New White Matter Brain Injury After Infant Heart Surgery Is Associated With Diagnostic Group and the Use of Circulatory Arrest

Study Questions:

What magnetic resonance imaging (MRI) abnormalities occur, and how are they related to developmental outcome in infants undergoing cardiac surgery with and without cardiopulmonary bypass (CPB)?

Methods:

A prospective trial was performed at two cardiac surgical centers. Infants underwent serial MRI scans before and after surgery and at 3 months of age. Subjects underwent neurodevelopmental assessment with the Bayley Scales of Infant and Toddler Development (3rd Edition [BSID-III]) at 2 years of age. Brain maturity was described using MRI assessment of myelination, cortical infolding, and the state of the germinal matrix.

Results:

A total of 153 patients were enrolled. The most common injury seen on MRI was white matter injury (WMI). Preoperative WMI was present in 20% of patients, and was associated with brain immaturity. New WMI occurred in 44% of patients after surgery (mild in 67%, moderate in 21%, and severe in 12%), with no difference in patients undergoing surgery with or without CPB. The most important association with WMI was diagnostic group, with patients undergoing two ventricle repairs without arch surgery at the lowest risk. In infants having arch surgery, circulatory arrest was associated with new WMI. Other predictors of WMI included duration of CPB, postoperative lactate level, brain maturity, and preoperative WMI. Brain immaturity, but not WMI, was associated with impaired neurodevelopment at 2 years of age.

Conclusions:

New WMI is common after surgery for congenital heart disease. WMI occurs at the same rate for infants undergoing surgery with or without CPB, but is associated with diagnostic group and the use of circulatory arrest in infants undergoing arch surgery.

Perspective:

This prospective study investigated brain abnormalities and neurodevelopment outcomes in infants undergoing cardiac surgery. WMI was the most common abnormality, but was mild in a large proportion of patients, and there was no difference in neurodevelopmental outcome at 2 years of age. The significance of these lesions will become better understood with longer follow-up. Brain immaturity appears to be an important factor, with brain maturity lagging gestational age in patients with congenital heart disease. As brain immaturity was associated both with WMI and impaired neurodevelopment, this issue deserves further investigation.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, Interventions and Structural Heart Disease

Keywords: Gestational Age, Infant, Synaptic Transmission, Heart Defects, Congenital, Brain Injuries, Kidd Blood-Group System, Heart Arrest, Lactic Acid, Cardiopulmonary Bypass, Cardiac Surgical Procedures, Postoperative Period, Nerve Fibers, Myelinated


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