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J Thorac Cardiovasc Surg 2004;128:841-849
© 2004 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Preoperative cerebral blood flow is diminished in neonates with severe congenital heart defects

^a Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
^c Division of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
^d Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
^e Division of Respiratory Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
^f Division of Biostatistics and Epidemiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
^g Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
^h Division of Neuroradiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA
^b Department of Radiology The Hospital of the University of Pennsylvania, Philadelphia, Pa, USA
ⁱ Department of Neurology, The Hospital of the University of Pennsylvania, Philadelphia, Pa, USA

Read at the Eighty-fourth Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, April 25-28, 2004.

Received for publication April 23, 2004; revisions received July 12, 2004; accepted for publication July 19, 2004.

^* Address for reprints: Daniel Licht, MD, The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Neurology, Wood Bldg, 6th Floor, 34th and Civic Center Blvd, Philadelphia, PA 19104 (E-mail: licht{at}email.chop.edu).

OBJECTIVE: Impaired neurodevelopmental outcome represents a major morbidity for survivors of infant heart surgery for congenital heart defects. Previous studies in these neonates have reported preoperative microcephaly, periventricular leukomalacia, and other findings. The hypothesis of this study is that preoperative cerebral blood flow is substantially diminished and might relate to preoperative neurologic conditions.

METHODS: Preoperative brain magnetic resonance imaging was performed. Cerebral blood flow measurements in infants with congenital heart defects were obtained by using a novel noninvasive magnetic resonance imaging technique, pulsed arterial spin-label perfusion magnetic resonance imaging. Cerebral blood flow was measured before the operation under standard ventilation and repeated after increased carbon dioxide.

RESULTS: A total of 25 term infants were studied. The average age at the time of the operation was 4.4 ± 4.6 days. Congenital heart defects varied widely. Microcephaly occurred in 24% (6/25). Baseline cerebral blood flow was 19.7 ± 9.2 mL · 100 g^–1 · min^–1 (8.0-42.2 mL · 100 g^–1 · min^–1). Five patients had cerebral blood flow measurements of less than 10 mL · 100 g^–1 · min^–1. Mean hypercarbic cerebral blood flow increased to 40.1 ± 20.3 mL · 100 g^–1 · min^–1 (11.4-94.0 mL · 100 g^–1 · min^–1, P < .001). Pairwise analyses found that low hemoglobin levels were associated with higher baseline cerebral blood flow values (P = .04). Periventricular leukomalacia occurred in 28% (7/25) and was associated with decreased baseline cerebral blood flow values (P = .05) and a smaller change in cerebral blood flow with hypercarbia (P = .003).

CONCLUSIONS: Structural brain abnormalities are common in these neonates before surgical intervention. Preoperative cerebral blood flow for this cohort was low and drastically reduced in some patients. Low cerebral blood flow values were associated with periventricular leukomalacia. Carbon dioxide reactivity was preserved but might be compromised by some aspects of the cardiac anatomy. The full spectrum of cerebral blood flow measurements with this technique in congenital heart defects and their long-term significance require continued investigation.

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