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. 2023 Dec 4:17:229-247.
doi: 10.1016/j.xjon.2023.11.018. eCollection 2024 Feb.

Brain injury and neurodevelopmental outcomes in children undergoing surgery for congenital heart disease

Justus G Reitz  1 , David Zurakowski  2 , Viktoria A Kuhn  3 , Johnathan Murnick  4 , Mary T Donofrio  5 , Yves d'Udekem  6 , Daniel Licht  7 , Agnieszka Kosiorek  8 , Catherine Limperopoulos  9 , Roland Axt-Fliedner  3 , Can Yerebakan  7 , Jessica L Carpenter  10
Affiliations

Brain injury and neurodevelopmental outcomes in children undergoing surgery for congenital heart disease

Justus G Reitz et al. JTCVS Open. .

Abstract

Objectives: Brain injury is commonly seen on magnetic resonance imaging in infants with complex congenital heart disease. The impact of perioperative brain injury on neurodevelopmental outcomes is not well understood. We evaluate the association of brain injury and other markers on neurodevelopmental outcomes in patients undergoing surgery for congenital heart surgery during infancy.

Methods: Term newborns with infant cardiac surgery performed between 2008 and 2019 at a single tertiary center, and both preoperative and postoperative brain magnetic resonance imaging were included. Those with underlying genetic conditions were excluded. Brain injury was characterized using an magnetic resonance imaging scoring system. Neurodevelopmental outcomes were assigned using the Pediatric Stroke Outcome Measure and Glasgow Outcome Scale Extended. Independent risk factors for poor neurodevelopmental outcomes were determined by multivariable Cox regression.

Results: A total of 122 patients were included. New or progressive postoperative brain injury was noted in 69 patients (57%). A total of 101 patients (83%) had at least 1 neurodevelopmental assessment (median age 36 months) with an early assessment (5-24 months) performed in 95 children. Multivariable Cox regression analysis of early neurodevelopmental outcomes identified new stroke on postoperative magnetic resonance imaging to be an independent predictor of poor neurodevelopmental outcome. Postoperative peak lactate was an independent predictor of poor outcome assessed by the Pediatric Stroke Outcome Measure and Glasgow Outcome Scale Extended.

Conclusions: Our study reveals that evidence of new stroke on magnetic resonance imaging after infant congenital heart surgery is a predictor of poor neurodevelopmental outcomes in early childhood. Postoperative lactic acidosis is associated with poor neurodevelopmental outcome and may be a surrogate biomarker for ischemic brain injury.

Keywords: brain injury; cardiac surgery; congenital heart disease; magnetic resonance imaging; neurodevelopmental outcome; stroke.

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Conflict of interest statement

The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

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Graphical abstract
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Elevated postoperative serum lactate levels are a useful clinical biomarker to identify patients at risk for ischemic brain injury with impact on ND outcome in childhood.
Figure 1
Figure 1
ND outcome by stroke time and severity (includes only patients with ND assessment). Mild: less than 1/3 of vascular territory of ACA, MCA, or PCA in 1 hemisphere, total size 1 to 5 mm. Moderate: 1/3 to 2/3 of vascular territory, total size 6 to 15 mm. Severe: greater than 2/3 of vascular territory, total size greater than 15 mm. MRI, Magnetic resonance imaging; ND, neurodevelopmental.
Figure 2
Figure 2
Significant risk factors in multivariable analysis for poor ND outcome (GOS-E) at 5 to 24 months of age. CI, Confidence interval.
Figure 3
Figure 3
Predicted probability of poor neurological outcome based on peak lactate. GOS-E, Glasgow Outcome Scale Extended; PSOM, Pediatric Stroke Outcome Measure; CI, confidence interval.
Figure 4
Figure 4
Graphical Abstract: new ischemic stroke on postoperative MRI increases the risk for early ND disability and lactate peaks during the postoperative course is a predictor for poor ND outcome in childhood. CHD, Congenital heart disease; ND, neurodevelopmental; CI, confidence interval; GOS-E, Glasgow Outcome Scale Extended; PSOM, Pediatric Stroke Outcome Measure.
Figure E1
Figure E1
Significant risk factors in multivariable analysis for PSOM at 5 to 24 months of age.
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