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a Division of Pediatric Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
b Division of Neuroradiology, Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
d Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
e Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
f Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
g Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
c Department of Medicine (Medical Genetics), University of Washington, Seattle, Washington
Accepted for publication March 11, 2009.
* Address correspondence to Dr Chen, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Room 7C26, Philadelphia, PA 19104 (Email: chenjo{at}email.chop.edu).
Background: The prevalence of perioperative stroke in infants undergoing operations for congenital heart disease has not been well described. The objectives of this study were to determine the prevalence of stroke as assessed by postoperative brain magnetic resonance imaging (MRI), characterize the neuroanatomic features of focal ischemic injury, and identify risk factors for its development.
Methods: Brain MRI was performed in 122 infants 3 to 14 days after cardiac operation with cardiopulmonary bypass, with or without deep hypothermic circulatory arrest. Preoperative, intraoperative, and postoperative data were collected. Risk factors were tested by logistic regression for univariate and multivariate associations with stroke.
Results: Stroke was identified in 12 of 122 patients (10%). Strokes were preoperative in 6 patients and possibly intraoperative or postoperative in the other 6 patients, and were clinically silent except in 1 patient who had clinical seizures. Arterial-occlusive and watershed infarcts were identified with equal distribution in both hemispheres. Multivariate analysis identified lower birth weight, preoperative intubation, lower intraoperative hematocrit, and higher blood pressure at admission to the cardiac intensive care unit postoperatively as significant factors associated with stroke. Prematurity, younger age at operation, duration of cardiopulmonary bypass, and use of deep hypothermic circulatory arrest were not significantly associated with stroke.
Conclusions: The prevalence of stroke in infants undergoing operations for congenital heart disease was 10%, half of which occurred preoperatively. Most were clinically silent and undetected without neuroimaging. Mechanisms included thromboembolism and hypoperfusion, with patient-specific, procedure-specific, and postoperative contributions to increased risk.
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Ann. Thorac. Surg. 2009 88: 829.
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  G. Van Arsdell Invited commentary. Ann. Thorac. Surg., September 1, 2009; 88(3): 829 - 829. [Full Text] [PDF]
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