Changes in cerebral oxygen saturation correlate with S100B in infants undergoing cardiac surgery with cardiopulmonary bypass

Utility of Brain Injury Biomarkers in Children With Congenital Heart Disease Undergoing Cardiac Surgery

BACKGROUND

Congenital heart disease (CHD) affects roughly 40,000 children annually. Despite advancements, children undergoing surgery for CHD are at an increased risk for adverse neurological outcomes. At present, there is no gold standard for the diagnosis of cerebral injury during the perioperative period.

OBJECTIVE

To determine the utility of brain injury biomarkers in children undergoing cardiac surgery.

METHODS

We searched PUBMED, EMBASE, LILACS, EBSCO, ClinicalTrials.gov, Cochrane Databases, and OVID interface to search MEDLINE through July 2021 and assessed the literature following the snowball method. The search terms used were "congenital heart disease," "cardiopulmonary bypass," "biomarkers," "diagnosis," "prognosis," and "children." No language or publication date restrictions were used. Papers studying inflammatory and imaging biomarkers were excluded. The risk of bias, strengths, and limitations of the study were reported. Study was registered in PROSPERO ID: CRD42021258385.

RESULTS

A total of 1449 articles were retrieved, and 27 were included. Eight neurological biomarkers were examined. Outcomes assessed included prognosis of poor neurological outcome, mortality, readmission, and diagnosis of brain injury. Results from these studies support that significant perioperative elevations in brain injury biomarkers in cerebrospinal fluid and serum, including S100B, GFAP, NSE, and activin A, may be diagnostic of real-time brain injury and serve as an independent predictor of adverse neurological outcomes in patients with CHD undergoing cardiopulmonary bypass.

CONCLUSIONS

There are limited homogeneous data in the field, limiting the generalizability and comparability of the results. Further large-scale longitudinal studies addressing neurological biomarkers in children undergoing CHD corrective surgery are required to support the routine use of neuronal biomarkers in this population.

S100B in cardiac surgery brain monitoring: friend or foe?

Recent advances in perioperative management of adult and pediatric patients requiring open heart surgery (OHS) and cardiopulmonary bypass (CPB) for cardiac and/or congenital heart diseases repair allowed a significant reduction in the mortality rate. Conversely morbidity rate pattern has a flat trend. Perioperative period is crucial since OHS and CPB are widely accepted as a deliberate hypoxic-ischemic reperfusion damage representing the cost to pay at a time when standard of care monitoring procedures can be silent or unavailable. In this respect, the measurement of neuro-biomarkers (NB), able to detect at early stage perioperative brain damage could be especially useful. In the last decade, among a series of NB, S100B protein has been investigated. After the first promising results, supporting the usefulness of the protein as predictor of short/long term adverse neurological outcome, the protein has been progressively abandoned due to a series of limitations. In the present review we offer an up-dated overview of the main S100B pros and cons in the peri-operative monitoring of adult and pediatric patients.

Effects of Arterial Carbon Dioxide Tension on Cerebral and Somatic Regional Tissue Oxygenation and Blood Flow in Neonates After the Norwood Procedure With Deep Hypothermic Cardiopulmonary Bypass

Neonates undergoing the Norwood procedure for hypoplastic left heart syndrome are at higher risk of impaired systemic oxygen delivery with resultant brain, kidney, and intestinal ischemic injury, shock, and death. Complex developmental, anatomic, and treatment-related influences on cerebral and renal-somatic circulations make individualized treatment strategies physiologically attractive. Monitoring cerebral and renal circulations with near infrared spectroscopy can help drive rational therapeutic interventions. The primary aim of this study was to describe the differential effects of carbon dioxide tension on cerebral and renal circulations in neonates after the Norwood procedure. Using a prospectively-maintained database of postoperative physiologic and hemodynamic parameters, we analyzed the relationship between postoperative arterial carbon dioxide tension and tissue oxygen saturation and arteriovenous saturation difference in cerebral and renal regions, applying univariate and multivariate multilevel mixed regression techniques. Results were available from 7,644 h of data in 178 patients. Increases in arterial carbon dioxide tension were associated with increased cerebral and decreased renal oxygen saturation. Differential changes in arteriovenous saturation difference explained these effects. The cerebral circulation showed more carbon dioxide sensitivity in the early postoperative period, while sensitivity in the renal circulation increased over time. Multivariate models supported the univariate findings and defined complex time-dependent interactions presented graphically. The cerebral and renal circulations may compete for blood flow with critical limitations of cardiac output. The cerebral and renal-somatic beds have different circulatory control mechanisms that can be manipulated to change the distribution of cardiac output by altering the arterial carbon dioxide tension. Monitoring cerebral and renal circulations with near infrared spectroscopy can provide rational physiologic targets for individualized treatment.

Effects of different ventilation on cerebral oxygen saturation and cerebral blood flow before and after modified ultrafiltration in infants during ventricular septal defect repair

OBJECTIVE

To analyse the changes of different ventilation on regional cerebral oxygen saturation and cerebral blood flow in infants during ventricular septal defect repair.

METHODS

Ninety-two infants younger than 1 year were enrolled in the study. End-expiratory tidal pressure of carbon dioxide was maintained at 40-45 and 35-39 mmHg in relative low and high ventilation groups. Regional cerebral oxygen saturation and flow velocity of the middle cerebral artery were recorded after anaesthesia (T0), cut pericardium (T1), separation from cardiopulmonary bypass (T2), the end of modified ultrafiltration, (T3) and at the end of operation (T4).

RESULTS

The relative low ventilation group exhibited a significantly high regional cerebral oxygen saturation at each time point except for T2 (T0:77 ± 4, T1:76 ± 5, T3:76 ± 8, T4:76 ± 8, respectively, p < 0.001). Flow velocity of the middle cerebral artery in the relative low ventilation group was higher compared to the relative high ventilation group at each time point except for T2 (T0:53 ± 14, T1:54 ± 15, T3:53 ± 17, T4:52 ± 16, respectively, p < 0.001). Between the two groups, T2 showed the lowest middle cerebral artery flow velocity (relative low ventilation: 39 ± 15, relative high ventilation: 39 ± 11, p < 0.001).

CONCLUSION

The infants' regional cerebral oxygen saturation and middle cerebral artery flow velocity performed better in the range of 40-45 mmHg end-expiratory tidal pressure of carbon dioxide during CHD surgery. Modified ultrafiltration increased cerebral oxygen saturation. It was important to regulate ventilation in order to balance cerebral oxygen in infants.

Mechanisms of perioperative brain damage in children with congenital heart disease

Congenital heart disease, particularly cyanotic congenital heart disease (CCHD), may lead to a neurodevelopmental delay through central nervous system injury, more unstable central nervous system development, and increased vulnerability of the nervous system. Neurodevelopmental disease is the most serious disorder of childhood, affecting the quality of life of children and their families. Therefore, the monitoring and optimization of nerve damage treatments are important. The factors contributing to neurodevelopmental disease are primarily related to preoperative, intraoperative, postoperative, genetic, and environmental causes, with intraoperative causes being the most influential. Nevertheless, few studies have examined these factors, particularly the influencing factors during early postoperative care. Children with congenital heart disease may experience brain damage during early heart intensive care due to unstable haemodynamics and total body oxygen transfer, particularly early postoperative inflammatory reactions in the brain, blood glucose levels, and other factors that potentially influence long-term neural development. This study analyses the forms of structural and functional brain damage in the early postoperative period, along with the recent evolution of research on its contributing factors.

Age-related cerebrovascular carbon dioxide reactivity in children with ventricular septal defect younger than 3 years

BACKGROUND

Impaired cerebrovascular reactivity to carbon dioxide was proposed to contribute to neurological morbidity in children undergoing cardiac surgery. The objective of this study was to assess carbon dioxide reactivity and regional cerebral oxygen saturation in children younger than 3 years.

METHODS

This study enrolled children younger than 3 years undergoing ventricular septal defect repair. The cohort was divided into three age groups: younger than 6 months, 6-12 months, and 12-36 months. Under steady-state anesthesia, carbon dioxide reactivity was calculated by measuring changes in middle cerebral artery blood flow velocity using transcranial Doppler sonography. Regional cerebral oxygen saturation changes were measured by near-infrared spectroscopy while endtidal carbon dioxide pressure was adjusted from 30 to 45 mm Hg.

RESULTS

Carbon dioxide reactivity showed a statistically significant increasing relationship with age (younger than 6 months group: 4.42% ± 2.73%, 6-12 months group: 5.86% ± 1.91%, 12-36 months group: 7.58% ± 1.49%; P < .001). Regional cerebral oxygen saturation showed a statistically significant increasing relationship with age (younger than 6 months group: 65% ± 6%, 6-12 months group: 68% ± 5%, 12-36 months group: 70% ± 5%; P = .027). Regional cerebral oxygen saturation showed a statistically significant increasing relationship with endtidal carbon dioxide pressure in all children (P < .001).

CONCLUSION

Abnormal carbon dioxide reactivity is prevalent in children younger than 3 years and the degree varies according to age.

Effect of xenon and dexmedetomidine as adjuncts for general anesthesia on postoperative emergence delirium after elective cardiac catheterization in children: study protocol for a randomized, controlled, pilot trial

Background

Emergence delirium, a manifestation of acute postoperative brain dysfunction, is frequently observed after pediatric anesthesia and has been associated with the use of sevoflurane. Both xenon and dexmedetomidine possess numerous desirable properties for the anesthesia of children with congenital heart disease, including hemodynamic stability, lack of neurotoxicity, and a reduced incidence of emergence delirium. Combining both drugs has never been studied as a balanced-anesthesia technique. This combination allows the provision of anesthesia without administering anesthetic drugs against which the Food and Drug Administration (FDA) issued a warning for the use in young children.

Methods/Design

In this phase-II, mono-center, prospective, single-blinded, randomized, controlled pilot trial, we will include a total of 80 children aged 0–3 years suffering from congenital heart disease and undergoing general anesthesia for elective diagnostic and/or interventional cardiac catheterization. Patients are randomized into two study groups, receiving either a combination of xenon and dexmedetomidine or mono-anesthesia with sevoflurane for the maintenance of anesthesia.

The purpose of this study is to estimate the effect size for xenon-dexmedetomidine versus sevoflurane anesthesia with respect to the incidence of emergence delirium in children. We will also describe group differences for a variety of secondary outcome parameters including peri-interventional hemodynamics, emergence characteristics, incidence of postoperative vomiting, and the feasibility of a combined xenon-dexmedetomidine anesthesia in children.

Discussion

Sevoflurane is the most frequently used anesthetic in young children, but has been indicated as an independent risk factor in the development of emergence delirium. Xenon and dexmedetomidine have both been associated with a reduction in the incidence of emergence delirium. Combining xenon and dexmedetomidine has never been described as a balanced-anesthesia technique in children. Our pilot study will therefore deliver important data required for future prospective clinical trials.

Trial registration

EudraCT, 2018–002258-56. Registered on 20 August 2018. https://www.clinicaltrialsregister.eu.

Effect of End-Tidal Carbon Dioxide on Cerebral Dynamics in Infants With Ventricular Septal Defect: A Comparison Between Sevoflurane and Intravenous Anesthetics

OBJECTIVES

The primary aim was to compare the changes in regional cerebral oxygen saturation (rSO₂) and cerebral blood flow velocity (CBFV) during sevoflurane and intravenous anesthesia when the end-tidal carbon dioxide partial pressure (P_ETCO₂) changed in infants undergoing ventricular septal defect (VSD) repair.

DESIGN

Prospective, observational study.

SETTING

Tertiary care hospital.

PARTICIPANTS

Patients younger than 6 months with VSDs.

INTERVENTIONS

End-tidal carbon dioxide was increased by decreasing tidal volume or respiratory rate.

MEASUREMENTS AND MAIN RESULTS

The infants were randomly assigned to receive either sevoflurane (SA group) or midazolam-sufentanil based intravenous anesthesia (IA group). P_ETCO₂ levels of 30 mmHg (T1), 35 mmHg (T2), 40 mmHg (T3), or 45 mmHg (T4) were obtained by adjusting the tidal volume and respiratory rate. There were no significant intergroup differences in rSO_2. In the SA group, as P_ETCO₂ increased from T1 to T4, rSO₂ increased significantly from 68.8% ± 5.9% to 76.4% ± 6.0% (p < 0.001). CBFV increased linearly, whereas the pulsatility index and resistance index decreased linearly from T1 to T4 (p < 0.001). In the IA group, rSO₂ showed a significant increase from 68.6% ± 4.6% to 76.1% ± 6.2% with the change in P_ETCO₂ from T1 to T4 (p < 0.001). CBFV increased linearly, whereas the pulsatility index and resistance index decreased linearly from T1 to T4 (p < 0.001).

CONCLUSION

Cerebrovascular response to different P_ETCO₂ levels was preserved and similar during clinically relevant doses of sevoflurane anesthesia and midazolam-sufentanil based intravenous anesthesia in infants younger than 6 months old undergoing VSD repair.

S100B and its relation to cerebral oxygenation in neonates and infants undergoing surgery for congenital heart disease

OBJECTIVES

Neonates and infants undergoing surgery for congenital heart disease are at risk for developmental impairment. Hypoxic-ischemic brain injury might be one contributing factor. We aimed to investigate the perioperative release of the astrocyte protein S100B and its relation to cerebral oxygenation.

METHODS

Serum S100B was measured before and 0, 12, 24, and 48 hours after surgery. Cerebral oxygen saturation was derived by near-infrared spectroscopy. S100B reference values based on preoperative samples; concentrations above the 75th percentile were defined as elevated. Patients with elevated S100B at 24 or 48 hours were compared to cases with S100B in the normal range. Neonates (≤28 days) and infants (>28 and ≤365 days) were analyzed separately due to age-dependent release of S100B.

RESULTS

Seventy-four patients underwent 94 surgical procedures (neonates, n = 38; infants, n = 56). S100B concentrations were higher in neonates before and after surgery at all time points (P ≤ .015). Highest values were noticed immediately after surgery. Postoperative S100B was elevated after 15 (40.5%) surgeries in neonates. There was no difference in pre-, intra-, or postoperative cerebral oxygenation. In infants, postoperative S100B was elevated after 23 (41.8%) procedures. Preoperative cerebral oxygen saturations tended to be lower (53 ± 12% vs 59 ± 12%, P = .069) and arterial-cerebral oxygen saturation difference was higher (35 ± 11% vs 28 ± 11%, P = .018) in infants with elevated postoperative S100B. In the early postoperative course, cerebral oxygen saturation was lower (54 ± 13% vs 63 ± 12%, P = .011) and arterial-cerebral oxygen saturation difference was wider (38 ± 11% vs 30 ± 10%, P = .008). Cerebral oxygen saturation was also lower for the entire postoperative course (62 ± 18% vs 67 ± 9%, P = .047).

CONCLUSIONS

Postoperative S100B was elevated in about 40% of neonates and infants undergoing cardiac surgery. Infants with elevated postoperative S100B had impaired perioperative cerebral tissue oxygenation. No relation between S100B and cerebral oxygenation could be demonstrated in neonates.

The effect of xenon-augmented sevoflurane anesthesia on intraoperative hemodynamics and early postoperative neurocognitive function in children undergoing cardiac catheterization: A randomized controlled pilot trial

BACKGROUND

In adults, xenon has only minimal hemodynamic side effects when compared with other anesthetics. Moreover, in preclinical experiments, xenon has been demonstrated to possess cardio- and neuroprotective properties. Altogether, the favorable hemodynamic profile combined with its potential for organ-protection could render xenon an attractive option for anesthesia in children with cardiovascular compromise.

AIMS

The aim of this study was to explore safety and feasibility of sevoflurane-augmented xenon anesthesia in school-aged children and to assess early postoperative neurocognitive effects of xenon-sevoflurane and sevoflurane anesthesia when compared to a control group that did not have anesthesia.

METHODS

Forty children aged 4-12 years, suffering from congenital heart disease, undergoing diagnostic or interventional cardiac catheterization were randomized to either xenon-augmented sevoflurane anesthesia or sevoflurane alone. Safety was assessed by the incidence of intraprocedural hemodynamic instability and feasibility by anesthetic depth and respiratory profile. In addition, neurocognitive performance was assessed preoperatively, 2 hours after discharge from PACU and at 24 hours after anesthesia using the Amsterdam Neuropsychological Tasks system. A healthy control group of 22 age- and gender-matched children not exposed to anesthesia underwent an identical neurocognitive test battery, at comparable time intervals.

RESULTS

Overall hemodynamics did not differ between groups. Xenon-sevoflurane anesthesia resulted in decreased intraoperative ephedrine requirements (median [IQR]) (0.00 mg/kg [0.00-0.00] vs 0.00 mg/kg [0.00-0.01], P = 0.047). Only neurocognitive tests in the domain of alertness were significantly impaired 2 hours postoperatively in both anesthesia groups in comparison with the control group (alertness variability: P = 0.02, odds ratio 5.8), but recovered at 24 hours. For working memory, inhibition, cognitive flexibility, and motor coordination tasks, no significant interaction effects of anesthesia were found in the early postoperative period.

CONCLUSION

In this pilot trial, xenon-augmented sevoflurane anesthesia in school-aged children was feasible, and associated with decreased ephedrine requirements. All children exposed to anesthesia showed impaired neurocognitive performance in the immediate postoperative period when compared to control children; however, without significant differences between both treatment groups.

S100B increases in cyanotic versus noncyanotic infants undergoing heart surgery and cardiopulmonary bypass (CPB)

AIMS

S100B has been proposed as a consolidated marker of brain damage in infants with congenital heart disease (CHD) undergoing cardiac surgery and cardiopulmonary bypass (CPB). The present study aimed to investigate whether S100B blood levels in the perioperative period differed in infants complicated or not by cyanotic CHD (CHDc) and correlated with oxygenation status (PaO₂).

METHODS

We conducted a case-control study of 48 CHD infants without pre-existing neurological disorders undergoing surgical repair and CPB. 24 infants were CHDc and 24 were CHD controls. Blood samples for S100B assessment were collected at six monitoring time-points: before the surgical procedure (T0), after sternotomy but before CPB (T1), at the end of the cross-clamp CPB phase (T2), at the end of CPB (T3), at the end of the surgical procedure (T4), at 24 h postsurgery (T5).

RESULTS

In the CHDc group, S100B multiples of median (MoM) were significantly higher (p < .05, for all) from T0 to T5. PaO₂ was significantly lower (p < .05, for all) in CHDc infants at T0-T1 and at T4 while no differences (p > .05, for all) were found at T2, T3, T5. Linear regression analysis showed a positive correlation between S100B MoM at T3 and PaO₂ (R = 0.84; p < .001).

CONCLUSIONS

The present data showing higher hypoxia/hyperoxia-mediated S100B concentrations in CHDc infants suggest that CHDc are more prone to perioperative brain stress/damage and suggest the usefulness of further investigations to detect the "optimal" PaO₂ target in order to avoid the side effects associated with reoxygenation during CPB.

Serum Neuronal Biomarkers in Neonates With Congenital Heart Disease Undergoing Cardiac Surgery

BACKGROUND

Newborns with congenital heart disease have associated brain damage that affects short-and long-term neurodevelopment. Several neuronal biomarkers exist that could predict brain damage. We investigated the pattern of neuron-specific enolase (NSE) and s100B levels after cardiopulmonary bypass surgery in neonates with congenital heart disease.

METHODS

We completed a prospective observational study of neonates with congenital heart disease who were undergoing cardiopulmonary bypass surgery. NSE and s100B levels were measured from serum samples obtained preoperatively, immediately postoperatively, and once daily on postoperative days one to seven. Cranial ultrasounds were obtained preoperatively and postoperatively and findings were scored using an internally developed scoring system.

RESULTS

Eighteen neonates were included. Immediate postoperative and peak levels of both NSE (58.0 [21.6] and 68.1 [55.7] μg/L) and s100B (0.14 [0.3] and 0.14 [0.3] μg/L) were significantly increased when compared with preoperative levels (34.0 [21.6] μg/L; P < 0.01 and 0.08 [0.1] μg/L; P < 0.02). By postoperative day seven, NSE and s100B levels were lower than preoperative levels: NSE (18 [5.7]; P = 0.09) and s100B (0.03 [0.05]; P < 0.01). Postoperative s100B levels were negatively correlated with age at surgery and positively correlated with circulatory arrest time. Although there was no significant correlation between either NSE or s100B levels and intensive care unit length of stay, hospital length of stay, and pediatric cerebral performance category score, there was a negative correlation between postoperative levels of NSE and ventriculomegaly.

CONCLUSIONS

NSE and s100B levels increase after bypass surgery and return below preoperative baseline levels by postoperative day seven. The levels of s100B were positively correlated with circulatory arrest time and negatively correlated with age at time of surgery. This finding may be supportive of pre-existing prenatal brain injury that could be enhanced by longer surgical times but also of some brain protection effect associated with longer wait until surgery.

Brain injury with systemic inflammation in newborns with congenital heart disease undergoing heart surgery

The potential role of systemic inflammation on brain injury in newborns with congenital heart disease (CHD) was assessed by measuring levels of central nervous system (CNS)-derived proteins in serum prior to and following cardiac surgery. A total of 23 newborns (gestational age, 39±1 weeks) with a diagnosis of CHD that required cardiac surgery with cardiopulmonary bypass (CPB) were enrolled in the current study. Serum samples were collected immediately prior to surgery and 2, 24 and 48 h following CPB, and serum levels of phosphorylated neurofilament-heavy subunit (pNF-H), neuron-specific enolase (NSE) and S100B were analyzed. Systemic inflammation was assessed by measuring serum concentrations of complement C5a and complement sC5b9, and the following cytokines: Interleukin (IL)-1β, IL-6, IL-8, IL-10, IL12p70, interferon γ and tumor necrosis factor (TNF)-α. Analysis of cord blood from normal term deliveries (n=26) provided surrogate normative values for newborns. pNF-H and S100B were 2.4- to 2.8-fold higher (P<0.0001) in patient sera than in cord blood prior to surgery and remained elevated following CPB. Pre-surgical serum pNF-H and S100B levels directly correlated with interleukin (IL)-12p70 (ρ=0.442, P<0.05). pNF-H was inversely correlated with arterial pO₂ prior to surgery (ρ=−0.493, P=0.01) and directly correlated with arterial pCO₂ post-CPB (ρ=0.426, P<0.05), suggesting that tissue hypoxia and inflammation contribute to blood brain barrier (BBB) dysfunction and neuronal injury. Serum IL12p70, IL-6, IL-8, IL-10 and TNF-α levels were significantly higher in patients than in normal cord blood and levels of these cytokines increased following CPB (P<0.001). Activation of complement was observed in all patients prior to surgery, and serum C5a and sC5b9 remained elevated up to 48 h post-surgery. Furthermore, they were correlated (P<0.05) with low arterial pO₂, high pCO₂ and elevated arterial pressure in the postoperative period. Length of mechanical ventilation was associated directly with post-surgery serum IL-12p70 and IL-8 concentrations (P<0.05). Elevated serum concentrations of pNF-H and S100B in neonates with CHD suggest BBB dysfunction and CNS injury, with concurrent hypoxemia and an activated inflammatory response potentiating this effect.

Altered hippocampal microRNA expression profiles in neonatal rats caused by sevoflurane anesthesia: MicroRNA profiling and bioinformatics target analysis

Although accumulating evidence has suggested that microRNAs (miRNAs) have a serious impact on cognitive function and are associated with the etiology of several neuropsychiatric disorders, their expression in sevoflurane-induced neurotoxicity in the developing brain has not been characterized. In the present study, the miRNAs expression pattern in neonatal hippocampus samples (24 h after sevoflurane exposure) was investigated and 9 miRNAs were selected, which were associated with brain development and cognition in order to perform a bioinformatic analysis. Previous microfluidic chip assay had detected 29 upregulated and 24 downregulated miRNAs in the neonatal rat hippocampus, of which 7 selected deregulated miRNAs were identified by the quantitative polymerase chain reaction. A total of 85 targets of selected deregulated miRNAs were analyzed using bioinformatics and the main enriched metabolic pathways, mitogen-activated protein kinase and Wnt pathways may have been involved in molecular mechanisms with regard to neuronal cell body, dendrite and synapse. The observations of the present study provided a novel understanding regarding the regulatory mechanism of miRNAs underlying sevoflurane-induced neurotoxicity, therefore benefitting the improvement of the prevention and treatment strategies of volatile anesthetics related neurotoxicity.

Effect of Intercurrent Operation and Cerebral Oxygenation on Developmental Trajectory in Congenital Heart Disease

BACKGROUND

Children with congenital heart disease are at increased risk of abnormal neurodevelopment (ND). Demographic and perioperative physiologic factors have both been associated with developmental outcome. The acute physiologic effect of a surgical procedure, anesthesia, and hospitalization may offset any potential advantage gained from anatomic correction and circulatory palliation. The specific risk/benefit balance on ND outcome of the insult of the operation, offset by the benefit of improved anatomy and physiology, has not been addressed. We therefore sought to identify interval procedural and physiologic factors assessed at outpatient ND evaluation visits that were associated with outcome.

METHODS

The study included children with congenital heart disease at high risk for impaired ND performance with at least three ND assessments using the Bayley Scales of Infant Development-III during the first 3 years of life. The number of cardiac procedures, duration of hospitalization, feeding status, height, weight, and arterial, cerebral, and somatic oxygen saturations by near-infrared spectroscopy were recorded at each visit and used as predictors of language, motor, and cognitive composite scores and slopes (change over time) in general linear models.

RESULTS

Data on 178 children derived from 632 visits (median, 4 visits/child) were analyzed, with ages at first and last assessment of 7.7 and 30.2 months. Fifty-one had 1 ventricle (1V), 88 had 2 ventricles, and 39 had genetic syndrome conditions. Motor performance increased with age in all diagnostic categories. Cognitive and language performance increased with age in 1V patients but exhibited no significant change in 2-ventricle and genetic syndrome groups. At the first visit, 1V patients performed less well than 2-ventricle patients in the motor domain, but the rate of improvement was higher for 1V patients; by 24 months, there were no differences, and both groups were normal in all domains. Performance in genetic syndrome patients was below normal in all domains at the first visit and did not improve. Higher arterial saturation and narrower arterial-cerebral and arterial-somatic near-infrared spectroscopy saturation differences were associated with better or improving motor performance. Incremental cardiopulmonary bypass time, cumulative hospital length of stay, and tube feedings were risk factors in all domains. Total and incremental times for deep hypothermic circulatory arrest, extracorporeal membrane oxygenation, total open and total surgical procedures, and birth weight were not risk factors.

CONCLUSIONS

Patient physiologic status assessed by cerebral and somatic near-infrared spectroscopy is associated with ND performance. Incremental surgical procedures are not associated with ND performance when adjusted for cardiopulmonary bypass time and physiologic status. Treatment strategies that target improved physiologic status may also improve ND outcome.

The Year in Review

Congenital cardiac anesthesiology is a rapidly expanding field at both ends of the life spectrum. The care of the unborn child with congenital heart disease is becoming highly specialized in regional centers that offer advanced imaging techniques, coordinated specialist care, and potentially fetal interventions. As more children with congenital heart disease survive to adulthood, patients and their health care providers are facing new challenges. The growing volume of publications reflects this expanding field of congenital cardiac anesthesiology. This year in review article highlights some developing trends in the literature.