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J Thorac Cardiovasc Surg 2007;133:1351-1353
© 2007 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Discussion

The first 300 words of the full text of this article appear below.

Dr Richard A. Jonas (Washington, DC). I congratulate you and your colleagues for providing some data that will help us to unravel the specific impact of patient-related factors on neurodevelopmental outcome before general cardiac surgery.

What you have done is to perform a meta-analysis of a prospective but nonrandomized study of the impact of a specific genotype on neurodevelopmental outcome. Not surprisingly, you found that patient-specific factors were more important than intraoperative manipulations such as the use of circulatory arrest, hematocrit, or pH strategy.

I say "not surprisingly" because, as you yourself have pointed out in the limitations of the study, this is a very heterogeneous patient population. For example, unlike previous work in this area, you included low birth weight patients and you included patients with known genetic factors and confirmed what is widely known, that both of these factors have an important impact on outcome.

In addition, you made no attempt in your study to subject patients to a uniform bypass strategy. The duration of cooling before circulatory arrest in some patients was as short as 5 minutes, and the lowest NP temperature recorded before circulatory arrest was as high as 28°C.

I am concerned that the subliminal message that comes through is that since patient-related factors are so important, we really do not need to focus any attention on remediable intraoperative factors.

Surely you would agree that studies that have attempted to enroll only a very homogeneous patient population and then have subjected patients to a carefully controlled set of intraoperative conditions with variation of only one factor, such as hematocrit or pH, are far more likely to produce specific information regarding the relative importance of intraoperative factors, and the conclusions derived from such studies should be interpreted in that light.

My first question for you . . . [Full Text of this Article]


Related Article

Patient characteristics are important determinants of neurodevelopmental outcome at one year of age after neonatal and infant cardiac surgery
J. William Gaynor, Gil Wernovsky, Gail P. Jarvik, Judy Bernbaum, Marsha Gerdes, Elaine Zackai, Alex S. Nord, Robert R. Clancy, Susan C. Nicolson, and Thomas L. Spray
J. Thorac. Cardiovasc. Surg. 2007 133: 1344-1353. [Abstract] [Full Text] [PDF]





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