de Vries
, et al
Brain injury in infants with critical congenital heart disease: insights from two clinical cohorts with different practice approaches
J Pediatr.
; doi:

Investigators from Wilhelmina Children’s Hospital, Utrecht, Netherlands, and The Hospital for Sick Children, Toronto, Canada, conducted a prospective observational cohort study of infants with critical congenital heart disease (CHD) to assess prevalence of and risk factors for acquired brain injury after cardiac surgery. Children with critical CHD who underwent open heart surgery with cardiopulmonary bypass (CPB) at ≤60 days after birth at the 2 study hospitals from 2016 to 2017 were included. Demographic characteristics were collected at baseline.

The primary predictor variables included pre- and postoperative clinical characteristics, including CHD lesion, Apgar score, delivery mode, gestational age, balloon atrioseptostomy, postoperative low cardiac output syndrome (LCOS; defined as lactate >4 and pH <7.30), duration of CPB, surgery duration, selective cerebral perfusion (SCP), and delayed sternal closure. The primary outcomes were preoperative and new or extended postoperative brain injury, as determined by means of brain MRI performed according to clinical protocol. Brain injury was classified as hemorrhagic, cerebral sinovenous thrombosis, or ischemic. Ischemic brain injury was further classified as focal, defined as a single white matter lesion or stroke, or multifocal. Investigators determined the prevalence of preoperative and postoperative brain injury and used multivariable logistic regression models to determine the independent association of predictors with outcomes after adjusting for potential confounders.

There were 124 infants included. The most common CHD lesion was transposition of the great arteries with an intact ventricular septum (n=45); the second most common was single-ventricle physiology with aortic arch obstruction. Among the 100 infants who had undergone preoperative MRI, 30% had ischemic injury, 57% had parenchymal injury, and 4% had sinovenous thrombosis. Among the 120 infants who had undergone postoperative MRI, 51% had new ischemic injury, 21% had new or extended hemorrhagic injury, and 12% had new or extended sinovenous thrombosis. In multivariable analyses, single-ventricle physiology with aortic arch obstruction (adjusted OR [aOR], 3.5; 95% CI, 1.1–12.0) and LCOS (aOR, 4.6; 95% CI, 1.4–15.4) were associated with preoperative multifocal ischemic injury; balloon atrioseptostomy (aOR, 3.2; 95% CI, 1.1–9.7) was associated with preoperative focal ischemic injury. LCOS and SCP were significantly associated with postoperative multifocal and focal ischemic injury, respectively.

The investigators conclude that brain injury is common in infants with critical CHD.

Dr Spar has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

CHD occurs in 3 in 1,000 children, and in these children neurodevelopmental disabilities and psychosocial issues occur in at least 50% of those requiring surgical correction. Cerebral ischemia before, during, and after surgical repair of CHD has been proposed to be the primary mechanism of central nervous system injury, though additional factors may contribute to neurological dysfunction. Injury can...

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