201
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Bertelsen C, Jacobson L, Osterbauer B, Hochstim C. Safety and efficacy of Early injection laryngoplasty in pediatric patients. Laryngoscope 2018; 129:1699-1705. [DOI: 10.1002/lary.27436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/08/2018] [Accepted: 06/18/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Caitlin Bertelsen
- Caruso Department of Otolaryngology-Head and Neck Surgery; Los Angeles California U.S.A
| | - Lia Jacobson
- Caruso Department of Otolaryngology-Head and Neck Surgery; Los Angeles California U.S.A
| | - Beth Osterbauer
- Division of Otolaryngology-Head and Neck Surgery, Children's Hospital of Los Angeles; Keck School of Medicine of the University of Southern California; Los Angeles California U.S.A
| | - Christian Hochstim
- Division of Otolaryngology-Head and Neck Surgery, Children's Hospital of Los Angeles; Keck School of Medicine of the University of Southern California; Los Angeles California U.S.A
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202
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Physical Therapy Management of a Critically-Ill Infant After Cardiac Surgery: A Case Report and Literature Review. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2018. [DOI: 10.1097/jat.0000000000000084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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203
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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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204
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Fister P, Robek D, Paro-Panjan D, Mazić U, Lenasi H. Decreased tissue oxygenation in newborns with congenital heart defects: a case-control study. Croat Med J 2018; 59:71-78. [PMID: 29740991 PMCID: PMC5941290 DOI: 10.3325/cmj.2018.59.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim To compare regional tissue oxygenation (rSO2) in the brain, intestine, and kidney between newborns with and without congenital heart defects (CHD). Methods This observational case-control study was conducted at the Neonatal Deparetment of Children's Hospital Ljubljana between December 2012 and April 2014. It included 35 newborns with CHD and 30 healthy age- and sex-matched controls. CHD were assessed echocardiographically and divided into acyanotic and cyanotic group. RSO2 in the brain, intestine, and kidney was measured using near-infrared spectroscopy (NIRS). Simultaneously, heart rate (HR), breathing frequency (BF), mean arterial blood pressure (MAP), and arterial oxygen saturation (Sao2) were recorded. Results Newborns with CHD had significantly lower rSO2 in the left brain hemisphere (67 ± 11% vs 76 ± 8%, P = 0.004), right brain hemisphere (68 ± 11% vs 77 ± 8%, P < 0.001), and the kidney (68 ± 13% vs 77 ± 10%, P = 0.015). RSO2 in the intestine did not significantly differ between the groups. HR, MAP, and Sao2 also did not differ between the groups, whereas BF was significantly higher in the CHD group (57 ± 12 vs 39 ± 10 breaths/min, P < 0.001). Between cyanotic and acyanotic group, we found no significant differences in rSO2 of any tissue. Conclusions Monitoring tissue oxygenation by NIRS could enable a timely detection of hemodynamically important CHD.
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Affiliation(s)
| | | | | | | | - Helena Lenasi
- Helena Lenasi, Institute of Physiology, Medical Faculty, University of Ljubljana, Zaloška 4, 1000 Ljubljana, Slovenia,
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205
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Yörüker U, Akintürk H. Giessen Procedure as Comprehensive Stage II Palliation With Aortic Arch Reconstruction After Hybrid Bilateral Pulmonary Artery Banding and Ductal Stenting for Hypoplastic Left Heart Syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2018; 21:19-27. [PMID: 29425520 DOI: 10.1053/j.pcsu.2017.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/08/2017] [Indexed: 11/11/2022]
Abstract
This article reviews our experience using hybrid stage I palliation in the neonatal period and subsequently with comprehensive stage II palliation for hypoplastic left heart syndrome. Between June 1998 and April 2017, 154 patients with the diagnosis of hypoplastic left heart syndrome and variants underwent a hybrid stage I palliation (bilateral pulmonary artery banding and ductal stenting). One hundred thirty-nine patients could be further univentricularly palliated. One hundred twenty-one patients underwent a comprehensive stage II operation with an operative mortality of 6.6%. The hybrid procedure provides reproducible results with reduced in-hospital, interstage, and long-term mortality and lower rates of aortic arch reinterventions.
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Affiliation(s)
- Uygar Yörüker
- Department of Pediatric Cardiac Surgery, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Hakan Akintürk
- Department of Pediatric Cardiac Surgery, Pediatric Heart Center, Justus Liebig University, Giessen, Germany..
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206
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Altered White Matter Microstructure Correlates with IQ and Processing Speed in Children and Adolescents Post-Fontan. J Pediatr 2018; 200:140-149.e4. [PMID: 29934026 DOI: 10.1016/j.jpeds.2018.04.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 03/20/2018] [Accepted: 04/11/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare white matter microstructure in children and adolescents with single ventricle who underwent the Fontan procedure with healthy controls, and to explore the association of white matter injury with cognitive performance as well as patient and medical factors. STUDY DESIGN Fontan (n = 102) and control subjects (n = 47) underwent diffusion tensor imaging (DTI) at ages 10-19 years. Mean DTI measures (fractional anisotropy, radial diffusivity, axial diffusivity, and mean diffusivity) were calculated for 33 fiber tracts from standard white matter atlases. Voxel-wise group differences in DTI measures were assessed using Tract-Based Spatial Statistics. Associations of regional fractional anisotropy with IQ and processing speed as well as medical characteristics were examined. RESULTS Subjects with Fontan, compared with controls, had reduced bilateral regional and voxel-wise fractional anisotropy in multiple white matter tracts along with increased regional radial diffusivity in several overlapping tracts; regional mean diffusivity differed in 2 tracts. The groups did not differ in voxel-wise radial diffusivity or mean diffusivity. Among subjects with Fontan, fractional anisotropy in many tracts correlated positively with Full-Scale Intelligence Quotient and processing speed, although similar findings were absent in controls. Lower mean fractional anisotropy in various tracts was associated with more complications in the first operation, a greater number of total operations, and history of neurologic event. CONCLUSIONS Children and adolescents who have undergone the Fontan procedure have widespread abnormalities in white matter microstructure. Furthermore, white matter microstructure in several tracts is associated with cognitive performance and operative and medical history characteristics.
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207
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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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208
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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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209
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Tan AP, Svrckova P, Cowan F, Chong WK, Mankad K. Intracranial hemorrhage in neonates: A review of etiologies, patterns and predicted clinical outcomes. Eur J Paediatr Neurol 2018; 22:690-717. [PMID: 29731328 DOI: 10.1016/j.ejpn.2018.04.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 03/31/2018] [Accepted: 04/18/2018] [Indexed: 12/29/2022]
Abstract
Intracranial hemorrhage (ICH) in neonates often results in devastating neurodevelopmental outcomes as the neonatal period is a critical window for brain development. The neurodevelopmental outcomes in neonates with ICH are determined by the maturity of the brain, the location and extent of the hemorrhage, the specific underlying etiology and the presence of other concomitant disorders. Neonatal ICH may result from various inherited and acquired disorders. We classify the etiologies of neonatal ICH into eight main categories: (1) Hemorrhagic stroke including large focal hematoma, (2) Prematurity-related hemorrhage, (3) Bleeding diathesis, (4) Genetic causes, (5) Infection, (6) Trauma-related hemorrhage, (7) Tumor-related hemorrhage and (8) Vascular malformations. Illustrative cases showing various imaging patterns that can be helpful to predict clinical outcomes will be highlighted. Potential mimics of ICH in the neonatal period are also reviewed.
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Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Imaging, National University Health System, 1E Kent Ridge Rd 119228, Singapore.
| | - Patricia Svrckova
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| | - Frances Cowan
- Dept. of Neonatology, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, SW10 9NH, UK.
| | - Wui Khean Chong
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
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210
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Peyvandi S, Latal B, Miller SP, McQuillen PS. The neonatal brain in critical congenital heart disease: Insights and future directions. Neuroimage 2018; 185:776-782. [PMID: 29787864 DOI: 10.1016/j.neuroimage.2018.05.045] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 04/18/2018] [Accepted: 05/18/2018] [Indexed: 12/17/2022] Open
Abstract
Neurodevelopmental outcomes are impaired in survivors of critical congenital heart disease (CHD) in several developmental domains including motor, cognitive and sensory outcomes. These deficits can extend into the adolescent and early adulthood years. The cause of these neurodevelopmental impairments is multi-factorial and includes patient specific risk factors, cardiac anatomy and physiology as well as brain changes seen on MRI. Advances in imaging techniques have identified delayed brain development in the neonate with critical CHD as well as acquired brain injury. These abnormalities are seen even before corrective neonatal cardiac surgery. This review focuses on describing brain changes seen on MRI in neonates with CHD, risk factors for these changes and the association with neurodevelopmental outcome. There is an emerging focus on the impact of cardiovascular physiology on brain health and the complex heart-brain interplay that influences ultimate neurodevelopmental outcome in these patients.
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Affiliation(s)
- Shabnam Peyvandi
- Division of Pediatric Cardiology, University of California San Francisco Benioff Children's Hospital, USA.
| | - Beatrice Latal
- University Children's Hospital Zurich, Child Development Center and Children's Research Center, Zurich, Switzerland
| | - Steven P Miller
- University of Toronto, Hospital for Sick Children, Department of Neurology, Canada
| | - Patrick S McQuillen
- Division of Critical Care, University of California San Francisco Benioff Children's Hospital, USA
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211
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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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212
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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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213
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Lynch JM, Ko T, Busch DR, Newland JJ, Winters ME, Mensah-Brown K, Boorady TW, Xiao R, Nicolson SC, Montenegro LM, Gaynor JW, Spray TL, Yodh AG, Naim MY, Licht DJ. Preoperative cerebral hemodynamics from birth to surgery in neonates with critical congenital heart disease. J Thorac Cardiovasc Surg 2018; 156:1657-1664. [PMID: 29859676 DOI: 10.1016/j.jtcvs.2018.04.098] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Hypoxic-ischemic white matter brain injury commonly occurs in neonates with critical congenital heart disease. Recent work has shown that longer time to surgery is associated with increased risk for this injury. In this study we investigated changes in perinatal cerebral hemodynamics during the transition from fetal to neonatal circulation to ascertain mechanisms that might underlie this risk. METHODS Neonates with either transposition of the great arteries (TGA) or hypoplastic left heart syndrome (HLHS) were recruited for preoperative noninvasive optical monitoring of cerebral oxygen saturation, cerebral oxygen extraction fraction, and cerebral blood flow using diffuse optical spectroscopy and diffuse correlation spectroscopy, 2 noninvasive optical techniques. Measurements were acquired daily from day of consent until the morning of surgery. Temporal trends in these measured parameters during the preoperative period were assessed with a mixed effects model. RESULTS Forty-eight neonates with TGA or HLHS were studied. Cerebral oxygen saturation was significantly and negatively correlated with time, and oxygen extraction fraction was significantly and positively correlated with time. Cerebral blood flow did not significantly change with time during the preoperative period. CONCLUSIONS In neonates with TGA or HLHS, increasing cerebral oxygen extraction combined with an abnormal cerebral blood flow response during the time between birth and heart surgery leads to a progressive decrease in cerebral tissue oxygenation The results support and help explain the physiological basis for recent studies that show longer time to surgery increases the risk of acquiring white matter injury.
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Affiliation(s)
- Jennifer M Lynch
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Penn.
| | - Tiffany Ko
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pa; Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa
| | - David R Busch
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa; Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - John J Newland
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Madeline E Winters
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kobina Mensah-Brown
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Timothy W Boorady
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Rui Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesia, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Lisa M Montenegro
- Division of Cardiothoracic Anesthesia, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pa
| | - Maryam Y Naim
- Division of Cardiac Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
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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: 96] [Impact Index Per Article: 16.0] [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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215
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Olshaker H, Ber R, Hoffman D, Derazne E, Achiron R, Katorza E. Volumetric Brain MRI Study in Fetuses with Congenital Heart Disease. AJNR Am J Neuroradiol 2018; 39:1164-1169. [PMID: 29674414 DOI: 10.3174/ajnr.a5628] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 02/14/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE It is well-established that a high prevalence of infants with congenital heart defects surviving to childhood have neurodevelopmental abnormalities. The etiology is not clear. In this study, we aimed to find prenatal neuroanatomic changes in fetuses with congenital heart disease to better understand the pathophysiology behind these sequelae. MATERIALS AND METHODS A retrospective study of 46 fetal brain MR imaging scans was performed at a tertiary medical center during a 4-year period. Clinical data were collected from electronic medical charts. Volumes of the supratentorial brain, right hemisphere, left hemisphere, and cerebellum were measured using a semiautomated method and were compared with the normal growth percentiles. RESULTS We found that cerebellar volume and the cerebellar-supratentorial volume ratio were significantly lower among fetuses with congenital heart disease. Supratentorial and hemisphere volumes showed no difference between groups. This difference was not observed in fetuses with septation defects. CONCLUSIONS Fetuses with congenital heart disease have smaller cerebellar volumes than healthy fetuses. Additional research is needed to assess this finding as a radiologic marker for long-term outcome.
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Affiliation(s)
- H Olshaker
- From the Antenatal Diagnostic Unit (H.O., R.B., D.H., R.A., E.K.), Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel .,Sackler School of Medicine (H.O., R.B., D.H., E.D., R.A., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - R Ber
- From the Antenatal Diagnostic Unit (H.O., R.B., D.H., R.A., E.K.), Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine (H.O., R.B., D.H., E.D., R.A., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - D Hoffman
- From the Antenatal Diagnostic Unit (H.O., R.B., D.H., R.A., E.K.), Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine (H.O., R.B., D.H., E.D., R.A., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - E Derazne
- Sackler School of Medicine (H.O., R.B., D.H., E.D., R.A., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - R Achiron
- From the Antenatal Diagnostic Unit (H.O., R.B., D.H., R.A., E.K.), Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine (H.O., R.B., D.H., E.D., R.A., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - E Katorza
- From the Antenatal Diagnostic Unit (H.O., R.B., D.H., R.A., E.K.), Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine (H.O., R.B., D.H., E.D., R.A., E.K.), Tel Aviv University, Tel Aviv, Israel
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216
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Cerebral Oxygen Metabolism Before and After RBC Transfusion in Infants Following Major Surgical Procedures. Pediatr Crit Care Med 2018; 19:318-327. [PMID: 29406374 DOI: 10.1097/pcc.0000000000001483] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Although infants following major surgery frequently require RBC transfusions, there is still controversy concerning the best definition for requirement of transfusion in the individual patient. The aim of this study was to determine the impact of RBC transfusion on cerebral oxygen metabolism in noncardiac and cardiac postsurgical infants. DESIGN Prospective observational cohort study. SETTING Pediatric critical care unit of a tertiary referral center. PATIENTS Fifty-eight infants (15 after pediatric surgery and 43 after cardiac surgery) with anemia requiring RBC transfusion were included. INTERVENTIONS RBC transfusion. MEASUREMENTS AND MAIN RESULTS We measured noninvasively regional cerebral oxygen saturation and microperfusion (relative cerebral blood flow) using tissue spectrometry and laser Doppler flowmetry before and after RBC transfusion. Cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen were calculated. Fifty-eight RBC transfusions in 58 patients were monitored (15 after general surgery, 24 after cardiac surgery resulting in acyanotic biventricular physiology and 19 in functionally univentricular hearts including hypoplastic left heart following neonatal palliation). The posttransfusion hemoglobin concentrations increased significantly (9.7 g/dL vs 12.8 g/dL; 9.7 g/dL vs 13.8 g/dL; 13.1 g/dL vs 15.6 g/dL; p < 0.001, respectively). Posttransfusion cerebral oxygen saturation was significantly higher than pretransfusion (61% [51-78] vs 72% [59-89]; p < 0.001; 58% [35-77] vs 71% [57-88]; p < 0.001; 51% [37-61] vs 58% [42-73]; p = 0.007). Cerebral fractional tissue oxygen extraction decreased posttransfusion significantly 0.37 (0.16-0.47) and 0.27 (0.07-039), p = 0.002; 0.40 (0.2-0.62) vs 0.26 (0.11-0.57), p = 0.001; 0.42 (0.23-0.52) vs 0.32 (0.1-0.42), p = 0.017. Cerebral blood flow and approximated cerebral metabolic rate of oxygen showed no significant change during the observation period. The increase in cerebral oxygen saturation and the decrease in cerebral fractional tissue oxygen extraction were most pronounced in patients after cardiac surgery with a pretransfusion cerebral fractional tissue oxygen extraction greater than or equal to 0.4. CONCLUSION Following RBC transfusion, cerebral oxygen saturation increases and cerebral fractional tissue oxygen extraction decreases. The data suggest that cerebral oxygenation in postoperative infants with cerebral fractional tissue oxygen extraction greater than or equal to 0.4 may be at risk in instable hemodynamic or respiratory situations.
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217
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Chen JM. Don't Just Do Something, Stand There! Semin Thorac Cardiovasc Surg 2018; 30:79-80. [PMID: 29501562 DOI: 10.1053/j.semtcvs.2018.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jonathan M Chen
- Congenital Cardiac Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington.
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218
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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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219
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González-González G, Bernardo Pliego-Rivero F, Rodríguez-Camacho M, Mendieta Alcántara G, Otero Ojeda GA. Assessment of cognitive performance among Mexican children and adolescents afflicted by simple to complex congenital heart diseases. Preliminary study. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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220
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Identification of juvenility-associated genes in the mouse hepatocytes and cardiomyocytes. Sci Rep 2018; 8:3132. [PMID: 29449671 PMCID: PMC5814429 DOI: 10.1038/s41598-018-21445-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 02/05/2018] [Indexed: 12/29/2022] Open
Abstract
Young individuals possess distinct properties that adults do not. The juvenile animals show higher activities for growth, healing, learning and plasticity than adults. The machinery for establishing these juvenile properties is not fully understood. To better understand the molecular constituents for the above properties, we performed a comprehensive transcriptome analysis of differently aged cells of mice by high-throughput sequencing and identified the genes selectively highly expressed in the young cells. These genes, collectively called as juvenility-associated genes (JAGs), show significant enrichments in the functions such as alternative splicing, phosphorylation and extracellular matrix (ECM). This implies the juvenescence might be achieved by these functions at the cell level. The JAG mutations are associated with progeria syndromes and growth disorders. Thus, the JAGs might organize the juvenile property of young animals and analysis of JAGs may provide scientific and therapeutic approaches toward treating the genetic diseases.
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221
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Watson CG, Stopp C, Newburger JW, Rivkin MJ. Graph theory analysis of cortical thickness networks in adolescents with d-transposition of the great arteries. Brain Behav 2018; 8:e00834. [PMID: 29484251 PMCID: PMC5822582 DOI: 10.1002/brb3.834] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 08/07/2017] [Accepted: 08/16/2017] [Indexed: 01/01/2023] Open
Abstract
Objective Adolescents with d-transposition of the great arteries (d-TGA) who had the arterial switch operation in infancy have been found to have structural brain differences compared to healthy controls. We used cortical thickness measurements obtained from structural brain MRI to determine group differences in global brain organization using a graph theoretical approach. Methods Ninety-two d-TGA subjects and 49 controls were scanned using one of two identical 1.5-Tesla MRI systems. Mean cortical thickness was obtained from 34 regions per hemisphere using Freesurfer. A linear model was used for each brain region to adjust for subject age, sex, and scanning location. Structural connectivity for each group was inferred based on the presence of high inter-regional correlations of the linear model residuals, and binary connectivity matrices were created by thresholding over a range of correlation values for each group. Graph theory analysis was performed using packages in R. Permutation tests were performed to determine significance of between-group differences in global network measures. Results Within-group connectivity patterns were qualitatively different between groups. At lower network densities, controls had significantly more long-range connections. The location and number of hub regions differed between groups: controls had a greater number of hubs at most network densities. The control network had a significant rightward asymmetry compared to the d-TGA group at all network densities. Conclusions Using graph theory analysis of cortical thickness correlations, we found differences in brain structural network organization among d-TGA adolescents compared to controls. These may be related to the white matter and gray matter differences previously found in this cohort, and in turn may be related to the cognitive deficits this cohort presents.
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Affiliation(s)
- Christopher G. Watson
- Graduate Program for NeuroscienceBoston UniversityBostonMAUSA
- Department of NeurologyBoston Children's HospitalBostonMAUSA
| | - Christian Stopp
- Department of CardiologyBoston Children's HospitalBostonMAUSA
| | - Jane W. Newburger
- Department of CardiologyBoston Children's HospitalBostonMAUSA
- Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Michael J. Rivkin
- Department of NeurologyBoston Children's HospitalBostonMAUSA
- Department of RadiologyBoston Children's HospitalBostonMAUSA
- Department of PsychiatryBoston Children's HospitalBostonMAUSA
- Department of NeurologyHarvard Medical SchoolBostonMAUSA
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222
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Morton PD, Korotcova L, Lewis BK, Bhuvanendran S, Ramachandra SD, Zurakowski D, Zhang J, Mori S, Frank JA, Jonas RA, Gallo V, Ishibashi N. Abnormal neurogenesis and cortical growth in congenital heart disease. Sci Transl Med 2018; 9:9/374/eaah7029. [PMID: 28123074 DOI: 10.1126/scitranslmed.aah7029] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 08/04/2016] [Accepted: 10/05/2016] [Indexed: 12/21/2022]
Abstract
Long-term neurological deficits due to immature cortical development are emerging as a major challenge in congenital heart disease (CHD). However, cellular mechanisms underlying dysregulation of perinatal corticogenesis in CHD remain elusive. The subventricular zone (SVZ) represents the largest postnatal niche of neural stem/progenitor cells (NSPCs). We show that the piglet SVZ resembles its human counterpart and displays robust postnatal neurogenesis. We present evidence that SVZ NSPCs migrate to the frontal cortex and differentiate into interneurons in a region-specific manner. Hypoxic exposure of the gyrencephalic piglet brain recapitulates CHD-induced impaired cortical development. Hypoxia reduces proliferation and neurogenesis in the SVZ, which is accompanied by reduced cortical growth. We demonstrate a similar reduction in neuroblasts within the SVZ of human infants born with CHD. Our findings demonstrate that SVZ NSPCs contribute to perinatal corticogenesis and suggest that restoration of SVZ NSPCs' neurogenic potential is a candidate therapeutic target for improving cortical growth in CHD.
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Affiliation(s)
- Paul D Morton
- 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
| | - Ludmila Korotcova
- 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
| | - Bobbi K Lewis
- Frank Laboratory and Laboratory of Diagnostic Radiology Research, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD 20892, USA
| | - Shivaprasad Bhuvanendran
- Center for Genetic Medicine Research, Children's National Health System, Washington, DC 20010, USA
| | - Shruti D Ramachandra
- 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
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
| | - Jiangyang Zhang
- Department of Biomedical Engineering and The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Susumu Mori
- Department of Biomedical Engineering and The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Joseph A Frank
- Frank Laboratory and Laboratory of Diagnostic Radiology Research, Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD 20892, USA.,Intramural Research Program, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, MD 20892, USA
| | - Richard A Jonas
- 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
| | - 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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223
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Abstract
OBJECTIVES Determine the prevalence of intraventricular hemorrhage in infants with moderate to severe congenital heart disease, investigate the impact of gestational age, cardiac diagnosis, and cardiac intervention on intraventricular hemorrhage, and compare intraventricular hemorrhage rates in preterm infants with and without congenital heart disease. DESIGN A single-center retrospective review. SETTING A tertiary care children's hospital. PATIENTS All infants admitted to St. Louis Children's Hospital from 2007 to 2012 with moderate to severe congenital heart disease requiring cardiac intervention in the first 90 days of life and all preterm infants without congenital heart disease or congenital anomalies/known genetic diagnoses admitted during the same time period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cranial ultrasound data were reviewed for presence/severity of intraventricular hemorrhage. Head CT and brain MRI data were also reviewed in the congenital heart disease infants. Univariate analyses were undertaken to determine associations with intraventricular hemorrhage, and a final multivariate logistic regression model was performed. There were 339 infants with congenital heart disease who met inclusion criteria and 25.4% were born preterm. Intraventricular hemorrhage was identified on cranial ultrasound in 13.3% of infants, with the majority of intraventricular hemorrhage being low-grade (grade I/II). The incidence increased as gestational age decreased such that intraventricular hemorrhage was present in 8.7% of term infants, 19.2% of late preterm infants, 26.3% of moderately preterm infants, and 53.3% of very preterm infants. There was no difference in intraventricular hemorrhage rates between cardiac diagnoses. Additionally, the rate of intraventricular hemorrhage did not increase after cardiac intervention, with only three infants demonstrating new/worsening high-grade (grade III/IV) intraventricular hemorrhage after surgery. In a multivariate model, only gestational age at birth and African-American race were predictors of intraventricular hemorrhage. In the subset of infants with CT/MRI data, there was good sensitivity and specificity of cranial ultrasound for presence of intraventricular hemorrhage. CONCLUSIONS Infants with congenital heart disease commonly develop intraventricular hemorrhage, particularly when born preterm. However, the vast majority of intraventricular hemorrhage is low-grade and is associated with gestational age and African-American race.
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224
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Calderon J, Willaime M, Lelong N, Bonnet D, Houyel L, Ballon M, Goffinet F, Khoshnood B. Population-based study of cognitive outcomes in congenital heart defects. Arch Dis Child 2018; 103:49-56. [PMID: 28780508 DOI: 10.1136/archdischild-2016-310830] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 07/04/2017] [Accepted: 07/18/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To characterise and compare cognitive outcomes in children with operated (open-heart surgery) and non-operated (catheter-based interventions only or no intervention) congenital heart defects (CHD) and to determine associated risk factors. DESIGN This prospective population-based study reports outcomes of 3-year-old children with CHD with or without open-heart surgery. MAIN OUTCOME MEASURES Standardised cognitive scores (mean scores and proportions below normative values) were assessed with the Kaufman Assessment Battery for Children II. We analysed demographic, perinatal and operative variables as predictors of cognitive outcomes. RESULTS 419 children participated (154 with open-heart surgery; 265 without surgery). Global cognitive scores did not differ between the groups. Compared with the non-operated group, children who underwent surgery obtained lower scores in expressive language (p=0.03) and logical reasoning (p=0.05). When compared with test norms, the frequency of global cognitive scores >1 SDs below the expected mean was higher in the surgical group (25% vs 16% in the general population) (p=0.03). A higher-than-expected proportion of children in the non-operated group scored >2 SDs below the expected mean (7% vs 2%) (p=0.05). Being small for gestational age (SGA) significantly increased the risk of cognitive impairment in the surgical group, after adjustments for multiple covariates including maternal education, complexity of the CHD and operative-related variables (adjusted OR=5.9; 95% CI (1.7 to 20.1)). CONCLUSIONS Despite mean scores within the normative range, a high proportion of preschool children with CHD with or without surgery are at early cognitive risk. SGA is a strong predictor of the neurodevelopmental prognosis in CHD.
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Affiliation(s)
- Johanna Calderon
- Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA.,Inserm, UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris Descartes University, Paris, France
| | - Marion Willaime
- Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nathalie Lelong
- Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Damien Bonnet
- Centre de référence M3C, Necker, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Lucile Houyel
- Service de chirurgie des cardiopathies congénitales, Hôpital Marie Lannelongue, Paris, France
| | - Morgane Ballon
- Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - François Goffinet
- Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA.,Maternité Port Royal, Paris, France
| | - Babak Khoshnood
- Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
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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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226
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Grasty MA, Ittenbach RF, Knightly C, Solot CB, Gerdes M, Bernbaum JC, Wernovsky G, Spray TL, Nicolson SC, Clancy RR, Licht DJ, Zackai E, Gaynor JW, Burnham NB. Hearing Loss after Cardiac Surgery in Infancy: An Unintended Consequence of Life-Saving Care. J Pediatr 2018; 192:144-151.e1. [PMID: 29246336 PMCID: PMC6447030 DOI: 10.1016/j.jpeds.2017.09.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 08/30/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To investigate the prevalence of hearing loss after cardiac surgery in infancy, patient and operative factors associated with hearing loss, and the relationship of hearing loss to neurodevelopmental outcomes. STUDY DESIGN Audiologic and neurodevelopmental evaluations were conducted on 348 children who underwent repair of congenital heart disease at the Children's Hospital of Philadelphia as part of a prospective study evaluating neurodevelopmental outcomes at 4 years of age. A prevalence estimate was calculated based on presence and type of hearing loss. Potential risk factors and the impact of hearing loss on neurodevelopmental outcomes were evaluated. RESULTS The prevalence of hearing loss was 21.6% (95% CI, 17.2-25.9). The prevalence of conductive hearing loss, sensorineural hearing loss, and indeterminate hearing loss were 12.4% (95% CI, 8.8-16.0), 6.9% (95% CI, 4.1-9.7), and 2.3% (95% CI, 0.6-4.0), respectively. Only 18 of 348 subjects (5.2%) had screened positive for hearing loss before this study and 10 used a hearing aid. After adjusting for patient and operative covariates, younger gestational age, longer postoperative duration of stay, and a confirmed genetic anomaly were associated with hearing loss (all P < .01). The presence of hearing loss was associated with worse language, cognition and attention (P <.01). CONCLUSIONS These findings suggest that the prevalence of hearing loss in preschool children after heart surgery in infancy may be 20-fold higher than in the 1% prevalence seen in the general population. Younger gestational age, presence of a genetic anomaly, and longer postoperative duration of stay were associated with hearing loss. Hearing loss was associated with worse neurodevelopmental outcomes.
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Affiliation(s)
- Madison A. Grasty
- Division of Cardiothoracic Surgery, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Richard F. Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Carol Knightly
- Center for Childhood Communication, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia B. Solot
- Center for Childhood Communication, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Marsha Gerdes
- Center for Psychology, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - Judy C. Bernbaum
- Center for Pediatrics, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - Gil Wernovsky
- Center for Cardiology, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania,Department of Anesthesia and Critical Care Medicine,
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas L. Spray
- Division of Cardiothoracic Surgery, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Susan C. Nicolson
- Department of Anesthesia and Critical Care Medicine,
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert R. Clancy
- Department of Pediatrics Division of Neurology, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel J. Licht
- Department of Pediatrics Division of Neurology, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine Zackai
- Center for Pediatrics, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania,Department of Genetics, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Nancy B. Burnham
- Division of Cardiothoracic Surgery, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
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Heye KN, Knirsch W, Latal B, Scheer I, Wetterling K, Hahn A, Akintürk H, Schranz D, Beck I, O´Gorman Tuura R, Reich B. Reduction of brain volumes after neonatal cardiopulmonary bypass surgery in single-ventricle congenital heart disease before Fontan completion. Pediatr Res 2018; 83:63-70. [PMID: 29278641 DOI: 10.1038/pr.2017.203] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 08/10/2017] [Indexed: 11/09/2022]
Abstract
BackgroundLittle is known about the relationship between brain volumes and neurodevelopmental outcome at 2 years of age in children with single-ventricle congenital heart disease (CHD). We hypothesized that reduced brain volumes may be associated with adverse neurodevelopmental outcome.MethodsVolumetric segmentation of cerebral magnetic resonance imaging (MRI) scans was carried out in 44 patients without genetic comorbidities and in 8 controls. Neurodevelopmental outcome was assessed with the Bayley-III scales.ResultsGray matter (GM), deep GM, white matter (WM), and cerebrospinal fluid (CSF) volumes were 611±59, 43±4.5, 277±30, and 16.4 ml, respectively (interquartile range (IQR) 13.1, 23.3 ml). Children undergoing neonatal cardiopulmonary bypass surgery showed smaller deep GM (P=0.005) and WM (P=0.021) volumes. Brain volumes were smaller in patients compared with controls (GM: P=0.017, deep GM: P=0.012, and WM: P=0.015), whereas CSF volumes were greater (P=0.014). Of all intracranial volumes, only CSF volume was associated with neurodevelopmental outcome, accounting for 21% (P=0.011) of variability in the cognitive composite score when combined with common risk factors in a multivariable analysis.ConclusionIncreased CSF volume represents a significant risk factor for neurodevelopmental impairment in children with single-ventricle CHD. Later assessments are warranted to determine the prognostic role of intracranial volumes for long-term outcome.
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Affiliation(s)
- Kristina N Heye
- Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Walter Knirsch
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital, Zurich, Switzerland
| | - Ianina Scheer
- Department of Diagnostic Imaging, MR-Center, University Children's Hospital, Zurich, Switzerland
| | | | - Andreas Hahn
- Department of Pediatric Neurology, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| | - Hakan Akintürk
- Pediatric Heart Center, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| | - Ingrid Beck
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Zurich, Switzerland
| | - Ruth O´Gorman Tuura
- Department of Diagnostic Imaging, MR-Center, University Children's Hospital, Zurich, Switzerland
| | - Bettina Reich
- Pediatric Heart Center, University Hospital Giessen, Justus Liebig University, Giessen, Germany
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228
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Singh S, Kumar R, Roy B, Woo MA, Lewis A, Halnon N, Pike N. Regional brain gray matter changes in adolescents with single ventricle heart disease. Neurosci Lett 2017; 665:156-162. [PMID: 29222023 DOI: 10.1016/j.neulet.2017.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/20/2017] [Accepted: 12/04/2017] [Indexed: 11/25/2022]
Abstract
Adolescents with single ventricle heart disease (SVHD) show autonomic, mood, and cognitive deficits, indicating aberrations in brain areas that regulate these functions. However, the gray matter integrity in autonomic, mood, and cognitive control sites is unclear. We examined regional brain gray matter changes, using high-resolution T1-weighted images (3.0-T magnetic resonance scanner) with voxel based morphometry procedures, as well as mood and cognitive functions in SVHD (n=18; age, 15.7±1.1years; male, 10) and controls (n=31; age, 16.0±1.1years; male, 17). High-resolution T1-weighted images were realigned, gray matter tissue type partitioned, normalized to a common space, smoothed, and compared between groups (analysis of covariance; covariates, age and gender). The mood and cognitive scores were compared between groups using independent samples t-tests. SVHD subjects showed significantly altered mood and cognitive functions over controls. Significantly reduced gray matter emerged in multiple brain areas, including the thalamus, caudate nuclei, putamen, insula, prefrontal, post-central and precentral gyrus, occipital gyrus, para-hippocampal gyrus, temporal gyrus, and cerebellar sites in SVHD over controls. SVHD subjects show compromised gray matter integrity in autonomic, mood and cognitive control sites. The findings indicate that frequent deficits found in SVHD subjects have a brain structural basis in the condition.
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Affiliation(s)
- Sadhana Singh
- Department of Anesthesiology, University of California, Los Angeles, CA, USA
| | - Rajesh Kumar
- Department of Anesthesiology, University of California, Los Angeles, CA, USA; Department of Radiological Sciences, University of California, Los Angeles, CA, USA; Department of Bioengineering, University of California, Los Angeles, CA, USA; Brain Research Institute, University of California, Los Angeles, CA, USA.
| | - Bhaswati Roy
- UCLA School of Nursing, University of California, Los Angeles, CA, USA
| | - Mary A Woo
- UCLA School of Nursing, University of California, Los Angeles, CA, USA
| | - Alan Lewis
- Division of Pediatric Cardiology, Children's Hospital, Los Angeles, CA, USA
| | - Nancy Halnon
- Division of Pediatric Cardiology, University of California, Los Angeles, CA, USA
| | - Nancy Pike
- UCLA School of Nursing, University of California, Los Angeles, CA, USA.
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229
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Hypoplastic Left Heart Syndrome Is Not a Predictor of Worse Intermediate Mortality Post Fontan. Ann Thorac Surg 2017; 104:2037-2044. [DOI: 10.1016/j.athoracsur.2017.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 11/20/2022]
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230
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Neunhoeffer F, Sandner K, Wiest M, Haller C, Renk H, Kumpf M, Schlensak C, Hofbeck M. Non-invasive assessment of cerebral oxygen metabolism following surgery of congenital heart disease. Interact Cardiovasc Thorac Surg 2017; 25:96-102. [PMID: 28419229 DOI: 10.1093/icvts/ivx080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 02/08/2017] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Cerebral protection is a major issue in the treatment of infants with complex congenital heart disease. We tested a new device combining tissue spectrometry and laser Doppler flowmetry for non-invasive determination of cerebral oxygen metabolism following cardiac surgery in infants. METHODS We prospectively measured regional cerebral oxygen saturation cSO 2 and microperfusion (rcFlow) in 43 infants 12-24 h following corrective ( n = 30) or palliative surgery ( n = 13) of congenital heart defects. For comparison, cerebral blood flow (CBF) was determined by colour duplex sonography of the extracranial cerebral arteries. Cerebral fractional tissue oxygen extraction, approximated cerebral metabolic rate of oxygen (aCMRO 2 ) and cerebral metabolic rate of oxygen (CMRO 2 ) were calculated. RESULTS cSO 2 was lower [54.6% (35.7-64.0) vs 59.7% (44.5-81.7); P < 0.01] after neonatal palliation, while rcFlow [69.7 AU (42.5-165.3) vs 77.0 AU (41.2-168.1); P = 0.06] and cerebral fractional tissue oxygen extraction [0.34 (0.24-0.82) vs 0.38 (0.17-0.55); P = 0.63] showed a trend towards lower values. We found a positive correlation between aCMRO 2 and CMRO 2 ( r = 0.27; P = 0.03). aCMRO 2 was significantly lower after neonatal palliation [4.0 AU (2.1-6.3) vs 4.9 AU (2.2-15.6); P = 0.02]. CONCLUSIONS According to our experience, combined photospectrometry and laser Doppler flowmetry enable non-invasive assessment of cerebral oxygen metabolism. The method promises new insights into perioperative cerebral perfusion following palliation or corrective surgery in infancy.
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Affiliation(s)
- Felix Neunhoeffer
- Department of Paediatric Cardiology, Pulmology and Paediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Katharina Sandner
- Department of Paediatric Cardiology, Pulmology and Paediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Milena Wiest
- Department of Paediatric Cardiology, Pulmology and Paediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Christoph Haller
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Hanna Renk
- Department of Paediatric Cardiology, Pulmology and Paediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Matthias Kumpf
- Department of Paediatric Cardiology, Pulmology and Paediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Paediatric Cardiology, Pulmology and Paediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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231
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Verma RK, Keller D, Grunt S, Bigi S, Weisstanner C, Wiest R, Gralla J, Hutter D, Wagner B. Decreased oxygen saturation levels in neonates with transposition of great arteries: Impact on appearance of cerebral veins in susceptibility-weighted imaging. Sci Rep 2017; 7:15471. [PMID: 29133891 PMCID: PMC5684390 DOI: 10.1038/s41598-017-15591-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/27/2017] [Indexed: 12/24/2022] Open
Abstract
Purpose of this study was to investigate a potential correlation between the pattern of cerebral veins (CV) on susceptibility-weighted imaging (SWI) and blood oxygen saturation, as well as preoperative brain injury, in neonates with transposition of the great arteries (TGA). Eleven neonates with TGA underwent MRI preoperatively, including SWI, T1- and T2-weighted scans. Images were retrospectively evaluated and appearance of CV was graded from 0 (normal appearance) to 3 (severe prominent appearance). White matter injuries (WMI) and strokes were analysed. Results were correlated with preductal arterial oxygen saturation. As findings one subject showed a normal CV appearance (grade 0) whereas 10 showed pathological prominent CV (grades 1–3); median 2. Mean oxygen saturation ranged between 67.5% and 89.0% (median 81.0%). CV grade and mean oxygen saturation correlated significantly (p = 0.011). WMI were absent in 5 cases, mild in 4, and moderate in 2 cases. We conclude, that SWI has the potential to be used to estimate the current hypoxic burden on brain tissue in TGA newborns by assessing the prominence of the CV.
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Affiliation(s)
- Rajeev Kumar Verma
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland. .,Institute of Radiology and Neuroradiology, Tiefenau Hospital, Division Stadt, Inselgroup, Bern, Switzerland.
| | - Desislava Keller
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Sebastian Grunt
- University Department of Pediatrics, Division of Pediatric Neurology, Development and Rehabilitation, Inselspital, University of Bern, Bern, Switzerland
| | - Sandra Bigi
- University Department of Pediatrics, Division of Pediatric Neurology, Development and Rehabilitation, Inselspital, University of Bern, Bern, Switzerland
| | - Christian Weisstanner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Roland Wiest
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Damian Hutter
- University Department of Pediatrics, Division of Pediatric Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Bendicht Wagner
- University Department of Pediatrics, Division of Pediatric Intensive Care Medicine, Inselspital Bern, University of Bern, Bern, Switzerland
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232
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Kelly CJ, Makropoulos A, Cordero-Grande L, Hutter J, Price A, Hughes E, Murgasova M, Teixeira RPAG, Steinweg JK, Kulkarni S, Rahman L, Zhang H, Alexander DC, Pushparajah K, Rueckert D, Hajnal JV, Simpson J, Edwards AD, Rutherford MA, Counsell SJ. Impaired development of the cerebral cortex in infants with congenital heart disease is correlated to reduced cerebral oxygen delivery. Sci Rep 2017; 7:15088. [PMID: 29118365 PMCID: PMC5678433 DOI: 10.1038/s41598-017-14939-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/19/2017] [Indexed: 12/22/2022] Open
Abstract
Neurodevelopmental impairment is the most common comorbidity associated with complex congenital heart disease (CHD), while the underlying biological mechanism remains unclear. We hypothesised that impaired cerebral oxygen delivery in infants with CHD is a cause of impaired cortical development, and predicted that cardiac lesions most associated with reduced cerebral oxygen delivery would demonstrate the greatest impairment of cortical development. We compared 30 newborns with complex CHD prior to surgery and 30 age-matched healthy controls using brain MRI. The cortex was assessed using high resolution, motion-corrected T2-weighted images in natural sleep, analysed using an automated pipeline. Cerebral oxygen delivery was calculated using phase contrast angiography and pre-ductal pulse oximetry, while regional cerebral oxygen saturation was estimated using near-infrared spectroscopy. We found that impaired cortical grey matter volume and gyrification index in newborns with complex CHD was linearly related to reduced cerebral oxygen delivery, and that cardiac lesions associated with the lowest cerebral oxygen delivery were associated with the greatest impairment of cortical development. These findings suggest that strategies to improve cerebral oxygen delivery may help reduce brain dysmaturation in newborns with CHD, and may be most relevant for children with CHD whose cardiac defects remain unrepaired for prolonged periods after birth.
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Affiliation(s)
- Christopher J Kelly
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Antonios Makropoulos
- Biomedical Image Analysis Group, Department of Computing, Imperial College London, London, United Kingdom
| | - Lucilio Cordero-Grande
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Jana Hutter
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Anthony Price
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Emer Hughes
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Maria Murgasova
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Rui Pedro A G Teixeira
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Johannes K Steinweg
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Sagar Kulkarni
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Loay Rahman
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Hui Zhang
- Department of Computer Science and Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Daniel C Alexander
- Department of Computer Science and Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Kuberan Pushparajah
- Paediatric Cardiology Department, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Daniel Rueckert
- Biomedical Image Analysis Group, Department of Computing, Imperial College London, London, United Kingdom
| | - Joseph V Hajnal
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - John Simpson
- Paediatric Cardiology Department, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - A David Edwards
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Mary A Rutherford
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Serena J Counsell
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom.
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233
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Knirsch W, Mayer KN, Scheer I, Tuura R, Schranz D, Hahn A, Wetterling K, Beck I, Latal B, Reich B. Structural cerebral abnormalities and neurodevelopmental status in single ventricle congenital heart disease before Fontan procedure. Eur J Cardiothorac Surg 2017; 51:740-746. [PMID: 28013288 DOI: 10.1093/ejcts/ezw399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/07/2016] [Indexed: 01/22/2023] Open
Abstract
Objectives Neonates with single ventricle congenital heart disease are at risk for structural cerebral abnormalities. Little is known about the further evolution of cerebral abnormalities until Fontan procedure. Methods Between August 2012 and July 2015, we conducted a prospective cross-sectional two centre study using cerebral magnetic resonance imaging (MRI) and neuro-developmental outcome assessed by the Bayley-III. Forty-seven children (31 male) were evaluated at a mean age of 25.9 ± 3.4 months with hypoplastic left heart syndrome (25) or other single ventricle (22). Results Cerebral MRI was abnormal in 17 patients (36.2%) including liquor space enlargements (10), small grey (9) and minimal white (5) matter injuries. Eight of 17 individuals had combined lesions. Median (range) cognitive composite score (CCS) (100, 65-120) and motor composite score (MCS) (97, 55-124) were comparable to the reference data, while language composite score (LCS) (97, 68-124) was significantly lower ( P = 0.040). Liquor space enlargement was associated with poorer performance on all Bayley-III subscores (CCS: P = 0.02; LCS: P = 0.002; MCS: P = 0.013). The number of re-operations [odds ratio (OR) 2.2, 95% confidence interval (CI) 1.1-4.3] ( P = 0.03) and re-interventions (OR 2.1, 95% CI 1.1-3.8) ( P = 0.03) was associated with a higher rate of overall MRI abnormalities. Conclusions Cerebral MRI abnormalities occur in more than one third of children with single ventricle, while the neuro-developmental status is less severely affected before Fontan procedure. Liquor space enlargement is the predominant MRI finding associated with poorer neuro-developmental status, warranting further studies to determine aetiology and further evolution until school-age.
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Affiliation(s)
- Walter Knirsch
- Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Switzerland
| | - Kristina Nadine Mayer
- Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Switzerland.,Diagnostic Imaging, MR center, University Children's Hospital Zurich, Switzerland.,Child Development Center, University Children's Hospital Zurich, Switzerland
| | - Ianina Scheer
- Children's Research Center, University Children's Hospital Zurich, Switzerland.,Diagnostic Imaging, MR center, University Children's Hospital Zurich, Switzerland
| | - Ruth Tuura
- Children's Research Center, University Children's Hospital Zurich, Switzerland.,Diagnostic Imaging, MR center, University Children's Hospital Zurich, Switzerland
| | - Dietmar Schranz
- Pediatric Heart Center, University Hospital Giessen, Germany
| | - Andreas Hahn
- Pediatric Neurology, University Hospital Giessen, Germany
| | | | - Ingrid Beck
- Children's Research Center, University Children's Hospital Zurich, Switzerland.,Child Development Center, University Children's Hospital Zurich, Switzerland
| | - Beatrice Latal
- Children's Research Center, University Children's Hospital Zurich, Switzerland.,Child Development Center, University Children's Hospital Zurich, Switzerland
| | - Bettina Reich
- Pediatric Heart Center, University Hospital Giessen, Germany
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234
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Genetic contribution to neurodevelopmental outcomes in congenital heart disease: are some patients predetermined to have developmental delay? Curr Opin Pediatr 2017; 29:529-533. [PMID: 28719389 PMCID: PMC5653279 DOI: 10.1097/mop.0000000000000530] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Neurodevelopmental impairment is common in children with moderate to severe congenital heart disease (CHD). As children live longer and healthier lives, research has focused on identifying causes of neurodevelopmental morbidity that significantly impact long-term quality of life. This review will address the role of genetic factors in predicting neurodevelopmental outcome in CHD. RECENT FINDINGS A robust literature suggests that among children with various forms of CHD, those with known genetic/extracardiac anomalies are at highest risk of neurodevelopmental impairment. Advances in genetic technology have identified genetic causes of CHD in an increasing percentage of patients. Further, emerging data suggest substantial overlap between mutations in children with CHD and those that have previously been associated with neurodevelopmental disorders. SUMMARY Innate and patient factors appear to be more important in predicting neurodevelopmental outcome than medical/surgical variables. Future research is needed to establish a broader understanding of the mutations that contribute to neurodevelopmental disorders and the variations in expressivity and penetrance.
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235
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Steurer MA, Baer RJ, Keller RL, Oltman S, Chambers CD, Norton ME, Peyvandi S, Rand L, Rajagopal S, Ryckman KK, Moon-Grady AJ, Jelliffe-Pawlowski LL. Gestational Age and Outcomes in Critical Congenital Heart Disease. Pediatrics 2017; 140:peds.2017-0999. [PMID: 28885171 DOI: 10.1542/peds.2017-0999] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is unknown how gestational age (GA) impacts neonatal morbidities in infants with critical congenital heart disease (CCHD). We aim to quantify GA-specific mortality and neonatal morbidity in infants with CCHD. METHODS Cohort study using a database linking birth certificate, infant hospital discharge, readmission, and death records, including infants 22 to 42 weeks' GA without chromosomal anomalies (2005-2012, 2 988 925 live births). The International Classification of Diseases, Ninth Revision diagnostic and procedure codes were used to define CCHD and neonatal morbidities (intraventricular hemorrhage, retinopathy, periventricular leukomalacia, chronic lung disease, necrotizing enterocolitis). Adjusted absolute risk differences (ARDs) with 95% confidence intervals (CIs) were calculated. RESULTS We identified 6903 out of 2 968 566 (0.23%) infants with CCHD. The incidence of CCHD was highest at 29 to 31 weeks' GA (0.9%) and lowest at 39 to 42 weeks (0.2%). Combined neonatal morbidity or mortality in infants with and without CCHD was 82.8% and 57.9% at <29 weeks and declined to 10.9% and 0.1% at 39 to 42 weeks' GA. In infants with CCHD, being born at 34 to 36 weeks was associated with a higher risk of death or morbidity than being born at 37 to 38 weeks (adjusted ARD 9.1%, 95% CI 5.5% to 12.7%), and being born at 37 to 38 weeks was associated with a higher risk of death or morbidity than 39 to 42 weeks (adjusted ARD 3.2%, 95% CI 1.6% to 4.9%). CONCLUSIONS Infants born with CCHD are at high risk of neonatal morbidity. Morbidity remains increased across all GA groups in comparison with infants born at 39 to 42 weeks. This substantial risk of neonatal morbidity is important to consider when caring for this patient population.
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Affiliation(s)
| | - Rebecca J Baer
- Department of Pediatrics, University of California, San Diego, La Jolla, California; and
| | | | | | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, La Jolla, California; and
| | - Mary E Norton
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | | | - Larry Rand
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | | | - Kelli K Ryckman
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
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236
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Cassidy AR, Ilardi D, Bowen SR, Hampton LE, Heinrich KP, Loman MM, Sanz JH, Wolfe KR. Congenital heart disease: A primer for the pediatric neuropsychologist. Child Neuropsychol 2017; 24:859-902. [DOI: 10.1080/09297049.2017.1373758] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Adam R. Cassidy
- Department of Psychiatry, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Susan R. Bowen
- Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lyla E. Hampton
- Department of Child & Adolescent Psychiatry and Behavioral Sciences, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Michelle M. Loman
- Departments of Neurology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jacqueline H. Sanz
- Division of Neuropsychology, Children’s National Health System, Departments of Psychiatry and Behavioral Sciences & Pediatrics, George Washington University School of Medicine, , Washington, DC, USA
| | - Kelly R. Wolfe
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
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237
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Koning IV, van Graafeiland AW, Groenenberg IAL, Husen SC, Go ATJI, Dudink J, Willemsen SP, Cornette JMJ, Steegers-Theunissen RPM. Prenatal influence of congenital heart defects on trajectories of cortical folding of the fetal brain using three-dimensional ultrasound. Prenat Diagn 2017; 37:1008-1016. [PMID: 28768058 DOI: 10.1002/pd.5135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/13/2017] [Accepted: 07/24/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objective of the study is to investigate the prenatal influence of congenital heart defects (CHD) on trajectories of fetal cortical folding using three-dimensional ultrasound (3D US). METHOD We included 20 CHD fetuses and 193 controls for studying the fetal brain at 22, 26 and 32 weeks' gestational age (GA). The Sylvian, insula and parieto-occipital fissure (POF) depths were measured using 3D US, and reliability was evaluated. Doppler indices of the umbilical artery and middle cerebral artery were measured to calculate the cerebro-placental ratio. Associations between CHD and cortical folding were estimated using linear mixed models. RESULTS Brain fissure measurements were successful in over 80% of 3D US scans, except for the POF at 32 weeks' GA (65%). All measurements showed a good reliability (intraclass correlation coefficients > 0.84). Growth trajectories of the left insula depth (ß = -2.753, 95% CI = -5.375; -0.130, p = 0.040) and right POF (ß = -3.762, 95% CI = -7.178; -0.346, p = 0.031) were decreased in CHD compared with controls, whereas growth rates were increased (ß = 0.014, 95% CI = 0.001; 0.027, p = 0.036 and ß = 0.024, 95% CI = 0.007; 0.041, p = 0.006). In contrast to controls, we found no associations between cerebro-placental ratio and cortical folding in CHD. CONCLUSION Fetal cortical folding can be evaluated reliably by measuring brain fissure depths. Trajectories of cortical folding between 22 and 32 weeks' GA seem to be influenced by CHD. © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Irene V Koning
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Paediatrics, Division of Neonatology, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Anne W van Graafeiland
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Irene A L Groenenberg
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Sofie C Husen
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Attie T J I Go
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jeroen Dudink
- Department of Paediatrics, Division of Neonatology, Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, the Netherlands
| | - Sten P Willemsen
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jerome M J Cornette
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Régine P M Steegers-Theunissen
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Paediatrics, Division of Neonatology, Sophia Children's Hospital, Rotterdam, the Netherlands
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Peterson JK, Evangelista LS. Developmentally Supportive Care in Congenital Heart Disease: A Concept Analysis. J Pediatr Nurs 2017; 36:241-247. [PMID: 28579078 PMCID: PMC6567997 DOI: 10.1016/j.pedn.2017.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
THEORETICAL PRINCIPLES Improved survival of infants and children with congenital heart disease experience has led to recognition that up to half of congenital heart disease survivors also experience developmental delay. Developmentally supportive care is a care model shown in Neonatal Intensive Care Units to be associated with improved outcomes, but developmentally supportive practices with premature infants may not be equally effective in the cardiac population that includes all ages. PHENOMENA ADDRESSED The purpose of this paper is to present a concept analysis using the Walker and Avant method in order to identify and define characteristics of developmentally supportive care as it may be applied to the population of neonates, infants, and children with congenital heart disease. A theoretical definition of developmentally supportive care is presented. RESEARCH LINKAGES This concept analysis will provide nurses and allied health professionals with a theoretical basis to implement high quality, family-centered care that meets individual developmental needs in a population at high risk for developmental sequelae. Nursing implications for developmentally supportive care as it applies to infants and children with heart disease are discussed.
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Affiliation(s)
- Jennifer K Peterson
- Sue & Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States.
| | - Lorraine S Evangelista
- Sue & Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States.
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239
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Late-Term Gestation Is Associated With Improved Survival in Neonates With Congenital Heart Disease Following Postoperative Extracorporeal Life Support. Pediatr Crit Care Med 2017; 18:876-883. [PMID: 28658196 DOI: 10.1097/pcc.0000000000001249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Several population-based studies have shown that gestational age 39-40 weeks at birth is associated with superior outcomes in various pediatric settings. A high proportion of births for neonates with congenital heart disease occur before 39 weeks. We aimed to assess the influence of late-term gestation (39-40 wk) on survival in neonates requiring extracorporeal life support following surgery for congenital heart disease. DESIGN Retrospective cohort study. SETTING The Royal Children's Hospital, Melbourne, Australia. PATIENTS Neonates requiring extracorporeal life support after cardiac surgery for congenital heart disease. MEASUREMENTS AND MAIN RESULTS From 2005 to 2014, 110 neonates (10.5% of neonates undergoing cardiac surgery) required extracorporeal life support after cardiac surgery. Indications were failure to separate from cardiopulmonary bypass in 40 (36%), extracorporeal cardiopulmonary resuscitation in 48 (44%), progressive low cardiac output in 15 (14%), and other reasons in seven (6%). Extracorporeal life support duration was 94 hours (interquartile range, 53-135), and 54 (49%) underwent single ventricle repair. Gestation at birth (n [%]) was as follows: less than 37 weeks, 19 (17%); 37-38 weeks, 38 (35%); 39-40 weeks, 50 (45%); 41 weeks or more, 3 (3%). By multivariable analysis (controlling for age, era of extracorporeal life support 2005-2009 vs 2010-2014, single ventricle status and acute renal failure), gestational age of 39-40 weeks was associated with the lowest odds for intensive care mortality: using less than 37 weeks as referent, the adjusted odds ratio (95% CI) for 37-38 weeks was 0.41 (0.12-1.33); for 39-40 weeks, 0.27 (0.08-0.84); and for 41 weeks or more, 1.06 (0.07-14.7). Similar association was also seen in a subcohort of study neonates (n = 66) who were commenced on extracorporeal life support after admission to intensive care: using less than 37 weeks as referent, the adjusted odds ratio (95% CI) for 37-38 weeks was 0.52 (0.10-2.80) and for 39-40 weeks, 0.15 (0.03-0.81). CONCLUSIONS In this cohort of neonates requiring extracorporeal life support following cardiac surgery, 39-40 weeks of gestation at birth is associated with the best survival. The additional maturity gained by reaching a gestation of at least 39 weeks is likely to confer a survival advantage in this high-risk cohort.
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240
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Back SA. White matter injury in the preterm infant: pathology and mechanisms. Acta Neuropathol 2017; 134:331-349. [PMID: 28534077 PMCID: PMC5973818 DOI: 10.1007/s00401-017-1718-6] [Citation(s) in RCA: 272] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/27/2017] [Accepted: 04/29/2017] [Indexed: 12/22/2022]
Abstract
The human preterm brain is particularly susceptible to cerebral white matter injury (WMI) that disrupts the normal progression of developmental myelination. Advances in the care of preterm infants have resulted in a sustained reduction in the severity of WMI that has shifted from more severe focal necrotic lesions to milder diffuse WMI. Nevertheless, WMI remains a global health problem and the most common cause of chronic neurological morbidity from cerebral palsy and diverse neurobehavioral disabilities. Diffuse WMI involves maturation-dependent vulnerability of the oligodendrocyte (OL) lineage with selective degeneration of late oligodendrocyte progenitors (preOLs) triggered by oxidative stress and other insults. The magnitude and distribution of diffuse WMI are related to both the timing of appearance and regional distribution of susceptible preOLs. Diffuse WMI disrupts the normal progression of OL lineage maturation and myelination through aberrant mechanisms of regeneration and repair. PreOL degeneration is accompanied by early robust proliferation of OL progenitors that regenerate and augment the preOL pool available to generate myelinating OLs. However, newly generated preOLs fail to differentiate and initiate myelination along their normal developmental trajectory despite the presence of numerous intact-appearing axons. Disrupted preOL maturation is accompanied by diffuse gliosis and disturbances in the composition of the extracellular matrix and is mediated in part by inhibitory factors derived from reactive astrocytes. Signaling pathways implicated in disrupted myelination include those mediated by Notch, WNT-beta catenin, and hyaluronan. Hence, there exists a potentially broad but still poorly defined developmental window for interventions to promote white matter repair and myelination and potentially reverses the widespread disturbances in cerebral gray matter growth that accompanies WMI.
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Affiliation(s)
- Stephen A Back
- Division of Pediatric Neuroscience, Departments of Pediatrics and Neurology, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239-3098, USA.
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241
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Peyvandi S, Kim H, Lau J, Barkovich AJ, Campbell A, Miller S, Xu D, McQuillen P. The association between cardiac physiology, acquired brain injury, and postnatal brain growth in critical congenital heart disease. J Thorac Cardiovasc Surg 2017; 155:291-300.e3. [PMID: 28918207 DOI: 10.1016/j.jtcvs.2017.08.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/10/2017] [Accepted: 08/05/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To assess the trajectory of perioperative brain growth in relationship to cardiac diagnosis and acquired brain injuries. METHODS This was a cohort study of term neonates with hypoplastic left heart syndrome (HLHS) and d-transposition of the great arteries (d-TGA). Subjects underwent magnetic resonance imaging of the brain pre- and postoperatively to determine the severity of brain injury and total and regional brain volumes by the use of automated morphometry. Comparisons were made by cardiac lesion and injury status. RESULTS A total of 79 subjects were included (49, d-TGA; 30, HLHS). Subjects with HLHS had more postoperative brain injury (55.6% vs 30.4%, P = .03) and more severe brain injury (moderate-to-severe white matter [WM] injury, P = .01). Total and regional perioperative brain growth was not different by brain injury status (either pre- or postoperative). However, subjects with moderate-to-severe WM injury had a slower rate of brain growth in WM and gray matter compared with those with no injury. Subjects with HLHS had a slower rate of growth globally and in WM and deep gray matter as compared with d-TGA (total brain volume: 12 cm3/wk vs 7 cm3; WM: 2.1 cm3/wk vs 0.6 cm3; deep gray matter: 1.5 cm3/wk vs 0.7 cm3; P < .001), after we adjusted for gestational age at scan and the presence of brain injury. This difference remained after excluding subjects with moderate-to-severe WM injury. CONCLUSIONS Neonates with HLHS have a slower rate of global and regional brain growth compared with d-TGA, likely related to inherent physiologic differences postoperatively. These findings demonstrate the complex interplay between cardiac lesion, brain injury, and brain growth.
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Affiliation(s)
- Shabnam Peyvandi
- Department of Pediatrics, Division of Cardiology, University of California San Francisco, San Francisco, Calif.
| | - Hosung Kim
- Department of Neurology, University of Southern California, Los Angeles, Calif
| | - Joanne Lau
- Department of Radiology, University of California San Francisco, San Francisco, Calif
| | - A James Barkovich
- Department of Radiology, University of California San Francisco, San Francisco, Calif
| | - Andrew Campbell
- Department of Pediatric Cardiovascular and Thoracic Surgery, University of British Columbia, Vancouver, Canada
| | - Steven Miller
- Department of Neurology, the University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Duan Xu
- Department of Radiology, University of California San Francisco, San Francisco, Calif
| | - Patrick McQuillen
- Division of Critical Care, University of California San Francisco, San Francisco, Calif
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242
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Holland JE, Cassidy AR, Stopp C, White MT, Bellinger DC, Rivkin MJ, Newburger JW, DeMaso DR. Psychiatric Disorders and Function in Adolescents with Tetralogy of Fallot. J Pediatr 2017; 187:165-173. [PMID: 28533034 DOI: 10.1016/j.jpeds.2017.04.048] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/09/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To assess psychiatric disorders and function in adolescents with repaired tetralogy of Fallot (TOF) without and with a genetic diagnosis and to evaluate associations of functioning with medical factors, IQ, and demographics. STUDY DESIGN Adolescents with TOF (n = 91) and 87 healthy referents completed a clinician-rated structured psychiatric interview, parent-/self-report measures of psychopathology, and brain magnetic resonance imaging. Twenty-three of the adolescents with TOF had a known genetic diagnosis. RESULTS The prevalence of anxiety disorders did not differ significantly between adolescents with TOF without genetic diagnosis (n = 68) and referents. Adolescents with TOF and a genetic diagnosis showed an increased lifetime prevalence of anxiety disorder (43%) and lower global psychosocial functioning (median, 70; IQR, 63-75) compared with adolescents with TOF without genetic diagnosis (15% and 83; IQR, 79-87, respectively; P = .04 and <.001, respectively) and referents (6% and 85; IQR, 76-90, respectively; P = .001 and <.001, respectively). Adolescents with TOF without and with a genetic diagnosis had a higher lifetime prevalence of attention deficit-hyperactivity disorder (ADHD) than referents (19% and 39%, respectively, vs 5%; P = .04 and .002, respectively) and worse outcomes on parent-/self-report ratings of anxiety and disruptive behavior compared with referents. Risk factors for anxiety, ADHD, and lower psychosocial functioning for adolescents with TOF without a genetic diagnosis included older age, male sex, and low IQ. Medical variables were not predictive of psychiatric outcomes. CONCLUSION Adolescents with TOF, particularly those with a genetic diagnosis, show increased rates of psychiatric disorder and dysfunction. Continued mental health screening and surveillance into young adulthood is warranted for adolescents with TOF.
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Affiliation(s)
| | - Adam R Cassidy
- Department of Psychiatry, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Matthew T White
- Department of Psychiatry, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - David C Bellinger
- Department of Psychiatry, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Neurology, Boston Children's Hospital, Boston, MA; Department of Neurology, Harvard Medical School, Boston, MA
| | - Michael J Rivkin
- Department of Psychiatry, Boston Children's Hospital, Boston, MA; Department of Neurology, Boston Children's Hospital, Boston, MA; Department of Neurology, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David R DeMaso
- Department of Psychiatry, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA.
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243
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Hansen T, Henriksen TB, Bach CC, Matthiesen NB. Congenital Heart Defects and Measures of Prenatal Brain Growth: A Systematic Review. Pediatr Neurol 2017; 72:7-18.e1. [PMID: 28549654 DOI: 10.1016/j.pediatrneurol.2017.03.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 02/16/2017] [Accepted: 03/26/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND We summarize the evidence for an association between congenital heart defects and prenatal brain growth through a systematic literature review. Congenital heart defects are among the most common malformations, affecting approximately six per 1000 live births. The association between congenital heart defects and long-term neurodevelopmental disorders is well established. Increasing evidence suggests an association between impaired prenatal brain growth and neurodevelopmental disorders in children with congenital heart defects. METHODS Systematic literature searches were performed in PubMed and EMBASE. We included original studies comparing fetuses or newborns with congenital heart defects to reference fetuses or newborns with respect to brain biometrics, including biparietal diameter, brain volume, and head circumference at birth. The study characteristics and the results were extracted and presented in tables. No meta-analysis was undertaken. RESULTS Twenty-eight studies were included. All except two studies found an association between congenital heart defects and measures of reduced prenatal brain growth. The strongest evidence concerned hypoplastic left heart syndrome, tetralogy of Fallot, and transposition of the great arteries. CONCLUSIONS The literature suggests an association between congenital heart defects and measures of impaired prenatal brain growth. However, most studies were small and failed to include important potential confounding factors and to address other sources of potential bias as well. Future large-scale studies that address potential confounders are warranted.
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Affiliation(s)
- Thommy Hansen
- Perinatal Epidemiology Research Unit, Aarhus University Hospital, Aarhus, Denmark; Department of Medicine, Silkeborg Regional Hospital, Silkeborg, Denmark.
| | - Tine Brink Henriksen
- Perinatal Epidemiology Research Unit, Aarhus University Hospital, Aarhus, Denmark; Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Cathrine Carlsen Bach
- Perinatal Epidemiology Research Unit, Aarhus University Hospital, Aarhus, Denmark; Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Bjerregård Matthiesen
- Perinatal Epidemiology Research Unit, Aarhus University Hospital, Aarhus, Denmark; Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark; Department of Pediatrics, Herning Regional Hospital, Herning, Denmark
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244
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Mebius MJ, Kooi EMW, Bilardo CM, Bos AF. Brain Injury and Neurodevelopmental Outcome in Congenital Heart Disease: A Systematic Review. Pediatrics 2017; 140:peds.2016-4055. [PMID: 28607205 DOI: 10.1542/peds.2016-4055] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 12/17/2022] Open
Abstract
CONTEXT Brain injury during prenatal and preoperative postnatal life might play a major role in neurodevelopmental impairment in infants with congenital heart disease (CHD) who require corrective or palliative surgery during infancy. A systematic review of cerebral findings during this period in relation to neurodevelopmental outcome (NDO), however, is lacking. OBJECTIVE To assess the association between prenatal and postnatal preoperative cerebral findings and NDO in infants with CHD who require corrective or palliative surgery during infancy. DATA SOURCES PubMed, Embase, reference lists. STUDY SELECTION We conducted 3 different searches for English literature between 2000 and 2016; 1 for prenatal cerebral findings, 1 for postnatal preoperative cerebral findings, and 1 for the association between brain injury and NDO. DATA EXTRACTION Two reviewers independently screened sources and extracted data on cerebral findings and neurodevelopmental outcome. Quality of studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. RESULTS Abnormal cerebral findings are common during the prenatal and postnatal preoperative periods. Prenatally, a delay of cerebral development was most common; postnatally, white matter injury, periventricular leukomalacia, and stroke were frequently observed. Abnormal Doppler measurements, brain immaturity, cerebral oxygenation, and abnormal EEG or amplitude-integrated EEG were all associated with NDO. LIMITATIONS Observational studies, different types of CHD with different pathophysiological effects, and different reference values. CONCLUSIONS Prenatal and postnatal preoperative abnormal cerebral findings might play an important role in neurodevelopmental impairment in infants with CHD. Increased awareness of the vulnerability of the young developing brain of an infant with CHD among caregivers is essential.
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Affiliation(s)
- Mirthe J Mebius
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, Netherlands; and
| | - Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, Netherlands; and
| | - Catherina M Bilardo
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Arend F Bos
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, Netherlands; and
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245
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何 嘉, 李 胜, 陈 曦, 文 华, 袁 鹰, 罗 丹. [A prenatal ultrasound study of cerebral sulci and gyrus development in fetuses with tetralogy of Fallot]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:721-729. [PMID: 28669943 PMCID: PMC6744134 DOI: 10.3969/j.issn.1673-4254.2017.06.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate the development of the cerebral sulci and gyrus and cerebral blood flow in fetuses with tetralogy of Fallot (ToF) in the second and third trimesters using ultrasound imaging. METHODS Forty fetuses (23-33+6 weeks) with ToF diagnosed using ultrasound imaging between December, 2015 and September, 2016 were analyzed in this study. The development of the cerebral sulci and gyrus was evaluated by measuring the parietal-occipital fissure (POF) depth, POF angle, sylvian fissure (SF) depth, SF width, uncovered insular width, calcarine fissure (CF) depth, hemisphere depth on the views of POF, SF and CF, uncovered insular ratio, biparietal diameter (BPD), and head circumference (HC). Cerebral hemodynamics were assessed by measuring the umbilical artery resistance index, umbilical artery pulsation index, middle cerebral artery pulsation index (MCA-PI), middle cerebral artery resistance index, the cerebral-to-placental resistance ratio, and the cerebroplacental ratio. RESULTS In ToF fetuses, the POF depth, SF depth, CF depth, BPD, HC and hemisphere depth on the views of parietal-occipital sulcus and calcarine sulcus were significantly smaller than those in the control group (P<0.05). The middle cerebral artery resistance index, middle cerebral artery pulsation index, the cerebral-to-placental resistance ratio and the cerebroplacental ratio were also significantly lower in ToF fetuses than in the control group (P<0.05). CONCLUSION The cerebral sulci and gyrus in ToF fetuses in second and third trimesters show underdevelopment compared with those in normal fetuses, and the changes in hemodynamics caused by abnormal cardiac structure might be one of the reasons for cerebral sulci and gyrus underdevelopment in fetuses with ToF.
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Affiliation(s)
- 嘉敏 何
- 南方医科大学附属深圳市妇幼保健院超声科,广东 深圳 5180281Department of Ultrasonography, Shenzhen Maternity and Child Healthcare Hospital Affiliated to Southern Medical University, Shenzhen 518028, China
| | - 胜利 李
- 南方医科大学附属深圳市妇幼保健院超声科,广东 深圳 5180281Department of Ultrasonography, Shenzhen Maternity and Child Healthcare Hospital Affiliated to Southern Medical University, Shenzhen 518028, China
| | - 曦 陈
- 四川省妇幼保健院超声科,四川 成都 6100312Department of Ultrasonography, Sichuan Provincial Maternity and Child Healthcare Hospital, Chengdu 610031, China
| | - 华轩 文
- 南方医科大学附属深圳市妇幼保健院超声科,广东 深圳 5180281Department of Ultrasonography, Shenzhen Maternity and Child Healthcare Hospital Affiliated to Southern Medical University, Shenzhen 518028, China
| | - 鹰 袁
- 南方医科大学附属深圳市妇幼保健院超声科,广东 深圳 5180281Department of Ultrasonography, Shenzhen Maternity and Child Healthcare Hospital Affiliated to Southern Medical University, Shenzhen 518028, China
| | - 丹丹 罗
- 南方医科大学附属深圳市妇幼保健院超声科,广东 深圳 5180281Department of Ultrasonography, Shenzhen Maternity and Child Healthcare Hospital Affiliated to Southern Medical University, Shenzhen 518028, China
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246
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Licht DJ. "The more things change…": The challenges ahead. J Thorac Cardiovasc Surg 2017. [PMID: 28623100 DOI: 10.1016/j.jtcvs.2017.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Daniel J Licht
- June and Steve Wolfson Laboratory for Clinical and Biomedical Optics, The Children's Hospital of Philadelphia, Philadelphia, Pa.
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247
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Martin BJ, De Villiers Jonker I, Joffe AR, Bond GY, Acton BV, Ross DB, Robertson CMT, Rebeyka IM, Atallah J. Hypoplastic Left Heart Syndrome is not Associated with Worse Clinical or Neurodevelopmental Outcomes Than Other Cardiac Pathologies After the Norwood-Sano Operation. Pediatr Cardiol 2017; 38:922-931. [PMID: 28341901 DOI: 10.1007/s00246-017-1598-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/28/2017] [Indexed: 11/29/2022]
Abstract
There is evidence to suggest that patients undergoing a Norwood for non-HLHS anatomy may have lower mortality than classic HLHS, but differences in neurodevelopmental outcome have not been assessed. Our objective was to compare survival and neurodevelopmental outcome during the same surgical era in a large, well-described cohort. All subjects who underwent a Norwood-Sano operation between 2005 and 2014 were included. Follow-up clinical, neurological, and developmental data were obtained from the Western Canadian Complex Pediatric Therapies Follow-up Program database. Developmental outcomes were assessed at 2 years of age using the Bayley Scales of Infant and Toddler Development (Bayley-III). Survival was assessed using Kaplan-Meier analysis. Baseline characteristics, survival, and neurodevelopmental outcomes were compared between those with HLHS and those with non-HLHS anatomy (non-HLHS). The study comprised 126 infants (75 male), 87 of whom had HLHS. Five-year survival was the same for subjects with HLHS and those with non-HLHS (HLHS 71.8%, non-HLHS 76.9%; p = 0.592). Ninety-three patients underwent neurodevelopmental assessment including Bayley-III scores. The overall mean cognitive composite score was 91.5 (SD 14.6), language score was 86.6 (SD 16.7) and overall mean motor composite score was 85.8 (SD 14.5); being lower than the American normative population mean score of 100 (SD 15) for each (p-value for each comparison, <0.0001). None of the cognitive, language, or motor scores differed between those with HLHS and non-HLHS (all p > 0.05). In the generalized linear models, dominant right ventricle anatomy (present in 117 (93%) of patients) was predictive of lower language and motor scores. Comparative analysis of the HLHS and non-HLHS groups undergoing single ventricle palliation including a Norwood-Sano, during the same era, showed comparable 2-year survival and neurodevelopmental outcomes.
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Affiliation(s)
| | | | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Gwen Y Bond
- Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Canada.,Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Bryan V Acton
- Royal University Hospital, University of Saskatchewan, Saskatoon, Canada
| | - David B Ross
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, Canada.,Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Canada
| | - Ivan M Rebeyka
- Department of Surgery, University of Alberta, Edmonton, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Joseph Atallah
- Department of Surgery, University of Alberta, Edmonton, Canada
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248
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Votava-Smith JK, Statile CJ, Taylor MD, King EC, Pratt JM, Nelson DP, Michelfelder EC. Impaired cerebral autoregulation in preoperative newborn infants with congenital heart disease. J Thorac Cardiovasc Surg 2017. [PMID: 28634025 DOI: 10.1016/j.jtcvs.2017.05.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To characterize cerebral autoregulation (CA) in preoperative newborn infants with congenital heart disease (CHD). METHODS This was a prospective, pilot study of term newborns with CHD who required intensive care. Continuous mean arterial blood pressure (MAP), cerebral tissue oxygen saturation (SCTO2) via near-infrared spectroscopy, and arterial oxygen saturation (SaO2) were collected. Significant low-frequency coherence between MAP and SCTO2 was used to define impaired CA in 20-minute epochs. Cerebral fractional tissue oxygen extraction (FTOE) = (SaO2 - SCTO2)/SaO2 was calculated. Spearman's and rank bi-serial correlations and logistic linear models accounting for multiple measures were used to identify associations with impaired CA and coherence. RESULTS Twenty-four term neonates were evaluated for 23.4 ± 1.8 hours starting the first day of life. Periods of SaO2 variability >5% were excluded, leaving 63 ± 10 epochs per subject, 1515 total for analysis. All subjects demonstrated periods of abnormal CA, mean 15.3% ± 12.8% of time studied. Significant associations with impaired CA per epoch included greater FTOE (P = .02) and lack of sedation (P = .02), and associations with coherence included greater FTOE (P = .03), lack of sedation (P = .03), lower MAP (P = .006), and lower hemoglobin (P = .02). CONCLUSIONS Term newborns with CHD display time-varying CA abnormalities. Associations seen between abnormal CA and greater FTOE, lack of sedation, and lower hemoglobin suggest that impaired oxygen delivery and increased cerebral metabolic demand may overwhelm autoregulatory capacity in these infants. Further studies are needed to determine the significance of impaired CA in this population.
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Affiliation(s)
- Jodie K Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, Calif.
| | | | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eileen C King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jesse M Pratt
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David P Nelson
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erik C Michelfelder
- Emory University School of Medicine, Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga
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249
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Pironkova RP, Giamelli J, Seiden H, Parnell VA, Gruber D, Sison CP, Kowal C, Ojamaa K. Brain injury with systemic inflammation in newborns with congenital heart disease undergoing heart surgery. Exp Ther Med 2017; 14:228-238. [PMID: 28672919 PMCID: PMC5488503 DOI: 10.3892/etm.2017.4493] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/13/2017] [Indexed: 12/03/2022] Open
Abstract
The potential role of systemic inflammation on brain injury in newborns with congenital heart disease (CHD) was assessed by measuring levels of central nervous system (CNS)-derived proteins in serum prior to and following cardiac surgery. A total of 23 newborns (gestational age, 39±1 weeks) with a diagnosis of CHD that required cardiac surgery with cardiopulmonary bypass (CPB) were enrolled in the current study. Serum samples were collected immediately prior to surgery and 2, 24 and 48 h following CPB, and serum levels of phosphorylated neurofilament-heavy subunit (pNF-H), neuron-specific enolase (NSE) and S100B were analyzed. Systemic inflammation was assessed by measuring serum concentrations of complement C5a and complement sC5b9, and the following cytokines: Interleukin (IL)-1β, IL-6, IL-8, IL-10, IL12p70, interferon γ and tumor necrosis factor (TNF)-α. Analysis of cord blood from normal term deliveries (n=26) provided surrogate normative values for newborns. pNF-H and S100B were 2.4- to 2.8-fold higher (P<0.0001) in patient sera than in cord blood prior to surgery and remained elevated following CPB. Pre-surgical serum pNF-H and S100B levels directly correlated with interleukin (IL)-12p70 (ρ=0.442, P<0.05). pNF-H was inversely correlated with arterial pO2 prior to surgery (ρ=−0.493, P=0.01) and directly correlated with arterial pCO2 post-CPB (ρ=0.426, P<0.05), suggesting that tissue hypoxia and inflammation contribute to blood brain barrier (BBB) dysfunction and neuronal injury. Serum IL12p70, IL-6, IL-8, IL-10 and TNF-α levels were significantly higher in patients than in normal cord blood and levels of these cytokines increased following CPB (P<0.001). Activation of complement was observed in all patients prior to surgery, and serum C5a and sC5b9 remained elevated up to 48 h post-surgery. Furthermore, they were correlated (P<0.05) with low arterial pO2, high pCO2 and elevated arterial pressure in the postoperative period. Length of mechanical ventilation was associated directly with post-surgery serum IL-12p70 and IL-8 concentrations (P<0.05). Elevated serum concentrations of pNF-H and S100B in neonates with CHD suggest BBB dysfunction and CNS injury, with concurrent hypoxemia and an activated inflammatory response potentiating this effect.
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Affiliation(s)
- Rossitza P Pironkova
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA
| | - Joseph Giamelli
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA
| | - Howard Seiden
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA
| | - Vincent A Parnell
- Division of Pediatric Cardiothoracic Surgery, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA
| | - Dorota Gruber
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA.,Department of Pediatrics, Hofstra Northwell School of Medicine, Hempstead, NY 11549, USA
| | - Cristina P Sison
- Biostatistics Unit, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA.,Department of Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY 11549, USA
| | - Czeslawa Kowal
- Center for Musculoskeletal and Autoimmune Diseases, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA
| | - Kaie Ojamaa
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA.,Department of Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY 11549, USA.,Center for Immunology and Inflammation, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA
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250
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Laraja K, Sadhwani A, Tworetzky W, Marshall AC, Gauvreau K, Freud L, Hass C, Dunbar-Masterson C, Ware J, Lafranchi T, Wilkins-Haug L, Newburger JW. Neurodevelopmental Outcome in Children after Fetal Cardiac Intervention for Aortic Stenosis with Evolving Hypoplastic Left Heart Syndrome. J Pediatr 2017; 184:130-136.e4. [PMID: 28233547 PMCID: PMC6343658 DOI: 10.1016/j.jpeds.2017.01.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/19/2016] [Accepted: 01/12/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To characterize neurodevelopmental outcomes after fetal aortic valvuloplasty for evolving hypoplastic left heart syndrome and determine the risk factors for adverse neurodevelopment. STUDY DESIGN Questionnaires were mailed to families of children who underwent fetal aortic valvuloplasty from 2000 to 2012, and medical records were reviewed retrospectively. The primary outcome was the General Adaptive Composite score of the Adaptive Behavior Assessment System Questionnaire-Second Edition. Other questionnaires included the Behavior Assessment System for Children, Behavior Rating Inventory of Executive Function, Ages and Stages, and Pediatric Quality of Life Inventory. RESULTS Among 69 eligible subjects, 52 (75%) completed questionnaires at median age of 5.5 (range 1.3-12) years; 30 (58%) had biventricular status circulation. The General Adaptive Composite mean score (92 ± 17) was lower than population norms (P < .001) and similar to published reports in patients with hypoplastic left heart syndrome without fetal intervention; scores in the single ventricular versus biventricular group were 97 ± 19 vs 89 ± 14, respectively (P = .10). On multivariable analysis, independent predictors of a lower General Adaptive Composite score were total hospital duration of stay in the first year of life (P = .001) and, when forced into the model, biventricular status (P = .02). For all other neurodevelopmental questionnaires (Behavior Assessment System for Children, Behavior Rating Inventory of Executive Function, Ages and Stages, Pediatric Quality of Life Inventory), most subscale scores for patients with biventricular and single ventricular status were similar. CONCLUSION Children who underwent fetal aortic valvuloplasty have neurodevelopmental delay, similar to patients with hypoplastic left heart syndrome without fetal intervention. Achievement of biventricular circulation was not associated with better outcomes. We infer that innate patient factors and morbidity during infancy have the greatest effect on neurodevelopmental outcomes.
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Affiliation(s)
- Kristin Laraja
- Departments of Cardiology, Boston Children’s Hospital,Departments of Pediatrics, Harvard Medical School, Boston, MA
| | - Anjali Sadhwani
- Departments of Psychiatry, Boston Children’s Hospital,Departments of Psychiatry, Harvard Medical School, Boston, MA
| | - Wayne Tworetzky
- Departments of Cardiology, Boston Children’s Hospital,Departments of Pediatrics, Harvard Medical School, Boston, MA
| | - Audrey C. Marshall
- Departments of Cardiology, Boston Children’s Hospital,Departments of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Departments of Cardiology, Boston Children’s Hospital,Departments of Pediatrics, Harvard Medical School, Boston, MA
| | - Lindsay Freud
- Departments of Cardiology, Boston Children’s Hospital,Departments of Pediatrics, Harvard Medical School, Boston, MA
| | - Cara Hass
- Departments of Cardiology, Boston Children’s Hospital
| | | | - Janice Ware
- Developmental Medicine Center, Boston Children’s Hospital,Departments of Psychiatry, Harvard Medical School, Boston, MA
| | | | - Louise Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital,Departments of Obstetrics and Gynecology, Harvard Medical School, Boston, MA
| | - Jane W. Newburger
- Departments of Cardiology, Boston Children’s Hospital,Departments of Pediatrics, Harvard Medical School, Boston, MA
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