1
|
Iskander C, Nwankwo U, Kumanan KK, Chiwane S, Exil V, Lowrie L, Tan C, Huddleston C, Agarwal HS. Comparison of Morbidity and Mortality Outcomes between Hybrid Palliation and Norwood Palliation Procedures for Hypoplastic Left Heart Syndrome: Meta-Analysis and Systematic Review. J Clin Med 2024; 13:4244. [PMID: 39064284 PMCID: PMC11277754 DOI: 10.3390/jcm13144244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/20/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Hybrid palliation (HP) procedures for hypoplastic left heart syndrome (HLHS) are increasing. Our objective was to compare mortality and morbidity following HP and NP (Norwood palliation) procedures. Methods: Systematic review and meta-analysis of HLHS patients of peer-reviewed literature between 2000 and 2023. Mortality and/or heart transplantation in HP versus NP in the neonatal period, interstage period, and at 1, 3 and 5 years of age, and morbidity including completion of Stage II and Stage III palliation, unexpected interventions, pulmonary artery pressures, right ventricle function, neurodevelopmental outcomes and length of hospital stay were evaluated. Results: Twenty-one (meta-analysis: 16; qualitative synthesis: 5) studies evaluating 1182 HLHS patients included. HP patients had higher interstage mortality (RR = 1.61; 95% CI: 1.10-2.33; p = 0.01) and 1-year mortality (RR = 1.22; 95% CI: 1.03-1.43; p = 0.02) compared to NP patients without differences in 3- and 5-years mortality. HP procedure in high-risk HLHS patients had lower mortality (RR = 0.48; 95% CI: 0.27-0.87; p = 0.01) only in the neonatal period. HP patients underwent fewer Stage II (RR = 0.90; 95% CI: 0.81-1.00; p = 0.05) and Stage III palliation (RR = 0.78; 95% CI: 0.69-0.90; p < 0.01), had more unplanned interventions (RR = 3.38; 95% CI: 2.04-5.59; p < 0.01), and longer hospital stay after Stage I palliation (weighted mean difference = 12.88; 95% CI: 1.15-24.62; p = 0.03) compared to NP patients. Conclusions: Our study reveals that HP, compared to NP for HLHS, is associated with increased morbidity risk without an improved survival rate.
Collapse
Affiliation(s)
- Christopher Iskander
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Ugonna Nwankwo
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Krithika K. Kumanan
- Advanced Data Health Institution, Saint Louis University, Saint Louis, MO 63104, USA;
| | - Saurabh Chiwane
- Division of Pediatric Critical Care Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Vernat Exil
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Lia Lowrie
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
| | - Corinne Tan
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Charles Huddleston
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Hemant S. Agarwal
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
| |
Collapse
|
2
|
Vu EL, Brown CH, Brady KM, Hogue CW. Monitoring of cerebral blood flow autoregulation: physiologic basis, measurement, and clinical implications. Br J Anaesth 2024; 132:1260-1273. [PMID: 38471987 DOI: 10.1016/j.bja.2024.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 01/18/2024] [Accepted: 01/28/2024] [Indexed: 03/14/2024] Open
Abstract
Cerebral blood flow (CBF) autoregulation is the physiologic process whereby blood supply to the brain is kept constant over a range of cerebral perfusion pressures ensuring a constant supply of metabolic substrate. Clinical methods for monitoring CBF autoregulation were first developed for neurocritically ill patients and have been extended to surgical patients. These methods are based on measuring the relationship between cerebral perfusion pressure and surrogates of CBF or cerebral blood volume (CBV) at low frequencies (<0.05 Hz) of autoregulation using time or frequency domain analyses. Initially intracranial pressure monitoring or transcranial Doppler assessment of CBF velocity was utilised relative to changes in cerebral perfusion pressure or mean arterial pressure. A more clinically practical approach utilising filtered signals from near infrared spectroscopy monitors as an estimate of CBF has been validated. In contrast to the traditional teaching that 50 mm Hg is the autoregulation threshold, these investigations have found wide interindividual variability of the lower limit of autoregulation ranging from 40 to 90 mm Hg in adults and 20-55 mm Hg in children. Observational data have linked impaired CBF autoregulation metrics to adverse outcomes in patients with traumatic brain injury, ischaemic stroke, subarachnoid haemorrhage, intracerebral haemorrhage, and in surgical patients. CBF autoregulation monitoring has been described in both cardiac and noncardiac surgery. Data from a single-centre randomised study in adults found that targeting arterial pressure during cardiopulmonary bypass to above the lower limit of autoregulation led to a reduction of postoperative delirium and improved memory 1 month after surgery compared with usual care. Together, the growing body of evidence suggests that monitoring CBF autoregulation provides prognostic information on eventual patient outcomes and offers potential for therapeutic intervention. For surgical patients, personalised blood pressure management based on CBF autoregulation data holds promise as a strategy to improve patient neurocognitive outcomes.
Collapse
Affiliation(s)
- Eric L Vu
- Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenneth M Brady
- The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charles W Hogue
- The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| |
Collapse
|
3
|
McGetrick ME, Riviello JJ. Neurological injury in pediatric heart disease: A review of developmental and acquired risk factors and management considerations. Semin Pediatr Neurol 2024; 49:101115. [PMID: 38677794 DOI: 10.1016/j.spen.2024.101115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/29/2024]
Abstract
Medical and surgical advancements have improved survival in children with acquired and congenital heart disease (CHD), but the burden of neurological morbidity is high. Brain disorders associated with CHD include white matter injury, stroke, seizure, and neurodevelopmental delays. While genetics and disease-specific factors play a substantial role in early brain injury, therapeutic management of the heart disease intensifies the risk. There is a growing interest in understanding how to reduce brain injury and improve neurodevelopmental outcomes in cardiac diseases. Pediatric neurologists serve a vital role in care teams managing these complex patients, providing interpretation of neuromonitoring and imaging, managing neurologic emergencies, assisting with neuro prognostication, and identifying future research aims.
Collapse
Affiliation(s)
- Molly E McGetrick
- Division of Cardiology and Critical Care, Department of Pediatrics, the University of Texas Southwestern, Children's Medical Center, Dallas, Texas, USA.
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
4
|
Tang J, Ou J, Chen Y, Li L, Liu H, Sun M, Luo M, Zhong T, Wang T, Wei J, Chen Q, Qin J. The risk of attention-deficit hyperactivity disorder among children with congenital heart disease: A systematic review and meta-analysis. Child Care Health Dev 2024; 50:e13174. [PMID: 37734724 DOI: 10.1111/cch.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/14/2023] [Accepted: 08/31/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Although current treatments are effective in dealing with congenital heart disease (CHD), non-cardiac comorbidities such as attention-deficit hyperactivity disorder (ADHD) have received widespread attention. The purpose of this systematic review and meta-analysis is to assess the risk of ADHD associated with CHD. METHODS The literature search was carried out systematically through eight different databases by the end of September 2022. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. The heterogeneity of the studies was assessed by the Cochran Q test and the I2 statistic. Subgroup and sensitivity analyses were used to explore the potential sources of heterogeneity. RESULTS Eleven studies were included in this study, which involved a total of 296 741 participants. Our study showed that the children with CHD were at a significantly increased risk of ADHD compared with the reference group (OR = 2.98, 95% CI: 2.18-4.08). The results were moderately heterogeneous. These factors including study design, geographic region and study quality were identified as the first three of the most relevant heterogeneity moderators by subgroup analyses. Sensitivity analysis yielded consistent results. There was no evidence of publication bias. CONCLUSIONS The present study suggests that CHD children have a significantly higher risk of ADHD when compared with those without CHD. Early identification and intervention of ADHD is important to reduce its symptoms and adverse effects; therefore, clinicians should increase screening for ADHD in children with CHD and intervene promptly to reduce its effects whenever possible.
Collapse
Affiliation(s)
- Jiapeng Tang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jun Ou
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Yige Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Liuxuan Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Hanjun Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Mengting Sun
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Manjun Luo
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Taowei Zhong
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jianhui Wei
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Qian Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, China
| |
Collapse
|
5
|
Sanz JH, Cox S, Donofrio MT, Ishibashi N, McQuillen P, Peyvandi S, Schlatterer S. [Formula: see text] Trajectories of neurodevelopment and opportunities for intervention across the lifespan in congenital heart disease. Child Neuropsychol 2023; 29:1128-1154. [PMID: 36752083 PMCID: PMC10406974 DOI: 10.1080/09297049.2023.2173162] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
Children with congenital heart disease (CHD) are at increased risk for neurodevelopmental challenges across the lifespan. These are associated with neurological changes and potential acquired brain injury, which occur across a developmental trajectory and which are influenced by an array of medical, sociodemographic, environmental, and personal factors. These alterations to brain development lead to an array of adverse neurodevelopmental outcomes, which impact a characteristic set of skills over the course of development. The current paper reviews existing knowledge of aberrant brain development and brain injury alongside associated neurodevelopmental challenges across the lifespan. These provide a framework for discussion of emerging and potential interventions to improve neurodevelopmental outcomes at each developmental stage.
Collapse
Affiliation(s)
- Jacqueline H Sanz
- Division of Neuropsychology, Children's National Hospital, Washington, D.C
- Departments of Psychiatry and Behavioral Sciences & Pediatrics at The George Washington University School of Medicine
| | - Stephany Cox
- Department of Pediatrics, Division of Developmental Medicine, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Mary T Donofrio
- Division of Cardiology, Children's National Health System, Washington, D.C
- Department of Pediatrics at The George Washington University School of Medicine
| | - Nobuyuki Ishibashi
- Department of Pediatrics at The George Washington University School of Medicine
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington D.C
| | - Patrick McQuillen
- Department of Pediatrics, Division of Developmental Medicine, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Shabnam Peyvandi
- Department of Pediatrics, Division of Developmental Medicine, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Sarah Schlatterer
- Department of Pediatrics at The George Washington University School of Medicine
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, D.C
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, D.C
| |
Collapse
|
6
|
Liang S, Ti Y, Huang J, Li X, Zhou W. Inhibition of Microglial Activation by Delayed Mild Hypothermia Reduced Preoligodendrocyte Injury in a Neonatal Rat Brain Slice Model. Ther Hypothermia Temp Manag 2023; 13:134-140. [PMID: 36862528 DOI: 10.1089/ther.2022.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Periventricular leukomalacia (PVL), characterized by distinctive form of white matter injury, often arises after neonatal cardiac surgery. Proven therapies for PVL are absent. In this study, we designed to quest therapeutic effects of delayed mild hypothermia on PVL and its mechanism in a neonatal rat brain slice model. With the increase of delayed mild hypothermia-treating time, the reduced expression of myelin basic protein and loss of preoligodendrocytes were significantly attenuated after oxygen-glucose deprivation. In addition, the proportion of ionized calcium binding adapter molecule 1 (Iba-1)-positive cells and the expression of Iba-1 were apparently reduced with the increased duration of mild hypothermia treatment. Furthermore, the levels of tumor necrosis factor alpha and interleukin-6 reduced after the mild hypothermia treatment relative to the control. Inhibition of microglial activation with prolonged mild hypothermia may be a potential strategy for white matter protection during cardiopulmonary bypass and hypothermic circulatory arrest.
Collapse
Affiliation(s)
- Suixin Liang
- Department of CICU and Shenzhen Children's Hospital, Shenzhen, China
| | - Yunxing Ti
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Junrong Huang
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Xiuhong Li
- Department of CICU and Shenzhen Children's Hospital, Shenzhen, China
| | - Wenjia Zhou
- Department of CICU and Shenzhen Children's Hospital, Shenzhen, China
| |
Collapse
|
7
|
Pliego-Rivero FB, Isaac-Olivé K, Otero GA. Brainstem auditory-evoked responses among children afflicted by severely hypoxic CHD. Cardiol Young 2023; 33:1569-1573. [PMID: 36062556 DOI: 10.1017/s1047951122002591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
MAIN AIM To electrophysiologically determine the impact of moderate to severe chronic hypoxia (H) resulting from a wide array of CHD (HCHD) conditions on the integrity of brainstem function. MATERIALS AND METHODS Applying brainstem auditory-evoked response methodology, 30 chronically afflicted HCHD patients, who already had undergone heart surgery, were compared to 28 healthy control children (1-15 yo) matched by age, gender and socioeconomic condition. Blood oxygen saturation was clinically determined and again immediately before brainstem auditory-evoked response testing. RESULTS Among HCHD children, auditory wave latencies (I, III and V) were significantly longer (medians: I, 2.02 ms; III, 4.12 ms, and; V, 6.30 ms) compared to control (medians: I, 1.67ms; III, 3.72 ms, and; V, 5.65 ms), as well as interpeak intervals (HCHD medians: I-V, 4.25 ms, and; III-V, 2.25ms; control medians: I-V, 3.90 ms and, III-V, 1.80 ms) without significant differences in wave amplitudes between groups. A statistically significant and inverse correlation between average blood oxygen saturation of each group (control, 94%; HCHD, 78%) and their respective wave latencies and interpeak intervals was found. CONCLUSIONS As determined by brainstem auditory-evoked responses, young HCHD patients manifestly show severely altered neuronal conductivity in the auditory pathway strongly correlated with their hypoxic condition. These observations are strongly supported by different brainstem neurological and image studies showing that alterations, either in microstructure or function, result from the condition of chronic hypoxia in CHD. The non-altered wave amplitudes are indicative of relatively well-preserved neuronal relay nuclei.
Collapse
Affiliation(s)
| | - Keila Isaac-Olivé
- Laboratory of Theragnostics Research, Universidad Autonoma del Estado de Mexico, Toluca, Mexico
| | - Gloria A Otero
- Laboratory of Neurophysiology, Universidad Autonoma del Estado de Mexico, Toluca, Mexico
| |
Collapse
|
8
|
Zou M, Yu L, Lin R, Feng J, Zhang M, Ning S, Cui Y, Li J, Li L, Ma L, Huang G, Wang H, Chen X, Li J. Cerebral Autoregulation Status in Relation to Brain Injury on Electroencephalogram and Magnetic Resonance Imaging in Children Following Cardiac Surgery. J Am Heart Assoc 2023:e028147. [PMID: 37301753 DOI: 10.1161/jaha.122.028147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 04/06/2023] [Indexed: 06/12/2023]
Abstract
Background Disturbed cerebral autoregulation has been reported in children with congenital heart disease before and during cardiopulmonary bypass surgery, but not after. We sought to characterize the cerebral autoregulation status in the early postoperative period in relation to perioperative variables and brain injuries. Methods and Results A prospective and observational study was conducted in 80 patients in the first 48 hours following cardiac surgery. Cerebral oximetry/pressure index (COPI) was retrospectively calculated as a moving linear correlation coefficient between mean arterial blood pressure and cerebral oxygen saturation. Disturbed autoregulation was defined as COPI >0.3. Correlations of COPI with demographic and perioperative variables as well as brain injuries on electroencephalogram and magnetic resonance imaging and early outcomes were analyzed. Thirty-six (45%) patients had periods of abnormal COPI for 7.81 hours (3.38 hours) either at hypotension (median <45 mm Hg) or hypertension (median >90 mm Hg) or both. Overall, COPI became significantly lower over time, suggesting improved autoregulatory status during the 48 postoperative hours. All of the demographic and perioperative variables were significantly associated with COPI, which in turn was associated with the degree of brain injuries and early outcomes. Conclusions Children with congenital heart disease following cardiac surgery often have disturbed autoregulation. Cerebral autoregulation is at least partly the underlying mechanism of brain injury in those children. Careful clinical management to manipulate the related and modifiable factors, particularly arterial blood pressure, may help to maintain adequate cerebral perfusion and reduce brain injury early after cardiopulmonary bypass surgery. Further studies are warranted to determine the significance of impaired cerebral autoregulation in relation to long-term neurodevelopment outcomes.
Collapse
Affiliation(s)
- Minghui Zou
- Heart Center, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
- Department of Pediatric Surgery, Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
| | - Linyang Yu
- Department of Pediatric Surgery, 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
| | - Rouyi Lin
- Department of Pediatric Surgery, 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
| | - Jinqing Feng
- Department of Pediatric Surgery, 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
| | - Mingjie Zhang
- Department of Radiology, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangzhou Guangdong Province China
| | - Shuyao Ning
- Department of Electroneurophysiology, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangzhou Guangdong Province China
| | - Yanqin Cui
- Heart Center, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
- Department of Pediatric Surgery, Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
| | - Jianbin Li
- Heart Center, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
- Department of Pediatric Surgery, Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
| | - Lijuan Li
- Heart Center, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
- Department of Pediatric Surgery, Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
| | - Li Ma
- Heart Center, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
- Department of Pediatric Surgery, Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
| | - Guodong Huang
- Heart Center, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
- Department of Pediatric Surgery, Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
| | - Huaizhen Wang
- Heart Center, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
- Department of Pediatric Surgery, Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
| | - Xinxin Chen
- Heart Center, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
- Department of Pediatric Surgery, Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangdong China
| | - Jia Li
- Department of Pediatric Surgery, 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
| |
Collapse
|
9
|
Wang C, Bhutta A, Zhang X, Liu F, Liu S, Latham LE, Talpos JC, Patterson TA, Slikker W. Development of a primate model to evaluate the effects of ketamine and surgical stress on the neonatal brain. Exp Biol Med (Maywood) 2023; 248:624-632. [PMID: 37208914 PMCID: PMC10350805 DOI: 10.1177/15353702231168144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/06/2023] [Indexed: 05/21/2023] Open
Abstract
With advances in pediatric and obstetric surgery, pediatric patients are subject to complex procedures under general anesthesia. The effects of anesthetic exposure on the developing brain may be confounded by several factors including pre-existing disorders and surgery-induced stress. Ketamine, a noncompetitive N-methyl-d-aspartate (NMDA) receptor antagonist, is routinely used as a pediatric general anesthetic. However, controversy remains about whether ketamine exposure may be neuroprotective or induce neuronal degeneration in the developing brain. Here, we report the effects of ketamine exposure on the neonatal nonhuman primate brain under surgical stress. Eight neonatal rhesus monkeys (postnatal days 5-7) were randomly assigned to each of two groups: Group A (n = 4) received 2 mg/kg ketamine via intravenous bolus prior to surgery and a 0.5 mg/kg/h ketamine infusion during surgery in the presence of a standardized pediatric anesthetic regimen; Group B (n = 4) received volumes of normal saline equivalent to those of ketamine given to Group A animals prior to and during surgery, also in the presence of a standardized pediatric anesthetic regimen. Under anesthesia, the surgery consisted of a thoracotomy followed by closing the pleural space and tissue in layers using standard surgical techniques. Vital signs were monitored to be within normal ranges throughout anesthesia. Elevated levels of cytokines interleukin (IL)-8, IL-15, monocyte chemoattractant protein-1 (MCP-1), and macrophage inflammatory protein (MIP)-1β at 6 and 24 h after surgery were detected in ketamine-exposed animals. Fluoro-Jade C staining revealed significantly higher neuronal degeneration in the frontal cortex of ketamine-exposed animals, compared with control animals. Intravenous ketamine administration prior to and throughout surgery in a clinically relevant neonatal primate model appears to elevate cytokine levels and increase neuronal degeneration. Consistent with previous data on the effects of ketamine on the developing brain, the results from the current randomized controlled study in neonatal monkeys undergoing simulated surgery show that ketamine does not provide neuroprotective or anti-inflammatory effects.
Collapse
Affiliation(s)
- Cheng Wang
- Division of Neurotoxicology, National Center for Toxicological Research, Food and Drug Administration (FDA), Jefferson, AR 72079, USA
| | - Adnan Bhutta
- University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
- Riley Children’s Hospital, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Xuan Zhang
- Division of Neurotoxicology, National Center for Toxicological Research, Food and Drug Administration (FDA), Jefferson, AR 72079, USA
| | - Fang Liu
- Division of Neurotoxicology, National Center for Toxicological Research, Food and Drug Administration (FDA), Jefferson, AR 72079, USA
| | - Shuliang Liu
- Division of Neurotoxicology, National Center for Toxicological Research, Food and Drug Administration (FDA), Jefferson, AR 72079, USA
| | - Leah E Latham
- Division of Neurotoxicology, National Center for Toxicological Research, Food and Drug Administration (FDA), Jefferson, AR 72079, USA
| | - John C Talpos
- Division of Neurotoxicology, National Center for Toxicological Research, Food and Drug Administration (FDA), Jefferson, AR 72079, USA
| | - Tucker A Patterson
- Office of Research, National Center for Toxicological Research, Food and Drug Administration (FDA), Jefferson, AR 72079, USA
| | | |
Collapse
|
10
|
Peyvandi S, Xu D, Barkovich AJ, Gano D, Chau V, Reddy VM, Selvanathan T, Guo T, Gaynor JW, Seed M, Miller SP, McQuillen P. Declining Incidence of Postoperative Neonatal Brain Injury in Congenital Heart Disease. J Am Coll Cardiol 2023; 81:253-266. [PMID: 36653093 PMCID: PMC10548869 DOI: 10.1016/j.jacc.2022.10.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/30/2022] [Accepted: 10/18/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Brain injury is common in neonates with complex neonatal congenital heart disease (CHD) and affects neurodevelopmental outcomes. OBJECTIVES Given advancements in perioperative care, we sought to determine if the rate of preoperative and postoperative brain injury detected by using brain magnetic resonance imaging (MRI) and associated clinical risk factors have changed over time in complex CHD. METHODS A total of 270 term newborns with complex CHD were prospectively enrolled for preoperative and postoperative brain MRIs between 2001 and 2021 with a total of 466 MRI scans. Brain injuries in the form of white matter injury (WMI) or focal stroke and clinical factors were compared across 4 epochs of 5-year intervals with logistic regression. RESULTS Rates of preoperative WMI and stroke did not change over time. After adjusting for timing of the postoperative MRI, site, and cardiac group, the odds of newly acquired postoperative WMI were significantly lower in Epoch 4 compared with Epoch 1 (OR: 0.29; 95% CI: 0.09-1.00; P = 0.05). The adjusted probability of postoperative WMI declined significantly by 18.7% from Epoch 1 (24%) to Epoch 4 (6%). Among clinical risk factors, lowest systolic, mean, and diastolic blood pressures in the first 24 hours after surgery were significantly higher in the most recent epoch. CONCLUSIONS The prevalence of postoperative WMI has declined, whereas preoperative WMI rates remain constant. More robust postoperative blood pressures may explain these findings by minimizing periods of ischemia and supporting cerebral perfusion. These results suggest potential modifiable clinical targets in the postoperative time period to minimize the burden of WMI.
Collapse
Affiliation(s)
- Shabnam Peyvandi
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA.
| | - Duan Xu
- Department of Radiology, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - A James Barkovich
- Department of Radiology, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Dawn Gano
- Department of Neurology, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Vann Chau
- Department of Neurology, The University of Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | - V Mohan Reddy
- Department of Surgery, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Thiviya Selvanathan
- Department of Neurology, The University of Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ting Guo
- Department of Neurology, The University of Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | - J William Gaynor
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mike Seed
- Department of Pediatrics, The University of Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | - Steven P Miller
- Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Patrick McQuillen
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| |
Collapse
|
11
|
Chowdhury D, Toms R, Brumbaugh JE, Bindom S, Ather M, Jaquiss R, Johnson JN. Evaluation and Management of Noncardiac Comorbidities in Children With Congenital Heart Disease. Pediatrics 2022; 150:189884. [PMID: 36317973 DOI: 10.1542/peds.2022-056415e] [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] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
Outcomes for patients with neonatal heart disease are affected by numerous noncardiac and genetic factors. These can include neonatal concerns, such as prematurity and low birth weight, and congenital anomalies, such as airway, pulmonary, gastrointestinal, and genitourinary anomalies, and genetic syndromes. This section will serve as a summary of these issues and how they may affect the evaluation and management of a neonate with heart disease. These noncardiac factors are heavily influenced by conditions common to neonatologists, making a strong argument for multidisciplinary care with neonatologists, cardiologists, surgeons, anesthesiologists, and cardiovascular intensivists. Through this section and this project, we aim to facilitate a comprehensive approach to the care of neonates with congenital heart disease.
Collapse
Affiliation(s)
- Devyani Chowdhury
- Cardiology Care for Children, Lancaster, Pennsylvania Nemours Cardiac Center.,These two co-first authors contributed equally to this manuscript
| | - Rune Toms
- Division of Neonatal-Perinatal Medicine, Joe DiMaggio Children's Hospital, Hollywood, Florida.,These two co-first authors contributed equally to this manuscript
| | | | - Sharell Bindom
- Division of Neonatal-Perinatal Medicine, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Mishaal Ather
- Cardiology Care for Children, Lancaster, Pennsylvania Nemours Cardiac Center
| | - Robert Jaquiss
- Division of Pediatric and Congenital Cardiothoracic Surgery, Children's Medical Center, Dallas, Texas
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Correlation of Cerebral Microdialysis with Non-Invasive Diffuse Optical Cerebral Hemodynamic Monitoring during Deep Hypothermic Cardiopulmonary Bypass. Metabolites 2022; 12:metabo12080737. [PMID: 36005609 PMCID: PMC9416552 DOI: 10.3390/metabo12080737] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
Neonates undergoing cardiac surgery involving aortic arch reconstruction are at an increased risk for hypoxic-ischemic brain injury. Deep hypothermia is utilized to help mitigate this risk when periods of circulatory arrest are needed for surgical repair. Here, we investigate correlations between non-invasive optical neuromonitoring of cerebral hemodynamics, which has recently shown promise for the prediction of postoperative white matter injury in this patient population, and invasive cerebral microdialysis biomarkers. We compared cerebral tissue oxygen saturation (StO2), relative total hemoglobin concentration (rTHC), and relative cerebral blood flow (rCBF) measured by optics against the microdialysis biomarkers of metabolic stress and injury (lactate–pyruvate ratio (LPR) and glycerol) in neonatal swine models of deep hypothermic cardiopulmonary bypass (DHCPB), selective antegrade cerebral perfusion (SACP), and deep hypothermic circulatory arrest (DHCA). All three optical parameters were negatively correlated with LPR and glycerol in DHCA animals. Elevation of LPR was found to precede the elevation of glycerol by 30–60 min. From these data, thresholds for the detection of hypoxic-ischemia-associated cerebral metabolic distress and neurological injury are suggested. In total, this work provides insight into the timing and mechanisms of neurological injury following hypoxic-ischemia and reports a quantitative relationship between hypoxic-ischemia severity and neurological injury that may inform DHCA management.
Collapse
|
14
|
Calderon J, Newburger JW, Rollins CK. Neurodevelopmental and Mental Health Outcomes in Patients With Fontan Circulation: A State-of-the-Art Review. Front Pediatr 2022; 10:826349. [PMID: 35356444 PMCID: PMC8959547 DOI: 10.3389/fped.2022.826349] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Children, adolescents and adults living with Fontan circulation face numerous neurological and developmental challenges. As the population with complex CHD increases thanks to outstanding improvement in medical and surgical care, the long-term developmental and mental health sequelae have become a public health priority in pediatric and congenital cardiology. Many patients with a Fontan circulation experience difficulty in areas of cognition related to attention and executive functioning, visual spatial reasoning and psychosocial development. They are also at high risk for mental health morbidities, particularly anxiety disorders and depression. Several hemodynamic risk factors, beginning during the fetal period, may influence outcomes and yield to abnormal brain growth and development. Brain injury such as white matter lesions, stroke or hemorrhage can occur before, during, or after surgery. Other sociodemographic and surgical risk factors such as multiple catheterizations and surgeries and prolonged hospital stay play a detrimental role in patients' neurodevelopmental prognosis. Prevention and intervention to optimize long-term outcomes are critical in the care of this vulnerable population with complex CHD.
Collapse
Affiliation(s)
- Johanna Calderon
- PhyMedExp, Université de Montpellier, National Institute of Health and Medical Research (INSERM), CNRS, Montpellier, France.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, United States.,Department of Neurology, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
15
|
Long-term neurodevelopmental effects of intraoperative blood pressure during surgical closure of a septal defect in infancy or early childhood. Cardiol Young 2021; 31:2002-2008. [PMID: 33843536 DOI: 10.1017/s1047951121001414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Many children born with congenital heart defects are faced with cognitive deficits and psychological challenges later in life. The mechanisms behind are suggested to be multifactorial and are explained as an interplay between innate and modifiable risk factors. The aim was to assess whether there is a relationship between mean arterial pressure during surgery of a septal defect in infancy or early childhood and intelligence quotient scores in adulthood. METHODS In a retrospective study, patients were included if they underwent surgical closure of a ventricular septal defect or an atrial septal defect in childhood between 1988 and 2002. Every patient completed an intelligence assessment upon inclusion, 14-27 years after surgery, using the Wechsler Adult Intelligence Scale Version IV. RESULTS A total of 58 patients met the eligibility criteria and were included in the analyses. No statistically significant correlation was found between blood pressure during cardiopulmonary bypass and intelligence quotient scores in adulthood (r = 0.138; 95% CI-0.133-0.389). Although amongst patients with mean arterial pressure < 40 mmHg during cardiopulmonary bypass, intelligence quotient scores were significantly lower (91.4; 95% CI 86.9-95.9) compared to those with mean arterial pressure > 40 mmHg (99.8; 95% CI 94.7-104.9). CONCLUSIONS Mean arterial pressure during surgery of ventricular septal defects or atrial septal defects in childhood does not correlate linearly with intelligence quotient scores in adulthood. Although there may exist a specific cut-off value at which low blood pressure becomes harmful. Larger studies are warranted in order to confirm this, as it holds the potential of partly relieving CHD patients of their cognitive deficits.
Collapse
|
16
|
Stegeman R, Feldmann M, Claessens NHP, Jansen NJG, Breur JMPJ, de Vries LS, Logeswaran T, Reich B, Knirsch W, Kottke R, Hagmann C, Latal B, Simpson J, Pushparajah K, Bonthrone AF, Kelly CJ, Arulkumaran S, Rutherford MA, Counsell SJ, Benders MJNL. A Uniform Description of Perioperative Brain MRI Findings in Infants with Severe Congenital Heart Disease: Results of a European Collaboration. AJNR Am J Neuroradiol 2021; 42:2034-2039. [PMID: 34674999 PMCID: PMC8583253 DOI: 10.3174/ajnr.a7328] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/19/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE A uniform description of brain MR imaging findings in infants with severe congenital heart disease to assess risk factors, predict outcome, and compare centers is lacking. Our objective was to uniformly describe the spectrum of perioperative brain MR imaging findings in infants with congenital heart disease. MATERIALS AND METHODS Prospective observational studies were performed at 3 European centers between 2009 and 2019. Brain MR imaging was performed preoperatively and/or postoperatively in infants with transposition of the great arteries, single-ventricle physiology, or left ventricular outflow tract obstruction undergoing cardiac surgery within the first 6 weeks of life. Brain injury was assessed on T1, T2, DWI, SWI, and MRV. A subsample of images was assessed jointly to reach a consensus. RESULTS A total of 348 MR imaging scans (180 preoperatively, 168 postoperatively, 146 pre- and postoperatively) were obtained in 202 infants. Preoperative, new postoperative, and cumulative postoperative white matter injury was identified in 25%, 30%, and 36%; arterial ischemic stroke, in 6%, 10%, and 14%; hypoxic-ischemic watershed injury in 2%, 1%, and 1%; intraparenchymal cerebral hemorrhage, in 0%, 4%, and 5%; cerebellar hemorrhage, in 6%, 2%, and 6%; intraventricular hemorrhage, in 14%, 6%, and 13%; subdural hemorrhage, in 29%, 17%, and 29%; and cerebral sinovenous thrombosis, in 0%, 10%, and 10%, respectively. CONCLUSIONS A broad spectrum of perioperative brain MR imaging findings was found in infants with severe congenital heart disease. We propose an MR imaging protocol including T1-, T2-, diffusion-, and susceptibility-weighted imaging, and MRV to identify ischemic, hemorrhagic, and thrombotic lesions observed in this patient group.
Collapse
Affiliation(s)
- R Stegeman
- From the Departments of Neonatology (R.S., N.H.P.C., L.S.d.V., M.J.N.L.B.)
- Pediatric Intensive Care (R.S., N.H.P.C., N.J.G.J.)
- Pediatric Cardiology (R.S., N.H.P.C., J.M.P.J.B.), Wilhelmina Children's Hospital, UMC Utrecht, Utrecht, the Netherlands
- Utrecht Brain Center (R.S., L.S.d.V., M.J.N.L.B.), UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - N H P Claessens
- From the Departments of Neonatology (R.S., N.H.P.C., L.S.d.V., M.J.N.L.B.)
- Pediatric Intensive Care (R.S., N.H.P.C., N.J.G.J.)
- Pediatric Cardiology (R.S., N.H.P.C., J.M.P.J.B.), Wilhelmina Children's Hospital, UMC Utrecht, Utrecht, the Netherlands
| | - N J G Jansen
- Pediatric Intensive Care (R.S., N.H.P.C., N.J.G.J.)
- Department of Pediatrics (N.J.G.J.), Beatrix Children's Hospital, UMC Groningen, Groningen, the Netherlands
| | - J M P J Breur
- Pediatric Cardiology (R.S., N.H.P.C., J.M.P.J.B.), Wilhelmina Children's Hospital, UMC Utrecht, Utrecht, the Netherlands
| | - L S de Vries
- From the Departments of Neonatology (R.S., N.H.P.C., L.S.d.V., M.J.N.L.B.)
- Utrecht Brain Center (R.S., L.S.d.V., M.J.N.L.B.), UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - T Logeswaran
- Pediatric Heart Center (T.L., B.R.), University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - B Reich
- Pediatric Heart Center (T.L., B.R.), University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - W Knirsch
- Division of Pediatric Cardiology (W.K.), Pediatric Heart Center
| | - R Kottke
- Department of Diagnostic Imaging (R.K.)
| | - C Hagmann
- Department of Neonatology and Pediatric Intensive Care (C.H.), University Children's Hospital Zurich, Zurich, Switzerland
| | - B Latal
- Child Development Center (M.F., B.L.)
| | - J Simpson
- Department of Pediatric Cardiology (J.S., K.P.), Evelina Children's Hospital London, London, UK
| | - K Pushparajah
- Department of Pediatric Cardiology (J.S., K.P.), Evelina Children's Hospital London, London, UK
- Centre for the Developing Brain (K.P., A.F.B., C.J.K., S.A., M.A.R., S.J.C.), School of Biomedical Engineering and Imaging Sciences, King.s College London, London, UK
| | - A F Bonthrone
- Centre for the Developing Brain (K.P., A.F.B., C.J.K., S.A., M.A.R., S.J.C.), School of Biomedical Engineering and Imaging Sciences, King.s College London, London, UK
| | - C J Kelly
- Centre for the Developing Brain (K.P., A.F.B., C.J.K., S.A., M.A.R., S.J.C.), School of Biomedical Engineering and Imaging Sciences, King.s College London, London, UK
| | - S Arulkumaran
- Centre for the Developing Brain (K.P., A.F.B., C.J.K., S.A., M.A.R., S.J.C.), School of Biomedical Engineering and Imaging Sciences, King.s College London, London, UK
| | - M A Rutherford
- Centre for the Developing Brain (K.P., A.F.B., C.J.K., S.A., M.A.R., S.J.C.), School of Biomedical Engineering and Imaging Sciences, King.s College London, London, UK
| | - S J Counsell
- Centre for the Developing Brain (K.P., A.F.B., C.J.K., S.A., M.A.R., S.J.C.), School of Biomedical Engineering and Imaging Sciences, King.s College London, London, UK
| | - M J N L Benders
- From the Departments of Neonatology (R.S., N.H.P.C., L.S.d.V., M.J.N.L.B.)
- Utrecht Brain Center (R.S., L.S.d.V., M.J.N.L.B.), UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| |
Collapse
|
17
|
Spilka JM, O'Halloran CP, Marino BS, Brady KM. Perspective on Cerebral Autoregulation Monitoring in Neonatal Cardiac Surgery Requiring Cardiopulmonary Bypass. Front Neurol 2021; 12:740185. [PMID: 34675872 PMCID: PMC8523884 DOI: 10.3389/fneur.2021.740185] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/09/2021] [Indexed: 11/23/2022] Open
Abstract
The autoregulation of cerebral blood flow protects against brain injury from transient fluctuations in arterial blood pressure. Impaired autoregulation may contribute to hypoperfusion injury in neonates and infants. Monitoring cerebral autoregulation in neonatal cardiac surgery as a guide for arterial blood pressure management may reduce neurodevelopmental morbidity. Cerebral autoregulation monitoring has been validated in animal models and in an adult trial autoregulation monitoring during bypass improved postoperative delirium scores. The nuances of pediatric cardiac disease and congenital heart surgery make simply applying adult trial findings to this unique population inappropriate. Therefore, dedicated pediatric clinical trials of cerebral autoregulation monitoring are indicated.
Collapse
Affiliation(s)
- Jared M Spilka
- Division of Cardiac Anesthesia, Department of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Conor P O'Halloran
- Division of Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, OH, United States
| | - Kenneth M Brady
- Division of Cardiac Anesthesia, Department of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| |
Collapse
|
18
|
Carra G, Flechet M, Jacobs A, Verstraete S, Vlasselaers D, Desmet L, Van Cleemput H, Wouters P, Vanhorebeek I, Van den Berghe G, Güiza F, Meyfroidt G. Postoperative Cerebral Oxygen Saturation in Children After Congenital Cardiac Surgery and Long-Term Total Intelligence Quotient: A Prospective Observational Study. Crit Care Med 2021; 49:967-976. [PMID: 33591016 PMCID: PMC8132917 DOI: 10.1097/ccm.0000000000004852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES During the early postoperative period, children with congenital heart disease can suffer from inadequate cerebral perfusion, with possible long-term neurocognitive consequences. Cerebral tissue oxygen saturation can be monitored noninvasively with near-infrared spectroscopy. In this prospective study, we hypothesized that reduced cerebral tissue oxygen saturation and increased intensity and duration of desaturation (defined as cerebral tissue oxygen saturation < 65%) during the early postoperative period, independently increase the probability of reduced total intelligence quotient, 2 years after admission to a PICU. DESIGN Single-center, prospective study, performed between 2012 and 2015. SETTING The PICU of the University Hospitals Leuven, Belgium. PATIENTS The study included pediatric patients after surgery for congenital heart disease admitted to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Postoperative cerebral perfusion was characterized with the mean cerebral tissue oxygen saturation and dose of desaturation of the first 12 and 24 hours of cerebral tissue oxygen saturation monitoring. The independent association of postoperative mean cerebral tissue oxygen saturation and dose of desaturation with total intelligence quotient at 2-year follow-up was evaluated with a Bayesian linear regression model adjusted for known confounders. According to a noninformative prior, reduced mean cerebral tissue oxygen saturation during the first 12 hours of monitoring results in a loss of intelligence quotient points at 2 years, with a 90% probability (posterior β estimates [80% credible interval], 0.23 [0.04-0.41]). Similarly, increased dose of cerebral tissue oxygen saturation desaturation would result in a loss of intelligence quotient points at 2 years with a 90% probability (posterior β estimates [80% credible interval], -0.009 [-0.016 to -0.001]). CONCLUSIONS Increased dose of cerebral tissue oxygen saturation desaturation and reduced mean cerebral tissue oxygen saturation during the early postoperative period independently increase the probability of having a lower total intelligence quotient, 2 years after PICU admission.
Collapse
Affiliation(s)
- Giorgia Carra
- All authors: Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, UZ Leuven and KU Leuven, Leuven, Belgium
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Shimoda T, Mathis BJ, Kato H, Matsubara M, Suzuki Y, Suetsugu F, Hiramatsu Y. Architecture matters: Tissue preservation strategies for tetralogy of Fallot repair. J Card Surg 2021; 36:2836-2849. [PMID: 33908656 DOI: 10.1111/jocs.15584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/11/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Great variability exists in repair strategies for the tetralogy of Fallot. While transannular patching, as introduced by Kirklin, was a breakthrough for primary repair, pulmonary regurgitation and a need for reoperation have led to the development of methods that preserve the natural morphology of the right ventricular outflow tract. METHODS State-of-the-art details of tetralogy of Fallot repair are explained from the standpoint of architectural preservation, especially with regard to sparing native tissue such as the annulus, valve, or infundibulum. Particular attention is given to the latest technical details of each approach, benefits and disadvantages, and any long-term data available. RESULTS The choice of procedure is complex and unique to each case as transannular patching alone may carry long-term pulmonary risks. Modifications that spare the annulus, valves, or infundibulum may thus be essential as preservation of natural morphology has resulted in excellent mid-term results. CONCLUSIONS The complexity of tetralogy of Fallot repair demands constant attention to clinical presentation and vigilance against long-term sequelae. Techniques will continue to improve over time as long-term data guides the refinement of these innovative surgical methods.
Collapse
Affiliation(s)
- Tomonari Shimoda
- Department of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Bryan J Mathis
- Department of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hideyuki Kato
- Department of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Muneaki Matsubara
- Department of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yasuyuki Suzuki
- Department of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Fuminaga Suetsugu
- Department of Cardiovascular Surgery, Suetsugu Clinic , Kitakyushu, Fukuoka, Japan
| | - Yuji Hiramatsu
- Department of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| |
Collapse
|
20
|
Alkhatip AAAMM, Kamel MG, Farag EM, Elayashy M, Farag A, Yassin HM, Bahr MH, Abdelhaq M, Sallam A, Kamal AM, Emady MFE, Wagih M, Naguib AA, Helmy M, Algameel HZ, Abdelkader M, Mohamed H, Younis M, Purcell A, Elramely M, Hamza MK. Deep Hypothermic Circulatory Arrest in the Pediatric Population Undergoing Cardiac Surgery With Electroencephalography Monitoring: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2021; 35:2875-2888. [PMID: 33637420 DOI: 10.1053/j.jvca.2021.01.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Cardiac surgery for repair of congenital heart defects poses unique hazards to the developing brain. Deep hypothermic circulatory arrest (DHCA) is a simple and effective method for facilitating a bloodless surgical field during congenital heart defect repair. There are, however, some concerns that prolonged DHCA increases the risk of nervous system injury. The electroencephalogram (EEG) is used in adult and, to a lesser extent, pediatric cardiac procedures as a neuromonitoring method. The present study was performed to assess outcomes following DHCA with EEG monitoring in the pediatric population. DESIGN In this systematic review and meta-analysis, the PubMed, Cochrane Central Register of Controlled Trials, Scopus, Institute of Science Index, and Embase databases were searched from inception for relevant articles. A fixed- or random-effects model, as appropriate, was used. SETTING Surgical setting. PARTICIPANTS Pediatric population (≤18 y old). INTERVENTIONS DHCA (18°C) with EEG monitoring. MEASUREMENTS AND MAIN RESULTS Nineteen articles with 1,267 pediatric patients ≤18 years were included. The event rate of clinical and EEG seizures among patients who underwent DHCA was 12.9% and 14.9%, respectively. Mortality was found to have a 6.3% prevalence. A longer duration of DHCA was associated with a higher risk of EEG seizure and neurologic abnormalities. In addition, seizures were associated with increased neurologic abnormalities and neurodevelopmental delay. CONCLUSIONS EEG and neurologic abnormalities were common after DHCA. A longer duration of DHCA was found to lead to more EEG seizure and neurologic abnormalities. Moreover, EEG seizures were more common than clinical seizures. Seizures were found to be associated with increased neurologic abnormalities and neurodevelopmental delay.
Collapse
Affiliation(s)
- Ahmed Abdelaal Ahmed Mahmoud M Alkhatip
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK; Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt.
| | | | - Ehab Mohamed Farag
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed Elayashy
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Farag
- Department of Anesthesia, King Abdullah Medical City - Holy Capital, Makkah, Saudi Arabia
| | - Hany Mahmoud Yassin
- Department of Anesthesia, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Mahmoud Hussein Bahr
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed Abdelhaq
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Sallam
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland; Department of Anaesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ahmed Mostafa Kamal
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Mohamed Wagih
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Ahmed Naguib
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Helmy
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Mohamed Abdelkader
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Hassan Mohamed
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt; Department of Anaesthesia, Royal Papworth Hospital, Cambridge, UK
| | - Mohamed Younis
- Department of Anaesthesia, Cambridge University Hospital, Cambridge, UK
| | - Andrew Purcell
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland
| | - Mohamed Elramely
- Department of Anaesthesia, National Cancer Institute, Cairo University, Cairo, Egypt
| | | |
Collapse
|
21
|
Das D, Dutta N, Roy Chowdhuri K. Total circulatory arrest as a support modality in congenital heart surgery: review and current evidence. Indian J Thorac Cardiovasc Surg 2021; 37:165-173. [PMID: 33584032 PMCID: PMC7859125 DOI: 10.1007/s12055-020-00930-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 11/24/2022] Open
Abstract
The use of total circulatory arrest (TCA)/deep hypothermic circulatory arrest (DHCA) as a support modality in congenital heart surgery is a time-tested strategy. However, with technological advances, the widespread use of this technique has decreased. Adjunctive cerebral perfusion with continuous cardiopulmonary bypass (CPB) gradually has become more popular with a view to reduce the complications related to DHCA. In addition, better neuromonitoring and neuroprotective strategies have made DHCA much safer. However, the level of evidence to support the best way to protect the brain during congenital heart surgery is insufficient. This review analyzes the history, physiology, techniques of DHCA, as well as other alternative strategies like selective cerebral perfusion and presents the current available evidence.
Collapse
Affiliation(s)
- Debasis Das
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah, 711103 India
| | - Nilanjan Dutta
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah, 711103 India
| | - Kuntal Roy Chowdhuri
- Department of Cardiac Surgery, BM Birla Heart Research Centre, 1, National Library Avenue, Alipore, Kolkata, 700027 India
| |
Collapse
|
22
|
Barkhuizen M, Abella R, Vles JSH, Zimmermann LJI, Gazzolo D, Gavilanes AWD. Antenatal and Perioperative Mechanisms of Global Neurological Injury in Congenital Heart Disease. Pediatr Cardiol 2021; 42:1-18. [PMID: 33373013 PMCID: PMC7864813 DOI: 10.1007/s00246-020-02440-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/17/2020] [Indexed: 12/01/2022]
Abstract
Congenital heart defects (CHD) is one of the most common types of birth defects. Thanks to advances in surgical techniques and intensive care, the majority of children with severe forms of CHD survive into adulthood. However, this increase in survival comes with a cost. CHD survivors have neurological functioning at the bottom of the normal range. A large spectrum of central nervous system dysmaturation leads to the deficits seen in critical CHD. The heart develops early during gestation, and CHD has a profound effect on fetal brain development for the remainder of gestation. Term infants with critical CHD are born with an immature brain, which is highly susceptible to hypoxic-ischemic injuries. Perioperative blood flow disturbances due to the CHD and the use of cardiopulmonary bypass or circulatory arrest during surgery cause additional neurological injuries. Innate patient factors, such as genetic syndromes and preterm birth, and postoperative complications play a larger role in neurological injury than perioperative factors. Strategies to reduce the disability burden in critical CHD survivors are urgently needed.
Collapse
Affiliation(s)
- Melinda Barkhuizen
- Department of Pediatrics and Neonatology, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Raul Abella
- Department of Pediatric Cardiac Surgery, University of Barcelona, Vall d'Hebron, Spain
| | - J S Hans Vles
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Luc J I Zimmermann
- Department of Pediatrics and Neonatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Diego Gazzolo
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Fetal, Maternal and Neonatal Health, C. Arrigo Children's Hospital, Alessandria, Italy
| | - Antonio W D Gavilanes
- Department of Pediatrics and Neonatology, Maastricht University Medical Center, Maastricht, The Netherlands.
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands.
- Instituto de Investigación e Innovación de Salud Integral, Facultad de Ciencias Médicas, Universidad Católica de Guayaquil, Guayaquil, Ecuador.
- Department of Pediatrics, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| |
Collapse
|
23
|
Ma S, Li Y, Liu Y, Xu C, Li H, Yao Q, Wang Y, Yang Z, Zuo P, Yang M, Mo X. Changes in Cortical Thickness Are Associated With Cognitive Ability in Postoperative School-Aged Children With Tetralogy of Fallot. Front Neurol 2020; 11:691. [PMID: 32765405 PMCID: PMC7380078 DOI: 10.3389/fneur.2020.00691] [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] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/09/2020] [Indexed: 11/25/2022] Open
Abstract
In children with tetralogy of Fallot (TOF), there is a risk of brain injury even if intracardiac deformities are corrected. This population follow-up study aimed to identify the correlation between cerebral morphology changes and cognition in postoperative school-aged children with TOF. Resting-state functional magnetic resonance imaging (rs-fMRI) and the Wechsler Intelligence Scale for Children–Chinese revised edition (WISC-CR) were used to assess the difference between children with TOF and healthy children (HCs). Multiple linear regression showed that the TOF group had a lower verbal intelligence quotient (VIQ, 95.000 ± 13.433, p = 0.001) than the HC group and that VIQ had significant positive correlations with the cortical thickness of both the left precuneus (p < 0.05) and the right caudal middle frontal gyrus (p < 0.05) after adjustment for preoperative SpO2, preoperative systolic blood pressure (SBP), preoperative diastolic blood pressure (DBP) and time of aortic override (AO). Our results suggested that brain injury induced by TOF would exert lasting effects on cortical and cognitive development at least to school age. This study provides direct evidence of the relationship between cortical thickness and VIQ and of the need for strengthened verbal training in school-aged TOF patients after corrective surgery.
Collapse
Affiliation(s)
- Siyu Ma
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yaping Li
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yuting Liu
- Department of Radiology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Cheng Xu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Huijun Li
- Department of Radiology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Qiong Yao
- Department of Radiology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Wang
- Department of Radiology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhaocong Yang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Pengcheng Zuo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ming Yang
- Department of Radiology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
24
|
Decreased Brain Volumes and Infants With Congenital Heart Disease Undergoing Venoarterial Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:738-745. [PMID: 32195905 DOI: 10.1097/pcc.0000000000002336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of this study were to: i) determine the spectrum of brain injury and ii) compare brain volumes between pre- and postoperative brain MRI in the infants receiving extracorporeal membrane oxygenation compared with those who did not require extracorporeal membrane oxygenation. DESIGN Cohort study of infants with D-transposition of the great arteries or single ventricle physiology. Brain volume (cm) was measured using a segmentation of a volumetric T1-weighted gradient echo sequence. Brain imaging findings (intraventricular hemorrhage, white matter injuries, and stroke) were analyzed with respect to known clinical risk factors for brain injury and adverse neurodevelopmental outcomes. Clinical factors were collected by retrospective chart review. The association between brain volume and extracorporeal membrane oxygenation was evaluated using generalized estimating equations to account for repeated measures. SETTING Prospective and single-centered study. PATIENTS One hundred nine infants (median gestational age, 39.1 wk) with D-transposition of the great arteries (n = 77) or single ventricle physiology (n = 32) were studied pre- and postoperatively with MRI as per clinical protocol. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 28 infants (26%) receiving extracorporeal membrane oxygenation, 19 (68%) were supported with extracorporeal membrane oxygenation once, and nine (32%) were supported 2-4 times. On postoperative MRI, new white matter injury was found in only five (17%) of the extracorporeal membrane oxygenation infants versus 40 (49%) in the non-extracorporeal membrane oxygenation group (p = 0.073). The rate of stroke (9% vs 10%), intraventricular hemorrhage (24% vs 29%), and hypoxic ischemia (3% vs 14%) did not differ between the non-extracorporeal membrane oxygenation and extracorporeal membrane oxygenation groups (all p > 0.5). Accounting for D-transposition of the great arteries or single ventricle physiology diagnosis, infants requiring extracorporeal membrane oxygenation had slower brain volume with single (β = -1.67) or multiple extracorporeal membrane oxygenation runs ([β = -6.54]; overall interaction p = 0.012). CONCLUSIONS Patients with d-transposition of the great arteries or single ventricle physiology undergoing extracorporeal membrane oxygenation at our center have a similar incidence of brain injury but more significant impairment of perioperative brain volumes than those not requiring extracorporeal membrane oxygenation.
Collapse
|
25
|
Neurocognition in Adult Congenital Heart Disease: How to Monitor and Prevent Progressive Decline. Can J Cardiol 2019; 35:1675-1685. [DOI: 10.1016/j.cjca.2019.06.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 12/31/2022] Open
|
26
|
Abstract
Neurodevelopmental outcomes after neonatal congenital heart surgery are significantly influenced by brain injury detectable by MRI imaging techniques. This brain injury can occur in the prenatal and postnatal periods even before cardiac surgery. Given the significant incidence of new MRI brain injury after cardiac surgery, much work is yet to be done on strategies to detect, prevent, and treat brain injury in the neonatal period in order to optimize longer-term neurodevelopmental outcomes.
Collapse
|
27
|
Bailey J, Elci OU, Mascio CE, Mercer-Rosa L, Goldmuntz E. Staged Versus Complete Repair in the Symptomatic Neonate With Tetralogy of Fallot. Ann Thorac Surg 2019; 109:802-808. [PMID: 31783017 DOI: 10.1016/j.athoracsur.2019.10.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/08/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The optimal management of tetralogy of Fallot (TOF) in symptomatic neonates remains unknown. We compared outcomes for those undergoing palliation vs complete repair in the neonatal period. METHODS In a retrospective cohort study of symptomatic neonates with TOF who had a neonatal complete repair (group 1, n = 112) or staged repair (group 2, n = 26) from 2000 to 2013, we compared outcomes at 4 time points: neonatal complete repair vs palliation (group 1 vs 2A), neonatal vs later complete repair (group 1 vs 2B), the single vs combined admissions to achieve a complete repair (group 1 vs group 2A + 2B), and cumulative events 2 years after complete repair for both groups. RESULTS Demographics, anatomy, comorbidities, surgical approach, and mortality were similar between groups 1 and 2. Group 1 had a longer duration of cardiopulmonary bypass and deep hypothermic circulatory arrest and more postprocedure cardiac events compared with group 2A; a longer duration of intubation, intensive care, and postprocedure hospital stay compared with groups 2A and 2B; and a longer total hospital stay compared with group 2B. With combined admissions for group 2, there was no difference in the total duration of intensive care, total hospital stay, or reinterventions compared with group 1. CONCLUSIONS Both management options result in similar survival; however, early morbidity was greater with neonatal complete repair. The impact of increased neonatal exposures, such as cardiopulmonary bypass, deep hypothermic circulatory arrest, and intensive care, on neurocognitive development requires further study but should be considered when choosing an optimal strategy.
Collapse
Affiliation(s)
- Jennifer Bailey
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Okan U Elci
- Biostatistics and Data Management Core-Westat, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
28
|
Perioperative Assessment of Cerebral Oxygen Metabolism in Infants With Functionally Univentricular Hearts Undergoing the Bidirectional Cavopulmonary Connection. Pediatr Crit Care Med 2019; 20:923-930. [PMID: 31232848 DOI: 10.1097/pcc.0000000000002016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The transition from single-ventricle lesions with surgically placed systemic-to-pulmonary artery shunt to the circulation following a bidirectional cavopulmonary connection results in higher pressure in the superior vena cava when compared with the preceding circulation. The aim of this study was to evaluate the impact of this transition on the perioperative cerebral oxygen metabolism. DESIGN Prospective observational cohort study. SETTING Pediatric critical care unit of a tertiary referral center. PATIENTS Sixteen infants after bidirectional cavopulmonary connection. INTERVENTION Cardiac surgery (bidirectional cavopulmonary connection). MEASUREMENTS AND MAIN RESULTS We measured regional cerebral oxygen saturation, amount of hemoglobin, blood flow velocity, and microperfusion immediately before, 12-24 hours, and 36-48 hours following bidirectional cavopulmonary connection. Based on these measurements, we calculated cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen. Mean pressure in the superior vena cava increased significantly (8 vs 17 mm Hg; p < 0.001) following bidirectional cavopulmonary connection. Mean cerebral oxygen saturation increased from 49.0% (27.4-61.0) to 56.9% (39.5-64.0) (p = 0.008), whereas mean cerebral blood flow velocity decreased from 80.0 arbitrary units (61.9-93.0) to 67.3 arbitrary units (59.0-83.3) (p < 0.001). No change was found in the cerebral amount of hemoglobin and in the cerebral microperfusion. Mean cerebral fractional tissue oxygen extraction (0.48 [0.17-0.63] vs 0.30 [0.19-0.56]; p = 0.006) and approximated cerebral metabolic rate of oxygen (5.82 arbitrary units [2.70-8.78] vs 2.27 arbitrary units [1.19-7.35]; p < 0.001) decreased significantly. CONCLUSIONS Establishment of bidirectional cavopulmonary connection is associated with postoperative improvement in cerebral oxygen metabolism. Cerebral amount of hemoglobin did not increase, although creation of the bidirectional cavopulmonary connection results in significant elevation in superior vena cava pressure. Improvement in cerebral oxygen metabolism was due to lower cerebral blood flow velocity and stable microperfusion, which may indicate intact cerebral autoregulation.
Collapse
|
29
|
Howell HB, Zaccario M, Kazmi SH, Desai P, Sklamberg FE, Mally P. Neurodevelopmental outcomes of children with congenital heart disease: A review. Curr Probl Pediatr Adolesc Health Care 2019; 49:100685. [PMID: 31708366 DOI: 10.1016/j.cppeds.2019.100685] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Congenital heart defects are the most common birth anomaly affecting approximately 1% of births. With improved survival in this population, there is enhanced ability to assess long-term morbidities including neurodevelopment. There is a wide range of congenital heart defects, from those with minimal physiologic consequence that do not require medical or surgical intervention, to complex structural anomalies requiring highly specialized medical management and intricate surgical repair or palliation. The impact of congenital heart disease on neurodevelopment is multifactorial. Susceptibility for adverse neurodevelopment increases with advancing severity of the defect with initial risk factors originating during gestation. Complex structural heart anomalies may pre-dispose the fetus to abnormal circulatory patterns in utero that ultimately impact delivery of oxygen rich blood to the fetal brain. Thus, the brain of a neonate born with complex congenital heart disease may be particularly vulnerable from the outset. That vulnerability is compounded during the newborn period and through childhood, as this population endures a myriad of medical and surgical interventions. For each individual patient, these factors are likely cumulative and synergistic with progression from fetal life through childhood. This review discusses the spectrum of risk factors that may impact neurodevelopment in children with congenital heart disease, describes current recommendations and practices for neurodevelopmental follow-up of children with congenital heart disease and reviews important neurodevelopmental trends in this high risk population.
Collapse
Affiliation(s)
- Heather B Howell
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA.
| | - Michele Zaccario
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA; Pace University, Department of Psychology, 41 Park Row, New York, NY 10038 USA
| | - Sadaf H Kazmi
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA
| | - Purnahamsi Desai
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA
| | - Felice E Sklamberg
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA
| | - Pradeep Mally
- New York University School of Medicine, Department of Pediatrics, 317 East 34th Street, Suite 902, New York, NY 10016, USA
| |
Collapse
|
30
|
Lawrence KM, McGovern PE, Mejaddam A, Rossidis AC, Baumgarten H, Kim AG, Grinspan JB, Licht DJ, Radaelli E, Rychik J, Peranteau WH, Davey MG, Flake AW, Gaynor JW. Prenatal hypoxemia alters microglial morphology in fetal sheep. J Thorac Cardiovasc Surg 2019; 159:270-277. [PMID: 31597618 DOI: 10.1016/j.jtcvs.2019.06.102] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/06/2019] [Accepted: 06/25/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Neuroimmune cells, particularly microglia and astrocytes, play a critical role in neurodevelopment. Neurocognitive delays are common in children with congenital heart disease, but their etiology is poorly understood. Our objective was to determine whether prenatal hypoxemia, at levels common in congenital heart disease, induced neuroimmune activation to better understand the origins of neurobehavioral disorders in congenital heart disease. METHODS Eight fetal sheep at gestational age 109 ± 3 days (term ∼145 days) were cannulated onto a pumpless extracorporeal oxygenator via the umbilical vessels and supported in a fluid environment for 22 ± 2 days under normoxic (n = 4) or hypoxic (n = 4) conditions. Control fetuses (n = 7) were harvested at gestational age 133 ± 4 days. At necropsy, brains were stained with ionized calcium-binding adaptor molecule 1 and glial fibrillary acidic protein antibodies to quantify microglia and astrocytes, respectively, in gray and white matter in frontotemporal and cerebellar sections. Microglia were classified into 4 morphologic types based on cell shape. Data were analyzed with 1-way analysis of variance or Fisher exact test, as appropriate. RESULTS Oxygen delivery was significantly reduced in hypoxic fetuses (15.6 ± 1.8 mL/kg/min vs 24.3 ± 2.3 mL/kg/min; P < .01). Rates of apoptosis were similar in hypoxic, normoxic, and intrauterine control animals in all examined areas. There were also no differences between groups in area occupied by glial fibrillary acidic protein-labeled astrocytes or ionized calcium-binding adaptor molecule 1-labeled microglia in all examined areas. However, round microglia were significantly increased in hypoxic animals compared with normoxic animals (33% vs 6%; P < .01) and control animals (33% vs 11%; P < .01). CONCLUSIONS Prenatal hypoxemia altered microglial morphology without significant gliosis. Additional studies characterizing these mechanisms may provide insight into the origins of neurobehavioral disabilities in children with congenital heart disease.
Collapse
Affiliation(s)
- Kendall M Lawrence
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Patrick E McGovern
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ali Mejaddam
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Avery C Rossidis
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Heron Baumgarten
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Aimee G Kim
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Judith B Grinspan
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Enrico Radaelli
- Division of Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pa
| | - Jack Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - William H Peranteau
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Marcus G Davey
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Alan W Flake
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa.
| |
Collapse
|
31
|
Romanowicz J, Leonetti C, Dhari Z, Korotcova L, Ramachandra SD, Saric N, Morton PD, Bansal S, Cheema A, Gallo V, Jonas RA, Ishibashi N. Treatment With Tetrahydrobiopterin Improves White Matter Maturation in a Mouse Model for Prenatal Hypoxia in Congenital Heart Disease. J Am Heart Assoc 2019; 8:e012711. [PMID: 31331224 PMCID: PMC6761654 DOI: 10.1161/jaha.119.012711] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/24/2019] [Indexed: 01/05/2023]
Abstract
Background Reduced oxygen delivery in congenital heart disease causes delayed brain maturation and white matter abnormalities in utero. No treatment currently exists. Tetrahydrobiopterin (BH4) is a cofactor for neuronal nitric oxide synthase. BH4 availability is reduced upon NOS activation, such as during hypoxic conditions, and leads to toxin production. We hypothesize that BH4 levels are depleted in the hypoxic brain and that BH4 replacement therapy mitigates the toxic effects of hypoxia on white matter. Methods and Results Transgenic mice were used to visualize oligodendrocytes. Hypoxia was introduced during a period of white matter development equivalent to the human third trimester. BH4 was administered during hypoxia. BH4 levels were depleted in the hypoxic brain by direct quantification (n=7-12). The proliferation (n=3-6), apoptosis (n=3-6), and developmental stage (n=5-8) of oligodendrocytes were determined immunohistologically. Total oligodendrocytes increased after hypoxia, consistent with hypoxia-induced proliferation seen previously; however, mature oligodendrocytes were less prevalent in hypoxia, and there was accumulation of immature oligodendrocytes. BH4 treatment improved the mature oligodendrocyte number such that it did not differ from normoxia, and accumulation of immature oligodendrocytes was not observed. These results persisted beyond the initial period of hypoxia (n=3-4). Apoptosis increased with hypoxia but decreased with BH4 treatment to normoxic levels. White matter myelin levels decreased following hypoxia by western blot. BH4 treatment normalized myelination (n=6-10). Hypoxia worsened sensory-motor coordination on balance beam tasks, and BH4 therapy normalized performance (n=5-9). Conclusions Suboptimal BH4 levels influence hypoxic white matter abnormalities. Repurposing BH4 for use during fetal brain development may limit white matter dysmaturation in congenital heart disease.
Collapse
Affiliation(s)
- Jennifer Romanowicz
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
| | - Camille Leonetti
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Zaenab Dhari
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Ludmila Korotcova
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Shruti D. Ramachandra
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Nemanja Saric
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Paul D. Morton
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Shivani Bansal
- Lombardi Comprehensive Cancer CenterGeorgetown University Medical CenterWashingtonDC
| | - Amrita Cheema
- Lombardi Comprehensive Cancer CenterGeorgetown University Medical CenterWashingtonDC
| | - Vittorio Gallo
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Richard A. Jonas
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Nobuyuki Ishibashi
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| |
Collapse
|
32
|
Cole AR, Perry DA, Raza A, Nedder AP, Pollack E, Regan WL, van den Bosch SJ, Polizzotti BD, Yang E, Davila D, Afacan O, Warfield SK, Ou Y, Sefton B, Everett AD, Neil JJ, Lidov HG, Mayer JE, Kheir JN. Perioperatively Inhaled Hydrogen Gas Diminishes Neurologic Injury Following Experimental Circulatory Arrest in Swine. JACC Basic Transl Sci 2019; 4:176-187. [PMID: 31061920 PMCID: PMC6488769 DOI: 10.1016/j.jacbts.2018.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 12/30/2022]
Abstract
This study used a swine model of mildly hypothermic prolonged circulatory arrest and found that the addition of 2.4% inhaled hydrogen gas to inspiratory gases during and after the ischemic insult significantly decreased neurologic and renal injury compared with controls. With proper precautions, inhalational hydrogen may be administered safely through conventional ventilators and may represent a complementary therapy that can be easily incorporated into current workflows. In the future, inhaled hydrogen may diminish the sequelae of ischemia that occurs in congenital heart surgery, cardiac arrest, extracorporeal life-support events, acute myocardial infarction, stroke, and organ transplantation.
Collapse
Affiliation(s)
- Alexis R. Cole
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Dorothy A. Perry
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ali Raza
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Arthur P. Nedder
- Animal Resources at Children’s Hospital, Boston Children’s Hospital, Boston, Massachusetts
| | - Elizabeth Pollack
- Animal Resources at Children’s Hospital, Boston Children’s Hospital, Boston, Massachusetts
| | - William L. Regan
- Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Brian D. Polizzotti
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Edward Yang
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Daniel Davila
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Onur Afacan
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Simon K. Warfield
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Yangming Ou
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Brenda Sefton
- Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, Massachusetts
| | - Allen D. Everett
- Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey J. Neil
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Hart G.W. Lidov
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - John E. Mayer
- Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - John N. Kheir
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
33
|
Hansen JH, Kissner L, Logoteta J, Jung O, Dütschke P, Attmann T, Scheewe J, Kramer HH. S100B and its relation to cerebral oxygenation in neonates and infants undergoing surgery for congenital heart disease. CONGENIT HEART DIS 2019; 14:427-437. [PMID: 30604917 DOI: 10.1111/chd.12741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 11/03/2018] [Accepted: 12/10/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Neonates and infants undergoing surgery for congenital heart disease are at risk for developmental impairment. Hypoxic-ischemic brain injury might be one contributing factor. We aimed to investigate the perioperative release of the astrocyte protein S100B and its relation to cerebral oxygenation. METHODS Serum S100B was measured before and 0, 12, 24, and 48 hours after surgery. Cerebral oxygen saturation was derived by near-infrared spectroscopy. S100B reference values based on preoperative samples; concentrations above the 75th percentile were defined as elevated. Patients with elevated S100B at 24 or 48 hours were compared to cases with S100B in the normal range. Neonates (≤28 days) and infants (>28 and ≤365 days) were analyzed separately due to age-dependent release of S100B. RESULTS Seventy-four patients underwent 94 surgical procedures (neonates, n = 38; infants, n = 56). S100B concentrations were higher in neonates before and after surgery at all time points (P ≤ .015). Highest values were noticed immediately after surgery. Postoperative S100B was elevated after 15 (40.5%) surgeries in neonates. There was no difference in pre-, intra-, or postoperative cerebral oxygenation. In infants, postoperative S100B was elevated after 23 (41.8%) procedures. Preoperative cerebral oxygen saturations tended to be lower (53 ± 12% vs 59 ± 12%, P = .069) and arterial-cerebral oxygen saturation difference was higher (35 ± 11% vs 28 ± 11%, P = .018) in infants with elevated postoperative S100B. In the early postoperative course, cerebral oxygen saturation was lower (54 ± 13% vs 63 ± 12%, P = .011) and arterial-cerebral oxygen saturation difference was wider (38 ± 11% vs 30 ± 10%, P = .008). Cerebral oxygen saturation was also lower for the entire postoperative course (62 ± 18% vs 67 ± 9%, P = .047). CONCLUSIONS Postoperative S100B was elevated in about 40% of neonates and infants undergoing cardiac surgery. Infants with elevated postoperative S100B had impaired perioperative cerebral tissue oxygenation. No relation between S100B and cerebral oxygenation could be demonstrated in neonates.
Collapse
Affiliation(s)
- Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Lydia Kissner
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jana Logoteta
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Olaf Jung
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Peter Dütschke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Tim Attmann
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jens Scheewe
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Hans-Heiner Kramer
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Hamburg/Kiel/Lübeck, Germany
| |
Collapse
|
34
|
Glass TJ, Seed M, Chau V. Congenital Heart Disease. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
35
|
Bolduc ME, Lambert H, Ganeshamoorthy S, Brossard-Racine M. Structural brain abnormalities in adolescents and young adults with congenital heart defect: a systematic review. Dev Med Child Neurol 2018; 60:1209-1224. [PMID: 30028505 DOI: 10.1111/dmcn.13975] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 12/19/2022]
Abstract
AIM The primary objective of this systematic review is to define and quantify brain structural abnormalities present in adolescents and young adults with complex congenital heart defect (CHD). We also aim to evaluate the extent to which these structural abnormalities are associated with functional outcomes. METHOD A search of studies examining brain structure by magnetic resonance imaging in adolescents and young adults with complex CHD was performed in Embase, MEDLINE, and Web of Science. A meta-analysis was conducted to determine the odds of brain abnormalities in young people with CHD. Results not included in the meta-analysis were collated using descriptive statistics. RESULTS Two hundred and fifty-four studies were identified through the literature search. Among these, 14 original studies were included in the review. The odds of brain abnormalities in young people with CHD were 7.9 times higher (p<0.001) than in typically developing comparison individuals. Focal and multifocal lesions were the most common types of abnormality (odds ratio 22.5 [p<0.001]). Preliminary evidence from volumetric, cortical, and microstructural integrity measurements suggests that brain abnormalities are associated with poorer neurocognitive outcomes. INTERPRETATION This review provides strong evidence that adolescents and young adults with CHD are at increased risk of presenting with structural brain abnormalities and highlights the contribution of advanced quantitative magnetic resonance imaging techniques to identify the subtle but frequent brain alterations in this population. However, more studies are needed to clarify how these abnormalities relate to function. WHAT THIS PAPER ADDS There is a high prevalence of brain abnormalities in young people with congenital heart defect (CHD). Brain volumes, cortical measurements, and white matter microstructure are altered in young people with CHD. Brain abnormalities are associated with poorer function in young people with CHD.
Collapse
Affiliation(s)
- Marie-Eve Bolduc
- Advances in Brain and Child Development Research Laboratory, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Heather Lambert
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Sylviya Ganeshamoorthy
- Advances in Brain and Child Development Research Laboratory, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Marie Brossard-Racine
- Advances in Brain and Child Development Research Laboratory, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada.,Department of Pediatrics, Division of Child Neurology, McGill University, Montreal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| |
Collapse
|
36
|
Szwast A, Putt M, Gaynor JW, Licht DJ, Rychik J. Cerebrovascular response to maternal hyperoxygenation in fetuses with hypoplastic left heart syndrome depends on gestational age and baseline cerebrovascular resistance. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:473-478. [PMID: 28976608 PMCID: PMC6719779 DOI: 10.1002/uog.18919] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/26/2017] [Accepted: 09/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Compared with normal fetuses, fetuses with hypoplastic left heart syndrome (HLHS) have smaller brain volumes and are at higher risk of brain injury, possibly due to diminished cerebral blood flow and oxygen content. By increasing cerebral oxygen delivery, maternal hyperoxygenation (MH) might improve brain development and reduce the risk of brain injury in these fetuses. This study investigated whether gestational age and baseline cerebrovascular resistance affect the response to MH in fetuses with HLHS. METHODS The study population comprised 43 fetuses with HLHS or HLHS variant referred for fetal echocardiography between January 2004 and September 2008. Middle cerebral artery (MCA) pulsatility index (PI), a surrogate measure of cerebrovascular resistance, was assessed between 20 and 41 weeks' gestation at baseline in room air (RA) and after 10 min of MH. Z-scores of MCA-PI were generated. A mixed-effects model was used to determine whether change in MCA-PI depends upon gestational age and baseline MCA-PI. RESULTS In RA and following MH, MCA-PI demonstrated a curvilinear relationship with gestational age in fetuses with HLHS, peaking at around 28 weeks and then falling more steeply near term. MCA-PI Z-score declined in a linear manner, such that it was 1.4 SD below that in normal fetuses at 38 weeks. Increase in MCA-PI Z-score after MH was first seen at ≥ 28 weeks. A baseline MCA-PI Z-score ≤ -0.96 was predictive of an increase in cerebrovascular resistance in response to MH. CONCLUSION In fetuses with HLHS, MCA-PI first increases in response to MH at ≥ 28 weeks' gestation. A baseline MCA-PI Z-score ≤ -0.96 predicts an increase in cerebrovascular resistance in response to MH. These results may have implications for clinical trials utilizing MH as a neuroprotective agent. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A Szwast
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Putt
- Division of Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - J W Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - D J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
37
|
Prediction of Periventricular Leukomalacia in Neonates after Cardiac Surgery Using Machine Learning Algorithms. J Med Syst 2018; 42:177. [DOI: 10.1007/s10916-018-1029-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
|
38
|
Inhibition of microglial activation by minocycline reduced preoligodendrocyte injury in a neonatal rat brain slice model. J Thorac Cardiovasc Surg 2018; 156:2271-2280. [PMID: 30121135 DOI: 10.1016/j.jtcvs.2018.06.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 05/09/2018] [Accepted: 06/11/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Periventricular leukomalacia is a common white-matter injury after neonatal cardiac surgery; however, its potential cellular mechanism remains uncertain. There is limited study regarding periventricular leukomalacia treatment. METHODS A neonatal rat brain slice perfusion model was used for reproducing the condition of cardiopulmonary bypass, and oxygen glucose deprivation simulated circulatory arrest. Seven-day-old Sprague-Dawley rats were randomly divided into 7 groups: (1) control group with 36°C; (2) 60 minutes of oxygen glucose deprivation group on 15°C, 25°C, 36°C, respectively; and (3) 60 minutes of oxygen glucose deprivation group on 15°C, 25°C, 36°C, plus minocycline (10 μmol/L), respectively. Immunohistochemistry, Western blot, and inflammatory mediators were compared after the perfusion procedures in the different groups. RESULTS This neonatal rat brain slice perfusion with oxygen glucose deprivation model could replicate the pathophysiologic process and injury after cardiopulmonary bypass and hypothermic circulatory arrest. With the increase of oxygen glucose deprivation perfusion temperature, we found that both microglia activation and preoligodendrocyte loss increased. The application of minocycline can significantly inhibit microglial activation and preoligodendrocyte cells loss in the normothermic (36°C) and moderate hypothermia (25°C) oxygen glucose deprivation groups (P < .05), with accompanying significant decreasing microglial inflammatory productions; however, no significant improvement was found in the deep hypothermia (15°C) group. CONCLUSIONS The microglial activation may play a key role in preoligodendrocyte injury in the ex vivo neonatal rat brain slice perfusion and circulatory arrest model. Inhibition of microglial activation with minocycline may be an attractive target for white-matter protection during cardiopulmonary bypass and hypothermic circulatory arrest.
Collapse
|
39
|
Peyvandi S, Latal B, Miller SP, McQuillen PS. The neonatal brain in critical congenital heart disease: Insights and future directions. Neuroimage 2018; 185:776-782. [PMID: 29787864 DOI: 10.1016/j.neuroimage.2018.05.045] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 04/18/2018] [Accepted: 05/18/2018] [Indexed: 12/17/2022] Open
Abstract
Neurodevelopmental outcomes are impaired in survivors of critical congenital heart disease (CHD) in several developmental domains including motor, cognitive and sensory outcomes. These deficits can extend into the adolescent and early adulthood years. The cause of these neurodevelopmental impairments is multi-factorial and includes patient specific risk factors, cardiac anatomy and physiology as well as brain changes seen on MRI. Advances in imaging techniques have identified delayed brain development in the neonate with critical CHD as well as acquired brain injury. These abnormalities are seen even before corrective neonatal cardiac surgery. This review focuses on describing brain changes seen on MRI in neonates with CHD, risk factors for these changes and the association with neurodevelopmental outcome. There is an emerging focus on the impact of cardiovascular physiology on brain health and the complex heart-brain interplay that influences ultimate neurodevelopmental outcome in these patients.
Collapse
Affiliation(s)
- Shabnam Peyvandi
- Division of Pediatric Cardiology, University of California San Francisco Benioff Children's Hospital, USA.
| | - Beatrice Latal
- University Children's Hospital Zurich, Child Development Center and Children's Research Center, Zurich, Switzerland
| | - Steven P Miller
- University of Toronto, Hospital for Sick Children, Department of Neurology, Canada
| | - Patrick S McQuillen
- Division of Critical Care, University of California San Francisco Benioff Children's Hospital, USA
| |
Collapse
|
40
|
Abstract
Utilization of extraocorporeal membrane oxygenation (ECMO) has become increasingly widespread as a bridging therapy for neonates with severe, reversible respiratory or cardiac diseases. While significant risks remain, due to advances in medical and surgical management, overall mortality has decreased. However, short and long-term neurological morbidity has remained high. Therefore, increasing attention has been focused on multimodal neuromonitoring to track and optimally, minimize or prevent intracranial injury. This review will explore the the indications, advantages, disadvantages, timing, frequency, duration, and any known correlation with neurodevelopmental outcomes of common types of neuromonitoring in the neonatal ECMO population. Investigational monitoring techniques such as NIRS will be briefly reviewed.
Collapse
Affiliation(s)
- Nan Lin
- Division of Neurology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - John Flibotte
- Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
| |
Collapse
|
41
|
Ferentzi H, Pfitzer C, Rosenthal LM, Berger F, Schmitt KRL. Long-term early development research in congenital heart disease (LEADER-CHD): a study protocol for a prospective cohort observational study investigating the development of children after surgical correction for congenital heart defects during the first 3 years of life. BMJ Open 2017; 7:e018966. [PMID: 29288186 PMCID: PMC5770821 DOI: 10.1136/bmjopen-2017-018966] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common birth defect. Studies on the development of children with CHD point towards deficits in motoric, cognitive and language development. However, most studies are cross-sectional and there is a gap in the knowledge concerning developmental trajectories, risk and protective factors and a lack of research concerning environmental predictors. Specifically, no studies have so far considered the importance of early caregiving experiences and child temperament for the development of children with CHD. METHODS In a single-centre prospective cohort study, cognitive, motoric and language development of 180 children after corrective surgery for a simple transposition of the great arteries (TGA), tetralogy of Fallot (TOF) or ventricular septal defect (VSD) will be assessed at ages 12, 24 and 36 months with the Bayley Scales of Infant Development 3rd Edition (BSID-III). At age 12 months, a free-play video observation will be conducted to investigate the relationship between primary caregiver and child, and child temperament will be assessed with the Infant Behavior Questionnaire-Revised Short Version. Medical information will be obtained from patient records and demographic information via questionnaires. ANALYSIS Frequency and severity of developmental delays will be reported descriptively. Differences between groups (TGA, TOF, VSD) will be subjected to repeated-measures analysis across time points. Multiple regressions will be applied for the analysis of predictors at each time point. For the analysis of differential developmental trajectories, mixed-model analysis will be applied. ETHICS AND DISSEMINATION The study has been approved by the local medical ethics committee. Written informed consent will be obtained from all participants. Parents have the option to be debriefed about BSID-III results after each assessment and about the study results after project completion. Results will be disseminated in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER DRKS00011006; Pre-results.
Collapse
Affiliation(s)
- Hannah Ferentzi
- Department of Congenital Heart Disease-Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Unit for Psychosomatic Medicine, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Constanze Pfitzer
- Department of Congenital Heart Disease-Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Department of Paediatry, Division of Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | - Lisa-Maria Rosenthal
- Department of Congenital Heart Disease-Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease-Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Paediatry, Division of Cardiology, Charité Universitätsmedizin, Berlin, Germany
- German Centre for Cardiovascular Disease (DZHK), Berlin, Germany
| | - Katharina R L Schmitt
- Department of Congenital Heart Disease-Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- German Centre for Cardiovascular Disease (DZHK), Berlin, Germany
| |
Collapse
|
42
|
Singh S, Kumar R, Roy B, Woo MA, Lewis A, Halnon N, Pike N. Regional brain gray matter changes in adolescents with single ventricle heart disease. Neurosci Lett 2017; 665:156-162. [PMID: 29222023 DOI: 10.1016/j.neulet.2017.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/20/2017] [Accepted: 12/04/2017] [Indexed: 11/25/2022]
Abstract
Adolescents with single ventricle heart disease (SVHD) show autonomic, mood, and cognitive deficits, indicating aberrations in brain areas that regulate these functions. However, the gray matter integrity in autonomic, mood, and cognitive control sites is unclear. We examined regional brain gray matter changes, using high-resolution T1-weighted images (3.0-T magnetic resonance scanner) with voxel based morphometry procedures, as well as mood and cognitive functions in SVHD (n=18; age, 15.7±1.1years; male, 10) and controls (n=31; age, 16.0±1.1years; male, 17). High-resolution T1-weighted images were realigned, gray matter tissue type partitioned, normalized to a common space, smoothed, and compared between groups (analysis of covariance; covariates, age and gender). The mood and cognitive scores were compared between groups using independent samples t-tests. SVHD subjects showed significantly altered mood and cognitive functions over controls. Significantly reduced gray matter emerged in multiple brain areas, including the thalamus, caudate nuclei, putamen, insula, prefrontal, post-central and precentral gyrus, occipital gyrus, para-hippocampal gyrus, temporal gyrus, and cerebellar sites in SVHD over controls. SVHD subjects show compromised gray matter integrity in autonomic, mood and cognitive control sites. The findings indicate that frequent deficits found in SVHD subjects have a brain structural basis in the condition.
Collapse
Affiliation(s)
- Sadhana Singh
- Department of Anesthesiology, University of California, Los Angeles, CA, USA
| | - Rajesh Kumar
- Department of Anesthesiology, University of California, Los Angeles, CA, USA; Department of Radiological Sciences, University of California, Los Angeles, CA, USA; Department of Bioengineering, University of California, Los Angeles, CA, USA; Brain Research Institute, University of California, Los Angeles, CA, USA.
| | - Bhaswati Roy
- UCLA School of Nursing, University of California, Los Angeles, CA, USA
| | - Mary A Woo
- UCLA School of Nursing, University of California, Los Angeles, CA, USA
| | - Alan Lewis
- Division of Pediatric Cardiology, Children's Hospital, Los Angeles, CA, USA
| | - Nancy Halnon
- Division of Pediatric Cardiology, University of California, Los Angeles, CA, USA
| | - Nancy Pike
- UCLA School of Nursing, University of California, Los Angeles, CA, USA.
| |
Collapse
|
43
|
Risk Factors for Peri-Procedural Arterial Ischaemic Stroke in Children with Cardiac Disease. Pediatr Cardiol 2017; 38:1385-1392. [PMID: 28695245 DOI: 10.1007/s00246-017-1674-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: 02/27/2017] [Accepted: 06/30/2017] [Indexed: 10/19/2022]
Abstract
Improved survival of children with congenital heart disease has led to increasing focus on neurodevelopmental outcome, as close to half of the infants undergoing cardiac surgery are affected by neurodevelopmental disability. Stroke is particularly important as it frequently results in permanent neurologic sequelae. The aim of this study was to investigate risk factors for peri-procedural arterial ischaemic stroke (AIS) in children with cardiac disease. A retrospective case-control analysis of children aged <18 years with radiologically confirmed AIS following a cardiac procedure admitted to the Royal Children's Hospital Melbourne between 1993 and 2010. Each case was matched with two controls with similar cardiac diagnosis, procedure type, age and date of procedure. Demographics and peri-procedural data were collected from medical records and departmental database. Fifty-two cases were identified. Multivariable analysis identified post-procedural infection (OR 6.1, CI 1.3-27, p = 0.017) and length of ICU stay (OR 4.0, CI 1.4-11, p = 0.009) as risk factors for AIS. Although the study is limited to a single-centre cohort, length of ICU stay and post-procedural infection were identified as risk factors for AIS. These findings demonstrate these factors to be important areas to focus attention for stroke prevention in children with cardiac disease.
Collapse
|
44
|
Smith B, Vu E, Kibler K, Rusin C, Easley RB, Andropoulos D, Heinle J, Czosnyka M, Licht D, Lynch J, Brady K. Does hypothermia impair cerebrovascular autoregulation in neonates during cardiopulmonary bypass? Paediatr Anaesth 2017; 27:905-910. [PMID: 28653463 DOI: 10.1111/pan.13194] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Autoregulation monitoring has been proposed as a means to identify optimal arterial blood pressure goals during cardiopulmonary bypass, but it has been observed that cerebral blood flow is pressure passive during hypothermic bypass. When neonates cooled during cardiopulmonary bypass are managed with vasodilators and controlled hypotension, it is not clear whether hypothermia or hypotension were the cause of impaired autoregulation. AIM We sought to measure the effect of both arterial blood pressure and hypothermia on autoregulation in a cohort of infants cooled for bypass, hypothesizing a collinear relationship between hypothermia, hypotension, and dysautoregulation. METHODS Cardiopulmonary bypass was performed on 72 infants at Texas Children's Hospital during 2015 and 2016 with automated physiologic data capture, including arterial blood pressure, nasopharyngeal temperature, cerebral oximetry, and a cerebral blood volume index derived from near infrared spectroscopy. Cooling to 18°C, 24°C, and 30°C was performed on 33, 12, and 22 subjects, respectively. The hemoglobin volume index was calculated as a moving correlation coefficient between mean arterial blood pressure and the cerebral blood volume index. Positive values of the hemoglobin volume index indicate impaired autoregulation. Relationships between variables were assessed utilizing a generalized estimating equation approach. RESULTS Hypothermia was associated with hypotension, dysautoregulation, and increased cerebral oximetry. Comparing the baseline temperature of 36°C with 18°C, arterial blood pressure was 44 mm Hg (39-52) vs 25 mm Hg (21-31); the hemoglobin volume index was 0.0 (-0.02 to 0.004) vs 0.5 (0.4-0.7) and cerebral oximetry was 59% (57-61) vs 88% (80-92) (Median, 95% CI of median; P<.0001 for all three associations by linear regression with generalized estimation of equations with data from all temperatures measured). CONCLUSIONS Arterial blood pressure, temperature, and cerebral autoregulation were collinear in this cohort. The conclusion that hypothermia causes impaired autoregulation is thus confounded. The effect of temperature on autoregulation should be delineated before clinical deployment of autoregulation monitors to prevent erroneous determination of optimal arterial blood pressure. Showing the effect of temperature on autoregulation will require a normotensive hypothermic model.
Collapse
Affiliation(s)
- Brendan Smith
- Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Eric Vu
- Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Kathleen Kibler
- Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Craig Rusin
- Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ronald B Easley
- Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Dean Andropoulos
- Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey Heinle
- Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Marek Czosnyka
- Academic Neurosurgery, Addenbrooke's Hospital, Cambridge University, Cambridge, UK
| | - Daniel Licht
- Pediatric Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Pennsylvania, PA, USA
| | - Jennifer Lynch
- New York University School of Medicine, New York, NY, USA
| | - Ken Brady
- Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
45
|
Goswami D, McLeod K, Leonard S, Kibler K, Easley RB, Fraser CD, Andropoulos D, Brady K. Static cerebrovascular pressure autoregulation remains intact during deep hypothermia. Paediatr Anaesth 2017; 27:911-917. [PMID: 28719038 DOI: 10.1111/pan.13205] [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] [Accepted: 06/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical studies measuring cerebral blood flow in infants during deep hypothermia have demonstrated diminished cerebrovascular pressure autoregulation. The coexistence of hypotension in these cohorts confounds the conclusion that deep hypothermia impairs cerebrovascular pressure autoregulation. AIM We sought to compare the lower limit of autoregulation and the static rate of autoregulation between normothermic and hypothermic piglets. METHODS Twenty anesthetized neonatal piglets (5-7 days old; 10 normothermic and 10 hypothermic to 20°C) had continuous measurements of cortical red cell flux using laser Doppler flowmetry, while hemorrhagic hypotension was induced without cardiopulmonary bypass. Lower limit of autoregulation was determined for each subject using piecewise regression and SRoR was determined above and below each lower limit of autoregulation as (%change cerebrovascular resistance/%change cerebral perfusion pressure). RESULTS The estimated difference in lower limit of autoregulation was 1.4 mm Hg (lower in the hypothermic piglets; 95% C.I. -10 to 14 mm Hg; P=0.6). The median lower limit of autoregulation in the normothermic group was 39 mm Hg [IQR 38-51] vs 35 mm Hg [31-50] in the hypothermic group. Intact steady-state pressure autoregulation was defined as static rate of autoregulation >0.5 and was demonstrated in all normothermic subjects (static rate of autoregulation=0.72 [0.65-0.87]) and in 9/10 of the hypothermic subjects (static rate of autoregulation=0.65 [0.52-0.87]). This difference in static rate of autoregulation of 0.06 (95% C.I. -0.3 to 0.1) was not significant (P=0.4). CONCLUSION Intact steady-state cerebrovascular pressure autoregulation is demonstrated in a swine model of profound hypothermia. Lower limit of autoregulation and static rate of autoregulation were similar in hypothermic and normothermic subjects.
Collapse
Affiliation(s)
- Dheeraj Goswami
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katherine McLeod
- Department of Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Samantha Leonard
- Department of Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Kathleen Kibler
- Department of Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ronald Blaine Easley
- Department of Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Charles D Fraser
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dean Andropoulos
- Department of Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ken Brady
- Department of Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
46
|
Stinnett GR, Lin S, Korotcov AV, Korotcova L, Morton PD, Ramachandra SD, Pham A, Kumar S, Agematsu K, Zurakowski D, Wang PC, Jonas RA, Ishibashi N. Microstructural Alterations and Oligodendrocyte Dysmaturation in White Matter After Cardiopulmonary Bypass in a Juvenile Porcine Model. J Am Heart Assoc 2017; 6:JAHA.117.005997. [PMID: 28862938 PMCID: PMC5586442 DOI: 10.1161/jaha.117.005997] [Citation(s) in RCA: 9] [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: 12/11/2022]
Abstract
Background Newly developed white matter (WM) injury is common after cardiopulmonary bypass (CPB) in severe/complex congenital heart disease. Fractional anisotropy (FA) allows measurement of macroscopic organization of WM pathology but has rarely been applied after CPB. The aims of our animal study were to define CPB‐induced FA alterations and to determine correlations between these changes and cellular events after congenital heart disease surgery. Methods and Results Normal porcine WM development was first assessed between 3 and 7 weeks of age: 3‐week‐old piglets were randomly assigned to 1 of 3 CPB‐induced insults. FA was analyzed in 31 WM structures. WM oligodendrocytes, astrocytes, and microglia were assessed immunohistologically. Normal porcine WM development resembles human WM development in early infancy. We found region‐specific WM vulnerability to insults associated with CPB. FA changes after CPB were also insult dependent. Within various WM areas, WM within the frontal cortex was susceptible, suggesting that FA in the frontal cortex should be a biomarker for WM injury after CPB. FA increases occur parallel to cellular processes of WM maturation during normal development; however, they are altered following surgery. CPB‐induced oligodendrocyte dysmaturation, astrogliosis, and microglial expansion affect these changes. FA enabled capturing CPB‐induced cellular events 4 weeks postoperatively. Regions most resilient to CPB‐induced FA reduction were those that maintained mature oligodendrocytes. Conclusions Reducing alterations of oligodendrocyte development in the frontal cortex can be both a metric and a goal to improve neurodevelopmental impairment in the congenital heart disease population. Studies using this model can provide important data needed to better interpret human imaging studies.
Collapse
Affiliation(s)
- Gary R Stinnett
- Children's National Heart Institute, Children's National Health System, Washington, DC.,Center for Neuroscience Research, Children's National Health System, Washington, DC
| | - Stephen Lin
- Department of Radiology, Howard University, Washington, DC
| | - Alexandru V Korotcov
- Department of Radiology, Howard University, Washington, DC.,Center for Neuroscience and Regenerative Medicine, Uniformed Services University, Bethesda, MD
| | - Ludmila Korotcova
- Children's National Heart Institute, Children's National Health System, Washington, DC.,Center for Neuroscience Research, Children's National Health System, Washington, DC
| | - Paul D Morton
- Children's National Heart Institute, Children's National Health System, Washington, DC.,Center for Neuroscience Research, Children's National Health System, Washington, DC
| | - Shruti D Ramachandra
- Children's National Heart Institute, Children's National Health System, Washington, DC.,Center for Neuroscience Research, Children's National Health System, Washington, DC
| | - Angeline Pham
- George Washington University School of Medicine and Health Science, Washington, DC
| | - Sonali Kumar
- George Washington University School of Medicine and Health Science, Washington, DC
| | - Kota Agematsu
- Children's National Heart Institute, Children's National Health System, Washington, DC.,Center for Neuroscience Research, Children's National Health System, Washington, DC
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Paul C Wang
- Department of Radiology, Howard University, Washington, DC.,College of Science and Engineering, Fu Jen Catholic University, Taipei, Taiwan
| | - Richard A Jonas
- Children's National Heart Institute, Children's National Health System, Washington, DC .,Center for Neuroscience Research, Children's National Health System, Washington, DC.,George Washington University School of Medicine and Health Science, Washington, DC
| | - Nobuyuki Ishibashi
- Children's National Heart Institute, Children's National Health System, Washington, DC .,Center for Neuroscience Research, Children's National Health System, Washington, DC.,George Washington University School of Medicine and Health Science, Washington, DC
| |
Collapse
|
47
|
Reduced cortical volume and thickness and their relationship to medical and operative features in post-Fontan children and adolescents. Pediatr Res 2017; 81:881-890. [PMID: 28157834 DOI: 10.1038/pr.2017.30] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/15/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND We compared brain cortical and subcortical gray matter volumes and cortical thickness between post-Fontan patients and healthy controls, and examined brain anatomical associations with operative and medical history characteristics. METHODS Post-Fontan (n = 128 volumes; n = 115 thickness) and control subjects (n = 48 volumes; n = 45 thickness) underwent brain MRI at ages 10-19 y. Subcortical and cortical volumes and cortical thicknesses were measured for intergroup comparison. Associations between brain measures and clinical measures were assessed in the Fontan group. RESULTS Widespread, significant reduction in brain volumes and thicknesses existed in the Fontan group compared to controls, spanning all brain lobes and subcortical gray matter. Fontan subjects treated with vs. without the Norwood procedure had smaller volumes in several terminal clusters, but did not differ in cortical thickness. Older age at first operation and increasing numbers of cardiac catheterizations, operative complications, and catheterization complications were associated with lower regional volumes and thicknesses. Increasing numbers of operative complications and cardiac catheterizations were associated with smaller regional volumes in the Norwood group. CONCLUSION The post-Fontan adolescent brain differs from the normal control brain. Some of these differences are associated with potentially modifiable clinical variables, suggesting that interventions might improve long-term neurocognitive outcome.
Collapse
|
48
|
Pironkova RP, Giamelli J, Seiden H, Parnell VA, Gruber D, Sison CP, Kowal C, Ojamaa K. Brain injury with systemic inflammation in newborns with congenital heart disease undergoing heart surgery. Exp Ther Med 2017; 14:228-238. [PMID: 28672919 PMCID: PMC5488503 DOI: 10.3892/etm.2017.4493] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/13/2017] [Indexed: 12/03/2022] Open
Abstract
The potential role of systemic inflammation on brain injury in newborns with congenital heart disease (CHD) was assessed by measuring levels of central nervous system (CNS)-derived proteins in serum prior to and following cardiac surgery. A total of 23 newborns (gestational age, 39±1 weeks) with a diagnosis of CHD that required cardiac surgery with cardiopulmonary bypass (CPB) were enrolled in the current study. Serum samples were collected immediately prior to surgery and 2, 24 and 48 h following CPB, and serum levels of phosphorylated neurofilament-heavy subunit (pNF-H), neuron-specific enolase (NSE) and S100B were analyzed. Systemic inflammation was assessed by measuring serum concentrations of complement C5a and complement sC5b9, and the following cytokines: Interleukin (IL)-1β, IL-6, IL-8, IL-10, IL12p70, interferon γ and tumor necrosis factor (TNF)-α. Analysis of cord blood from normal term deliveries (n=26) provided surrogate normative values for newborns. pNF-H and S100B were 2.4- to 2.8-fold higher (P<0.0001) in patient sera than in cord blood prior to surgery and remained elevated following CPB. Pre-surgical serum pNF-H and S100B levels directly correlated with interleukin (IL)-12p70 (ρ=0.442, P<0.05). pNF-H was inversely correlated with arterial pO2 prior to surgery (ρ=−0.493, P=0.01) and directly correlated with arterial pCO2 post-CPB (ρ=0.426, P<0.05), suggesting that tissue hypoxia and inflammation contribute to blood brain barrier (BBB) dysfunction and neuronal injury. Serum IL12p70, IL-6, IL-8, IL-10 and TNF-α levels were significantly higher in patients than in normal cord blood and levels of these cytokines increased following CPB (P<0.001). Activation of complement was observed in all patients prior to surgery, and serum C5a and sC5b9 remained elevated up to 48 h post-surgery. Furthermore, they were correlated (P<0.05) with low arterial pO2, high pCO2 and elevated arterial pressure in the postoperative period. Length of mechanical ventilation was associated directly with post-surgery serum IL-12p70 and IL-8 concentrations (P<0.05). Elevated serum concentrations of pNF-H and S100B in neonates with CHD suggest BBB dysfunction and CNS injury, with concurrent hypoxemia and an activated inflammatory response potentiating this effect.
Collapse
Affiliation(s)
- Rossitza P Pironkova
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA
| | - Joseph Giamelli
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA
| | - Howard Seiden
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA
| | - Vincent A Parnell
- Division of Pediatric Cardiothoracic Surgery, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA
| | - Dorota Gruber
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA.,Department of Pediatrics, Hofstra Northwell School of Medicine, Hempstead, NY 11549, USA
| | - Cristina P Sison
- Biostatistics Unit, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA.,Department of Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY 11549, USA
| | - Czeslawa Kowal
- Center for Musculoskeletal and Autoimmune Diseases, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA
| | - Kaie Ojamaa
- Division of Pediatric Cardiology, Department of Pediatrics, Cohen Children's Medical Center of New York at Northwell Health, New Hyde Park, NY 11040, USA.,Department of Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY 11549, USA.,Center for Immunology and Inflammation, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA
| |
Collapse
|
49
|
Morton PD, Ishibashi N, Jonas RA. Neurodevelopmental Abnormalities and Congenital Heart Disease: Insights Into Altered Brain Maturation. Circ Res 2017; 120:960-977. [PMID: 28302742 PMCID: PMC5409515 DOI: 10.1161/circresaha.116.309048] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/14/2023]
Abstract
In the past 2 decades, it has become evident that individuals born with congenital heart disease (CHD) are at risk of developing life-long neurological deficits. Multifactorial risk factors contributing to neurodevelopmental abnormalities associated with CHD have been identified; however, the underlying causes remain largely unknown, and efforts to address this issue have only recently begun. There has been a dramatic shift in focus from newly acquired brain injuries associated with corrective and palliative heart surgery to antenatal and preoperative factors governing altered brain maturation in CHD. In this review, we describe key time windows of development during which the immature brain is vulnerable to injury. Special emphasis is placed on the dynamic nature of cellular events and how CHD may adversely impact the cellular units and networks necessary for proper cognitive and motor function. In addition, we describe current gaps in knowledge and offer perspectives about what can be done to improve our understanding of neurological deficits in CHD. Ultimately, a multidisciplinary approach will be essential to prevent or improve adverse neurodevelopmental outcomes in individuals surviving CHD.
Collapse
Affiliation(s)
- Paul D Morton
- From the Center for Neuroscience Research and Children's National Heart Institute, Children's National Health System, Washington, DC
| | - Nobuyuki Ishibashi
- From the Center for Neuroscience Research and Children's National Heart Institute, Children's National Health System, Washington, DC.
| | - Richard A Jonas
- From the Center for Neuroscience Research and Children's National Heart Institute, Children's National Health System, Washington, DC.
| |
Collapse
|
50
|
Weeke LC, Brilstra E, Braun KP, Zonneveld-Huijssoon E, Salomons GS, Koeleman BP, van Gassen KL, van Straaten HL, Craiu D, de Vries LS. Punctate white matter lesions in full-term infants with neonatal seizures associated with SLC13A5 mutations. Eur J Paediatr Neurol 2017; 21:396-403. [PMID: 27913086 DOI: 10.1016/j.ejpn.2016.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/13/2016] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Early-onset epileptic encephalopathy caused by biallelic SLC13A5 mutations is characterized by seizure onset in the first days of life, refractory epilepsy and developmental delay. Little detailed information about the brain MRI features is available in these patients. METHODS Observational study describing the neuro-imaging findings in eight patients (five families) with mutations in the SLC13A5 gene. Seven infants had an MRI in the neonatal period, two had a follow-up MRI at the age of 6 and 18 months and one only at 13 months. One patient had follow-up MRIs at 11 and 16 months and 3 and 6 years of age, but no neonatal MRI. RESULTS All patients presented with refractory neonatal seizures on the first day of life after an uncomplicated pregnancy and term delivery. Six out of seven infants with a neonatal MRI had a characteristic MRI pattern, with punctate white matter lesions (PWML), which were no longer visible at the age of 6 months, but led to gliotic scarring visible on MRI at the age of 18 months. The same pattern of gliotic scarring was seen on the MRIs of the infant without a neonatal scan. One infant had signal abnormalities in the white matter suspected of PWML on T2WI, but these could not be confirmed on other sequences. CONCLUSION In infants presenting with therapy resistant seizures in the first days after birth, without a clear history of hypoxic-ischemic encephalopathy, but with PWML on their neonatal MRI, a diagnosis of SCL13A5 related epileptic encephalopathy should be considered.
Collapse
Affiliation(s)
- Lauren C Weeke
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eva Brilstra
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kees P Braun
- Department of Pediatric Neurology, Brain Center Rudolf Magnus, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Gajja S Salomons
- Metabolic Unit, Department of Clinical Chemistry, VU University Medical Center/Neuroscience Campus, Amsterdam, The Netherlands
| | - Bobby P Koeleman
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Koen L van Gassen
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Dana Craiu
- Pediatric Neurology Discipline, Department of Clinical Neurosciences, "Carol Davila" University of Medicine, Bucharest, Romania; Pediatric Neurology Clinic, Alexandru Obregia Hospital, Bucharest, Romania
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
| |
Collapse
|