Abstract:Because of advances in surgical and cardiopulmonary bypass techniques it is now possible to definitively repair the vast majority of congenital heart disease in infancy or childhood. Although the majority of survivors do not have obvious cerebral sequelae, there is increasing disquiet about the high incidence of acute neurological events in the immediated postoperative period as well as evidence that at long-term follow-up there are subtle cognitive and motor deficits in many. Some children are more at risk of… Show more
“…29,33 Specific in utero and perioperative neuroprotective strategies to achieve these goals should be further investigated. 49,50 The strengths of this study include the high proportion of children assessed at 4. …”
BACKGROUND AND OBJECTIVES: Little is known about chronic neuromotor disability (CND) including cerebral palsy and motor impairments after acquired brain injury in children surviving early complex cardiac surgery (CCS). We sought to determine the frequency and presentation of CND in this population while exploring potentially modifiable acute care predictors.METHODS: This prospective follow-up study included 549 children after CCS requiring cardiopulmonary bypass at #6 weeks of age. Groups included those with only 1 CCS, mostly biventricular CHD, and those with .1 CCS, predominantly single ventricle defects. At 4.5 years of age, 420 (94.6%) children received multidisciplinary assessment. Frequency of CND is given as percentage of assessed survivors. Predictors of CND were analyzed using multiple logistic regression analysis.RESULTS: CND occurred in 6% (95% confidence interval [CI] 3.7%-8.2%) of 4.5-year survivors; for 1 CCS, 4.2% (CI 2.3%-6.1%) and .1, 9.8% (CI 7%-12.6%). CND presentation showed: hemiparesis, 72%; spasticity, 80%; ambulation, 72%; intellectual disability, 44%; autism, 16%; epilepsy, 12%; permanent vision and hearing impairment, 12% and 8%, respectively. Overall, 32% of presumed causative events happened before first CCS. Independent odds ratio for CND are age (days) at first CCS, 1.08 (CI 1.04-1.12; P , .001); highest plasma lactate before first CCS (mmol/L), 1.13 (CI 1.03-1.23; P = 0.008); and .1 CCS, 3.57 (CI 1.48-8.9; P = .005).CONCLUSIONS: CND is not uncommon among CCS survivors. The frequency of associated disabilities characterized in this study informs pediatricians caring for this vulnerable population. Shortening the waiting period and reducing preoperative plasma lactate levels at first CCS may assist in reducing the frequency of CND.
WHAT'S KNOWN ON THIS SUBJECT:Neurodevelopmental outcomes after cardiac surgery in early life provide critical information for understanding and improving care. Studies show these children are at risk for arterial ischemic stroke and acquired brain injury; further characterization of motor impairment is needed.
WHAT THIS STUDY ADDS:This study focuses on the presence of chronic neuromotor disabilities including cerebral palsy and motor impairments after acquired brain injury in children surviving early complex cardiac surgery, providing information on the frequency, characteristics, and predictors that may assist in prevention.
“…29,33 Specific in utero and perioperative neuroprotective strategies to achieve these goals should be further investigated. 49,50 The strengths of this study include the high proportion of children assessed at 4. …”
BACKGROUND AND OBJECTIVES: Little is known about chronic neuromotor disability (CND) including cerebral palsy and motor impairments after acquired brain injury in children surviving early complex cardiac surgery (CCS). We sought to determine the frequency and presentation of CND in this population while exploring potentially modifiable acute care predictors.METHODS: This prospective follow-up study included 549 children after CCS requiring cardiopulmonary bypass at #6 weeks of age. Groups included those with only 1 CCS, mostly biventricular CHD, and those with .1 CCS, predominantly single ventricle defects. At 4.5 years of age, 420 (94.6%) children received multidisciplinary assessment. Frequency of CND is given as percentage of assessed survivors. Predictors of CND were analyzed using multiple logistic regression analysis.RESULTS: CND occurred in 6% (95% confidence interval [CI] 3.7%-8.2%) of 4.5-year survivors; for 1 CCS, 4.2% (CI 2.3%-6.1%) and .1, 9.8% (CI 7%-12.6%). CND presentation showed: hemiparesis, 72%; spasticity, 80%; ambulation, 72%; intellectual disability, 44%; autism, 16%; epilepsy, 12%; permanent vision and hearing impairment, 12% and 8%, respectively. Overall, 32% of presumed causative events happened before first CCS. Independent odds ratio for CND are age (days) at first CCS, 1.08 (CI 1.04-1.12; P , .001); highest plasma lactate before first CCS (mmol/L), 1.13 (CI 1.03-1.23; P = 0.008); and .1 CCS, 3.57 (CI 1.48-8.9; P = .005).CONCLUSIONS: CND is not uncommon among CCS survivors. The frequency of associated disabilities characterized in this study informs pediatricians caring for this vulnerable population. Shortening the waiting period and reducing preoperative plasma lactate levels at first CCS may assist in reducing the frequency of CND.
WHAT'S KNOWN ON THIS SUBJECT:Neurodevelopmental outcomes after cardiac surgery in early life provide critical information for understanding and improving care. Studies show these children are at risk for arterial ischemic stroke and acquired brain injury; further characterization of motor impairment is needed.
WHAT THIS STUDY ADDS:This study focuses on the presence of chronic neuromotor disabilities including cerebral palsy and motor impairments after acquired brain injury in children surviving early complex cardiac surgery, providing information on the frequency, characteristics, and predictors that may assist in prevention.
“…105,164,166,168,169 Severe neurological complications are more common in children who have HLH [170][171][172][173] after surgery in younger infants (<3 months old), 171 in operations involving the aortic arch, 81 in surgery that is complicated by multiple organ failure 174 and possibly in acyanotic heart malformations. 175 As children grow older, the frequency of diagnosis of neurodevelopmental problems increases, particularly of neurological deficits (nerve palsies, dyspraxias, seizures, etc.)…”
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HTANewborn screening for congenital heart defects: a systematic review and cost-effectiveness analysis
NHS R&D HTA ProgrammeT he research findings from the NHS R&D Health Technology Assessment (HTA) Programme directly influence key decision-making bodies such as the National Institute for Health and Clinical Excellence (NICE) and the National Screening Committee (NSC) who rely on HTA outputs to help raise standards of care. HTA findings also help to improve the quality of the service in the NHS indirectly in that they form a key component of the 'National Knowledge Service' that is being developed to improve the evidence of clinical practice throughout the NHS.The HTA Programme was set up in 1993. Its role is to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and provide care in the NHS. 'Health technologies' are broadly defined to include all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care, rather than settings of care.The HTA Programme commissions research only on topics where it has identified key gaps in the evi...
“…Newburger et al [14], in a study of hypothermic circulatory arrest versus low-flow bypass, demonstrated that seizures are important indicators of neurodevelopmental outcome, and seizures were higher in patients with circulatory arrest. Even though the rate of postsurgical stroke is known in HLHS patients, the incidence of medically intractable seizures in those patients who underwent Fontan operation is unknown [13,15,16,17]. …”
Hypoplastic left heart syndrome (HLHS) accounts for 4–9% of congenital heart disease in children. The mortality rate among children with HLHS undergoing cardiac repair is well documented, but comparable data for noncardiac surgical procedures are not well known. Medically intractable epilepsy is one of those problems, which arises as a complication of cardiovascular surgery in HLHS and necessitates neurosurgical intervention. There is no published knowledge about neurosurgical procedures performed in children with HLHS in the English literature. Thus, we present a 10-year-old boy who developed medically intractable epilepsy after cardiac surgery for HLHS. The aim of this study is to outline the pre-, intra- and postoperative precautions needed for neurosurgical intervention in HLHS patients to decrease morbidity and mortality.
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