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Leclair G, Dingankar A, Robertson CMT, Bond GY, Mohammadian P, Dinu I, Averin K, Guerra GG, Atallah J. Neurodevelopmental Outcomes of Infants after Neonatal Surgical Intervention for Tetralogy of Fallot or Pulmonary Atresia. J Pediatr 2023; 262:113640. [PMID: 37517650 DOI: 10.1016/j.jpeds.2023.113640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To determine the 2-year neurodevelopmental outcomes for survivors of neonatal cardiac surgery for the most common right ventricular outflow tract obstructive lesions: tetralogy of Fallot and pulmonary atresia with a ventricular septal defect. STUDY DESIGN A single-center consecutive cohort of 77 children underwent neonatal surgery for tetralogy of Fallot or pulmonary atresia with a ventricular septal defect at ≤6 weeks of age between 2006 and 2017. The patients underwent a multidisciplinary neurodevelopmental assessment at 18-24 months of age. Survivor outcomes were compared by univariable and multivariable analyses. RESULTS The 2-year mortality was 7.8% (6/77) with a postoperative in-hospital mortality of 3.9% (3/77). Freedom from reintervention by cardiac catheterization or surgical intervention at 2 years was 36%. Functional and neurodevelopmental assessment for 69 of 71 survivors was completed at a mean age of 22.6 ± 4.0 months using the Bayley Scales of Infant and Toddler Development III. The mean neurodevelopmental outcome scores were 83.4 ± 16.5 for cognitive skills, 82.2 ± 18.7 for language skills, and 81.4 ± 18.1 for motor skills. Cognitive, language, and motor delay, defined as a score of <70, was identified in 25%, 25%, and 23% of patients, respectively. Multivariable analyses for factors associated with worse neurodevelopmental outcomes identified chromosomal anomalies (P < .001) and postoperative complications (P < .03). CONCLUSIONS Cyanotic tetralogy of Fallot and pulmonary atresia with ventricular septal defect requiring neonatal repair showed similar 2-year neurodevelopmental outcomes below normative values and a high prevalence of cognitive, language and motor delays.
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Affiliation(s)
- Guillaume Leclair
- Departments of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Adil Dingankar
- Departments of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Charlene M T Robertson
- Departments of Pediatrics, University of Alberta, Edmonton, AB, Canada; Complex Pediatric Therapies Follow-up Program, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Gwen Y Bond
- Complex Pediatric Therapies Follow-up Program, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Parsa Mohammadian
- Institute of Biostatistics and Registry Research, Brandenburg Medical School, Neuruppin, Germany
| | - Irina Dinu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Konstantin Averin
- Departments of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | - Joseph Atallah
- Departments of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Filho HQ, Garros D. Out of the PICU and Beyond! J Pediatr (Rio J) 2023; 99:531-533. [PMID: 37643719 PMCID: PMC10594005 DOI: 10.1016/j.jped.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- Helio Queiroz Filho
- Obras Sociais Irmã Dulce, Centro de Terapia Intensiva Pediátrica (CTIP), Salvador, BA, Brazil; Hospital Teresa de Lisieux (HAPVIDA), UTI Neo e Pediátrica, Salvador, BA, Brazil
| | - Daniel Garros
- University of Alberta, Faculty of Medicine, Department of Pediatrics, Division of Critical Care, Alberta, Canada; Stollery Children's Hospital, Edmonton, Alberta, Canada.
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Averin K, Ryerson L, Hajihosseini M, Dinu IA, Freed DH, Bond G, Joffe AR, Jonker DV, Hendson L, Robertson CM, Atallah J. Infants less than or equal to 2.5 kg have increased mortality and worse motor neurodevelopmental outcomes at 2 years of age after Norwood-Sano palliation. JTCVS OPEN 2023; 14:417-425. [PMID: 37425435 PMCID: PMC10328833 DOI: 10.1016/j.xjon.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/11/2023] [Accepted: 03/07/2023] [Indexed: 07/11/2023]
Abstract
Objectives In infants with single-ventricle congenital heart disease, prematurity and low weight at the time of the Norwood operation are risk factors for mortality. Reports assessing outcomes (including neurodevelopment) post Norwood palliation in infants ≤2.5 kg are limited. Methods All infants who underwent a Norwood-Sano procedure between 2004 and 2019 were identified. Infants ≤2.5 kg at the time of the operation (cases) were matched 3:1 with infants >3.0 kg (comparisons) for year of surgery and cardiac diagnosis. Demographic and perioperative characteristics, survival, and functional and neurodevelopmental outcomes were compared. Results Twenty-seven cases (mean ± standard deviation: weight 2.2 ± 0.3 kg and age 15.6 ± 14.1 days at surgery) and 81 comparisons (3.5 ± 0.4 kg and age 10.9 ± 7.9 days at surgery) were identified. Post-Norwood, cases had a longer time to lactate ≤2 mmol/L (33.1 ± 27.5 vs 17.9 ± 12.2 hours, P < .001), longer duration of ventilation (30.5 ± 24.5 vs 18.6 ± 17.5 days, P = .005), greater need for dialysis (48.1% vs 19.8%, P = .007), and greater need for extracorporeal membrane oxygenation support (29.6% vs 12.3%, P = .004). Cases had significantly greater postoperative (in-hospital) (25.9% vs 1.2%, P < .001) and 2-year (59.2% vs 11.1%, P < .001) mortality. Neurodevelopmental assessment showed the following for cases versus comparisons, respectively: cognitive delay (18.2% vs 7.9%, P = .272), language delay (18.2% vs 11.1%, P = .505), and motor delay (27.3% vs 14.3%, P = .013). Conclusions Infants ≤2.5 kg at Norwood-Sano palliation have significantly increased postoperative morbidity and mortality up to 2-year follow-up. Neurodevelopmental motor outcomes were worse in these infants. Additional studies are warranted to assess the outcome of alternative medical and interventional treatment plans in this patient population.
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Affiliation(s)
- Konstantin Averin
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsay Ryerson
- Division of Critical Care, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Irina A. Dinu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Gwen Bond
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Ari R. Joffe
- Division of Critical Care, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Leonora Hendson
- Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charlene M.T. Robertson
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Atallah
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Sha L, Li Y, Zhang Y, Tang Y, Li B, Chen Y, Chen L. Heart-brain axis: Association of congenital heart abnormality and brain diseases. Front Cardiovasc Med 2023; 10:1071820. [PMID: 37063948 PMCID: PMC10090520 DOI: 10.3389/fcvm.2023.1071820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
Brain diseases are a major burden on human health worldwide, and little is known about how most brain diseases develop. It is believed that cardiovascular diseases can affect the function of the brain, and many brain diseases are associated with heart dysfunction, which is called the heart-brain axis. Congenital heart abnormalities with anomalous hemodynamics are common treatable cardiovascular diseases. With the development of cardiovascular surgeries and interventions, the long-term survival of patients with congenital heart abnormalities continues to improve. However, physicians have reported that patients with congenital heart abnormalities have an increased risk of brain diseases in adulthood. To understand the complex association between congenital heart abnormalities and brain diseases, the paper reviews relevant clinical literature. Studies have shown that congenital heart abnormalities are associated with most brain diseases, including stroke, migraine, dementia, infection of the central nervous system, epilepsy, white matter lesions, and affective disorders. However, whether surgeries or other interventions could benefit patients with congenital heart abnormalities and brain diseases remains unclear because of limited evidence.
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Affiliation(s)
- Leihao Sha
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Yajiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yunwu Zhang
- Fujian Provincial Key Laboratory of Neurodegenerative Disease and Aging Research, Institute of Neuroscience, School of Medicine, Xiamen University, Xiamen, China
| | - Yusha Tang
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Baichuan Li
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Chen
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
- Correspondence: Lei Chen
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Khoury M, Hajihosseini M, Robertson CMT, Bond G, Freed D, Dinu I, Makarchuk S, Joffe A, Atallah J. Evaluating the Prevalence and Factors Associated With an Optimal Neurodevelopmental Outcome in 4- to 6-Year-Old Children With Fontan Circulation. Can J Cardiol 2023; 39:144-153. [PMID: 36544295 DOI: 10.1016/j.cjca.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We sought to evaluate the prevalence and factors associated with "optimal" neurodevelopmental outcomes in 4- to 6-year-old children with Fontan circulation. METHODS Patients followed through the Western Canadian Complex Pediatric Therapies Follow-Up Program, and born between September 1996 and December 2015, were included. Optimal neurodevelopmental outcome was defined as full-scale intelligence quotient; visual-motor integration; adaptive behaviour assessment system-general adaptive composite scores of ≥ 80 each; and the absence of chronic motor disability, permanent hearing loss, visual impairment, and seizure disorder. Multivariable regression models and decision algorithms evaluated variables associated with optimal outcomes. RESULTS The Fontan procedure was completed on 225 children, with neurodevelopmental outcome data available for 205 (mean [standard deviation]) age at Fontan 3.4 (0.9) years, 37% female). Optimal neurodevelopmental outcome was identified in 55% (112 of 205). Factors independently associated with optimal neurodevelopmental outcome were female sex (odds ratio [OR], 2.1; 95% confidence interval [CI] 1.1-4.1), years of maternal schooling (OR, 1.2 [1.1-1.4]), age at Fontan (years) (OR, 0.97 [0.94-1.0]), need for concomitant atrioventricular valve (AVV) intervention (OR, 0.4 [0.2-1.0]), and time (hours) for lactate to be ≤ 2 mmol/L (OR, 0.9 [0.8-1.0]). Of those with Fontan completion < 3.25 years, without concomitant AVV intervention and lactate normalization within 8 hours post-Fontan, 87% (27 of 31) had optimal neurodevelopmental outcomes. CONCLUSIONS Optimal neurodevelopmental outcome was present in more than one-half of 4- to 6-year-old children with Fontan circulation in this cohort study, with important associated factors identified, including potentially modifiable factors such as younger age at Fontan surgery and lack of concomitant AVV intervention.
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Affiliation(s)
- Michael Khoury
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Gwen Bond
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Darren Freed
- Department of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Irina Dinu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Sue Makarchuk
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Ari Joffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Cheung PY, Hajihosseini M, Dinu IA, Switzer H, Joffe AR, Bond GY, Robertson CMT. Outcomes of Preterm Infants With Congenital Heart Defects After Early Surgery: Defining Risk Factors at Different Time Points During Hospitalization. Front Pediatr 2021; 8:616659. [PMID: 33585367 PMCID: PMC7876369 DOI: 10.3389/fped.2020.616659] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/11/2020] [Indexed: 01/28/2023] Open
Abstract
Background: Compared with those born at term gestation, infants with complex congenital heart defects (CCHD) who were delivered before 37 weeks gestational age and received neonatal open-heart surgery (OHS) have poorer neurodevelopmental outcomes in early childhood. We aimed to describe the growth, disability, functional, and neurodevelopmental outcomes in early childhood of preterm infants with CCHD after neonatal OHS. Prediction models were evaluated at various timepoints during hospitalization which could be useful in the management of these infants. Study Design: We studied all preterm infants with CCHD who received OHS within 6 weeks of corrected age between 1996 and 2016. The Western Canadian Complex Pediatric Therapies Follow-up Program completed multidisciplinary comprehensive neurodevelopmental assessments at 2-year corrected age at the referral-site follow-up clinics. We collected demographic and acute-care clinical data, standardized age-appropriate outcome measures including physical growth with calculated z-scores; disabilities including cerebral palsy, visual impairment, permanent hearing loss; adaptive function (Adaptive Behavior Assessment System-II); and cognitive, language, and motor skills (Bayley Scales of Infant and Toddler Development-III). Multiple variable logistic or linear regressions determined predictors displayed as Odds Ratio (OR) or Effect Size (ES) with 95% confidence intervals. Results: Of 115 preterm infants (34 ± 2 weeks gestation, 2,339 ± 637 g, 64% males) with CCHD and OHS, there were 11(10%) deaths before first discharge and 21(18%) deaths by 2-years. Seven (6%) neonates had cerebral injuries, 7 had necrotizing enterocolitis; none had retinopathy of prematurity. Among 94 survivors, 9% had cerebral palsy and 6% had permanent hearing loss, with worse outcomes in those with syndromic diagnoses. Significant predictors of mortality included birth weight z-score [OR 0.28(0.11,0.72), P = 0.008], single-ventricle anatomy [OR 5.92(1.31,26.80), P = 0.021], post-operative ventilation days [OR 1.06(1.02,1.09), P = 0.007], and cardiopulmonary resuscitation [OR 11.58 (1.97,68.24), P = 0.007]; for adverse functional outcome in those without syndromic diagnoses, birth weight 2,000-2,499 g [ES -11.60(-18.67, -4.53), P = 0.002], post-conceptual age [ES -0.11(-0.22,0.00), P = 0.044], post-operative lowest pH [ES 6.75(1.25,12.25), P = 0.017], and sepsis [ES -9.70(-17.74, -1.66), P = 0.050]. Conclusions: Our findings suggest preterm neonates with CCHD and early OHS had significant mortality and morbidity at 2-years and were at risk for cerebral palsy and adverse neurodevelopment. This information may be important for management, parental counseling and the decision-making process.
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Affiliation(s)
- Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- NICU, Northern Alberta Neonatal Program of Alberta Health Services, Edmonton, AB, Canada
| | | | - Irina A. Dinu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | | | - Ari R. Joffe
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- PICU Stollery Children's Hospital, Edmonton, AB, Canada
| | - Gwen Y. Bond
- Complex Pediatric Therapies Developmental Assessment Clinic at the Glenrose Rehabilitation Hospital of Alberta Health Services, Edmonton, AB, Canada
| | - Charlene M. T. Robertson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Complex Pediatric Therapies Developmental Assessment Clinic at the Glenrose Rehabilitation Hospital of Alberta Health Services, Edmonton, AB, Canada
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Huisenga D, La Bastide‐Van Gemert S, Van Bergen A, Sweeney J, Hadders‐Algra M. Developmental outcomes after early surgery for complex congenital heart disease: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:29-46. [PMID: 32149404 PMCID: PMC7754445 DOI: 10.1111/dmcn.14512] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
AIM (1) To systematically review the literature on developmental outcomes from infancy to adolescence of children with complex congenital heart disease (CHD) who underwent early surgery; (2) to run a meta-regression analysis on the Bayley Scales of Infant Development, Second Edition Mental Developmental Index and Psychomotor Developmental Index (PDI) of infants up to 24 months and IQs of preschool-aged children to adolescents; (3) to assess associations between perioperative risk factors and outcomes. METHOD We searched pertinent literature (January 1990 to January 2019) in PubMed, Embase, CINAHL, and PsycINFO. Selection criteria included infants with complex CHD who had primary surgery within the first 9 weeks of life. Methodological quality, including risk of bias and internal validity, were assessed. RESULTS In total, 185 papers met the inclusion criteria; the 100 with high to moderate methodological quality were analysed in detail. Substantial heterogeneity in the group with CHD and in methodology existed. The outcome of infants with single-ventricle CHD was inferior to those with two-ventricle CHD (respectively: average scores for PDI 77 and 88; intelligence scores 92 and 98). Perioperative risk factors were inconsistently associated with developmental outcomes. INTERPRETATION The literature on children undergoing surgery in early infancy suggests that infants with a single ventricle are at highest risk of adverse developmental outcomes.
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Affiliation(s)
- Darlene Huisenga
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
| | - Sacha La Bastide‐Van Gemert
- University of GroningenUniversity Medical Center GroningenDepartment of EpidemiologyGroningenthe Netherlands
| | - Andrew Van Bergen
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,Advocate Children’s Heart Institute Division of Pediatric Cardiac Critical CareAdvocate Children’s HospitalOak LawnILUSA
| | - Jane Sweeney
- Pediatric Science Doctoral ProgramRocky Mountain University of Health ProfessionsProvoUTUSA
| | - Mijna Hadders‐Algra
- University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
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Abeysekera JB, Gyenes DL, Atallah J, Robertson CMT, Bond GY, Rebeyka IM, Moez EK, Dinu IA, Switzer HN, Hornberger LK. Fetal Umbilical Arterial Pulsatility Correlates With 2-Year Growth and Neurodevelopmental Outcomes in Congenital Heart Disease. Can J Cardiol 2020; 37:425-432. [PMID: 32653583 DOI: 10.1016/j.cjca.2020.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Jayani B Abeysekera
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Dora L Gyenes
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Glenrose Rehabilitation Hospital, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gwen Y Bond
- Glenrose Rehabilitation Hospital, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ivan M Rebeyka
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | | | - Irina A Dinu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Atallah J, Garcia Guerra G, Joffe AR, Bond GY, Islam S, Ricci MF, AlAklabi M, Rebeyka IM, Robertson CMT. Survival, Neurocognitive, and Functional Outcomes After Completion of Staged Surgical Palliation in a Cohort of Patients With Hypoplastic Left Heart Syndrome. J Am Heart Assoc 2020; 9:e013632. [PMID: 32067591 PMCID: PMC7070198 DOI: 10.1161/jaha.119.013632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Management of patients with hypoplastic left heart syndrome has benefited from advancements in medical and surgical care. Outcomes have improved, although survival and long‐term functional and cognitive deficits remain a concern. Methods and Results This is a cohort study of all consecutive patients with hypoplastic left heart syndrome undergoing surgical palliation at a single center. We aimed to examine demographic and perioperative factors from each surgical stage for their association with survival and neurocognitive outcomes. A total of 117 consecutive patients from 1996 to 2010 underwent surgical palliation. Seventy patients (60%) survived to the Fontan stage and 68 patients (58%) survived to undergo neurocognitive assessment at a mean (SD) age of 56.6 months (6.4 months). Full‐scale, performance, and verbal intelligence quotient, as well as visual‐motor integration mean (SD) scores were 86.7 (16.1), 86.3 (15.8), 88.8 (17.2), and 83.2 (14.8), respectively. On multivariable analysis, older age at Fontan, sepsis peri‐Norwood, lowest arterial partial pressure of oxygen postbidirectional cavopulmonary anastomosis, and presence of neuromotor disability pre‐Fontan were strongly associated with lower scores for all intelligence quotient domains. Older age at Fontan and sepsis peri‐Norwood remained associated with lower scores for all intelligence quotient domains in a subgroup analysis excluding patients with disability pre‐Fontan or with chromosomal abnormalities. Conclusions Older age at Fontan and sepsis are among independent predictors of poor neurocognitive outcomes for patients with hypoplastic left heart syndrome. Further studies are required to identify the appropriate age range for Fontan completion, balancing a lower risk of acute and long‐term hemodynamic complications while optimizing long‐term neurocognitive outcomes.
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Affiliation(s)
- Joseph Atallah
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | | | - Ari R Joffe
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Gwen Y Bond
- Glenrose Rehabilitation Hospital Edmonton Alberta Canada
| | - Sunjidatul Islam
- Department of Medicine University of Alberta Edmonton Alberta Canada
| | - M Florencia Ricci
- Department of Pediatrics and Child Health University of Manitoba Winnipeg Manitoba Canada
| | | | - Ivan M Rebeyka
- Department of Surgery University of Alberta Edmonton Alberta Canada
| | - Charlene M T Robertson
- Department of Pediatrics University of Alberta Edmonton Alberta Canada.,Glenrose Rehabilitation Hospital Edmonton Alberta Canada
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Prevalence of Childhood Permanent Hearing Loss after Early Complex Cardiac Surgery. J Pediatr 2018; 198:104-109. [PMID: 29631768 DOI: 10.1016/j.jpeds.2018.02.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/20/2018] [Accepted: 02/14/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To estimate the prevalence of childhood permanent hearing loss (PHL) after early cardiac surgery. STUDY DESIGN This prospective observational (1996-2015) study after complex cardiac surgery with cardiopulmonary bypass at ≤6 weeks of life reports audiology follow-up by registered pediatric-experienced audiologists at 6-8 months postsurgery, age 2 years, and as required throughout and thereafter to complete diagnoses. PHL at any frequency (500-4000 Hz) is defined as responses of >25-decibel hearing level in either ear. PHL was evaluated by type (conductive or sensorineural), pattern (flat or sloping), and severity (mild to profound). RESULTS Survival rate was 83.4% (706 of 841 children) with a 97.9% follow-up rate (691 children); 41 children had PHL, 5.9% (95% CI 4.3%, 8.0%). By cardiac defect, prevalence was biventricular, 4.0% (95%CI 2.5%, 6.1%); single ventricle, 10.8% (95%CI 6.8%, 16.1%). Eighty-seven (12.6%) of 691 had syndromes/genetic abnormalities with known association with PHL; of these, 17 (41.5%) had PHL. Of 41 children, 4 had permanent conductive, moderate to severe loss (1 bilateral); 37 had moderate to profound sensorineural loss (29 bilateral with 20 sloping and 9 flat), 6 with cochlear implant done or recommended. CONCLUSIONS Infants surviving complex cardiac surgery are at high risk for PHL. Over 40% with PHL have known syndromes/genetic abnormalities, but others do not have easily identifiable risk indicators. Early cardiac surgery should be considered a risk indicator for PHL.
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Post-operative Outcomes in Children Undergoing Fontan Palliation in a Regionalized Surgical System. Pediatr Cardiol 2017; 38:1654-1662. [PMID: 28831564 DOI: 10.1007/s00246-017-1710-x] [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: 03/06/2017] [Accepted: 08/09/2017] [Indexed: 02/05/2023]
Abstract
Evidence suggests that outcomes in pediatric cardiac surgery are improved by consolidating care into centers of excellence. Our objective was to determine if outcomes are equivalent in patients across a large regional referral base, or if patients from centers without on-site surgery are at a disadvantage. Since 1996, all pediatric cardiac surgery has been offered at one of two centers within the region assessed, with the majority being performed at Stollery Children's Hospital. All patients who underwent a Fontan between 1996 and 2016 were included. Follow-up data including length of stay (LOS), repeat surgical interventions, and transplant-free survival were acquired for each patient. The association between post-operative outcomes and home center was assessed using Kaplan-Meier survival analysis and Cox proportional Hazards models. 320 children (median age 3.3 years, IQR 2.8-4.0) were included; 120 (37.5%) had the surgical center as their home center. Cardiac anatomy was hypoplastic left heart syndrome in 107 (33.4%) subjects. Median LOS was 11 days (IQR, 8-17), and there were 8 in-hospital deaths. There were 17 deaths and 11 transplants over the course of follow-up. Five-year transplant-free survival was 92.5%. There was no difference in hospital re-intervention, late re-intervention, or survival by referral center (all p > 0.05). In multivariable analysis, home center was not predictive of either LOS (R 2 = -0.40, p = 0.87) or transplant-free survival (1.52, 95%CI 0.66, 3.54). In children with complex congenital heart disease, a regionalized surgical care model achieves good outcomes, which do not differ according to a patient's home base.
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Siddiqui S, Fifer WP, Ordonez-Retamar M, Nugent JD, Williams IA. An antenatal marker of neurodevelopmental outcomes in infants with congenital heart disease. J Perinatol 2017; 37:953-957. [PMID: 28471442 PMCID: PMC5578909 DOI: 10.1038/jp.2017.59] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/23/2017] [Accepted: 03/31/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Prenatal exposures are known to alter fetal neurodevelopment and autonomic control. We aimed to explore the correlation between fetal autonomic activity, measured by fetal heart rate variability, and 18-month developmental outcome in subjects with congenital heart disease. STUDY DESIGN From 2010 to 2013, 5 fetuses with hypoplastic left heart syndrome, 9 with transposition of the great arteries and 9 with tetralogy of Fallot were included in this prospective cohort study. A maternal abdominal fetal electrocardiogram monitor recorded fetal heart rate at 34 to 38 weeks gestational age. We assessed associations between fetal heart rate parameters including interquartile range and s.d. of the fetal RR intervals and 18-month Bayley Scales of Infant Development-III scores using Pearson's correlation coefficient. Multivariable regression modeling identified predictors of neurodevelopmental scores. RESULTS Fetal heart rate variability parameters at 34 to 38 weeks gestational age correlated with 18-month Cognition (r=0.47, P=0.03) and Motor scores (r=0.66, P=0.001). The interquartile range of the fetal RR intervals predicted Cognition (β=0.462, P=0.028, R2=0.282) and Motor (β=0.637, P<0.001, R2=0.542) scores. CONCLUSIONS In fetuses with congenital heart disease, low heart rate variability at 34 to 38 weeks gestational age predicts diminished 18-month Cognitive and Motor performance. Prenatal autonomic activity may serve as a marker of early childhood development in these high-risk patients.
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Affiliation(s)
- Saira Siddiqui
- Department of Pediatrics, Columbia University Medical Center, New
York, NY
| | - William P. Fifer
- Department of Psychiatry, Columbia University Medical Center, New
York, NY
- Department of Pediatrics, Columbia University Medical Center, New
York, NY
- Division of Developmental Neuroscience, New York State Psychiatric
Institute, New York, NY
| | - Maria Ordonez-Retamar
- Division of Developmental Neuroscience, New York State Psychiatric
Institute, New York, NY
| | - J. David Nugent
- Division of Developmental Neuroscience, New York State Psychiatric
Institute, New York, NY
| | - Ismée A. Williams
- Department of Pediatrics, Columbia University Medical Center, New
York, NY
- Division of Developmental Neuroscience, New York State Psychiatric
Institute, New York, NY
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Martin BJ, De Villiers Jonker I, Joffe AR, Bond GY, Acton BV, Ross DB, Robertson CMT, Rebeyka IM, Atallah J. Hypoplastic Left Heart Syndrome is not Associated with Worse Clinical or Neurodevelopmental Outcomes Than Other Cardiac Pathologies After the Norwood-Sano Operation. Pediatr Cardiol 2017; 38:922-931. [PMID: 28341901 DOI: 10.1007/s00246-017-1598-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/28/2017] [Indexed: 11/29/2022]
Abstract
There is evidence to suggest that patients undergoing a Norwood for non-HLHS anatomy may have lower mortality than classic HLHS, but differences in neurodevelopmental outcome have not been assessed. Our objective was to compare survival and neurodevelopmental outcome during the same surgical era in a large, well-described cohort. All subjects who underwent a Norwood-Sano operation between 2005 and 2014 were included. Follow-up clinical, neurological, and developmental data were obtained from the Western Canadian Complex Pediatric Therapies Follow-up Program database. Developmental outcomes were assessed at 2 years of age using the Bayley Scales of Infant and Toddler Development (Bayley-III). Survival was assessed using Kaplan-Meier analysis. Baseline characteristics, survival, and neurodevelopmental outcomes were compared between those with HLHS and those with non-HLHS anatomy (non-HLHS). The study comprised 126 infants (75 male), 87 of whom had HLHS. Five-year survival was the same for subjects with HLHS and those with non-HLHS (HLHS 71.8%, non-HLHS 76.9%; p = 0.592). Ninety-three patients underwent neurodevelopmental assessment including Bayley-III scores. The overall mean cognitive composite score was 91.5 (SD 14.6), language score was 86.6 (SD 16.7) and overall mean motor composite score was 85.8 (SD 14.5); being lower than the American normative population mean score of 100 (SD 15) for each (p-value for each comparison, <0.0001). None of the cognitive, language, or motor scores differed between those with HLHS and non-HLHS (all p > 0.05). In the generalized linear models, dominant right ventricle anatomy (present in 117 (93%) of patients) was predictive of lower language and motor scores. Comparative analysis of the HLHS and non-HLHS groups undergoing single ventricle palliation including a Norwood-Sano, during the same era, showed comparable 2-year survival and neurodevelopmental outcomes.
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Affiliation(s)
| | | | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Gwen Y Bond
- Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Canada.,Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Bryan V Acton
- Royal University Hospital, University of Saskatchewan, Saskatoon, Canada
| | - David B Ross
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, Canada.,Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Canada
| | - Ivan M Rebeyka
- Department of Surgery, University of Alberta, Edmonton, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Joseph Atallah
- Department of Surgery, University of Alberta, Edmonton, Canada
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Gunn JK, Beca J, Hunt RW, Goldsworthy M, Brizard CP, Finucane K, Donath S, Shekerdemian LS. Perioperative risk factors for impaired neurodevelopment after cardiac surgery in early infancy. Arch Dis Child 2016; 101:1010-1016. [PMID: 27272973 DOI: 10.1136/archdischild-2015-309449] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 04/09/2016] [Accepted: 05/08/2016] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Julia K Gunn
- Newborn Intensive Care, The Royal Children's Hospital, Melbourne, Australia.,Neonatal Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Australia
| | - John Beca
- Department of Paediatric Intensive Care, Starship Children's Hospital, Auckland, New Zealand
| | - Rodney W Hunt
- Newborn Intensive Care, The Royal Children's Hospital, Melbourne, Australia.,Neonatal Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Australia
| | - Michelle Goldsworthy
- Department of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas, USA
| | - Christian P Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Kirsten Finucane
- Department of Cardiac Surgery, Starship Children's Hospital, Auckland, New Zealand
| | - Susan Donath
- Department of Paediatrics, The University of Melbourne, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - Lara S Shekerdemian
- Department of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas, USA
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15
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Martin BJ, Ross DB, Alton GY, Joffe AR, Robertson CMT, Rebeyka IM, Atallah J. Clinical and Functional Developmental Outcomes in Neonates Undergoing Truncus Arteriosus Repair: A Cohort Study. Ann Thorac Surg 2016; 101:1827-33. [PMID: 26952297 DOI: 10.1016/j.athoracsur.2015.10.114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 09/19/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Truncus arteriosus (TA) is an uncommon congenital cardiac lesion that portends an exceedingly poor prognosis if not repaired. The objective of this study was to assess the clinical and developmental outcomes in a prospective cohort of patients who underwent TA repair. METHODS All patients who underwent a TA repair between 1996 and 2012 were included. Follow-up clinical, neurologic, and developmental data were obtained from the Western Canadian Complex Pediatric Therapies Follow-up Program database. Functional developmental outcomes were assessed at 21.1 ± 2.5 months of age with the Adaptive Behavior Assessment System-II, General Adaptive Composite (GAC) score. Survival and outcomes were compared between those with and without chromosomal abnormalities (CA). Survival and freedom from reintervention were assessed by Kaplan-Meier analysis. RESULTS The study comprised 36 infants (19 male). CA was identified in 13, with 22q11.2 deletion in 10 patients. Patients underwent TA repair at a median age of 10 days; 5 patients underwent concomitant interrupted arch repair. There were 8 deaths, 2 of which occurred in the hospital. The 5-year survival was 79.4%. Survival was similar between those with and without CA. At 5 years, freedom from reoperation was 77.2%. The mean GAC was higher in the patients without CA (93.6 ± 12.8 vs 76.1 ± 13.1, p = 0.0016). CONCLUSIONS Patients with surgically repaired TA continue to have significant postoperative mortality. Reoperation and cardiac catheterization are eventualities for a quarter of patients in the first 5 years of life. Functional developmental outcome in patients without CA is good, although it is significantly impaired in those with CA.
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Affiliation(s)
- Billie-Jean Martin
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - David B Ross
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Gwen Y Alton
- Pediatric Rehabilitation Outcomes Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; Pediatric Intensive Care, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Ari R Joffe
- Pediatric Intensive Care, Stollery Children's Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Charlene M T Robertson
- Pediatric Rehabilitation Outcomes Unit, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ivan M Rebeyka
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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16
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Ricci MF, Andersen JC, Joffe AR, Watt MJ, Moez EK, Dinu IA, Garcia Guerra G, Ross DB, Rebeyka IM, Robertson CMT. Chronic Neuromotor Disability After Complex Cardiac Surgery in Early Life. Pediatrics 2015; 136:e922-33. [PMID: 26391946 DOI: 10.1542/peds.2015-1879] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known about chronic neuromotor disability (CND) including cerebral palsy and motor impairments after acquired brain injury in children surviving early complex cardiac surgery (CCS). We sought to determine the frequency and presentation of CND in this population while exploring potentially modifiable acute care predictors. METHODS This prospective follow-up study included 549 children after CCS requiring cardiopulmonary bypass at ≤6 weeks of age. Groups included those with only 1 CCS, mostly biventricular CHD, and those with >1 CCS, predominantly single ventricle defects. At 4.5 years of age, 420 (94.6%) children received multidisciplinary assessment. Frequency of CND is given as percentage of assessed survivors. Predictors of CND were analyzed using multiple logistic regression analysis. RESULTS CND occurred in 6% (95% confidence interval [CI] 3.7%-8.2%) of 4.5-year survivors; for 1 CCS, 4.2% (CI 2.3%-6.1%) and >1, 9.8% (CI 7%-12.6%). CND presentation showed: hemiparesis, 72%; spasticity, 80%; ambulation, 72%; intellectual disability, 44%; autism, 16%; epilepsy, 12%; permanent vision and hearing impairment, 12% and 8%, respectively. Overall, 32% of presumed causative events happened before first CCS. Independent odds ratio for CND are age (days) at first CCS, 1.08 (CI 1.04-1.12; P < .001); highest plasma lactate before first CCS (mmol/L), 1.13 (CI 1.03-1.23; P = 0.008); and >1 CCS, 3.57 (CI 1.48-8.9; P = .005). CONCLUSIONS CND is not uncommon among CCS survivors. The frequency of associated disabilities characterized in this study informs pediatricians caring for this vulnerable population. Shortening the waiting period and reducing preoperative plasma lactate levels at first CCS may assist in reducing the frequency of CND.
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Affiliation(s)
| | - John C Andersen
- Division of Developmental Pediatrics, Department of Pediatrics, Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Canada; and
| | - Ari R Joffe
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Canada
| | - Man-Joe Watt
- Division of Developmental Pediatrics, Department of Pediatrics, Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Canada; and
| | | | | | - Gonzalo Garcia Guerra
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Canada
| | - David B Ross
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Ivan M Rebeyka
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Charlene M T Robertson
- Division of Developmental Pediatrics, Department of Pediatrics, Pediatric Rehabilitation, Glenrose Rehabilitation Hospital, Edmonton, Canada; and
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17
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Mackie AS, Vatanpour S, Alton GY, Dinu IA, Ryerson L, Moddemann DM, Thomas Petrie J. Clinical Outcome Score Predicts Adverse Neurodevelopmental Outcome After Infant Heart Surgery. Ann Thorac Surg 2015; 99:2124-32. [PMID: 25912744 DOI: 10.1016/j.athoracsur.2015.02.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 01/29/2015] [Accepted: 02/10/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to determine whether a clinical outcome score derived from early postoperative events is associated with Bayley-III scores at 18 to 24 months among infants undergoing cardiopulmonary bypass surgery. METHODS Included were infants aged 6 weeks or less who underwent surgery between 2005 and 2009, all of whom were referred for neurodevelopmental evaluation at 18 to 24 months. We excluded children with chromosomal abnormalities. The prespecified clinical outcome score had a range of 0 to 7. Lower scores indicated a more rapid postoperative recovery. Patients requiring extracorporeal life support were assigned a score of 7. RESULTS One hundred and ninety-nine subjects were included. Surgical procedures were arterial switch (72), Norwood (60), repair of total anomalous pulmonary venous connection (29), and other (38). Nine subjects had postoperative extracorporeal life support. Mean clinical outcome score in the Norwood group was 4.0 ± 1.4 versus the arterial switch group (2.6 ± 1.5, p < 0.001), total anomalous pulmonary venous connection group (2.8 ± 1.8, p < 0.01), and other group (4.0 ± 1.8, p = not significant). Among children who had a clinical outcome score of 4 or greater, there was a decrease in Bayley-III cognitive score of 5.7 (95% confidence interval: 1.5 to 9.9, p = 0.009), a decrease in language score of 10.0 (95% confidence interval: 4.9 to 15.1, p < 0.001), and a decrease in motor score of 9.7 (95% confidence interval: 4.8 to 14.5, p < 0.001). Time until lactate of 2.0 mmol/L or less and highest 24-hour inotrope score increased with increasing clinical outcome score (p < 0.0001). CONCLUSIONS Clinical outcome scores of 4 or greater were associated with significantly lower Bayley-III scores at 18 to 24 months. This score may be valuable as an endpoint when evaluating novel potential therapies for this high-risk population.
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Affiliation(s)
- Andrew S Mackie
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Stollery Children's Hospital, Edmonton, Alberta, Canada.
| | - Shabnam Vatanpour
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Gwen Y Alton
- Stollery Children's Hospital, Edmonton, Alberta, Canada; Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Irina A Dinu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsay Ryerson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Diane M Moddemann
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Thomas Petrie
- Department of Psychology, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
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18
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Abstract
BACKGROUND It is important to identify early predictors of functional limitations in children after congenital heart surgery to optimise their independence as they prepare for school. The purpose of this study is to determine potentially modifiable predictor variables of functional abilities in pre-school children who underwent complex cardiac surgery at 6 weeks of age or earlier. METHODS This prospective inception cohort study comprised a sample of 165 survivors (63% boys) who had complex cardiac surgery (75% biventricular repairs) at Stollery Children's Hospital, Edmonton, Alberta. We excluded children with chromosomal abnormalities. When children were 4-5 years of age, the parents completed the Adaptive Behavioral Assessment System II. Regression analysis was used to assess the association between multiple risk factors and each of the four continuous composite scores. RESULTS The mean scores for the practical domain and general adaptive composite score of the Adaptive Behavioural Assessment System were lower than the conceptual and social domains, with 13.3% of the children having a delay in the practical domain. There was a significant association between the general adaptive (p=0.003; 0.012), conceptual (p=0.0004; 0.042), social (p=0.0007; 0.028), and the practical (p=0.046; 0.003) domain composite scores with the mother's education and preoperative plasma lactate, respectively. CONCLUSION Maternal education may be a marker for the social context of children, and warrants societal attention to improve functional outcomes. Preoperative lactate as a potentially modifiable variable may warrant increased attention to early diagnosis and aggressive resuscitation of young infants with congenital heart disease.
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Robertson CMT, Dinu IA, Joffe AR, Alton GY, Yap JYK, Asthana S, Acton BV, Sauve RS, Martin SR, Kneteman NM, Gilmour SM. Neurocognitive outcomes at kindergarten entry after liver transplantation at <3 yr of age. Pediatr Transplant 2013; 17:621-30. [PMID: 23961979 DOI: 10.1111/petr.12134] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2013] [Indexed: 12/22/2022]
Abstract
This prospective inception cohort study determines kindergarten-entry neurocognitive abilities and explores their predictors following liver transplantation at age <3 yr. Of 52 children transplanted (1999-2008), 33 (89.2%) of 37 eligible survivors had psychological assessment at age 54.7 (8.4) months: 21 with biliary atresia, seven chronic cholestasis, and five acute liver failure. Neurocognitive scores (mean [s.d.], 100 [15]) as tested by a pediatric-experienced psychologist did not differ in relation to age group at transplant (≤12 months and >12 months): FSIQ, 93.9 (17.1); verbal (VIQ), 95.3 (16.5); performance (PIQ), 94.3 (18.1); and VMI, 90.5 (15.9), with >70% having scores ≥85, average or above. Adverse predictors from the pretransplant, transplant, and post-transplant (30 days) periods using univariate linear regressions for FSIQ were post-transplant use of inotropes, p = 0.029; longer transplant warm ischemia time, p = 0.035; and post-transplant highest serum creatinine, (p = 0.04). For PIQ, they were pretransplant encephalopathy, p = 0.027; post-transplant highest serum creatinine, p = 0.034; and post-transplant inotrope use, p = 0.037. For VMI, they were number of post-transplant infections, p = 0.019; post-transplant highest serum creatinine, p = 0.025; and lower family socioeconomic index, p = 0.039. Changes in care addressing modifiable predictors, including reducing acute post-transplant illness, pretransplant encephalopathy, transplant warm ischemia times, and preserving renal function, may improve neurocognitive outcomes.
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Affiliation(s)
- Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Pediatric Rehabilitation Outcomes Unit, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
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Abstract
Hemodynamic monitoring is central to the management of critically ill patients in the cardiac intensive care unit (CICU). The goals of hemodynamic monitoring are to anticipate threats and complications before they arise, to gauge the effectiveness of interventions, and to avoid progression to a decompensated shock state. Although there are numerous modalities of hemodynamic monitoring in the CICU, discordance exists between assessments based on physical exam and standard hemodynamic parameters and those based on measurements of cardiac output. This article will review both the standard and advanced hemodynamic monitoring strategies employed in the CICU.
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Affiliation(s)
- Rocky Tsang
- Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex, USA
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21
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Morgan CJ, Zappitelli M, Robertson CMT, Alton GY, Sauve RS, Joffe AR, Ross DB, Rebeyka IM. Risk factors for and outcomes of acute kidney injury in neonates undergoing complex cardiac surgery. J Pediatr 2013; 162:120-7.e1. [PMID: 22878115 DOI: 10.1016/j.jpeds.2012.06.054] [Citation(s) in RCA: 174] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 05/15/2012] [Accepted: 06/27/2012] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To characterize the epidemiology of and identify risk factors for neonatal cardiac surgery-associated acute kidney injury (CS-AKI) and determine its impact on clinical outcomes. STUDY DESIGN Using secondary analysis of data from an ongoing multiprovincial prospective cohort study, we studied 264 neonates undergoing complex cardiac repair. CS-AKI was defined based on the Acute Kidney Injury Network (AKIN) definition. We used regression modeling and survival analysis (adjusting for covariates) to evaluate associations. RESULTS CS-AKI occurred in 64% of the neonates in our study cohort. Lower age, longer cardiopulmonary bypass time, hypothermic circulatory arrest, type of repair, lower preoperative serum creatinine (SCr) level, lower gestational age, and preoperative ventilation were independent risk factors for developing CS-AKI. Neonates with CS-AKI had longer times to extubation, intensive care discharge, and hospital discharge, after adjusting for covariates. Mortality was significantly increased in neonates with AKIN stage 2 or higher CS-AKI. The neonates with CS-AKI had a lower z-score for height at 2-year follow-up and were seen by more specialists. CONCLUSION Neonatal CS-AKI is common and independently predicts important clinical outcomes, including mortality. Many risk factors are similar to those in older children, but some are unique to neonates. The observation that lower baseline SCr predicts CS-AKI merits further study. The AKIN definition, based on preoperative SCr value, is a reasonable method for defining CS-AKI in neonates. Many previous studies of CS-AKI have excluded neonates; we suggest that future intervention studies on approaches to reducing CS-AKI incidence and improving outcomes should include neonates.
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Affiliation(s)
- Catherine J Morgan
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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22
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Abstract
OBJECTIVE To describe the gross motor development of infants who had undergone cardiac surgery in the neonatal or early infant period. METHODS Gross motor performance was assessed when infants were 4, 8, 12, and 16 months of age with the Alberta Infant Motor Scale. This scale is a discriminative gross motor outcome measure that may be used to assess infants from birth to independent walking. Infants were videotaped during the assessment and were later evaluated by a senior paediatric physiotherapist who was blinded to each infant's medical history, including previous clinical assessments. Demographic, diagnostic, surgical, critical care, and medical variables were considered with respect to gross motor outcomes. RESULTS A total of 50 infants who underwent elective or emergency cardiac surgery at less than or up to 8 weeks of age, between July 2006 and January 2008, were recruited to this study and were assessed at 4 months of age. Approximately, 92%, 84%, and 94% of study participants returned for assessment at 8, 12, and 16 months of age, respectively. Study participants had delayed gross motor development across all study time points; 62% of study participants did not have typical gross motor development during the first year of life. Hospital length of stay was associated with gross motor outcome across infancy. CONCLUSION Active gross motor surveillance of all infants undergoing early cardiac surgery is recommended. Further studies of larger congenital heart disease samples are required, as are longitudinal studies that determine the significance of these findings at school age and beyond.
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Abstract
OBJECTIVE This study compares the developmental and functional outcomes at school entry between boys and girls born with a congenital cardiac defect who required early surgical correction. STUDY DESIGN A prospective cohort of 94 children, including 49 percent boys, were followed up to 5 years of age and assessed for developmental progress. Developmental measures included Wechsler Preschool and Primary Scale of Intelligence - cognitive; Peabody Picture Vocabulary Test - receptive language; Peabody Developmental Motor Scale - motor; and Child Behaviour Checklist - behaviour. Measures of function included the Vineland Adaptive Behavior Scale and Functional Independence Measure for Children (WeeFIM). RESULTS The mean scores of the boys on the WeeFIM subscales, such as self-care, mobility, cognition, were significantly lower than that of the girls. There was a trend for a greater proportion of boys to have abnormalities on neurological examination (boys 37.5 percent abnormal, girls 19.5 percent abnormal). Verbal, performance, and full scale Intellectual Quotients were 5-7 points lower in boys but did not reach significance (full scale Intellectual Quotient: boys 87.7 plus or minus 22.2; girls 93.9 plus or minus 19.3). Boys were more likely to have fine motor delays (50 percent, 82.7 plus or minus 16.5) compared with girls (28.2 percent, 87.0 plus or minus 15.8). There were no gender differences in receptive language or behavioural difficulties. CONCLUSIONS Boys born with congenital heart disease requiring early surgical repair appear to be at enhanced risk for neuromotor impairments and activity limitations. Findings support gender differences in the pathogenesis of early brain injury following hypoxic-ischaemic insults. This has implications for neuroprotective strategies to prevent brain injury.
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Mackie AS, Alton GY, Dinu IA, Joffe AR, Roth SJ, Newburger JW, Robertson CMT. Clinical outcome score predicts the need for neurodevelopmental intervention after infant heart surgery. J Thorac Cardiovasc Surg 2012; 145:1248-1254.e2. [PMID: 22959319 DOI: 10.1016/j.jtcvs.2012.04.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/23/2012] [Accepted: 04/13/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Our goal was to determine if a clinical outcome score derived from early postoperative events is associated with 18- to 24-month Psychomotor Developmental Index (PDI) score among infants undergoing cardiopulmonary bypass surgery. METHODS We included infants aged ≤6 weeks who underwent surgery during 2002-2006, all of whom were referred for neurodevelopmental evaluation at age 18 to 24 months. We excluded children with chromosomal abnormalities, hearing loss, cerebral palsy, or a Bayley III assessment. The prespecified clinical outcome score had a range of 0 to 7. Lower scores indicated a more rapid postoperative recovery. Patients requiring extracorporeal membrane oxygenation were assigned a score of 7. RESULTS Ninety-nine subjects were included. Surgical procedures were arterial switch (n = 36), Norwood (n = 26), repair of total anomalous pulmonary venous connection (n = 16), and other (n = 21). Four subjects had postoperative extracorporeal membrane oxygenation. Clinical outcome scores were highest in the Norwood group (mean 4.1 ± 1.4) compared with the arterial switch group (1.9 ± 1.6) (P < .001), total anomalous pulmonary venous connection group (1.6 ± 2.0) (P < .001), and other group (3.3 ± 1.6, P = not significant). A mean decrease in PDI of 10.9 points (95% confidence interval, 4.9-16.9; P = .0005) was observed among children who had a clinical outcome score ≥3, compared with those with a clinical outcome score <3. Time until lactate ≤2.0 mmol/L increased with increasing clinical outcome score (P = .0003), as did highest 24-hour inotrope score (P < .0001). CONCLUSIONS Clinical outcome scores of ≥3 were associated with a significantly lower PDI at age 18 to 24 months. This score may be valuable as an end point when evaluating novel potential therapies for this high-risk population.
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Affiliation(s)
- Andrew S Mackie
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Long SH, Galea MP, Eldridge BJ, Harris SR. Performance of 2-year-old children after early surgery for congenital heart disease on the Bayley Scales of Infant and Toddler Development, Third Edition. Early Hum Dev 2012; 88:603-7. [PMID: 22336496 DOI: 10.1016/j.earlhumdev.2012.01.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Revised: 01/09/2012] [Accepted: 01/10/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Previous research on developmental outcomes of infants with congenital heart disease (CHD) has shown delays in both cognitive and motor skills. AIMS To describe outcomes on the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III) for infants with CHD and to compare those findings to published results for similar samples of infants assessed on the 2nd edition of the Bayley Scales (BSID-II). STUDY DESIGN Prospective cohort. PARTICIPANTS AND OUTCOME MEASURES Of 50 infants with CHD who participated in this longitudinal study (2006-2008) at the Royal Children's Hospital in Melbourne, Australia, 47 were assessed on the Bayley-III (median age=24.5 months), administered by a psychologist or neonatologist. Although neither assessor was blind to the CHD diagnosis, they were unaware of results of previous developmental assessments conducted in this longitudinal study. RESULTS For the Bayley-III cognitive composite score, 17.0% of infants showed mild delays (1-2 SD below the mean), 2.1% had moderate delays (2-3 SD below the mean), and none had severe delays (greater than 3 SD below the mean). Motor composite scores showed mild delays in 10.9% of infants and moderate delays in 2.2%; none had severe motor delays. These findings differ from study results using the BSID-II in similar infants. CONCLUSIONS The Bayley-III may underestimate developmental delay in 2-year-old children with CHD when compared to results of similar children tested at 12-36 months of age on the BSID-II.
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Affiliation(s)
- Suzanne H Long
- The Murdoch Children's Research Institute and The University of Melbourne, Melbourne, Australia
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Robertson CMT, Alton GY, Bork KT, Joffe AR, Tawfik GC, Sauve RS, Moddemann DM, Ross DB, Rebeyka IM. Bilateral sensory permanent hearing loss after palliative hypoplastic left heart syndrome operation. Ann Thorac Surg 2011; 93:1248-53. [PMID: 22105869 DOI: 10.1016/j.athoracsur.2011.08.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/16/2011] [Accepted: 08/18/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Bilateral sensory permanent hearing loss (PHL) has been reported after neonatal respiratory failure but has rarely been noted in survivors after cardiac operations. We report the prevalence and severity of PHL after Norwood right ventricular-pulmonary artery shunt for hypoplastic left heart syndrome (HLHS), document progressive loss, and explore markers of acute illness and ototoxic medications for PHL. METHODS This interprovincial longitudinal outcome study after neonatal complex cardiac operations at Stollery Children's Hospital, Edmonton, Alberta, Canada, 2002 to 2007, completed repeated diagnostic audiologic assessments for all survivors by registered pediatric-experienced audiologists. Demographic, surgical, and perisurgical variables, including ototoxic medications, were collected. The association of potentially predictive variables with PHL and its severity were determined by univariate analysis and multiple logistic and linear regression analysis. RESULTS At an age older than 3.5 years, progressive PHL was present in 12 of 42 survivors (28.6%, 95% confidence interval, 16.2% to 44.8%; mortality, 20.9%). Overall lowest partial pressure of arterial oxygen (odds ratio, 1.315; 95% confidence interval, 1.051 to 1.506), and cumulative dose of furosemide given as bolus (odds ratio, 1.062; 95% confidence interval, 1.018 to 1.109) combined to predict PHL and gave 39% of the variance of PHL severity. Antibiotics and neuromuscular blockers were not associated with PHL. CONCLUSIONS Monitoring outcomes of neonates after HLHS surgery revealed unexpected PHL associated with hypoxia and bolus administration of furosemide. As survival improves, close follow-up is necessary to identify outcomes and seek modifiable predictive variables. Changes in the mode of furosemide administration may prevent this complication.
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Affiliation(s)
- Charlene M T Robertson
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Canada.
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Acton BV, Biggs WSG, Creighton DE, Penner KAH, Switzer HN, Thomas JHP, Joffe AR, Robertson CMT. Overestimating neurodevelopment using the Bayley-III after early complex cardiac surgery. Pediatrics 2011; 128:e794-800. [PMID: 21949148 DOI: 10.1542/peds.2011-0331] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The newest measure of neurodevelopmental outcomes, the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III), gives higher-than-expected scores for preterm infants; results after cardiac surgery are unknown. OBJECTIVES The goal of this study was to report Bayley-III scores after cardiac surgery and compare the results with those of the Bayley Scales of Infant Development, 2nd Edition (BSID-II) on a subset of the same children. METHODS In this prospective, inception cohort, neurodevelopmental outcome study after complex cardiac surgery in infants from 2004 to 2007, the Bayley-III was given to 110 survivors (68% boys) at a mean age of 21 months (SD: 4 months). Analysis of variance was used to compare intergroup differences. Results for both test editions on the same 25 children were compared by using paired-samples statistics. RESULTS Mean (SD) Bayley-III mean composite scores (CSs) for 110 children were as follows: cognitive, 95.9 (14.1); language, 90.8 (18.1); and motor, 93.7 (14.2), differentiating selected cardiac surgery groups. The average difference in mean CSs was 7.4 points higher than BSID-II scores for a previous cohort from this site and 7.2 points higher than a systematic review report. Direct comparison of BSID-II and Bayley-III revealed an average difference in mean CSs of 6.1 points, similar to normative results. Mean cognitive CSs increased by 10.0 (P <.001), language by 1.4 (P = .526), and motor by 6.9 points (P = .009). CONCLUSIONS Researchers should be careful attributing higher Bayley-III scores to changes in acute care. At-risk children who previously qualified for early developmental intervention may no longer do so. School-age longitudinal studies are needed to determine the accuracy of early developmental estimates using the Bayley-III.
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Affiliation(s)
- Bryan V Acton
- aDepartment of Psychology, University of Saskatchewan,Saskatoon, Saskatchewan, Canada
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Abstract
PURPOSE OF REVIEW Advances in cardiac surgical techniques and intensive care have led to improved survival in babies with congenital heart disease (CHD). Although it is true that the majority of children with CHD today survive, many have impaired neurodevelopmental outcome. Although continuing to improve short-term morbidity and mortality are important goals, recent research has focused on defining the impact of CHD on brain development and brain injury in utero. RECENT FINDINGS The impact of CHD on the developing brain of the fetus and infant will be discussed. Neurologic abnormalities detectable prior to surgery will be described and postnatal progression of abnormalities will be highlighted. Potential causes of these findings will be discussed, including altered cerebral blood flow in utero, and brain development and risk for in-utero and postnatal brain injury. Finally, neurologic and developmental outcome after surgical repair of CHD will be reviewed. SUMMARY Neurodevelopmental evaluation preoperatively and postoperatively in CHD patients should be standard practice, not only to identify those with impairments who would benefit from intervention services but also to identify risk factors and strategies to optimize outcome. Fetal management and intervention strategies for specific defects may ultimately play a role in improving in-utero hemodynamics and increasing cerebral oxygen delivery to enhance brain development.
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Guerra GG, Robertson CMT, Alton GY, Joffe AR, Cave DA, Dinu IA, Creighton DE, Ross DB, Rebeyka IM. Neurodevelopmental outcome following exposure to sedative and analgesic drugs for complex cardiac surgery in infancy. Paediatr Anaesth 2011; 21:932-41. [PMID: 21507125 DOI: 10.1111/j.1460-9592.2011.03581.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES/AIM To determine whether sedation/analgesia drugs used before, during, and after infant cardiac surgery are associated with neurodevelopmental outcome. BACKGROUND Animal models suggest detrimental effects of anesthetic drugs on the developing brain. Whether these results can be extrapolated to human neonates is unclear. METHODS/MATERIALS This is a prospective follow-up project conducted in Western Canada. In all infants ≤6 weeks of age having surgery for congenital heart disease between April 2003 and December 2006, demographic and perioperative variables were collected prospectively. Sedation/analgesia variables were collected retrospectively. For each drug class (inhalationals, opioids, benzodiazepines, ketamine, and chloral hydrate), we calculated the cumulative dose received during hospitalization, average dose received per day, and cumulative number of days the patient received the drug. The outcomes at 18-24 months were as follows: General Adaptive Composite and motor scaled scores of the Adaptive Behavior Assessment System, significant mental, motor, and vocabulary delay. Multivariable logistic and linear regression was used to analyze the data. RESULTS One hundred and thirty-five neonates underwent open heart surgery; 19 died, 16 had chromosomal abnormality, and five were lost to follow up, leaving 95 survivors for analysis. Multiple linear regression analysis found no evidence of an association between sedation/analgesia variables and ABAS-GAC score or motor scale score. Multiple logistic regression analysis found no evidence of an association between sedation/analgesia variables and significant mental, motor, or vocabulary delay. CONCLUSION We found no evidence of an association between dose and duration of sedation/analgesia drugs during the operative and perioperative period and adverse neurodevelopmental outcomes.
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Abstract
BACKGROUND : The intra- and postoperative monitoring of lactate and acid-base has been advocated in pediatric cardiac critical care as surrogate markers of cardiac output, oxygen delivery, and cellular perfusion. Many clinicians use lactate and base excess routinely as markers of tissue perfusion and to assess the effectiveness of their intervention. This review discusses the strengths and weaknesses of using these measurements in pediatric cardiac critical care. METHODOLOGY : A search of MEDLINE, EMBASE, PubMed, and the Cochrane Database was conducted to find controlled trials of lactate and base excess. Adult and pediatric data were considered. Guidelines published by the Society of Critical Care Medicine, the American Heart Association, the American Academy of Pediatrics, and the International Liaison Committee on Resuscitation were reviewed including further review of references cited. RESULTS AND CONCLUSIONS : Many factors other than tissue hypoxia may contribute to hyperlactemia in critical illness. Although the presence of hyperlactemia on admission appears to be associated with intensive care unit mortality and morbidity in some retrospective analyses, significant overlap between survivors and nonsurvivors means that nonsurvivors cannot be predicted from admission lactate measurement. Persistently elevated postoperative lactate is associated with increased morbidity and mortality in the pediatric cardiac population. To date there is no randomized control trial of goal-directed therapy in adult or pediatric cardiac care that includes normalization of lactate as a target. Overall equivalent time measurements of base excess, anion gap, and pH have a low predictive value for morbidity and mortality in children after cardiac surgery. Lactate is one of a cluster of markers of cellular perfusion and oxygen delivery. Alone, as a single measurement, it has minimal predictive value and is nondiscriminatory for survival.
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Outcomes After Heart Transplantation in Children Under Six Years of Age. Ann Thorac Surg 2011; 92:174-82. [DOI: 10.1016/j.athoracsur.2011.02.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 02/08/2011] [Accepted: 02/11/2011] [Indexed: 11/20/2022]
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Owen M, Shevell M, Majnemer A, Limperopoulos C. Abnormal brain structure and function in newborns with complex congenital heart defects before open heart surgery: a review of the evidence. J Child Neurol 2011; 26:743-55. [PMID: 21610172 DOI: 10.1177/0883073811402073] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Newborns with complex congenital heart defects are at high risk for developing neurological abnormalities. It is important to understand the timing, progression, and extent of these abnormalities to better elucidate their potential impact on neurodevelopment, and their implications for early screening and intervention. This review synthesizes the recent literature describing neurological and neurobehavioral abnormalities observed in fetuses and newborns before cardiac surgery. A considerable proportion of newborns with complex congenital heart defects exhibit neurobehavioral and electrophysiological abnormalities preoperatively. Likewise, conventional neuroimaging studies reported that a high percentage of this population experienced brain injury. Advanced neuroimaging modalities indicated that fetuses showed delayed third trimester brain growth, and newborns showed impaired white matter maturation, reduced N-acetylaspartate, and increased lactate. These findings suggest a fetal or early postnatal onset of impaired brain growth and development. Consequently, reliable methods for early screening and subsequent developmental intervention must be implemented.
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Affiliation(s)
- Mallory Owen
- McGill University, Neurology and Neurosurgery, Montreal, Quebec, Canada
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Robertson CMT, Sauve RS, Joffe AR, Alton GY, Moddemann DM, Blakley PM, Synnes AR, Dinu IA, Harder JR, Soni R, Bodani JP, Kakadekar AP, Dyck JD, Human DG, Ross DB, Rebeyka IM. The registry and follow-up of complex pediatric therapies program of Western Canada: a mechanism for service, audit, and research after life-saving therapies for young children. Cardiol Res Pract 2011; 2011:965740. [PMID: 21629801 PMCID: PMC3099206 DOI: 10.4061/2011/965740] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 02/15/2011] [Accepted: 02/25/2011] [Indexed: 01/21/2023] Open
Abstract
Newly emerging health technologies are being developed to care for children with complex cardiac defects. Neurodevelopmental and childhood school-related outcomes are of great interest to parents of children receiving this care, care providers, and healthcare administrators. Since the 1970s, neonatal follow-up clinics have provided service, audit, and research for preterm infants as care for these at-risk children evolved. We have chosen to present for this issue the mechanism for longitudinal follow-up of survivors that we have developed for western Canada patterned after neonatal follow-up. Our program provides registration for young children receiving complex cardiac surgery, heart transplantation, ventricular assist device support, and extracorporeal life support among others. The program includes multidisciplinary assessments with appropriate neurodevelopmental intervention, active quality improvement evaluations, and outcomes research. Through this mechanism, consistently high (96%) follow-up over two years is maintained.
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Two-year survival and neurodevelopmental outcomes after cardiopulmonary resuscitation in neonatal patients after complex cardiac surgery. Resuscitation 2011; 82:313-8. [DOI: 10.1016/j.resuscitation.2010.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 10/17/2010] [Indexed: 11/19/2022]
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Functional outcomes after neonatal open cardiac surgery: comparison of survivors of the Norwood staged procedure and the arterial switch operation. Cardiol Young 2010; 20:668-75. [PMID: 20810009 DOI: 10.1017/s1047951110000971] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Improvements in long-term survival of children undergoing the Norwood staged procedure and the arterial switch operation have resulted in the need to prepare these at-risk children for each stage of their developmental trajectory, including school readiness. This study describes and compares functional outcomes following the Norwood staged procedure and arterial switch operations. METHODS This prospective inception cohort study comprised a sample of 73 children (71% boys) who had the Norwood staged procedure (n = 28) or the arterial switch operation (n = 45) at the age of 6 weeks or younger at the Stollery Children’s Hospital, Edmonton, Alberta, between 2002 and 2005. We excluded children who had chromosomal abnormalities or cerebral palsy. When children were 18-24 months of age, parents completed the Adaptive Behavioral Assessment System II. Standard scores for the domains are mean 100, standard deviation (15); skill area scaled scores, 10 (3). Student’s t-test with Bonferonni correction was used to compare groups. RESULTS This population has greater than four times the number of children delayed on the General Adaptive Composite than the normative group. Functional outcomes were similar in the two groups other than those of home living (Norwood: 8.8 (2.8) compared with arterial switch: 11.2 (3.1), t = 3.389, p = 0.001) and self-care (Norwood: 5.9 (3.5) versus arterial switch: 8.1 (2.6), t = 3.140, p = 0.002). CONCLUSION These survivors are at increased risk for delayed functional abilities. Self-care, necessary for independence and confidence as children reach school age, was particularly low in the Norwood group. Reasons for low self-care abilities require further study.
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Matsuzaki T, Matsui M, Ichida F, Nakazawa J, Hattori A, Yoshikosi K, Miyazaki M, Fujii M, Hagino I, Kagisaki K, Yagihara T. Neurodevelopment in 1-year-old Japanese infants after congenital heart surgery. Pediatr Int 2010; 52:420-7. [PMID: 19807876 DOI: 10.1111/j.1442-200x.2009.02974.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to determine the prevalence of persistent neurodevelopmental sequelae in 1-year-old infants after open heart surgery for congenital heart disease, using the Bayley Scales of Infant Development second edition (BSID-II). A secondary objective was to confirm the applicability and usefulness of the BSID-II in Japanese infants. METHODS Thirty-nine infants who underwent repair of a ventricular septal defect before 6 months of age and 108 normal Japanese infants at 1 year of age were assessed using the BSID-II. RESULTS In normal infants, scores on the Mental Development Index and the Psychomotor Development Index components of the BSID-II ranged from borderline retardation to very superior following a normal distribution similar to those obtained for US controls. No problems were encountered, either in translation or in following the instructions when the BSID-II was used to evaluate the 1-year-old Japanese infants. On the other hand, the mean scores on the Mental Development Index and the Psychomotor Development Index were significantly lower in Japanese patients than in normal Japanese infants, particularly for gross motor development (P < 0.001). Linear regression analysis showed that a longer intensive care unit stay was associated with impaired cognitive development at 1 year of age (P= 0.03). CONCLUSIONS Neurodevelopmental functions in 1-year-old infants with congenital heart disease were lower than those in normal infants, especially for gross motor function using the BSID-II. One risk factor that correlated with neurodevelopmental sequelae was the length of intensive care unit stay.
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Affiliation(s)
- Tachiyo Matsuzaki
- Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Japan.
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Blackwood J, Joffe AR, Robertson CM, Dinu IA, Alton G, Penner K, Ross DB, Rebeyka IM. Association of Hemoglobin and Transfusion With Outcome After Operations for Hypoplastic Left Heart. Ann Thorac Surg 2010; 89:1378-84.e1-2. [DOI: 10.1016/j.athoracsur.2010.01.064] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 01/24/2010] [Accepted: 01/25/2010] [Indexed: 12/17/2022]
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Snookes SH, Gunn JK, Eldridge BJ, Donath SM, Hunt RW, Galea MP, Shekerdemian L. A systematic review of motor and cognitive outcomes after early surgery for congenital heart disease. Pediatrics 2010; 125:e818-27. [PMID: 20231182 DOI: 10.1542/peds.2009-1959] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
CONTEXT Brain injury is the most common long-term complication of congenital heart disease requiring surgery during infancy. It is clear that the youngest patients undergoing cardiac surgery, primarily neonates and young infants, are at the greatest risk for brain injury. Developmental anomalies sustained early in life have lifelong repercussions. OBJECTIVE We conducted a systematic review to examine longitudinal studies of cognitive and/or motor outcome after cardiac surgery during early infancy. METHODS Electronic searches were performed in Medline, the Cumulative Index to Nursing and Allied Health Literature (Cinahl), and Embase (1998-2008). The search strategy yielded 327 articles, of which 65 were reviewed. Eight cohorts provided prospective data regarding the cognitive and/or motor outcome of infants who had undergone surgery for congenital heart disease before 6 months of age. Two authors, Ms Snookes and Dr Gunn, independently extracted data and presented results according to 3 subgroups for age of follow-up: early development (1 to <3 years); preschool age (3-5 years); and school age (>5 to 17 years). Weighted analysis was undertaken to pool the results of studies when appropriate. RESULTS All of the identified studies reported results of the Bayley Scales of Infant Development for children younger than the age of 3. Outcome data as reported by the Bayley Scales were combined for infants assessed at 1 year of age, revealing a weighted mean Mental Development Index of 90.3 (95% confidence interval: 88.9-91.6) and Psychomotor Development Index of 78.1 (95% confidence interval: 76.4-79.7). Additional analysis was limited by a lack of data at preschool and school age. CONCLUSIONS With this review we identified a limited number of prospective studies that systematically addressed outcome in patients at the highest risk. These studies consistently revealed cognitive and motor delay in children after cardiac surgery during early infancy. Additional investigation is required to ascertain the consequences of such impairment during later childhood and into adult life.
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Affiliation(s)
- Suzanne H Snookes
- Physiotherapy Department, Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia
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Abstract
Even in the presence of normal placental function, cerebral oxygen-substrate supply may be disrupted by disturbances in the fetal circulation caused by anomalous cardiac development. The impact of these cardiac lesions is likely dictated primarily by the volume and oxygen-substrate composition of transverse aortic arch perfusion. Advances in fetal echocardiography, fetal Doppler ultrasound, and advanced fetal magnetic resonance imaging techniques capable of quantitative structural and functional measurements are providing major insights into the in vivo effects of these cardiac lesions on brain growth and development. The progress to date with the application of these techniques is reviewed in this article.
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Affiliation(s)
- Catherine Limperopoulos
- Department of Neurology and Neurosurgery, McGill University, 2300 Tupper Street, Montreal, QC H3H 1P3, Canada.
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Joynt CA, Robertson CMT, Cheung PY, Nettel-Aguirre A, Joffe AR, Sauve RS, Biggs WSG, Leonard NJ, Ross DB, Rebeyka IM. Two-year neurodevelopmental outcomes of infants undergoing neonatal cardiac surgery for interrupted aortic arch: a descriptive analysis. J Thorac Cardiovasc Surg 2009; 138:924-32. [PMID: 19660371 DOI: 10.1016/j.jtcvs.2009.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 12/17/2008] [Accepted: 03/08/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study determined neurodevelopmental outcomes of survivors of neonatal cardiac surgery for interrupted aortic arch through an interprovincial program and explored preoperative, intraoperative, and postoperative outcome predictors. METHODS Children who underwent neonatal cardiac surgery for interrupted aortic arch at 6 weeks old or younger between 1996 and 2006 had a multidisciplinary neurodevelopmental assessment at 18 to 24 months old (mental and psychomotor developmental indices as mean +/- SD and delay [score <70]). Survivor outcomes were compared by univariate and multivariate analyses and compared between children with and without chromosomal abnormality. RESULTS Outcomes were available for all 26 survivors (mortality, 3.7%). Mental and psychomotor developmental indices were 75.8 +/- 17.1 and 72.3 +/- 16.9, respectively, with significantly lower scores for children with chromosomal abnormalities, which accounted for 29% of the variance in developmental indices. For the remaining 17 children without chromosomal abnormalities, mental and psychomotor developmental indices were 82.7 +/- 14.5 and 79.1 +/- 14.3, respectively, with deep hypothermic circulatory arrest time and Apgar score at 5 minutes contributing 46% of the variance in mental developmental index. CONCLUSIONS The neurodevelopmental indices of children who have undergone neonatal cardiac surgery for interrupted aortic arch are below normative values; those of children with chromosomal abnormalities are even lower. For children without a chromosomal abnormality, longer deep hypothermic circulatory arrest times and low Apgar scores predict lower mental developmental indices at 18 to 24 months of age.
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Affiliation(s)
- Chloe A Joynt
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Gilmour S, Adkins R, Liddell GA, Jhangri G, Robertson CM. Assessment of psychoeducational outcomes after pediatric liver transplant. Am J Transplant 2009; 9:294-300. [PMID: 19067656 DOI: 10.1111/j.1600-6143.2008.02480.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Outcomes research in pediatric liver transplant (LT) has focused on mortality and morbidity but there is a need to also evaluate functional outcomes. Standardized cognitive testing was administered to a cohort of children with infantile chronic liver disease who were transplanted at the University of Alberta during their preschool years. Thirty children had comprehensive assessments with the Bayley Scales of Infant Development or Wechsler testing. Patient variables potentially associated with cognitive delay were analyzed with multiple regression analysis. The mean DQ/IQ score (developmental quotient/intelligence quotient) was 81 +/- 17. Delay (DQ/IQ score < 70), and borderline delay (DQ/IQ 70-84) were each present in 27% of the cohort, with only 46% demonstrating normal cognition. Regression analysis demonstrated that the decreased IQ was associated with pretransplant growth retardation and elevated calcineurin inhibitor levels. Performance IQ had strong correlation with pretransplant growth retardation and elevated serum ammonia, R(2)= 45%, compared to verbal IQ that was associated was elevated calcineurin inhibitor levels, R(2)= 23%. Children post-LT are at high risk for cognitive delay or borderline delay. This is the first study to demonstrate the association calcineurin inhibitors with impaired IQ and also the unique finding of different variables predictive of impaired verbal intelligence quotient (VIQ) versus performance intelligence quotient (PIQ).
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Affiliation(s)
- S Gilmour
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada.
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Sarajuuri A, Lönnqvist T, Mildh L, Rajantie I, Eronen M, Mattila I, Jokinen E. Prospective follow-up study of children with univentricular heart: Neurodevelopmental outcome at age 12 months. J Thorac Cardiovasc Surg 2009; 137:139-45, 145.e1-2. [DOI: 10.1016/j.jtcvs.2008.06.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2008] [Revised: 04/01/2008] [Accepted: 06/15/2008] [Indexed: 11/26/2022]
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Atallah J, Dinu IA, Joffe AR, Robertson CM, Sauve RS, Dyck JD, Ross DB, Rebeyka IM. Two-Year Survival and Mental and Psychomotor Outcomes After the Norwood Procedure. Circulation 2008; 118:1410-8. [DOI: 10.1161/circulationaha.107.741579] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The Norwood procedure for stage 1 palliation of hypoplastic left heart syndrome is performed with either the modified Blalock-Taussig (MBTS) or the right ventricle–to–pulmonary artery (RVPA) shunt. In our institution, surgical practice changed from use of the MBTS to use of the RVPA shunt in 2002. We analyzed survival and mental and psychomotor outcomes of the 2 consecutive surgical eras.
Methods and Results—
Between September 1996 and July 2005, 94 neonates with hypoplastic left heart syndrome underwent the Norwood procedure. Patients were recruited as neonates and followed up prospectively. Health, mental, and psychomotor outcomes (Bayley Scales of Infant Development-II) were assessed at 2 years. The study subjects were from the Norwood-MBTS era (n=62; 1996 to 2002) or the Norwood-RVPA era (n=32; 2002 to 2005). In the MBTS era, early and 2-year mortality rates were 23% (14/62) and 52% (32/62); the mean (SD) mental and psychomotor developmental indices were 79 (18) and 67 (19). In the RVPA era, early and 2-year mortality rates were 6% (2/32) and 19% (6/32); the mean (SD) mental and psychomotor developmental indices were 85 (18) and 78 (18). The 2-year mortality rate (
P
=0.002) and the psychomotor developmental index (
P
=0.029) were improved in the more recent surgical era. On multivariable Cox regression analysis, postoperative highest serum lactate independently predicted 2-year mortality in the MBTS and RVPA eras.
Conclusions—
Analysis of 2 consecutive surgical eras of hypoplastic left heart syndrome patients undergoing the Norwood procedure showed a significant improvement in 2-year survival and psychomotor development in the more recent era. Adverse neurodevelopmental outcome in this patient population remains a concern.
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Affiliation(s)
- Joseph Atallah
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Irina A. Dinu
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Ari R. Joffe
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Charlene M.T. Robertson
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Reg S. Sauve
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - John D. Dyck
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - David B. Ross
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Ivan M. Rebeyka
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
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Lequier L, Joffe AR, Robertson CMT, Dinu IA, Wongswadiwat Y, Anton NR, Ross DB, Rebeyka IM. Two-year survival, mental, and motor outcomes after cardiac extracorporeal life support at less than five years of age. J Thorac Cardiovasc Surg 2008; 136:976-983.e3. [PMID: 18954639 DOI: 10.1016/j.jtcvs.2008.02.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Revised: 01/20/2008] [Accepted: 02/03/2008] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Comprehensive outcome assessment of children receiving cardiac extracorporeal life support. METHODS From 2000 to 2004, 39 consecutive children (aged 1 day to 4.4 years) had cardiac extracorporeal life support. Neurodevelopmental follow-up of all survivors was performed more than 6 months after life support (aged 53 +/- 12 months). Developmental delay was defined as a score of less than 70 on the Bayley Scales of Infant Development II or Wechsler Preschool and Primary Scale of Intelligence. Predictor variables for mortality (at 2 years' follow-up) and delay were examined by univariate and multivariate analyses. RESULTS Indications for extracorporeal life support were progressive low cardiac output in 14 (36%), failed weaning from cardiopulmonary bypass in 13 (33%), cardiac arrest in 9 (23%), and hypoxia in 3 (8%). Cardiac anatomy was single ventricle in 16 (41%), biventricular in 21 (54%), and myocarditis in 2 (5%). Survival was 18 (46%) at hospital discharge and 16 (41%) at 2 years. In survivors, mental score was 73 +/- 16 (normal 100 +/- 15), and 8 (50%) had mental delay. Initiating extracorporeal life support during cardiopulmonary resuscitation and duration of this resuscitation were not associated with death or mental delay. On multivariable Cox regression, lactate on admission to the pediatric intensive care unit (hazard rate 1.13; 95% confidence intervals 1.08-1.27) and single ventricle anatomy (hazard rate 3.93; 95% confidence intervals 1.62-9.49) were associated with death at 2 years. Stepwise multiple regression found time for lactate to normalize on extracorporeal life support, highest inotrope score during 120 hours of life support, and chromosomal abnormality explained 76.7% of the variance in mental score. CONCLUSION Cardiac extracorporeal life support had a 41% 2-year survival. Potentially modifiable variables (time for lactate to normalize and highest inotrope score early during extracorporeal life support) explained 69% of mental score variance.
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Affiliation(s)
- Laurance Lequier
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Nelson DP, Andropoulos DB, Fraser CD. Perioperative neuroprotective strategies. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2008; 11:49-56. [PMID: 18396225 DOI: 10.1053/j.pcsu.2008.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Long-term neurodevelopmental impairment is common in newborns and infants undergoing corrective or palliative congenital heart surgery. The etiologies of neurodevelopmental morbidity in these children are multifactorial and include prenatal, preoperative, intraoperative, and postoperative factors. Perioperative neurologic monitoring is thought to be integral to prevention or rescue from adverse neurologic events. Recent advances in perfusion techniques for congenital heart surgery now ensure adequate cerebral O(2) delivery during all phases of cardiopulmonary bypass. Periventricular leukomalacia and other serious neurologic injury can be minimized by an optimized perfusion strategy of continuous high-flow, high hematocrit cardiopulmonary bypass, minimal use of deep hypothermic circulatory arrest, antegrade cerebral perfusion during aortic arch reconstruction, pH-stat blood gas strategy, and cerebral monitoring with NIRS and trans-cranial Doppler. Because there is evidence that brain injury can also occur in the prenatal, preoperative, and postoperative periods, improved strategies to prevent injury in these arenas are much needed. Extensive further clinical investigation is warranted to identify neuroprotective management strategies for the operating room and intensive care unit to preserve neurologic function and optimize long-term neurodevelopmental outcomes in children with congenital heart disease.
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Affiliation(s)
- David P Nelson
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030-2399, USA.
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Creighton DE, Robertson CMT, Sauve RS, Moddemann DM, Alton GY, Nettel-Aguirre A, Ross DB, Rebeyka IM. Neurocognitive, functional, and health outcomes at 5 years of age for children after complex cardiac surgery at 6 weeks of age or younger. Pediatrics 2007; 120:e478-86. [PMID: 17766491 DOI: 10.1542/peds.2006-3250] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This work provides neurocognitive, functional, and health outcomes for 5-year survivors of early infant complex cardiac surgery, including those with chromosomal abnormalities. PATIENTS AND METHODS Of 85 children (22.4% mortality), 61 received multidisciplinary, individual evaluation and parental questionnaires at 5 years. Full-scale, verbal, and performance IQ scores were compared by using analysis of variance among children who received different surgeries (arterial switch, 20; Norwood for hypoplastic left heart syndrome, 14; simple total anomalous pulmonary venous connection, 6; miscellaneous, 21; and chromosomal abnormalities, 8). Predictions from mental scores at 2 years for IQ scores at 5 years were determined. RESULTS Children with chromosomal abnormalities had lower full-scale and verbal IQs at 5 years than other survivors, with no differences found among the remaining groups. For children post-Norwood, performance IQ scores remained lower than for children after the arterial-switch operation. Prediction of full-scale IQ (<70) from 2-year mental scores for all 61 children were as follows: sensitivity, 87.5%; specificity, 88.1%; positive predictive value, 53.8%; and negative predictive value, 97.9%. For full-scale IQ of <85, predictions were 90.0%, 87.8%, 78.3%, and 94.7%, respectively. For those 53 without chromosomal abnormalities, full-scale IQ <70, respective predictions were 86.7%, 90.0%, 28.6%, and 97.8%, and for full-scale IQ <85, respective predictions were 85.7%, 89.7%, 75.0%, and 94.6%. Parental report indicated good health in 80% and adequate function in 67% to 88% of the children, although health-utilization numbers suggest that these reports are optimistic. CONCLUSIONS Five-year full-scale and verbal IQs were similar among groups, excluding those with chromosomal abnormalities. Children with chromosomal abnormalities had the lowest scores. Excluding those with chromosomal abnormalities, the mean mental scores for the children as a group tended to increase from 2 to 5 years of age, with an overall high percentage of correct classifications at 2 years.
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Affiliation(s)
- Dianne E Creighton
- Cardiorespiratory Services, Alberta Children's Hospital, Calgary, Alberta, Canada
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Atallah J, Joffe AR, Robertson CMT, Leonard N, Blakley PM, Nettel-Aguirre A, Sauve RS, Ross DB, Rebeyka IM. Two-year general and neurodevelopmental outcome after neonatal complex cardiac surgery in patients with deletion 22q11.2: A comparative study. J Thorac Cardiovasc Surg 2007; 134:772-9. [PMID: 17723832 DOI: 10.1016/j.jtcvs.2007.03.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 02/02/2007] [Accepted: 03/14/2007] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Neonatal complex cardiac surgery carries a significant risk for adverse neurodevelopmental outcome. We hypothesized this risk to be higher in patients with deletion 22q11.2. METHODS From 1996 to 2004, neonates who had complex cardiac surgery at age 6 weeks or less had multisite, multidisciplinary health and neurodevelopmental outcomes (Bayley Scales of Infant Development II; mental and psychomotor developmental indices [MDI, PDI] as mean [SD] and delay [<70]) assessed at 18 to 24 months of age. All 16 patients with deletion 22q11.2 (group 1) were compared with 16 patients without deletion 22q11.2 (group 2) having undergone neonatal complex cardiac surgery at the same center and matched for cardiac lesion, socioeconomic status, and year of operation. Outcomes were compared by univariate and multivariate analyses. RESULTS Heart lesions in each group consisted of 6 (37.5%) cases of interrupted aortic arch, 6 (37.5%) cases of truncus arteriosus, and 4 (25%) cases of tetralogy of Fallot. Outcomes were available for all survivors. Mortality was 3 (19%) and 1 (6%) in groups 1 and 2, respectively (P = .6). MDI and PDI scores were 66.1 (10.6) and 55.0 (9.4) for group 1 and 86.3 (14.6) and 82.3 (14.3) for group 2 (P < .001). Only deletion 22q11.2 was significant in stepwise multiple regression to predict MDI and PDI scores. Mental delay occurred in 8 (61.5%) of 13 in group 1 and 2 (13.8%) of 15 in group 2 (P = .016). Psychomotor delay occurred in 11 (84.6%) of 13 in group 1 and 1 (6.7%) of 15 in group 2 (P < .001). CONCLUSION Neonates affected by deletion 22q11.2 and having neonatal complex cardiac surgery have significantly worse neurodevelopmental outcome than do those without deletion 22q11.2.
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Affiliation(s)
- Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Joffe AR, Robertson CMT, Nettel-Aguirre A, Rebeyka IM, Sauve RS. Mortality after neonatal cardiac surgery: Prediction from mean arterial pressure after rewarming in the operating room. J Thorac Cardiovasc Surg 2007; 134:311-8. [PMID: 17662767 DOI: 10.1016/j.jtcvs.2007.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Revised: 01/19/2007] [Accepted: 02/01/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the predictive contribution of mean arterial pressure after rewarming to > or =34 degrees C in the operating room to mortality after cardiac surgery in infants < or =6 weeks old. METHODS In this prospective inception cohort study, 70 consecutive infants who had open cardiac surgery with deep hypothermic circulatory arrest when < or =6 weeks old in the years 1996 to 1999 had follow-up to 5 years of age. Demographic, preoperative, operative, and postoperative variables were recorded prospectively. The previously unexplored variables of lowest mean arterial pressure in the operating room after rewarming to 34 degrees C were recorded retrospectively from anesthesia records. Predictor variables for death were examined using univariate and multivariate analyses. RESULTS Deep hypothermic circulatory arrest time, re-cardiopulmonary bypass in the operating room, duration of mean arterial pressure below 40, 35, 30, and 25 mm Hg after rewarming in the operating room, time for lactate to return to < or =2 mmol/L postoperatively, and cardiopulmonary resuscitation were significantly associated with death at 1 and 5 years of age on univariate analysis. Multivariate stepwise forward logistic regression analysis found the duration of mean arterial pressure after rewarming below 30 mm Hg (odds ratio 1.094; 95% confidence interval 1.033-1.158) and cardiopulmonary resuscitation (odds ratio 13.800, 95% CI 3.062-62.194) were significant predictors of death by 5 years of age. Stepwise multiple regression using pre- and intraoperative variables accounted for 30.1% of the variability related to mean arterial pressure < or =30 mm Hg after rewarming. CONCLUSION In these infants, low mean arterial pressure after rewarming in the operating room, even for brief times, is significantly associated with death.
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Affiliation(s)
- Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Alton GY, Robertson CMT, Sauve R, Divekar A, Nettel-Aguirre A, Selzer S, Joffe AR, Rebeyka IM, Ross DB. Early childhood health, growth, and neurodevelopmental outcomes after complete repair of total anomalous pulmonary venous connection at 6 weeks or younger. J Thorac Cardiovasc Surg 2007; 133:905-11. [PMID: 17382624 DOI: 10.1016/j.jtcvs.2006.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 11/22/2006] [Accepted: 12/13/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This interprovincial inception cohort study explores early childhood outcomes and their operative and perioperative predictors after total anomalous pulmonary venous connection repair, simple (patent ductus arteriosus, atrial septal defect, or both) or complex (any associated major cardiac anomalies). METHODS From 1996 through 2004, a total of 41 consecutive neonates with total anomalous pulmonary venous connection underwent complete repair with deep hypothermic circulatory arrest. Multidisciplinary health and neurodevelopmental outcomes (Bayley Scales of Infant Development II [1993], Mental and Psychomotor Developmental Indices) were assessed at 18 to 24 months of age. Regression analyses explored potentially modifiable predictors of outcome. RESULTS Survival after simple total anomalous pulmonary venous connection repair was 31 of 32 (97%); that after complex repair was 3 of 9 (33%). Relative risk of death was higher for complex (21.3) and obstructive (8.4) total anomalous pulmonary venous connections. Those who died had longer deep hypothermic circulatory arrest times (P < .001). For 34 survivors, Mental Developmental Index was 87 +/- 16 and Psychomotor Developmental Index was 89 +/- 13. Among survivors, 24.6% of variability in Mental Developmental Index was explained by its linear relationship with socioeconomic status, whereas 35.5% of variability in Psychomotor Developmental Index was explained by its linear relationship with weight at surgery and highest plasma lactate level after surgery. North American native peoples made up 38% of survivors, a higher than expected number. CONCLUSION Mean developmental scores were in the low average range of normative data. Socioeconomic factors predicted mental outcome. High postoperative lactate level on day 1 predicted low motor scores. Other potentially modifiable variables will need to be explored. Further epidemiologic study relating race to occurrence of total anomalous pulmonary venous connection is suggested. Early neurodevelopmental assessment is recommended.
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Affiliation(s)
- Gwen Y Alton
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Freed DH, Robertson CMT, Sauve RS, Joffe AR, Rebeyka IM, Ross DB, Dyck JD. Intermediate-term outcomes of the arterial switch operation for transposition of great arteries in neonates: Alive but well? J Thorac Cardiovasc Surg 2006; 132:845-52. [PMID: 17000296 DOI: 10.1016/j.jtcvs.2006.05.046] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Revised: 04/06/2006] [Accepted: 05/03/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This interprovincial inception cohort study outlines the operative and intermediate outcomes of all neonates at a single institution with a broad referral area who underwent the arterial switch operation for transposition of great arteries, including complex types. Predictors of outcome are explored. METHODS A total of 88 consecutive neonates underwent the arterial switch operation between 1996 and 2004 with full-flow (150 mg/kg/min) cardiopulmonary bypass with selective deep hypothermic circulatory arrest. Overall and event-free survivals were calculated. Health and neurodevelopment (Bayley Scales of Infant Development II) were assessed at 18 to 24 months of age. Univariate and multivariate analyses, sensitivity, and specificity were determined to identify preoperative, intraoperative, and postoperative factors associated with mental and/or motor delay. RESULTS There was 1 operative mortality (1.1%). At the average 4-year follow-up, survival was 98.9% and freedom from reintervention was 93.2%. Eighty-five children were assessed. Three were excluded because of unrelated postoperative diagnoses. For the remaining 82, mean scores were 89 +/- 17 (49-118) for mental skills and 92 +/- 15 (49-125) for motor skills. Anatomic complexity, cardiopulmonary bypass, and deep hypothermic circulatory arrest times were not associated with developmental outcome. Preoperative variables of low gestational age and high preoperative lactate correctly classified 84.1% of mentally and/or motor-delayed children. CONCLUSION Transposition of great arteries, including complex types, can be corrected with low surgical risk and good intermediate survival; however, neurodevelopmental outcome is a concern. These data suggest that although anatomic complexity may not affect late outcome, there may be potentially modifiable preoperative factors that can be optimized to improve developmental outcomes.
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Affiliation(s)
- Darren H Freed
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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