Brain injury and neurodevelopmental outcomes in children undergoing surgery for congenital heart disease

Justus G Reitz; David Zurakowski; Viktoria A Kuhn; Johnathan Murnick; Mary T Donofrio; Yves d'Udekem; Daniel Licht; Agnieszka Kosiorek; Catherine Limperopoulos; Roland Axt-Fliedner; Can Yerebakan; Jessica L Carpenter

doi:10.1016/j.xjon.2023.11.018

Brain injury and neurodevelopmental outcomes in children undergoing surgery for congenital heart disease

JTCVS Open. 2023 Dec 4:17:229-247. doi: 10.1016/j.xjon.2023.11.018. eCollection 2024 Feb.

Authors

Affiliations

¹ Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, University Hospital Giessen and Marburg, Justus-Liebig University Giessen, Giessen, Germany.
² Departments of Surgery and Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
³ Division of Prenatal Medicine and Fetal Therapy, Department of Obstetrics and Gynecology, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.
⁴ Division of Neuroradiology, Department of Radiology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC.
⁵ Division of Cardiology, Children's National Medical Center, Washington, DC.
⁶ Department of Cardiovascular Surgery, Children's National Medical Center, Washington, DC.
⁷ Department of Neurology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC.
⁸ Diagnostic and Interventional Radiology, University Hospital Zurich, University Zurich, Zurich, Switzerland.
⁹ Institute for the Developing Brain, Children's National Hospital, Washington, DC.
¹⁰ Division of Pediatric Neurology, Departments of Pediatrics and Neurology, University of Maryland, Baltimore, Md.

Abstract

Objectives: Brain injury is commonly seen on magnetic resonance imaging in infants with complex congenital heart disease. The impact of perioperative brain injury on neurodevelopmental outcomes is not well understood. We evaluate the association of brain injury and other markers on neurodevelopmental outcomes in patients undergoing surgery for congenital heart surgery during infancy.

Methods: Term newborns with infant cardiac surgery performed between 2008 and 2019 at a single tertiary center, and both preoperative and postoperative brain magnetic resonance imaging were included. Those with underlying genetic conditions were excluded. Brain injury was characterized using an magnetic resonance imaging scoring system. Neurodevelopmental outcomes were assigned using the Pediatric Stroke Outcome Measure and Glasgow Outcome Scale Extended. Independent risk factors for poor neurodevelopmental outcomes were determined by multivariable Cox regression.

Results: A total of 122 patients were included. New or progressive postoperative brain injury was noted in 69 patients (57%). A total of 101 patients (83%) had at least 1 neurodevelopmental assessment (median age 36 months) with an early assessment (5-24 months) performed in 95 children. Multivariable Cox regression analysis of early neurodevelopmental outcomes identified new stroke on postoperative magnetic resonance imaging to be an independent predictor of poor neurodevelopmental outcome. Postoperative peak lactate was an independent predictor of poor outcome assessed by the Pediatric Stroke Outcome Measure and Glasgow Outcome Scale Extended.

Conclusions: Our study reveals that evidence of new stroke on magnetic resonance imaging after infant congenital heart surgery is a predictor of poor neurodevelopmental outcomes in early childhood. Postoperative lactic acidosis is associated with poor neurodevelopmental outcome and may be a surrogate biomarker for ischemic brain injury.

Keywords: brain injury; cardiac surgery; congenital heart disease; magnetic resonance imaging; neurodevelopmental outcome; stroke.