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J Thorac Cardiovasc Surg 2009;137:536-537
© 2009 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr C. Fraser (Houston, Tex). Dr Licht and colleagues from Children's Hospital of Philadelphia have conducted an outstanding investigation, adding another puzzle piece to understanding the complex interplay between normal brain development and serious congenital heart disease. Term babies with TGA and HLHS have smaller head circumferences and immature brains when compared with their age-matched peers with normal hearts. The maturation scores appear comparable to those of babies with normal hearts at 35 weeks' gestation. Babies with HLHS and TGA have brains that on MRI appear similar to late preterm babies who are otherwise normal. This finding is significant.

Late preterm babies have rapidly maturing brains with white matter predominated by premyelinizing oligodendrocytes. These cells are known to be particularly susceptible to ischemia-reperfusion injury. This must at least, in part, explain the observation of a high incidence of PVL in the study group. These patients' brains may be more susceptible to injury. In preterm and near preterm baby neurologic research, there is a working hypothesis that there is a hierarchy of vulnerability of the maturing brain related to the level of immaturity of the cerebral white matter. The present study suggests that this hierarchy has shifted in the wrong direction by the association of critical congenital heart disease.

To me, one of the most disturbing issues is that despite significant effort by many investigators to modulate the potentially deleterious effects of intraoperative care, particularly limiting . . . [Full Text of this Article]