Preoperative Brain Injury in Transposition of the Great Arteries Is Associated With Oxygenation and Time to Surgery, Not Balloon Atrial Septostomy

Abstract

Background-Preoperative brain injury is an increasingly recognized phenomenon in neonates with complex congenital heart disease. Recently, reports have been published that associate preoperative brain injury in neonates with transposition of the great arteries with the performance of balloon atrial septostomy (BAS), a procedure that improves systemic oxygenation preoperatively. It is unclear whether BAS is the cause of brain injury or is a confounder, because neonates who require BAS are typically more hypoxemic. We sought to determine the relationship between preoperative brain injury in neonates with transposition of the great arteries and the performance of BAS. We hypothesized that brain injury results from hypoxic injury, not from the BAS itself. Methods and Results-Infants with transposition of the great arteries (nϭ26) were retrospectively included from a larger cohort of infants with congenital heart disease who underwent preoperative brain MRI as part of 2 separate prospective studies. Data collected included all preoperative pulse oximetry recordings, all values from preoperative arterial blood gas measurements, and BAS procedure data. MRI scans were performed on the day of surgery, before the surgical repair.Of the 26 neonates, 14 underwent BAS. No stroke was seen in the entire cohort, whereas 10 (38%) of 26 patients were found to have hypoxic brain injury in the form of periventricular leukomalacia. Periventricular leukomalacia was not associated with BAS; however, neonates with periventricular leukomalacia had lower preoperative oxygenation (Pϭ0.026) and a longer time to surgery (Pϭ0.028) than those without periventricular leukomalacia. Conclusions-Preoperative brain injury in neonates with transposition of the great arteries is associated with hypoxemia and longer time to surgery. We found no association between BAS and brain injury.

Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease

“…Balloon atrial septostomy is typically performed without the use of procedural heparinization. 683 Other interventions such as the creation of atrial communications with the use of various techniques are typically done with full heparinization because most of these patients do need femoral arterial access, as well as catheterization of the left side of the heart. Specific recommendations in this regard cannot be formulated because there is a paucity of published information.…”

Impact of balloon atrial septostomy in neonates with transposition of great arteries

“…In another study, Petit et al, in a cohort of 26 infants with TGA found periventricular leucomalacia in 38%, which was not associated with BAS but with lower preoperative oxygenation and longer time to surgery. 28 The limitations of our study include its retrospective nature and the inherent associated biases. Our sample size was small, although in line with similar studies.…”

Effect of balloon atrial septostomy on cerebral oxygenation in neonates with transposition of the great arteries

“…However, Applegate and Lim did not find this association in 2,000 children with TGA (21). Furthermore, recent magnetic resonance imaging studies have suggested that decreased arterial oxygenation and the presence of an intact ventricular septum, and not BAS, are associated with preoperative brain injury (7,22). Nevertheless, the risk of thrombosis remains a possible adverse risk factor associated with BAS.…”

“…Magnetic resonance imaging studies demonstrate that 25-40% of neonates with complex congenital heart disease already have evidence of brain injury before surgery (6)(7)(8)(9). Severe preoperative hypoxia and acidosis have already been identified as predisposing factors to preoperative brain injury and motor delay in school-aged children with TGA (3,7).…”

“…Severe preoperative hypoxia and acidosis have already been identified as predisposing factors to preoperative brain injury and motor delay in school-aged children with TGA (3,7).…”