Monitoring the brain before, during, and after cardiac surgery to improve long-term neurodevelopmental outcomes

Abstract

Innovation in surgical and medical management of cardiac disease has generated a dramatic improvement in operative survival. Along with these favourable results in terms of survival is the heightened awareness of neurologic complications, which often become evident beyond the early postoperative period. A large, multicentre prospective study found serious neurologic injury occurs in about one-twentieth of patients after myocardial revascularization in adults.1 More subtle evidence of persistent cognitive decline and functional impairment has been shown to occur in over two-fifths of such patients.2 Acute neurologic abnormalities are reported in up to one-fifth of infants and children who undergo cardiac surgery.3–6 Lasting impairments in cognitive, motor, and expressive functioning have been reported in up to three-fifths of children who have undergone complex cardiac surgery during infancy.7 Specifically, gross and fine motor delays, visual-spatial problems, language deficits and long-term emotional and behavioural problems have been found.8–13

Cerebral and somatic venous oximetry in adults and infants

“…[2550] The use of perirenal monitoring as an indicator of peripheral perfusion has been well established in hemodynamic management of infant and neonatal congenital heart patients in the operating room (OR) and ICU. [2351718212224313546]…”

“…Cerebral saturation thresholds for intervention have been established in adults and neonates based on clinical[31317182333354548] and animal[2732] data indicating that significant neural damage can occur when cerebral rSO 2 is below 40% for more than 180 or 30 minutes, respectively. Though prolonged values below 40% should always be of concern, impact on outcome can be patient specific due to the potential for ischemic preconditioning.…”

Non-invasive assessment of cerebral oxygen metabolism following surgery of congenital heart disease

“…New methods, allowing non-invasive monitoring of cerebral oxygen delivery and metabolism in the postnatal and perioperative period should improve our understanding of CBF in these patients and stimulate the development of concepts for cerebral protection. Non-invasive assessment of cerebral perfusion is still limited [7,20,21]. Ehehalt et al described quantitative measurement of CBF, based on colour duplex sonography of the extracranial arteries [13,14].…”

Changes in Cerebral Oxygen Saturation Correlate With S100B in Infants Undergoing Cardiac Surgery With Cardiopulmonary Bypass

“…The results of this study contribute to the growing body of literature clarifying the role and limitations of NIRS in pediatric heart surgery by correlating continuous, real-time NIRS values to the serum biomarker of brain injury S100B. The study and validation of neuroprotective strategies in CHD surgery are hampered by the lack of a timely, inexpensive, and reliable gold standard test of neurologic injury (29,30). Although the ultimate test of neuroprotection is long-term neurodevelopmental outcome, this endpoint requires lengthy follow-up, and multiple intervening factors can obscure the impact of early perioperative events on later neurocognitive function and development.…”