First things first: The importance of the preoperative period for neurocognitive outcomes in hypoplastic left heart syndrome

Lynch, Jennifer M.; Licht, Daniel J.

doi:10.1016/j.jtcvs.2016.03.001

Cited by 3 publications

(3 citation statements)

References 15 publications

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“…The significance of longer time-to-surgery has been previously demonstrated. 10, 11, 40 Further, we have shown that in patients with HLHS there exists a strong correlation between lower cerebral oxygen saturations and longer time-to-surgery and that these factors increased the risk for both the prevalence and severity of WMI/PVL. The current results provide insight into the underlying cause of this increased risk.…”

Section: Discussionmentioning

confidence: 88%

Preoperative cerebral hemodynamics from birth to surgery in neonates with critical congenital heart disease

Lynch

Busch

et al. 2018

The Journal of Thoracic and Cardiovascular Surgery

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Section: Discussionmentioning

confidence: 88%

Preoperative cerebral hemodynamics from birth to surgery in neonates with critical congenital heart disease

Lynch

Busch

et al. 2018

The Journal of Thoracic and Cardiovascular Surgery

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“…[7][8][9] Risk factors for WMI have been well-characterized. 7,10,11 In contrast, although cerebral microhemorrhages (CMH) are the most common finding on perioperative brain magnetic resonance imaging (MRI), there is limited available data on risk factors for and clinical significance of CMH. In this study, we aimed to identify the prevalence of, risk factors for, and impact of CMH on neurodevelopmental outcomes in a cohort of infants with CHD who underwent surgery with CPB within the first two weeks of life.…”

Section: Introductionmentioning

confidence: 99%

Cerebral microhemorrhages in children with congenital heart disease: Prevalence, risk factors, and impact on neurodevelopmental outcomes

Andersen,

Yao,

White

et al. 2023

Preprint

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BackgroundInfants with complex congenital heart disease (CHD) require life-saving corrective/palliative heart surgery in the first weeks of life. These infants are at risk for brain injury and poor neurodevelopmental outcomes. Cerebral microhemorrhages (CMH) are frequently seen after neonatal bypass heart surgery, but it remains unknown if CMH are a benign finding or constitute injury. Herein, we investigate the risk factors for developing CMH and their clinical significance.Methods192 infants with CHD undergoing corrective cardiac surgery with cardiopulmonary bypass (CPB) at a single institution were prospectively evaluated with pre-(n = 183) and/or postoperative (n = 162) brain magnetic resonance imaging (MRI). CMH severity was scored based on total number of microhemorrhages. Antenatal, perioperative, and postoperative candidate risk factors for CMH and neurodevelopmental (ND) outcomes were analyzed. Eighteen-month neurodevelopmental outcomes were assessed using the Bayley-III Scales of Infants and Toddler Development in a subset of patients (n = 82). Linear regression was used to analyze associations between risk factors or ND outcomes and presence/number of CMH.ResultsThe most common CHD subtypes were hypoplastic left heart syndrome (HLHS) (37%) and transposition of the great arteries (TGA) (33%). Forty-two infants (23%) had CMH present on MRI before surgery and 137 infants (85%) post-surgery. No parameters evaluated were significant risk factors for preoperative CMH. In multivariate analysis, cardiopulmonary bypass (CPB) duration (p < 0.0001), use of extracorporeal membrane oxygenation (ECMO) support (p < 0.0005), postoperative seizure(s) (p < 0.03), and lower birth weight (p < 0.03) were associated with new or worsened CMH postoperatively. Higher CMH number was associated with lower scores on motor (p < 0.03) testing at 18 months.ConclusionCMH is a common imaging finding in infants with CHD with increased prevalence and severity after CPB and adverse impact on neurodevelopmental outcomes starting at a young age. Longer duration of CPB and need for postoperative ECMO were the most significant risk factors for developing CMH. However, presence of CMH on preoperative scans indicates non-surgical risk factors that are yet to be identified. Neuroprotective strategies to mitigate risk factors for CMH may improve neurodevelopmental outcomes in this vulnerable population.

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“…Lynch and colleagues 4 suggest that preoperative patients may be particularly vulnerable because of an inability to decrease cerebral vascular resistance and increase cerebral blood flow in response to increasing oxygen demand, or to other stresses such as hypoxia or anemia. 4,23 Their previous work, however, has shown that preoperative neonates with either TGA or HLHS consistently demonstrate increased cerebral blood flow in response to hypercapnia, 8,24 indicating preservation of physiologic reserve in the cerebral vascular bed. Certainly, more work is necessary to clarify and reconcile these findings.…”

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confidence: 97%

Cerebral oxygenation and white matter injury: Pieces in a puzzle unsolved

Bradley

2018

The Journal of Thoracic and Cardiovascular Surgery

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White matter injury detected by brain magnetic resonance imaging (MRI) is now recognized to be a common finding both before and after cardiac surgery in neonates. In 2 previous studies, investigators from the Children's Hospital of Philadelphia (CHOP) have reported that older age at surgery is associated with white matter injury, characterized by periventricular leukomalacia (PVL). 1,2 Among 26 neonates with transposition of the great arteries (TGA), a longer time to surgery was independently associated with PVL on preoperative brain MRI. 1 The mean time to surgery was 5.6 days among patients with PVL, versus 3.9 days among those without PVL. In a subsequent study, 37 neonates with hypoplastic left heart syndrome (HLHS) underwent brain MRI both before and approximately 1 week after stage 1 palliation. 2 A longer time from birth to surgery was independently associated with the development of new or worsened postoperative PVL. The mean time to surgery was 5.3 days among those with a large volume of acquired postoperative PVL, versus 3.1 days among those with a small volume or no new PVL. 2 These findings are provocative, especially given the age at surgery for patients with TGA and HLHS in current practice. In the most recent data from the Society of Thoracic Surgeons Congenital Heart Surgery Database, the median age at surgery was 6 days for both an arterial switch and a Norwood procedure. 3 The mechanisms underlying an association between older age at surgery and white matter injury are not known. This knowledge gap serves as an impetus for further study of preoperative cerebral blood flow and oxygenation. In this issue of the Journal, Lynch and colleagues 4 from CHOP examine cerebral hemodynamics between the time of birth and surgery in neonates with either TGA or HLHS. Lynch and colleagues 4 used a custom-made optical instrument that combines 2 distinct near-infrared light techniques, diffuse optical spectroscopy (DOS) and diffuse correlation spectroscopy (DCS). DOS is akin to the commercially available near-infrared spectrographic (NIRS) devices now in widespread use. The commercial

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First things first: The importance of the preoperative period for neurocognitive outcomes in hypoplastic left heart syndrome

Cited by 3 publications

References 15 publications

Preoperative cerebral hemodynamics from birth to surgery in neonates with critical congenital heart disease

Preoperative cerebral hemodynamics from birth to surgery in neonates with critical congenital heart disease

Cerebral microhemorrhages in children with congenital heart disease: Prevalence, risk factors, and impact on neurodevelopmental outcomes

Cerebral oxygenation and white matter injury: Pieces in a puzzle unsolved

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