Changing Expectations for Neurological Outcomes After the Neonatal Arterial Switch Operation

Abstract

Background Expectations for outcomes after the neonatal arterial switch operation (ASO) continue to change. This cohort study describes neurodevelopmental outcomes at age 12 months after neonatal ASO, and analyzes both modifiable, and non-modifiable factors for association with adverse outcomes. Methods ASO patients (n=30) were enrolled in a prospective outcome study, with comprehensive clinical data collection over the first 12 months of life. Brain magnetic resonance imaging (MRI) was done preoperatively and 7 days postoperatively, Bayley Scales of Infant Development III was performed at age 12 months. Results Ten of 30 patients (33%) had preoperative MRI injury; 13 of 30 (43%) had new postoperative MRI injury. 20 (67%) patients had Bayley Scales of Infant Development III: Cognitive score mean was 104.8 ± 15.0, Language score median was 90.0 (25th–75th percentile 83–94), and Motor score mean was 92.3 ± 14.2. Best subsets multivariable analysis found associations between lower preoperative and intraoperative cerebral oxygen saturation, preoperative MRI brain injury, total bypass time, and total midazolam dose and lower Bayley Scales of Infant Development III scores at age 12 months. Conclusions At 12 months after ASO, neurodevelopmental outcome means were within normal population ranges. The new associations reported in this study between potentially modifiable perioperative factors and outcomes require investigations in larger patient cohorts. Beyond survival, which was 100% in this cohort, factors influencing quality of life including neurodevelopmental outcomes, should be routinely investigated in studies of ASO patients.

Usefulness of Routine Head Ultrasound Scans Before Surgery for Congenital Heart Disease

“…A number of studies have reported the rate of preoperative brain injury on MRI in young infants undergoing surgery for CHD to be between 25% and 40%. [12][13][14][15][16] In noncardiac infant populations, MRI has been shown to be superior to HUS in sensitivity and specificity for detection of brain injury, which included white matter abnormalities or periventricular leukomalacia (PVL), 6 ischemia, 17 and hemorrhage, 6,17 but this comparison has not been made in infants with CHD.The purpose of the current study was to assess the utility of preoperative HUS in a cohort of newborns and infants who also underwent preoperative MRI as part of prospective research studies of brain injury in the setting of surgery for CHD. …”

Patent Ductus Arteriosus and the Immature Brain: Is Early Intervention Protective?

“…Numerous studies have reported that PDA leads to lower cerebral oxygenation, 10-12 and Lemmers et al 13 previously reported that infants with PDA had mean arterial blood pressure and regional cerebral oxygen saturation that were significantly lower than those of control infants (mean arterial blood pressure, 33 ± 5 mm Hg vs 38 ± 6 mm Hg; regional cerebral oxygen saturation, 62% ± 9% vs 72% ± 10%, for PDA and controls, respectively). Although lower cerebral oxygenation has been shown to be associated with worse neurodevelopmental outcome in term infants undergoing surgery for congenital heart disease, [14][15][16] this relationship is not addressed in the current article. In preterm infants, lower cerebral volume, specifically decreased total brain volume and deep nuclear gray matter volume, is known to be associated with worse cognitive and motor development and a higher incidence of cerebral palsy.…”

Usefulness of Routine Head Ultrasound Scans Before Surgery for Congenital Heart Disease

“…A number of studies have reported the rate of preoperative brain injury on MRI in young infants undergoing surgery for CHD to be between 25% and 40%. [12][13][14][15][16] In noncardiac infant populations, MRI has been shown to be superior to HUS in sensitivity and specificity for detection of brain injury, which included white matter abnormalities or periventricular leukomalacia (PVL), 6 ischemia, 17 and hemorrhage, 6,17 but this comparison has not been made in infants with CHD.…”