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. 2009 Feb 10;119(5):709-16.
doi: 10.1161/CIRCULATIONAHA.107.760819. Epub 2009 Jan 26.

Preoperative brain injury in transposition of the great arteries is associated with oxygenation and time to surgery, not balloon atrial septostomy

Christopher J Petit  1 , Jonathan J Rome, Gil Wernovsky, Stefanie E Mason, David M Shera, Susan C Nicolson, Lisa M Montenegro, Sarah Tabbutt, Robert A Zimmerman, Daniel J Licht
Affiliations

Preoperative brain injury in transposition of the great arteries is associated with oxygenation and time to surgery, not balloon atrial septostomy

Christopher J Petit et al. Circulation. .

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 (n=26) 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 (P=0.026) and a longer time to surgery (P=0.028) 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.

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Figures

Figure 1
Figure 1
Arterial oxygenation before and after BAS. Six neonates were found to have PVL on MRI imaging (heavy lines). Those 6 patients with PVL had a mean improvement in arterial Po2 of 5.9 mm Hg compared with an improvement of 14.3 mm Hg in the no-PVL group (thin lines). Student t testing demonstrated a significant difference between the mean improvement in BAS patients with PVL compared with those who did not have PVL (P=0.02).
Figure 2
Figure 2
Brain MRI of preoperative infants with TGA: T1 imaging (A) and diffusion-weighted imaging (B) in a patient with mild PVL, which is a unifocal, small (<3 mm) white matter lesion. The lower MRI images demonstrate axial (C) and coronal (D) T1 imaging in a patient with bilateral, multifocal (moderate PVL) white matter disease.
Figure 3
Figure 3
A daily mean Po2 was calculated for the PVL and no-PVL groups. Repeated-measures ANOVA demonstrated a significant difference in mean daily Po2 between the PVL group (dashed line) and the no-PVL group (solid line; P=0.02). The PVL group never achieved a mean daily Po2 >40 mm Hg.
Figure 4
Figure 4
Risk model of PVL: Mean preoperative arterial Po2 is plotted against time to surgery for each patient in the entire cohort. Quartiles of risk were derived by logistic regression analysis. Patients who underwent BAS are represented by triangles, whereas those who did not undergo BAS are represented by circles. The patients found to have PVL (solid black characters) had lower preoperative Po2 and longer time to surgery.
Figure 5
Figure 5
Logistic link function estimating risk of PVL by preoperative Po2 and time to surgery. The probability of PVL (y-axis) rises with the log odds (x-axis), which is derived with the equation: Log odds=14.04-0.45 (Po2)+0.63 (days to surgery). The effects of oxygenation and time to surgery are linear in the log-odds scale (x-axis) but are nonlinear in the probability scale (y-axis).
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References

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