Infection and white matter injury in infants with congenital cardiac disease

Glass, Hannah C.; Bowman, Chelsea; Chau, Vann; Moosa, Alisha; Hersh, Adam L.; Campbell, Andrew; Poskitt, Kenneth J.; Azakie, Anthony; Barkovich, A. James; Miller, Steven P.; McQuillen, Patrick S.

doi:10.1017/s1047951111000473

Cited by 13 publications

(18 citation statements)

References 39 publications

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“…The association between infection and WMI has been observed before in both neonates undergoing cardiac surgery and preterm neonates. 18,23 Furthermore, the use of diuretics was much more common in the UMCU group. Although commonly administered to treat tachypnea and pulmonary edema, diuretics carry a risk of reducing preload and further compromising systemic perfusion, which may result in a higher prevalence of WMI.…”

Section: Discussionmentioning

confidence: 98%

“…1,7,18 For our analysis, UCSF and UBC were considered a single center owing to the smaller sample size of patients with arch obstruction at UBC (n = 10) and initial comparisons showing similar perioperative management at these 2 centers (Table I; available at www.jpeds.com). Informed consent was obtained from all participating parents and from the institutional Medical Ethical Boards.…”

Section: Methodsmentioning

confidence: 99%

“…Infections were assessed as defined previously. 18 All clinical and imaging data were analysed separately by category of prenatal diagnosis.…”

Section: Methodsmentioning

confidence: 99%

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Minimizing the Risk of Preoperative Brain Injury in Neonates with Aortic Arch Obstruction

Algra

Haas

Poskitt

et al. 2014

The Journal of Pediatrics

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Objective To determine whether prenatal diagnosis lowers the risk of preoperative brain injury by assessing differences in the incidence of preoperative brain injury across centers. Study design From 2 prospective cohorts of newborns with complex congenital heart disease studied by preoperative cerebral magnetic resonance imaging, one cohort from the University Medical Center Utrecht (UMCU) and a combined cohort from the University of California San Francisco (UCSF) and University of British Columbia (UBC), patients with aortic arch obstruction were selected and their imaging and clinical course reviewed. Results Birth characteristics were comparable between UMCU (n = 33) and UCSF/UBC (n = 54). Patients had a hypoplastic aortic arch with either coarctation/interruption or hypoplastic left heart syndrome. In subjects with prenatal diagnosis, there was a significant difference in the prevalence of white matter injury (WMI) between centers (11 of 22 [50%] at UMCU vs 4 of 30 [13%] at UCSF/UBC; P < .01). Prenatal diagnosis was protective for WMI at UCSF/UBC (13% prenatal diagnoses vs 50% postnatal diagnoses; P < .01), but not at UMCU (50% vs 46%, respectively; P > .99). Differences in clinical practice between prenatally diagnosed subjects at UMCU vs UCSF/UBC included older age at surgery, less time spent in the intensive care unit, greater use of diuretics, less use of total parenteral nutrition (P < .01), and a greater incidence of infections (P = .01). In patients diagnosed postnatally, the prevalence of WMI was similar in the 2 centers (46%at UMCU vs 50% at UCSF/UBC; P > .99). Stroke prevalence was similar in the 2 centers regardless of prenatal diagnosis (prenatal diagnosis: 4.5% at Utrecht vs 6.7% at UCSF/UBC, P = .75; postnatal diagnosis: 9.1% vs 13%, respectively, P > .99). Conclusion Prenatal diagnosis can be protective for WMI, but this protection may be dependent on specific clinical management practices that differ across centers.

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Section: Discussionmentioning

confidence: 98%

Section: Methodsmentioning

confidence: 99%

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Minimizing the Risk of Preoperative Brain Injury in Neonates with Aortic Arch Obstruction

Algra

Haas

Poskitt

et al. 2014

The Journal of Pediatrics

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“…4 Similarly, previous MRI studies performed after neonatal cardiac surgery have found that lower postoperative blood pressure, regional cerebral saturation, and a preceding infection are associated with the occurrence of new lesions. 5,8,24 Animal models of CPB underscore this and have found that lower oxygenation and higher inflammation lead to more WMI. Hence, as proposed by Andropoulos et al, 5 a targeted protocol aiming for acceptable postoperative regional cerebral saturation values may be necessary to ensure adequate cerebral perfusion.…”

Section: Discussionmentioning

confidence: 99%

Neurological Injury After Neonatal Cardiac Surgery

et al. 2014

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S urvival after neonatal cardiac surgery has improved over the past decades to >90% because of major advances in surgical techniques and perioperative management. However, it has also become evident that neurodevelopment is impaired in approximately one third of children who underwent surgery at a neonatal age.1 As seen on magnetic resonance imaging (MRI), 23% to 40% of neonates presenting with a complex cardiac defect already have evidence of cerebral injury preoperatively.2-6 After surgery, 36% to 73% of patients have evidence of new cerebral lesions on MRI. [2][3][4][5][6][7][8] This suggests that much of the injury develops perioperatively. Clinical Perspective on p 233Neonates diagnosed with aortic arch obstruction (ie, hypoplastic left heart syndrome or other complex cardiac defects) are consistently at the highest risk of cerebral injury. 5,7,9 This may be attributable to the fact that full-flow cardiopulmonary bypass (CPB) is not feasible during the reconstruction of the aortic arch, obligating the use of either deep hypothermic circulatory arrest (DHCA) or antegrade cerebral perfusion (ACP). Despite initial reports on the adverse cerebral effects after DHCA and the intuitive benefit of ACP, previous studies have not been able to show superiority of ACP in studies of neurodevelopmental outcome at 1 year of age. 10,11 However, these results may be confounded by the reoperations that frequently take place in the interim.Therefore, in the present randomized, controlled trial, we used preoperative and postoperative MRI as the most sensitive measure to assess perioperative cerebral injury. Specifically, in neonates undergoing aortic arch reconstruction, the incidence of new postoperative injury on MRI was compared between DHCA and ACP.Background-Complex neonatal cardiac surgery is associated with cerebral injury. In particular, aortic arch repair, requiring either deep hypothermic circulatory arrest (DHCA) or antegrade cerebral perfusion (ACP), entails a high risk of perioperative injury. It is unknown whether ACP results in less cerebral injury than DHCA. Methods and Results-Thirty-seven neonates with an aortic arch obstruction presenting for univentricular or biventricular repair were randomized to either DHCA or ACP. Preoperatively and 1 week after surgery, magnetic resonance imaging was performed in 36 patients (1 patient died during the hospital stay). The presence of new postoperative cerebral injury was scored, and results were entered into a sequential analysis, which allows for immediate data analysis. After the 36th patient, it was clear that there was no difference between DHCA and ACP in terms of new cerebral injury. Preoperatively, 50% of patients had evidence of cerebral injury.

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“…All studies were conducted in tertiary urban or teaching hospitals. Among studies conducted in highincome settings, 15 were in European countries, [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] 19 in the United States of America, [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] one in Australia, 36 three elsewhere in North America, [37][38][39] and three in Asia. [40][41][42] There were three nonrandomised interventional studies, 6,22,23 32 cohort studies, [2][3][4][5][7][8]...…”

Section: Epidemiology Of Perioperative Infections In High-income Counmentioning

confidence: 99%

Perioperative infections in congenital heart disease

et al. 2017

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Background: Perioperative infections have significant consequences for children with congenital heart disease (CHD), which can manifest as acute or chronic infection followed by poor growth and progressive cardiac failure. The consequences include delayed or higher-risk surgery, and increased postoperative morbidity and mortality. Methods: A systematic search for studies evaluating the burden and interventions to reduce perioperative infections in children with CHD was undertaken using PubMed. Results: Limited studies conducted in low-to middle-income countries demonstrated the large burden of perioperative infections among children with CHD. Most studies focussed on infections after surgery. Few studies evaluated strategies to prevent preoperative infection or the impact of infection on decision-making around the timing of surgery. Children with CHD have multiple risk factors for infections including delayed presentation, inadequate treatment of cardiac failure, and poor nutrition. Conclusions: The burden of perioperative infections is high among children with CHD, and studies evaluating the effectiveness of interventions to reduce these infections are lacking. As good nutrition, early corrective surgery, and measures to reduce nosocomial infection are likely to play a role, practical steps can be taken to make surgery safer.

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Infection and white matter injury in infants with congenital cardiac disease

Cited by 13 publications

References 39 publications

Minimizing the Risk of Preoperative Brain Injury in Neonates with Aortic Arch Obstruction

Minimizing the Risk of Preoperative Brain Injury in Neonates with Aortic Arch Obstruction

Neurological Injury After Neonatal Cardiac Surgery

Perioperative infections in congenital heart disease

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