Therapeutic Hypothermia in a Neonate with Perinatal Asphyxia and Transposition of the Great Arteries

Tricuspid atresia 1c accompanying neonatal encephalopathy treated with pulmonary trunk banding and therapeutic hypothermia

The influence of therapeutic hypothermia, known to improve neurodevelopmental outcomes in neonatal encephalopathy, remains unknown in newborns with severe congenital heart diseases. We report a neonate with tricuspid atresia type 1c suffering from moderate neonatal encephalopathy. A burst suppression pattern on amplitude-integrated electroencephalography recovered after inducing moderate therapeutic hypothermia, but exacerbated pulmonary overcirculation still persisted even after the rewarming. Since the medical treatment for pulmonary overcirculation had reached the limit, semi-urgent pulmonary trunk banding was performed on the 4th day of life. Postoperative brain magnetic resonance imaging showed no apparent brain injuries; the patient was discharged uneventfully. We share our perioperative management experience of a patient with tricuspid atresia type Ic who required therapeutic hypothermia for neonatal encephalopathy.

Therapeutic hypothermia for encephalopathic newborns with congenital heart defect: A cross-sectional survey on current practices and opinions in Germany

BACKGROUND

Therapeutic hypothermia (TH) reduces neonatal mortality and long-term neurodevelopmental impairment in infants with moderate-to-severe hypoxic-ischemic encephalopathy (HIE) caused by perinatal asphyxia. There is an increasing trend to apply TH in other indications and populations, such as infants with mild HIE or neonates with congenital heart defects (CHD), even though there is little evidence to support or refute this.

OBJECTIVE

The aim of this survey was to analyze practice variations with respect to TH use in neonates with CHD and to assess expert opinions on this topic across tertiary neonatal departments in Germany.

METHODS/DESIGN

A web-based survey was sent to all tertiary neonatal departments in Germany. The questionnaire contained 32 multiple-choice questions. The survey inquired current practices on TH in newborns with CHD and expert opinions on various clinical scenarios.

MAIN RESULTS

A total 80 (51.3%) neonatal departments partially completed the survey, and 69 (44.2%) respondents filled out the whole questionnaire. All 80 (100.0%) departments perform TH. TH is offered by 76 (95.0%) respondents to encephalopathic newborns with simple CHD. In infants with critical/complex CHD, TH is offered after perinatal asphyxial HIE and in newborns with encephalopathy after severe acidosis associated with cardiac complications by 25 (31.3%), or 17 (22.1%) respondents, respectively, whereas a clear majority of centers reject TH in these infants. Unclear effects of TH on any ongoing prostaglandin therapy (57.6 and 52.3%, respectively), an increased risk for adverse reactions during TH (51.6 and 52.3%, respectively) and lack of evidence (33.3 and 53.8%, respectively) are the most frequently cited reasons for not performing TH in these infants. The majority of experts from neonatal departments providing comprehensive care for neonates with severe CHD support the initiation of TH in encephalopathic neonates.

DISCUSSION

The considerable heterogeneity in the use of TH in neonates with CHD emphasizes the need for further research to optimize treatment strategies for these patients.

Delivery room asphyxia in neonates with ductal-dependent congenital heart disease: a retrospective cohort study

OBJECTIVE

We aimed to investigate the clinical course and outcome of newborns with ductal-dependent congenital heart disease (CHD) who suffered from perinatal asphyxia.

STUDY DESIGN

Clinical data of 504 patients with ductal-dependent CHD and perinatal asphyxia were retrospectively analyzed over a 10-year period (2005-2014).

RESULT

Perinatal asphyxia was diagnosed in 17 (3.4%) patients, comprising two nonoverlapping groups: Five infants with intrauterine acidosis (umbilical artery pH < 7.0), and 12 infants with persistent or deteriorating postnatal depression (Apgar score <6 at 10 min of life). Preoperative (41.7%, p < 0.001) and overall mortality (50.0%, p = 0.001) were increased in infants with asphyxia caused by persistent or deteriorating postnatal depression. Apgar scores at 10 min were independently associated with preoperative (OR 0.479, 95% CI 0.342-0.672, p < 0.001) and overall death (OR 0.655, 95% CI 0.537-0.799, p < 0.001).

CONCLUSIONS

Asphyxia caused by postnatally deteriorating depression rather than fetal acidosis is associated with high mortality.

TTB Protects Astrocytes Against Oxygen-Glucose Deprivation/Reoxygenation-Induced Injury via Activation of Nrf2/HO-1 Signaling Pathway

Neonatal hypoxic/ischemic encephalopathy (NHIE) is a severe condition that leads to death or neurological disability in newborns. The underlying pathological mechanisms are unclear, and developing the target neuroprotective strategies are urgent. 2,7,2′-trihydroxy-4,4′7′-trimethoxy-1,1′-biphenanthrene (TTB) is a natural product isolated from Cremastra appendiculata (D. Don) Makino and Liparis nervosa (Thunb.) Lindl. TTB has demonstrated potent cytotoxic activity against stomach (HGC-27) and colon (HT-29) cancer cell lines. However, none of the studies have addressed the effects of TTB in NHIE. In the present study, an oxygen-glucose deprivation/reoxygenation (OGD/R)-induced astrocyte injury model was established to investigate the effect of TTB and its potential mechanisms. Our results showed that TTB alleviated the OGD/R-induced reactive oxygen species increase and the intracellular antioxidant capacity of superoxide dismutase activity decrease. Moreover, TTB potentially prolonged the activation state of the nuclear factor erythroid 2-related factor 2 (Nrf2)/heme oxygenase-1 (HO-1) pathway and maintained the protection against oxidative stress in OGD/R-induced astrocytes by inducing the nuclear translocation and up-regulation of Nrf2 along with the enhanced expression of the downstream target gene HO-1. Furthermore, TTB treatment diminished the accumulation of hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) expression induced by OGD/R. We also found TTB-treated astrocytes reversed the inhibition of OGD/R on neurite growth of neurons by the astrocyte-neuron coculture system. In conclusion, TTB inhibited the OGD/R-induced astrocyte oxidative stress at least partially through the inhibition of HIF-1α and VEGF via the Nrf2/HO-1 signaling pathway.

Therapeutic Hypothermia After Perinatal Asphyxia in Infants With Severe, Ductal-Dependent Congenital Heart Disease

OBJECTIVES

Patients with severe congenital heart disease and cardiac anomalies such as restrictive foramen ovale, intact atrial septum, or narrowing of ductus arteriosus are at risk for perinatal asphyxia, leading to hypoxic-ischemic encephalopathy. We hypothesize that therapeutic hypothermia can be applied to these patients and seek to investigate feasibility and safety of this method.

DESIGN

A retrospective observational study.

SETTING

The Department of Neonatology of Charité, University Hospital, Berlin, Germany.

PATIENTS

Newborns with severe congenital heart disease and perinatal asphyxia were retrospectively analyzed over a 6-year period.

INTERVENTIONS

Application of therapeutic hypothermia.

MEASUREMENTS AND MAIN RESULTS

Ten patients with perinatal asphyxia were enrolled in this study. All patients received low-dose prostaglandin E1 for ductal maintenance. Three patients without evidence for hypoxic-ischemic encephalopathy did not receive therapeutic hypothermia. One patient died at the age of 15 hours, and therapeutic hypothermia was discontinued after 19 hours in another patient with severe arterial hypotension. Adverse effects during hypothermia included respiratory insufficiency (100%), arterial hypotension (71%), the need for inotropic support (71%), and pulmonary hypertension (43%), the latter associated with prolonged postoperative inotropic support. No neurologic complications occurred before or after the surgery. Operative outcome of surviving patients was excellent. Early brain MRI scans were suggestive of good neurodevelopmental prognosis for most patients.

CONCLUSIONS

Therapeutic hypothermia can be applied to patients with severe congenital heart disease and hypoxic-ischemic encephalopathy. Low-dose prostaglandin E1 infusions are safe for ductal maintenance during cooling, but cardiopulmonary adverse effects should be anticipated.

Amplitude-integrated EEG in newborns with critical congenital heart disease predicts preoperative brain magnetic resonance imaging findings

OBJECTIVE

The study aims are to evaluate cerebral background patterns using amplitude-integrated electroencephalography in newborns with critical congenital heart disease, determine if amplitude-integrated electroencephalography is predictive of preoperative brain injury, and assess the incidence of preoperative seizures. We hypothesize that amplitude-integrated electroencephalography will show abnormal background patterns in the early preoperative period in infants with congenital heart disease that have preoperative brain injury on magnetic resonance imaging.

METHODS

Twenty-four newborns with congenital heart disease requiring surgery at younger than 30 days of age were prospectively enrolled within the first 3 days of age at a tertiary care pediatric hospital. Infants had amplitude-integrated electroencephalography for 24 hours beginning close to birth and preoperative brain magnetic resonance imaging. The amplitude-integrated electroencephalographies were read to determine if the background pattern was normal, mildly abnormal, or severely abnormal. The presence of seizures and sleep-wake cycling were noted. The preoperative brain magnetic resonance imaging scans were used for brain injury and brain atrophy assessment.

RESULTS

Fifteen of 24 infants had abnormal amplitude-integrated electroencephalography at 0.71 (0-2) (mean [range]) days of age. In five infants, the background pattern was severely abnormal. (burst suppression and/or continuous low voltage). Of the 15 infants with abnormal amplitude-integrated electroencephalography, 9 (60%) had brain injury. One infant with brain injury had a seizure on amplitude-integrated electroencephalography. A severely abnormal background pattern on amplitude-integrated electroencephalography was associated with brain atrophy (P = 0.03) and absent sleep-wake cycling (P = 0.022).

CONCLUSION

Background cerebral activity is abnormal on amplitude-integrated electroencephalography following birth in newborns with congenital heart disease who have findings of brain injury and/or brain atrophy on preoperative brain magnetic resonance imaging.

Cooling neonates who do not fulfil the standard cooling criteria - short- and long-term outcomes

AIM

Therapeutic hypothermia is effective and without serious adverse effects in term infants with hypoxic-ischaemic encephalopathy. It is unknown whether other neonatal patient groups could benefit from therapeutic hypothermia. Since 2006, our centre has offered cooling to infants fulfilling the standard cooling criteria, but also to those who did not.

METHODS

Observational study with prospective data collection over a 6-year period in a regional cooling centre. Complications and outcome were compared between infants who were cooled not fulfilling the standard inclusion and exclusion criteria as set out in the CoolCap/TOBY protocol (n = 36) and infants who fulfilled the standard entry criteria (n = 129).

RESULTS

21.8% of cooled infants did not fulfil standard cooling entry criteria. This included infants cooled >6 postnatal hours, late preterm infants, and infants with postnatal collapse, major cranial haemorrhage, congenital cardiac disease and surgical conditions. Complication rates and long-term outcome did not differ significantly between the groups, apart from in infants with a major cranial haemorrhage, who had higher rates of coagulopathy and the worst outcome (80% death/disability).

CONCLUSION

Cooling can be considered for infants with neonatal encephalopathy following postnatal collapse or preterm birth, those with underlying surgical or cardiac conditions, and infants starting cooling >6 postnatal hours.

White matter injury in newborns with congenital heart disease: a diffusion tensor imaging study

BACKGROUND

Brain injury is observed on cranial magnetic resonance imaging preoperatively in up to 50% of newborns with congenital heart disease. Newer imaging techniques such as diffusion tensor imaging provide sensitive measures of the white matter integrity. The objective of this study was to evaluate the diffusion tensor imaging analysis technique of tract-based spatial statistics in newborns with congenital heart disease.

METHODS

Term newborns with congenital heart disease who would require surgery at less than 1 month of age were prospectively enrolled (n = 19). Infants underwent preoperative and postoperative brain magnetic resonance imaging with diffusion tensor imaging. Tract-based spatial statistics, an objective whole-brain diffusion tensor imaging analysis technique, was used to determine differences in white matter fractional anisotropy between infant groups. Term control infants were also compared with congenital heart disease infants. Postmenstrual age was equivalent between congenital heart disease infant groups and between congenital heart disease and control infants.

RESULTS

Ten infants had preoperative brain injury, either infarct or white matter injury, by conventional brain magnetic resonance imaging. The technique of tract-based spatial statistics showed significantly lower fractional anisotropy (P < 0.05, corrected) in multiple major white matter tracts in the infants with preoperative brain injury compared with infants without preoperative brain injury. Fractional anisotropy values increased in the white matter tracts from the preoperative to the postoperative brain magnetic resonance imaging correlating with brain maturation. Control infants had higher fractional anisotropy in multiple white matter tracts compared with infants with congenital heart disease.

CONCLUSION

Tract-based spatial statistics is a valuable diffusion tensor imaging analysis technique that may have better sensitivity in detecting white matter injury compared with conventional brain magnetic resonance imaging in term newborns with congenital heart disease.