Long-Term Neurodevelopmental Outcome and Exercise Capacity After Corrective Surgery for Tetralogy of Fallot or Ventricular Septal Defect in Infancy

Hövels-Gürich, Hedwig H.; Konrad, Kerstin; Skorzenski, Daniela; Nacken, Claudia; Minkenberg, Ralf; Messmer, Bruno J.; Seghaye, Marie-Christine

doi:10.1016/j.athoracsur.2005.09.010

Cited by 141 publications

(102 citation statements)

References 37 publications

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“…However, with increasing time spent under XC, significant differences in rSO 2 and PI values emerge, with a consistent benefit of pulsatile flow seen in all measures analyzed at advanced time points. Studies have reported increasing rates of adverse acute and neurodevelopmental outcomes in patients experiencing longer times under hypothermic CPB, which is exacerbated by worsening operative conditions posing greater challenges for surgical procedures in general at these time points (22,23), and as such methods that may ameliorate adverse events during long operative protocols are of great relevance to brain protection. Results of this study provide further evidence of the benefits of pulsatile over nonpulsatile flow by demonstrating improved readings in brain monitoring modalities that represent novel measures in the context of perfusion mode comparisons.…”

Section: Discussionmentioning

confidence: 99%

Improved Cerebral Oxygen Saturation and Blood Flow Pulsatility With Pulsatile Perfusion During Pediatric Cardiopulmonary Bypass

Guan

Barnes

et al. 2011

Pediatr Res

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Brain monitoring techniques near-infrared spectroscopy (NIRS) and transcranial Doppler (TCD) ultrasound were used in pediatric patients undergoing cardiopulmonary bypass for congenital heart defect (CHD) repair to analyze the effect of pulsatile or nonpulsatile flow on brain protection. Regional cerebral oxygen saturation (rSO 2 ) and cerebrovascular pulsatility index (PI) were measured by NIRS and TCD, respectively, in 111 pediatric patients undergoing bypass for CHD repair randomized to pulsatile (n ϭ 77) or nonpulsatile (n ϭ 34) perfusion. No significant differences in demographic and intraoperative data, including surgical risk stratification, existed between groups. Patients undergoing pulsatile perfusion had numerically lower decreases in rSO 2 from baseline for all time points analyzed compared with the nonpulsatile group, with significant ϳ12% lower decreases at 40 and 60 min after crossclamp. Patients undergoing pulsatile perfusion had numerically lower decreases in PI from baseline for the majority of time points compared with the nonpulsatile group, with significant ϳ30% lower decreases between 5 and 40 min after crossclamp. Pulsatile flow has advantages over nonpulsatile flow as measured by NIRS and TCD, especially at advanced time points, which may improve postoperative neurodevelopmental outcomes. A dvances in intraoperative surgical techniques and postoperative intensive care have substantively improved patient outcomes and decreased mortality rates in pediatric cardiac surgery for the repair of congenital heart defects (CHDs). With in-hospital mortality reported to be below 3% for categorized operations in a recent study despite an increase in case complexity (1), there is a growing need to address the paradoxical increased incidence of adverse neurological outcomes in the survivors of surgery. Cardiopulmonary bypass (CPB) presents unique challenges in this regard, with the extreme conditions encountered during extracorporeal support coupled with requisite surgical techniques that place severe stress on the patient acting in tandem to cause insult and injury to the brain. With increased incidence of postoperative neurologic complications reported in pediatric patients undergoing CPB, including neuromotor disabilities, learning disabilities, and behavioral abnormalities (2,3), there is increasing relevance for intra-and early postoperative brain monitoring techniques, which may predict neurologic outcomes and provide medical professionals actionable information to aid in the minimization of adverse sequelae (4).The debate between pulsatile and nonpulsatile perfusion modes further complicates considerations of best practices during pediatric CPB with the aim of minimizing neurological morbidity (5). Although current findings suggest that pulsatile flow imparts distinct advantages including increased hemodynamic energy leading to better blood flow to major organs such as brain, movement of lymph that prevents edema and sludging in microcapillaries, maintained microcirculatory flow, improve...

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Section: Discussionmentioning

confidence: 99%

Improved Cerebral Oxygen Saturation and Blood Flow Pulsatility With Pulsatile Perfusion During Pediatric Cardiopulmonary Bypass

Guan

Barnes

et al. 2011

Pediatr Res

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“…28 Adult patients with CHD, even after correction of CHD, may display lower academic abilities, including in language expression, intelligence, and motor skills. 29,30 With these handicaps, psychosocial functioning may be jeopardized and the risk of suicide or accidental death may increase. Third, depression is also a common problem in adult patients with CHD, and may significantly affect their quality of life and late mortality.…”

Section: Importance Of Unnatural Deathsmentioning

confidence: 99%

Long-Term Survival and Unnatural Deaths of Patients With Repaired Tetralogy of Fallot in an Asian Cohort

Chiu

Wang

Chen

et al. 2012

Circ: Cardiovascular Quality and Outcomes

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Background— Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease in Taiwan. This study investigates the long-term survival and risks of TOF in an Asian cohort. Methods and Results— This study enrolled 819 consecutive patients with TOF (61.1% male), who received total correction between 1970 and 2002, as participants. Patient medical records were reviewed, and the survival status of those out of contact was confirmed by death records retrieved from the National Health database. The mean (±SD) patient age at cardiac repair was 6.5±7.6 years, and a prior shunt operation was performed in 119 (14.5%) of the patients. At cardiac repair, a transannular patch for right ventricle outlet reconstruction was required in 444 (54.2%) of the patients. After 13 808 patient-years of follow-up, the 30-year survival rate was 90.5%. The annual mortality rate increased from 0.123% in the initial 15 years after repair to 0.395% thereafter ( P <0.05). The presence of major aortopulmonary collateral arteries, older operative age, and previous shunt operation are independent risks of late cardiac deaths. Secondary to cardiac mortality, unnatural deaths (accident and suicide) accounted for 27.6% of late deaths, significantly higher compared with that of the general population (odds ratio, 2.18; P =0.028). Conclusions— In this Asian TOF cohort, except for a late decrease after 15 years, long-term survival after cardiac repair was satisfactory. Although cardiac death was the most common cause of late death, accidents or suicide may also be associated with late mortality, suggesting a potential role for psychosocial support.

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“…Galli et al 19 have shown the presence of periventricular white matter changes on MRI in 54% of neonates who underwent cardiopulmonary bypass for repair of congenital heart disease and have identified both arterial PaO 2 and diastolic blood pressure to be independent risk factors for this abnormal outcome. Hovels-Gurich et al 20 have also shown preoperative hypoxemia to be associated with an increased risk of motor dysfunction in long-term follow up. Toet et al 21 studied cerebral oxygen saturation in term infants undergoing the arterial switch procedure.…”

Section: Resultsmentioning

confidence: 99%

Early discontinuation of intravenous prostaglandin E1 after balloon atrial septostomy is associated with an increased risk of rebound hypoxemia

et al. 2008

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Objective: A comparison of the effects of early (<2 h) and late (X2 h) discontinuation of prostaglandin E 1 (PGE 1 ), on systemic oxygenation following a successful balloon atrial septostomy (BAS), in neonates with confirmed diagnosis of d-transposition of the great arteries (d-TGA).Study Design: Neonates with a postnatal diagnosis of d-TGA who were admitted to a quaternary neonatal intensive care unit between January 1999 and December 2004 were identified from the local database. The effects of time of discontinuation of PGE 1 on oxygen saturations, oxygen requirement, need for reinstitution of prostaglandin infusion and postoperative stability were analyzed.Result: Sixty neonates with a diagnosis of d-TGA were identified, 45 of whom had a BAS performed. Of these, 25 cases had early (<2 h) discontinuation of PGE 1 whereas in the remaining 20 discontinuation was late (X2 h). PGE 1 infusion was recommenced in 20 neonates (20/45 (44%)) after a successful BAS due to rebound hypoxemia. Of these, there was a threefold increase in the need for reinstitution of prostaglandin in the early compared to late discontinuation group (16/25 (64%) vs 4/20 (20%), P<0.006). There was no difference in postoperative cardiorespiratory stability. Conclusion:Early discontinuation of intravenous PGE 1 following BAS was associated with an increased risk of rebound hypoxemia, necessitating the recommencement of PGE 1 . We speculate the rapid improvement in oxygenation on reinstitution of PGE 1 is secondary to pulmonary vasodilation and improved pulmonary blood flow. We propose a more cautious and graded approach to discontinuation of PGE 1 based on illness severity and the magnitude and duration of hypoxemia at presentation.

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Long-Term Neurodevelopmental Outcome and Exercise Capacity After Corrective Surgery for Tetralogy of Fallot or Ventricular Septal Defect in Infancy

Cited by 141 publications

References 37 publications

Improved Cerebral Oxygen Saturation and Blood Flow Pulsatility With Pulsatile Perfusion During Pediatric Cardiopulmonary Bypass

Improved Cerebral Oxygen Saturation and Blood Flow Pulsatility With Pulsatile Perfusion During Pediatric Cardiopulmonary Bypass

Long-Term Survival and Unnatural Deaths of Patients With Repaired Tetralogy of Fallot in an Asian Cohort

Early discontinuation of intravenous prostaglandin E1 after balloon atrial septostomy is associated with an increased risk of rebound hypoxemia

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