Clinically silent preoperative brain injuries do not worsen with surgery in neonates with congenital heart disease

Block, A.J.; McQuillen, P.S.; Chau, V.; Glass, H.; Poskitt, K.J.; Barkovich, A.J.; Esch, M.; Soulikias, W.; Azakie, A.; Campbell, A.; Miller, S.P.

doi:10.1016/j.jtcvs.2010.03.035

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 140, Issue 3 , Pages 550-557, September 2010

Clinically silent preoperative brain injuries do not worsen with surgery in neonates with congenital heart disease

A.J. Block, BSc
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
P.S. McQuillen, MD
- Department of Pediatrics, The University of California San Francisco, San Francisco, Calif
- Department of Neurology, The University of California San Francisco, San Francisco, Calif
- Address for reprints: Patrick S. McQuillen, MD, Department of Pediatrics, University of California, San Francisco, 505 Parnassus Ave, Room M680, Box 0106, San Francisco, CA 94143-0106.
V. Chau, MD
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
H. Glass, MD
- Department of Pediatrics, The University of California San Francisco, San Francisco, Calif
- Department of Neurology, The University of California San Francisco, San Francisco, Calif
K.J. Poskitt, MDCM
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
A.J. Barkovich, MD
- Department of Neurology, The University of California San Francisco, San Francisco, Calif
- Department of Radiology, The University of California San Francisco, San Francisco, Calif
M. Esch, BA
- Department of Pediatrics, The University of California San Francisco, San Francisco, Calif
W. Soulikias, RN
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
A. Azakie, MD
- Department of Surgery, The University of California San Francisco, San Francisco, Calif
A. Campbell, MD
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
S.P. Miller, MDCM, MAS
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Neurology, The University of California San Francisco, San Francisco, Calif

Received 22 October 2009; received in revised form 15 December 2009; accepted 21 March 2010. published online 30 April 2010.

Objective

Preoperative brain injury, particularly stroke and white matter injury, is common in neonates with congenital heart disease. The objective of this study was to determine the risk of hemorrhage or extension of preoperative brain injury with cardiac surgery.

Methods

This dual-center prospective cohort study recruited 92 term neonates, 62 with transposition of the great arteries and 30 with single ventricle physiology, from 2 tertiary referral centers. Neonates underwent brain magnetic resonance imaging scans before and after cardiac surgery.

Results

Brain injury was identified in 40 (43%) neonates on the preoperative magnetic resonance imaging scan (median 5 days after birth): stroke in 23, white matter injury in 21, and intraventricular hemorrhage in 7. None of the brain lesions presented clinically with overt signs or seizures. Preoperative brain injury was associated with balloon atrial septostomy (P = .003) and lowest arterial oxygen saturation (P = .007); in a multivariable model, only the effect of balloon atrial septostomy remained significant when adjusting for lowest arterial oxygen saturation. On postoperative magnetic resonance imaging in 78 neonates (median 21 days after birth), none of the preoperative lesions showed evidence of extension or hemorrhagic transformation (0/40 [95% confidence interval: 0%–7%]). The presence of preoperative brain injury was not a significant risk factor for acquiring new injury on postoperative magnetic resonance imaging (P = .8).

Conclusions

Clinically silent brain injuries identified preoperatively in neonates with congenital heart disease, including stroke, have a low risk of progression with surgery and cardiopulmonary bypass and should therefore not delay clinically indicated cardiac surgery. In this multicenter cohort, balloon atrial septostomy remains an important risk factor for preoperative brain injury, particularly stroke.

CTSNet classification: 19, 20, 36.4

Abbreviations and Acronyms: BAS, balloon atrial septostomy, CHD, congenital heart disease, CI, confidence interval, CPB, cardiopulmonary bypass, IQR, interquartile range, IVH, intraventricular hemorrhage, MRI, magnetic resonance imaging, OR, odds ratio, RR, relative risk, Sao₂, arterial oxygen saturation, TGA, transposition of the great arteries, UBC, British Columbia Children's Hospital University of British Columbia, UCSF, University of California San Francisco Children's Hospital, WMI, white matter injury

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This work is supported by a grant (5-FY05-1231, #6-FY2009-303) from the March of Dimes Foundation, a grant (0365018Y) from the American Heart Association, a grant (2002/3E) from the Larry L. Hillblom Foundation, grants (RO1 NS40117, R01NS063876, and P50 NS35902) from the National Institutes of Health, a grant (5-M01-RR-01271) from the National Center for Research Resources, and a grant from the Canadian Institutes of Health Research (93780). Dr Miller is supported by a Canadian Institutes of Health Research Clinician Scientist award and a Michael Smith Foundation for Health Research Scholar award.

Disclosures: None.

PII: S0022-5223(10)00330-2

doi:10.1016/j.jtcvs.2010.03.035

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 140, Issue 3 , Pages 550-557, September 2010

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