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J Thorac Cardiovasc Surg 2005;130:1094-1100
© 2005 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Systemic venous oxygen saturation after the Norwood procedure and childhood neurodevelopmental outcome

^a Department of Pediatric Anesthesiology, Medical College of Wisconsin, Milwaukee, Wis.
^b Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wis.
^c Department of Cardiovascular Surgery, Medical College of Wisconsin, Milwaukee, Wis.
^d Department of Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wis.
^e Department of Pediatric Psychology, Medical College of Wisconsin, Milwaukee, Wis.
^f Children's Hospital of Wisconsin, and the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wis.
^g Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.
^h Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis.

Presented in part at the annual meeting of the American Society of Anesthesiologists, Las Vegas, Nevada, October 2004.

Received for publication May 12, 2005; revisions received June 16, 2005; accepted for publication June 28, 2005.

^_* Address for reprints: George M. Hoffman, MD, Anesthesiology and Pediatrics, Children's Hospital of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI 53226. (Email: ghoffman{at}mcw.edu).

OBJECTIVE: Neonates with hypoplastic left heart syndrome have impaired systemic oxygen delivery and also have a high risk of hypoxic ischemic brain injury with resultant neurodevelopmental impairment. We hypothesized that decreased postoperative oxygen delivery, as measured on the basis of systemic venous oxyhemoglobin saturation, would be related to persistent neurodevelopmental abnormality assessed in childhood.

METHODS: Early perioperative hemodynamic data, prospectively acquired from neonates undergoing staged palliation of hypoplastic left heart syndrome by using deep hypothermic circulatory arrest with uniform perioperative management, were tested for relationship to later neurodevelopmental outcome assessed at age 4 years.

RESULTS: Complete hemodynamic and neurodevelopmental data were available in 13 patients aged 7 ± 8 days at the time of the Norwood procedure and aged 4.5 ± 0.7 years at follow-up assessment. The subjects scored significantly below the population mean for motor, visual-motor integration, and composite neurodevelopmental outcomes. The 5 (38%) patients with abnormal outcomes had significantly lower postoperative systemic venous oxygen saturation values than those with normal outcomes (46% ± 8% vs 56% ± 6%, P = .024). Standard hemodynamic parameters did not differentiate patient outcomes. The risk of abnormal outcome increased with increasing time at a systemic venous oxygen saturation of less than 40% (P < .001). A multivariate model of deep hypothermic circulatory arrest time, systemic venous oxygen saturation, blood pressure, and carbon dioxide tension accounted for 79% of the observed variance (P < .001).

CONCLUSIONS: Decreased systemic oxygen delivery in the neonatal postoperative period is associated with hypoxic-ischemic brain injury and childhood neurodevelopmental abnormality. Measures of systemic oxygen delivery should be used to guide perioperative strategies to reduce the risk of hypoxic-ischemic brain injury.

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