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J Thorac Cardiovasc Surg 2002;124:448-458
© 2002 The American Association for Thoracic Surgery
Surgery for Congenital Heart Disease (CHD) |
From the Departments of Pediatric Cardiology,a Neurolinguistics,b Pediatric Neurology,d and Thoracic and Cardiovascular Surgery,e Aachen University of Technology, and the Institute for Medical Research and Information Processing,c Repges & Partner, Aachen, Germany.
Supported by grants of Deutsche Stiftung für Herzforschung, Frankfurt/Main, and Bundesverband Herzkranke Kinder e.V., Aachen, Germany.
Received for publication June 28, 2001. Revisions requested Nov 5, 2001; revisions received Nov 14, 2001. Accepted for publication Dec 14, 2001. Address for reprints: Hedwig H. Hövels-Gürich, MD, Department of Pediatric Cardiology, Aachen University of Technology, Pauwelsstr 30, D-52057 Aachen, Germany (E-mail: hhoevels-guerich{at}ukaachen.de).
Objective: Neurodevelopmental status of children between 8 and 14 years of age after neonatal arterial switch operation for transposition of the great arteries has not previously been systematically evaluated.
Methods: Within a longitudinal study, 60 unselected children operated on as neonates with combined deep hypothermic circulatory arrest and low-flow cardiopulmonary bypass were reevaluated at the age of 7.9 to 14.3 years (mean ± SD 10.5 ± 1.6 years). Clinical neurologic status and standardized tests to assess gross motor function, intelligence, acquired abilities, language, and speech were carried out, and the results were related to preoperative, perioperative, and postoperative status, to management, and to neurodevelopmental status at a mean age of 5.4 years.
Results: Neurologic and speech impairments were evidently more frequent (27% and 40%, respectively) than in the general population. Intelligence and socioeconomic status were not different (P = .29 and P = .11), whereas motor function, acquired abilities, and language were reduced (P 
.04 for each). Overall rate of developmental impairment in one or more domains was 55%, compared with 26% at age 5.4 years. Multivariable analysis showed that severe preoperative acidosis and hypoxia predicted reduced motor function (mean deficit 52.7 points, P < .001), whereas longer bypass duration predicted both neurologic (odds ratio per 10 minutes of bypass duration 1.8, P = .04) and speech (odds ratio per 10 minutes of bypass duration 1.9, P = .02) dysfunction, and perioperative and postoperative cardiocirculatory insufficiency predicted neurologic (odds ratio 6.5, P = .04) and motor (mean deficit 6.8 points, P = .03) dysfunction.
Conclusions: The neonatal arterial switch operation with combined circulatory arrest and low-flow bypass is associated increasingly with age, with reduced neurodevelopmental outcome but not with cognitive dysfunction. In our experience, the risk of long-term neurodevelopmental impairment after neonatal corrective cardiac surgery is related to deleterious effects of the global perioperative management and to special adverse effects of prolonged bypass duration. Severe preoperative acidosis and hypoxia and postoperative hemodynamic instability must be considered as important additional risk factors.
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