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J Thorac Cardiovasc Surg 2003;126:1397-1403
© 2003 The American Association for Thoracic Surgery

Surgery for congenital heart disease

The effect of duration of deep hypothermic circulatory arrest in infant heart surgery on late neurodevelopment: The Boston Circulatory Arrest Trial

David Wypij, PhDa,e,f,i, Jane W. Newburger, MD, MPHa,f, Leonard A. Rappaport, MDb,f, Adre J. duPlessis, MBChBc,g, Richard A. Jonas, MDd,h, Gil Wernovsky, MDa,f, Ming Lin, MSe,i, David C. Bellinger, PhD, MScc,g,*

c Department of Neurology, Children's Hospital, Boston, Mass, USA
a Department of Cardiology, Children's Hospital, Boston, Mass, USA
b Department of Medicine, Children's Hospital, Boston, Mass, USA
d Department of Cardiovascular Surgery, Children's Hospital, Boston, Mass, USA
e Clinical Research Program, Children's Hospital, Boston, Mass, USA
f Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
g Department of Neurology, 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 12, 2002; revisions received December 10, 2002; revisions received May 28, 2003; accepted for publication June 3, 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: Despite the technical advantages of total circulatory arrest for vital organ support during infant heart surgery, many centers have moved away from its use because of the demonstrated effects of circulatory arrest of long duration on neurodevelopmental outcomes. Our goal was to determine the functional form of the association between duration of circulatory arrest and risk of neurodevelopmental dysfunction.

METHODS: From 1988 to 1992, in a single-center trial, infants with D-transposition of the great arteries underwent the arterial switch operation after random assignment to circulatory arrest or low-flow bypass. The alpha-stat method was used, and hematocrit on bypass was maintained at 20%. Developmental, neurologic, and speech outcomes were assessed at 8 years of age in 155 of 160 eligible children (97%). Outcomes selected for analysis were Full-Scale, Verbal, and Performance IQ, Reading and Mathematics Composite, time to complete the Grooved Pegboard (dominant hand), and the Mayo Test for Apraxia.

RESULTS: Nonparametric regression and piecewise linear models indicated that neurodevelopmental outcomes were generally not adversely affected unless the duration of circulatory arrest exceeded a threshold of 41 minutes (95% 1-sided lower confidence limit of 32 minutes).

CONCLUSIONS: We found that the effect of duration of total circulatory arrest on later neurodevelopmental outcomes is nonlinear, with little influence at shorter durations and with steadily worsening outcomes after longer durations of circulatory arrest. Because the effects of duration of circulatory arrest may vary according to diagnosis, age at surgery, and other bypass and perioperative variables, this study cannot ascertain a universally "safe" duration of total circulatory arrest.


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J. Thorac. Cardiovasc. Surg. 2004 127: 1256-1261. [Extract] [Full Text] [PDF]



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