation. The goal of stage I palliation is to provide pulmonary blood flow and create an unobstructed systemic outflow tract. Advances in surgical techniques and intraoperative and postoperative care have helped decrease morbidity and mortality for patients with hypoplastic left heart syndrome who have the stage I Norwood operation, but the patients continue to be at increased risk for hemodynamic collapse and adverse outcomes. This article discusses risk factors, surgical approach, postoperative nursing and medical management strategies, differences between and outcomes for the Norwood operation with the right ventricle to pulmonary artery conduit and the Norwood operation with a modified Blalock-Taussig shunt.
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Affiliation(s)
- Dorothy M Beke
- Dorothy M. Beke is a clinical nurse specialist in the cardiac intensive care unit at Boston Children's Hospital, Boston, Massachusetts. She is the unit's mechanical circulatory support clinical resource, the cardiovascular program bereavement coordinator, and a nurse practitioner in the cardiology preoperative clinic.
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148
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Abstract
OBJECTIVE Children with hypoplastic left heart syndrome are at a risk for neurodevelopmental delays. Current guidelines recommend systematic evaluation and management of neurodevelopmental outcomes with referral for early intervention services. The Single Ventricle Reconstruction Trial represents the largest cohort of children with hypoplastic left heart syndrome ever assembled. Data on life events and resource utilisation have been collected annually. We sought to determine the type and prevalence of early intervention services used from age 1 to 4 years and factors associated with utilisation of services. METHODS Data from 14-month neurodevelopmental assessment and annual medical history forms were used. We assessed the impact of social risk and geographic differences. Fisher exact tests and logistic regression were used to evaluate associations. RESULTS Annual medical history forms were available for 302 of 314 children. Greater than half of the children (52-69%) were not receiving services at any age assessed, whereas 20-32% were receiving two or more therapies each year. Utilisation was significantly lower in year 4 (31%) compared with years 1-3 (with a range from 40 to 48%) (p<0.001). Social risk factors were not associated with the use of services at any age but there were significant geographic differences. Significant delay was reported by parents in 18-43% of children at ages 3 and 4. CONCLUSION Despite significant neurodevelopmental delays, early intervention service utilisation was low in this cohort. As survival has improved for children with hypoplastic left heart syndrome, attention must shift to strategies to optimise developmental outcomes, including enrolment in early intervention when merited.
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149
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Ruggiero KM, Hickey PA, Leger RR, Vessey JA, Hayman LL. Parental perceptions of disease-severity and health-related quality of life in school-age children with congenital heart disease. J SPEC PEDIATR NURS 2018; 23. [PMID: 29266743 DOI: 10.1111/jspn.12204] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 11/20/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Understanding parents' perceptions of their child's health status is important as parents are drivers of healthcare utilization in the pediatric setting. Understanding parent-perceived disease-severity and its effects on a child's health-related quality of life (HRQOL) in children with congenital heart disease (CHD) is necessary to evaluate outcomes of care, improve care coordination, and inform policies focused on advancing family-centered care for pediatric cardiac patients. The impact of CHDs and disease-severity on the child's HRQOL has been investigated with inconsistent results. The overall aim of this study was to examine parents' perceptions of HRQOL in their school-age child with CHD, and to compare HRQOL among patients with CHD across severity categories. DESIGN This was a descriptive correlational study design. METHODS A total of 71 parents of school-age children aged 5-12 years completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (PedsQL) (including total, physical health, and psychosocial health summary scores) and cardiac-specific HRQOL Scale (PedsQL 3.0). PedsQL scores among CHD severity categories were compared by analysis of variance. RESULTS School-age children with CHDs had an overall good HRQOL with significant differences among disease severity categories for all scores. Parents reported lower scores on their HRQOL of older children compared to younger children across severity groups (p < .01) and for those children with more severe disease (p < .01). PRACTICE IMPLICATIONS Based on the results of this study, interventions should focus on targeting psychosocial health in older children with CHD and physical health in younger children with CHD. This information is useful in providing practical recommendations in caring for children with CHDs while informing relevant policies.
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Affiliation(s)
- Kristine M Ruggiero
- Pediatric Nurse Practitioner/ Nurse Scientist, Medical Services, Boston Children's Hospital, Boston, MA, USA; Assistant professor, Department of Nursing, MGH Institute of Health Professions, Boston, MA, USA
| | - Patricia A Hickey
- Vice President; Associate Cheif Nurse, Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA
| | - Robin R Leger
- Professor, Department of Nursing, Salem State University, Salem, MA, USA
| | - Judith A Vessey
- Nurse Scientist, Medical Services, Boston Children's Hospital, Boston, MA, USA; Professor, Department of Nursing, Boston College, Boston, MA, USA
| | - Laura L Hayman
- Professor, Department of of Nursing, University of Massachusetts Boston, Boston, MA, USA
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150
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Verrall CE, Walker K, Loughran-Fowlds A, Prelog K, Goetti R, Troedson C, Ayer J, Egan J, Halliday R, Orr Y, Sholler GF, Badawi N, Winlaw DS. Contemporary incidence of stroke (focal infarct and/or haemorrhage) determined by neuroimaging and neurodevelopmental disability at 12 months of age in neonates undergoing cardiac surgery utilizing cardiopulmonary bypass†. Interact Cardiovasc Thorac Surg 2017; 26:644-650. [DOI: 10.1093/icvts/ivx375] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/27/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Charlotte E Verrall
- Heart Centre for Children, The Children’s Hospital at Westmead, Sydney, Australia
| | - Karen Walker
- Grace Centre for Newborn Care, The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Cerebral Palsy Alliance, Sydney, Australia
| | - Alison Loughran-Fowlds
- Grace Centre for Newborn Care, The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kristina Prelog
- Department of Medical Imaging, The Children’s Hospital at Westmead, Sydney, Australia
| | - Robert Goetti
- Department of Medical Imaging, The Children’s Hospital at Westmead, Sydney, Australia
| | | | - Julian Ayer
- Heart Centre for Children, The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Jonathan Egan
- Sydney Medical School, University of Sydney, Sydney, Australia
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, Australia
| | - Robert Halliday
- Grace Centre for Newborn Care, The Children’s Hospital at Westmead, Sydney, Australia
| | - Yishay Orr
- Heart Centre for Children, The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Gary F Sholler
- Heart Centre for Children, The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Nadia Badawi
- Grace Centre for Newborn Care, The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Cerebral Palsy Alliance, Sydney, Australia
| | - David S Winlaw
- Heart Centre for Children, The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
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