No abstract

Background: Critical congenital heart defects (CCHD) are a subset of mostly cyanotic lesions that require intervention within the first days to weeks of life for survival. For children born with CCHD, the neonatal period is considered the time of highest risk for brain injury as abnormalities in fetal circulation can lead to vulnerabilities in cerebral perfusion prior to corrective cardiac procedures. The prevalence and timing of cerebrovascular events associated with CCHD after the neonatal period is less clear. Methods: We performed a cross-sectional analysis using the National Inpatient Sample database from 2012-2018. We included all children aged 1-18 years hospitalized with either ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). We created multivariable linear and logistic regression models to assess differences in age at stroke onset and mortality after stroke. Results: We identified 4,647 pediatric strokes, 162 (3.5%) of which were associated with CCHD. Adjusting for demographic and clinical covariates, the median age at time of stroke was lower in CCHD patients across all stroke subtypes (Figure). Children with CCHD experienced a higher proportion of IS compared to children without CCHD (75.3% vs 49.5%, P<0.001); and a lower proportion of ICH and SAH (10.5% vs 25.7% and 14.2% vs 24.9%; both P = 0.002). In-hospital mortality for the entire sample following stroke was 10.4% for IS, 14.5% for ICH, and 13.4% for SAH. Adjusting for demographics and confounders, presence of CCHD doubled the odds of death following stroke (OR 2.05; 95% CI 1.35-3.11). Conclusion: Beyond the first year of life, children with CCHD have earlier age at stroke onset and higher post-stroke mortality compared to children without CCHD. Continued vigilance and monitoring of potential neurological complications is warranted in children with CCHD.

Background: Critical congenital heart defects (CCHD) are a subset of cyanotic lesions that require intervention within the first days to weeks of life for survival. For children born with CCHD, the neonatal period is considered the time of highest risk for stroke and overall poor outcomes. Prior studies have identified racial differences in neonatal outcomes among children with CCHD. Whether these differences persist throughout childhood is unclear. Methods: Using the National Inpatient Sample database, we analyzed all children with CCHD ≤ 18 years hospitalized from 2005-2018. Primary outcome was a composite of incident stroke (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) and all-cause mortality within strata of ages and years and over the 14-year period of observation. Chi-square tests and multivariable regression were used to assess differences in outcomes. Trends were analyzed adjusting for sex, insurance, and hospital features. Results: A total of 59,438 children with CCHD were hospitalized during the study period: 58% were White (W), 15% Black (B), and 27% Hispanic (H). Overall rate of stroke or death was 4.7% in White children, 6.6% in Black, and 5.6% in Hispanic. Disparities were most pronounced in infancy (Figure; relative differences (RD) compared to White children: 27% (B) and 20% (H), P=0.000) and in early childhood (Figure; RD: 42% (B) and 9% (H), P=0.002). Black and Hispanic children with CCHD had higher rates of stroke and death from 2005-2009 (Figure; RD compared to White children: 24% (B), 22% (H); P = 0.001) and in 2015-2018 (Figure; RD: 21% (B), 18% (H); P = 0.000). These disparities did not change significantly over time in crude or adjusted models (P=0.07, P=0.06). Conclusion: Racial and ethnic disparities in stroke and death among children with CCHD persist after the neonatal period with only modest change in these differences in recent years. Further work identifying the mediators of these disparities is necessary to improve outcomes in this vulnerable pediatric population.