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Feng J, Lin R, Zhang Y, Ning S, Du N, Li J, Cui Y, Huang G, Wang H, Chen X, Liu T, Chen W, Ma L, Li J. Postoperative EEG abnormalities in relation to neurodevelopmental outcomes after pediatric cardiac surgery. Pediatr Res 2024:10.1038/s41390-024-03401-2. [PMID: 38992156 DOI: 10.1038/s41390-024-03401-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND We had reported that postoperative EEG background including sleep-wake cycle (SWC) and discharge (seizures, spikes/sharp waves) abnormalities were significantly correlated with adverse early outcomes in children after cardiac surgery. We aimed to analyze the relations between these EEG abnormalities and neurodevelopmental outcomes at about 2 years after cardiac surgery. METHODS We enrolled 121 patients undergoing cardiac surgery at 3.3 months (0.03 ~ 28 months). EEG abnormalities described above during the first postoperative 48 h were evaluated. Griffiths Mental Development Scales-Chinese was used to evaluate the quotients of overall development and 5 subscales of the child's locomotor, language, personal-social, eye-hand coordination and performance skills at 16 ~ 31 months of age. RESULTS EEG background abnormalities occurred in 59/121 (48.8%) patients and 33 (55.9%) unrecovered to normal by 48 h. Abnormal SWC occurred in 15 (12.4%) patients and 7 (5.8%) unrecovered to normal by 48 h. EEG seizures occurred in 11 (9.1%) patients with frontal lobe seizures in 4. Spikes/sharp waves occurred in 100 (82.6%). EEG background abnormalities, number of spikes/sharp waves and frontal lobe seizures were significantly associated with neurodevelopmental impairment at about 1 ~ 2 year after surgery (Ps ≤ 0.05). CONCLUSIONS Most parameters of EEG abnormalities were significantly associated with neurodevelopmental impairment after cardiac surgery. IMPACT Neurodevelopmental impairment in children with congenital heart disease remain poorly understood. Previous studies had reported that either EEG seizures or background abnormalities were associated with worse neurodevelopmental outcomes. Our present study showed that all the EEG background and discharge abnormalities including EEG background, seizures and spikes/sharp waves in the early postoperative period were significantly associated with neurodevelopmental impairment at about 1 ~ 2 years after cardiac surgery. Comprehensive evaluation of early postoperative EEG may provide further insights about postoperative brain injury, its relation with neurodevelopmental impairment, and guide to improve clinical management.
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Affiliation(s)
- Jinqing Feng
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Rouyi Lin
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Yani Zhang
- Department of Neurology, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Shuyao Ning
- Department of Electroneurophysiology, Guangzlhou Medical University, Guangzhou, Guangdong Province, China
| | - Na Du
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Jianbin Li
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Yanqin Cui
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Guodong Huang
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Huaizhen Wang
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Xinxin Chen
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Techang Liu
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Wenxiong Chen
- Department of Neurology, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Li Ma
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China
- Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Jia Li
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Medical University, Guangzhou, Guangdong Province, China.
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Medical University, Guangzhou, Guangdong Province, China.
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Cañizo-Vazquez D, Hadley S, Leonhardt M, Camprubí-Camprubí M, Sanchez-de-Toledo J. Early post-operative neurodevelopment and visual assessment in neonates with congenital heart disease undergoing cardiac surgery. J Perinatol 2023; 43:856-863. [PMID: 36347968 DOI: 10.1038/s41372-022-01555-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assessment of neurobehavior and visual function of newborns with congenital heart disease during the post-operative period to identify infants at risk of neurodevelopmental and visual impairment. STUDY DESIGN Prospective study that included 45 newborns who underwent cardiac surgery. Newborn Behavioral Observations test (NBO) and "ML Battery of Optotypes" were used for assessment. RESULTS The median NBO global score was 2.4 [2.1-2.6]. Total days of oral morphine [p = 0.005] and total days of sedation [p = 0.009] were strongly related to abnormal evaluations. Time of cerebral regional oxygen saturation (CrSO2) under 40% during surgery and increased lactate were related to abnormal motor evaluation. Only 14.5% of patients presented pathological results in visual evaluation. CONCLUSIONS We have demonstrated alterations in attention, autonomic, motor, and oral motor function. Duration of sedative medication, time of CrSO2 under 40% during surgery, and increased lactate are the most important risk factors. No significant visual impairment was detected.
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Affiliation(s)
- D Cañizo-Vazquez
- BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - S Hadley
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - M Leonhardt
- BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - M Camprubí-Camprubí
- BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clinic, University of Barcelona, Barcelona, Spain.
- Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain.
| | - J Sanchez-de-Toledo
- Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain
- Pediatric Cardiology Department. Sant Joan de Déu Hospital, Barcelona, Spain
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Lin R, Du N, Feng J, Li J, Li L, Cui Y, Ning S, Zhang M, Huang G, Wang H, Zou M, Ma L, Chen X, Li J. Perioperative EEG background and discharge abnormalities in children undergoing cardiac surgery: a prospective single-centre observational study. Br J Anaesth 2023:S0007-0912(23)00240-4. [PMID: 37328305 DOI: 10.1016/j.bja.2023.04.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND We analysed the characteristics of abnormal electroencephalogram (EEG) patterns before, during, and 48 h after cardiac surgery in patients with heterogeneous congenital heart disease to assess their relationship to demographic and perioperative variables and to early patient outcomes. METHODS In 437 patients enrolled in a single centre, EEG was evaluated for background (including sleep-wake cycle) and discharge (seizures, spikes/sharp waves, pathological delta brushes) abnormalities. Clinical data (arterial blood pressure, doses of inotropic drugs, and serum lactate concentrations) were recorded every 3 h. Postoperative brain MRI was performed before discharge. RESULTS Preoperative, intraoperative, and postoperative EEG was monitored in 139, 215, and 437 patients, respectively. Patients with a degree of preoperative background abnormalities (n=40) had more severe intraoperative and postoperative EEG abnormalities (P<0.0001). Intraoperatively, 106/215 (49.3%) patients progressed into an isoelectric EEG. Longer durations of isoelectric EEG were associated with more severe postoperative EEG abnormalities and brain injury on MRI (Ps≤0.003). Postoperative background abnormalities occurred in 218/437 (49.9%) patients, and 119 (54.6%) of them had not recovered after surgery. Seizures occurred in 36/437 (8.2%) patients, spikes/sharp waves in 359/437 (82.2%), and pathological delta brushes in 9/437 (2.0%). Postoperative EEG abnormalities correlated with degree of brain injury on MRI (Ps≤0.02). Demographic and perioperative variables were significantly correlated with postoperative EEG abnormalities, which in turn correlated with adverse clinical outcomes. CONCLUSIONS Perioperative EEG abnormalities occurred frequently and correlated with numerous demographic and perioperative variables and adversely correlated with postoperative EEG abnormalities and early outcomes. The relation of EEG background and discharge abnormalities with long-term neurodevelopmental outcomes remains to be explored.
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Affiliation(s)
- Rouyi Lin
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Na Du
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Jinqing Feng
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Jianbin Li
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Lijuan Li
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Yanqin Cui
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Shuyao Ning
- Department of Electroneurophysiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Province, China
| | - Mingjie Zhang
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Province, China
| | - Guodong Huang
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Huaizhen Wang
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Minghui Zou
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Li Ma
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Xinxin Chen
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Jia Li
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China; Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China.
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Continuous electroencephalography (cEEG) in infants with congenital heart disease (CHD). Pediatr Res 2023:10.1038/s41390-023-02520-6. [PMID: 36792651 DOI: 10.1038/s41390-023-02520-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/22/2022] [Accepted: 01/23/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Neonates with congenital heart disease (CHD) undergoing cardiopulmonary bypass (CPB) surgery have increased risk of impaired neurodevelopmental outcomes secondary to brain injury. This study aims to characterize pre- and post-operative continuous EEG (cEEG) patterns to detect abnormal cerebral activity in infants with CHD and investigate whether an association exists between the degree of encephalopathy in pre- and post-operative cEEG. METHODS This retrospective cohort study conducted between 2010 and 2018 at a tertiary hospital in Cleveland, OH included infants with CHD with cEEG monitoring, who underwent CPB surgery within first 6 months of life. RESULTS Study included 77 patients, of which 61% were males who were operated at median age 6 days. Pre-operatively, 69% and 87% had normal cEEG and sleep-wake cycles, respectively. Post-operatively, 80% had abnormal cEEG. Longer circulatory arrest time and CPB were associated with lack of continuity (p 0.011), excessive discontinuity (p 0.007) and prolonged inter-burst interval (IBI) duration (p value < 0.001). A significant association existed between severity of encephalopathy in immediate and 24-h post-operative period (p value < 0.001). CONCLUSIONS More than 80% of neonates with CHD have abnormal post-operative EEG. Longer circulatory arrest time and CPB were associated with lack of continuity, excessive discontinuity, and prolonged IBI duration on post-operative EEG. IMPACT This study shows that majority of neonates with congenital heart disease (CHD) have normal pre-operative EEG with a continuous background and normal sleep-wake cycles. Also, 80% of neonates had abnormal post-operative EEG. Longer duration of arrest time and bypass time was associated with lack of continuity, excessive discontinuity, and prolonged IBI duration during post-operative EEG monitoring. These findings will help clinicians when counseling parents in the intensive care unit, risk stratification, and long-term neurodevelopmental monitoring in these high-risk patients.
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Feldmann M, Hagmann C, de Vries L, Disselhoff V, Pushparajah K, Logeswaran T, Jansen NJG, Breur JMPJ, Knirsch W, Benders M, Counsell S, Reich B, Latal B. Neuromonitoring, neuroimaging, and neurodevelopmental follow-up practices in neonatal congenital heart disease: a European survey. Pediatr Res 2023; 93:168-175. [PMID: 35414671 PMCID: PMC9876786 DOI: 10.1038/s41390-022-02063-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Brain injury and neurodevelopmental impairment remain a concern in children with complex congenital heart disease (CHD). A practice guideline on neuromonitoring, neuroimaging, and neurodevelopmental follow-up in CHD patients undergoing cardiopulmonary bypass surgery is lacking. The aim of this survey was to systematically evaluate the current practice in centers across Europe. METHODS An online-based structured survey was sent to pediatric cardiac surgical centers across Europe between April 2019 and June 2020. Results were summarized by descriptive statistics. RESULTS Valid responses were received by 25 European centers, of which 23 completed the questionnaire to the last page. Near-infrared spectroscopy was the most commonly used neuromonitoring modality used in 64, 80, and 72% preoperatively, intraoperatively, and postoperatively, respectively. Neuroimaging was most commonly performed by means of cranial ultrasound in 96 and 84% preoperatively and postoperatively, respectively. Magnetic resonance imaging was obtained in 72 and 44% preoperatively and postoperatively, respectively, but was predominantly reserved for clinically symptomatic patients (preoperatively 67%, postoperatively 64%). Neurodevelopmental follow-up was implemented in 40% of centers and planned in 24%. CONCLUSIONS Heterogeneity in perioperative neuromonitoring and neuroimaging practice in CHD in centers across Europe is large. The need for neurodevelopmental follow-up has been recognized. A clear practice guideline is urgently needed. IMPACT There is large heterogeneity in neuromonitoring, neuroimaging, and neurodevelopmental follow-up practices among European centers caring for neonates with complex congenital heart disease. This study provides a systematic evaluation of the current neuromonitoring, neuroimaging, and neurodevelopmental follow-up practice in Europe. The results of this survey may serve as the basis for developing a clear practice guideline that could help to early detect and prevent neurological and neurodevelopmental sequelae in neonates with complex congenital heart disease.
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Affiliation(s)
- Maria Feldmann
- grid.412341.10000 0001 0726 4330Child Development Centre, University Children’s Hospital Zurich, Zurich, Switzerland ,grid.412341.10000 0001 0726 4330Children’s Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Cornelia Hagmann
- grid.412341.10000 0001 0726 4330Children’s Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland ,grid.412341.10000 0001 0726 4330Department of Neonatology and Pediatric Intensive Care, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Linda de Vries
- grid.5477.10000000120346234Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Vera Disselhoff
- grid.412341.10000 0001 0726 4330Child Development Centre, University Children’s Hospital Zurich, Zurich, Switzerland ,grid.412341.10000 0001 0726 4330Children’s Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Kuberan Pushparajah
- Pediatric Cardiology Department, Evelina Children’s Hospital London, London, UK ,grid.13097.3c0000 0001 2322 6764Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Thushiha Logeswaran
- grid.8664.c0000 0001 2165 8627Pediatric Heart Center, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Nicolaas J. G. Jansen
- grid.417100.30000 0004 0620 3132Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital, UMC Utrecht, Utrecht, The Netherlands ,grid.4494.d0000 0000 9558 4598Department of Pediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Johannes M. P. J. Breur
- grid.417100.30000 0004 0620 3132Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, UMC Utrecht, Utrecht, The Netherlands
| | - Walter Knirsch
- grid.412341.10000 0001 0726 4330Pediatric Cardiology, Pediatric Heart Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Manon Benders
- grid.5477.10000000120346234Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands ,grid.417100.30000 0004 0620 3132Department of Neonatology, Wilhelmina Children’s Hospital, UMC Utrecht, Utrecht, The Netherlands
| | - Serena Counsell
- grid.13097.3c0000 0001 2322 6764Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Bettina Reich
- grid.472754.70000 0001 0695 783XPediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Munich, Germany
| | - Beatrice Latal
- Child Development Centre, University Children's Hospital Zurich, Zurich, Switzerland. .,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.
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Ortinau CM, Smyser CD, Arthur L, Gordon EE, Heydarian HC, Wolovits J, Nedrelow J, Marino BS, Levy VY. Optimizing Neurodevelopmental Outcomes in Neonates With Congenital Heart Disease. Pediatrics 2022; 150:e2022056415L. [PMID: 36317967 PMCID: PMC10435013 DOI: 10.1542/peds.2022-056415l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Neurodevelopmental impairment is a common and important long-term morbidity among infants with congenital heart disease (CHD). More than half of those with complex CHD will demonstrate some form of neurodevelopmental, neurocognitive, and/or psychosocial dysfunction requiring specialized care and impacting long-term quality of life. Preventing brain injury and treating long-term neurologic sequelae in this high-risk clinical population is imperative for improving neurodevelopmental and psychosocial outcomes. Thus, cardiac neurodevelopmental care is now at the forefront of clinical and research efforts. Initial research primarily focused on neurocritical care and operative strategies to mitigate brain injury. As the field has evolved, investigations have shifted to understanding the prenatal, genetic, and environmental contributions to impaired neurodevelopment. This article summarizes the recent literature detailing the brain abnormalities affecting neurodevelopment in children with CHD, the impact of genetics on neurodevelopmental outcomes, and the best practices for neonatal neurocritical care, focusing on developmental care and parental support as new areas of importance. A framework is also provided for the infrastructure and resources needed to support CHD families across the continuum of care settings.
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Affiliation(s)
- Cynthia M. Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher D. Smyser
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Lindsay Arthur
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Erin E. Gordon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Haleh C. Heydarian
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joshua Wolovits
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan Nedrelow
- Department of Neonatology, Cook Children’s Medical Center, Fort Worth, Texas
| | - Bradley S. Marino
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Divisions of Cardiology and Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Victor Y. Levy
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children’s Hospital, Palo Alto, California
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7
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Stegeman R, Nijman M, Breur JMPJ, Groenendaal F, Haas F, Derks JB, Nijman J, van Beynum IM, Taverne YJHJ, Bogers AJJC, Helbing WA, de Boode WP, Bos AF, Berger RMF, Accord RE, Roes KCB, de Wit GA, Jansen NJG, Benders MJNL. CeRebrUm and CardIac Protection with ALlopurinol in Neonates with Critical Congenital Heart Disease Requiring Cardiac Surgery with Cardiopulmonary Bypass (CRUCIAL): study protocol of a phase III, randomized, quadruple-blinded, placebo-controlled, Dutch multicenter trial. Trials 2022; 23:174. [PMID: 35197082 PMCID: PMC8867620 DOI: 10.1186/s13063-022-06098-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/10/2022] [Indexed: 05/31/2023] Open
Abstract
Background Neonates with critical congenital heart disease (CCHD) undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at risk of brain injury that may result in adverse neurodevelopment. To date, no therapy is available to improve long-term neurodevelopmental outcomes of CCHD neonates. Allopurinol, a xanthine oxidase inhibitor, prevents the formation of reactive oxygen and nitrogen species, thereby limiting cell damage during reperfusion and reoxygenation to the brain and heart. Animal and neonatal studies suggest that allopurinol reduces hypoxic-ischemic brain injury and is cardioprotective and safe. This trial aims to test the hypothesis that allopurinol administration in CCHD neonates will result in a 20% reduction in moderate to severe ischemic and hemorrhagic brain injury. Methods This is a phase III, randomized, quadruple-blinded, placebo-controlled, multicenter trial. Neonates with a prenatal or postnatal CCHD diagnosis requiring cardiac surgery with CPB in the first 4 weeks after birth are eligible to participate. Allopurinol or mannitol-placebo will be administered intravenously in 2 doses early postnatally in neonates diagnosed antenatally and 3 doses perioperatively of 20 mg/kg each in all neonates. The primary outcome is a composite endpoint of moderate/severe ischemic or hemorrhagic brain injury on early postoperative MRI, being too unstable for postoperative MRI, or mortality within 1 month following CPB. A total of 236 patients (n = 188 with prenatal diagnosis) is required to demonstrate a reduction of the primary outcome incidence by 20% in the prenatal group and by 9% in the postnatal group (power 80%; overall type 1 error controlled at 5%, two-sided), including 1 interim analysis at n = 118 (n = 94 with prenatal diagnosis) with the option to stop early for efficacy. Secondary outcomes include preoperative and postoperative brain injury severity, white matter injury volume (MRI), and cardiac function (echocardiography); postnatal and postoperative seizure activity (aEEG) and regional cerebral oxygen saturation (NIRS); neurodevelopment at 3 months (general movements); motor, cognitive, and language development and quality of life at 24 months; and safety and cost-effectiveness of allopurinol. Discussion This trial will investigate whether allopurinol administered directly after birth and around cardiac surgery reduces moderate/severe ischemic and hemorrhagic brain injury and improves cardiac function and neurodevelopmental outcome in CCHD neonates. Trial registration EudraCT 2017-004596-31. Registered on November 14, 2017. ClinicalTrials.gov NCT04217421. Registered on January 3, 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06098-y.
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Affiliation(s)
- Raymond Stegeman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center (UMC) Utrecht, Utrecht University, KE 04.123.1, PO Box 85909, 3508, AB, Utrecht, The Netherlands.,Department of Pediatric Cardiology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands.,Congenital Cardiothoracic Surgery, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maaike Nijman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center (UMC) Utrecht, Utrecht University, KE 04.123.1, PO Box 85909, 3508, AB, Utrecht, The Netherlands.,Department of Pediatric Cardiology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Johannes M P J Breur
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center (UMC) Utrecht, Utrecht University, KE 04.123.1, PO Box 85909, 3508, AB, Utrecht, The Netherlands.,Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Felix Haas
- Congenital Cardiothoracic Surgery, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan B Derks
- Department of Obstetrics, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Joppe Nijman
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ingrid M van Beynum
- Department of Pediatrics, Division of Pediatric Cardiology, Academic Center for Congenital Heart Disease, Erasmus Medical Center (MC) - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus MC, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Willem A Helbing
- Department of Pediatrics, Division of Pediatric Cardiology, Academic Center for Congenital Heart Disease, Erasmus Medical Center (MC) - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatrics, Division of Pediatric Cardiology, Academic Center for Congenital Heart Disease, Radboudumc - Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Willem P de Boode
- Department of Neonatology, Radboudumc, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Arend F Bos
- Division of Neonatology, Beatrix Children's Hospital, UMC Groningen, University of Groningen, Groningen, The Netherlands
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, UMC Groningen, University of Groningen, Groningen, The Netherlands
| | - Ryan E Accord
- Center for Congenital Heart Diseases, Department of Cardiothoracic Surgery, UMC Groningen, University of Groningen, Groningen, The Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Section Biostatistics, Radboudumc, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolaas J G Jansen
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pediatrics, Beatrix Children's Hospital, UMC Groningen, University of Groningen, Groningen, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center (UMC) Utrecht, Utrecht University, KE 04.123.1, PO Box 85909, 3508, AB, Utrecht, The Netherlands.
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8
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Artificial Intelligence Analysis of EEG Amplitude in Intensive Heart Care. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:6284035. [PMID: 34306595 PMCID: PMC8272660 DOI: 10.1155/2021/6284035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/08/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023]
Abstract
This article first studied the morphological characteristics of the EEG for intensive cardiac care; that is, based on the analysis of the mechanism of disease diagnosis and treatment, a signal processing and machine learning model was constructed. Then, the methods of signal preprocessing, signal feature extraction, new neural network model structure, training mechanism, optimization algorithm, and efficiency are studied, and experimental verification is carried out for public data sets and clinical big data. Then, the principle of intensive cardiac monitoring, the mechanism of disease diagnosis, the types of arrhythmia, and the characteristics of the typical signal are studied, and the rhythm performance, individual variability, and neurophysiological basis of electrical signals in intensive cardiac monitoring are researched. Finally, the automatic signal recognition technology is studied. In order to improve the training speed and generalization ability, a multiclassification model based on Least Squares Twin Support Vector Machine (LS-TWIN-SVM) is proposed. The computational complexity of the classification model algorithm is compared, and intelligence is adopted. The optimization algorithm selects the parameters of the classifier and uses the EEG signal to simulate the model. Support Vector Machines and their improved algorithms have achieved the ultimum in shallow neural networks and have achieved good results in the classification and recognition of bioelectric signals. The LS-TWIN-SVM algorithm proposed in this paper has achieved good results in the classification and recognition of bioelectric signals. It can perform bioinformatics processing on intensive cardiac care EEG signals, systematically biometric information, diagnose diseases, the real-time detection, auxiliary diagnosis, and rehabilitation of patients.
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9
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Lu WN, Yang XY, Ning SY, Chen ZG, Pan SN. Fully automated simultaneous peripheral arteriovenous exchange transfusion not seen to aggravate brain function and the disorder of the internal environment in neonates with severe hyperbilirubinemia. Pediatr Neonatol 2021; 62:312-320. [PMID: 33678593 DOI: 10.1016/j.pedneo.2021.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/24/2020] [Accepted: 02/04/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The acute changes in brain function in newborn infants undergoing ET remain unclear. This study aimed to determine whether fully automated simultaneous peripheral arteriovenous ET would influence the brain function. METHODS A retrospective analysis was conducted on the clinical data of 39 neonates with hyperbilirubinemia who received ET. Seventeen patients were in the encephalopathy group, and the other 22 patients were in the non-encephalopathy group. Changes in amplitude-integrated electroencephalogram (aEEG) during ETs were analyzed, including background activities, sleep-wake cycling (SWC), and seizures. Before and after the ET, routine blood test parameters, electrolytes, blood glucose, and blood gas parameters were measured. RESULTS After ETs, there were no significant changes in the levels of pH, PaO2, PaCO2, lactate, and red blood cells, while the levels of total bilirubin, indirect bilirubin, blood potassium, blood sodium, serum calcium, while blood cells, and platelets were significantly lower and the level of blood glucose was significantly higher compared to those before therapy. There was no significant difference in the changes of electroencephalographic activities during ETs, including background activities, SWC, and seizures. However, there were significant differences in suppressions on background activities, while there were no significant statistical differences in SWC or seizures between the 2 groups. CONCLUSION Fully automated simultaneous peripheral arteriovenous ET is safe and efficient without significant influence on the disorder of the internal environment and electroencephalographic activities after ET in neonates. However, background activities are more significantly depressed in infants of bilirubin encephalopathy than infants of non-encephalopathy during ET.
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Affiliation(s)
- Wei-Neng Lu
- Neonatology Department, The First Affiliated Hospital of Jinan University, Guangzhou, China; Neonatology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Xiao-Yuan Yang
- Pediatric Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shu-Yao Ning
- EEG Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Zhuang-Gui Chen
- Pediatric Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Si-Nian Pan
- Pediatric Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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10
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Consensus protocol for EEG and amplitude-integrated EEG assessment and monitoring in neonates. Clin Neurophysiol 2021; 132:886-903. [PMID: 33684728 DOI: 10.1016/j.clinph.2021.01.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/19/2020] [Accepted: 01/06/2021] [Indexed: 12/23/2022]
Abstract
The aim of this work is to establish inclusive guidelines on electroencephalography (EEG) applicable to all neonatal intensive care units (NICUs). Guidelines on ideal EEG monitoring for neonates are available, but there are significant barriers to their implementation in many centres around the world. These include barriers due to limited resources regarding the availability of equipment and technical and interpretive round-the-clock personnel. On the other hand, despite its limitations, amplitude-integrated EEG (aEEG) (previously called Cerebral Function Monitor [CFM]) is a common alternative used in NICUs. The Italian Neonatal Seizure Collaborative Network (INNESCO), working with all national scientific societies interested in the field of neonatal clinical neurophysiology, performed a systematic literature review and promoted interdisciplinary discussions among experts (neonatologists, paediatric neurologists, neurophysiologists, technicians) between 2017 and 2020 with the aim of elaborating shared recommendations. A consensus statement on videoEEG (vEEG) and aEEG for the principal neonatal indications was established. The authors propose a flexible frame of recommendations based on the complementary use of vEEG and aEEG applicable to the various neonatal units with different levels of complexity according to local resources and specific patient features. Suggestions for promoting cooperation between neonatologists, paediatric neurologists, and neurophysiologists, organisational restructuring, and teleneurophysiology implementation are provided.
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11
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Trollmann R. Neuromonitoring in Neonatal-Onset Epileptic Encephalopathies. Front Neurol 2021; 12:623625. [PMID: 33603712 PMCID: PMC7884638 DOI: 10.3389/fneur.2021.623625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/12/2021] [Indexed: 12/31/2022] Open
Abstract
Considering the wide spectrum of etiologies of neonatal-onset epileptic encephalopathies (EE) and their unfavorable consequences for neurodevelopmental prognoses, neuromonitoring at-risk neonates is increasingly important. EEG is highly sensitive for early identification of electrographic seizures and abnormal background activity. Amplitude-integrated EEG (aEEG) is recommended as a useful bedside monitoring method but as a complementary tool because of methodical limitations. It is of special significance in monitoring neonates with acute symptomatic as well as structural, metabolic and genetic neonatal-onset EE, being at high risk of electrographic-only and prolonged seizures. EEG/aEEG monitoring is established as an adjunctive tool to confirm perinatal hypoxic-ischemic encephalopathy (HIE). In neonates with HIE undergoing therapeutic hypothermia, burst suppression pattern is associated with good outcomes in about 40% of the patients. The prognostic specificity of EEG/aEEG is lower compared to cMRI. As infants with HIE may develop seizures after cessation of hypothermia, recording for at least 24 h after the last seizure is recommended. Progress in the identification of genetic etiology of neonatal EE constantly increases. However, presently, no specific EEG changes indicative of a genetic variant have been characterized, except for individual variants associated with typical EEG patterns (e.g., KCNQ2, KCNT1). Long-term monitoring studies are necessary to define and classify electro-clinical patterns of neonatal-onset EE.
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Affiliation(s)
- Regina Trollmann
- Department of Pediatrics and Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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12
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Liu MC, Wang MT, Chen PKT, Niu DM, Fan Chiang YH, Hsieh MH, Tsai HC. Case Report: Anesthetic Management and Electrical Cardiometry as Intensive Hemodynamic Monitoring During Cheiloplasty in an Infant With Enzyme-Replaced Pompe Disease and Preserved Preoperative Cardiac Function. Front Pediatr 2021; 9:729824. [PMID: 34966699 PMCID: PMC8710755 DOI: 10.3389/fped.2021.729824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/28/2021] [Indexed: 12/18/2022] Open
Abstract
Introduction: Pompe disease is caused by deficiency of the lysosomal enzyme acid α-glucosidase, which results in cardiac and muscular complications that can jeopardize perioperative outcomes. We report a 4-month-old infant with Pompe disease receiving cheiloplasty under general anesthesia with the aid of peripheral nerve blocks and intensive hemodynamic monitoring. Case Description: This case report describes a 4-month-old full-term Taiwanese female infant who presented with left unilateral cleft lip and palate in the prenatal examination. She was diagnosed with infantile-onset Pompe disease after acidic α-glucosidase (GAA) gene sequencing. She also received enzyme replacement therapy (ERT) 15 days after birth and regular ERT every other week. Cheiloplasty was performed under general anesthesia uneventfully, and peripheral nerve blocks were adopted for analgesia. Intensive hemodynamic monitoring using electrical cardiometry technology (ICON®) and pulse contour analysis (FloTrac system) were applied during the operation. No adverse effects were observed, and the wound healed well. Therefore, the patient was discharged 4 days after surgery. Conclusion: With the availability of ERT, severe organ dysfunction in infantile-onset Pompe disease patients is no longer common. However, moderate cardiac depression can still occur while increasing inspiratory pressure and deepening the anesthesia level despite a normal preoperative echocardiogram report. Therefore, careful, gradual titration is desirable. Furthermore, electrical cardiometry can detect hemodynamic changes more instantaneously and reliably than pulse contour analysis. In addition, we suggest taking advantage of the peripheral nerve block as a part of balanced anesthesia to alleviate the cardiac suppression caused by general anesthesia.
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Affiliation(s)
- Meng-Chen Liu
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Tse Wang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Philip Kuo-Ting Chen
- Department of Plastic and Reconstructive Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Dau-Ming Niu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Hsuan Fan Chiang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Hui Hsieh
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsiao-Chien Tsai
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Dianthus MFM Clinic Taoyuan, Dianthus MFM Center, Taipei, Taiwan
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13
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Lee IC, Hong SY, Weng YH, Chen YT. Amplitude Integrated Electroencephalography and Continuous Electroencephalography Monitoring Is Crucial in High-Risk Infants and Their Findings Correlate With Neurodevelopmental Outcomes. Front Pediatr 2021; 9:691764. [PMID: 34414144 PMCID: PMC8369262 DOI: 10.3389/fped.2021.691764] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To evaluate seizure diagnosis in sick infants in the neonatal intensive care unit (NICU) based on electroencephalography (EEG) monitoring combined with amplitude integrated electroencephalography (aEEG). Methods: We retrospectively reviewed EEG and aEEG findings and determined their correlations with neurodevelopmental outcomes at the age of >1 year in 65 patients with diagnosed seizures, encephalopathy, or both. Results: Seizure identification rate was 43.1%. The rate in nonstructural groups (hypocalcemic, hypoglycemic, and genetic seizures) was 71.4%, which was higher (p < 0.05) than the rate of 35.3% of structural brain lesion group [hypoxic-ischemic encephalopathy (HIE) and congenital brain structural malformation]. The aEEG background correlating with neurodevelopmental outcomes had 70.0% positive prediction value (PPV), 65.5%% negative prediction value (NPV), 67.7% specificity, and 67.9% sensitivity (p < 0.005). The aEEG background strongly (PPV, 93.8%; p < 0.005) correlated with the outcomes in HIE. For genetic seizures, the detected rate was high. The ictal recordings for the nonstructural seizures revealed downflected on the aEEG background initially, which differed from the structural lesion. Conclusions: EEG monitoring combined with aEEG can detect seizures, facilitating early treatment. EEG changes during seizures could exhibit delta-theta waves with or without clinical seizures in patients with brain lesions. In non-structural etiologies (hypocalcemic and KCNQ2 seizures), aEEG initially exhibited lower background during seizures that could aid in differentiating these EEG changes from those of other etiologies. The aEEG background was correlated with neurodevelopmental outcome and exhibited high PPV but not NPV in neonatal HIE.
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Affiliation(s)
- Inn-Chi Lee
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Syuan-Yu Hong
- Division of Pediatrics Neurology, Department of Pediatrics, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Yi-Ho Weng
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yi-Ting Chen
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
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14
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Finucane E, Jooste E, Machovec KA. Neuromonitoring Modalities in Pediatric Cardiac Anesthesia: A Review of the Literature. J Cardiothorac Vasc Anesth 2020; 34:3420-3428. [DOI: 10.1053/j.jvca.2020.02.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 12/13/2022]
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15
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Interrater Agreement Between Critical Care Providers for Background Classification and Seizure Detection After Implementation of Amplitude-Integrated Electroencephalography in Neonates, Infants, and Children. J Clin Neurophysiol 2020; 37:259-262. [PMID: 31567529 DOI: 10.1097/wnp.0000000000000634] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
PURPOSES Amplitude-integrated EEG (aEEG) has been widely developed in neonatal intensive care unit, but few studies focused on pediatric intensive care unit. Furthermore, reliability of aEEG under real-life conditions is unknown. METHODS Participants were nurses from a 12-bed pediatric intensive care unit in a referral university hospital in France. Amplitude EEG was implemented after standardized training, including e-learning course, individual feedback and bedside teaching concerning monitoring installation, background classification patterns recognition, artefact analysis, and seizure detection. The primary judgment criterion was the agreement (Cohen Kappa) between nurses and aEEG experts for the detection of abnormal aEEG traces (moderately or severely altered background pattern according to Hellström-Westas classification and/or seizure activity). RESULTS During the study period, 196 consecutives traces from 79 patients were analyzed by 51 nurses. According to expert's classification, 53% of traces were abnormal, including 17.5% of severely abnormal traces (severely altered traces and/or seizure activity) and 14% exhibiting seizure activity. Moderate agreement between experts and nurses was found for detection of any abnormal trace (k = 0.53; 95% confidence interval [CI]: 0.39-0.67). Substantial agreement was found for severely altered traces (k = 0.71; 95% CI: 0.57-0.85). Finally, fair agreement was found for seizure detection (irrespective of background classification, k = 0.40; 95% CI: 0.25-0.54). CONCLUSIONS These results suggest that aEEG monitoring may be implemented in routine nursing care in pediatric intensive care unit. Further training courses are needed to enhance nurses' skill in detecting seizures activity at the bedside.
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16
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Ortinau CM, Shimony JS. The Congenital Heart Disease Brain: Prenatal Considerations for Perioperative Neurocritical Care. Pediatr Neurol 2020; 108:23-30. [PMID: 32107137 PMCID: PMC7306416 DOI: 10.1016/j.pediatrneurol.2020.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/21/2019] [Accepted: 01/05/2020] [Indexed: 12/17/2022]
Abstract
Altered brain development has been highlighted as an important contributor to adverse neurodevelopmental outcomes in children with congenital heart disease. Abnormalities begin prenatally and include micro- and macrostructural disturbances that lead to an altered trajectory of brain growth throughout gestation. Recent progress in fetal imaging has improved understanding of the neurobiological mechanisms and risk factors for impaired fetal brain development. The impact of the prenatal environment on postnatal neurological care has also gained increased focus. This review summarizes current data on the timing and pattern of altered prenatal brain development in congenital heart disease, the potential mechanisms of these abnormalities, and the association with perioperative neurological complications.
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Affiliation(s)
- Cynthia M Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri.
| | - Joshua S Shimony
- Mallinkrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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17
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Swartz MF, Seltzer LE, Cholette JM, Yoshitake S, Darrow N, Algahim MF, Alfieris GM. Intraoperative Cortical Asynchrony Predicts Abnormal Postoperative Electroencephalogram. Ann Thorac Surg 2020; 111:645-654. [PMID: 32511999 DOI: 10.1016/j.athoracsur.2020.04.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Postoperative electroencephalograms (EEGs) can identify seizure activity and neurologic dysfunction in high-risk neonates requiring cardiac surgical procedures. Although intraoperative EEG monitoring is uncommon, variations in cerebral blood flow and temperature during antegrade cerebral perfusion (ACP) can manifest as cortical asynchrony during EEG monitoring. We hypothesized that intraoperative EEG cortical asynchrony would identify neonates at risk for abnormal postoperative EEG tracings. METHODS Neonates requiring ACP for cardiac repair or palliation had continuous baseline, intraoperative, and postoperative hemodynamic and EEG monitoring. Synchronous and asynchronous cortical bursts were quantified during (1) cooling before ACP, (2) ACP, and (3) rewarming. Asynchronous bursts were defined as interhemispheric variations in electrical voltage or frequency. Neonates were divided into 2 groups, those with and without an abnormal postoperative EEG, which was defined as either persistent asynchrony for more than 2 hours or seizure activity on EEG. RESULTS Among 40 neonates, 296 asynchronous bursts were noted, most commonly during rewarming. Eight (20%) neonates had an abnormal postoperative EEG (seizure activity, n = 3; persistent asynchrony, n = 5). Baseline demographics and intraoperative hemodynamics were similar between the groups. However, the total number of intraoperative asynchronous bursts was greater in neonates with an abnormal postoperative EEG (17 [11, IQR:24] vs 3 [IQR:1, 7]; P < .001). Multivariate analysis confirmed that the number of asynchronous bursts was independently associated with an abnormal postoperative EEG (odds ratio,1.35; confidence interval,:1.10, 1.65; P = .004). CONCLUSIONS Neonates with a greater number of intraoperative asynchronous cortical bursts had an abnormal postoperative EEG.
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Affiliation(s)
- Michael F Swartz
- Department of Surgery, University of Rochester Medical Center, Rochester, New York.
| | - Laurie E Seltzer
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Shuichi Yoshitake
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Nathan Darrow
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Mohamed F Algahim
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - George M Alfieris
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
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18
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Peri- and Post-operative Amplitude-integrated Electroencephalography in Infants with Congenital Heart Disease. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1730-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Yuan X, Kang W, Song J, Guo J, Guo L, Zhang R, Liu S, Zhang Y, Liu D, Wang Y, Ding X, Dong H, Chen X, Cheng Y, Zhang X, Xu F, Zhu C. Prognostic value of amplitude-integrated EEG in neonates with high risk of neurological sequelae. Ann Clin Transl Neurol 2020; 7:210-218. [PMID: 32031755 PMCID: PMC7034499 DOI: 10.1002/acn3.50989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To determine the efficacy and the prognostic value of amplitude-integrated electroencephalography (aEEG) in term and near-term neonates with high risk of neurological sequelae. METHODS Infants of ≥35 weeks of gestation diagnosed with neonatal encephalopathy or with high risk of brain injury were included. All eligible infants underwent aEEG within 6 h after clinical assessment. The infants were followed up 12 months to evaluate neurological development. RESULTS A total of 250 infants were eligible, of which 85 had normal aEEG, 81 had mildly abnormal aEEG, and 84 had severely abnormal aEEG. Of these infants, 168 were diagnosed with different neonatal encephalopathies, 27 with congenital or metabolic diseases, and 55 with high risk of brain injury. In all, 22 infants died, 19 were lost to follow-up, and 209 completed the follow-up at 12 months, of which 62 were diagnosed with a neurological disability. Statistical analysis showed that severely abnormal aEEG predicted adverse neurological outcome with a sensitivity of 70.2%, a specificity of 87.1%, a positive predictive value of 75.6%, and a negative predictive value of 83.7%. INTERPRETATION aEEG can predict adverse outcomes in high-risk neonates and is a useful method for monitoring neonates with high risk of adverse neurological outcomes.
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Affiliation(s)
- Xiao Yuan
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Wenqing Kang
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Juan Song
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Jing Guo
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Lanlan Guo
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Ruili Zhang
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Shasha Liu
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Yaodong Zhang
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Dapeng Liu
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Yong Wang
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Xue Ding
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Huimin Dong
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Xi Chen
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Yanchao Cheng
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Xiaoli Zhang
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Falin Xu
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450052, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, 40530, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, 2995, Sweden
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20
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Feldmann M, Rousson V, Nguyen TD, Bernet V, Hagmann C, Latal B, Natalucci G. Cognitive outcome of early school-aged children born very preterm is not predicted by early short-term amplitude-integrated electroencephalography. Acta Paediatr 2020; 109:78-84. [PMID: 31254357 DOI: 10.1111/apa.14919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 02/06/2023]
Abstract
AIM We investigated the association between early amplitude-integrated electroencephalography (aEEG) and cognitive outcome in very preterm infants at early school-age. METHODS This prospective cohort study, conducted in the Department of Neonatology, University Hospital Zurich, Switzerland, from 2009 to 2012, comprised of infants born at <32 weeks of gestation, who underwent continuous aEEG recording during the first 4 days of life. Cognitive outcome was assessed with the Kaufman-Assessment Battery for Children at 5 years. Univariate and multivariate logistic regressions were calculated between aEEG parameters and normal cognitive outcome, defined as an intelligence quotient (IQ) of at least 85. RESULTS The 118 (52.5% male) infants were born at a mean gestational age of 29.9 weeks and a mean birth weight of 1235 ± 363 g. We followed up 89 children at the age of five, and they had a mean IQ of 97.8 ± 12.7 with 21.3% under 85-and 2.2% had cerebral palsy. Univariate analyses found associations between aEEG measures and normal cognitive outcome, but these were no longer significant after adjustment for confounders. Socioeconomic status and neonatal morbidity were independent predictors of cognitive outcome. CONCLUSION Early short-term aEEG did not predict later cognitive outcome in our cohort of very preterm infants.
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Affiliation(s)
- Maria Feldmann
- Child Development Centre University Children's Hospital Zurich Zurich Switzerland
- Children's Research Centre University Children's Hospital Zurich Zurich Switzerland
| | - Valentin Rousson
- Institute for Social and Preventive Medicine, Statistical Unit Lausanne University Hospital Lausanne Switzerland
| | - Thi Dao Nguyen
- Department of Neonatology University of Zurich and University Hospital Zurich Zurich Switzerland
| | - Vera Bernet
- Department of Neonatology and Paediatric Intensive care University Children's Hospital Zurich Zurich Switzerland
| | - Cornelia Hagmann
- Children's Research Centre University Children's Hospital Zurich Zurich Switzerland
- Department of Neonatology and Paediatric Intensive care University Children's Hospital Zurich Zurich Switzerland
| | - Beatrice Latal
- Child Development Centre University Children's Hospital Zurich Zurich Switzerland
- Children's Research Centre University Children's Hospital Zurich Zurich Switzerland
| | - Giancarlo Natalucci
- Child Development Centre University Children's Hospital Zurich Zurich Switzerland
- Department of Neonatology University of Zurich and University Hospital Zurich Zurich Switzerland
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21
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White BR, Rogers LS, Kirschen MP. Recent advances in our understanding of neurodevelopmental outcomes in congenital heart disease. Curr Opin Pediatr 2019; 31:783-788. [PMID: 31693588 PMCID: PMC6852883 DOI: 10.1097/mop.0000000000000829] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Patients with congenital heart disease (CHD) suffer from a pattern of neurodevelopmental abnormalities including deficits in language and executive function. In this review, we summarize recent studies that examine these outcomes, their risk factors, possible biomarkers, and attempts to develop therapeutic interventions. RECENT FINDINGS The latest literature has highlighted the role of genetics in determining neurologic prognosis, as we have increased our understanding of potentially modifiable perioperative risk factors. The role of potentially neurotoxic medical therapies has become more salient. One recent focus has been how neurodevelopment affects quality of life and leads to a high prevalence of mental illness. Neuroimaging advances have provided new insights into the pathogenesis of deficits. SUMMARY Although many risk factors in CHD are not modifiable, there is promise for interventions to improve neurodevelopmental outcomes in patients with CHD. Biomarkers are needed to better understand the timing and prognosis of injury and to direct therapy. Research into psychosocial interventions is urgently needed to benefit the many survivors with CHD.
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Affiliation(s)
- Brian R. White
- Division of Pediatric Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Lindsay S. Rogers
- Division of Pediatric Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Matthew P. Kirschen
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
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22
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Ryan KR, Jones MB, Allen KY, Marino BS, Casey F, Wernovsky G, Lisanti AJ. Neurodevelopmental Outcomes Among Children With Congenital Heart Disease: At-Risk Populations and Modifiable Risk Factors. World J Pediatr Congenit Heart Surg 2019; 10:750-758. [PMID: 31658880 DOI: 10.1177/2150135119878702] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
As survivable outcomes among patients with complex congenital heart disease (cCHD) have continued to improve over the last several decades, more attention is being dedicated to interventions that impact not just survival but quality of life among patients with cCHD. In particular, patients with cCHD are at risk for impaired neurodevelopmental outcomes. In this review summarizing select presentations given at the 14th Annual Pediatric Cardiac Intensive Care Society's Annual Meeting in 2019, we discuss the neurodevelopmental phenotype of patients with cCHD, patients at greatest risk of impaired development, and three specific modifiable risk factors impacting development.
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Affiliation(s)
- Kathleen R Ryan
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Melissa B Jones
- Division of Cardiac Critical Care, Children's National Health System, Washington, DC, USA.,Division of Pediatric Cardiology, Children's National Health System, Washington, DC, USA
| | - Kiona Y Allen
- Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, IL, USA.,Division of Critical Care Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Bradley S Marino
- Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, IL, USA.,Division of Critical Care Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Frank Casey
- Department of Cardiology, Belfast Health and Social Care Trust, Belfast, Ireland
| | - Gil Wernovsky
- Division of Cardiac Critical Care, Children's National Health System, Washington, DC, USA.,Division of Pediatric Cardiology, Children's National Health System, Washington, DC, USA
| | - Amy Jo Lisanti
- Department of Cardiac Nursing and the Center for Pediatric Nursing Research and Evidence-based Practice, Children's Hospital of Philadelphia, PA, USA
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23
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Liamlahi R, Latal B. Neurodevelopmental outcome of children with congenital heart disease. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:329-345. [PMID: 31324319 DOI: 10.1016/b978-0-444-64029-1.00016-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Congenital heart disease (CHD) constitutes the most common congenital malformation, with moderate or severe CHD occurring in around 6 in 1000 live births. Due to advances in medical care, survival rates have increased significantly. Thus, the majority of children with CHD survive until adolescence and adulthood. Children with CHD requiring cardiopulmonary bypass surgery are at risk for neurodevelopmental impairments in various domains, including mild impairments in cognitive and neuromotor functions, difficulties with social interaction, inattention, emotional symptoms, and impaired executive function. The prevalence for these impairments ranges from 20% to 60% depending on age and domain ("high prevalence-low severity"). Domains are often affected simultaneously, leading to school problems with the need for learning support and special interventions. The etiology of neurodevelopmental impairments is complex, consisting of a combination of delayed intrauterine brain development and newly occurring perioperative brain injuries. Mechanisms include altered intrauterine hemodynamic flow as well as neonatal hypoxia and reduced cerebral blood flow. The surgical procedure and postoperative phase add to this cascade of factors interfering with normal brain development. Early identification of children at high risk through structured follow-up programs is mandated to provide individually tailored early interventions and counseling to improve developmental health.
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Affiliation(s)
- Rabia Liamlahi
- Child Development Center, University Children's Hospital Zürich, Zürich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital Zürich, Zürich, Switzerland.
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