Neurological Injury After Neonatal Cardiac Surgery

Abstract

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.

Perioperative and bedside cerebral monitoring identifies cerebral injury after surgical correction of congenital aortic arch obstruction

“…As recently published, we found new postoperative MRI injury in 55 % of patients, and at 2 years of age (n = 32), three patients had cerebral palsy, one had a mild motor delay (total motor delay of 13 %) and two had a cognitive delay (6 %) [3].…”

Neurodevelopmental Outcomes After Neonatal Surgery for Major Noncardiac Anomalies

“…In a high percentage of the cardiac patients, both preoperative and de novo postoperative brain damage were visible on MRI. 8,9 These lesions could contribute to the risk of adverse neurodevelopmental outcome. The mechanism and factors increasing the risk of neurodevelopmental delay in NCCA remain unknown.…”

Goal-directed-perfusion in neonatal aortic arch surgery

“…If the blood flow is vertical to the ultrasonic waves, a movement of blood cannot be detected. It remains unclear whether our results can be extrapolated to other RCP strategies including "real" pH-stat regime and deep hypothermia (10,12,14,15,19,22,34). A superiority to other modes of RCP or neuroprotective strategies as deep hypothermic circulatory arrest cannot be derived from our experience to date, but may become likely when gathering data from an increasing number of patients.…”

“…Goal-directed-perfusion in neonatal aortic arch surgery outcome (10,11). Several studies suggested that longer duration of deep hypothermic circulatory arrest is associated with neurocognitive impairment (12)(13)(14), but despite the missing evidence of a clear time limit (12,15), perioperative seizures with impaired motor development (16) and brain damage evident on MRI were consistent with RCP as well (10,17,18).…”

“…Several studies suggested that longer duration of deep hypothermic circulatory arrest is associated with neurocognitive impairment (12)(13)(14), but despite the missing evidence of a clear time limit (12,15), perioperative seizures with impaired motor development (16) and brain damage evident on MRI were consistent with RCP as well (10,17,18). Nevertheless, improved outcome reports (early and late) about shorter postoperative ventilation, improved renal function and adequate time-related neurodevelopment have been subsequently published after using RCP (15,19,20).…”