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Gil LA, Apfeld JC, Gehred A, Walczak AB, Frazier WJ, Seabrook RB, Olutoye OO, Minneci PC. A Systematic Review of Clinical Outcomes After Carotid Artery Ligation Versus Carotid Artery Reconstruction Following Venoarterial Extracorporeal Membrane Oxygenation in Infants and Children. J Surg Res 2023; 291:423-432. [PMID: 37517350 DOI: 10.1016/j.jss.2023.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/24/2023] [Accepted: 06/25/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION In pediatric and neonatal populations, the carotid artery is commonly cannulated for venoarterial (VA) extracorporeal membrane oxygenation (ECMO). The decision to ligate (carotid artery ligation [CAL]) versus reconstruct (carotid artery reconstruction [CAR]) the artery at decannulation remains controversial as long-term neurologic outcomes remain unknown. The objective of this study was to summarize current literature on clinical outcomes following CAL and CAR after Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO). METHODS PubMed (MEDLINE), Embase, Web of Science, and Cochrane databases were searched using keywords from January 1950 to October 2020. Studies examining clinical outcomes following CAL and CAR for VA-ECMO in patients <18 y of age were included. Prospective and retrospective cohort studies, case series, case-control studies, and case reports were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were performed independently by two reviewers. Assessment of risk of bias was performed. RESULTS Eighty studies were included and classified into four categories: noncomparative clinical outcomes after CAL (n = 23, 28.8%), noncomparative clinical outcomes after CAR (n = 12, 15.0%), comparative clinical outcomes after CAL and/or CAR (n = 28, 35.0%), and case reports of clinical outcomes after CAL and/or CAR (n = 17, 21.3%). Follow-up ranged from 0 to 11 y. CAR patency rates ranged from 44 to 100%. There was no substantial evidence supporting an association between CAL versus CAR and short-term neurologic outcomes. CONCLUSIONS Studies evaluating outcomes after CAL versus CAR for VA-ECMO are heterogeneous with limited generalizability. Further studies are needed to evaluate long-term consequences of CAL versus CAR, especially as the first survivors of pediatric/neonatal ECMO approach an age of increased risk of carotid stenosis and stroke.
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Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Jordan C Apfeld
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Alison Gehred
- Grant Morrow III Library, Nationwide Children's Hospital, Columbus, Ohio
| | - Ashely B Walczak
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - W Joshua Frazier
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ruth B Seabrook
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Oluyinka O Olutoye
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio.
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Sanford EL, Akorede R, Miller I, Morriss MC, Nandy K, Raman L, Busch DR. Association Between Disrupted Cerebral Autoregulation and Radiographic Neurologic Injury for Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study. ASAIO J 2023; 69:e315-e321. [PMID: 37172001 DOI: 10.1097/mat.0000000000001970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Validation of a real-time monitoring device to evaluate the risk or occurrence of neurologic injury while on extracorporeal membrane oxygenation (ECMO) may aid clinicians in prevention and treatment. Therefore, we performed a pilot prospective cohort study of children under 18 years old on ECMO to analyze the association between cerebral blood pressure autoregulation as measured by diffuse correlation spectroscopy (DCS) and radiographic neurologic injury. DCS measurements of regional cerebral blood flow were collected on enrolled patients and correlated with mean arterial blood pressure to determine the cerebral autoregulation metric termed DCSx. The primary outcome of interest was radiographic neurologic injury on eligible computed tomography (CT) or magnetic resonance imaging (MRI) scored by a blinded pediatric neuroradiologist utilizing a previously validated scale. Higher DCSx scores, which indicate disruption of cerebral autoregulation, were associated with higher radiographic neurologic injury score (slope, 11.0; 95% confidence interval [CI], 0.29-22). Patients with clinically significant neurologic injury scores of 10 or more had higher median DCSx measures than patients with lower neurologic injury scores (0.48 vs . 0.13; p = 0.01). Our study indicates that obtaining noninvasive DCS measures for children on ECMO is feasible and disruption of cerebral autoregulation determined from DCS is associated with higher radiographic neurologic injury score.
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Affiliation(s)
- Ethan L Sanford
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Rufai Akorede
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Isabel Miller
- UT Southwestern Medical Center Medical School, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Karabi Nandy
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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Rose AT, Davis J, Williams HO, Clifton M, Paden M, Keene SD. Utility of cephalic drains in infants receiving extracorporeal membrane oxygenation. Perfusion 2022; 38:747-754. [PMID: 35343293 DOI: 10.1177/02676591221080506] [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: 10/18/2022]
Abstract
INTRODUCTION The addition of cephalic drains (CDs) in extracorporeal membrane oxygenation (ECMO) to augment venous drainage may offer benefit, though their use is varied. Our objective was to describe our institution's experience with CDs including flow rates and patency. We also compared complication rates between patients with and without a CD. METHODS This retrospective cohort study included infants <12 months of age cannulated for ECMO between January 1, 2010 and September 30, 2019 at a single institution. Flow data were obtained for those with a CD. Demographic and complication rates were obtained for all. RESULTS Of 264 patients in the final cohort, 220 (83%) had a CD of which 93.2% remained patent to decannulation. CDs typically provided 30% or more of ECMO flow throughout the ECMO run. The median time to CD clot was 139 h (range 48-635 h). Patients with a clotted CD had longer ECMO runs than those whose CD remained patent (median 382 h [IQR 217-538] vs 139 h [IQR 91-246], p < 0.001). Survival to discharge was lower for those with clotted versus patent CD (14% vs 70%, p < 0.001). Mechanical complications were more common in patients with CD (p = 0.005). Seizures were more common in those without a CD (p = 0.021). CONCLUSIONS In this cohort, the majority of CDs placed remained patent at decannulation and provided substantial additional venous drainage. Mechanical problems were common in patients with CDs, but without clinical sequelae. Further study is warranted to elucidate CD impact on short- and long-term outcomes.
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Affiliation(s)
- Allison T Rose
- Division of Neonatology, Department of Pediatrics, 12239Emory University School of Medicine, Atlanta, GA, USA.,138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Joel Davis
- 138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Helen O Williams
- Division of Neonatology, Department of Pediatrics, 12239Emory University School of Medicine, Atlanta, GA, USA.,138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Matthew Clifton
- 138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA.,Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew Paden
- 138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA.,Division of Critical Care, Department of Pediatrics, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah D Keene
- Division of Neonatology, Department of Pediatrics, 12239Emory University School of Medicine, Atlanta, GA, USA.,138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
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Busch DR, Baker WB, Mavroudis CD, Ko TS, Lynch JM, McCarthy AL, DuPont-Thibodeau G, Buckley EM, Jacobwitz M, Boorady TW, Mensah-Brown K, Connelly JT, Yodh AG, Kilbaugh TJ, Licht DJ. Noninvasive optical measurement of microvascular cerebral hemodynamics and autoregulation in the neonatal ECMO patient. Pediatr Res 2020; 88:925-933. [PMID: 32172282 PMCID: PMC7492409 DOI: 10.1038/s41390-020-0841-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/12/2020] [Accepted: 02/19/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Extra-corporeal membrane oxygenation (ECMO) is a life-saving intervention for severe respiratory and cardiac diseases. However, 50% of survivors have abnormal neurologic exams. Current ECMO management is guided by systemic metrics, which may poorly predict cerebral perfusion. Continuous optical monitoring of cerebral hemodynamics during ECMO holds potential to detect risk factors of brain injury such as impaired cerebrovascular autoregulation (CA). METHODS We conducted daily measurements of microvascular cerebral blood flow (CBF), oxygen saturation, and total hemoglobin concentration using diffuse correlation spectroscopy (DCS) and frequency-domain diffuse optical spectroscopy in nine neonates. We characterize CA utilizing the correlation coefficient (DCSx) between CBF and mean arterial blood pressure (MAP) during ECMO pump flow changes. RESULTS Average MAP and pump flow levels were weakly correlated with CBF and were not correlated with cerebral oxygen saturation. CA integrity varied between individuals and with time. Systemic measurements of MAP, pulse pressure, and left cardiac dysfunction were not predictive of impaired CA. CONCLUSIONS Our pilot results suggest that systemic measures alone cannot distinguish impaired CA from intact CA during ECMO. Furthermore, optical neuromonitoring could help determine patient-specific ECMO pump flows for optimal CA integrity, thereby reducing risk of secondary brain injury. IMPACT Cerebral blood flow and oxygenation are not well predicted by systemic proxies such as ECMO pump flow or blood pressure. Continuous, quantitative, bedside monitoring of cerebral blood flow and oxygenation with optical tools enables new insight into the adequacy of cerebral perfusion during ECMO. A demonstration of hybrid diffuse optical and correlation spectroscopies to continuously measure cerebral blood oxygen saturation and flow in patients on ECMO, enabling assessment of cerebral autoregulation. An observation of poor correlation of cerebral blood flow and oxygenation with systemic mean arterial pressure and ECMO pump flow, suggesting that clinical decision making guided by target values for these surrogates may not be neuroprotective. ~50% of ECMO survivors have long-term neurological deficiencies; continuous monitoring of brain health throughout therapy may reduce these tragically common sequelae through brain-focused adjustment of ECMO parameters.
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Affiliation(s)
- David R Busch
- Departments of Anesthesiology & Pain Management and Neurology & Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wesley B Baker
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Constantine D Mavroudis
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tiffany S Ko
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer M Lynch
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ann L McCarthy
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy W Boorady
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kobina Mensah-Brown
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James T Connelly
- ECMO Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Aly S, El-Dib M, Lu Z, El Tatawy S, Mohamed M, Aly H. Factors affecting cerebrovascular reactivity to CO2 in premature infants. J Perinat Med 2019; 47:979-985. [PMID: 31562803 DOI: 10.1515/jpm-2019-0031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 08/22/2019] [Indexed: 11/15/2022]
Abstract
Background Hypercarbia increases cerebral blood flow secondary to cerebral vasodilatation, while hypocarbia can lead to vasoconstriction with a subsequent decrease in cerebral blood flow. The aim of this study was to examine CO2 cerebral vasoreactivity in a cohort of premature infants and to identify factors which influence this reactivity. Methods We prospectively studied a cohort of hemodynamically stable premature infants [birth weight (BW) <1500 g and gestational age (GA) ≤34 weeks]. Subjects underwent two studies, one in the first 72 h and the second after 1 week of life. Infants were continuously monitored via a physiology station that included transcutaneous CO2 (tcPCO2) monitor, near-infrared spectroscopy (NIRS), arterial pulse oximetry and heart rate. The total hemoglobin (Hb-T) signal of NIRS was used as an indicator of cerebral blood volume (CBV). Correlation between tcPCO2 and Hb-T was performed in each 1-h period using Pearson's correlation. Factors affecting the CO2 cerebrovascular reactivity were examined using bivariate and linear regression analyses. Results A total of 3847 1-h epochs were obtained from 140 studies of 72 premature infants. tcPCO2 correlated positively with Hb-T in 42% of epochs. In regression analysis, factors associated with increased percentage of positive correlation epochs were male sex and younger postmenstrual age (PMA; β = 0.176, 0.169 and P-value = 0.036, 0.047 respectively). Factors associated with increased strength of positive correlation were mechanical ventilation and increased average tcPCO2 (β = 0.198, 0.220 and P-value = 0.024, 0.011 respectively). Conclusion Increased prematurity, male sex, mechanical ventilation and hypercarbia are associated with stronger PCO2 cerebrovascular reactivity in premature infants. This association may explain their role in the pathogenesis of brain injury.
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Affiliation(s)
- Safwat Aly
- The George Washington University, Washington, DC, USA.,Department of Paediatrics, The Labatt Family Heart Center, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard School of Medicine, 75 Francis Street, Boston, MA 02115, USA
| | - Zhigang Lu
- Brigham and Women's Hospital and Harvard School of Medicine, Boston, MA, USA
| | | | - Mohamed Mohamed
- Newborn Services, The George Washington University, Washington, DC, USA
| | - Hany Aly
- Department of Pediatrics, Cleveland Clinic, Cleveland, OH, USA
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Eipe N, Doherty DR. A review of pediatric capnography. J Clin Monit Comput 2010; 24:261-8. [DOI: 10.1007/s10877-010-9243-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 07/01/2010] [Indexed: 10/19/2022]
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Durduran T, Zhou C, Buckley EM, Kim MN, Yu G, Choe R, Gaynor JW, Spray TL, Durning SM, Mason SE, Montenegro LM, Nicolson SC, Zimmerman RA, Putt ME, Wang J, Greenberg JH, Detre JA, Yodh AG, Licht DJ. Optical measurement of cerebral hemodynamics and oxygen metabolism in neonates with congenital heart defects. JOURNAL OF BIOMEDICAL OPTICS 2010; 15:037004. [PMID: 20615033 PMCID: PMC2887915 DOI: 10.1117/1.3425884] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 03/02/2010] [Accepted: 03/12/2010] [Indexed: 05/18/2023]
Abstract
We employ a hybrid diffuse correlation spectroscopy (DCS) and near-infrared spectroscopy (NIRS) monitor for neonates with congenital heart disease (n=33). The NIRS-DCS device measured changes during hypercapnia of oxyhemoglobin, deoxyhemoglobin, and total hemoglobin concentrations; cerebral blood flow (rCBF(DCS)); and oxygen metabolism (rCMRO(2)). Concurrent measurements with arterial spin-labeled magnetic resonance imaging (rCBF(ASL-MRI), n=12) cross-validate rCBF(DCS) against rCBF(ASL-MRI), showing good agreement (R=0.7, p=0.01). The study demonstrates use of NIRS-DCS on a critically ill neonatal population, and the results indicate that the optical technology is a promising clinical method for monitoring this population.
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Affiliation(s)
- Turgut Durduran
- ICFO-Institut de Ciencies Fotoniques, Av Canal Olimpic s/n, Castelldefels 08860, Spain.
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Ejike JC, Schenkman KA, Seidel K, Ramamoorthy C, Roberts JS. Cerebral oxygenation in neonatal and pediatric patients during veno-arterial extracorporeal life support. Pediatr Crit Care Med 2006; 7:154-8. [PMID: 16446597 DOI: 10.1097/01.pcc.0000200969.65438.83] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To observe the effects of right carotid artery ligation and variations in extracorporeal life support (ECLS) flow on regional cerebral oxygenation index (rSO2i) measured using near infrared spectroscopy. DESIGN Prospective observational study. SETTING Tertiary children's hospital. PATIENTS Eleven neonatal and pediatric patients requiring veno-arterial ECLS support between June 2000 and March 2003. INTERVENTIONS Near infrared spectroscopy probe placement on left and right frontal regions of patients undergoing ECLS, before vessel cannulation or within 24 hrs of initiation of ECLS. MEASUREMENTS AND MAIN RESULTS Regional cerebral oxygenation was measured every minute for 72 hrs or until the patient was decannulated. The effect of cannulation on rSO2i from each hemisphere of the brain and the relationship between ECLS flow and rSO2i during ECLS support and "trialing off" periods were determined. Ligation of the right carotid artery resulted in a 12-25% decrease in rSO2i from baseline in the right frontal region for a duration ranging from 17 to 45 mins before returning toward baseline. No substantial change in the left frontal region rSO2i was detected during cannulation. Following this depression in rSO2i on the right, there was a transient increase above baseline in rSO2i observed in both hemispheres on initiating ECLS. No correlation between ECLS flow and rSO2i was found over the 72-hr period. Periods of "trialing off" ECLS were not related to any change in rSO2i in either hemisphere. CONCLUSIONS This study demonstrated no relationship between ECLS flow and rSO2i changes during the 72-hr observation period. A brief period of cerebral oxygen desaturation of the right frontal region at the time of right carotid ligation was seen in all three study patients examined during cannulation, followed by an increased rSO2i with initiation of ECLS flow. Near infrared spectroscopy measurement may offer an important adjunct for neurologic monitoring of ECLS patients.
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Affiliation(s)
- Janeth C Ejike
- Loma Linda University School of Medicine, Loma Linda, CA, USA
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Abstract
Cerebral blood flow (CBF, cerebral perfusion) mirrors cerebral metabolic demand and neuronal function, and therefore, is a vital parameter in the evaluation of pediatric brain injury and recovery. Until recently, measurement of CBF involved intravenous bolus injection of contrast agents or nuclear medicine methods that were technically difficult or ethically problematic in pediatrics. The development of arterial spin label (ASL) perfusion MR imaging as a noninvasive method for measuring CBF allows for the increased ability to measure this vital physiologic parameter in any age group. This article presents the technical aspects of performing ASL perfusion MR imaging in pediatrics, and discusses its current use in clinical studies and its potential for influencing important management strategies in specific disease entities.
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Affiliation(s)
- Jiongjiong Wang
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Licht DJ, Wang J, Silvestre DW, Nicolson SC, Montenegro LM, Wernovsky G, Tabbutt S, Durning SM, Shera DM, Gaynor JW, Spray TL, Clancy RR, Zimmerman RA, Detre JA. Preoperative cerebral blood flow is diminished in neonates with severe congenital heart defects. J Thorac Cardiovasc Surg 2004; 128:841-9. [PMID: 15573068 DOI: 10.1016/j.jtcvs.2004.07.022] [Citation(s) in RCA: 240] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Impaired neurodevelopmental outcome represents a major morbidity for survivors of infant heart surgery for congenital heart defects. Previous studies in these neonates have reported preoperative microcephaly, periventricular leukomalacia, and other findings. The hypothesis of this study is that preoperative cerebral blood flow is substantially diminished and might relate to preoperative neurologic conditions. METHODS Preoperative brain magnetic resonance imaging was performed. Cerebral blood flow measurements in infants with congenital heart defects were obtained by using a novel noninvasive magnetic resonance imaging technique, pulsed arterial spin-label perfusion magnetic resonance imaging. Cerebral blood flow was measured before the operation under standard ventilation and repeated after increased carbon dioxide. RESULTS A total of 25 term infants were studied. The average age at the time of the operation was 4.4 +/- 4.6 days. Congenital heart defects varied widely. Microcephaly occurred in 24% (6/25). Baseline cerebral blood flow was 19.7 +/- 9.2 mL . 100 g -1 . min -1 (8.0-42.2 mL . 100 g -1 . min -1 ). Five patients had cerebral blood flow measurements of less than 10 mL . 100 g -1 . min -1 . Mean hypercarbic cerebral blood flow increased to 40.1 +/- 20.3 mL . 100 g -1 . min -1 (11.4-94.0 mL . 100 g -1 . min -1 , P < .001). Pairwise analyses found that low hemoglobin levels were associated with higher baseline cerebral blood flow values ( P = .04). Periventricular leukomalacia occurred in 28% (7/25) and was associated with decreased baseline cerebral blood flow values ( P = .05) and a smaller change in cerebral blood flow with hypercarbia ( P = .003). CONCLUSIONS Structural brain abnormalities are common in these neonates before surgical intervention. Preoperative cerebral blood flow for this cohort was low and drastically reduced in some patients. Low cerebral blood flow values were associated with periventricular leukomalacia. Carbon dioxide reactivity was preserved but might be compromised by some aspects of the cardiac anatomy. The full spectrum of cerebral blood flow measurements with this technique in congenital heart defects and their long-term significance require continued investigation.
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Affiliation(s)
- Daniel J Licht
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia, Wood Building 6th Floor, 34th & Civic Center Boulevard, Philadelphia, PA 19104, USA.
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