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Ehrler M, von Rhein M, Schlosser L, Brugger P, Greutmann M, Kretschmar O, Latal B, Tuura O'Gorman R. Microstructural alterations of the corticospinal tract are associated with poor motor function in patients with severe congenital heart disease. NEUROIMAGE: CLINICAL 2021; 32:102885. [PMID: 34911191 PMCID: PMC8628013 DOI: 10.1016/j.nicl.2021.102885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/08/2021] [Accepted: 11/16/2021] [Indexed: 10/25/2022] Open
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Madan N, Carvalho KS. Neurological Complications of Cardiac Disease. Semin Pediatr Neurol 2017; 24:3-13. [PMID: 28779863 DOI: 10.1016/j.spen.2017.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article focuses on the complex interactions between the cardiovascular and neurologic systems. Initially, we focus on neurological complications in children with congenital heart disease both secondary to the underlying cardiac disease and complications of interventions. We later discuss diagnosis and management of common syncope syndromes with emphasis on vasovagal syncope. We also review the diagnosis, classification, and management of children and adolescents with postural orthostatic tachycardia syndrome. Lastly, we discuss long QT syndrome and sudden unexpected death in epilepsy (SUDEP), reviewing advances in genetics and current knowledge of pathophysiology of these conditions. This article attempts to provide an overview of these disorders with focus on pathophysiology, advances in molecular genetics, and current medical interventions.
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Affiliation(s)
- Nandini Madan
- From the Section of Cardiology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
| | - Karen S Carvalho
- Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
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Neurologic injury in neonates with congenital heart disease during extracorporeal membrane oxygenation: an analysis of extracorporeal life support organization registry data. ASAIO J 2015; 61:43-8. [PMID: 25248045 DOI: 10.1097/mat.0000000000000151] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this article is to describe the epidemiology and factors associated with acute neurologic injury in neonates with congenital heart disease (CHD) undergoing extracorporeal membrane oxygenation (ECMO). It is a retrospective cohort study. Multi-institutional data for purposes of this study were obtained from the extracorporeal life support organization registry Neonates with CHD supported with ECMO during 2005-2010. Of 1,898 neonates with CHD supported with ECMO, 273 (14%) had neurologic injury. Birth weight less than 3 kg (odds ratio [OR]: 1.5; 95% confidence intervals [CI]: 1.1-1.9), pre-ECMO blood pH ≤ 7.15 (OR: 1.5, 95% CI: 1.1-2.1) need for cardiopulmonary resuscitation before ECMO (OR: 1.7, 95% CI: 1.5-2.0) increased neurologic injury. In-hospital mortality was higher in patients with neurologic injury compared with those without (73% vs. 53%; p < 0.001). Neonates with CHD undergoing ECMO are highly vulnerable to acute neurologic injury regardless of cardiac lesion-specific physiology or the occurrence of cardiac surgery. The incidence of neurologic injuries in this population is higher in sicker patients. Severity of illness should therefore become the main target for improvement. Timely deployment of ECMO may therefore influence the development of ECMO complications.
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Apers S, Luyckx K, Moons P. Quality of life in adult congenital heart disease: what do we already know and what do we still need to know? Curr Cardiol Rep 2014; 15:407. [PMID: 23955787 DOI: 10.1007/s11886-013-0407-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Quality of life (QOL) is a key outcome in patients with congenital heart disease (CHD) because CHD has become a chronic condition accompanied by lifelong impairments. Recently, published studies on QOL in adults with CHD have reported inconsistent findings. Patients' QOL seems to depend on multiple factors and is not solely determined by their heart defect and various medical or demographic characteristics. For instance, evidence suggests that a strong sense of coherence might be an important pathway to improve QOL. However, studies on QOL and its determinants are characterized by important methodological differences and limitations, making it impossible to draw firm conclusions. To fill the gaps in the current evidence base, longitudinal and international research is needed. Furthermore, the research field on QOL in CHD should move on from observational studies to interventional research to guide health professionals in improving QOL.
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Affiliation(s)
- Silke Apers
- Centre for Health Services and Nursing Research, KU Leuven Department of Public Health and Primary Care, Kapucijnenvoer 35, Box 7001, 3000, Leuven, Belgium.
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Klausen SH, Buys R, Andersen LL, Hirth A, McCrindle BW, Kjaergaard H, Wetterslev J. Interventions to increase physical activity for people with congenital heart disease. Hippokratia 2014. [DOI: 10.1002/14651858.cd011030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Susanne H Klausen
- Copenhagen University Hospital, Rigshospitalet; The Research Unit Women and Children's Health, The Juliane Marie Centre; Section 7821 Blegdamsvej 9 Copenhagen Denmark DK 2100
| | - Roselien Buys
- Catholic University of Leuven; Research Center for Cardiovascular and Respiratory Rehabilitation; Tervuursevest 101 Heverlee Belgium 3001
| | - Lars Louis Andersen
- National Research Centre for the Working Environment; Department of Musculoskeletal Disorders; Lersø Parkalle 105 Copenhagen Denmark DK-2100
| | - Asle Hirth
- Haukeland University Hospital; Children's Department; Jonas Lies vei 1 Bergen Norway N-5021
| | - Brian W McCrindle
- The Hospital for Sick Children; University of Toronto; 555 University Avenue Toronto Ontario Canada M5G 1X8
| | | | - Jørn Wetterslev
- Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Blegdamsvej 9 Copenhagen Denmark DK-2100
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Mlczoch E, Schmidt L, Schmid M, Kasprian G, Frantal S, Berger-Kulemann V, Prayer D, Michel-Behnke I, Salzer-Muhar U. Fetal cardiac disease and fetal lung volume: an in utero
MRI investigation. Prenat Diagn 2014; 34:273-8. [DOI: 10.1002/pd.4308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/10/2013] [Accepted: 12/16/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Elisabeth Mlczoch
- Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Austria
| | - Lisa Schmidt
- Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Austria
| | - Maximilian Schmid
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology; Medical University of Vienna; Austria
| | - Gregor Kasprian
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology; Medical University Vienna; Austria
| | - Sophie Frantal
- Department for Medical Statistics; Medical University of Vienna; Austria
| | - Vanessa Berger-Kulemann
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology; Medical University Vienna; Austria
| | - Daniela Prayer
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology; Medical University Vienna; Austria
| | - Ina Michel-Behnke
- Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Austria
| | - Ulrike Salzer-Muhar
- Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Austria
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Holtby HM. Neurological injury and anesthetic neurotoxicity following neonatal cardiac surgery: does the head rule the heart or the heart rule the head? Future Cardiol 2012; 8:179-88. [DOI: 10.2217/fca.11.92] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The improvements in care of children with heart disease have resulted in a major decrease in mortality and increased attention to adverse events and quality of survival. There is important neurological morbidity in children with congenital heart disease. Some problems such as stroke or seizure may be immediately apparent, but others, such as learning disability and motor delay emerge over time. The etiology is multifactorial and includes genetic, procedural and social causes. Only some factors are modifiable. Over the last decade, evidence has been presented that anesthetic drugs may be a potential cause of CNS morbidity. Neonates and infants may be particularly vulnerable to this. The purpose of this article is to describe the multiple known causes of neurodevelopmental impairment in children with heart disease, including anesthetic agents, and to explore the relationship between congenital heart disease and its treatment in this regard.
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Affiliation(s)
- Helen M Holtby
- University of Toronto, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Laing S, Spence K, McMahon C, Ungerer J, Badawi N. Challenges in conducting prospective research of developmentally directed care in surgical neonates: a case study. Early Hum Dev 2012; 88:171-8. [PMID: 21911278 DOI: 10.1016/j.earlhumdev.2011.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 07/18/2011] [Accepted: 08/08/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Evaluation is fundamental to evidence-based practice. Due to practical constraints inherent in real-world clinical environments, however, innovations in clinical practice are often implemented without rigorous research. We set out to evaluate the effectiveness of developmentally directed care in surgical neonates using a randomised controlled trial with a Newborn Individualized Care and Assessment Program (NIDCAP) intervention. AIM The aim of this paper is to inform future studies by sharing lessons learnt in conducting prospective research of a practice-intervention in a critical care setting. METHOD Three intervention components were used to assess implementation: number of NIDCAP observations; infant allocation to project nurses, and consistency of care. Barriers to implementation were identified through discussions with nurses who had key roles. RESULTS Insufficient episodes of NIDCAP observation and infant allocation to project nurses, and lack of consistency of care indicated that the intervention had not been successfully implemented. Barriers to implementation (fast 'turnover' of patients, unpredictable changes in medical status, staff/skill shortages, and inconsistent care) were attributed to the competing demands between service provision and research in a busy critical care context. CONCLUSIONS The findings regarding barriers to successful implementation of NIDCAP in this case study are relevant to any critical care setting where complex interventions are under consideration, as similar challenges are plausible across a range of clinical contexts. Adopting a critical methodologically-informed approach to appraise implementation and evaluate complex interventions is essential.
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Affiliation(s)
- Sharon Laing
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney, NSW, Australia
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Human DG. Living with complex congenital heart disease. Paediatr Child Health 2011; 14:161-82. [PMID: 20190896 DOI: 10.1093/pch/14.3.161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2009] [Indexed: 11/12/2022] Open
Abstract
A child with complex congenital heart disease in 2008 is very likely to survive a series of surgical and medical interventions, and confront an array of medical and psychosocial stressors that are presently poorly understood. As approaches to medical problems change, careful assessment of those results is essential, and the initial work of the multicentre Pediatric Heart Network is a huge step in the right direction, setting the stage for proper controlled trials of therapies. Major complications, notably ventricular failure, rhythm problems and thromboembolism, will affect nearly one-quarter of survivors, necessitating further interventions. Appropriate educational and psychosocial support for these children and their families is the next challenge for all of us in the field of paediatrics. How ironic would it be to have invested so much in early survival, only to allow the child to fail in life itself.
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Affiliation(s)
- Derek G Human
- BC Children's Hospital and BC Women's Hospital & Health Centre, Vancouver, British Columbia
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Costello JM, Polito A, Brown DW, McElrath TF, Graham DA, Thiagarajan RR, Bacha EA, Allan CK, Cohen JN, Laussen PC. Birth before 39 weeks' gestation is associated with worse outcomes in neonates with heart disease. Pediatrics 2010; 126:277-84. [PMID: 20603261 DOI: 10.1542/peds.2009-3640] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Recent studies have revealed increased morbidity and mortality rates in term neonates without birth defects who were delivered before 39 weeks of completed gestation. We sought to determine if a similar association exists between gestational age at delivery and adverse outcomes in neonates with critical congenital heart disease, with particular interest in those born at 37 to 38 weeks' gestation. PATIENTS AND METHODS We studied 971 consecutive neonates who had critical congenital heart disease and a known gestational age and were admitted to our cardiac ICU from 2002 through 2008. Gestational age was stratified into 5 groups: >41, 39 to 40, 37 to 38, 34 to 36, and <34 completed weeks. Multivariate logistic regression analyses were used to evaluate mortality and a composite morbidity variable. Multivariate Poisson regression was used to evaluate duration of ventilation, intensive care, and hospitalization. RESULTS Compared with the referent group of neonates who were delivered at 39 to 40 completed weeks' gestation, neonates born at 37 to 38 weeks had increased mortality (6.9% vs 2.6%; adjusted P = .049) and morbidity (49.7% vs 39.7%; adjusted P = .02) rates and tended to require a longer duration of mechanical ventilation (adjusted P = .05). Patients born after 40 or before 37 weeks also had greater adjusted mortality rates, and those born before 37 weeks had increased morbidity rates and required more days of mechanical ventilation and intensive care. CONCLUSIONS For neonates with critical congenital heart disease, delivery before 39 weeks' gestation is associated with greater mortality and morbidity rates and more resource use. With respect to neonatal mortality, the ideal gestational age for delivery of these patients may be 39 to 40 completed weeks.
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Affiliation(s)
- John M Costello
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.
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Ethical issues in fetal management: a cardiac perspective. Int J Pediatr 2010; 2010:857460. [PMID: 20368771 PMCID: PMC2846337 DOI: 10.1155/2010/857460] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 02/23/2010] [Indexed: 11/17/2022] Open
Abstract
The ethical issues behind the management of a fetus with a serious abnormality and the decisions made in relation to the outcome of the pregnancy are complex. This reflective paper deals with the ethical principles of managing a pregnancy with a congenital anomaly, with particular emphasis on the fetus with a serious cardiac abnormality. One major ethical concern is whether the fetus is or is not independent being to whom obligations of beneficence are owed. We review the debate on this matter, and suggest that it is ethically more appropriate for physicians who are involved in management of fetal abnormality not to adopt and insist on their own position on this matter. Rather, the appropriate course is to respect the pregnant woman's own view of her fetus and how it should be regarded. This is an application of the principle of respect for autonomy. Within this framework, we discuss the difficulties in counselling a pregnant woman or expectant couple in this situation, and recommend three key steps in ethically sound counselling.
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Malhotra A, Menahem S, Shekleton P, Gillam L. Medical and ethical considerations in twin pregnancies discordant for serious cardiac disease. J Perinatol 2009; 29:662-7. [PMID: 19626028 DOI: 10.1038/jp.2009.88] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Prenatal ultrasound has led to the early diagnosis of major anomalies. However, the ready availability of this technology has led to increasing challenges for physicians counseling affected parents, which is all the more difficult in a twin pregnancy with only one affected fetus. This paper reviews the medical and ethical considerations in twin pregnancies discordant for a serious cardiac condition. STUDY DESIGN Six recent twin pregnancies discordant for a serious cardiac condition and their outcomes are presented. Options considered in the management of the pregnancy were to continue or terminate the pregnancy, selectively terminate the affected twin or to decide whether to treat the affected twin once delivered. An approach to decision making in such situations has been formulated after critical analysis of the factors involved. RESULTS Four of the six pregnancies were monochorionic twins. Two sets of parents decided to terminate the pregnancy. In the four that continued, two opted for the affected twin to be appropriately managed once delivered. A further two considered selective termination but opted to continue the pregnancy because of the risk of premature labor and/or cerebral hypoxia following such intervention. They sought a commitment, however, that they be given the option whether to treat the affected twin following delivery. Eventually both elected to have their babies treated, one of whom died in the postoperative period. DISCUSSION Medical considerations included the risks of continuation of the pregnancy for the mother and her twins, the safety of termination (total or selective), and the risks to the unaffected fetus. Ethical issues revolved around concepts of autonomy, beneficence and justice from the standpoint of the family and the twins. The gestation and the viability of the twins played an important role in decision making and approaches, taking into account the local legal and other considerations. CONCLUSION Attention is drawn to the complexities of the issues involved in twin pregnancies complicated by a serious cardiac condition in one of the twins. Optimal counseling requires sound clinical knowledge about the medical risks to the mother and her twins, and a clear understanding of the key ethical considerations. Such an approach will assist parents in their very difficult decision making.
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Affiliation(s)
- A Malhotra
- Department of Neonatalogy, Monash Medical Centre, Melbourne, Australia
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Neurological complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease. Cardiol Young 2008; 18 Suppl 2:234-9. [PMID: 19063797 PMCID: PMC2742973 DOI: 10.1017/s1047951108002977] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A complication is an event or occurrence that is associated with a disease or a healthcare intervention, is a departure from the desired course of events, and may cause, or be associated with suboptimal outcome. A complication does not necessarily represent a breech in the standard of care that constitutes medical negligence or medical malpractice. An operative or procedural complication is any complication, regardless of cause, occurring (1) within 30 days after surgery or intervention in or out of the hospital, or (2) after 30 days during the same hospitalization subsequent to the operation or intervention. Operative and procedural complications include both intraoperative/intraprocedural complications and postoperative/postprocedural complications in this time interval. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has set forth a comprehensive list of complications associated with the treatment of patients with congenital cardiac disease, related to cardiac, pulmonary, renal, haematological, infectious, neurological, gastrointestinal, and endocrine systems, as well as those related to the management of anaesthesia and perfusion, and the transplantation of thoracic organs. The objective of this manuscript is to examine the definitions of operative morbidity as they relate specifically to the neurological system. These specific definitions and terms will be used to track morbidity associated with surgical and transcatheter interventions and other forms of therapy in a common language across many separate databases. Although neurological injury and adverse neurodevelopmental outcome can follow procedures for congenital cardiac defects, much of the variability in neurological outcome is now recognized to be more related to patient specific factors rather than procedural factors. Additionally, the recognition of pre and postoperative neurological morbidity requires procedures and imaging modalities that can be resource-intensive to acquire and analyze, and little is known or described about variations in "sampling rate" from centre to centre. The purpose of this effort is to propose an initial set of consensus definitions for neurological complications following congenital cardiac surgery and intervention. Given the dramatic advances in understanding achieved to date, and those yet to occur, this effort is explicitly recognized as only the initial first step of a process that must remain iterative. This list is a component of a systems-based compendium of complications that may help standardize terminology and possibly enhance the study and quantification of morbidity in patients with congenital cardiac malformations. Clinicians caring for patients with congenital cardiac disease may be able to use this list for databases, initiatives to improve quality, reporting of complications, and comparing strategies of treatment.
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