Onset of brain injury in infants with prenatally diagnosed congenital heart disease

Abstract

Background: The exact onset of brain injury in infants with congenital heart disease (CHD) is unknown. Our aim was, therefore, to assess the association between prenatal Doppler flow patterns, postnatal cerebral oxygenation and short-term neurological outcome.

Methods: Prenatally, we measured pulsatility indices of the middle cerebral (MCA-PI) and umbilical artery (UA-PI) and calculated cerebroplacental ratio (CPR). After birth, cerebral oxygen saturation (rcSO2) and fractional tissue oxygen extraction (FTOE) were assessed during the first 3 days after birth, and during and for 24 hours after every surgical procedure within the first 3 months after birth. Neurological outcome was determined preoperatively and at 3 months of age by assessing general movements and calculating the Motor Optimality Score (MOS).

Results: Thirty-six infants were included. MOS at 3 months was associated with MCA-PI (rho 0.41, P = 0.04), UA-PI (rho -0.39, P = 0.047, and CPR (rho 0.50, P = 0.01). Infants with abnormal MOS had lower MCA-PI (P = 0.02) and CPR (P = 0.01) and higher UA-PI at the last measurement (P = 0.03) before birth. In infants with abnormal MOS, rcSO2 tended to be lower during the first 3 days after birth, and FTOE was significantly higher on the second day after birth (P = 0.04). Intraoperative and postoperative rcSO2 and FTOE were not associated with short-term neurological outcome.

Conclusion: In infants with prenatally diagnosed CHD, the prenatal period may play an important role in developmental outcome. Additional research is needed to clarify the relationship between preoperative, intra-operative and postoperative cerebral oxygenation and developmental outcome in infants with prenatally diagnosed CHD.

Fig 1. Flow chart inclusion and exclusion.

CHD, congenital heart disease; TOP, termination of pregnancy; IUFD, intrauterine fetal demise; NICU, neonatal intensive care unit. * Cardiac lesions that require birth at a congenital heart center.

Fig 2. Fetal Doppler flow patterns, postnatal r_cSO₂ and FTOE according to GMs assessment at the age of 3 months.

Data are shown in box-and-whisker plots. Circles represent outliers. N, normal general movements based on MOS ≥25; A, abnormal general movements based on MOS <25; MCA-PI, pulsatility index of the middle cerebral artery; UA-PI, pulsatility index of the umbilical artery; CPR, cerebroplacental ratio; r_cSO₂, regional cerebral oxygen saturation; FTOE, fractional tissue oxygen extraction.