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Agarwal D, Hunt ML, Sridharan A, Larson AC, Rychik J, Licht DJ, Davey MG, Flake AW, Gaynor JW, Didier RA. Unique model of chronic hypoxia in fetal lambs demonstrates abnormal contrast-enhanced ultrasound brain perfusion. Pediatr Res 2024:10.1038/s41390-024-03206-3. [PMID: 38849480 DOI: 10.1038/s41390-024-03206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/28/2024] [Accepted: 03/31/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Children with congenital heart disease (CHD) demonstrate long-term neurodevelopmental impairments. We investigated contrast-enhanced ultrasound (CEUS) cerebral perfusion in a fetal animal model exposed to sub-physiologic oxygen at equivalent levels observed in human fetuses with CHD. METHODS Fifteen fetal lambs [hypoxic animals (n = 9) and normoxic controls (n = 6)] maintained in an extrauterine environment underwent periodic brain CEUS. Perfusion parameters including microvascular flow velocity (MFV), transit time, and microvascular blood flow (MBF) were extrapolated from a standardized plane; regions of interest (ROI) included whole brain, central/thalami, and peripheral parenchymal analyses. Daily echocardiographic parameters and middle cerebral artery (MCA) pulsatility indices (PIs) were obtained. RESULTS Hypoxic lambs demonstrated decreased MFV, increased transit time, and decreased MBF (p = 0.026, p = 0.016, and p < 0.001, respectively) by whole brain analyses. MFV and transit time were relatively preserved in the central/thalami (p = 0.11, p = 0.08, p = 0.012, respectively) with differences in the peripheral parenchyma (all p < 0.001). In general, cardiac variables did not correlate with cerebral CEUS perfusion parameters. Hypoxic animals demonstrated decreased MCA PI compared to controls (0.65 vs. 0.78, respectively; p = 0.027). CONCLUSION Aberrations in CEUS perfusion parameters suggest that in environments of prolonged hypoxia, there are regional microvascular differences incompletely characterized by MCA interrogation offering insights into fetal conditions which may contribute to patient outcomes. IMPACT This work utilizes CEUS to study cerebral microvascular perfusion in a unique fetal animal model subjected to chronic hypoxic conditions equal to fetuses with congenital heart disease. CEUS demonstrates altered parameters with regional differences that are incompletely characterized by MCA Doppler values. These findings show that routine MCA Doppler interrogation may be inadequate in assessing microvascular perfusion differences. To our knowledge, this study is the first to utilize CEUS to assess microvascular perfusion in this model. The results offer insight into underlying conditions and physiological changes which may contribute to known neurodevelopmental impairments in those with congenital heart disease.
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Affiliation(s)
- Divyansh Agarwal
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mallory L Hunt
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abby C Larson
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J William Gaynor
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryne A Didier
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA.
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Stewart NP, Quinlan C, Best S, Mynard JP. Noninvasive pediatric blood pressure assessment: exploring the clinicians' perspective. Blood Press Monit 2024; 29:127-135. [PMID: 38386314 DOI: 10.1097/mbp.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Obtaining accurate and reliable blood pressure (BP) readings in pediatric patients is challenging, given difficulties in adhering to measurement guidelines, limited device validation and variable patient cooperation. This study aimed to investigate clinicians' perspectives surrounding noninvasive pediatric BP assessment to identify opportunities for improvement in BP technology and clinical practice. METHOD Based on an adapted version of the extended Technology Acceptance Model 2, semi-structured interviews were conducted with clinicians involved in noninvasive pediatric BP assessment in a major Australian children's hospital. Transcripts were analyzed thematically and guided by Technology Acceptance Model 2. RESULTS Clinician responses ( n = 20) revealed that poor patient tolerance of BP measurement resulting from excessive cuff inflation is a major hindrance to reliable pediatric BP assessment. Clinicians described low trust in BP readings from automated devices, often relating to poor patient tolerance to cuff inflation, thereby diminishing the clinical utility of these readings in informing treatment decisions. Auscultatory measurement was regarded as more trustworthy and better tolerated, but less convenient to perform as compared with oscillometric measurement. CONCLUSION A dissonance exists between (1) low trust and clinical utility of the most common and easy-to-use BP measurement approach (automated devices), versus (2) higher trust and clinical utility, but efficiency and user-related impediments, for the auscultatory method. Based on our results, we have developed the Blood Pressure Acceptance Model, which can be used to explain and predict clinicians' acceptance of BP technology. Further work is needed to improve the tolerability and accuracy of automated BP devices in real-world pediatric settings.
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Affiliation(s)
- Natalie P Stewart
- Heart Research, Murdoch Children's Research Institute
- Department of Paediatrics, University of Melbourne
| | - Catherine Quinlan
- Department of Paediatrics, University of Melbourne
- Department of Nephrology, Royal Children's Hospital
- Kidney Regeneration, Murdoch Children's Research Institute, Parkville VIC
| | - Stephanie Best
- Department of Health Services Research, Peter MacCallum Cancer Centre
- Victorian Comprehensive Cancer Centre, Melbourne, VIC
- Australian Genomics, Murdoch Children's Research Institute, Parkville, VIC
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC
| | - Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute
- Department of Paediatrics, University of Melbourne
- Department of Biomedical Engineering, University of Melbourne, Parkville VIC, Australia
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Lee VK, Ceschin R, Reynolds WT, Meyers B, Wallace J, Landsittel D, Joseph HM, Badaly D, Gaynor JW, Licht D, Greene NH, Brady KM, Hunter JV, Chu ZD, Wilde EA, Easley RB, Andropoulos D, Panigrahy A. Postnatal Brain Trajectories and Maternal Intelligence Predict Childhood Outcomes in Complex CHD. J Clin Med 2024; 13:2922. [PMID: 38792464 PMCID: PMC11121951 DOI: 10.3390/jcm13102922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024] Open
Abstract
Objective: To determine whether early structural brain trajectories predict early childhood neurodevelopmental deficits in complex CHD patients and to assess relative cumulative risk profiles of clinical, genetic, and demographic risk factors across early development. Study Design: Term neonates with complex CHDs were recruited at Texas Children's Hospital from 2005-2011. Ninety-five participants underwent three structural MRI scans and three neurodevelopmental assessments. Brain region volumes and white matter tract fractional anisotropy and radial diffusivity were used to calculate trajectories: perioperative, postsurgical, and overall. Gross cognitive, language, and visuo-motor outcomes were assessed with the Bayley Scales of Infant and Toddler Development and with the Wechsler Preschool and Primary Scale of Intelligence and Beery-Buktenica Developmental Test of Visual-Motor Integration. Multi-variable models incorporated risk factors. Results: Reduced overall period volumetric trajectories predicted poor language outcomes: brainstem ((β, 95% CI) 0.0977, 0.0382-0.1571; p = 0.0022) and white matter (0.0023, 0.0001-0.0046; p = 0.0397) at 5 years; brainstem (0.0711, 0.0157-0.1265; p = 0.0134) and deep grey matter (0.0085, 0.0011-0.0160; p = 0.0258) at 3 years. Maternal IQ was the strongest contributor to language variance, increasing from 37% at 1 year, 62% at 3 years, and 81% at 5 years. Genetic abnormality's contribution to variance decreased from 41% at 1 year to 25% at 3 years and was insignificant at 5 years. Conclusion: Reduced postnatal subcortical-cerebral white matter trajectories predicted poor early childhood neurodevelopmental outcomes, despite high contribution of maternal IQ. Maternal IQ was cumulative over time, exceeding the influence of known cardiac and genetic factors in complex CHD, underscoring the importance of heritable and parent-based environmental factors.
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Affiliation(s)
- Vincent K. Lee
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15260, USA;
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
| | - Rafael Ceschin
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15206, USA
| | - William T. Reynolds
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15206, USA
| | - Benjamin Meyers
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
| | - Julia Wallace
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
| | - Douglas Landsittel
- Department of Biostatistics, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY 14260, USA;
| | - Heather M. Joseph
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Daryaneh Badaly
- Learning and Development Center, Child Mind Institute, New York, NY 10022, USA;
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Daniel Licht
- Perinatal Pediatrics Institute, Children’s National Hospital, Washinton, DC 20010, USA;
| | - Nathaniel H. Greene
- Anesthesiology, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Ken M. Brady
- Department of Pediatrics and Department of Anesthesiology, Lurie Children’s Hospital, Northwestern University, Chicago, IL 60611, USA;
| | - Jill V. Hunter
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA; (J.V.H.); (Z.D.C.); (E.A.W.)
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Zili D. Chu
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA; (J.V.H.); (Z.D.C.); (E.A.W.)
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Elisabeth A. Wilde
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA; (J.V.H.); (Z.D.C.); (E.A.W.)
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - R. Blaine Easley
- Department of Pediatric Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA; (R.B.E.); (D.A.)
| | - Dean Andropoulos
- Department of Pediatric Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA; (R.B.E.); (D.A.)
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Ashok Panigrahy
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15260, USA;
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA; (R.C.); (W.T.R.); (B.M.); (J.W.)
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15206, USA
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Hashiya M, Okubo Y, Kato T. Effects of Dexmedetomidine on Brain and Inflammatory Outcomes In Pediatric Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2023; 37:1013-1020. [PMID: 36907706 DOI: 10.1053/j.jvca.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/16/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Dexmedetomidine use decreases adverse neurocognitive outcomes in adults undergoing cardiovascular surgery, but its effect has been unclear in children with congenital heart disease. METHODS The authors conducted a systematic review using the PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) that compared intravenous dexmedetomidine with normal saline during pediatric cardiac surgery under anesthesia. Published randomized controlled trials that evaluated children aged <18 years who underwent congenital heart surgery were included. Nonrandomized trials, observational studies, case series and case reports, editorials, reviews, and conference papers were excluded. The quality of the included studies was assessed using the Cochrane revised tool for assessing risk-of-bias in randomized trials. Meta-analysis was performed to estimate the effects of intravenous dexmedetomidine on brain markers (neuron-specific enolase [NSE], S-100β protein) and inflammatory markers (interleukin-6, tumor necrosis factor [TNF]-α, nuclear factor kappa-B [NF-κB]) during and after cardiac surgery, using random-effect models for standardized mean difference (SMD). RESULTS Seven RCTs involving 579 children were eligible for the following meta-analyses. Most children underwent cardiac surgery for atrial or ventricular septum defects. Pooled analyses (5 treatment groups in 3 RCTs with 260 children) showed that dexmedetomidine use was associated with reduced serum levels of NSE (pooled SMD, -0.54; 95% CI, -0.96 to -0.12) and S-100β (pooled SMD, -0.85; 95% CI, -1.67 to -0.04) within 24 hours after the surgery. Also, dexmedetomidine use was associated with reduced levels of interleukin-6 (pooled SMD, -1.55; 95% CI, -2.82 to -0.27; 4 treatment groups in 2 RCTs with 190 children). In contrast, the authors observed similar levels of TNF-α (pooled SMD, -0.07; 95% CI, -0.33 to 0.19; 4 treatment groups in 2 RCTs with 190 children) and NF-κB (pooled SMD, -0.27; 95% CI, -0.62 to 0.09; 2 treatment groups in 1 RCT with 90 children) between the dexmedetomidine and control groups. CONCLUSIONS The authors' findings support the effect of dexmedetomidine on reductions in brain markers among children who undergo cardiac surgery. Further studies would be needed to elucidate its clinically meaningful effects using cognitive functions in the long term, and its effects among children who undergo more complex cardiac surgeries.
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Affiliation(s)
- Mai Hashiya
- Department of Anesthesiology, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Okubo
- Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan.
| | - Tsuguhiko Kato
- Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan
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Yin MW, Chen BH, Chen XJ, Zhang T, Jin J, Xu J. The characteristics of blood transfusion and analysis of preoperative factors associated with intraoperative blood transfusion in congenital heart surgery: a case-control study. J Cardiothorac Surg 2022; 17:337. [PMID: 36566199 PMCID: PMC9789642 DOI: 10.1186/s13019-022-02068-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 12/09/2022] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Blood transfusion is a common and life-saving procedure in congenital heart surgery (CHS), and it is critical for patients to identify risk factors prior to surgery. Our objective is to conduct an analysis of the preoperative factors that influence blood use during CHS and to offer guidance on preoperative blood preparation. METHODS A total of 1550 cases were retrospectively analyzed in our institution between May 2019 and June 2020. We determined whether to employ red blood cells (RBCs), platelets, and plasma as dependent variables; we treated the data from characteristics and laboratory tests as binary data, except for the Risk Adjustment for Congenital Heart Surgery (RACHS) methods as multinomial data, and finally taken into binary logistic regression analysis. RESULTS The total amounts of transfused RBCs, platelets, and plasma were 850.5 U (N = 713, 46%), 159 U (N = 21, 1.4%), and 1374.2 U (N = 953, 61.5%), respectively. Multivariate analysis found age (OR 0.142, 95% CI 0.099-0.203, P < 0.001), weight (0.170, 0.111-0.262, P < 0.001) RACHS method (RACHS2 vs. RACHS1, 3.444, 2.521-4.704, P < 0.001; RACHS3 vs. RACHS1, 9.333, 4.731-18.412, P < 0.001; RACHS4 vs. RACHS1, 31.327, 2.916-336.546, P = 0.004), and hemoglobin (0.524, 0.315-0.871, P = 0.013) to be independent risk predictors of RBC transfused volume; age (9.911, 1.008-97.417, P = 0.049), weight (0.029, 0.003-0.300, P = 0.029), RACHS method (RACHS3 vs. RACHS1, 13.001, 2.482-68.112, P = 0.002; RACHS4 vs. RACHS1, 59.748, 6.351-562.115, P < 0.001) to be platelets; and age (0.488, 0.352-0.676, P < 0.001), weight (0.252, 0.164-0.386, P < 0.001), RACHS method (RACHS2 vs. RACHS1, 2.931, 2.283-3.764, P < 0.001; RACHS3 vs. RACHS1, 10.754, 4.751-24.342, P < 0.001), APTT (1.628, 1.058-2.503, P = 0.027), and PT (2.174, 1.065-4.435, P = 0.033) to be plasma. CONCLUSION Although patients' age, weight, routine blood test, coagulation function, and protein levels should all be considered for preparing blood before CHS, the RACHS method is the most important factor influencing intraoperative blood transfused volume and should be considered first in clinical blood preparation.
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Affiliation(s)
- Ming-wei Yin
- grid.13402.340000 0004 1759 700XBlood Transfusion Department, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333, Binsheng Rd, Binjiang District, Hangzhou, 310052 Zhejiang Province People’s Republic of China
| | - Bao-hai Chen
- grid.13402.340000 0004 1759 700XInformation Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang Province People’s Republic of China
| | - Xue-jun Chen
- grid.13402.340000 0004 1759 700XBlood Transfusion Department, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333, Binsheng Rd, Binjiang District, Hangzhou, 310052 Zhejiang Province People’s Republic of China
| | - Tao Zhang
- grid.511341.30000 0004 1772 8591Blood Transfusion Department, Tai’an City Central Hospital, Taian, Shandong Province People’s Republic of China
| | - Jie Jin
- grid.13402.340000 0004 1759 700XCardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang Province People’s Republic of China
| | - Jun Xu
- grid.13402.340000 0004 1759 700XBlood Transfusion Department, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333, Binsheng Rd, Binjiang District, Hangzhou, 310052 Zhejiang Province People’s Republic of China
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Lo E, Kalish BT. Neurodevelopmental outcomes after neonatal surgery. Pediatr Surg Int 2022; 39:22. [PMID: 36449183 DOI: 10.1007/s00383-022-05285-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 12/05/2022]
Abstract
Children who require surgery in the newborn period are at risk for long-term neurodevelopmental impairment (NDI). There is growing evidence that surgery during this critical window of neurodevelopment gives rise to an increased risk of brain injury, predisposing to neurodevelopmental challenges including motor delays, learning disabilities, executive function impairments, and behavioral disorders. These impairments can have a significant impact on the quality of life of these children and their families. This review explores the current literature surrounding the effect of neonatal surgery on neurodevelopment, as well as the spectrum of proposed mechanisms that may impact neurodevelopmental outcomes. The goal is to identify modifiable risk factors and patients who may benefit from close neurodevelopmental follow-up and early referral to therapy.
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Affiliation(s)
- Emily Lo
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Brian T Kalish
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Molecular Genetics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Schlapbach LJ, Gibbons KS, Horton SB, Johnson K, Long DA, Buckley DHF, Erickson S, Festa M, d’Udekem Y, Alphonso N, Winlaw DS, Delzoppo C, van Loon K, Jones M, Young PJ, Butt W, Schibler A. Effect of Nitric Oxide via Cardiopulmonary Bypass on Ventilator-Free Days in Young Children Undergoing Congenital Heart Disease Surgery: The NITRIC Randomized Clinical Trial. JAMA 2022; 328:38-47. [PMID: 35759691 PMCID: PMC9237803 DOI: 10.1001/jama.2022.9376] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE In children undergoing heart surgery, nitric oxide administered into the gas flow of the cardiopulmonary bypass oxygenator may reduce postoperative low cardiac output syndrome, leading to improved recovery and shorter duration of respiratory support. It remains uncertain whether nitric oxide administered into the cardiopulmonary bypass oxygenator improves ventilator-free days (days alive and free from mechanical ventilation). OBJECTIVE To determine the effect of nitric oxide applied into the cardiopulmonary bypass oxygenator vs standard care on ventilator-free days in children undergoing surgery for congenital heart disease. DESIGN, SETTING, AND PARTICIPANTS Double-blind, multicenter, randomized clinical trial in 6 pediatric cardiac surgical centers in Australia, New Zealand, and the Netherlands. A total of 1371 children younger than 2 years undergoing congenital heart surgery were randomized between July 2017 and April 2021, with 28-day follow-up of the last participant completed on May 24, 2021. INTERVENTIONS Patients were assigned to receive nitric oxide at 20 ppm delivered into the cardiopulmonary bypass oxygenator (n = 679) or standard care cardiopulmonary bypass without nitric oxide (n = 685). MAIN OUTCOMES AND MEASURES The primary end point was the number of ventilator-free days from commencement of bypass until day 28. There were 4 secondary end points including a composite of low cardiac output syndrome, extracorporeal life support, or death; length of stay in the intensive care unit; length of stay in the hospital; and postoperative troponin levels. RESULTS Among 1371 patients who were randomized (mean [SD] age, 21.2 [23.5] weeks; 587 girls [42.8%]), 1364 (99.5%) completed the trial. The number of ventilator-free days did not differ significantly between the nitric oxide and standard care groups, with a median of 26.6 days (IQR, 24.4 to 27.4) vs 26.4 days (IQR, 24.0 to 27.2), respectively, for an absolute difference of -0.01 days (95% CI, -0.25 to 0.22; P = .92). A total of 22.5% of the nitric oxide group and 20.9% of the standard care group developed low cardiac output syndrome within 48 hours, needed extracorporeal support within 48 hours, or died by day 28, for an adjusted odds ratio of 1.12 (95% CI, 0.85 to 1.47). Other secondary outcomes were not significantly different between the groups. CONCLUSIONS AND RELEVANCE In children younger than 2 years undergoing cardiopulmonary bypass surgery for congenital heart disease, the use of nitric oxide via cardiopulmonary bypass did not significantly affect the number of ventilator-free days. These findings do not support the use of nitric oxide delivered into the cardiopulmonary bypass oxygenator during heart surgery. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12617000821392.
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Affiliation(s)
- Luregn J. Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kristen S. Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Stephen B. Horton
- Cardiac Surgical Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Kerry Johnson
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Debbie A. Long
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David H. F. Buckley
- Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand
| | - Simon Erickson
- Paediatric Critical Care, Perth Children’s Hospital, Western Australia and The University of Western Australia, Crawley, Western Australia, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network, Sydney, New South Wales, Australia
| | - Yves d’Udekem
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Children’s National Hospital and The George Washington University School of Medicine and Health Sciences, Seattle, Washington
- Heart Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Nelson Alphonso
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Cardiac Surgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
- School of Medicine, Children’s Health Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - David S. Winlaw
- Heart Centre for Children, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Carmel Delzoppo
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kim van Loon
- Department of Anaesthesiology, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Mark Jones
- Institute of Evidence Based Healthcare, Bond University, Gold Coast, Australia
| | - Paul J. Young
- The Intensive Care Research Programme, Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Warwick Butt
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School University of Melbourne, Victoria, Australia
- Central Clinical School Faculty of Medicine Monash University, Melbourne, Victoria, Australia
| | - Andreas Schibler
- Critical Care Research Group, Wesley Medical Research, St Andrew’s War Memorial Hospital, Brisbane, Queensland, Australia
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Elassal AA, Al-Radi OO, Debis RS, Zaher ZF, Abdelmohsen GA, Faden MS, Noaman NA, Elakaby AR, Abdelmotaleb ME, Abdulgawad AM, Elhudairy MS, Jabbad AH, Ismail AA, Aljohani NB, Alghamdi AM, Dohain AM. Neonatal congenital heart surgery: contemporary outcomes and risk profile. J Cardiothorac Surg 2022; 17:80. [PMID: 35443734 PMCID: PMC9022284 DOI: 10.1186/s13019-022-01830-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/09/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Many studies still dispute the identification of independent risk factors that influence outcome after neonatal cardiac surgery. We present our study to announce the contemporary outcomes and risk profile of neonatal cardiac surgery at our institute. METHODS We designed a retrospective study of neonatal patients who underwent surgery for congenital heart diseases between June 2011 and April 2020. Demographic, operative, and postoperative data were collected from medical records and surgical databases. The primary outcome was the operative mortality (in-hospital death) and secondary outcomes included hospital length of stay, intensive care unit stay, duration of mechanical ventilation. RESULTS In total, 1155 cardiac surgeries in children were identified; of these, 136 (11.8%) were performed in neonates. Arterial switch operations (48 cases) were the most frequent procedures. Postoperatively, 11 (8.1%) patients required extracorporeal membrane oxygenation, and 4 (2.9%) patients had complete heart block. Postoperative in-hospital mortality was 11%. The median postoperative duration of mechanical ventilation, intensive care unit stay, and hospital length of stay were 6, 18, and 24 days, respectively. CONCLUSION The early outcomes of neonatal cardiac surgery are encouraging. The requirement of postoperative extracorporeal membrane oxygenation support, postoperative intracranial hemorrhage, and acute kidney were identified as independent risk factors of mortality following surgery for congenital heart defects in neonates.
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Affiliation(s)
- Ahmed Abdelrahman Elassal
- Cardiac Surgery Unit, Department of Surgery, King Abdulaziz University, Jeddah, 21589, Saudi Arabia. .,Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt.
| | - Osman Osama Al-Radi
- Cardiac Surgery Unit, Department of Surgery, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Ragab Shehata Debis
- Cardiac Surgery Unit, Department of Surgery, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Cardiothoracic Surgery Department, Al-Azhar University, Cairo, Egypt
| | - Zaher Faisal Zaher
- Department of Pediatric Cardiology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Gaser Abdelmohsen Abdelmohsen
- Department of Pediatric Cardiology, King Abdulaziz University, Jeddah, Saudi Arabia.,Pediatric Cardiology Division, Department of Pediatrics, Cairo University, Cairo, Egypt
| | | | - Nada Ahmed Noaman
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Ragab Elakaby
- Pediatrics Department, Faculty of Medicine (Boys), Al-Azhar University, Cairo, Egypt
| | | | | | | | - Abdulla Husain Jabbad
- Sixth Grade, Faculty of Human Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Abdelaziz Ismail
- Department of Anesthesia and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Norah Bakheet Aljohani
- Cardiac Surgery Unit, Patient Coordination Unit, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Arwa Mohammed Alghamdi
- Cardiac Surgery Unit, Patient Coordination Unit, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Mohamed Dohain
- Department of Pediatric Cardiology, King Abdulaziz University, Jeddah, Saudi Arabia.,Pediatric Cardiology Division, Department of Pediatrics, Cairo University, Cairo, Egypt
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9
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Dextro-Transposition of Great Arteries and Neurodevelopmental Outcomes: A Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9040502. [PMID: 35455546 PMCID: PMC9027469 DOI: 10.3390/children9040502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022]
Abstract
Background: Arterial switch operation (ASO) is the gold-standard surgical approach for dextro-transposition of the great arteries (D-TGA). It is performed during the neonatal period and has almost diminished the previously high mortality rate (from 90% if left untreated to <0.5%). Despite the impressively high survival rates, the surgical procedure itself—along with the chronic post-operative complications and the perinatal impaired cerebral oxygen delivery—introduces multiple and cumulative risk factors for neurodevelopmental impairment. Method: This study is a review of English articles, using PUBMED and applying the following search terms, “transposition of the great arteries”, “neurodevelopment”, “autism”, “cerebral palsy”, and “attention-deficit hyperactivity disorder”. Data were extracted by two authors. Results: Even though general IQ is mainly found within the normal range, D-TGA children and adolescents display reduced performance in the assignments of executive functions, fine motor functions, attention, working memory, visual−spatial skills, and higher-order language skills. Moreover, D-TGA survivors may eventually struggle with inferior academic achievements and psychiatric disorders such as depression, anxiety, and ADHD. Conclusions: The existing literature concerning the neurodevelopment of D-TGA patients suggests impairment occurring during their lifespan. These findings underline the importance of close developmental surveillance so that D-TGA patients can better reach their full potential.
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10
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Long-term neurodevelopmental effects of intraoperative blood pressure during surgical closure of a septal defect in infancy or early childhood. Cardiol Young 2021; 31:2002-2008. [PMID: 33843536 DOI: 10.1017/s1047951121001414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Many children born with congenital heart defects are faced with cognitive deficits and psychological challenges later in life. The mechanisms behind are suggested to be multifactorial and are explained as an interplay between innate and modifiable risk factors. The aim was to assess whether there is a relationship between mean arterial pressure during surgery of a septal defect in infancy or early childhood and intelligence quotient scores in adulthood. METHODS In a retrospective study, patients were included if they underwent surgical closure of a ventricular septal defect or an atrial septal defect in childhood between 1988 and 2002. Every patient completed an intelligence assessment upon inclusion, 14-27 years after surgery, using the Wechsler Adult Intelligence Scale Version IV. RESULTS A total of 58 patients met the eligibility criteria and were included in the analyses. No statistically significant correlation was found between blood pressure during cardiopulmonary bypass and intelligence quotient scores in adulthood (r = 0.138; 95% CI-0.133-0.389). Although amongst patients with mean arterial pressure < 40 mmHg during cardiopulmonary bypass, intelligence quotient scores were significantly lower (91.4; 95% CI 86.9-95.9) compared to those with mean arterial pressure > 40 mmHg (99.8; 95% CI 94.7-104.9). CONCLUSIONS Mean arterial pressure during surgery of ventricular septal defects or atrial septal defects in childhood does not correlate linearly with intelligence quotient scores in adulthood. Although there may exist a specific cut-off value at which low blood pressure becomes harmful. Larger studies are warranted in order to confirm this, as it holds the potential of partly relieving CHD patients of their cognitive deficits.
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11
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Gibbons KS, Schlapbach LJ, Horton SB, Long DA, Beca J, Erickson S, Festa M, d’Udekem Y, Alphonso N, Winlaw D, Johnson K, Delzoppo C, van Loon K, Gannon B, Fooken J, Blumenthal A, Young PJ, Butt W, Schibler A. Statistical analysis plan for the NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) trial. CRIT CARE RESUSC 2021; 23:47-58. [PMID: 38046394 PMCID: PMC10692519 DOI: 10.51893/2021.1.oa4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The NITric oxide during cardiopulmonary bypass (CPB) to improve Recovery in Infants with Congenital heart defects (NITRIC) trial, a 1320-patient, multicentre, randomised controlled trial, is aiming to improve survival free of ventilation after CPB by using nitric oxide delivered into the oxygenator of the CPB. Objective: To provide a statistical analysis plan before completion of patient recruitment and data monitoring. Final analyses for this study will adhere to this statistical analysis plan, which details all key pre-planned analyses. Stata scripts for analyses have been prepared alongside this statistical analysis plan. Methods: The statistical analysis plan was designed collaboratively by the chief investigators and trial statistician and builds on the previously published study protocol. All authors remain blinded to treatment allocation. Detail is provided on statistical analyses including cohort description, analysis of primary and secondary outcomes and adverse events. Statistical methods to compare outcomes are planned in detail to ensure methods are verifiable and reproducible. Results: The statistical analysis plan developed provides the trial outline, list of mock tables, and analysis scripts. The plan describes statistical analyses on cohort and baseline description, primary and secondary outcome analyses, process of care measures, physiological descriptors, and safety and adverse event reporting. We define the pre-specified subgroup analyses and the respective statistical tests used to compare subgroups. Conclusion: The statistical analysis plan for the NITRIC trial establishes detailed pre-planned analyses alongside Stata scripts to analyse the largest trial in the field of neonatal and paediatric heart surgery. The plan ensures standards for trial analysis validity aiming to minimise bias of analyses. Trial registration: ACTRN12617000821392.
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Affiliation(s)
- Kristen S. Gibbons
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Luregn J. Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephen B. Horton
- Cardiac Surgical Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Debbie A. Long
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand
| | - Simon Erickson
- Paediatric Critical Care, Perth Children’s Hospital, Western Australia and The University of Western Australia, Crawley, Western Australia, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network, Sydney, New South Wales, Australia
| | - Yves d’Udekem
- Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Heart Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nelson Alphonso
- Cardiac Surgery, Queensland Children’s Hospital, Brisbane, Queensland, Australia
- School of Medicine, Children’s Health Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - David Winlaw
- Heart Centre for Children, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kerry Johnson
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Carmel Delzoppo
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kim van Loon
- Division of Anaesthetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Brenda Gannon
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Jonas Fooken
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Antje Blumenthal
- The University of Queensland, Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Paul J. Young
- The Intensive Care Research Programme, Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Warwick Butt
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - On behalf of the NITRIC Study Group, the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG), and the ANZICS Paediatric Study Group (PSG)
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Cardiac Surgical Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand
- Paediatric Critical Care, Perth Children’s Hospital, Western Australia and The University of Western Australia, Crawley, Western Australia, Australia
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network, Sydney, New South Wales, Australia
- Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Heart Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Cardiac Surgery, Queensland Children’s Hospital, Brisbane, Queensland, Australia
- School of Medicine, Children’s Health Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
- Heart Centre for Children, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
- Division of Anaesthetics, University Medical Center Utrecht, Utrecht, The Netherlands
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
- The University of Queensland, Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
- The Intensive Care Research Programme, Medical Research Institute of New Zealand, Wellington, New Zealand
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12
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Pulcine E, deVeber G. Neurologic complications of pediatric congenital heart disease. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:1-13. [PMID: 33632428 DOI: 10.1016/b978-0-12-819814-8.00010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Improved medical management and surgical outcomes have significantly decreased mortality in children with congenital heart disease; however, with increased survival, there is a greater lifetime exposure to neurologic complications with serious long-term neurodevelopmental consequences. Thus, recent focus has shifted to recognition and reduction of these extracardiac comorbidities. Vascular and infective complications, such as arterial ischemic stroke, infective endocarditis, and localization-related epilepsy are some of the most common neurologic comorbidities of congenital heart disease. In addition, it is now well recognized that congenital heart disease has an impact on overall brain development and contributes to adverse neurodevelopmental outcomes across multiple domains. The goal of this chapter is to summarize the most common neurologic comorbidities of congenital heart disease and its management.
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Affiliation(s)
- Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.
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13
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Graupner O, Koch J, Enzensberger C, Götte M, Wolter A, Müller V, Kawecki A, Herrmann J, Axt-Fliedner R. Cerebroplacental and Uterine Doppler Indices in Pregnancies Complicated by Congenital Heart Disease of the Fetus. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:48-55. [PMID: 31200391 DOI: 10.1055/a-0900-4021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE Children with congenital heart disease (CHD) are known to have impaired neurodevelopment possibly influenced by altered cerebroplacental hemodynamics antenatally. We compared fetomaternal Doppler patterns in different CHD groups with published normative values during gestation. MATERIALS AND METHODS Retrospective cohort study consisting of 248 CHD fetuses. Subgroups were generated according to the expected ascending aorta oxygen saturation: low portion of high oxygenated umbilical venous (UV) blood (group 1: n = 108), intermediate portion of UV blood due to intracardiac mixing with oxygen poor systemic blood (group 2: n = 103), high (group 3: n = 13) and low portion of UV blood without mixing of blood (group 4: n = 24). Doppler examination included umbilical artery and middle cerebral artery pulsatility index (UA-PI, MCA-PI), cerebroplacental ratio (CPR) and mean uterine artery (mUtA) PI. For mean comparisons at different gestational ages (GA), estimated marginal means from regression models are reported for GA 22 weeks (wks), GA 30 wks and GA 38 wks. RESULTS Z-score transformed values of MCA-PI (zMCA-PI) were significantly lower in group 1 compared to all other subgroups at GA 30 wks (p < 0.05). At 38 wks, group 1 had significantly lower values of zMCA-PI and zCPR compared to groups 2 and 4. Group 1 fetuses showed a significant association between zMCA-PI and zCPR (negative) and GA as well as zmUtA-PI (positive) and GA compared to reference values. CONCLUSION Our data confirm that CHD fetuses have a higher rate of cerebral redistribution in the third trimester. Changes in Doppler patterns were mainly observed in CHD with a low portion of UV blood in the ascending aorta.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jessica Koch
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Malena Götte
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Aline Wolter
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Vera Müller
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Andreea Kawecki
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | | | - Roland Axt-Fliedner
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
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14
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Alkhatip AAAMM, Kamel MG, Farag EM, Elayashy M, Farag A, Yassin HM, Bahr MH, Abdelhaq M, Sallam A, Kamal AM, Emady MFE, Wagih M, Naguib AA, Helmy M, Algameel HZ, Abdelkader M, Mohamed H, Younis M, Purcell A, Elramely M, Hamza MK. Deep Hypothermic Circulatory Arrest in the Pediatric Population Undergoing Cardiac Surgery With Electroencephalography Monitoring: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2021; 35:2875-2888. [PMID: 33637420 DOI: 10.1053/j.jvca.2021.01.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Cardiac surgery for repair of congenital heart defects poses unique hazards to the developing brain. Deep hypothermic circulatory arrest (DHCA) is a simple and effective method for facilitating a bloodless surgical field during congenital heart defect repair. There are, however, some concerns that prolonged DHCA increases the risk of nervous system injury. The electroencephalogram (EEG) is used in adult and, to a lesser extent, pediatric cardiac procedures as a neuromonitoring method. The present study was performed to assess outcomes following DHCA with EEG monitoring in the pediatric population. DESIGN In this systematic review and meta-analysis, the PubMed, Cochrane Central Register of Controlled Trials, Scopus, Institute of Science Index, and Embase databases were searched from inception for relevant articles. A fixed- or random-effects model, as appropriate, was used. SETTING Surgical setting. PARTICIPANTS Pediatric population (≤18 y old). INTERVENTIONS DHCA (18°C) with EEG monitoring. MEASUREMENTS AND MAIN RESULTS Nineteen articles with 1,267 pediatric patients ≤18 years were included. The event rate of clinical and EEG seizures among patients who underwent DHCA was 12.9% and 14.9%, respectively. Mortality was found to have a 6.3% prevalence. A longer duration of DHCA was associated with a higher risk of EEG seizure and neurologic abnormalities. In addition, seizures were associated with increased neurologic abnormalities and neurodevelopmental delay. CONCLUSIONS EEG and neurologic abnormalities were common after DHCA. A longer duration of DHCA was found to lead to more EEG seizure and neurologic abnormalities. Moreover, EEG seizures were more common than clinical seizures. Seizures were found to be associated with increased neurologic abnormalities and neurodevelopmental delay.
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Affiliation(s)
- Ahmed Abdelaal Ahmed Mahmoud M Alkhatip
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK; Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt.
| | | | - Ehab Mohamed Farag
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed Elayashy
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Farag
- Department of Anesthesia, King Abdullah Medical City - Holy Capital, Makkah, Saudi Arabia
| | - Hany Mahmoud Yassin
- Department of Anesthesia, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Mahmoud Hussein Bahr
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed Abdelhaq
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Sallam
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland; Department of Anaesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ahmed Mostafa Kamal
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Mohamed Wagih
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Ahmed Naguib
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Helmy
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Mohamed Abdelkader
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Hassan Mohamed
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt; Department of Anaesthesia, Royal Papworth Hospital, Cambridge, UK
| | - Mohamed Younis
- Department of Anaesthesia, Cambridge University Hospital, Cambridge, UK
| | - Andrew Purcell
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland
| | - Mohamed Elramely
- Department of Anaesthesia, National Cancer Institute, Cairo University, Cairo, Egypt
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15
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Desai M, Yerebakan C. Commentary: The oxygen metabolism of the brain transparent. J Thorac Cardiovasc Surg 2020; 159:2024-2025. [DOI: 10.1016/j.jtcvs.2019.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/11/2019] [Accepted: 09/11/2019] [Indexed: 11/16/2022]
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16
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Qiu Y, Li C, Li X, Jia Y. Effects of dexmedetomidine on the expression of inflammatory factors in children with congenital heart disease undergoing intraoperative cardiopulmonary bypass: a randomized controlled trial. Pediatr Investig 2020; 4:23-28. [PMID: 32851338 PMCID: PMC7331422 DOI: 10.1002/ped4.12176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/17/2019] [Indexed: 11/09/2022] Open
Abstract
IMPORTANCE Dexmedetomidine inhibits the inflammatory response associated with cardiopulmonary bypass (CPB) and protects neural function. However, the mechanism of dexmedetomidine's anti-inflammatory pathway is unclear. OBJECTIVE To investigate the effect of dexmedetomidine on the cognitive level and expression of inflammatory factors in children with congenital heart disease undergoing intraoperative CPB. METHODS Ninety children with congenital heart disease were recruited and randomly divided into 3 groups of 30 children in each. In Group 1, a 1.0 µg·kg-1·h-1 intravenous bolus of dexmedetomidine was administered 10 minutes after induction of anesthesia, followed by a 0.2 µg·kg-1·h-1 infusion until the surgical incision. In Group 2, a 0.5 µg/kg intravenous bolus of dexmedetomidine was administered 10 minutes after induction of anesthesia, followed by a 0.1 µg·kg-1·h-1 infusion until the surgical incision. The control group was given physiological saline using the same method as in Groups 1 and 2. The serum levels of nuclear factor-kappa B (NF-κB), S-100β protein, neuron-specific enolase (NSE), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were measured before the surgery (T1), at the end of CPB (T2), 2 hours after CPB (T3), 6 hours after CPB (T4), and 24 hours after CPB (T5). The Wechsler Intelligence Scale for children (WISC) was measured before the operation and at 3, 6, and 12 months after the operation to evaluate the neurodevelopmental state of the children. RESULTS The levels of the NF-κB, S-100β protein, NSE, TNF-α, IL-6 were significantly higher at T2, T3, or T4 than before the surgery (T1) in the control group or the dexmedetomidine groups. However, the increases of NF-κB, TNF-α, IL-6, S-100β and NSE levels were significantly smaller in the dexmedetomidine groups than those in the control group (P < 0.017). The WISC scores were similar among the three groups before or after the operation. INTERPRETATION The increases in NF-κB, TNF-α, and IL-6 levels indicated aggravation of the inflammatory reaction and the increase S-100β protein and NSE levels indicated that the nervous system was damaged. Administration of dexmedetomidine to children with congenital heart disease undergoing intraoperative CPB can inhibit the inflammatory response and may ameliorate the neurodevelopmental damage caused by CPB.
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Affiliation(s)
- Yongsheng Qiu
- Department of AnesthesiologyChildren’s Hospital Affiliated to Zhengzhou UniversityHenan Children’s HospitalZhengzhou Children’ s HospitalHenan Engineering Research Center of Childhood NeurodevelopmentZhengzhouChina
| | - Chan Li
- Department of Pharmaceutical ScienceUniversity of BuffaloBuffaloNew YorkUSA
| | - Xiaoqin Li
- Department of AnesthesiologyChildren’s Hospital Affiliated to Zhengzhou UniversityHenan Children’s HospitalZhengzhou Children’ s HospitalHenan Engineering Research Center of Childhood NeurodevelopmentZhengzhouChina
| | - Yingping Jia
- Department of AnesthesiologyChildren’s Hospital Affiliated to Zhengzhou UniversityHenan Children’s HospitalZhengzhou Children’ s HospitalHenan Engineering Research Center of Childhood NeurodevelopmentZhengzhouChina
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17
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Golfenshtein N, Hanlon AL, Deatrick JA, Medoff-Cooper B. The Associations Between Infant Development and Parenting Stress in Infants with Congenital Heart Disease at Six and Twelve Months of Age. J Pediatr Nurs 2020; 51:1-7. [PMID: 31812926 DOI: 10.1016/j.pedn.2019.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/24/2019] [Accepted: 11/24/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Developmental delays are among the major morbidities of children with complex congenital heart disease. Parents of infants with complex congenital heart disease experience increased parenting stress levels, which can interfere with parenting processes during infancy. The current study examined associations between infant development and parenting stress in infants with complex congenital heart disease at six and twelve months of age. DESIGN AND METHODS A secondary analysis of data examined cross-sectional associations between infant's mental and psychomotor development and parenting stress, using general linear regression modeling (N = 75). Data were obtained from a larger prospective cohort study. RESULTS Mental development was negatively associated with the Parent Domain at six months, and with the Parent Domain and Total Stress at twelve months. Psychomotor development was not significantly associated with parenting stress at six and twelve months. CONCLUSIONS Parenting stress in parents of infant with complex congenital heart disease may be among the factors shaping the parent-child relationship during the first year of life, which plays an important role in infant development. A potential bidirectional relationship between parenting stress and infant development may fit a transactional model representing the phenomena. PRACTICE IMPLICATIONS Family interventions aiming to reshape illness perceptions may promote parental adaptive coping and productive parenting practices in populations at risk.
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Affiliation(s)
- Nadya Golfenshtein
- University of Pennsylvania, School of Nursing, Philadelphia, United States of America.
| | - Alexandra L Hanlon
- University of Pennsylvania, School of Nursing, Philadelphia, United States of America.
| | - Janet A Deatrick
- University of Pennsylvania, School of Nursing, Philadelphia, United States of America.
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18
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Wotherspoon JM, Eagleson KJ, Gilmore L, Auld B, Hirst A, Johnson S, Stocker C, Heussler H, Justo RN. Neurodevelopmental and health-related quality-of-life outcomes in adolescence after surgery for congenital heart disease in infancy. Dev Med Child Neurol 2020; 62:214-220. [PMID: 31025336 DOI: 10.1111/dmcn.14251] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2019] [Indexed: 12/17/2022]
Abstract
AIM To assess outcomes in adolescence after surgery for congenital heart disease (CHD) in infancy. Domains analysed included cognition and executive function, social and emotional well-being, adaptive behaviour, academic achievement, and health-related quality of life (HRQoL). METHOD Twenty-one participants (10 males, 11 females) ranged in age from 14 to 17 years (mean 15y 4.8mo, SD 8.4mo). Twenty had biventricular repairs. All were classified as New York Heart Association class I. Measures included: Wechsler Intelligence and Achievement scales; Wide Range Assessment of Memory and Learning, Second Edition; California Verbal Learning Test - Children's Version; Behaviour Rating Inventory of Executive Function; Conners, Third Edition; Adaptive Behavior Assessment System, Second Edition; Behavior Assessment System for Children, Second Edition; Rey-Osterrieth Complex Figure; and Pediatric Quality of Life Inventory. RESULTS Outcomes were significantly lower (p≤0.01) than population norms for processing speed, mathematical achievement, attention, and visual-spatial ability. Participants reported more frequent learning problems but more positive family relations. HRQoL was significantly lower across most domains by self- and parent-proxy report. INTERPRETATION Individuals with CHD may experience difficulties across a range of domains. These findings emphasize the importance of comprehensive screening, early intervention, and long-term follow-up, as deficits may extend into young adulthood. WHAT THIS PAPER ADDS Identified cognitive, learning, and attentional impairments in adolescents after congenital heart disease surgery in infancy. Combined self-report, caregiver report, and laboratory tasks in a comprehensive neurodevelopmental assessment protocol. Health-related quality of life was lower across most domains.
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Affiliation(s)
- Jane M Wotherspoon
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Karen J Eagleson
- Queensland Paediatric Cardiac Service, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Linda Gilmore
- Faculty of Education, School of Cultural and Professional Learning, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Benjamin Auld
- Queensland Paediatric Cardiac Service, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Anne Hirst
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Susan Johnson
- Queensland Paediatric Cardiac Service, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Christian Stocker
- Queensland Paediatric Cardiac Service, Children's Health Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Helen Heussler
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Child Development Program, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Robert N Justo
- Queensland Paediatric Cardiac Service, Children's Health Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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19
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Barron LC, Haas N, Hagl C, Schulze-Neick I, Ulrich S, Lehner A, Heinen F, Weinberger R, Rosenthal L, Gerstl L, Dalla-Pozza R. Motor outcome, executive functioning, and health-related quality of life of children, adolescents, and young adults after ventricular assist device and heart transplantation. Pediatr Transplant 2020; 24:e13631. [PMID: 31885156 DOI: 10.1111/petr.13631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/10/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the current study is to measure long-term executive function, motor outcome, and QoL in children, adolescents, and young adults after VAD and Htx. METHODS Patients were examined during routine follow-up. Investigation tools were used as follows: Examination for MND of motor outcomes, Epitrack® for attention and executive functioning, and Kidscreen-52 and EQ-5D-5L questionnaires for QoL. Additional data were retrospectively obtained by an analysis of patient medical records. RESULTS Out of 145 heart transplant recipients at the department of pediatric cardiology of the University Hospital Munich, 39 were implanted with a VAD between 1992 and 2016. Seventeen (43.6%) patients died before or after Htx; 22 (56.4%) patients were included in our study. Mean age at transplant was 9.52 years (range: 0.58-24.39 years, median 9), and the mean follow-up time after Htx was 6.18 years (range: 0.05-14.60 years, median 5.82). MND examination could be performed in 13 patients (normal MND: n = 11, simple MND: n = 1, complex MND: n = 1). Executive functioning was tested in 15 patients. Two (13.3%) patients had good results, six (40%) average results, three (20%) borderline results, and four (26.7%) impaired results. QoL (Kidscreen n = 7, EQ-5D-5L n = 8) was similar to a healthy German population. CONCLUSION Motor outcome, executive functioning and QoL in survivors of VAD bridging therapy and Htx can be good, though underlying diseases and therapies are associated with a high risk of cerebral ischemic or hemorrhagic complications.
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Affiliation(s)
- Lucie-Charlotte Barron
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Nikolaus Haas
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department for Cardiac Surgery, LMU Munich, Munich, Germany
| | - Ingram Schulze-Neick
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Sarah Ulrich
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Anja Lehner
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Florian Heinen
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children`s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Raphael Weinberger
- Division of Epidemiology, Institute of Social Paediatrics and Adolescent Medicine, LMU Munich, Munich, Germany
| | - Lale Rosenthal
- Department for Cardiac Surgery, LMU Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children`s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Robert Dalla-Pozza
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
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Schlapbach LJ, Horton SB, Long DA, Beca J, Erickson S, Festa M, d’Udekem Y, Alphonso N, Winlaw D, Johnson K, Delzoppo C, van Loon K, Gannon B, Fooken J, Blumenthal A, Young P, Jones M, Butt W, Schibler A. Study protocol: NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC trial): a randomised controlled trial. BMJ Open 2019; 9:e026664. [PMID: 31420383 PMCID: PMC6701583 DOI: 10.1136/bmjopen-2018-026664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) is a major cause of infant mortality. Many infants with CHD require corrective surgery with most operations requiring cardiopulmonary bypass (CPB). CPB triggers a systemic inflammatory response which is associated with low cardiac output syndrome (LCOS), postoperative morbidity and mortality. Delivery of nitric oxide (NO) into CPB circuits can provide myocardial protection and reduce bypass-induced inflammation, leading to less LCOS and improved recovery. We hypothesised that using NO during CPB increases ventilator-free days (VFD) (the number of days patients spend alive and free from invasive mechanical ventilation up until day 28) compared with standard care. Here, we describe the NITRIC trial protocol. METHODS AND ANALYSIS The NITRIC trial is a randomised, double-blind, controlled, parallel-group, two-sided superiority trial to be conducted in six paediatric cardiac surgical centres. One thousand three-hundred and twenty infants <2 years of age undergoing cardiac surgery with CPB will be randomly assigned to NO at 20 ppm administered into the CPB oxygenator for the duration of CPB or standard care (no NO) in a 1:1 ratio with stratification by age (<6 and ≥6 weeks), single ventricle physiology (Y/N) and study centre. The primary outcome will be VFD to day 28. Secondary outcomes include a composite of LCOS, need for extracorporeal membrane oxygenation or death within 28 days of surgery; length of stay in intensive care and in hospital; and, healthcare costs. Analyses will be conducted on an intention-to-treat basis. Preplanned secondary analyses will investigate the impact of NO on host inflammatory profiles postsurgery. ETHICS AND DISSEMINATION The study has ethical approval (HREC/17/QRCH/43, dated 26 April 2017), is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12617000821392) and commenced recruitment in July 2017. The primary manuscript will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ACTRN12617000821392.
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Affiliation(s)
- Luregn J Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Stephen Brian Horton
- Cardiac Surgical Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Debbie Amanda Long
- Paediatric Critical Care Research Group, Child Health Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand
| | - Simon Erickson
- Paediatric Critical Care, Perth Children’s Hospital, Western Australia and The University of Western Australia, Crawley, Western Australia, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network, Sydney, New South Wales, Australia
| | - Yves d’Udekem
- Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Heart Research, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- School of Medicine, Children’s Health Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Nelson Alphonso
- Cardiac Surgery, Queensland Children’s Hospital, Brisbane, Queensland, Australia
| | - David Winlaw
- Heart Centre for Children, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kerry Johnson
- Paediatric Critical Care Research Group, Child Health Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Carmel Delzoppo
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kim van Loon
- Division of Anaesthetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B Gannon
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Jonas Fooken
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Antje Blumenthal
- The Infection and Inflammation Group, The University of Queensland Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia
| | - Paul Young
- The Intensive Care Research Programme, Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Jones
- School of Public Health, Bond University, Gold Coast, Brisbane, Australia
| | - Warwick Butt
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Child Health Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
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Impact of congenital heart surgery on quality of life in children and adolescents with surgically corrected Ventricular Septal Defect, Tetralogy of Fallot, and Transposition of the Great Arteries. Cardiol Young 2019; 29:1082-1087. [PMID: 31284891 DOI: 10.1017/s1047951119001604] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe the impact of CHD surgery in early childhood on quality of life in children aged 10-16 years with surgically corrected Ventricular Septal Defect, Transposition of the Great Arteries, and Tetralogy of Fallot. METHOD A cross-sectional survey study of quality of life survey on 161 children and adolescents aged 10-16 years with surgically corrected Ventricular Septal Defect, Transposition of the Great Arteries, and Tetralogy of Fallot. The international Paediatric Quality of Life 4.0 quality of life questionnaires were applied and collected for assessment from patients and parents. The endpoints were total, physical, emotional, social, and school quality of life scores. RESULTS The quality of life total and school scores was significantly lower in children with CHD than their healthy peers. There was no significant difference in quality of life between the three CHD groups. All three CHD groups had a significantly lower total (7.7-13.2%, p<0.001) and school scores (21.1-31.6%, p<0.001) than the control group. The tetralogy of Fallot group was the only group that had significantly lower scores in the physical subscale (p<0.001) than the controls. CONCLUSION Children and adolescents with surgically corrected CHD show losses in quality of life in total and school scores compared to healthy controls. The tetralogy of Fallot group was the only CHD group that had significantly lower physical score than the controls.
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22
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Abouelella RS, Habib EA, AlHalees ZY, Alanazi MN, Ibhais ME, Alwadai AH. Outcome of cardiac surgery in adults with congenital heart disease: A single center experience. J Saudi Heart Assoc 2019; 31:145-150. [PMID: 31198399 PMCID: PMC6556753 DOI: 10.1016/j.jsha.2019.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 04/18/2019] [Accepted: 05/09/2019] [Indexed: 11/20/2022] Open
Abstract
Objectives Adult survivors with congenital heart diseases represent a large and growing population, yet the published data does not represent the magnitude of their needs specifically in the Middle East. We aimed to review our experience at King Faisal Heart Center, Riyadh, Saudi Arabia for the outcome of adult patients with congenital heart disease who underwent either primary or redo surgery. Methods A retrospective study at a tertiary care hospital. All patients who underwent surgery either as the first surgery or as a reoperation for congenital heart disease aged >16 years old at the time of cardiac surgery in the period between January 1, 2008 and January 1, 2013. We looked for incidence of postoperative bleeding, arrhythmias, acute kidney injury, neurological complications, duration of mechanical ventilation, hospital and intensive care unit (ICU) stay. Additionally, we assessed the mortality and 1- and 5-year survival. Results Ninety-eight patients were included in our study. Fifty-two (53%) were females and 46 (47%) were males, with a mean age of 26 ± 8.4 years and a mean weight of 62 ± 22.8 kg. Forty-nine patients (50%) required redo surgery. Ten patients (10%) suffered from postoperative bleeding. Eight patients (8%) had postoperative arrhythmias, of which two patients required permanent pacemaker insertion. Three patients (3%) had postoperative acute kidney injury and seven patients (7%) suffered from neurological complications. The mean duration of ventilation was 1.3 ± 2 days, with a mean ICU and hospital stay of 3.7 ± 3 days, and 10 ± 7 days, respectively. The overall mortality rate in our series was 4% with a 1–5-year survival of 96%. Conclusion Adult patients with congenital heart disease are prone to immediate postoperative multisystem complications, yet the majority of them are reversible. Their 1- and 5-year survival rate is excellent. Further follow up studies are required.
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Affiliation(s)
- Raja Said Abouelella
- Cardiac Surgical Intensive Care, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | | | - Zohair Yousef AlHalees
- Cardiac Surgery Department, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | - Musleh Naza Alanazi
- Cardiac Surgical Intensive Care, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | - Mohamed Essa Ibhais
- Cardiac Surgical Intensive Care, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | - Abdullah Hassan Alwadai
- Cardiac Surgical Intensive Care, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi ArabiaSaudi Arabia
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Early Neurodevelopmental Outcomes in Children Supported with ECMO for Cardiac Indications. Pediatr Cardiol 2019; 40:1072-1083. [PMID: 31079193 PMCID: PMC6876703 DOI: 10.1007/s00246-019-02115-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 04/27/2019] [Indexed: 02/07/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is lifesaving for many critically ill children with congenital heart disease (CHD). However, limited information is available about their ensuing neurodevelopmental (ND) outcomes. We describe early ND outcomes in a cohort of children supported with ECMO for cardiac indications. Twenty-eight patients supported with ECMO at age < 36 months underwent later ND testing at 12-42 months of age using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). ND scores were compared with normative means and with ND outcomes of a matched cohort of 79 children with CHD undergoing cardiac surgery but not requiring ECMO support. Risk factors for worse ND outcomes were identified using multivariable linear regression models. Cardiac ECMO patients had ND scores at least one standard deviation below the normative mean in the gross motor (61%), language (43%), and cognitive (29%) domains of the Bayley-III. Cardiac ECMO patients had lower scores on the motor, language, and cognitive domains as compared to the matched non-ECMO group and clinically important (1/2 SD) differences in the motor domain persisted after controlling for primary caregiver education and number of cardiac catheterizations. Risk factors of worse ND outcomes among cardiac ECMO patients in more than one developmental domain included older age at first cannulation and more cardiac catheterization and cardiac surgical procedures prior to ND assessment. Overall, children supported on ECMO for cardiac indications have significant developmental delays and warrant close ND follow-up.
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Pasupathy D, Denbow ML, Rutherford MA. The Combined Use of Ultrasound and Fetal Magnetic Resonance Imaging for a Comprehensive Fetal Neurological Assessment in Fetal Congenital Cardiac Defects: Scientific Impact Paper No. 60. BJOG 2019; 126:e142-e151. [PMID: 30916430 DOI: 10.1111/1471-0528.15620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Heart problems are common in newborn babies, affecting approximately 5-10 in 1000 babies. Some are more serious than others, but most babies born with heart problems do not have other health issues. Of those babies who have a serious heart problem, almost 1 in 4 will have heart surgery in their first year. In the UK, pregnant women are offered a scan at around 20 weeks to try and spot any heart problems. In most cases there is not a clear reason for the problem, but sometimes other issues, such as genetic conditions, are discovered. In recent years the care given to these babies after they are born has improved their chances of surviving. However, it is recognised that babies born with heart problems have a risk of delays in their learning and development. This may be due to their medical condition, or as a result of surgery and complications after birth. In babies with heart problems, there is a need for more research on ultrasound and magnetic resonance imaging (MRI) to understand how the brain develops and why these babies are more likely to have delays in learning and development. This paper discusses the way ultrasound and MRI are used in assessing the baby's brain. Ultrasound is often used to spot any problems, looking at how the baby's brain develops in pregnancy. Advances in ultrasound technologies have made this easier. MRI is well-established and safe in pregnancy, and if problems in the brain have been seen on ultrasound, MRI may be used to look at these problems in more detail. While it is not always clear what unusual MRI findings can mean for the baby in the long term, increased understanding may mean parents can be given more information about possible outcomes for the baby and may help to improve the counselling they are offered before their baby's birth.
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Bagge CN, Henderson VW, Laursen HB, Adelborg K, Olsen M, Madsen NL. Risk of Dementia in Adults With Congenital Heart Disease: Population-Based Cohort Study. Circulation 2018; 137:1912-1920. [PMID: 29440121 DOI: 10.1161/circulationaha.117.029686] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 12/12/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND More children with congenital heart disease (CHD) are surviving to adulthood, and CHD is associated with risk factors for dementia. We compared the risk of dementia in CHD adults to that of the general population. METHODS In this cohort study, we used medical registries and a medical record review covering all Danish hospitals to identify adults with CHD diagnosed between 1963 and 2012. These individuals with CHD were followed from January 1, 1981, 30 years of age, or date of first CHD registration (index date for matched members of the general population cohort) until hospital diagnosis of dementia, death, emigration, or end of study (December 31, 2012). For each individual with CHD, we identified 10 members of the general population utilizing the Danish Civil Registration System matched on sex and birth year. We computed cumulative incidences and hazard ratios (HRs) of dementia, adjusting for sex and birth year. RESULTS The cumulative incidence of dementia was 4% by 80 years of age in 10 632 adults with CHD (46% male). The overall HR comparing adults with CHD with the general population cohort was 1.6 (95% confidence interval [CI], 1.3-2.0). The HR among individuals with CHD without extracardiac defects was 1.4 (95% CI, 1.1-1.8). Adults with mild-to-moderate CHD had an HR of 1.5 (95% CI, 1.1-2.0), whereas the HR was 2.0 (95% CI, 1.2-3.3) for severe CHD, including univentricular hearts. The HR for early onset dementia (<65 years of age) was 2.6 (95% CI, 1.8-3.8), whereas the late-onset HR was 1.3 (95% CI, 1.0-1.8). CONCLUSIONS CHD was associated with an increased risk of dementia compared with the general population, in particular for early onset dementia. Further understanding of dementia risk in the population with CHD is a potential target for future investigation.
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Affiliation(s)
- Carina N Bagge
- Departments of Clinical Epidemiology (C.N.B., V.W.H., H.B.L., K.A., M.O., N.L.M.)
| | - Victor W Henderson
- Departments of Clinical Epidemiology (C.N.B., V.W.H., H.B.L., K.A., M.O., N.L.M.).,Aarhus University Hospital, Denmark. Departments of Health Research and Policy (Epidemiology) and Neurology and Neurological Sciences, Stanford University, CA (V.W.H.)
| | - Henning B Laursen
- Departments of Clinical Epidemiology (C.N.B., V.W.H., H.B.L., K.A., M.O., N.L.M.)
| | - Kasper Adelborg
- Departments of Clinical Epidemiology (C.N.B., V.W.H., H.B.L., K.A., M.O., N.L.M.).,Cardiology (K.A.)
| | - Morten Olsen
- Departments of Clinical Epidemiology (C.N.B., V.W.H., H.B.L., K.A., M.O., N.L.M.).,Cardiology (K.A.)
| | - Nicolas L Madsen
- Departments of Clinical Epidemiology (C.N.B., V.W.H., H.B.L., K.A., M.O., N.L.M.).,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH (N.L.M.)
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26
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McKechnie AC, Rogstad J, Martin KM, Pridham KF. An exploration of co-parenting in the context of caring for a child prenatally diagnosed and born with a complex health condition. J Adv Nurs 2018; 74:350-363. [PMID: 28792608 PMCID: PMC8650808 DOI: 10.1111/jan.13415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2017] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to describe co-parenting communication in couples in the context of caregiving for children prenatally diagnosed and born with complex health conditions. BACKGROUND Foetal diagnosis of complex health conditions such as heart, central nervous system, or abdominal anomalies are confirmed more often than ever before. Following diagnosis, parents face challenges beginning before birth. The quality of co-parenting, when two individuals relate to each other as parents and share parental responsibilities, can have an impact on child health and development. Yet, little is known about co-parenting during the transition to parenthood after foetal diagnosis. DESIGN This secondary analysis of interview data was informed by Bowlby's theoretical work on a parent's view of self as caregiver and the literature on co-parenting. METHODS Data were drawn from a larger, mixed methods, longitudinal study and included audio-recorded interviews conducted with 16 parents participating as eight couples after foetal diagnosis during the third trimester of pregnancy in 2011-2012 and again when children were 14-37 months old in 2014. Analysis of interviews transcribed verbatim focused on co-parenting communication. FINDINGS Co-parenting communication regarding support, agreement and information sharing and a new category of shared meaning were related to the diagnosis before birth. Later, couples evolved in their co-parenting communication while caring for their toddlers and working towards achieving a sense of normalcy. CONCLUSION Variation in co-parenting communication among couples preparing and caring for children with complex health conditions, including the development of a shared meaning of the child's diagnosis, needs further investigation to inform nursing assessment and guide tailored interventions.
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Affiliation(s)
| | - Jamie Rogstad
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
| | | | - Karen F. Pridham
- School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
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Abstract
Maintaining optimal circulatory status is a key component of preterm neonatal care. Low-cardiac output (CO) in the preterm neonate leads to inadequate perfusion of vital organs and has been linked to a variety of adverse outcomes with heightened acute morbidity and mortality and adverse neurodevelopmental outcomes. Having technology available to monitor CO allows us to detect low-output states and potentially intervene to mitigate the unwanted effects of reduced organ perfusion. There are many technologies available for the monitoring of CO in the preterm neonatal population and while many act as useful adjuncts to aid clinical decision-making no technique is perfect. In this review, we discuss the relative merits and limitations of various common methodologies available for monitoring CO in the preterm neonatal population. We will discuss the ongoing challenges in monitoring CO in the preterm neonate along with current gaps in our knowledge. We conclude by discussing emerging technologies and areas that warrant further study.
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Affiliation(s)
- Matthew McGovern
- Neonatology Department, Coombe Women and Infant University Hospital, Dublin, Ireland.,Department of Paediatrics, Trinity College Dublin, National Children's Hospital Tallaght, Dublin, Ireland
| | - Jan Miletin
- Neonatology Department, Coombe Women and Infant University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czechia.,3rd School of Medicine, Charles University, Prague, Czechia.,UCD School of Medicine and Medical Sciences, Dublin, Ireland
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Kalfa D, Kasmi L, Geronikola N, Calderon J, Lambert V, Belli E, Bonnet D, Montreuil M. Cognitive outcomes and health-related quality of life in adults two decades after the arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 2017; 154:1028-1035. [DOI: 10.1016/j.jtcvs.2017.03.119] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 02/13/2017] [Accepted: 03/16/2017] [Indexed: 01/19/2023]
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Validity of the Montreal Cognitive Assessment Screener in Adolescents and Young Adults With and Without Congenital Heart Disease. Nurs Res 2017; 66:222-230. [PMID: 28448372 DOI: 10.1097/nnr.0000000000000192] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cognitive deficits are common, long-term sequelae in children and adolescents with congenital heart disease (CHD) who have undergone surgical palliation. However, there is a lack of a validated brief cognitive screening tool appropriate for the outpatient setting for adolescents with CHD. One candidate instrument is the Montreal Cognitive Assessment (MoCA) questionnaire. OBJECTIVE The purpose of the research was to validate scores from the MoCA against the General Memory Index (GMI) of the Wide Range Assessment of Memory and Learning, 2nd Edition (WRAML2), a widely accepted measure of cognition/memory, in adolescents and young adults with CHD. METHODS We administered the MoCA and the WRAML2 to 156 adolescents and young adults ages 14-21 (80 youth with CHD and 76 healthy controls who were gender and age matched). Spearman's rank order correlations were used to assess concurrent validity. To assess construct validity, the Mann-Whitney U test was used to compare differences in scores in youth with CHD and the healthy control group. Receiver operating characteristic curves were created and area under the curve, sensitivity, specificity, positive predictive value, and negative predictive value were also calculated. RESULTS The MoCA median scores in the CHD versus healthy controls were (23, range 15-29 vs. 28, range 22-30; p < .001), respectively. With the screening cutoff scores at <26 points for the MoCA and 85 for GMI (<1 SD, M = 100, SD = 15), the CHD versus healthy control groups showed sensitivity of .96 and specificity of .67 versus sensitivity of .75 and specificity of .90, respectively, in the detection of cognitive deficits. A cutoff score of 26 on the MoCA was optimal in the CHD group; a cutoff of 25 had similar properties except for a lower negative predictive value. The area under the receiver operating characteristic curve (95% CI) for the MoCA was 0.84 (95% CI [0.75, 0.93], p < .001) and 0.84 (95% CI [0.62, 1.00], p = .02) for the CHD and controls, respectively. DISCUSSION Scores on the MoCA were valid for screening to detect cognitive deficits in adolescents and young adults aged 14-21 with CHD when a cutoff score of 26 is used to differentiate youth with and without significant cognitive impairment. Future studies are needed in other adolescent disease groups with known cognitive deficits and healthy populations to explore the generalizability of validity of MoCA scores in adolescents and young adults.
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30
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Abstract
As survival after cardiac surgery continues to improve, an increasing number of patients with hypoplastic left heart syndrome are reaching school age and beyond, with growing recognition of the wide range of neurodevelopmental challenges many survivors face. Improvements in fetal detection rates, coupled with advances in fetal ultrasound and MRI imaging, are contributing to a growing body of evidence that abnormal brain architecture is in fact present before birth in hypoplastic left heart syndrome patients, rather than being solely attributable to postnatal factors. We present an overview of the contemporary data on neurodevelopmental outcomes in hypoplastic left heart syndrome, focussing on imaging techniques that are providing greater insight into the nature of disruptions to the fetal circulation, alterations in cerebral blood flow and substrate delivery, disordered brain development, and an increased potential for neurological injury. These susceptibilities are present before any intervention, and are almost certainly substantial contributors to adverse neurodevelopmental outcomes in later childhood. The task now is to determine which subgroups of patients with hypoplastic left heart syndrome are at particular risk of poor neurodevelopmental outcomes and how that risk might be modified. This will allow for more comprehensive counselling for carers, better-informed decision making before birth, and earlier, more tailored provision of neuroprotective strategies and developmental support in the postnatal period.
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Affiliation(s)
- David F A Lloyd
- 1Paediatric Cardiology Department,Evelina Children's Hospital,London,United Kingdom
| | - Mary A Rutherford
- 2Division of Imaging Sciences and Biomedical Engineering,King's College London,London,United Kingdom
| | - John M Simpson
- 1Paediatric Cardiology Department,Evelina Children's Hospital,London,United Kingdom
| | - Reza Razavi
- 1Paediatric Cardiology Department,Evelina Children's Hospital,London,United Kingdom
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31
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Ringle ML, Wernovsky G. Functional, quality of life, and neurodevelopmental outcomes after congenital cardiac surgery. Semin Perinatol 2016; 40:556-570. [PMID: 27989374 DOI: 10.1053/j.semperi.2016.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Throughout the past few decades, advances in cardiology, neonatal intensive care, and surgical techniques have resulted in a growing cohort of thriving school-aged children with previously lethal complex congenital heart diseases. While survival has increased, there remains significant morbidity following repair including neurodevelopmental sequelae. Compared to children with a structurally normal heart, these infants and children have a higher frequency of abnormalities in tone, feeding, and delayed developmental milestones, as well as challenges with speech and learning disabilities, while a higher proportion of adolescents suffer from problems with processing speed, executive function, and a unique set of medical hardships related to exercise intolerance and obesity, medication burden, and mental health comorbidities. Innovative perioperative techniques and early psychosocial intervention in these young survivors has shown that despite the obstacles, the majority of these children can grow to have fulfilling lives with intelligence and social skills in the normal range. Additionally, a comprehensive medical home aids in optimizing the quality of life for these children and their families.
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Affiliation(s)
- Megan L Ringle
- Pediatric Residency, Nicklaus Children׳s Hospital, Miami Children׳s Health System, Miami, FL.
| | - Gil Wernovsky
- The Heart Program, Nicklaus Children׳s Hospital, Miami Children׳s Health System, 3100 SW 62nd Ave, Miami, FL 33155
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32
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Peixoto AB, Tonni G, Araujo Júnior E. Changes in biometry and cerebroplacental hemodynamics in fetuses with congenital heart diseases. J Thorac Dis 2016; 8:E1282-E1286. [PMID: 27867608 PMCID: PMC5107481 DOI: 10.21037/jtd.2016.10.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 09/12/2016] [Indexed: 08/30/2023]
Affiliation(s)
- Alberto Borges Peixoto
- Mario Palmério University Hospital – University of Uberaba (UNIUBE), Uberaba-MG, Brazil
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo-SP, Brazil
| | - Gabriele Tonni
- Department of Obstetrics and Gynecology, Prenatal Diagnostic Center, Guastalla Civil Hospital, Reggio Emilia, Italy
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo-SP, Brazil
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Sadhwani A, Asaro LA, Goldberg C, Ware J, Butcher J, Gaies M, Smith C, Alexander JL, Wypij D, Agus MSD. Impact of Tight Glycemic Control on Neurodevelopmental Outcomes at 1 Year of Age for Children with Congenital Heart Disease: A Randomized Controlled Trial. J Pediatr 2016; 174:193-198.e2. [PMID: 27112038 PMCID: PMC4925287 DOI: 10.1016/j.jpeds.2016.03.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/03/2016] [Accepted: 03/21/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess the association of postoperative tight glycemic control and hypoglycemia in children undergoing cardiac surgery with neurodevelopmental outcomes at 1 year of age. STUDY DESIGN A 2-center, prospective, randomized trial of postoperative tight glycemic control vs standard care was conducted in 980 children undergoing cardiac surgery. Neurodevelopmental outcomes were assessed at nine to 18 months using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), the Adaptive Behavior Assessment System, Second Edition, the Ages and Stages Questionnaire, Third Edition, and the Brief Infant Toddler Social-Emotional Assessment. RESULTS Neurodevelopmental follow-up was performed on 237 patients with a mean age of 13 months. No significant treatment group differences were found in the Bayley-III and Adaptive Behavior Assessment System, Second Edition composite scores or percentage at risk based on the Ages and Stages Questionnaire, Third Edition and the Brief Infant Toddler Social-Emotional Assessment. Patients who experienced moderate to severe hypoglycemia (n = 8) had lower Bayley-III composite scores compared with patients with no to mild hypoglycemia, even after controlling for factors known to be associated with poorer neurodevelopmental outcomes. CONCLUSION For infants undergoing cardiac surgery, tight glycemic control did not impact neurodevelopmental outcomes compared with standard care. These data suggest a possible association between moderate to severe hypoglycemia and poorer neurodevelopmental outcomes at 1 year of age. TRIAL REGISTRATION ClinicalTrials.gov: NCT00443599.
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Affiliation(s)
- Anjali Sadhwani
- Cardiac Neurodevelopmental Program, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Lisa A. Asaro
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Caren Goldberg
- Division of Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI,Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Janice Ware
- Cardiac Neurodevelopmental Program, Boston Children's Hospital and Harvard Medical School, Boston, MA,Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jennifer Butcher
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI,Division of Pediatric Psychology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Michael Gaies
- Division of Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI,Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Cynthia Smith
- Division of Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI,Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Jamin L. Alexander
- Division of Medicine Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Michael S. D. Agus
- Division of Medicine Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Deladoëy J, Harrington K. Has Triiodothyronine Treatment of Children after Cardiopulmonary Bypass Surgery Any Long-Term Effects? Horm Res Paediatr 2016; 84:137-8. [PMID: 25999377 DOI: 10.1159/000380782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Johnny Deladoëy
- Endocrinology Service, Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Que., Canada
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Garcia RU, Aggarwal S, Natarajan G. Parental perception of functional status and impact on the family of children with congenital heart surgery. Early Hum Dev 2016; 96:45-51. [PMID: 27037482 DOI: 10.1016/j.earlhumdev.2016.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 01/20/2023]
Abstract
AIMS To assess the functional status and the family impact of children with congenital heart defects (CHD), using the parental Functional Status II (FS-II) and the Impact on Family (IOF) questionnaires. METHODS In this prospective observational study, parents of children who underwent surgery for CHD during the first year of life completed the FS-II and the IOF questionnaires. Genetic syndromes and prematurity <32weeks were exclusion criteria. The FS-II generates a total score and age specific general health (GH), activity (A) and, responsiveness (R) subscales. The IOF generates a total scale and financial and sibling subscales. RESULTS Our cohort (n=100), comprised 54% males; the median (IQR) age was 32 (10-56) months. Eighteen children had age-specific scores in the 1-2 SD below mean range (n=17) or more than 2 SD below the mean (n=1) for "ill children". There were significant negative correlations between the total FS-II and total IOF (r=-0.35, p<0.001) and financial IOF (r=-0.35, p<0.001). RACHS-1 category of CHD 4-6 was associated with higher likelihood of lower functional status. CONCLUSIONS More complex CHD was associated with lower functional status, which correlated with a greater impact on the families. Parental questionnaires may be useful instruments for developmental surveillance in this population.
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Affiliation(s)
- Richard U Garcia
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan, USA.
| | - Sanjeev Aggarwal
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Girija Natarajan
- Division of Neonatology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
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36
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Ricci MF, Alton GY, Ross DB, Dicken BJ, Moddemann DM, Robertson CMT, Garcia Guerra G, Atallah J, Dinu IA, Blakley P, Bodani J, Synnes A. Gastrostomy Tube Feeding after Neonatal Complex Cardiac Surgery Identifies the Need for Early Developmental Intervention. J Pediatr 2016; 169:160-5.e1. [PMID: 26651431 DOI: 10.1016/j.jpeds.2015.10.087] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/10/2015] [Accepted: 10/28/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the proportion of developmental delay in early complex cardiac surgery (CCS) survivors with and without gastrostomy tube feeding (GTF). To explore acute care predictors of GTF that might help improve care in CCS survivors. STUDY GROUP This comparison study of 2 groups within an inception cohort included 334 CCS survivors after cardiopulmonary bypass at ≤6 weeks of age (2005-2012) who did not require extracorporeal membrane oxygenation or heart transplantation. Children were assessed at 21 ± 3 months with the Bayley Scales of Infant and Toddler Development-Third Edition and the Adaptive Behavior Assessment System-Second Edition: general adaptive composite score. Delay was determined by scores >2 SD below mean. The χ(2) test compared groups. Predictors of GTF were analyzed using multiple logistic regression analysis, results expressed as OR with 95% CI. RESULTS Of the survivors, 67/334 (20%) had GTF any time before the 21-month assessment. Developmental delays in children with GTF were cognitive in 16 (24%), motor in 18 (27%), language in 24 (36%) vs without GTF in 7 (3%), 8 (3%), and 32 (12%), respectively (P < .001). Gastrostomy group had almost 8 times the number of children delayed on the general adaptive composite score. Independent OR for GTF are presence of a chromosomal abnormality, OR 4.6 (95% CI 1.8, 12.0) (P = .002), single ventricle anatomy, OR 3.4 (95% CI 1.7, 6.8) (P < .001), total postoperative days of open sternum, OR 1.15 (95% CI 1.1, 1.3) (P = .031), and total number of hospital days at CCS, OR 1.03 (95% CI 1.1, 1.04) (P = .002). CONCLUSIONS GTF identifies CCS survivors at risk for delay, who would benefit from early developmental intervention. The described mostly nonmodifiable predictors may guide counseling of these children's families.
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Affiliation(s)
- M Florencia Ricci
- Division of Developmental Pediatrics, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gwen Y Alton
- Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - David B Ross
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Bryan J Dicken
- Division of General Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Diane M Moddemann
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Charlene M T Robertson
- Division of Developmental Pediatrics, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada.
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37
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Impaired Global and Regional Cerebral Perfusion in Newborns with Complex Congenital Heart Disease. J Pediatr 2015; 167:1018-24. [PMID: 26384435 DOI: 10.1016/j.jpeds.2015.08.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 06/22/2015] [Accepted: 08/03/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare global and regional cerebral perfusion in newborns with congenital heart disease (CHD) and healthy controls using arterial spin labeling (ASL) magnetic resonance imaging (MRI) prior to open heart surgery. STUDY DESIGN We performed brain MRIs in 101 newborns (58 controls, 43 CHD) using 3-dimensional fast spin echo pseudo-continuous ASL. Cerebral blood flow (CBF) ASL images were linearly coregistered to T2-weighted images for anatomic delineation and selection of regions-of-interest. Anatomic regions included frontal white matter (FWM), occipital white matter (OWM), thalami, and basal ganglia (BG). RESULTS Newborns with single ventricle CHD demonstrated significantly lower global (P = .044) and regional BG (P = .025) CBF compared with controls. Mean regional CBF in the thalami in cyanotic newborns with CHD was lower compared with controls (P = .004). Mean regional CBF in thalami (P = .02), BG (P = .01), and OWM (P = .03) among newborns with cyanotic CHD was lower than those with acyanotic CHD. Newborns with CHD ventilated prior to MRI had increased global (P = .016) and OWM (P = .013) CBF compared with those not ventilated. CONCLUSIONS Newborns with uncorrected cyanotic or single ventricle CHD show disturbances in cerebral perfusion compared to healthy controls using ASL. Cardiac physiology and preoperative hemodynamic compromise play an important role in preoperative alterations in global and regional cerebral perfusion. Our data suggest that ASL may be useful for studying cerebral perfusion in newborns at high risk for cerebral ischemia, such as those with complex CHD.
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McKechnie AC, Pridham K, Tluczek A. Preparing Heart and Mind for Becoming a Parent Following a Diagnosis of Fetal Anomaly. QUALITATIVE HEALTH RESEARCH 2015; 25:1182-98. [PMID: 25294345 PMCID: PMC8627587 DOI: 10.1177/1049732314553852] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Using a cross-sectional, grounded dimensional analysis study design, we collected demographic and health information and conducted telephone interviews with 37 expectant parents of 26 fetuses within 25 families. We describe a theoretical model with a core process of preparing heart and mind for becoming a parent following a diagnosis of fetal anomaly. The process of preparing was influenced by fetal and future child health, experiences of previous loss, and social interactions within both new and familiar settings. Expectant parents reported varying turning points and strategies associated with three distinct trajectories of relating to the fetus or "baby" yet to be born. These relational trajectories include claiming the child as one's own, delaying the connection to the fetus, and doing the routine of pregnancy. With the findings presented in this article, we extend the understanding of how parenting develops during pregnancy in the context of a fetal anomaly.
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Affiliation(s)
| | - Karen Pridham
- University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Audrey Tluczek
- University of Wisconsin-Madison, Madison, Wisconsin, USA
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Ortega SB, Kong X, Venkataraman R, Savedra AM, Kernie SG, Stowe AM, Raman L. Perinatal chronic hypoxia induces cortical inflammation, hypomyelination, and peripheral myelin-specific T cell autoreactivity. J Leukoc Biol 2015; 99:21-9. [PMID: 26038434 DOI: 10.1189/jlb.5hi0914-447r] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 04/28/2015] [Indexed: 11/24/2022] Open
Abstract
pCH is an important risk factor for brain injury and long-term morbidity in children, occurring during the developmental stages of neurogenesis, neuronal migration, and myelination. We show that a rodent model of pCH results in an early decrease in mature myelin. Although pCH does increase progenitor oligodendrocytes in the developing brain, BrdU labeling revealed a loss in dividing progenitor oligodendrocytes, indicating a defect in mature cell replacement and myelinogenesis. Mice continued to exhibited hypomyelination, concomitant with long-term impairment of motor function, weeks after cessation of pCH. The implication of a novel neuroimmunologic interplay, pCH also induced a significant egress of infiltrating CD4 T cells into the developing brain. This pCH-mediated neuroinflammation included oligodendrocyte-directed autoimmunity, with an increase in peripheral myelin-specific CD4 T cells. Thus, both the loss of available, mature, myelin-producing glial cells and an active increase in autoreactive, myelin-specific CD4 T cell infiltration into pCH brains may contribute to early pCH-induced hypomyelination in the developing CNS. The elucidation of potential mechanisms of hypoxia-driven autoimmunity will expand our understanding of the neuroimmune axis during perinatal CNS disease states that may contribute to long-term functional disability.
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Affiliation(s)
- Sterling B Ortega
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Xiagmei Kong
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Ramgopal Venkataraman
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Allen Michael Savedra
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Steven G Kernie
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Ann M Stowe
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Lakshmi Raman
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
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Abnormal development of thalamic microstructure in premature neonates with congenital heart disease. Pediatr Cardiol 2015; 36:960-9. [PMID: 25608695 PMCID: PMC4433609 DOI: 10.1007/s00246-015-1106-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 01/11/2015] [Indexed: 10/24/2022]
Abstract
Preterm birth is associated with alteration in corticothalamic development, which underlies poor neurodevelopmental outcomes. Our hypothesis was that preterm neonates with CHD would demonstrate abnormal thalamic microstructure when compared to critically ill neonates without CHD. A secondary aim was to identify any association between thalamic microstructural abnormalities and perioperative clinical variables. We compared thalamic DTI measurements in 21 preterm neonates with CHD to two cohorts of neonates without CHD: 28 term and 27 preterm neonates, identified from the same neonatal intensive care unit. Comparison was made with three other selected white matter regions using ROI manual-based measurements. Correlation was made with post-conceptional age and perioperative clinical variables. In preterm neonates with CHD, there were age-related differences in thalamic diffusivity (axial and radial) compared to the preterm and term non-CHD group, in contrast to no differences in anisotropy. Contrary to our hypothesis, abnormal thalamic and optic radiation microstructure was most strongly associated with an elevated first arterial blood gas pO2 and elevated preoperative arterial blood gas pH (p < 0.05). Age-related thalamic microstructural abnormalities were observed in preterm neonates with CHD. Perinatal hyperoxemia and increased perioperative serum pH were associated with abnormal thalamic microstructure in preterm neonates with CHD. This study emphasizes the vulnerability of thalamocortical development in the preterm neonate with CHD.
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Naguib AN, Winch PD, Tobias JD, Yeates KO, Miao Y, Galantowicz M, Hoffman TM. Neurodevelopmental outcome after cardiac surgery utilizing cardiopulmonary bypass in children. Saudi J Anaesth 2015; 9:12-8. [PMID: 25558192 PMCID: PMC4279342 DOI: 10.4103/1658-354x.146255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Modulating the stress response and perioperative factors can have a paramount impact on the neurodevelopmental outcome of infants who undergo cardiac surgery utilizing cardiopulmonary bypass. Materials and Methods: In this single center prospective follow-up study, we evaluated the impact of three different anesthetic techniques on the neurodevelopmental outcomes of 19 children who previously underwent congenital cardiac surgery within their 1st year of life. Cases were done from May 2011 to December 2013. Children were assessed using the Stanford-Binet Intelligence Scales (5th edition). Multiple regression analysis was used to test different parental and perioperative factors that could significantly predict the different neurodevelopmental outcomes in the entire cohort of patients. Results: When comparing the three groups regarding the major cognitive scores, a high-dose fentanyl (HDF) patients scored significantly higher than the low-dose fentanyl (LDF) + dexmedetomidine (DEX) (LDF + DEX) group in the quantitative reasoning scores (106 ± 22 vs. 82 ± 15 P = 0.046). The bispectral index (BIS) value at the end of surgery for the -LDF group was significantly higher than that in LDF + DEX group (P = 0.011). For the entire cohort, a strong correlation was seen between the standard verbal intelligence quotient (IQ) score and the baseline adrenocorticotropic hormone level, the interleukin-6 level at the end of surgery and the BIS value at the end of the procedure with an R2 value of 0.67 and P < 0.04. There was an inverse correlation between the cardiac Intensive Care Unit length of stay and the full-scale IQ score (R = 0.4675 and P 0.027). Conclusions: Patients in the HDF group demonstrated overall higher neurodevelopmental scores, although it did not reach statistical significance except in fluid reasoning scores. Our results may point to a possible correlation between blunting the stress response and improvement of the neurodevelopmental outcome.
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Affiliation(s)
- Aymen N Naguib
- Department of Anesthesiology, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA ; The Heart Center, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Peter D Winch
- Department of Anesthesiology, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA ; The Heart Center, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA ; The Heart Center, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Keith O Yeates
- Department of Pediatrics, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Yongjie Miao
- The Heart Center, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Mark Galantowicz
- The Heart Center, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Timothy M Hoffman
- The Heart Center, Section of Critical Care Medicine, College of Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
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Cardiac index monitoring by femoral arterial thermodilution after cardiac surgery in children. J Crit Care 2014; 29:1132.e1-4. [DOI: 10.1016/j.jcrc.2014.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/05/2014] [Accepted: 06/03/2014] [Indexed: 02/07/2023]
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Gaynor JW, Kim DS, Arrington CB, Atz AM, Bellinger DC, Burt AA, Ghanayem NS, Jacobs JP, Lee TM, Lewis AB, Mahle WT, Marino BS, Miller SG, Newburger JW, Pizarro C, Ravishankar C, Santani AB, Wilder NS, Jarvik GP, Mital S, Russell MW. Validation of association of the apolipoprotein E ε2 allele with neurodevelopmental dysfunction after cardiac surgery in neonates and infants. J Thorac Cardiovasc Surg 2014; 148:2560-6. [PMID: 25282659 DOI: 10.1016/j.jtcvs.2014.07.052] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 06/27/2014] [Accepted: 07/12/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Apolipoprotein E (APOE) genotype is a determinant of neurologic recovery after brain ischemia and traumatic brain injury. The APOE ε2 allele has been associated with worse neurodevelopmental (ND) outcome after repair of congenital heart defects (CHD) in infancy. Replication of this finding in an independent cohort is essential to validate the observed genotype-phenotype association. METHODS The association of APOE genotype with ND outcomes was assessed in a combined cohort of patients with single-ventricle CHD enrolled in the Single Ventricle Reconstruction and Infant Single Ventricle trials. ND outcome was assessed at 14 months using the Psychomotor Development Index (PDI) and Mental Development Index (MDI) of the Bayley Scales of Infant Development-II. Stepwise multivariable regression was performed to develop predictive models for PDI and MDI scores. RESULTS Complete data were available for 298 of 435 patients. After adjustment for preoperative and postoperative covariates, the APOE ε2 allele was associated with a lower PDI score (P = .038). Patients with the ε2 allele had a PDI score approximately 6 points lower than those without the risk allele, explaining 1.04% of overall PDI variance, because the ε2 allele was present in only 11% of the patients. There was a marginal effect of the ε2 allele on MDI scores (P = .058). CONCLUSIONS These data validate the association of the APOE ε2 allele with adverse early ND outcomes after cardiac surgery in infants, independent of patient and operative factors. Genetic variants that decrease neuroresilience and impair neuronal repair after brain injury are important risk factors for ND dysfunction after surgery for CHD.
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Affiliation(s)
- J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Daniel Seung Kim
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington School of Medicine, Seattle, Wash
| | | | - Andrew M Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Boston, Mass, and Department of Neurology, Harvard Medical School, Boston, Mass
| | - Amber A Burt
- Division of Medical Genetics, Department of Medicine, University of Washington School of Medicine, Seattle, Wash
| | - Nancy S Ghanayem
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Jeffery P Jacobs
- Johns Hopkins Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, St Petersburg, Fla
| | - Teresa M Lee
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Alan B Lewis
- Children's Hospital Los Angeles, Los Angeles, Calif
| | | | - Bradley S Marino
- Ann and Robert F. Lurie Children's Hospital of Chicago, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen G Miller
- Division of Pediatric Oncology, Duke University Medical Center, Durham, NC
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Christian Pizarro
- Nemours Cardiac Center, Alfred I. Dupont Hospital for Children, Wilmington, Del
| | - Chitra Ravishankar
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Avni B Santani
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Nicole S Wilder
- Department of Anesthesia, University of Michigan Medical School, Ann Arbor, Mich
| | - Gail P Jarvik
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington School of Medicine, Seattle, Wash
| | - Seema Mital
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark W Russell
- Department of Pediatrics and Communicable Diseases (Division of Pediatric Cardiology), University of Michigan Medical School, Ann Arbor, Mich
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Fountain DM, Schaer M, Mutlu AK, Schneider M, Debbané M, Eliez S. Congenital heart disease is associated with reduced cortical and hippocampal volume in patients with 22q11.2 deletion syndrome. Cortex 2014; 57:128-42. [DOI: 10.1016/j.cortex.2014.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 01/08/2014] [Accepted: 04/02/2014] [Indexed: 11/24/2022]
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Jalali A, Buckley EM, Lynch JM, Schwab PJ, Licht DJ, Nataraj C. Prediction of periventricular leukomalacia occurrence in neonates after heart surgery. IEEE J Biomed Health Inform 2014; 18:1453-60. [PMID: 24122606 PMCID: PMC4122287 DOI: 10.1109/jbhi.2013.2285011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This paper is concerned with predicting the occurrence of periventricular leukomalacia (PVL) using vital and blood gas data which are collected over a period of 12 h after the neonatal cardiac surgery. A data mining approach has been employed to generate a set of rules for classification of subjects as healthy or PVL affected. In view of the fact that blood gas and vital data have different sampling rates, in this study we have divided the data into two categories: 1) high resolution (vital), and 2) low resolution (blood gas), and designed a separate classifier based on each data category. The developed algorithm is composed of several stages; first, a feature pool has been extracted from each data category and the extracted features have been ranked based on the data reliability and their mutual information content with the output. An optimal feature subset with the highest discriminative capability has been formed using simultaneous maximization of the class separability measure and mutual information of a set. Two separate decision trees (DTs) have been developed for the classification purpose and more importantly to discover hidden relationships that exist among the data to help us better understand PVL pathophysiology. The DT result shows that high amplitude 20 min variations and low sample entropy in the vital data and the defined out of range index as well as maximum rate of change in blood gas data are important factors for PVL prediction. Low sample entropy represents lack of variability in hemodynamic measurement, and constant blood pressure with small fluctuations is an important indicator of PVL occurrence. Finally, using the different time frames of data collection, we show that the first 6 h of data contain sufficient information for PVL occurrence prediction.
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Affiliation(s)
- Ali Jalali
- PhD candidate at the Department of Mechanical Engineering, Villanova University, Villanova, PA, 19085 USA
| | - Erin M. Buckley
- Post-Doctoral researcher at the Neurovascular Imaging Lab, Division of Child Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, 19140 USA
| | - Jennifer M. Lynch
- PhD candidate at the Neurovascular Imaging Lab, Division of Child Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, 19140 USA
| | - Peter J. Schwab
- Neurovascular Imaging Lab, Division of Child Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, 19140 USA
| | - Daniel J. Licht
- Director of the Neurovascular Imaging Lab, Division of Child Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, 19140 USA
| | - C Nataraj
- Mrs. and Mr. Mortiz, Sr. Endowed Professor in Engineered Systems and Chair of the Department of Mechanical Engineering, Villanova University, Villanova, PA, 19085 USA
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Mellion K, Uzark K, Cassedy A, Drotar D, Wernovsky G, Newburger JW, Mahony L, Mussatto K, Cohen M, Limbers C, Marino BS. Health-related quality of life outcomes in children and adolescents with congenital heart disease. J Pediatr 2014; 164:781-788.e1. [PMID: 24412135 DOI: 10.1016/j.jpeds.2013.11.066] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 10/18/2013] [Accepted: 11/26/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare health-related quality of life (HRQOL) in a group of pediatric patients with congenital heart disease (CHD) and healthy controls and patients with other chronic diseases, and to compare HRQOL among patients with CHD of various severity categories with one another, with controls, and with patients with other chronic diseases. STUDY DESIGN In this cross-sectional survey, t tests were used to compare patient and proxy-reported Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) scores (including total, physical health, and psychosocial health summary scores) in children (aged 8-12 years) and adolescents (aged 13-18 years) between controls and (1) a composite CHD population; and (2) patients in each of 3 CHD severity categories: mild (no intervention), biventricle (BV; postintervention), and single ventricle (SV; postpalliation). PedsQL scores among CHD severity categories were compared by ANOVA. PedsQL scores were also compared in the CHD population and children with other chronic diseases without age stratification using t tests. RESULTS There were 1138 (children, n = 625; adolescents, n = 513) and 771 (children, n = 528; adolescents, n = 243) patient and/or proxy reporters in the CHD and healthy control groups, respectively. Total, physical health, and psychosocial health summary scores were lower in the composite CHD, BV, and SV groups compared with controls (P < .0001). There were significant differences among disease severity categories for all scores (P < .01). The composite CHD, BV, and SV groups had similar PedsQL scores as end-stage renal disease, asthma, and obesity populations. CONCLUSION Children and adolescents with BV and SV CHD have significantly lower HRQOL than healthy controls and similar HRQOL as patients with other chronic pediatric diseases. Interventions targeting both physical and psychosocial domains are needed to improve HRQOL in this high-risk population.
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Affiliation(s)
- Katelyn Mellion
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Karen Uzark
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Amy Cassedy
- Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dennis Drotar
- Division of Behavioral and Clinical Psychology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gil Wernovsky
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jane W Newburger
- Division of Cardiology, Department of Pediatrics, Children's Hospital Boston, Boston, MA
| | - Lynn Mahony
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center Dallas, Dallas, TX
| | - Kathy Mussatto
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Mitchell Cohen
- Department of Cardiology, Phoenix Children's Hospital, Phoenix, AZ
| | - Christine Limbers
- Department of Psychology and Neuroscience, Baylor University, Waco, TX
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Oofuvong M, Geater AF, Chongsuvivatwong V, Chanchayanon T, Worachotekamjorn J, Sriyanaluk B, Saefung B, Nuanjun K. Comparison of intelligence, weight and height in children after general anesthesia with and without perioperative desaturation in non-cardiac surgery: a historical and concurrent follow-up study. SPRINGERPLUS 2014; 3:164. [PMID: 25674447 PMCID: PMC4320222 DOI: 10.1186/2193-1801-3-164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 03/21/2014] [Indexed: 11/10/2022]
Abstract
Purpose To determine whether perioperative desaturation (PD) in preschool children undergoing non-cardiac surgery is associated with subsequent impairment of intelligence or subsequent change in age-specific weight and height percentile. Method A historical-concurrent follow-up study was conducted in children aged ≤ 60 months who underwent general anesthesia (GA) for non-cardiac surgery between January 2008 and December 2011 at Songklanagarind Hospital. Children who developed PD (PD group) and children who did not develop perioperative respiratory events (no-PRE group) were matched on sex, age, year of having index GA, type of surgery and choice of anesthesia. The children’s age-specific weight and height percentile and intelligence quotient (IQ) scores by Standford Binet-LM or Wechsler Intelligence Scale for Children, 3rd edition 12–60 months after GA were compared using Student’s t- test and Wilcoxon’s rank sum test. Multivariate linear regression models for standardized IQ and multivariate mixed effects linear regression models for the change of age-specific weight and height percentile from the time of index GA to the time of IQ test were performed to identify independent predictors. The coefficients and 95% confidence intervals (CI) were displayed and considered significant if the F test p-values were < 0.05. Results Of 103 subjects in each group (PD vs no-PRE), there were no statistically significant differences in IQ (94.7 vs 98.3, p = 0.13), standardized IQ (−0.1 vs 0.1, p = 0.14) or age-specific weight percentile (38th vs 63th, p = 0.06). However, age-specific height percentile in the PD group at the time of IQ test was significantly lower (38th vs 50th, p = 0.02). In the multivariate analysis, PD was not a significant predictor for standardized IQ (coefficient: −0.06, 95% CI: −0.3, 0.19, p = 0.57), change in age-specific weight percentile (coefficient: 4.66, 95% CI: −2.63, 11.95, p = 0.21) or change in age-specific height percentile (coefficient: −1.65, 95% CI: −9.74, 6.44, p = 0.69) from the time of index GA to the time of IQ test after adjusting for family and anesthesia characteristics. Conclusion Our study could not demonstrate any serious effect of PD on subsequent intelligence or on the change in age-specific weight and height percentile of children after non-cardiac surgery. Electronic supplementary material The online version of this article (doi:10.1186/2193-1801-3-164) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maliwan Oofuvong
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Alan Frederick Geater
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | | | - Thavat Chanchayanon
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Juthamas Worachotekamjorn
- Division of Child Development, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Bussarin Sriyanaluk
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Boonthida Saefung
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
| | - Kanjana Nuanjun
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112 Thailand
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von Rhein M, Buchmann A, Hagmann C, Huber R, Klaver P, Knirsch W, Latal B. Brain volumes predict neurodevelopment in adolescents after surgery for congenital heart disease. Brain 2013; 137:268-76. [DOI: 10.1093/brain/awt322] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Yamada DC, Porter AA, Conway JL, LeBlanc JC, Shea SE, Hancock-Friesen CL, Warren AE. Early repair of congenital heart disease associated with increased rate of attention deficit hyperactivity disorder symptoms. Can J Cardiol 2013; 29:1623-8. [PMID: 24125582 DOI: 10.1016/j.cjca.2013.07.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/03/2013] [Accepted: 07/11/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND As more children survive with congenital heart disease, their neurodevelopmental outcomes (including attention deficit hyperactivity disorder [ADHD]) are becoming increasingly important. The objective of our study was to determine if school-aged children who underwent early cardiac surgery for congenital heart disease are more likely than healthy control subjects to have screening scores on the Swanson, Nolan, and Pelham IV (SNAP-IV) questionnaire suggestive of ADHD. METHODS Children aged 7-15 years who underwent open-heart surgery before 1 year of age were identified from the Izaak Walton Killam (IWK) Children's Heart Centre Database. Control subjects were recruited from healthy volunteers. The SNAP-IV questionnaire was administered to all participants and a chart review was performed on all eligible children in the cardiac surgery group. Case and control subjects were compared using Fisher's exact test, linear, and logistic regression analyses. Potential predictors of a positive screening score were sought. RESULTS A positive screening score was found in 29% (16/56) of the surgical group compared with 3% (2/60) of the control group (P < 0.001). Surgical and control subjects differed in average overall scores (0.93 vs 0.30; P < 0.001) and in scores for hyperactivity (0.83 vs 0.24; P < 0.001) and inattention (1.04 vs 0.37; P < 0.001). No other significant predictors of a positive screening score were identified. The early open-heart surgery participants who responded to the questionnaire did not differ in baseline characteristics compared with nonresponders. CONCLUSIONS Children who have open-heart surgery at younger than 1 year of age are more likely than healthy control subjects to have a SNAP-IV score suggestive of ADHD when they reach school age.
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Paquette LB, Wisnowski JL, Ceschin R, Pruetz JD, Detterich JA, Del Castillo S, Nagasunder AC, Kim R, Painter MJ, Gilles FH, Nelson MD, Williams RG, Blüml S, Panigrahy A. Abnormal cerebral microstructure in premature neonates with congenital heart disease. AJNR Am J Neuroradiol 2013; 34:2026-33. [PMID: 23703146 DOI: 10.3174/ajnr.a3528] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Abnormal cerebral microstructure has been documented in term neonates with congenital heart disease, portending risk for injury and poor neurodevelopmental outcome. Our hypothesis was that preterm neonates with congenital heart disease would demonstrate diffuse cerebral microstructural abnormalities when compared with critically ill neonates without congenital heart disease. A secondary aim was to identify any association between microstructural abnormalities, white matter injury (eg, punctate white matter lesions), and other clinical variables, including heart lesions. MATERIALS AND METHODS With the use of tract-based spatial statistics, an unbiased, voxelwise method for analyzing diffusion tensor imaging data, we compared 21 preterm neonates with congenital heart disease with 2 cohorts of neonates without congenital heart disease: 28 term and 27 preterm neonates, identified from the same neonatal intensive care unit. RESULTS Compared with term neonates without congenital heart disease, preterm neonates with congenital heart disease had microstructural abnormalities in widespread regions of the central white matter. However, 42% of the preterm neonates with congenital heart disease had punctate white matter lesions. When neonates with punctate white matter lesions were excluded, microstructural abnormalities remained only in the splenium. Preterm neonates with congenital heart disease had similar microstructure to preterm neonates without congenital heart disease. CONCLUSIONS Diffuse microstructural abnormalities were observed in preterm neonates with congenital heart disease, strongly associated with punctate white matter lesions. Independently, regional vulnerability of the splenium, a structure associated with visual spatial function, was observed in all preterm neonates with congenital heart disease.
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