Perioperative Stroke in Infants Undergoing Open Heart Operations for Congenital Heart Disease

Abstract

. INVITED COMMENTARYI read with interest the article by Chen and colleagues [1]. A 10% incidence of perioperative stroke is a possible partial explanation for less than ideal neurodevelopmental outcomes in congenital heart disease (CHD) [2,3]. Additional explanations are genetic causes [4], fetal development with CHD, and injury that is not measured by imaging. If we are to improve neurologic outcomes, there are four areas in which practice improvement needs to become uniform or further explored: (1) prenatal diagnosis and maternal care, (2) postnatal preoperative care, (3) operative interventional strategies, and (4) postoperative care. Specifics of these are briefly discussed. 1.Can fetal diagnosis and maternal care for all having CHD impact birth weight and thereby mitigate this as a risk? 2.Can fetal triage to a congenital cardiac liaised high-risk obstetrics and neonatal team preclude cardiorespiratory instability in more babies and thus lessen preoperative stroke? 3.Risk was shown to be modifiable in the operating room. A higher hematocrit (28% vs 26%) on cardiopulmonary bypass (CPB) was associated with a lower incidence of stroke. This corroborates previous findings that hematocrit on CPB is important [5]. Not all factors believed to be a risk in the operating room were actually a risk. Circulatory arrest, as performed and compared, did not impact neurodevelopment. Fruitful areas for further study will include hybrid stage I versus conventional stage I palliation for single ventricle and arch obstruction, further human studies on pCO2 management strategy for CPB, rate of CPB flow, and others. 4.Postoperative measurements, such as systemic oxygen delivery [6], length of stay in the intensive care unit, and other factors are also important and potentially modifiable.Survival with CHD has become an expectation. It is our duty to ensure that those unfortunate enough to have CHD not only survive, but live. Continued critical data analysis in the areas outlined, trials, and modification of practice will allow us to help our patients live-in the fullest sense. AbstractBackground-The prevalence of perioperative stroke in infants undergoing operations for congenital heart disease has not been well described. The objectives of this study were to determine the prevalence of stroke as assessed by postoperative brain magnetic resonance imaging (MRI), characterize the neuroanatomic features of focal ischemic injury, and identify risk factors for its development.

Neurodevelopmental Outcomes in Children With Congenital Heart Disease: Evaluation and Management

“…70 Low brain maturity scores have been shown to be associated with a higher risk of acquired brain injury in newborns with CHD. 132 Chen et al 79 found that the incidence of stroke on brain MRI in infants who had undergone an operation with CPB for CHD was 10%; however, most strokes were clinically silent and would not have been detected in the short-term without the use of neuroimaging. Another study found that the incidence of periventricular leukomalacia in neonates with CHD increased from 16% before surgery to 48% after surgery.…”

“…However, early ischemic stroke 175 or white matter injury 176 may be missed on head CT, because perioperative strokes in this population may be clinically silent. 79 Therefore, further imaging with MRI should be obtained as soon as clinically feasible. 177 Although MRI has been used to measure and differentiate the neurological impact of various surgical strategies on the brain, 77,178,179 the indications for brain MRI for the asymptomatic child with CHD are poorly defined given the unclear prognostic value of abnormal findings and the lack of a consensus on the need for treatment of asymptomatic periventricular leukomalacia.…”

“…These central nervous system events may contribute to the presence of acute arterial ischemic strokes or cerebral venous sinus thromboses or to the increased prevalence of periventricular leukomalacia in neonates and children after surgery for CHD. [77][78][79] In addition, for newborns with complex CHD who underwent cardiac surgery during the neonatal period or early infancy, subsequent operations with CPB during infancy are associated with decreased mental and psychomotor developmental indices at 1 year of age. 80 …”

Ischemic Stroke in Children and Young Adults With Congenital Heart Disease

“…Previous studies have reported that clinically silent ischemic strokes are quite common postoperatively in children as well as adult patients 8, 26, 27. Our study was limited to clinically evident ischemic strokes and clinically silent strokes were not included in the present study.…”

Challenges and Priorities for Research

“…For example, a 30% incidence of stroke was noted in the Berlin Heart EXCOR pediatric ventricular assist device trial 46 ; it is as high as 10% in newborns undergoing open-heart surgery. 47 Improved prevention and management of stroke will require (1) better methods to diagnose and assess the severity of stroke (ischemic and hemorrhagic), (2) defining risk factors and causes of stroke, and (3) defining the pattern and determinants of long-term outcome. Barriers to progress are numerous, including (1) the poor reliability of clinical diagnosis in very young and critically ill children, (2) the need for MRI to ensure specific and timely diagnosis, (3) a lack of noninvasive bedside neuromonitoring methodologies, and (4) a limited availability of neurovascular expertise and lack of stroke care pathways in many institutions.…”