Factors associated with adverse neurodevelopmental outcomes in infants with congenital heart disease

Prenatal Exposure to Opioids and Neurodevelopmental Disorders in Children: A Bayesian Mediation Analysis

This study explores natural direct and joint natural indirect effects (JNIE) of prenatal opioid exposure on neurodevelopmental disorders (NDDs) in children mediated through pregnancy complications, major and minor congenital malformations, and adverse neonatal outcomes, using Medicaid claims linked to vital statistics in Rhode Island, United States, 2008-2018. A Bayesian mediation analysis with elastic net shrinkage prior was developed to estimate mean time to NDD diagnosis ratio using posterior mean and 95% credible intervals (CrIs) from Markov chain Monte Carlo algorithms. Simulation studies showed desirable model performance. Of 11,176 eligible pregnancies, 332 had ≥2 dispensations of prescription opioids anytime during pregnancy, including 200 (1.8%) having ≥1 dispensation in the first trimester (T1), 169 (1.5%) in the second (T2), and 153 (1.4%) in the third (T3). A significant JNIE of opioid exposure was observed in each trimester (T1, JNIE = 0.97, 95% CrI: 0.95, 0.99; T2, JNIE = 0.97, 95% CrI: 0.95, 0.99; T3, JNIE = 0.96, 95% CrI: 0.94, 0.99). The proportion of JNIE in each trimester was 17.9% (T1), 22.4% (T2), and 56.3% (T3). In conclusion, adverse pregnancy and birth outcomes jointly mediated the association between prenatal opioid exposure and accelerated time to NDD diagnosis. The proportion of JNIE increased as the timing of opioid exposure approached delivery.

Early post-operative neurodevelopment and visual assessment in neonates with congenital heart disease undergoing cardiac surgery

OBJECTIVE

Assessment of neurobehavior and visual function of newborns with congenital heart disease during the post-operative period to identify infants at risk of neurodevelopmental and visual impairment.

STUDY DESIGN

Prospective study that included 45 newborns who underwent cardiac surgery. Newborn Behavioral Observations test (NBO) and "ML Battery of Optotypes" were used for assessment.

RESULTS

The median NBO global score was 2.4 [2.1-2.6]. Total days of oral morphine [p = 0.005] and total days of sedation [p = 0.009] were strongly related to abnormal evaluations. Time of cerebral regional oxygen saturation (CrSO2) under 40% during surgery and increased lactate were related to abnormal motor evaluation. Only 14.5% of patients presented pathological results in visual evaluation.

CONCLUSIONS

We have demonstrated alterations in attention, autonomic, motor, and oral motor function. Duration of sedative medication, time of CrSO2 under 40% during surgery, and increased lactate are the most important risk factors. No significant visual impairment was detected.

Relationship Between Human Milk Feeding Patterns and Growth in the First Year of Life in Infants with Congenital Heart Defects

The purpose of this study was to determine the relationship between patterning of human milk feeding and growth of infants with congenital heart defects in the first year of life. Inclusion criteria for this prospective cohort study included infants 0-21 days, who had undergone or had planned neonatal corrective or palliative surgery prior to hospital discharge, and whose mothers planned to feed human milk. Data on anthropometric measures (weight, length, head circumference) and infant milk type (human milk, formula, other) were collected at nine time points (0.5, 1, 2, 3, 4, 6, 8, 10, 12 months). Anthropometric data were converted to weight-for-age, length-for-age, head circumference-for-age, and weight-for-length Z-scores using World Health Organization growth reference data. Cluster analysis identified three milk type feeding patterns in the first year: Infants fed human milk only with no formula supplementation, infants fed human milk who then transitioned to a mix of human milk and formula, and infants who fed human milk and transitioned to formula only. General linear models assessed the effect of milk type feeding patterns on growth parameters over time. No effect of milk type pattern × time was found on longitudinal changes in weight-for-age (p for interaction = 0.228), length-for-age (p for interaction = 0.173), weight-for-length (p for interaction = 0.507), or head circumference-for-age (p for interaction = 0.311) Z-scores. In this cohort study, human milk alone or combined with infant formula supported age-appropriate growth in infants with congenital heart defects in the first year.

Vasopressin-Induced Hyponatremia in Infants Following Cardiovascular Surgery

BACKGROUND

Vasopressin is increasingly used in infants following cardiac surgery. Hyponatremia is a noted adverse event, but incidence and risk factors remain undefined.

OBJECTIVE

The primary objective was to identify the incidence of vasopressin-induced hyponatremia. Secondary objectives included comparing baseline and change in serum sodium concentrations between infants receiving vasopressin with and without hyponatremia, and comparing vasopressin dose, duration, and clinical characteristics in those with and without hyponatremia.

METHODS

This Institutional Review Board-approved, retrospective case-control study included infants <6 months following cardiac surgery receiving vasopressin for ≥6 hours at a tertiary care, academic hospital. Patients who developed hyponatremia, cases, were matched to controls in a 1:2 fashion. Demographics and clinical characteristics were collected. Descriptive and inferential statistics were employed. A conditional logistic regression was used to assess odds of hyponatremia.

RESULTS

Of the included 142 infants, 20 (14.1%) developed hyponatremia and were matched with 40 controls. There was significant difference in median nadir between controls and cases, 142.0 versus 128.5 mEq/L (<0.001). A significantly higher number of cases received corticosteroids, loop diuretics, and chlorothiazide versus controls. The regression analysis demonstrated that each additional hour of vasopressin increased the odds of developing hyponatremia by 5% (adjusted odds ratio 1.05 [confidence interval 1-1.1]).

CONCLUSIONS AND RELEVANCE

Vasopressin-induced hyponatremia incidence was <15%. Vasopressin duration was independently associated with hyponatremia development.

Evaluation of Intracranial Structures of Fetuses With Congenital Heart Defects

OBJECTIVES

We classified congenital heart defects (CHDs) according to cerebral blood flow oxygenation and aimed to evaluate the effect on the size of brain structures in these fetuses.

METHODS

The study which was designed retrospectively, included 28 patients with fetal CHDs and 76 patients without fetal anomalies.

RESULTS

The width and length of the cavum septum pellucidum significantly increased in the CHD group (P = .002, P = .004). The biparietal diameter and z scores were significantly lower in the single ventricle (SV) (P = .006, P = .019), and the head circumference (HC) and z scores were significantly lower in the transposition of great arteries (TGA) (P = .013, P = .038). The transverse cerebellar diameter, the cerebellar HC and the cerebellar hemisphere area values were lower in the SV (P = .005, P = .017, P = .044).

CONCLUSIONS

Brain structure changes are more pronounced in groups with low cerebral oxygenation, especially in the SV and the TGA.

Prevalence and Associated Factors of Long-term Growth Failure in Infants with Congenital Heart Disease Who Underwent Cardiac Surgery Before the Age of One

Long-term growth failure can have negative impact on health (by increasing morbidity and mortality) and on neurodevelopmental outcomes. Its prevalence among children with congenital heart disease (CHD) is not well described. The aim of our study was to evaluate the prevalence of growth failure in a population of infants with CHD away from cardiac surgery and identify associated factors. We conducted a retrospective and multicentric study that included infants from the North of France who underwent cardiac surgery before the age of one, between January 2013 and December 2017. 331 infants were included among which 48% had a prenatal diagnosis, 15% had a genetic syndrome, and 15% were premature infants. Mean birth weight was 3 ± 0.6 kg. At surgery, 35% presented feeding difficulties (need for enriched formula and/or feeding tube) and 14% had growth failure (defined by Z-score weight for age < -2SD). 6-12 months after surgery, 16% still presented growth failure. Several associated factors were identified: prenatal diagnosis, genetic syndrome association, birth weight ≤ 3 kg, complex CHD (≥ 2 significative lesions, or double outlet right ventricle or single ventricle physiology), surgery after 30 days, and need for diuretic drug before surgery and/or still needed 1 month after surgery. Growth failure persists between 6 and 12 months after surgery in 16% of infants with CHD. More studies are needed to link growth failure and neurodevelopment, which is the new challenge for this aging population.

Quality of Life of Families with Children Presenting Congenital Heart Disease:Longitudinal Study Protocol

BACKGROUND: Advances in medicine have caused a notable increase in the survival rates of children born with congenital heart disease, even in the most complicated cases, almost mitigating the disease’s pathology from lethal to chronic. The quality of life perceived by such children is influenced by the perceptions of their parents. However, the international literature has rarely considered the entire family nucleus. AIMS: This study aims to study the temporal trend of quality of life of families with children with congenital heart disease, particularly with respect to parents following a child’s hospitalization for an invasive procedure. DESIGN: A longitudinal study. METHOD: A sample of families (that is, those including a child with congenital heart disease and their parents) will be enrolled following the patient’s discharge from the hospital and examined every 3 months for 1 year. The study’s adopted hypothesis is that there is an interdependence between the subjects of the study that is capable of influencing individual perceptions of quality of life. RESULTS: This study will attempt to identify variables (and their temporal trend) that can be attributed to the family unit and—together with physical and clinical variables—that may influence the quality of life of children with congenital heart disease. CONCLUSION: Examining family quality of life with the longitudinal method will allow us to identify the predictors and interdependence of this factor with respect to children and their parents. This will help to correct and elaborate upon care guidelines, providing better assistance to patients and their caregivers.

Vasopressin associated hyponatremia in critically ill children: A cross-sectional study

Background

The association of hyponatremia with vasopressin therapy in children is controversial. We aimed to evaluate the incidence and severity of hyponatremia associated with the administration of vasopressin in critically ill pediatric patients.

Methods

This retrospective cross-sectional study included children younger than 14 years who were admitted to the pediatric or pediatric cardiac intensive care units and received vasopressin for at least 24 h.

Results

In total, 176 critically ill pediatric patients were enrolled, with a median age of 22 days (7.3–146). The mean sodium level was notably decreased from 143.5 mEq/L ± 7.15 at the baseline to 134.3 mEq/L ± 7.7 at the 72-hour measurement after the initiation of vasopressin and varied significantly at all intervals from the baseline measurement (P < 0.001). Twenty-four hours after the discontinuation of vasopressin, more than half of the patients had hyponatremia. The highest proportion had mild hyponatremia (32.8%), followed by moderate hyponatremia (13.1%), and profound hyponatremia (7.5%). The incidence of hyponatremia was independent of gender (P = 0.94) or age group (P = 0.087). However, more than two-thirds of the moderate-profound cases and more than one-third of mild cases were observed in the neonate group (P = 0.043). The vasopressin dose did not affect the incidence (P = 0.25) or the severity of the hyponatremia (P = 0.56). Notably, all laboratory and hemodynamic parameters varied significantly at the end of therapy, compared to the baseline.

Conclusions

Continuous monitoring for hyponatremia when children are placed on vasopressin is essential to protect against more severe complications.

Quality of life and other patient-reported outcomes across the lifespan among people with Fontan palliation

Traditional congenital heart disease (CHD) outcomes include mortality (survival to adulthood and life expectancy) as well as cardiac and non-cardiac morbidity. Strategies to identify and manage sequelae have primarily focused on objective data obtained though invasive and non-invasive diagnostic approaches. In contrast, patient-reported outcomes (PROs) provide subjective information, using standardized measures, about patients' health and wellbeing as reported directly by patients, without interpretation, interference, or assumptions made by clinicians or others. Selection of PRO measures entails thoughtful consideration of who the individuals being surveyed are, why assessment is occurring (e.g., what are the domains of interest; clinical vs. research), and what processes are in place for acquisition, administration, interpretation, and response. In this review, we focus on three domains of PROs for pediatric and adult patients with Fontan physiology: physical health status, psychological functioning, and quality of life (QOL). Infants, children, adolescents, and adults with CHD face a spectrum of challenges that may influence PROs across the lifespan. In general, patients with Fontan palliation tend to have lower physical health status, experience more psychological distress, and have equivalent or reduced QOL compared to healthy peers. Herein, we provide an overview of PROs among people with Fontan circulation as a group, yet simultaneously emphasize that the optimal way to understand the experiences of any individual patient is to ask and listen. We also offer clinical and research initiatives to improve the adoption and utility of PROs in CHD settings, which demonstrate commitment to capturing, understanding, and responding to the patient voice.

WeChat-assisted pre-operative health education improves the quality of life of parents of children with ventricular septal defects: A prospective randomised controlled study

AIM

This study aimed to explore the effect of implementing pre-operative WeChat-assisted health education for parents of children with restrictive ventricular septal defects to improve their quality of life.

METHODS

A prospective randomised controlled study was conducted in a provincial hospital in China. Participants were randomly divided into the intervention group (WeChat group, n = 35) and the control group (leaflet group, n = 35). The quality of life of parents of children with restricted ventricular septal defects was studied.

RESULTS

Compared with the leaflet group, the WeChat group had a significantly lower score for the pre-operative Self-Rating Anxiety Scale (SAS) (P < 0.05). The pre-operative SAS score in the WeChat group was significantly lower than that at the first visit (P < 0.05). However, the SAS score in the leaflet group was similar at the time of preoperation and the first visit (P > 0.05). The pre-operative scores of the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale in the physiological, psychological, social, and environmental fields and the total life quality score in the WeChat group were significantly higher than those of the leaflet group (P < 0.05).

CONCLUSION

Implementing pre-operative WeChat-assisted health education for parents of children with restrictive ventricular septal defects can effectively relieve their anxiety and improve their quality of life.

Neurodevelopmental status and follow-up in preschool children with heart disease in London, UK

OBJECTIVE

To describe neurodevelopment and follow-up services in preschool children with heart disease (HD).

DESIGN

Secondary analysis of a prospectively collected multicentre dataset.

SETTING

Three London tertiary cardiac centres.

PATIENTS

Preschool children<5 years of age: both inpatients and outpatients.

METHODS

We analysed results of Mullen Scales of Early Learning (MSEL) and parental report of follow-up services in a representative convenience sample evaluated between January 2014 and July 2015 within a previous study.

RESULTS

Of 971 preschool children: 577 (59.4%) had ≥1 heart operation, 236 (24.3%) had a known diagnosis linked to developmental delay (DD) ('known group') and 130 (13.4%) had history of clinical event linked to DD. On MSEL assessment, 643 (66.2%) had normal development, 181 (18.6%) had borderline scores and 147 (15.1%) had scores indicative of DD. Of 971 children, 609 (62.7%) were not receiving follow-up linked to child development and were more likely to be under these services with a known group diagnosis, history of clinical event linked to DD and DD (defined by MSEL). Of 236 in known group, parents of 77 (32.6%) and of 48 children not in a known group but with DD 29 (60.4%), reported no child development related follow-up. DD defined by MSEL assessment was more likely with a known group and older age at assessment.

CONCLUSIONS

Our findings indicate that a 'structured neurodevelopmental follow-up pathway' in preschool children with HD should be considered for development and evaluation as children get older, with particular focus on those at higher risk.

Cerebroplacental and Uterine Doppler Indices in Pregnancies Complicated by Congenital Heart Disease of the Fetus

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.

Prenatal evaluation of fetal atrioventricular valves by real-time 4D volume imaging with electronic matrix probe

Background

The purpose of this study is to evaluate the feasibility using real-time four-dimensional (RT 4D) volume imaging with electronic matrix probe to observe the morphology of atrioventricular valves in normal and abnormal fetuses, measure the area and circumference of atrioventricular valves in normal fetuses and analyze the correlation with gestational age.

Methods

RT 4D volume imaging with electronic matrix probe was used to collect cardiac volume data of 162 normal fetuses with the gestational age from 22 to 32 weeks and 19 fetuses with atrioventricular valves abnormalities were also enrolled. All the volume data were analyzed and processed in real-time. The morphology of mitral and tricuspid valves was observed in surface mode. The area and circumference of valves were measured in a 4D render view at the end of diastole and analyzed the correlation with gestational age.

Results

In 148 of 162 fetuses (91%), the 4D rendered image could be successfully obtained, which clearly showed the morphology of the atrioventricular valves. The area and circumference of mitral and tricuspid valves were positively correlated with gestational age (P < 0.01). Furthermore, 4D rendered images were successfully obtained in 17 of 19 fetuses (89%) with atrioventricular valves abnormalities.

Conclusions

The reference range of the area and circumference of atrioventricular valves in normal fetuses at different gestational weeks could be determined by using the RT 4D volume imaging with electronic matrix probe, which can provide certain diagnostic information for the clinic. The RT 4D images could display the valves morphology vividly in both normal and abnormal fetuses, including some subtle lesions which are not identified by traditional two-dimensional (2D) echocardiography. It is feasible to use the RT 4D volume imaging with electronic matrix probe to perform the prenatal evaluation in the fetal atrioventricular valves.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00240-7.

Associations Between Postoperative Management in the Critical Care Unit and Adolescent Developmental Outcomes Following Cardiac Surgery in Infancy: An Exploratory Study

OBJECTIVES

Children with congenital heart disease are at high risk for developmental sequelae. Most studies focus on preoperative and intraoperative predictors of developmental impairment, with less attention to the postoperative period. The relationship between patient-related factors specific to the postoperative course in the PICU following cardiac surgery with long-term neurodevelopmental outcomes in adolescence was examined.

DESIGN

Retrospective chart review of patients previously recruited to a study describing their developmental outcomes in adolescence.

SETTING

Single tertiary care pediatric hospital in Canada.

PATIENTS

Eighty adolescents, born between 1991 and 1999, with congenital heart disease who required open-heart surgery before 2 years old.

MEASUREMENTS AND MAIN RESULTS

Several variables related to acuity of illness and complexity of postoperative course in the PICU were collected. Outcome measures included the Movement-Assessment Battery for Children-2 (motor), Leiter Brief Intelligence Quotient (cognition), and Strength and Difficulties Questionnaire (behavior). Analyses examined associations between PICU variables and long-term outcomes. Longer mechanical ventilation (β = -0.49; p = 0.013) and dopamine use (β = -14.41; p = 0.012) were associated with lower motor scores. Dopamine use was associated with lower cognitive scores (β = -14.02; p = 0.027). Longer PICU stay (β = 0.18; p = 0.002), having an open chest postoperatively (β = 3.83; p = 0.017), longer mechanical ventilation (β = 0.20; p = 0.001), longer inotrope support (β = 0.27; p = 0.002), hours on dopamine (β = 0.01; p = 0.007), days to enteral feeding (β = 0.22; p = 0.012), lower hemoglobin (β = -0.11; p = 0.004), and higher creatinine (β = 0.05; p = 0.014) were all associated with behavioral difficulties.

CONCLUSIONS

Several important developmental outcomes in adolescents were associated with factors related to their postoperative course in the PICU as infants. Findings may highlight those children at highest risk for neurodevelopmental sequelae and suggest new approaches to critical care management following open-heart surgery, with the aim of mitigating or preventing adverse long-term outcomes.

Application of voxel-based morphometric method to detect brain changes in children with non-cyanotic congenital heart disease

BACKGROUND

Congenital heart disease (CHD) is a cardiovascular malformation caused by abnormal heart and/or vascular development in the fetus. In children with CHD, abnormalities in the development and function of the nervous system are common. At present, there is a lack of research on the preoperative neurological development and injury in young children with non-cyanotic CHD.

AIM

To determine the changes in white matter, gray matter, and cerebrospinal fluid (CSF) by magnetic resonance imaging (MRI) in children with non-cyanotic CHD as compared with healthy controls.

METHODS

Children diagnosed with non-cyanotic CHD on ultrasonography (n = 54) and healthy control subjects (n = 35) were included in the study. All the subjects were aged 1-3 years. Brain MRI was performed prior to surgery for CHD. The SPM v12 software was used to calculate the volumes of the gray matter, white matter, CSF, and the whole brain (sum of the gray matter, white matter, and CSF volumes). Volume differences between the two groups were analyzed. Voxel-based morphometry was used to compare specific brain regions with statistically significant atrophy.

RESULTS

Compared with the control group, the study group had significantly reduced whole-brain white matter volume (P < 0.05), but similar whole-brain gray matter, CSF, and whole-brain volumes (P > 0.05). As compared with the healthy controls, children with non-cyanotic CHD had mild underdevelopment in the white matter of the anterior central gyrus, the posterior central gyrus, and the pulvinar.

CONCLUSION

Children with non-cyanotic CHD show decreased white matter volume before surgery, and this volume reduction is mainly concentrated in the somatosensory and somatic motor nerve regions.

Effect of perioperative amplitude-integrated electroencephalography on neurodevelopmental outcomes following infant heart surgery

The purpose of the current study was to determine the effect of perioperative amplitude-integrated electroencephalography (aEEG) on neurodevelopmental outcomes in infants with congenital heart disease (CHD). A total of 93 children with CHD were included in the current study. All patients enrolled in the present study had undergone cardiac surgery prior to 3 months of age and pre- or postoperative aEEG was monitored. Participants were assessed after 1 year using the Bayley Scales of Infant Test. A total of 82.2% of infants exhibited continuous normal voltage preoperatively (CNV) and 93.7% exhibited CNV postoperatively. Seizures were indicated in 2 infants preoperatively and 3 infants postoperatively. Compared with infants with PDI, infants with cyanotic CHD (β=17.218) exhibited a significantly lower MDI, an increased length of intensive care stay, and lower PDI scores (β=-0.577). Infants that underwent surgery with CPB exhibited higher PDI scores (β=11.956). Infants that exhibited behavioral problems also had lower PDI scores (β=-10.605). An abnormal preoperative background pattern and an absent postoperative SWC independently predicted poorer motor (P=0.014) and cognitive (P=0.049) outcomes at 1 year. The current study demonstrated that infants with CHD who underwent cardiac surgery prior to 3 months of age exhibited delayed neurodevelopmental outcomes, and that an aEEG assessment can aid in predicting these outcomes following surgery.

Fetal Umbilical Arterial Pulsatility Correlates With 2-Year Growth and Neurodevelopmental Outcomes in Congenital Heart Disease

BACKGROUND

Children with congenital heart disease (CHD) are at risk of adverse long-term neurodevelopmental outcomes, believed to be, in part, secondary to prenatal insults. Placental pathology and altered fetal middle cerebral arterial (MCA) flow suggestive of brain sparing have been documented in fetal CHD. In the present study we investigated the relationship between MCA and umbilical arterial (UA) flow patterns in fetal transposition of the great arteries (d-TGA) and hypoplastic left heart syndrome (HLHS) and growth and 2-year neurodevelopmental outcomes.

METHODS

We included children with d-TGA and HLHS who had third-trimester fetal echocardiograms between 2004 and 2014, at which time umbilical artery (UA) and MCA pulsatility indices (PIs) were measured, and who underwent 2-year growth and neurodevelopmental assessments.

RESULTS

We identified 24 children with d-TGA and 36 with HLHS. Mean age at fetal echocardiography was 33.8 ± 3.5 weeks. At 2-year follow-up, head circumference z score (standard deviation [SD]) was -0.09 (1.07) and 0.17 (1.7) for the d-TGA and HLHS groups, respectively. Bayley III mean (SD) cognitive, language, and motor scores were 97.7 (10.8), 94.7 (13.4), and 98.6 (8.6) for the d-TGA group and 90.3 (13.9), 87.2 (17.5), and 85.3 (16.2) for the HLHS group. On multivariate linear regression analysis, UA-PI was associated (effect sizes [95% CI]) with length (-1.45 [-2.7, -0.17], P = 0.027), weight (-1.46 [-2.6 to -0.30], P = 0.015) and cognitive scores (-14.86 [-29.95 to 0.23], P = 0.05) at 2 years of age. MCA PI showed no statistically significant correlation.

CONCLUSIONS

In fetal d-TGA and HLHS, a higher UA-PI in the third trimester, suggestive of placental insufficiency-but not MCA-PI-is associated with worse 2-year growth and neurodevelopment.

Strategies for diagnosis of fetal right atrium dilation: based on fetal cardiac anatomy and hemodynamics

BACKGROUND

Fetal right atrium (RA) dilation is frequently detected in routine screenings while it remains a challenge to clarify the reasons. This study aimed to analyze the cardiac anatomy and hemodynamics of fetal RA dilation and the changes of hemodynamic indexes.

METHODS

In the retrospective study, 420 fetuses with RA dilation were included, which were classified into the physiological group (n = 202), volume overload group (n = 142), and the pressure overload group (n = 76). The ratio of right atrium to left atrium (RA/LA) were measured at four-chamber view. Peak velocity of tricuspid regurgitation (V_TR) was recorded in each case, if existed.

RESULTS

The RA/LA ratio in the volume overload group is significantly higher than both the pressure overload group and the physiological group (both P = 0.000) throughout the pregnancy while no difference presents between the pressure overload group and the physiological group (P = 0.694 for 19-31 GW, and P = 0.974 for 32-36 GW, respectively). The V_TR in the pressure overload group (3.29 ± 0.58 m/s) is significantly higher than both the volume overload group (1.85 ± 0.45 m/s, P = 0.000) and the physiological group (0.88 ± 0.45 m/s, P = 0.000). The volume overload group shows a significantly higher V_TR than the physiological group (P = 0.000). In the volume overload group, the ductal contraction/closure shows a significantly higher V_TR than that in the pulmonary valve stenosis/atresia (3.98 ± 0.41 m/s vs. 3.03 ± 0.38 m/s, P = 0.000).

CONCLUSIONS

A strategy proposed herein is useful to clarify the reasons for RA dilatation by systematically assessing fetal hemodynamics, which may facilitate the sonographers to make an accurate diagnosis of congenital heart disease.

Exploring disease comorbidity in a module-module interaction network

Understanding disease comorbidity contributes to improved quality of life in patients who are suffering from multiple diseases. Therefore, to better explore comorbid diseases, the clarification of associations between diseases based on biological functions is essential. In our study, we propose a method for identifying disease comorbidity in a module-based network, named the module-module interaction (MMI) network, which represents how biological functions influence each other. To construct the MMI network, we detected gene modules - sets of genes that have a higher probability of taking part in specific functions - and established a link between these modules. Subsequently, we constructed disease-related networks in the MMI network to understand inherent disease mechanisms and calculated comorbidity scores of disease pairs using Gene Ontology (GO) terms. Our results show that we can obtain further information on disease mechanisms by considering interactions between functional modules instead of between genes. In addition, we verified that predicted comorbid relationships of disease pairs based on the MMI network are more significant than those based on the protein-protein interaction (PPI) network. This study can be useful to elucidate the mechanisms underlying comorbidities for further study, which will provide a broader insight into the pathogenesis of diseases.

Inhaled nitric oxide reduces injury and microglia activation in porcine hippocampus after deep hypothermic circulatory arrest

OBJECTIVE

Dysregulation of local nitric oxide (NO) synthetases occurs during ischemia and reperfusion associated with cardiopulmonary bypass, deep hypothermic circulatory arrest (DHCA), and reperfusion. Rapid fluctuations in local NO occurring in neonates and infants probably contribute to inflammation-induced microglial activation and neuronal degeneration after these procedures, eventually impairing neurodevelopment. We evaluated the anti-inflammatory efficacy of inhaled NO (iNO) in a piglet model emulating conditions during pediatric open-heart surgery with DHCA.

METHODS

Infant Yorkshire piglets underwent DHCA (18°C) for 30 minutes, followed by reperfusion and rewarming either with or without iNO (20 ppm) in the ventilator at the onset of reperfusion for 3 hours (n = 5 per group, DHCA-iNO and DHCA). Through craniotomy, brains were extracted after perfusion fixation for histology.

RESULTS

Plasma NO metabolites were elevated 2.5 times baseline data before DHCA by iNO. Fluoro-Jade C staining identified significantly lower number of degenerating neurons in the hippocampus of the DHCA-iNO group (P = .02) compared with the DHCA group. Morphologic analyses of ionized calcium-binding adapter molecule-1 stained microglia, evaluating cell body and dendritic process geometry with Imaris imaging software, revealed subjectively less microglial activation in the hippocampus of pigs receiving iNO.

CONCLUSIONS

Using DHCA for 30 minutes, consistent with clinical exposure, we noted that iNO reduces neuronal degeneration in the hippocampus. In addition, iNO reduces microglial activation in the hippocampus after DHCA. The data suggest that iNO reduces neuronal degeneration by ameliorating inflammation and may be a practical mode of neuroprotection for infants undergoing DHCA.

Impacts of an Interdisciplinary Developmental Follow-Up Program on Neurodevelopment in Congenital Heart Disease: The CINC Study

Objectives: This study investigates the impact of an early systematic interdisciplinary developmental follow-up and individualized intervention program on the neurodevelopment of children with complex congenital heart disease (CHD) who required cardiac surgery. Study Design: We prospectively enrolled 80 children with CHD: 41 were already followed at our neurocardiac developmental follow-up clinic from the age of 4 months, while 39 were born before the establishment of the program and therefore received standard health care. We conducted cognitive, motor, and behavioral assessments at 3 years of age. We used one-way multivariate analyses of variance to compare the neurodevelopmental outcome of both groups. Results: Between-group analyses revealed a distinct neurodevelopmental profile with clinically significant effect size (P < 0.001, partial η² = 0.366). Children followed at our clinic demonstrated better receptive language performances (P = 0.048) and tended to show higher scores on visuo-constructive tasks (P = 0.080). Children who received standard health care exhibited greater performances in working memory tasks (P = 0.032). We found no group differences on global intellectual functioning, gross and fine motor skills, and behaviors. Referral rates for specific remedial services were higher in patients followed at our neurocardiac clinic compared to the historical cohort (P < 0.005). Conclusions: Overall, the impact of the developmental follow-up and individualized intervention program on neurodevelopmental outcomes remains subtle. Nevertheless, results, although limited by several factors, point toward an advantage for the children who took part in the program regarding receptive language skills over children who received standard health care. We hypothesize that group differences may be greater with growing age. Further research involving larger cohorts is needed to clearly assess the effectiveness of neurocardiac developmental follow-up programs at school age.

Mental health care for parents of babies with congenital heart disease during intensive care unit admission: Systematic review and statement of best practice

INTRODUCTION

Congenital heart disease (CHD) is one of the most common causes of infant admission to pediatric intensive care and is associated with profound psychological stress for mothers, fathers and their infants. Intensive care unit admission represents an opportunity to offer evidence-based strategies to prevent or minimize severe psychological distress and promote secure bonding and attachment, alongside high-quality infant medical care.

OBJECTIVES

We aimed to identify, synthesize and critically appraise published evidence on the efficacy and cost-effectiveness of mental health interventions delivered in neonatal, pediatric or cardiac intensive care units for parents of infants with CHD. A secondary goal was to develop recommendations for advancing health policy, practice and research in the field.

METHODS

In accordance with a prospectively registered protocol (CRD42019114507), six electronic databases were systematically searched for studies reporting results of a controlled trial of a mental health intervention for parents of infants aged 0-12 months with a congenital anomaly requiring intensive care unit admission. To maximize generalizability of results, trials involving infants with any type of structural congenital anomaly requiring surgery were included. Outcomes included intervention type, process, efficacy, and cost-effectiveness.

RESULTS

Across all forms of congenital anomaly, only five trials met inclusion criteria (four in CHD, one in gastrointestinal malformation). All interventions engaged parents face-to-face, but each had a distinct therapeutic approach (parent-infant interaction and bonding, early pediatric palliative care, psycho-education, parenting skills training, and family-centered nursing). Four of the five trials demonstrated efficacy in reducing maternal anxiety, although the quality of evidence was low. Positive results were also found for maternal coping, mother-infant attachment, parenting confidence and satisfaction with clinical care, as well as infant mental (but not psychomotor) development at 6 months. Mixed results were found for maternal depression and infant feeding. No evidence of efficacy was found for improving parent, infant or family quality of life, physical health or length of infant hospital stay, and there were no data on cost-effectiveness.

CONCLUSIONS

Stronger evidence for the efficacy of mental health interventions to buffer the effects of intensive care unit admission for parents of infants with CHD is urgently needed. Robust, high-quality trials are lacking, despite the established need and demand, and health policies prioritizing parent mental health care in the context of early childhood adversity are needed.

Neurodevelopmental outcomes of children with congenital heart disease: A review

Congenital heart defects are the most common birth anomaly affecting approximately 1% of births. With improved survival in this population, there is enhanced ability to assess long-term morbidities including neurodevelopment. There is a wide range of congenital heart defects, from those with minimal physiologic consequence that do not require medical or surgical intervention, to complex structural anomalies requiring highly specialized medical management and intricate surgical repair or palliation. The impact of congenital heart disease on neurodevelopment is multifactorial. Susceptibility for adverse neurodevelopment increases with advancing severity of the defect with initial risk factors originating during gestation. Complex structural heart anomalies may pre-dispose the fetus to abnormal circulatory patterns in utero that ultimately impact delivery of oxygen rich blood to the fetal brain. Thus, the brain of a neonate born with complex congenital heart disease may be particularly vulnerable from the outset. That vulnerability is compounded during the newborn period and through childhood, as this population endures a myriad of medical and surgical interventions. For each individual patient, these factors are likely cumulative and synergistic with progression from fetal life through childhood. This review discusses the spectrum of risk factors that may impact neurodevelopment in children with congenital heart disease, describes current recommendations and practices for neurodevelopmental follow-up of children with congenital heart disease and reviews important neurodevelopmental trends in this high risk population.

'Big issues' in neurodevelopment for children and adults with congenital heart disease

It is established that neurodevelopmental disability (NDD) is common in neonates undergoing complex surgery for congenital heart disease (CHD); however, the trajectory of disability over the lifetime of individuals with CHD is unknown. Several ‘big issues’ remain undetermined and further research is needed in order to optimise patient care and service delivery, to assess the efficacy of intervention strategies and to promote best outcomes in individuals of all ages with CHD. This review article discusses ‘gaps’ in our knowledge of NDD in CHD and proposes future directions.

Improving neurodevelopment in infants with complex congenital heart disease

Worldwide, more than 400,000 infants are born each year with complex congenital heart disease (CCHD) requiring surgical intervention within the first months of life. Although improvements in perioperative care have resulted in increased rates of survival, more than half of infants with CCHD have neurodevelopmental impairments affecting subsequent educational achievements, job opportunities, and mental health. Brain maturity and impaired outcomes in infants with CCHD are similar to those of prematurely born infants. Developmentally supportive care, including foundational application of kangaroo care (KC), improves neurodevelopment in premature infants. Provision of developmentally supportive care with KC during the early hospitalization of infants with CCHD has the potential to similarly improve neurodevelopment. The purposes of the article are to describe common congenital heart defects, describe developmentally supportive care with an emphasis on KC, and to offer specific recommendations for KC and research in infants with CCHD.

First steps to a clinical research unit for developmental research in paediatric cardiology: conception and progress of the LEADER project (Long Term Early Development Research) in CHD

OBJECTIVE

We developed the Long-term Early Development Research (LEADER) project to investigate the development of children with CHD and/or after cardiopulmonary resuscitation. Both populations are at risk for delays in motor, cognitive, and language development. However, few studies to date have investigated the longitudinal development in these children.

METHODS

To establish a clinical research unit, we planned three studies: a cross-sectional study in children after cardiopulmonary resuscitation (LEADER-REA Pilot Study), a longitudinal study in children after cardiopulmonary resuscitation, with a focus on evaluating various biomarkers as predictors for developmental outcome (LEADER-CPR study), and a longitudinal study in children with ventricular septal defect, tetralogy of Fallot, or transposition of the great arteries after cardiac surgery (LEADER-CHD study).

RESULTS

Implementation of all three LEADER studies was successful and study protocols were conducted as planned. Findings from the LEADER-REA Pilot study have been recently published and data collection for both prospective trials is ongoing. Descriptive analysis of the first 20 assessments of the LEADER-CHD study showed no severe deficits in overall cognitive, motor, and language developments in the children.

CONCLUSIONS

Children with CHD and/or after cardiopulmonary resuscitation are at risk for developmental delay. Therefore, a detailed developmental assessment is necessary as a pre-requisite for individual developmental support. Our LEADER project has been shown to be feasible in a clinical setting and is the first step towards the establishment of a clinical research unit in our clinic with a focus on longitudinal research.

Therapeutic Hypothermia After Perinatal Asphyxia in Infants With Severe, Ductal-Dependent Congenital Heart Disease

OBJECTIVES

Patients with severe congenital heart disease and cardiac anomalies such as restrictive foramen ovale, intact atrial septum, or narrowing of ductus arteriosus are at risk for perinatal asphyxia, leading to hypoxic-ischemic encephalopathy. We hypothesize that therapeutic hypothermia can be applied to these patients and seek to investigate feasibility and safety of this method.

DESIGN

A retrospective observational study.

SETTING

The Department of Neonatology of Charité, University Hospital, Berlin, Germany.

PATIENTS

Newborns with severe congenital heart disease and perinatal asphyxia were retrospectively analyzed over a 6-year period.

INTERVENTIONS

Application of therapeutic hypothermia.

MEASUREMENTS AND MAIN RESULTS

Ten patients with perinatal asphyxia were enrolled in this study. All patients received low-dose prostaglandin E1 for ductal maintenance. Three patients without evidence for hypoxic-ischemic encephalopathy did not receive therapeutic hypothermia. One patient died at the age of 15 hours, and therapeutic hypothermia was discontinued after 19 hours in another patient with severe arterial hypotension. Adverse effects during hypothermia included respiratory insufficiency (100%), arterial hypotension (71%), the need for inotropic support (71%), and pulmonary hypertension (43%), the latter associated with prolonged postoperative inotropic support. No neurologic complications occurred before or after the surgery. Operative outcome of surviving patients was excellent. Early brain MRI scans were suggestive of good neurodevelopmental prognosis for most patients.

CONCLUSIONS

Therapeutic hypothermia can be applied to patients with severe congenital heart disease and hypoxic-ischemic encephalopathy. Low-dose prostaglandin E1 infusions are safe for ductal maintenance during cooling, but cardiopulmonary adverse effects should be anticipated.

Cardiovascular profile and biophysical profile scores predict short-term prognosis in infants with congenital heart defect

AIM

To predict the prognosis of infants with congenital heart disease, accurate prenatal diagnosis of structural abnormality and heart failure are both necessary. The aim of this study was to investigate whether cardiovascular profile (CVP) and biophysical profile (BP) scores are useful for predicting prognosis in infants with congenital heart defect (CHD).

METHODS

A retrospective review of singletons prenatally diagnosed with CHD at a tertiary pediatric cardiac center between 2011 and 2015 was undertaken.

RESULTS

A total of 202 patients with CHD were analyzed. Perinatal and infant deaths occurred in 16 (7.9%) and 10 cases (5.0%), respectively. Infants with the last CVP score ≤ 5 had 18.7-fold higher perinatal mortality than those with a last CVP score > 5 (P < 0.01). Infants with a last BP score ≤ 6 had 18.7-fold higher perinatal mortality than those with a last BP score > 6 (P < 0.01). Infants with a CVP score decrease in utero had 4.5-fold higher infant mortality than those with an increase or no change (P < 0.01). Multivariate analysis showed that single-ventricle physiology, pre-term birth at <37 weeks of gestation, last CVP score ≤ 5, and last BP score ≤ 6 were independent predictors of perinatal mortality. Single-ventricle physiology and a CVP score decrease were independent predictors of infant mortality.

CONCLUSION

CVP and BP scores are useful for predicting perinatal prognosis in infants with CHD. A CVP score decrease in utero is associated with infant mortality, suggesting that serial CVP score assessment may be useful for management planning.

Acute Neurologic Injury in Children Admitted to the Cardiac Intensive Care Unit

BACKGROUND

Children with acquired and congenital heart disease both have low mortality but an increased risk of neurologic morbidity that is multifactorial. Our hypothesis was that acute neurologic injuries contribute to mortality in such children and are an important cause of death.

METHODS

All admissions to the pediatric cardiac intensive care unit (CICU) from January 2011 through January 2015 were retrospectively reviewed. Patients were assessed for any acute neurologic events (ANEs) during admission, as defined by radiologic findings or seizures documented on an electroencephalogram.

RESULTS

Of the 1,573 children admitted to the CICU, the incidence of ANEs was 8.6%. Mortality of the ANE group was 16.3% compared with 1.5% for those who did not have an ANE. The odds ratio for death with ANEs was 8.55 (95% confidence interval, 4.56 to 16.03). Patients with ANEs had a longer hospital length of stay than those without ANEs (41.4 ± 4 vs 14.2 ± 0.6 days; p < 0.001). Need for extracorporeal membrane oxygenation, previous cardiac arrest, and prematurity were independently associated with the presence of an ANE.

CONCLUSIONS

Neurologic injuries are common in pediatric CICUs and are associated with an increase in mortality and hospital length of stay. Children admitted to the CICU are likely to benefit from improved surveillance and neuroprotective strategies to prevent neurologic death.

Monitoring and management of brain hemodynamics and oxygenation

While cardiorespiratory monitoring is standard for newborns in the NICU, monitoring of brain hemodynamics and oxygenation is usually sporadic and targeted to newborns with suspected or confirmed neurologic disorders. This is unfortunate, since critically ill newborns, both preterm and term-born, are at high risk of brain injury and would benefit from improved techniques for continuous monitoring of brain hemodynamics and oxygenation, in addition to monitoring of systemic hemodynamics and oxygenation. Near-infrared spectroscopy (NIRS) and, to a lesser extent, Doppler ultrasound are techniques that have been used in research and increasingly for clinical purposes to measure and monitor brain hemodynamics and oxygenation in newborns. NIRS monitoring can be useful for detection of diverse pathologic conditions that occur frequently in very preterm newborns and in selected populations of term newborns at risk for brain injury related to disturbances of systemic hemodynamics. This chapter reviews the current state of the art with regard to brain-monitoring techniques and the research directed at this important area, and it concludes with suggestions for the use of currently available tools to manage newborns at high risk of neurologic injury from disturbances in brain hemodynamics and oxygenation.

Prevalence and risk factors associated with non-attendance in neurodevelopmental follow-up clinic among infants with CHD

BACKGROUND

Neurodevelopmental impairment is increasingly recognised as a potentially disabling outcome of CHD and formal evaluation is recommended for high-risk patients. However, data are lacking regarding the proportion of eligible children who actually receive neurodevelopmental evaluation, and barriers to follow-up are unclear. We examined the prevalence and risk factors associated with failure to attend neurodevelopmental follow-up clinic after infant cardiac surgery.

METHODS

Survivors of infant (<1 year) cardiac surgery at our institution (4/2011-3/2014) were included. Socio-demographic and clinical characteristics were evaluated in neurodevelopmental clinic attendees and non-attendees in univariate and multivariable analyses.

RESULTS

A total of 552 patients were included; median age at surgery was 2.4 months, 15% were premature, and 80% had moderate-severe CHD. Only 17% returned for neurodevelopmental evaluation, with a median age of 12.4 months. In univariate analysis, non-attendees were older at surgery, had lower surgical complexity, fewer non-cardiac anomalies, shorter hospital stay, and lived farther from the surgical center. Non-attendee families had lower income, and fewer were college graduates or had private insurance. In multivariable analysis, lack of private insurance remained independently associated with non-attendance (adjusted odds ratio 1.85, p=0.01), with a trend towards significance for distance from surgical center (adjusted odds ratio 2.86, p=0.054 for ⩾200 miles).

CONCLUSIONS

The majority of infants with CHD at high risk for neurodevelopmental dysfunction evaluated in this study are not receiving important neurodevelopmental evaluation. Efforts to remove financial/insurance barriers, increase access to neurodevelopmental clinics, and better delineate other barriers to receipt of neurodevelopmental evaluation are needed.

Long-term early development research in congenital heart disease (LEADER-CHD): a study protocol for a prospective cohort observational study investigating the development of children after surgical correction for congenital heart defects during the first 3 years of life

INTRODUCTION

Congenital heart disease (CHD) is the most common birth defect. Studies on the development of children with CHD point towards deficits in motoric, cognitive and language development. However, most studies are cross-sectional and there is a gap in the knowledge concerning developmental trajectories, risk and protective factors and a lack of research concerning environmental predictors. Specifically, no studies have so far considered the importance of early caregiving experiences and child temperament for the development of children with CHD.

METHODS

In a single-centre prospective cohort study, cognitive, motoric and language development of 180 children after corrective surgery for a simple transposition of the great arteries (TGA), tetralogy of Fallot (TOF) or ventricular septal defect (VSD) will be assessed at ages 12, 24 and 36 months with the Bayley Scales of Infant Development 3rd Edition (BSID-III). At age 12 months, a free-play video observation will be conducted to investigate the relationship between primary caregiver and child, and child temperament will be assessed with the Infant Behavior Questionnaire-Revised Short Version. Medical information will be obtained from patient records and demographic information via questionnaires.

ANALYSIS

Frequency and severity of developmental delays will be reported descriptively. Differences between groups (TGA, TOF, VSD) will be subjected to repeated-measures analysis across time points. Multiple regressions will be applied for the analysis of predictors at each time point. For the analysis of differential developmental trajectories, mixed-model analysis will be applied.

ETHICS AND DISSEMINATION

The study has been approved by the local medical ethics committee. Written informed consent will be obtained from all participants. Parents have the option to be debriefed about BSID-III results after each assessment and about the study results after project completion. Results will be disseminated in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00011006; Pre-results.

Structural cerebral abnormalities and neurodevelopmental status in single ventricle congenital heart disease before Fontan procedure

Objectives

Neonates with single ventricle congenital heart disease are at risk for structural cerebral abnormalities. Little is known about the further evolution of cerebral abnormalities until Fontan procedure.

Methods

Between August 2012 and July 2015, we conducted a prospective cross-sectional two centre study using cerebral magnetic resonance imaging (MRI) and neuro-developmental outcome assessed by the Bayley-III. Forty-seven children (31 male) were evaluated at a mean age of 25.9 ± 3.4 months with hypoplastic left heart syndrome (25) or other single ventricle (22).

Results

Cerebral MRI was abnormal in 17 patients (36.2%) including liquor space enlargements (10), small grey (9) and minimal white (5) matter injuries. Eight of 17 individuals had combined lesions. Median (range) cognitive composite score (CCS) (100, 65-120) and motor composite score (MCS) (97, 55-124) were comparable to the reference data, while language composite score (LCS) (97, 68-124) was significantly lower ( P  = 0.040). Liquor space enlargement was associated with poorer performance on all Bayley-III subscores (CCS: P  = 0.02; LCS: P  = 0.002; MCS: P  = 0.013). The number of re-operations [odds ratio (OR) 2.2, 95% confidence interval (CI) 1.1-4.3] ( P  = 0.03) and re-interventions (OR 2.1, 95% CI 1.1-3.8) ( P  = 0.03) was associated with a higher rate of overall MRI abnormalities.

Conclusions

Cerebral MRI abnormalities occur in more than one third of children with single ventricle, while the neuro-developmental status is less severely affected before Fontan procedure. Liquor space enlargement is the predominant MRI finding associated with poorer neuro-developmental status, warranting further studies to determine aetiology and further evolution until school-age.

Outcome of arterial ischemic stroke in children with heart disease

Arterial ischemic strokes (AIS) are rare in childhood. Congenital and acquired heart diseases are one of the most important risk factors of AIS in children.

OBJECTIVE

Study the outcome of children with heart disease that have suffered AIS and the factors that influence on prognosis.

PATIENTS AND METHODS

We evaluated all children with heart disease who had suffered AIS between 2000 and 2014 in our hospital.

RESULTS

Seventy-four children with heart disease suffered an arterial ischemic stroke. 20% of them died and 10% had new AIS during the study period. Fifty-two patients were evaluated an average of six years after AIS. According to the Paediatric Stroke Outcome Scale (PSOM), most of the patients had some degree of impairment, mainly in sensorimotor and in cognitive-behavioural areas. The modified Rankin scale (mRS) showed an unfavourable outcome in 70% of patients (including patients that have died). Upper limb was more functionally impaired than lower limb. Strokes in neonatal period and early life were associated with poor prognosis. Size of stroke, cortical and subcortical involvement and basal ganglia stroke were associated with an unfavourable outcome. Fever in the acute phase and hemiparesis at presentation were also poor prognostic factors. Epilepsy at time of evaluation was also associated with unfavourable outcome. On the other hand, a normal electroencephalogram was associated with favourable outcome.

CONCLUSIONS

AIS in children with heart disease had an unfavourable outcome, with impairment in different areas. Epilepsy happened in one third of the patients.

Clinical feasibility of pre-operative neurodevelopmental assessment of infants undergoing open heart surgery

AIM

Assessing the neurodevelopmental status of infants with congenital heart disease before surgery provides a means of identifying those at heightened risk of developmental delay. This study aimed to investigate factors impacting clinical feasibility of pre-operative neurodevelopmental assessment of infants undergoing early open heart surgery.

METHODS

Infants who underwent open heart surgery prior to 4 months of age participated in this cross-sectional study. The Test of Infant Motor Performance and Prechtl's Assessment of General Movements were undertaken on infants pre-operatively. When assessments could not be undertaken, reasons were ascribed to either infant or environmental circumstances. Demographic data and Aristotle scores were compared between groups of infants who did or did not undergo assessment. Binary logistic regression was used to explore associations.

RESULTS

A total of 60 infants participated in the study. Median gestational age was 38.78 weeks (interquartile range: 36.93-39.72). Of these infants, 37 (62%) were unable to undergo pre-operative assessment. Twenty-four (40%) could not complete assessment due to infant-related factors and 13 (22%) due to environmental-related factors. For every point increase in the Aristotle Patient-Adjusted Complexity score, the infants likelihood of being unable to undergo assessment increased by 35% (odds ratio: 0.35; 95% confidence interval: 1.03-1.77, P = 0.03).

CONCLUSION

Over half of the infants undergoing open heart surgery were unable to complete pre-operative neurodevelopmental assessment. The primary reason for this was infant-related medical instability. Findings suggest further research is warranted to investigate whether the Aristotle Patient-Adjusted Complexity score might serve as an indicator to inform developmental surveillance with this medically fragile cohort.

Congenital Heart Defects and Measures of Prenatal Brain Growth: A Systematic Review

BACKGROUND

We summarize the evidence for an association between congenital heart defects and prenatal brain growth through a systematic literature review. Congenital heart defects are among the most common malformations, affecting approximately six per 1000 live births. The association between congenital heart defects and long-term neurodevelopmental disorders is well established. Increasing evidence suggests an association between impaired prenatal brain growth and neurodevelopmental disorders in children with congenital heart defects.

METHODS

Systematic literature searches were performed in PubMed and EMBASE. We included original studies comparing fetuses or newborns with congenital heart defects to reference fetuses or newborns with respect to brain biometrics, including biparietal diameter, brain volume, and head circumference at birth. The study characteristics and the results were extracted and presented in tables. No meta-analysis was undertaken.

RESULTS

Twenty-eight studies were included. All except two studies found an association between congenital heart defects and measures of reduced prenatal brain growth. The strongest evidence concerned hypoplastic left heart syndrome, tetralogy of Fallot, and transposition of the great arteries.

CONCLUSIONS

The literature suggests an association between congenital heart defects and measures of impaired prenatal brain growth. However, most studies were small and failed to include important potential confounding factors and to address other sources of potential bias as well. Future large-scale studies that address potential confounders are warranted.

Early postoperative physical therapy for improving short-term gross motor outcome in infants with cyanotic and acyanotic congenital heart disease

PURPOSE

We analysed the gross motor recovery of infants and toddlers with cyanotic and acyanotic congenital heart disease (CHD) who received early postoperative physical therapy to see whether there was any difference in the duration to recovery.

METHODS

This study retrospectively evaluated the influence of early physical therapy on postoperative gross motor outcomes of patients with CHD. The gross motor ability of patients with cyanotic (n = 25, average age: 376.4 days) and acyanotic (n = 26, average age: 164.5 days) CHD was evaluated using our newly developed nine-grade mobility assessment scale.

RESULTS

Physical therapy was started at an average of five days after surgery, during which each patient's gross motor ability was significantly decreased compared with the preoperative level. Patients (who received early postoperative physical therapy) with cyanotic (88.0%) and acyanotic CHD (96.2%) showed improved preoperative mobility grades by the time of hospital discharge. However, patients with cyanotic CHD had a significantly prolonged recovery period compared to those with acyanotic CHD (p < .01). The postoperative recovery period to preoperative mobility grade was significantly correlated with pre-, intra-, and postoperative factors.

CONCLUSIONS

Our findings suggested that infants with cyanotic CHD are likely at a greater risk of gross motor delays, the recovery of which might differ between infants with cyanotic and acyanotic CHD after cardiac surgery. Early postoperative physical therapy promotes gross motor recovery. Implications of Rehabilitation Infants and toddlers with cyanotic congenital heart disease are likely at greater risk of gross motor delays and have a prolonged recovery period of gross motor ability compared to those with acyanotic congenital heart disease. Early postoperative physical therapy for patients with congenital heart disease after cardiac surgery promoted gross motor recovery. The postoperative recovery period to preoperative mobility grade was affected by pre-, intra-, and postoperative factors. Rehabilitation experts should consider the risk of gross motor delays of patients with congenital heart disease after cardiac surgery and the early postoperative physical therapy to promote their gross motor recovery.

The impact of congenital heart diseases on the quality of life of patients and their families in Saudi Arabia. Biological, psychological, and social dimensions

Objectives:

To assess the impact of congenital heart diseases (CHDs) on bio-psychosocial aspects of the quality of life (QOL) of patients and their families.

Methods:

A cross-sectional study was carried out between May 2014 and August 2015, including children aged <16 years, and followed-up at King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia for CHD. A broad questionnaire was administered to investigate biological, psychological, and social dimensions of afflicted children, their parents, and siblings. Outcomes were computed as impact scores (0-100%) for each dimension and family member.

Results:

A total of 180 children (104 [57.8%] males; mean age ± standard deviation [SD] = 5.65 ± 4.8 years) were included. There were 25% children complaining of recurrent respiratory infections, 35% of frequent hospitalizations, 38.9% had milestone delay, and 12 (6.7%) only had a social security registration. Mothers declared difficulty coping with their children’s disease in 20% of cases and 22.2% reported being depressed. Mean ± SD impact scores in afflicted children were: 26.1 ± 26.2 (biological), 28.7 ± 28.8 (psychological), and (20.2 ± 25.7) social dimensions. Mothers’ impact scores were higher than fathers’. Complex CHDs had an additional impact, and children from families with less knowledge on CHD had relatively greater impact scores.

Conclusion:

Congenital heart diseases impact all aspects of QOL of patients and their families, and are associated with high comorbidity. Social and psychological support and education for patients and their parents are crucial factors for improving QOL.

Cerebral and Renal Oxygen Saturation Are Not Compromised in the Presence of Retrograde Blood Flow in either the Ascending or Descending Aorta in Term or Near-Term Infants with Left-Sided Obstructive Lesions

BACKGROUND

In infants with left-sided obstructive lesions (LSOL), the presence of retrograde blood flow in either the ascending or descending aorta may lead to diminished cerebral and renal blood flow, respectively.

OBJECTIVES

Our aim was to compare cerebral and renal tissue oxygen saturation (rSO2) between infants with LSOL with antegrade and retrograde blood flow in the ascending aorta and with and without diastolic backflow in the descending aorta.

METHODS

Based on 2 echocardiograms, the study group was categorized according to the direction of blood flow in the ascending and descending aorta. We measured cerebral and renal rSO2 using near-infrared spectroscopy and calculated fractional tissue oxygen extraction (FTOE).

RESULTS

Nineteen infants with LSOL, admitted to the NICU between 0 and 28 days after birth, were included. Infants with antegrade blood flow (n = 12) and infants with retrograde blood flow in the ascending aorta (n = 7) had similar cerebral rSO2 and FTOE during both echocardiograms. Only during the first echocardiogram, infants with retrograde blood flow in the ascending aorta had lower renal FTOE (0.14 vs. 0.32, p = 0.04) and tended to have higher renal rSO2 (80 vs. 65%, p = 0.09). The presence of diastolic backflow in the descending aorta was not associated with cerebral or renal rSO2 and FTOE during the first (n = 8) as well as the second echocardiogram (n = 10).

CONCLUSIONS

Retrograde blood flow in the ascending aorta was not associated with cerebral oxygenation, while diastolic backflow in the descending aorta was not associated with renal oxygenation in infants with LSOL.

Functional, quality of life, and neurodevelopmental outcomes after congenital cardiac surgery

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.

Perioperative risk factors for impaired neurodevelopment after cardiac surgery in early infancy

OBJECTIVE

Historical cohort studies have reported adverse neurodevelopment following cardiac surgery during early infancy. Advances in surgical techniques and perioperative care have coincided with updating of neurodevelopmental assessment tools. We aimed to determine perioperative risk factors for impaired neurodevelopment at 2 years following surgery for congenital heart disease (CHD) in early infancy.

DESIGN AND PATIENTS

We undertook a prospective longitudinal study of 153 full-term infants undergoing surgery for CHD before 2 months of age. Infants were excluded if they had a genetic syndrome associated with neurodevelopmental impairment.

OUTCOME MEASURES

Predefined perioperative parameters were recorded and infants were classified according to cardiac anatomy. At 2 years, survivors were assessed using the Bayley Scales of Infant Development-III.

RESULTS

At 2 years, 130 children (98% of survivors) were assessed. Mean cognitive, language and motor scores were 93.4±13.6, 93.6±16.1 and 96.8±12.5 respectively (100±15 norm). Twenty (13%) died and 12 (9%) survivors had severe impairment (score <70), mostly language (8%). The lowest scores were in infants born with single ventricle physiology with obstruction to the pulmonary circulation who required a neonatal systemic-to-pulmonary artery shunt. Additional risk factors for impairment included reduced gestational age, postoperative elevation of lactate or S100B and repeat cardiac surgery.

CONCLUSIONS

In the modern era of infant cardiac surgery and perioperative care, children continue to demonstrate neurodevelopmental delays. The use of updated assessment tools has revealed early language dysfunction and relative sparing of motor function. Ongoing follow-up is critical in this high-risk population.

Head growth in fetuses with isolated congenital heart defects: lack of influence of aortic arch flow and ascending aorta oxygen saturation

OBJECTIVES

Congenital heart defects (CHDs) are reported to be associated with a smaller fetal head circumference (HC) and neurodevelopmental delay. Recent studies suggest that altered intrauterine brain hemodynamics may explain these findings. Our objectives were to evaluate the pattern of head growth in a large cohort of fetuses with various types of CHD, analyze these patterns according to the type of CHD and estimate the effect of cerebral hemodynamics with advancing gestation in the second and third trimesters.

METHODS

Singleton fetuses with an isolated CHD were selected from three fetal medicine units (n = 436). Cases with placental insufficiency or genetic syndromes were excluded. CHD types were clustered according to the flow and oxygen saturation in the aorta. Z-scores of biometric data were constructed using growth charts of a normal population. HC at different gestational ages was evaluated and univariate and multivariate mixed regression analyses were performed to examine the patterns of prenatal HC growth.

RESULTS

Fetuses with severe and less severe types of CHD demonstrated statistically significant HC growth restriction with increasing gestational age (slope of -0.017/day); however, there was no statistically significant effect of fetal hemodynamics on HC growth. Fetuses with CHD but normal brain oxygenation and normal aortic flow showed a significant decrease in HC growth (slope of -0.024/day). Only fetuses with isolated tetralogy of Fallot demonstrated a smaller HC z-score at 20 weeks of gestation (-0.67 (95% CI, -1.16 to -0.18)).

CONCLUSIONS

Despite the decline in head growth in fetuses with a prenatally detected isolated CHD, HC values were within the normal range, raising the question of its clinical significance. Furthermore, in contrast to other studies, this large cohort did not establish a significant correlation between aortic flow or oxygen saturation and HC growth. Factors other than altered fetal cerebral hemodynamics may contribute to HC growth restriction with increasing gestational age, such as (epi)genetic or placental factors. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Evaluation of fetal cardiac valve anomalies by four-dimensional echocardiography with spatiotemporal image correlation (4DSTIC)

BACKGROUND

Prenatal diagnosis of cardiac valve anomalies challenged most screening sonographers. The purpose of the study was to evaluate the use of four-dimensional echocardiography with spatiotemporal image correlation (4DSTIC) in detecting normal and abnormal fetal cardiac valves.

METHODS

Forty-three cases of confirmed cardiac valve anomalies identified by two-dimensional echocardiography (2DE) were retrospectively reviewed in this study. Additional 121 confirmed normal fetuses were included as controls. Four-dimensional volumes were acquired from each fetus using a transverse sweep. Four-dimensional rendered images were retrieved from the volumes for each of the cardiac valves for the normal fetuses and for the intended valves for fetuses with valve malformations.

RESULTS

The visualization rates of cardiac valves retrieved from 4D volumes in the normal fetuses ranged from 72.5% to 97.5% before 33 gestational weeks and from 46.3% to 80.5% in late pregnancy. Furthermore, 4D rendered images were successfully obtained in 38 of 43 (88.4%) fetuses with cardiac valve lesions.

CONCLUSIONS

The 4D images and cine loops displayed the valves anatomy vividly in both normal and abnormal fetuses, including some subtle malformations which were not identified by traditional 2DE. The standardized protocol we propose herein was important in obtaining the 4D images from the volumes. The 4D modality allows a better visualization of fetal cardiac valves and should be considered a valuable addition to traditional 2DE imaging.

Identification of fetal cardiac anatomy and hemodynamics: a novel enhanced screening protocol

Background

Prenatal cardiac screening is of great importance as it contributes to appropriate neonatal management and helps parents to make a decision regarding their pregnancy. The aim of our study was to evaluate the efficiency of a newly proposed screening protocol in the detection of fetal congenital heart disease (CHD).

Methods

This was a prospective study. A total of 52 cases of confirmed CHD fetuses and 248 cases of randomly selected normal fetuses were included in the study. Two sonographers with similar experience performed the cardiac screenings under two different protocols independently. The conventional protocol (Protocol A) paid greater attention to the four-chamber view and the outflow tract views. A 6-month training program was provided to sonographers performing scans under the new protocol (Protocol B), which emphasized systematically evaluating fetal cardiac anatomy and hemodynamics. Color Doppler was mandatory and some ultrasonic signs for special cardiac anomalies were also introduced into this protocol.

Results

Protocol B detected more cardiac anomalies than did Protocol A (96.2 % vs. 61.5 %, P < 0.01). Specifically, Protocol B was superior to Protocol A in detecting cardiac malpositions, abnormal systemic and pulmonary venous connection, right aortic arch, transposition of the great arteries, and congenital corrected transposition of the great arteries. By visualizing flow disturbance and retrograde flow with color Doppler, Protocol B was better than Protocol A in screening valvular associated malformations, such as pulmonary atresia, pulmonary stenosis, tricuspid dysplasia, etc. For the normal fetuses, Protocol B was better than Protocol A in reducing the false-positive detection of septal defects.

Conclusions

The current study introduces an enhanced protocol for fetal cardiac screening, under which the obstetric screening sonographers systematically identify fetal cardiac anatomy and hemodynamics. A short-term training program makes it possible for the screening sonographers to become familiar with the new protocol, and its value has been confirmed due to improvements made in screening efficiency.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0933-9) contains supplementary material, which is available to authorized users.

Long-Term Neurodevelopmental Outcomes in Children and Adolescents With Congenital Heart Disease

BACKGROUND

Effective medical and surgical management of pediatric congenital heart disease (CHD) to reduce long-term adverse neurodevelopmental outcomes is an important clinical objective in primary and specialty health care. We identify clinical predictors associated with an increased risk of 6 long-term neurodevelopmental outcomes in children with CHD compared to the general pediatric Medicaid population.

METHOD

South Carolina's retrospective, 15-year Medicaid data set (January 1, 1996-December 31, 2010) for 19,947 patients aged ≤ 17 years diagnosed with ≥ 1 CHD lesions (on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification codes) were compared to 19,948 patients without CHD matched on age at entry into and duration in Medicaid using logistic and Cox proportional hazards regression.

RESULTS

The CHD cohort was significantly less likely to have incident neurologic or psychiatric disorders, mental retardation, developmental delays, or inattention/hyperactivity (adjusted odds ratios [ORs] = 0.34, 0.56, 0.03, 0.01, 0.004, respectively) but was more likely to have incident seizures (OR = 2.00) compared to controls. Exposure to both cardiac and noncardiac surgical intervention was associated with a significantly increased risk of developing neurologic or psychiatric disorders, mental retardation, developmental delays, or inattention/hyperactivity (cardiac ORs = 1.66, 2.00, 1.67, 1.43, 1.76, respectively) (noncardiac ORs = 2.25, 1.59, 1.48, 1.29, 1.36, 2.46, respectively). Any documented hypoxemia was associated with a significantly increased risk of developing 5 of the neurodevelopmental conditions (neurologic OR = 4.52, psychiatric OR = 1.60, mental retardation OR = 2.90, developmental delay OR = 2.12, seizures OR = 4.23).

CONCLUSION

Practitioners should maintain vigilant surveillance of all CHD patients, especially those exposed to surgical procedures or experiencing hypoxemia, to identify any neurodevelopmental issues early and address them promptly.