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Schmid AS, Ehrler M, Naef N, Kretschmar O, Rousson V, Tuura R, Wehrle FM, Latal B. Processing Speed Partially Mediates Executive Function Impairments in Adolescents with Congenital Heart Disease: Results from a Prospective Cohort Study. J Pediatr 2024; 272:114091. [PMID: 38734135 DOI: 10.1016/j.jpeds.2024.114091] [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] [Received: 12/06/2023] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE To assess processing speed, fine motor function, attention, and executive function (EF) impairments in adolescents with complex congenital heart disease (CHD) who underwent open-heart surgery during infancy. STUDY DESIGN We administered a comprehensive neuropsychological test battery evaluating 5 EF domains: working memory, inhibition, cognitive flexibility, fluency, and planning and primary neurodevelopmental processes (PNPs): processing speed, fine motor function, and attention. The sample included 100 adolescents with complex CHD from a previous University Children's Hospital Zurich study, with 104 healthy controls for comparison. We generated scores for each EF domain and computed an EF summary score. Group comparisons and associations were analyzed with multiple regressions accounting for parental education. Mediation analysis explored how PNPs mediate the effect between a CHD diagnosis and EF. RESULTS In adolescents with complex CHD, all EF domains and the EF summary score were impaired (β = 0.20 to 0.37, all P < .05). Furthermore, they exhibited slower processing speed (β = 0.27, P < .01) than healthy controls, with no differences in attention (β = -0.07, P = .34) and fine motor function (β = 0.08, P = .34). Processing speed showed a strong association with the EF summary score (β = 0.60, P < .001) and partially mediated the relationship between CHD diagnosis and the EF summary score (β = 0.37, 95% CI [0.24, 0.50], P < .001). CONCLUSION Adolescents with complex CHD show difficulties in EFs and processing speed. Notably, processing speed is strongly associated with EFs and partly accounts for EFs disparities between patients and healthy controls. Early detection and interventions for processing speed difficulties may improve EF outcomes in these patients.
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Affiliation(s)
- Alenka S Schmid
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Melanie Ehrler
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland; University Research Priority Program (URPP), Adaptive Brain Circuits in Development and Learning (AdaBD), University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nadja Naef
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Oliver Kretschmar
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Children's Hospital Zurich, Zurich, Switzerland; Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Valentin Rousson
- Division of Biostatistics, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Ruth Tuura
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; Medical Faculty, University of Zurich, Zurich, Switzerland; MR Research Centre, University Children Hospital Zurich, Zurich, Switzerland
| | - Flavia M Wehrle
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; Medical Faculty, University of Zurich, Zurich, Switzerland; Department of Neonatology and Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; Medical Faculty, University of Zurich, Zurich, Switzerland.
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2
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Hofer J, Blum M, Wiltsche R, Deluggi N, Holzinger D, Fellinger J, Tulzer G, Blum G, Oberhuber R. Research gaps in the neurodevelopmental assessment of children with complex congenital heart defects: a scoping review. Front Pediatr 2024; 12:1340495. [PMID: 38846331 PMCID: PMC11155449 DOI: 10.3389/fped.2024.1340495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/15/2024] [Indexed: 06/09/2024] Open
Abstract
Background Children with congenital heart defects (CHD) are at risk for a range of developmental disabilities that challenge cognition, executive functioning, self-regulation, communication, social-emotional functioning, and motor skills. Ongoing developmental surveillance is therefore key to maximizing neurodevelopmental outcome opportunities. It is crucial that the measures used cover the spectrum of neurodevelopmental domains relevant to capturing possible predictors and malleable factors of child development. Objectives This work aimed to synthesize the literature on neurodevelopmental measures and the corresponding developmental domains assessed in children aged 1-8 years with complex CHD. Methods PubMed was searched for terms relating to psycho-social, cognitive and linguistic-communicative outcomes in children with CHD. 1,380 papers with a focus on complex CHD that reported neurodevelopmental assessments were identified; ultimately, data from 78 articles that used standardized neurodevelopmental assessment tools were extracted. Results Thirty-nine (50%) of these excluded children with syndromes, and 9 (12%) excluded children with disorders of intellectual development. 10% of the studies were longitudinal. The neurodevelopmental domains addressed by the methods used were: 53% cognition, 16% psychosocial functioning, 18% language/communication/speech production, and 13% motor development-associated constructs. Conclusions Data on social communication, expressive and receptive language, speech motor, and motor function are underrepresented. There is a lack of research into everyday use of language and into measures assessing language and communication early in life. Overall, longitudinal studies are required that include communication measures and their interrelations with other developmental domains.
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Affiliation(s)
- Johannes Hofer
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
- Institute of Neurology of Senses and Language, Hospital of St. John of God, Linz, Austria
| | - Marina Blum
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
| | - Regina Wiltsche
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
| | - Nikoletta Deluggi
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
| | - Daniel Holzinger
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
- Institute of Neurology of Senses and Language, Hospital of St. John of God, Linz, Austria
- Institute of Linguistics, University of Graz, Graz, Austria
| | - Johannes Fellinger
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
- Institute of Neurology of Senses and Language, Hospital of St. John of God, Linz, Austria
- Division of Social Psychiatry, University Clinic for Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Gerald Tulzer
- Department of Pediatric Cardiology, Children’s Heart Center Linz, Kepler University Hospital, Linz, Austria
| | - Gina Blum
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
| | - Raphael Oberhuber
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
- Department of Pediatric Cardiology, Children’s Heart Center Linz, Kepler University Hospital, Linz, Austria
- Department of Inclusive Education, University of Education Upper Austria, Linz, Austria
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3
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High throughput mutation screening of cardiac transcription factor GATA4 among Tanzania children with congenital heart diseases. THE NUCLEUS 2023. [DOI: 10.1007/s13237-022-00414-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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4
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Ritmeester E, Veger VA, van der Ven JPG, van Tussenbroek GMJW, van Capelle CI, Udink ten Cate FEA, Helbing WA. Fontan Circulation Associated Organ Abnormalities Beyond the Heart, Lungs, Liver, and Gut: A Systematic Review. Front Cardiovasc Med 2022; 9:826096. [PMID: 35391839 PMCID: PMC8981209 DOI: 10.3389/fcvm.2022.826096] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction Patients with a Fontan circulation are at risk for sequelae of Fontan physiology during follow-up. Fontan physiology affects all organ systems and an overview of end-organ damage is needed. Methods We performed a systematic review of abnormalities in multiple organ systems for patients with a longstanding Fontan circulation. We searched online databases for articles describing abnormalities in multiple organ systems. Cardio-pulmonary abnormalities, protein losing enteropathy, and Fontan associated liver disease have already extensively been described and were excluded from this systematic review. Results Our search returned 5,704 unique articles. After screening, we found 111 articles relating to multiple organ systems. We found abnormalities in, among others, the nervous system, pituitary, kidneys, and musculoskeletal system. Pituitary edema—relating to the unique pituitary vasculature- may affect the thyroid axis. Renal dysfunction is common. Creatinine based renal function estimates may be inappropriate due to myopenia. Both lean muscle mass and bone mineral density are decreased. These abnormalities in multiple organ systems may be related to Fontan physiology, cyanosis, iatrogenic factors, or lifestyle. Conclusions Health care providers should be vigilant for hypothyroidism, visual or hearing deficits, and sleep disordered breathing in Fontan patients. We recommend including cystatin C for assessment of renal function. This review may aid health care providers and guide future research. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021232461, PROSPERO, identifier: CRD42021232461.
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Affiliation(s)
- Evi Ritmeester
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Veerle A. Veger
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jelle P. G. van der Ven
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | | | - Carine I. van Capelle
- Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Floris E. A. Udink ten Cate
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem A. Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Willem A. Helbing
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5
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Burns J, Varughese R, Ganigara M, Kothare SV, McPhillips LA, Dhar A. Neurodevelopmental outcomes in congenital heart disease through the lens of single ventricle patients. Curr Opin Pediatr 2021; 33:535-542. [PMID: 34369410 DOI: 10.1097/mop.0000000000001052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize and organize the current body of literature on this contemporary topic, alongside a more general discussion of neurodevelopmental complications of congenital heart disease. RECENT FINDINGS It is theorized that the causes of the neurodevelopment disabilities are multifactorial resulting from structural central nervous system abnormalities, haemodynamic alterations and/or biochemical changes. It is therefore imperative that all patients with single ventricle anatomy and physiology receive long-term neurologic and developmental assessments in addition to their cardiac monitoring. SUMMARY Advancements in surgical techniques and medical management have improved survivorship of these medically complex patients. Neurodevelopmental sequelae are one of the most common comorbidities affecting this patient population leading to long-term challenges in motor, language, social and cognitive skills.
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Affiliation(s)
| | - Robin Varughese
- Division of Pediatric Neurology, Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Madhusudan Ganigara
- Children's Medical Center, Division of Pediatric Cardiology, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sanjeev V Kothare
- Division of Pediatric Neurology, Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Lindsey A McPhillips
- Division of Pediatric Cardiology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA
| | - Arushi Dhar
- Division of Pediatric Cardiology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA
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6
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Feldmann M, Bataillard C, Ehrler M, Ullrich C, Knirsch W, Gosteli-Peter MA, Held U, Latal B. Cognitive and Executive Function in Congenital Heart Disease: A Meta-analysis. Pediatrics 2021; 148:peds.2021-050875. [PMID: 34561266 DOI: 10.1542/peds.2021-050875] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Cognitive function and executive function (EF) impairments contribute to the long-term burden of congenital heart disease (CHD). However, the degree and profile of impairments are insufficiently described. OBJECTIVE To systematically review and meta-analyze the evidence on cognitive function and EF outcomes in school-aged children operated for CHD and identify the risk factors for an unfavorable outcome. DATA SOURCES Cochrane, Embase, Medline, and PsycINFO. STUDY SELECTION Original peer-reviewed studies reporting cognitive or EF outcome in 5- to 17-year old children with CHD after cardiopulmonary bypass surgery. DATA EXTRACTION Results of IQ and EF assessments were extracted, and estimates were transformed to means and SE. Standardized mean differences were calculated for comparison with healthy controls. RESULTS Among 74 studies (3645 children with CHD) reporting total IQ, the summary estimate was 96.03 (95% confidence interval: 94.91 to 97.14). Hypoplastic left heart syndrome and univentricular CHD cohorts performed significantly worse than atrial and ventricular septum defect cohorts (P = .0003; P = .027). An older age at assessment was associated with lower IQ scores in cohorts with transposition of the great arteries (P = .014). Among 13 studies (774 children with CHD) reporting EF compared with controls, the standardized mean difference was -0.56 (95% confidence interval: -0.65 to -0.46) with no predilection for a specific EF domain or age effect. LIMITATIONS Heterogeneity between studies was large. CONCLUSIONS Intellectual impairments in CHD are frequent, with severity and trajectory depending on the CHD subtype. EF performance is poorer in children with CHD without a specific EF profile. The heterogeneity in studied populations and applied assessments is large. A uniform testing guideline is urgently needed.
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Affiliation(s)
- Maria Feldmann
- Child Development Centre and Children's Research Centre.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Célina Bataillard
- Child Development Centre and Children's Research Centre.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Melanie Ehrler
- Child Development Centre and Children's Research Centre.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Cinzia Ullrich
- Child Development Centre and Children's Research Centre.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Walter Knirsch
- Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.,Pediatric Cardiology, Pediatric Heart Center, and
| | | | - Ulrike Held
- Department of Biostatistics, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Centre and Children's Research Centre .,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
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7
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Siciliano RE, Murphy LK, Prussien KV, Henry LM, Watson KH, Patel NJ, Lee CA, McNally CM, Markham LW, Compas BE, Jordan LC. Cognitive and Attentional Function in Children with Hypoplastic Left Heart Syndrome: A Pilot Study. J Clin Psychol Med Settings 2021; 28:619-626. [PMID: 33222094 PMCID: PMC8140062 DOI: 10.1007/s10880-020-09753-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 01/14/2023]
Abstract
While survival for children with hypoplastic left heart syndrome (HLHS) has improved, compromised cardiac output and oxygen delivery persist, and children show cognitive deficits. Most research has assessed young children on broad cognitive indices; less is known about specific indices in older youth. In this pilot study, cognitive function and attention in youth ages 8 to 16 years with HLHS (n = 20) was assessed with the Wechsler Intelligence Scale for Children - Fifth Edition (WISC-V) and NIH Toolbox Cognition Battery (NTCB); parents completed the Child Behavior Checklist. Children scored significantly lower than normative means on the WISC-V Full Scale IQ, Verbal Comprehension, Visual Spatial, Working Memory, and Processing Speed indices, and the NTCB Fluid Cognition Composite; effect sizes ranged from medium to large. Attention problems had a large significant effect. Child age corresponded to lower visual spatial scores. Findings highlight the importance of assessing multiple cognitive indices for targeted intervention and investigating age and disease factors as potential correlates in larger samples.
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Affiliation(s)
- Rachel E Siciliano
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Lexa K Murphy
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Kemar V Prussien
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Lauren M Henry
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Kelly H Watson
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Niral J Patel
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, DOT 11212, USA
| | - Chelsea A Lee
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, DOT 11212, USA
| | - Colleen M McNally
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Larry W Markham
- Department of Pediatrics, Division of Pediatric Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bruce E Compas
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, DOT 11212, USA.
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8
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Huisenga D, La Bastide‐Van Gemert S, Van Bergen A, Sweeney J, Hadders‐Algra M. Developmental outcomes after early surgery for complex congenital heart disease: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:29-46. [PMID: 32149404 PMCID: PMC7754445 DOI: 10.1111/dmcn.14512] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
AIM (1) To systematically review the literature on developmental outcomes from infancy to adolescence of children with complex congenital heart disease (CHD) who underwent early surgery; (2) to run a meta-regression analysis on the Bayley Scales of Infant Development, Second Edition Mental Developmental Index and Psychomotor Developmental Index (PDI) of infants up to 24 months and IQs of preschool-aged children to adolescents; (3) to assess associations between perioperative risk factors and outcomes. METHOD We searched pertinent literature (January 1990 to January 2019) in PubMed, Embase, CINAHL, and PsycINFO. Selection criteria included infants with complex CHD who had primary surgery within the first 9 weeks of life. Methodological quality, including risk of bias and internal validity, were assessed. RESULTS In total, 185 papers met the inclusion criteria; the 100 with high to moderate methodological quality were analysed in detail. Substantial heterogeneity in the group with CHD and in methodology existed. The outcome of infants with single-ventricle CHD was inferior to those with two-ventricle CHD (respectively: average scores for PDI 77 and 88; intelligence scores 92 and 98). Perioperative risk factors were inconsistently associated with developmental outcomes. INTERPRETATION The literature on children undergoing surgery in early infancy suggests that infants with a single ventricle are at highest risk of adverse developmental outcomes.
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Affiliation(s)
- Darlene Huisenga
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
| | - Sacha La Bastide‐Van Gemert
- University of GroningenUniversity Medical Center GroningenDepartment of EpidemiologyGroningenthe Netherlands
| | - Andrew Van Bergen
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,Advocate Children’s Heart Institute Division of Pediatric Cardiac Critical CareAdvocate Children’s HospitalOak LawnILUSA
| | - Jane Sweeney
- Pediatric Science Doctoral ProgramRocky Mountain University of Health ProfessionsProvoUTUSA
| | - Mijna Hadders‐Algra
- University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
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9
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Siciliano RE, Prussien KV, Lee CA, Patel NJ, Murphy LK, Compas BE, Jordan LC. Cognitive Function in Pediatric Hypoplastic Left Heart Syndrome: Systematic Review and Meta-Analysis. J Pediatr Psychol 2020; 44:937-947. [PMID: 31069392 DOI: 10.1093/jpepsy/jsz021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/06/2019] [Accepted: 03/14/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Despite surgical palliation, children with hypoplastic left heart syndrome (HLHS) have compromised cardiac functioning and increased risk for cognitive deficits. We quantitatively reviewed the empirical data from this literature. METHODS The present meta-analysis included 13 studies reporting cognitive function for children with HLHS between the ages of 2 years and 6 months and 17 years that used standardized assessments of Full Scale IQ (FSIQ), Verbal IQ (VIQ), and Performance IQ (PIQ). Differences in cognitive function were assessed relative to normative data, and we examined sample mean age and publication year as moderators. RESULTS Large effects were found for FSIQ (g = -.87, 95% CI [-1.10, -.65], M = 86.88) and PIQ (g = -.89, 95% CI [-1.11, -.68], M = 86.56), and a medium effect was found for VIQ (g = -.61, 95% CI [-.84, -.38], M = 90.82). All models demonstrated significant heterogeneity. Meta-regression analyses of effect size via Hedges' g on child age revealed a significant effect on FSIQ (coefficient = -.07, 95% CI [-.12, -.01], p < .01, R2 = .40) indicating a loss of 1.1 FSIQ points across studies with each increased year of mean sample age. CONCLUSIONS Deficits in FSIQ may reflect chronic brain injury or failure to make expected gains as children age. This review highlights the importance of early intervention in this population, and the need for longitudinal studies analyzing more specific domains of cognitive function and potential moderators.
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Affiliation(s)
| | - Kemar V Prussien
- Department of Psychology and Human Development, Vanderbilt University
| | - Chelsea A Lee
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center
| | - Niral J Patel
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center
| | - Lexa K Murphy
- Department of Psychology and Human Development, Vanderbilt University
| | - Bruce E Compas
- Department of Psychology and Human Development, Vanderbilt University
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center
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10
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Tamargo CL, Botros M, Saveanu RV. The relationship between neurocognitive decline and the heart-lung machine. J Card Surg 2020; 35:1057-1061. [PMID: 32176380 DOI: 10.1111/jocs.14505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Surgery involving the use of cardiopulmonary bypass (CPB) has long been associated with cerebral changes and may also contribute to adverse neurocognitive outcomes. However, there is a debate as to whether bypass itself is responsible for these changes. We conducted a systematic literature review on PubMed, supplementing our work with recent articles from other sources to examine the current evidence on neurocognitive decline associated with CPB. While surgeries involving CPB appear to be associated with cerebral changes and potentially with neurocognitive decline, it is unclear as to whether decline is related to the procedure itself. It is possible that the impacts of CPB can be more readily observed among individuals with preoperative cognitive impairment. It is thus important to screen for subtle and more apparent preoperative cognitive impairment as a risk factor for adverse outcomes. Further research, comparing on-pump and off-pump cohorts and involving intensive screening of preoperative cognitive decline, is indicated to elucidate the true neurocognitive consequences of the heart-lung machine.
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Affiliation(s)
- Christina L Tamargo
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Mousa Botros
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Radu V Saveanu
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
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11
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 429] [Impact Index Per Article: 85.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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12
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Bell JL, Saenz L, Domnina Y, Baust T, Panigrahy A, Bell MJ, Camprubí-Camprubí M, Sanchez-de-Toledo J. Acute Neurologic Injury in Children Admitted to the Cardiac Intensive Care Unit. Ann Thorac Surg 2019; 107:1831-1837. [PMID: 30682351 DOI: 10.1016/j.athoracsur.2018.12.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 11/20/2018] [Accepted: 12/12/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Children with acquired and congenital heart disease both have low mortality but an increased risk of neurologic morbidity that is multifactorial. Our hypothesis was that acute neurologic injuries contribute to mortality in such children and are an important cause of death. METHODS All admissions to the pediatric cardiac intensive care unit (CICU) from January 2011 through January 2015 were retrospectively reviewed. Patients were assessed for any acute neurologic events (ANEs) during admission, as defined by radiologic findings or seizures documented on an electroencephalogram. RESULTS Of the 1,573 children admitted to the CICU, the incidence of ANEs was 8.6%. Mortality of the ANE group was 16.3% compared with 1.5% for those who did not have an ANE. The odds ratio for death with ANEs was 8.55 (95% confidence interval, 4.56 to 16.03). Patients with ANEs had a longer hospital length of stay than those without ANEs (41.4 ± 4 vs 14.2 ± 0.6 days; p < 0.001). Need for extracorporeal membrane oxygenation, previous cardiac arrest, and prematurity were independently associated with the presence of an ANE. CONCLUSIONS Neurologic injuries are common in pediatric CICUs and are associated with an increase in mortality and hospital length of stay. Children admitted to the CICU are likely to benefit from improved surveillance and neuroprotective strategies to prevent neurologic death.
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Affiliation(s)
- Jamie L Bell
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Lucas Saenz
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yuliya Domnina
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tracy Baust
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael J Bell
- Division of Pediatric Intensive Care, Department of Pediatrics, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC
| | - Marta Camprubí-Camprubí
- Department of Neonatology, Hospital Sant Joan de Déu, Barcelona University, Barcelona, Spain
| | - Joan Sanchez-de-Toledo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Cardiology, Hospital Sant Joan de Déu, Barcelona University, Barcelona, Spain.
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Hoch JM, Fatusin O, Yenokyan G, Thompson WR, Lefton-Greif MA. Feeding methods for infants with single ventricle physiology are associated with length of stay during stage 2 surgery hospitalization. CONGENIT HEART DIS 2019; 14:438-445. [PMID: 30635975 DOI: 10.1111/chd.12742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/16/2018] [Accepted: 12/07/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tube feedings are often needed to achieve the growth and nutrition goals associated with decreased morbidity and mortality in patients with single ventricle anatomy. Variability in feeding method through the interstage period has been previously described, however, comparable information following stage 2 palliation is lacking. OBJECTIVES To identify types of feeding methods following stage 2 palliation and their influence on length of stay. DESIGN Secondary analysis of the National Pediatric Cardiology Quality Improvement Collaborative registry was performed on 932 patients. Demographic data, medical characteristics, postoperative complications, type of feeding method, and length of stay for stage 2 palliation were analyzed. RESULTS Type of feeding method remained relatively unchanged during hospitalization for stage 2 palliation. Gastrostomy tube fed only patients were the oldest at time of surgery (182.7 ± 57.7 days, P < .001) and had the lowest weight-for-age z scores at admission (-1.6 ± 1.4, P < .001). Oral + gastrostomy tube groups had the longest median bypass times (172.5 minutes, P = .001) and longest length of stay (median 12 days, P < .001). Multivariable modeling revealed that feeding by tube only (P < .001), oral + tube feeding (P ≤ .001), reintubation (P < .001), and prolonged intubation (P < .001) were associated with increased length of stay. Neither age (P = .156) nor weight-for-age z score at admission (P = .066) was predictive of length of stay. CONCLUSIONS Feeding methods established at admission for stage 2 palliation are not likely to change by discharge. Length of stay is more likely to be impacted by tube feeding and intubation history than age or weight-for-age z score at admission. Better understanding for selection of feeding methods and their impact on patient outcomes is needed to develop evidence-based guidelines to decrease variability in clinical practice patterns and provide appropriate counseling to caregivers.
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Affiliation(s)
- Jeannine M Hoch
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Oluwatosin Fatusin
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - W Reid Thompson
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maureen A Lefton-Greif
- Department of Pediatrics, Otolaryngology, Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Altered White Matter Microstructure Correlates with IQ and Processing Speed in Children and Adolescents Post-Fontan. J Pediatr 2018; 200:140-149.e4. [PMID: 29934026 DOI: 10.1016/j.jpeds.2018.04.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 03/20/2018] [Accepted: 04/11/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare white matter microstructure in children and adolescents with single ventricle who underwent the Fontan procedure with healthy controls, and to explore the association of white matter injury with cognitive performance as well as patient and medical factors. STUDY DESIGN Fontan (n = 102) and control subjects (n = 47) underwent diffusion tensor imaging (DTI) at ages 10-19 years. Mean DTI measures (fractional anisotropy, radial diffusivity, axial diffusivity, and mean diffusivity) were calculated for 33 fiber tracts from standard white matter atlases. Voxel-wise group differences in DTI measures were assessed using Tract-Based Spatial Statistics. Associations of regional fractional anisotropy with IQ and processing speed as well as medical characteristics were examined. RESULTS Subjects with Fontan, compared with controls, had reduced bilateral regional and voxel-wise fractional anisotropy in multiple white matter tracts along with increased regional radial diffusivity in several overlapping tracts; regional mean diffusivity differed in 2 tracts. The groups did not differ in voxel-wise radial diffusivity or mean diffusivity. Among subjects with Fontan, fractional anisotropy in many tracts correlated positively with Full-Scale Intelligence Quotient and processing speed, although similar findings were absent in controls. Lower mean fractional anisotropy in various tracts was associated with more complications in the first operation, a greater number of total operations, and history of neurologic event. CONCLUSIONS Children and adolescents who have undergone the Fontan procedure have widespread abnormalities in white matter microstructure. Furthermore, white matter microstructure in several tracts is associated with cognitive performance and operative and medical history characteristics.
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Di Maria MV, Menon SC. Role of comprehensive care in Fontan survivors: A multidisciplinary team approach. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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Impaired cerebral autoregulation and elevation in plasma glial fibrillary acidic protein level during cardiopulmonary bypass surgery for CHD. Cardiol Young 2018; 28:55-65. [PMID: 28835309 PMCID: PMC5955612 DOI: 10.1017/s1047951117001573] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cerebrovascular reactivity monitoring has been used to identify the lower limit of pressure autoregulation in adult patients with brain injury. We hypothesise that impaired cerebrovascular reactivity and time spent below the lower limit of autoregulation during cardiopulmonary bypass will result in hypoperfusion injuries to the brain detectable by elevation in serum glial fibrillary acidic protein level. METHODS We designed a multicentre observational pilot study combining concurrent cerebrovascular reactivity and biomarker monitoring during cardiopulmonary bypass. All children undergoing bypass for CHD were eligible. Autoregulation was monitored with the haemoglobin volume index, a moving correlation coefficient between the mean arterial blood pressure and the near-infrared spectroscopy-based trend of cerebral blood volume. Both haemoglobin volume index and glial fibrillary acidic protein data were analysed by phases of bypass. Each patient's autoregulation curve was analysed to identify the lower limit of autoregulation and optimal arterial blood pressure. RESULTS A total of 57 children had autoregulation and biomarker data for all phases of bypass. The mean baseline haemoglobin volume index was 0.084. Haemoglobin volume index increased with lowering of pressure with 82% demonstrating a lower limit of autoregulation (41±9 mmHg), whereas 100% demonstrated optimal blood pressure (48±11 mmHg). There was a significant association between an individual's peak autoregulation and biomarker values (p=0.01). CONCLUSIONS Individual, dynamic non-invasive cerebrovascular reactivity monitoring demonstrated transient periods of impairment related to possible silent brain injury. The association between an impaired autoregulation burden and elevation in the serum brain biomarker may identify brain perfusion risk that could result in injury.
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Poryo M, Paes LA, Pickardt T, Bauer UMM, Meyer S, Wagenpfeil S, Abdul-Khaliq H. Somatic Development in Children with Congenital Heart Defects. J Pediatr 2018; 192:136-143.e4. [PMID: 29246335 DOI: 10.1016/j.jpeds.2017.09.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/21/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Somatic development is impaired in children with congenital heart defects (CHDs), and head circumference seems to be a strong predictor of neurodevelopmental prognosis. The aim of this study was to generate up-to-date reference values for the somatic development (head circumference, body weight, and length/height) of children with CHDs. STUDY DESIGN Our study population consisted of all patients included in the PAN study (Prävalenz angeborener Herzfehler bei Neugeborenen in Deutschland), which was conducted prospectively over a 3-year study period by the Competence Network for Congenital Heart Defects. All children with mild, moderate, and severe CHDs born in 2006-2009 in Germany were enrolled. For computing of z-scores, only children with the following characteristics were included: appropriate for gestational age, nonsyndromic disease, term or post-term delivery, and no cardiac surgery. RESULTS There were 2818 patients included. New z-scores for the described somatic measures of children with mild, moderate, and severe CHDs were computed. Comparisons with the KiGGS study (Gesundheit von Kindern und Jugendlichen in Deutschland) and the Berlin Longitudinal Study revealed significantly lower measurements for all measures-most notably in children with severe CHDs and/or cardiac surgery. In our cohort, no catch-up growth was seen after cardiac surgery. CONCLUSION Children with severe CHDs demonstrated the most abnormal pattern in growth, including head circumference before and after cardiac surgery, which is indicative of accompanying brain pathology unrelated to operative injury.
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Affiliation(s)
- Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg/Saar, Germany.
| | | | - Thomas Pickardt
- Competence Network for Congenital Heart Defects, DZHK (German Center for Cardiovascular Research), Berlin, Germany
| | - Ulrike M M Bauer
- Competence Network for Congenital Heart Defects, DZHK (German Center for Cardiovascular Research), Berlin, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg/Saar, Germany
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Landmark lecture on interventional cardiology: interventional cardiac catheterisation for CHD: the past, present, and the future. Cardiol Young 2017; 27:1974-1985. [PMID: 29286271 DOI: 10.1017/s1047951117002141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
CHD affects millions of patients worldwide. Interventional therapies for CHD goes back to the mid-1960s when Bill Rashkind performed balloon atrial septostomy on a cyanotic baby with transposition of the great vessels. This was followed by development of balloon catheters to perform balloon valvuloplasties and angioplasties in the early to late 1980s. Although King and Mills performed the first transcatheter closure of secundum atrial septal defect in the mid-1970s, this procedure was better realised in the mid-1990s. More intracardiac defect closures were performed in the late 1990s and early 2000. This brings us to the current era of percutaneous valve implantation as developed by Bonhoeffer. In this paper, we will discuss the past, present, and future of interventional cardiac catheterisation for CHD patients.
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19
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Clinical and neuroimaging characteristics of cerebral sinovenous thrombosis in neonates undergoing cardiac surgery. J Thorac Cardiovasc Surg 2017; 155:1150-1158. [PMID: 29221746 DOI: 10.1016/j.jtcvs.2017.10.083] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 09/28/2017] [Accepted: 10/11/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Neonates with congenital heart disease may have an increased risk of cerebral sinovenous thrombosis, but incidence rates are lacking. This study describes the clinical and neuroimaging characteristics of cerebral sinovenous thrombosis in neonates undergoing cardiac surgery. METHODS Forty neonates (78% male) requiring neonatal univentricular or biventricular cardiac repair using cardiopulmonary bypass were included. All underwent preoperative (median postnatal day 7) and postoperative (median postoperative day 7) magnetic resonance imaging of the brain, including venography, to detect cerebral sinovenous thrombosis. Clinical characteristics were compared between cerebral sinovenous thrombosis positive and cerebral sinovenous thrombosis negative neonates. RESULTS Postoperatively, cerebral sinovenous thrombosis was diagnosed in 11 neonates (28%), with the transverse sinus affected in all, and involvement of multiple sinuses in 10 (91%). Preoperatively, signs of thrombosis were seen in 3 cases (8%). Focal infarction of the basal ganglia was significantly more common in cerebral sinovenous thrombosis positive than cerebral sinovenous thrombosis negative neonates (P = .025). Cerebral sinovenous thrombosis positive neonates spent more time in the intensive care unit preoperatively (P = .001), had lower weight (P = .024) and lower postmenstrual age (P = .030) at surgery, and had prolonged use of a central venous catheter (P = .023) and a catheter placed in the internal jugular vein more often (P = .039). Surgical and postoperative factors were not different between new postoperative cerebral sinovenous thrombosis positive and cerebral sinovenous thrombosis negative neonates. CONCLUSIONS Cerebral sinovenous thrombosis might be more common than previously understood in neonates undergoing cardiac surgery. In our study, cerebral sinovenous thrombosis was associated with a higher risk of additional intra-parenchymal brain injury.
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20
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Claessens NHP, Kelly CJ, Counsell SJ, Benders MJNL. Neuroimaging, cardiovascular physiology, and functional outcomes in infants with congenital heart disease. Dev Med Child Neurol 2017; 59:894-902. [PMID: 28542743 DOI: 10.1111/dmcn.13461] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2017] [Indexed: 01/12/2023]
Abstract
This review integrates data on brain dysmaturation and acquired brain injury using fetal and neonatal magnetic resonance imaging (MRI), including the contribution of cardiovascular physiology to differences in brain development, and the relationship between brain abnormalities and subsequent neurological impairments in infants with congenital heart disease (CHD). The antenatal and neonatal period are critical for optimal brain development; the developing brain is particularly vulnerable to haemodynamic disturbances during this time. Altered cerebral perfusion and decreased cerebral oxygen delivery in the antenatal period can affect functional and structural brain development, while postnatal haemodynamic fluctuations may cause additional injury. In critical CHD, brain dysmaturation and acquired brain injury result from a combination of underlying cardiovascular pathology and surgery performed in the neonatal period. MRI findings in infants with CHD can be used to evaluate potential clinical risk factors for brain abnormalities, and aid prediction of functional outcomes at an early stage. In addition, information on timing of brain dysmaturation and acquired brain injury in CHD has the potential to be used when developing strategies to optimize neurodevelopment.
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Affiliation(s)
- Nathalie H P Claessens
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Christopher J Kelly
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Serena J Counsell
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
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21
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Gunn JK, Beca J, Hunt RW, Goldsworthy M, Brizard CP, Finucane K, Donath S, Shekerdemian LS. Perioperative risk factors for impaired neurodevelopment after cardiac surgery in early infancy. Arch Dis Child 2016; 101:1010-1016. [PMID: 27272973 DOI: 10.1136/archdischild-2015-309449] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 04/09/2016] [Accepted: 05/08/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Historical cohort studies have reported adverse neurodevelopment following cardiac surgery during early infancy. Advances in surgical techniques and perioperative care have coincided with updating of neurodevelopmental assessment tools. We aimed to determine perioperative risk factors for impaired neurodevelopment at 2 years following surgery for congenital heart disease (CHD) in early infancy. DESIGN AND PATIENTS We undertook a prospective longitudinal study of 153 full-term infants undergoing surgery for CHD before 2 months of age. Infants were excluded if they had a genetic syndrome associated with neurodevelopmental impairment. OUTCOME MEASURES Predefined perioperative parameters were recorded and infants were classified according to cardiac anatomy. At 2 years, survivors were assessed using the Bayley Scales of Infant Development-III. RESULTS At 2 years, 130 children (98% of survivors) were assessed. Mean cognitive, language and motor scores were 93.4±13.6, 93.6±16.1 and 96.8±12.5 respectively (100±15 norm). Twenty (13%) died and 12 (9%) survivors had severe impairment (score <70), mostly language (8%). The lowest scores were in infants born with single ventricle physiology with obstruction to the pulmonary circulation who required a neonatal systemic-to-pulmonary artery shunt. Additional risk factors for impairment included reduced gestational age, postoperative elevation of lactate or S100B and repeat cardiac surgery. CONCLUSIONS In the modern era of infant cardiac surgery and perioperative care, children continue to demonstrate neurodevelopmental delays. The use of updated assessment tools has revealed early language dysfunction and relative sparing of motor function. Ongoing follow-up is critical in this high-risk population.
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Affiliation(s)
- Julia K Gunn
- Newborn Intensive Care, The Royal Children's Hospital, Melbourne, Australia.,Neonatal Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Australia
| | - John Beca
- Department of Paediatric Intensive Care, Starship Children's Hospital, Auckland, New Zealand
| | - Rodney W Hunt
- Newborn Intensive Care, The Royal Children's Hospital, Melbourne, Australia.,Neonatal Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Australia
| | - Michelle Goldsworthy
- Department of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas, USA
| | - Christian P Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Kirsten Finucane
- Department of Cardiac Surgery, Starship Children's Hospital, Auckland, New Zealand
| | - Susan Donath
- Department of Paediatrics, The University of Melbourne, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - Lara S Shekerdemian
- Department of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas, USA
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Comparison of in-hospital and longer-term outcomes of hybrid and Norwood stage 1 palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2015; 150:474-80.e2. [DOI: 10.1016/j.jtcvs.2015.06.071] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 06/08/2015] [Accepted: 06/28/2015] [Indexed: 11/24/2022]
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Sarrechia I, Miatton M, De Wolf D, François K, Gewillig M, Meyns B, Vingerhoets G. Neurocognitive development and behaviour in school-aged children after surgery for univentricular or biventricular congenital heart disease. Eur J Cardiothorac Surg 2015; 49:167-74. [DOI: 10.1093/ejcts/ezv029] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/14/2015] [Indexed: 11/14/2022] Open
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Singh U, Kumar S, Gour H, Singh N, Ramaraj M, Mittal V, Jhim D. Complicated hydatid cyst and "air bubble" sign: a stepping-stone to correct diagnosis. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:20-4. [PMID: 25612057 PMCID: PMC4307737 DOI: 10.12659/ajcr.892621] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hydatid cyst, or Echinococcosis, is an important helminthic zoonotic disease in humans that commonly affects the liver and lungs. Uncomplicated hydatid cysts, seen as round opaque lesions on chest radiography, are easily diagnosed, whereas complicated cysts (infected and or perforated) may change the radiographic appearance of the hydatid cyst, causing an incorrect diagnosis and delayed treatment. Although in radiology many signs have been described, the "air bubble" sign, seen in the mediastinal window of CECT as a single or multiple small rounded radiolucent areas with sharp margins within the periphery of a solid mass lesion, is being recognized as a sign with high sensitivity and specificity in the diagnosis of complicated hydatid cysts. CASE REPORT A 32-year-old female on anti-tubercular treatment for the past 3 months without any improvement was admitted to our hospital. CECT of the chest revealed a mass-like lesion with the "air bubble" sign. After 15 days the patient had a vigorous bout of coughing, leading to expectoration of pieces of whitish yellowish gelatinous membrane for the next 3 days. The ELISA result for Echinococcus was highly positive. On the basis of the "air bubble" sign, positive serology, and expectorated pieces of the membrane, the patient was diagnosed as having a complicated hydatid cyst. CONCLUSIONS Due to the varied presentations of complicated hydatid cyst, the knowledge and awareness of various signs in radiology associated with the hydatid cyst, in particular the "air bubble" sign, is imperative in making a prompt and accurate diagnosis of a complicated hydatid cyst.
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Affiliation(s)
- Urvinderpal Singh
- Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India
| | - Sunil Kumar
- Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India
| | - Hitesh Gour
- Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India
| | - Navdeep Singh
- Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India
| | - Murlidharan Ramaraj
- Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India
| | - Vidhu Mittal
- Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India
| | - Daksh Jhim
- Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India
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Bergemann A, Hansen JH, Rotermann I, Voges I, Scheewe J, Otto-Morris C, Geiger F, Kramer HH. Neuropsychological performance of school-aged children after staged surgical palliation of hypoplastic left heart syndrome. Eur J Cardiothorac Surg 2014; 47:803-11. [DOI: 10.1093/ejcts/ezu299] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/26/2014] [Indexed: 11/12/2022] Open
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Glial fibrillary acidic protein in children with congenital heart disease undergoing cardiopulmonary bypass. Cardiol Young 2014; 24:623-31. [PMID: 23845562 DOI: 10.1017/s1047951113000851] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To determine whether blood levels of the brain-specific biomarker glial fibrillary acidic protein rise during cardiopulmonary bypass for repair of congenital heart disease. METHODS This is a prospective observational pilot study to characterise the blood levels of glial fibrillary acidic protein during bypass. Children <21 years of age undergoing bypass for congenital heart disease at Johns Hopkins Hospital and Texas Children's Hospital were enrolled. Blood samples were collected during four phases: pre-bypass, cooling, re-warming, and post-bypass. RESULTS A total of 85 patients were enrolled between October, 2010 and May, 2011. The median age was 0.73 years (range 0.01-17). The median weight was 7.14 kilograms (range 2.2-86.5). Single ventricle anatomy was present in 18 patients (22%). Median glial fibrillary acidic protein values by phase were: pre-bypass: 0 ng/ml (range 0-0.35); cooling: 0.039 (0-0.68); re-warming: 0.165 (0-2.29); and post-bypass: 0.112 (0-0.97). There were significant elevations from pre-bypass to all subsequent stages, with the greatest increase during re-warming (p = 0.0001). Maximal levels were significantly related to younger age (p = 0.03), bypass time (p = 0.03), cross-clamp time (p = 0.047), and temperature nadir (0.04). Peak levels did not vary significantly in those with single ventricle anatomy versus two ventricle repairs. CONCLUSION There are significant increases in glial fibrillary acidic protein levels in children undergoing cardiopulmonary bypass for repair of congenital heart disease. The highest values were seen during the re-warming phase. Elevations are significantly associated with younger age, bypass and cross-clamp times, and temperature nadir. Owing to the fact that glial fibrillary acidic protein is the most brain-specific biomarker identified to date, it may act as a rapid diagnostic marker of brain injury during cardiac surgery.
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Academic proficiency in children after early congenital heart disease surgery. Pediatr Cardiol 2014; 35:344-52. [PMID: 24000004 PMCID: PMC3946912 DOI: 10.1007/s00246-013-0781-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 08/14/2013] [Indexed: 01/25/2023]
Abstract
Children with early surgery for congenital heart disease (CHD) are known to have impaired neurodevelopment; their performance on school-age achievement tests and their need for special education remains largely unexplored. The study aimed to determine predictors of academic achievement at school age and placement in special education services among early CHD surgery survivors. Children with CHD surgery at <1 year of age from January 1, 1998 to December 31, 2003, at the Arkansas Children's Hospital were identified. Out-of-state births and infants with known genetic and/or neurologic conditions were excluded. Infants were matched to an Arkansas Department of Education database containing standardized assessments at early school age and special-education codes. Predictors for achieving proficiency in literacy and mathematics and the receipt of special education were determined. Two hundred fifty-six children who attended Arkansas public schools and who had surgery as infants were included; 77.7 % had either school-age achievement-test scores or special-education codes of mental retardation or multiple disabilities. Scores on achievement tests for these children were 7-13 % lower than those of Arkansas students (p < 0.01). They had an eightfold increase in receipt of special education due to multiple disabilities [odds ratio (OR) 10.66, 95 % confidence interval (CI) 4.23-22.35] or mental retardation (OR 4.96, 95 % CI 2.6-8.64). Surgery after the neonatal period was associated with decreased literacy proficiency, and cardiopulmonary bypass during the first surgery was associated with decreased mathematics proficiency. Children who had early CHD surgery were less proficient on standardized school assessments, and many received special education. This is concerning because achievement-test scores at school age are "real-world" predictors of long-term outcomes.
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Hill GD, Silverman AH, Noel RJ, Simpson PM, Slicker J, Scott AE, Bartz PJ. Feeding dysfunction in children with single ventricle following staged palliation. J Pediatr 2014; 164:243-6.e1. [PMID: 24161218 PMCID: PMC3946833 DOI: 10.1016/j.jpeds.2013.09.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/30/2013] [Accepted: 09/13/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the prevalence of feeding dysfunction in children with single ventricle defects and identify associated risk factors. STUDY DESIGN Patients aged 2-6 years with single ventricle physiology presenting for routine cardiology follow-up at the Children's Hospital of Wisconsin were prospectively identified. Parents of the patients completed 2 validated instruments for assessment of feeding dysfunction. Chart review was performed to retrospectively obtain demographic and diagnostic data. RESULTS Instruments were completed for 56 patients; median age was 39 months. Overall, 28 (50%) patients had some form of feeding dysfunction. Compared with a normal reference population, patients with single ventricle had statistically significant differences in dysfunctional food manipulation (P < .001), mealtime aggression (P = .002), choking/gagging/vomiting (P < .001), resistance to eating (P < .001), and parental aversion to mealtime (P < .001). Weight and height for age z-scores were significantly lower in subjects with feeding dysfunction (-0.84 vs -0.33; P < .05 and -1.46 vs -0.56; P = .001, respectively). Multivariable analysis identified current gastrostomy tube use (P = .02) and a single parent household (P = .01) as risk factors for feeding dysfunction. CONCLUSION Feeding dysfunction is common in children with single ventricle defects, occurring in 50% of our cohort. Feeding dysfunction is associated with worse growth measures. Current gastrostomy tube use and a single parent household were identified as independent risk factors for feeding dysfunction.
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Affiliation(s)
- Garick D Hill
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - Alan H Silverman
- Division of Gastroenterology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Richard J Noel
- Division of Gastroenterology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Pippa M Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Julie Slicker
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Ann E Scott
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Peter J Bartz
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
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Brosig C, Mussatto K, Hoffman G, Hoffmann RG, Dasgupta M, Tweddell J, Ghanayem N. Neurodevelopmental outcomes for children with hypoplastic left heart syndrome at the age of 5 years. Pediatr Cardiol 2013; 34:1597-604. [PMID: 23503929 PMCID: PMC3982227 DOI: 10.1007/s00246-013-0679-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 02/13/2013] [Indexed: 11/28/2022]
Abstract
This study aimed to determine the neurodevelopmental (ND) outcome for children with hypoplastic left heart syndrome (HLHS) at early school age. English-speaking patients who underwent the Norwood procedure between 2000 and 2005 were eligible at 4-6 years of age for ND testing. Of the 72 eligible patients, 44 (61 %) agreed to participate, and 37 completed ND testing before the close of the study. Three subjects were excluded from analyses due to late stroke. The ND testing included intelligence, visual motor integration, memory and motor and language skills. Parents and teachers completed measures of behavior and attention problems. Subjects' scores and parent/teacher ratings were converted to z-scores and compared with test norms. Higher scores on child measures represent better outcomes, whereas higher scores on parent and teacher rating scales indicate more problems. The average ND performance of the tested cohort fell within one standard deviation of the test norms for all measures. However, the subjects performed significantly lower than the test norms on measures of visual-motor integration, fine motor skills, memory, and word structure (z = -0.42 to -0.54; p < 0.005). On the parent and teacher completed measures, the subjects scored higher than the test norms on attention problems (z = 0.40-0.62; p < 0.005). Although the overall ND performance of the cohort was normal, the subjects showed relative weakness in visual motor and attention skills. Ongoing developmental monitoring of these children is recommended to guide interventions that may improve individual outcomes and to assess the impact of changes in clinical management strategies on functional outcomes.
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Affiliation(s)
- Cheryl Brosig
- Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53201, USA,
| | - Kathleen Mussatto
- Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - George Hoffman
- Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53201, USA
| | - Raymond G. Hoffmann
- Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53201, USA
| | - Mahua Dasgupta
- Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53201, USA
| | - James Tweddell
- Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53201, USA
| | - Nancy Ghanayem
- Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53201, USA
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Shillingford M, Ceithaml E, Bleiweis M. Surgical considerations in the management of hypoplastic left heart syndrome. Semin Cardiothorac Vasc Anesth 2013; 17:128-36. [PMID: 23657434 DOI: 10.1177/1089253213488947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypoplastic left heart syndrome is a congenital heart defect characterized by hypoplasia of left heart structures. Over the past 3 decades, there have been advances in techniques and management in the care of these patients. We discuss shunt selection, operative strategies, transplantation, and outline various facets of management at the University of Florida. This is a review of the literature highlighting some of the technical aspects of the preoperative, operative, and postoperative care that are important in today's management of hypoplastic left heart syndrome.
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Sugimoto A, Ota N, Ibuki K, Miyakoshi C, Murata M, Tosaka Y, Yamazaki T, Sakamoto K. Risk factors for adverse neurocognitive outcomes in school-aged patients after the Fontan operation. Eur J Cardiothorac Surg 2013; 44:454-61; discussion 461. [PMID: 23423918 DOI: 10.1093/ejcts/ezt062] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES As the surgical results for Fontan candidates improve, much attention has been given to the long-term cognitive outcomes. This study aimed to assess the neurocognitive outcomes after Fontan completion, and to determine the factors associated with an extremely low intelligence quotient (IQ <70). METHODS A total of 70 local eligible school-aged patients were enrolled in the study (hypoplastic left heart syndrome, 17; right atrial isomerism, 15 and others, 38). Fontan operations were performed at a median age of 1.8 (range, 0.5-8.9) years (primary Fontan, 4 of 70 [6%]). The Wechsler Intelligence Test was taken at a median age of 9 (range, 5.1-14.4) years for the purpose of neurocognitive evaluation. Patients' data were collected from medical records, and a retrospective analysis of potential predictors for an IQ <70 was performed. RESULTS The median full-scale IQ (FSIQ) for the entire cohort was 85 (range, 43-118). Of the lower order composites, the perceptual reasoning index and the working memory index were significantly lower in low-FSIQ patients (P < 0.05). Overall, 15 of 70 (21%) of the cohort had an IQ <70. Univariate analysis identified three significant risk factors for FSIQ <70 (15 of 70, 21%): body weight <2.5 kg at initial palliative surgery (P < 0.05), low 5-min Apgar score <4 (P < 0.05) and inter-stage events requiring cardiopulmonary resuscitation (CPR) (P < 0.05). No other patient-specific factors (e.g. cardiac morphology) or modifiable surgical factors (e.g. the use of hypothermic cardiac arrest) were associated with FSIQ <70. CONCLUSIONS Low body weight (<2.5 kg) at initial operation, low 5-min Apgar score (<4) and inter-stage CPR were significant risk factors for impaired neurocognitive outcomes. An evolving strategy for preventing inter-stage CPR may improve cognitive outcomes.
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Affiliation(s)
- Ai Sugimoto
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
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Kon AA, Prsa M, Rohlicek CV. Choices doctors would make if their infant had hypoplastic left heart syndrome: comparison of survey data from 1999 and 2007. Pediatr Cardiol 2013; 34:348-53. [PMID: 23011191 DOI: 10.1007/s00246-012-0455-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 07/13/2012] [Indexed: 10/28/2022]
Abstract
Data suggest that despite improved surgical outcomes for infants with hypoplastic left heart syndrome (HLHS), the past two decades have seen little change in parents' decisions whether to choose surgery or palliative treatment without life-prolonging intervention. Data also suggest that doctors' predictions of the choices they would make if their own infant were diagnosed with HLHS do not correlate with their predictions of surgical outcomes. Although previous studies have compared rates of surgery and palliative treatment without life-prolonging intervention over time, no studies have assessed changes in doctors' attitudes. The current study used descriptive and quantitative statistics to compare responses from American pediatric cardiologists and congenital cardiac surgeons from studies conducted in 1999 and 2007. These doctors were asked what choice they believe they would make for their own affected infant. Comparison of responses from 1999 and 2007 showed no difference in the responses of cardiologists: 1999 (44 % surgery, 17 % palliative treatment, 40 % uncertain) versus 2007 (45 % surgery, 20 % palliative treatment, 35 % uncertain). Among surgeons, there was a non-statistically significant trend away from choosing surgery: 1999 (77 % surgery, 5 % palliative treatment, 18 % uncertain) versus 2007 (56 % surgery, 8 % palliative treatment, 36 % uncertain). In conclusion, these analyses suggest that despite improving surgical outcomes, doctors are no more likely to predict that they would choose surgery for their own hypothetical infant with HLHS. Further research is needed to determine what factors influence choice making in the care of infants with HLHS.
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Affiliation(s)
- Alexander A Kon
- Pediatric Intensive Care Unit, Naval Medical Center San Diego, University of California San Diego School of Medicine, 34800 Bob Wilson Drive, San Diego, CA 92134, USA.
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Abstract
PURPOSE To compare the motor development of patients with hypoplastic left heart syndrome (HLHS) and other types of univentricular heart (UVH) with peers who are healthy at the ages of 16 and 52 weeks. METHODS Motor development was assessed with the Alberta Infant Motor Scale (AIMS). RESULTS Both the 23 patients with HLHS and the 13 patients with UVH had lower total AIMS scores in both observations than the controls. At the age of 52 weeks, patients with HLHS had significantly lower scores in all 4 AIMS subscales, whereas patients with UVH had lower scores only in the prone and standing subscales. CONCLUSION Motor development of patients with HLHS or UVH is delayed during the first year of life, especially in the prone and standing subscales.
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Sarajuuri A, Jokinen E, Mildh L, Tujulin AM, Mattila I, Valanne L, Lönnqvist T. Neurodevelopmental burden at age 5 years in patients with univentricular heart. Pediatrics 2012; 130:e1636-46. [PMID: 23166336 DOI: 10.1542/peds.2012-0486] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite increasing survival, patients with hypoplastic left heart syndrome (HLHS) and other forms of functionally univentricular heart defects (UVHs) remain at increased risk of long-term neurodevelopmental deficits. METHODS A nationwide sample of 23 patients with HLHS, 13 with UVH, and 40 controls were followed prospectively until the age of 5 years, when neurologic, neuropsychological, and motor examinations and brain MRI were performed. RESULTS The median full-scale IQ was significantly lower in patients with HLHS (97, P < .001) and patients with UVH (112, P = .024) compared with controls (121). Major neurodevelopmental impairment was found in 26% of the patients with HLHS and 23% of those with UVH, and minor neurologic dysfunction was found in 43% and 46%, respectively. MRI revealed abnormalities, mostly ischemic changes of different degrees, in 82% of the patients with HLHS and in 56% of those with UVH. Prominent changes were significantly associated with neurodevelopmental findings and parental reports of adaptive behavior. In linear regression, significant risk factors for a worse outcome were a history of clinical seizures in connection with the primary operation, a lower diameter of the neonatal ascending aorta, and several pre-, peri-, and postoperative factors related to the primary and bidirectional Glenn operations. CONCLUSIONS Although median cognitive performance was within the normal range, neurodevelopmental and brain MRI abnormalities were found in the majority of the patients with UVH, and especially in those with HLHS, at preschool age. Both a narrowed ascending aorta and operation-related factors contributed to these findings.
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Affiliation(s)
- Anne Sarajuuri
- Divisions of Child Neurology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland.
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Ortinau C, Inder T, Lambeth J, Wallendorf M, Finucane K, Beca J. Congenital heart disease affects cerebral size but not brain growth. Pediatr Cardiol 2012; 33:1138-46. [PMID: 22450354 PMCID: PMC3702162 DOI: 10.1007/s00246-012-0269-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 02/21/2012] [Indexed: 11/25/2022]
Abstract
Infants with congenital heart disease (CHD) have delayed brain maturation and alterations in brain volume. Brain metrics is a simple measurement technique that can be used to evaluate brain growth. This study used brain metrics to test the hypothesis that alterations in brain size persist at 3 months of age and that infants with CHD have slower rates of brain growth than control infants. Fifty-seven infants with CHD underwent serial brain magnetic resonance imaging (MRI). To evaluate brain growth across the first 3 months of life, brain metrics were undertaken using 19 tissue and fluid spaces shown on MRIs performed before surgery and again at 3 months of age. Before surgery, infants with CHD have smaller frontal, parietal, cerebellar, and brain stem measures (p < 0.001). At 3 months of age, alterations persisted in all measures except the cerebellum. There was no difference between control and CHD infants in brain growth. However, the cerebellum trended toward greater growth in infants with CHD. Somatic growth was the primary factor that related to brain growth. Presence of focal white matter lesions before and after surgery did not relate to alterations in brain size or growth. Although infants with CHD have persistent alterations in brain size at 3 months of age, rates of brain growth are similar to that of healthy term infants. Somatic growth was the primary predictor of brain growth, emphasizing the importance of optimal weight gain in this population.
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Affiliation(s)
- Cynthia Ortinau
- Department of Pediatrics, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO 63110, USA.
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Risk factors for neurodevelopmental impairments in school-age children after cardiac surgery with full-flow cardiopulmonary bypass. J Thorac Cardiovasc Surg 2012; 144:577-83. [DOI: 10.1016/j.jtcvs.2012.02.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 01/09/2012] [Accepted: 02/03/2012] [Indexed: 11/20/2022]
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Porcayo-Mercado MR, Otero-Ojeda GA, Pliego-Rivero FB, Aguirre-Pérez DM, Ricardo-Garcell J. Neurobehavioral assessment of children presenting diverse congenital cardiopathologies. J Clin Psychol Med Settings 2012; 20:71-8. [PMID: 22886702 DOI: 10.1007/s10880-012-9314-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Brain maturation in 1-36 month old children suffering from congenital cardiopathologies was assessed after a study of psychomotor development. The Rogers' test (Rogers et al., Developmental programming for infants and young children. Volume 2. Early intervention developmental profile, Revised edition, ESL/ELT Michigan, Ann Arbor, 1981) was applied to 65 children, of whom 21 presented with simple cardiopathologies (CpS) and 22 with complex cardiopathologies (CpC). All children were matched by age, sex and socioeconomic status to 22 healthy children in a control group (C). Mean differences between the three groups were established by applying the Kruskal-Wallis test, and mean differences between the C and CpS/CpC groups were determined using the Mann-Whitney test. The proportion of cases evaluated as "low" in each group was calculated by applying the Rogers' test, and a test of proportion differences was applied between the C and CpS/CpC groups. CpS children performed similarly to the C, whereas CpC children scored significantly lower than C children on all variables. It is highly likely that the suboptimal psychomotor performance observed in CpC children was due to compromised hemodynamics and related to subclinical immaturity of cerebral development.
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Neurocognitive development and behavioral outcome of 2-year-old children with univentricular heart. J Int Neuropsychol Soc 2011; 17:1094-103. [PMID: 22014005 DOI: 10.1017/s135561771100110x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Recent advances in the treatment of children with severe congenital heart defects, such as hypoplastic left heart syndrome (HLHS) and other forms of univentricular heart (UVH), have significantly improved their survival rates. However, these children are at risk for various neurodevelopmental deficits. The aim of the present study was to assess cognitive development, expressive language, and behavior in 30-month-old children with univentricular heart. The participants were 22 children with HLHS, 14 with UVH, and 41 healthy control subjects. The Bayley Scales of Infant Development II, MacArthur Communicative Development Inventories, and Child Behavior Checklist were used for assessments. The results revealed that children with HLHS exhibited a significantly lower mean mental development index, more delays in expressive language functions, and more behavioral problems than did the control children. Two children with HLHS (9%) had mental development indexes below 50, indicating significantly delayed performance. The children with UVH differed from the control children with respect to their lower mean mental development index. These findings suggest that at the age of 30 months, neurodevelopmental deficits are especially prevalent in children with HLHS. Thus, early developmental screening, intervention, and neuropsychological follow-up until school age is recommended particularly for the children with HLHS.
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Acton BV, Biggs WSG, Creighton DE, Penner KAH, Switzer HN, Thomas JHP, Joffe AR, Robertson CMT. Overestimating neurodevelopment using the Bayley-III after early complex cardiac surgery. Pediatrics 2011; 128:e794-800. [PMID: 21949148 DOI: 10.1542/peds.2011-0331] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The newest measure of neurodevelopmental outcomes, the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III), gives higher-than-expected scores for preterm infants; results after cardiac surgery are unknown. OBJECTIVES The goal of this study was to report Bayley-III scores after cardiac surgery and compare the results with those of the Bayley Scales of Infant Development, 2nd Edition (BSID-II) on a subset of the same children. METHODS In this prospective, inception cohort, neurodevelopmental outcome study after complex cardiac surgery in infants from 2004 to 2007, the Bayley-III was given to 110 survivors (68% boys) at a mean age of 21 months (SD: 4 months). Analysis of variance was used to compare intergroup differences. Results for both test editions on the same 25 children were compared by using paired-samples statistics. RESULTS Mean (SD) Bayley-III mean composite scores (CSs) for 110 children were as follows: cognitive, 95.9 (14.1); language, 90.8 (18.1); and motor, 93.7 (14.2), differentiating selected cardiac surgery groups. The average difference in mean CSs was 7.4 points higher than BSID-II scores for a previous cohort from this site and 7.2 points higher than a systematic review report. Direct comparison of BSID-II and Bayley-III revealed an average difference in mean CSs of 6.1 points, similar to normative results. Mean cognitive CSs increased by 10.0 (P <.001), language by 1.4 (P = .526), and motor by 6.9 points (P = .009). CONCLUSIONS Researchers should be careful attributing higher Bayley-III scores to changes in acute care. At-risk children who previously qualified for early developmental intervention may no longer do so. School-age longitudinal studies are needed to determine the accuracy of early developmental estimates using the Bayley-III.
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Affiliation(s)
- Bryan V Acton
- aDepartment of Psychology, University of Saskatchewan,Saskatoon, Saskatchewan, Canada
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Hövels-Gürich H. Psychomotorische Entwicklung von Kindern mit angeborenem Herzfehler. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2498-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Lee JK, Blaine Easley R, Brady KM. Neurocognitive monitoring and care during pediatric cardiopulmonary bypass-current and future directions. Curr Cardiol Rev 2011; 4:123-39. [PMID: 19936287 PMCID: PMC2779352 DOI: 10.2174/157340308784245766] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 12/17/2007] [Accepted: 12/21/2007] [Indexed: 11/22/2022] Open
Abstract
Neurologic injury in patients with congenital heart disease remains an important source of morbidity and mortality. Advances in surgical repair and perioperative management have resulted in longer life expectancies for these patients. Current practice and research must focus on identifying treatable risk factors for neurocognitive dysfunction, advancing methods for perioperative neuromonitoring, and refining treatment and care of the congenital heart patient with potential neurologic injury. Techniques for neuromonitoring and future directions will be discussed.
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Affiliation(s)
- Jennifer K Lee
- Departments of Anesthesiology/Critical Care Medicine and Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Moffett BS, Mattamal R, Ocampo EC, Petit CJ. Impact of pharmacotherapy on interstage outcomes in single ventricle infants. CONGENIT HEART DIS 2011; 6:286-93. [PMID: 21696551 DOI: 10.1111/j.1747-0803.2011.00536.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To characterize the pharmacotherapeutic regimens used in infants with single ventricle heart disease and determine the influence of outpatient medications on interstage weight gain. DESIGN Retrospective review. SETTING Tertiary care pediatric hospital. PATIENTS All patients discharged from our institution with single ventricle heart disease that underwent neonatal first stage surgical palliation between 2002 and 2009 were included. Patients who died prior to second stage palliation or underwent orthotopic heart transplantation were excluded. OUTCOME MEASURES Outpatient medication regimens during the interstage period were reviewed. Medication regimens were compared between surgical eras and between patient groups experiencing different outcomes. A logistic regression model was developed to determine independent factors for an interstage increase in weight-for-age z-score (WAZ) and a linear regression model to determine medications significant for an increase in weight gain per day. RESULTS The study cohort consisted of 161 patients (58% male). Most patients in this cohort had either hypoplastic left heart syndrome (51%) or unbalanced complete atrioventricular canal (29%). Patients were placed on a median of four medications (range 1-9) at discharge from first surgical palliation, with aspirin (79%), furosemide (79%), and angiotensin converting enzyme inhibitors (ACE-I) (73%) most commonly prescribed. A median of six medication doses per day (range 2-18) were prescribed at discharge. Most patients (71%) had a decrease in WAZ during the interstage period. Use of digoxin (P < 0.01) and high-dose furosemide (P = .02) were associated with a decrease in WAZ score during the interstage period. Additionally, the use of ACE-I, ranitidine, proton-pump inhibitors, or promotility agents was not associated with improved somatic growth during the interstage period. CONCLUSIONS Infants with single ventricle heart disease have a high-medication burden during the interstage period. Despite the focused and intensified use of medications to improve feeding tolerance and somatic growth, current pharmacotherapeutic regimens appear to have little effect on interstage weight gain.
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Affiliation(s)
- Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, TX 77030, USA.
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Neurodevelopment in children with hypoplastic left heart syndrome. J Pediatr 2010; 157:414-20, 420.e1-4. [PMID: 20570285 DOI: 10.1016/j.jpeds.2010.04.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 02/23/2010] [Accepted: 04/12/2010] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess neurodevelopment in children with hypoplastic left heart syndrome (HLHS) or other types of functionally single ventricle (univentricular heart, UVH) and to estimate the effect of possible clinical predictors on outcome. STUDY DESIGN A total of 22 patients with HLHS and 14 with UVH, surviving after palliative surgery performed in the same center, and 42 healthy control subjects were examined at a median age of 30.2 months neurologically and according to the Bayley Scales of Infant Development in a population based prospective neurodevelopmental follow-up study. RESULTS The mean Mental Developmental Index was significantly lower (89.9) in patients with HLHS than in control subjects (105.5, P<.001), whereas there was no difference between patients with UVH (98.5) and control subjects. The mean Psychomotor Developmental Index in patients with HLHS (80.7, P<.001) as well as in those with UVH (94.5, P=.016) was significantly inferior to that in control subjects (105.3). CONCLUSIONS In patients with HLHS, mean Mental Developmental Index lags behind control subjects. Psychomotor Developmental Index is impaired in patients with both HLHS and UVH. Routine neurodevelopmental follow-up is recommended for this seriously ill patient group.
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Haavisto A, Korkman M, Jalanko H, Holmberg C, Qvist E. Neurocognitive function of pediatric heart transplant recipients. J Heart Lung Transplant 2010; 29:764-70. [DOI: 10.1016/j.healun.2010.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 02/11/2010] [Accepted: 02/15/2010] [Indexed: 10/19/2022] Open
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Snookes SH, Gunn JK, Eldridge BJ, Donath SM, Hunt RW, Galea MP, Shekerdemian L. A systematic review of motor and cognitive outcomes after early surgery for congenital heart disease. Pediatrics 2010; 125:e818-27. [PMID: 20231182 DOI: 10.1542/peds.2009-1959] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
CONTEXT Brain injury is the most common long-term complication of congenital heart disease requiring surgery during infancy. It is clear that the youngest patients undergoing cardiac surgery, primarily neonates and young infants, are at the greatest risk for brain injury. Developmental anomalies sustained early in life have lifelong repercussions. OBJECTIVE We conducted a systematic review to examine longitudinal studies of cognitive and/or motor outcome after cardiac surgery during early infancy. METHODS Electronic searches were performed in Medline, the Cumulative Index to Nursing and Allied Health Literature (Cinahl), and Embase (1998-2008). The search strategy yielded 327 articles, of which 65 were reviewed. Eight cohorts provided prospective data regarding the cognitive and/or motor outcome of infants who had undergone surgery for congenital heart disease before 6 months of age. Two authors, Ms Snookes and Dr Gunn, independently extracted data and presented results according to 3 subgroups for age of follow-up: early development (1 to <3 years); preschool age (3-5 years); and school age (>5 to 17 years). Weighted analysis was undertaken to pool the results of studies when appropriate. RESULTS All of the identified studies reported results of the Bayley Scales of Infant Development for children younger than the age of 3. Outcome data as reported by the Bayley Scales were combined for infants assessed at 1 year of age, revealing a weighted mean Mental Development Index of 90.3 (95% confidence interval: 88.9-91.6) and Psychomotor Development Index of 78.1 (95% confidence interval: 76.4-79.7). Additional analysis was limited by a lack of data at preschool and school age. CONCLUSIONS With this review we identified a limited number of prospective studies that systematically addressed outcome in patients at the highest risk. These studies consistently revealed cognitive and motor delay in children after cardiac surgery during early infancy. Additional investigation is required to ascertain the consequences of such impairment during later childhood and into adult life.
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Affiliation(s)
- Suzanne H Snookes
- Physiotherapy Department, Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia
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Mackensen GB, McDonagh DL, Warner DS. Perioperative hypothermia: use and therapeutic implications. J Neurotrauma 2009; 26:342-58. [PMID: 19231924 DOI: 10.1089/neu.2008.0596] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Perioperative cerebral ischemic insults are common in some surgical procedures. The notion that induced hypothermia can be employed to improve outcome in surgical patients has persisted for six decades. Its principal application has been in the context of cardiothoracic and neurosurgery. Mild (32-35 degrees C) and moderate (26-31 degrees C) hypothermia have been utilized for numerous procedures involving the heart, but intensive research has found little or no benefit to outcome. This may, in part, be attributable to confounding effects associated with rewarming and lack of understanding of the mechanisms of injury. Evidence of efficacy of mild hypothermia is absent for cerebral aneurysm clipping and carotid endarterectomy. Deep hypothermia (18-25 degrees C) during circulatory arrest has been practiced in the repair of congenital heart disease, adult thoracic aortas, and giant intracranial aneurysms. There is little doubt of the protective efficacy of deep hypothermia, but continued efforts to refine its application may serve to enhance its utility. Recent evidence that mild hypothermia is efficacious in out-of-hospital cardiac arrest has implications for patients incurring anoxic or global ischemic brain insults during anesthesia and surgery, or perioperatively. Advances in preclinical models of ischemic/anoxic injury and cardiopulmonary bypass that allow definition of optimal cooling strategies and study of cellular and subcellular events during perioperative ischemia can add to our understanding of mechanisms of hypothermia efficacy and provide a rationale basis for its implementation in humans.
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Affiliation(s)
- G Burkhard Mackensen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Pharoah P, Dundar Y. Monozygotic twinning, cerebral palsy and congenital anomalies. Hum Reprod Update 2009; 15:639-48. [DOI: 10.1093/humupd/dmp019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sarajuuri A, Lönnqvist T, Mildh L, Rajantie I, Eronen M, Mattila I, Jokinen E. Prospective follow-up study of children with univentricular heart: Neurodevelopmental outcome at age 12 months. J Thorac Cardiovasc Surg 2009; 137:139-45, 145.e1-2. [DOI: 10.1016/j.jtcvs.2008.06.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2008] [Revised: 04/01/2008] [Accepted: 06/15/2008] [Indexed: 11/26/2022]
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Impaired neuroanatomic development in infants with congenital heart disease. J Thorac Cardiovasc Surg 2008; 137:146-53. [PMID: 19154917 DOI: 10.1016/j.jtcvs.2008.06.036] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Revised: 05/29/2008] [Accepted: 06/24/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We performed a regional volumetric study of the brain using 3-dimensional magnetic resonance imaging in infants with congenital heart disease to search for variables in anatomic development of the brain that may be associated with functional impairment. METHODS Forty infants with congenital heart disease-17 infants with single ventricle physiology, 5 with transposition of great arteries, and 18 with ventricular septal defect-were studied prospectively by 3-dimensional magnetic resonance imaging of the brain several months after heart surgery. RESULTS The global volume of gray matter was significantly reduced in the patients with congenital heart disease compared with normal controls (P < .001), whereas no significant difference in the volume of white matter was observed. Further, the decrease in gray matter volume was more apparent in the frontal lobe than in the temporal lobe, especially in infants with single ventricle physiology or transposition of the great arteries. Multivariate analysis revealed that preoperative hypoxia is strongly associated with decreased frontal gray matter volume (P < .01), as well as a diagnosis of hypoplastic left heart syndrome (P < .05). Of note, frontal gray matter volume, which includes the motor area, correlated weakly with psychomotor developmental index scores (P < .01). CONCLUSIONS Brain developmental impairment occurs in many infants with congenital heart disease, especially in those who have preoperative hypoxia and critical congenital heart disease. This quantitative volumetric study encourages larger scale and longitudinal follow-up to elucidate the significance of impaired neuroanatomic development on functional outcome.
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