Contemporary incidence of stroke (focal infarct and/or haemorrhage) determined by neuroimaging and neurodevelopmental disability at 12 months of age in neonates undergoing cardiac surgery utilizing cardiopulmonary bypass†

Abstract

Stroke, established by neuroimaging in contemporary clinical practice, was detected in 12% of neonates having CPB, and those undergoing the Norwood procedure have a 3-fold risk of injury. Stroke was associated with NDD at 12 months of age.

‘Big issues’ in neurodevelopment for children and adults with congenital heart disease

“…Depending on the definition, NDD may be the most common adverse outcome in children with CHD. Up to 50% of children requiring cardiac intervention exhibit NDD, including mild cognitive impairments, difficulties with attention and hyperactivity, deficits in motor functioning, social interaction, language and communication skills, and delayed executive function,2–7 which may persist into school age and beyond 8–10. As expected, NDD has a detrimental effect on educational achievement and attainment, which consequently affects later employability, independence and relationships, and may heighten the burden of psychological disturbance and reduce overall QOL11–13 (figure 1).…”

“…Early research focused on intraoperative factors as the cause of adverse neurodevelopmental outcomes in CHD 29 30 49–51. Use of prolonged deep hypothermic circulatory arrest and extracorporeal membrane oxygenation are still considered to be contributory risk factors for adverse outcomes,2 51 and surgical techniques have been adapted, where possible, to minimise potential detrimental burden. Somewhat surprisingly, perioperative factors have been found to explain only 5%–8% of variability in NDD outcomes following cardiac surgery 2 52 53.…”

“…Use of prolonged deep hypothermic circulatory arrest and extracorporeal membrane oxygenation are still considered to be contributory risk factors for adverse outcomes,2 51 and surgical techniques have been adapted, where possible, to minimise potential detrimental burden. Somewhat surprisingly, perioperative factors have been found to explain only 5%–8% of variability in NDD outcomes following cardiac surgery 2 52 53. The fact that modification and improvements in surgical techniques have not been accompanied by improvement in neurodevelopmental outcomes supports this view 27 54.…”

The relationship between neurocognitive decline and the heart‐lung machine

“…However, it is important to note that the literature does explore a few more nuanced subjects related to neurocognitive function and CPB that hint at a relationship between the two. For example, much research has been done on children undergoing cardiac surgery on CPB, and many have found that certain on‐pump procedures are linked to increased risk of stroke, cerebral changes, cognitive impairment, and/or neurodevelopmental disability 39‐44 . However, the literature is not unanimous on this topic either, and some studies have reported no increased risk of neurodevelopmental impairment after such procedures 45 .…”

Goldilocks meets heparin dosing—enough but not too much

“…Neonates with intra-atrial lines after Norwood surgery are at particular risk of thromboembolism, and sometimes thrombus forms despite adequate anticoagulation. 6 Other practices, such as heparinizing patients after Fontan completion, also could be reconsidered, with diverse approaches seemingly yielding similar outcomes.…”