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J Thorac Cardiovasc Surg 2004;127:692-704
© 2004 The American Association for Thoracic Surgery

Surgery for congenital heart disease

Periventricular leukomalacia is common after neonatal cardiac surgery

Kristen K. Galli, MDa, Robert A. Zimmerman, MDb, Gail P. Jarvik, MD, PhDf, Gil Wernovsky, MDc, Marijn K. Kuypers, MDc, Robert R. Clancy, MDd, Lisa M. Montenegro, MDa, William T. Mahle, MDg, Mark F. Newman, MDh, Ann M. Saunders, PhDi, Susan C. Nicolson, MDa, Thomas L. Spray, MDe, J. William Gaynor, MDe,*

a Division of Cardiothoracic Anesthesiology, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
b Division of Neuroradiology, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
c Division of Pediatric Cardiology, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
d Division of Neurology, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
e Division of Cardiothoracic Surgery, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
f Department of Medicine (Medical Genetics), University of Washington, Seattle, Wash, USA
g Division of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga, USA
h Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
i Department of Neurology, Duke University Medical Center, Durham, NC, USA

Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.

* Address for reprints: J. W. Gaynor, MD, Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Suite 8527, Philadelphia, PA 19104, USA.
gaynor{at}email.chop.edu

OBJECTIVES: Periventricular leukomalacia is necrosis of the cerebral white matter adjacent to the lateral ventricles and results from injury to immature oligodendroglia. In infants without congenital heart disease, periventricular leukomalacia is associated with an increased incidence of developmental delay and attention deficit/hyperactivity disorder. The incidence of periventricular leukomalacia and the risk factors for development of periventricular leukomalacia after infant cardiac surgery are not known.

METHODS: Magnetic resonance imaging of the brain was performed 6 to 14 days after cardiac surgery utilizing cardiopulmonary bypass with or without deep hypothermic circulatory arrest in 105 neonates and infants <= 6 months of age.

RESULTS: Median age at surgery was 6 days (range 1-178), with 82 neonates (age <= 30 days). Periventricular leukomalacia was found in 44 of the neonates (54%) compared with 1 of 23 infants (4%). Forward logistic regression using age at surgery as a continuous variable identified a model containing longer total support time (cardiopulmonary bypass plus deep hypothermic circulatory arrest), lower systolic blood pressure at cardiac intensive care unit admission postoperatively, lower minimum diastolic blood pressure, and PO2 in the first 48 hours after surgery. When age at surgery was considered as a dichotomous variable (neonate versus infant), younger age at surgery replaced systolic blood pressure, PO2, and total support time in the model. Lower minimum diastolic blood pressure was a significant risk factor in both models.

CONCLUSIONS: Periventricular leukomalacia was found in >50% of neonates after cardiac surgery but rarely in older infants. Hypoxemia and hypotension in the early postoperative period, particularly diastolic hypotension, may be important risk factors for periventricular leukomalacia.




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