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J Thorac Cardiovasc Surg 2005;130:1523-1530
© 2005 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Brain magnetic resonance imaging abnormalities after the Norwood procedure using regional cerebral perfusion

Catherine L. Dent, MD a , * , James P. Spaeth, MD f , Blaise V. Jones, MD e , Steven M. Schwartz, MD a , Tracy A. Glauser, MD b , Barbara Hallinan, MD, PhD b , Jeffrey M. Pearl, MD d , Philip R. Khoury, MS a , c , C. Dean Kurth, MD f

a Departments of Pediatrics (Divisions of Cardiology
b Neurology
c Epidemiology/Biostatistics)
d Surgery (Division of Cardiothoracic Surgery)
e Radiology
f Anesthesiology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio

* Address for reprints: Catherine Dent, MD, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH 45229-3039 (Email: catherine.dent{at}cchmc.org).

OBJECTIVES: Neurologic deficits are common after the Norwood procedure for hypoplastic left heart syndrome. Because of the association of deep hypothermic circulatory arrest with adverse neurologic outcome, regional low-flow cerebral perfusion has been used to limit the period of intraoperative brain ischemia. To evaluate the effect of this technique on brain ischemia, we performed serial brain magnetic resonance imaging in a cohort of infants before and after the Norwood operation using regional cerebral perfusion.

METHODS: Twenty-two term neonates with hypoplastic left heart syndrome were studied with brain magnetic resonance imaging before and at a median of 9.5 days after the Norwood operation. Results were compared with preoperative, intraoperative, and postoperative risk factors to identify predictors of neurologic injury.

RESULTS: Preoperative magnetic resonance imaging (n = 22) demonstrated ischemic lesions in 23% of patients. Postoperative magnetic resonance imaging (n = 15) demonstrated new or worsened ischemic lesions in 73% of patients, with periventricular leukomalacia and focal ischemic lesions occurring most commonly. Prolonged low postoperative cerebral oximetry (<45% for >180 minutes) was associated with the development of new or worsened ischemia on postoperative magnetic resonance imaging (P = .029).

CONCLUSIONS: Ischemic lesions occur commonly in neonates with hypoplastic left heart syndrome before surgical intervention. Despite the adoption of regional cerebral perfusion, postoperative cerebral ischemic lesions are frequent, occurring in the majority of infants after the Norwood operation. Long-term follow-up is necessary to assess the functional effect of these lesions.

Abbreviations and Acronyms BT = Blalock-Taussig; CHD = congenital heart disease; CICU = cardiac intensive care unit; CPB = cardiopulmonary bypass; DHCA = deep hypothermic circulatory arrest; EEG = electroencephalography; HLHS = hypoplastic left heart syndrome; MRI = magnetic resonance imaging; NIRS = near-infrared spectroscopy; PVL = periventricular leukomalacia; RFLP = regional low-flow cerebral perfusion; rSO2 = regional cerebral oxygen saturation; SaO 2 = arterial oxygen saturation; SvO 2 = venous oxygen saturation




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