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J Thorac Cardiovasc Surg 2003;126:1385-1396
© 2003 The American Association for Thoracic Surgery
Surgery for congenital heart disease |
a Department of Neurology, Children's Hospital, Boston, Mass, USA
b Department of Cardiology, Children's Hospital, Boston, Mass, USA
c Department of Medicine, Children's Hospital, Boston, Mass, USA
d Department of Cardiovascular Surgery, Children's Hospital, Boston, Mass, USA
e Clinical Research Program,e Children's Hospital, Boston, Mass, USA
f Department of Neurology, Harvard Medical School, Boston, Mass, USA
g Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
h Department of Surgery, Harvard Medical School, Boston, Mass, USA
i Department of Biostatistics, Harvard School of Public Health, Boston, Mass, USA
Received for publication June 6, 2002; revisions received August 20, 2002; revisions received March 17, 2003; accepted for publication March 27, 2003.
* Address for reprints: David C. Bellinger, PhD, MSc, Neuroepidemiology Unit, Farley Basement 127, Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
david.bellinger{at}tch.harvard.edu
OBJECTIVES: Our goal was to determine which of the two major methods of vital organ support used in infant cardiac surgery, total circulatory arrest and low-flow cardiopulmonary bypass, results in better neurodevelopmental outcomes at school age.
METHODS: In a single-center trial, infants with dextrotransposition of the great arteries underwent the arterial switch operation after random assignment to either total circulatory arrest or low-flow cardiopulmonary bypass. Developmental, neurologic, and speech outcomes were assessed at 8 years of age in 155 of 160 eligible children (97%).
RESULTS: Treatment groups did not differ in terms of most outcomes, including neurologic status, Full-Scale or Performance IQ score, academic achievement, memory, problem solving, and visual-motor integration. Children assigned to total circulatory arrest performed worse on tests of motor function including manual dexterity with the nondominant hand (P = .003), apraxia of speech (P = .01), visual-motor tracking (P = .01), and phonologic awareness (P = .003). Assignment to low-flow cardiopulmonary bypass was associated with a more impulsive response style on a continuous performance test of vigilance (P < .01) and worse behavior as rated by teachers (P = .05). Although mean scores on most outcomes were within normal limits, neurodevelopmental status in the cohort as a whole was below expectation in many respects, including academic achievement, fine motor function, visual-spatial skills, working memory, hypothesis generating and testing, sustained attention, and higher-order language skills.
CONCLUSIONS: Use of total circulatory arrest to support vital organs during heart surgery in infancy is generally associated with greater functional deficits than is use of low-flow cardiopulmonary bypass, although both strategies are associated with increased risk of neurodevelopmental vulnerabilities.
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