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Original Articles: Pediatric Cardiac

Invited Commentary

Chief and Head of Pediatric Cardiothoracic Surgery, Heart Center University of Cologne, Kerpener Strasse 62, Cologne, 50937 Germany

(Email: gerardus.bennink{at}uk-koeln.de).

In the last decades, the improvements achieved in perioperative and postoperative surgical techniques and materials used for cardiopulmonary bypass have drastically changed. Therefore, the outcomes for pediatric patients undergoing cardiopulmonary bypass in the treatment of congenital heart defects have improved. With decreased mortality rates, the incidence of adverse neurologic outcomes, comprising cognitive and speech impairments, motor deficits, and behavioral abnormalities, has increased in those patients surviving bypass. The Boston circulatory arrest trial done in the late 1980's and early 1990's has strongly influenced congenital cardiac surgeons either to completely avoid or at least minimize the use of circulatory arrest [1]. A number of other mechanisms, including ischemia, reperfusion injury, hypothermia, inflammation, and hemodilution, contribute to brain insult, which is further confounded by unique challenges presented in the pediatric population. Today, there are still even indications for circulatory arrest, such as those that occurred in a small preterm neonate of < 2 kg in which the cannulas can be bothersome with the repair.

In the previously mentioned article [2], the results of psychological testing are described in a selected group of patients with ventricular septal defect closure and an average weight around 5 to 6 kg. In 91% of the cases, circulatory arrest with a mean duration of 30.5 ± 13.5 minutes was applied. The majority of these patients could have been operated without circulatory arrest and normothermic or slightly hypothermic temperature with double venous cannulation and cardioplegia. It is known that postoperative EEG seizures are reported to occur in 14% to 20% of neonates after cardiac surgery with cardiopulmonary bypass. These seizures are associated with prolonged deep hypothermic circulatory arrest and adverse long-term neurodevelopmental outcome. If changed to a regimen of high-flow bypass, the EEG seizures are very infrequent (approximately 1.5%) [3]. An interesting comparison is the difference in neurodevelopmental outcome in arterial switches operated on in two different centers. In one center, all arterial switches were repaired using deep hypothermic circulatory arrest with a mean duration of circulatory arrest of 65 minutes [4], whereas in the other center circulatory arrest was avoided or minimized to the time of closing of the atrial septal defect created by the Rashkind procedure [5]. In the center with circulatory arrest, one could see major and minor neurodevelopmental changes in more than 55% of their patient population, whereas the center with no or limited circulatory arrest showed neurodevelopmental problems in less than 10% of the patients.

It is often not very clear what the future will bring; however, there are more and more signs that tend to go in the direction of avoidance of circulatory arrest in the repair of congenital heart defects. If this also means a better neurodevelopmental outcome, then it needs to be proven in a few years, and strong indicators point in this direction.

	References

Top References

 

1. Jonas RA. Comprehensive surgical management of congenital heart diseaseLondon: Arnold; 2004. pp. 166.
2. Simons JS, Glidden R, Sheslow D, Pizarro C. Intermediate neurodevelopmental outcome after repair of ventricular septal defect Ann Thorac Surg 2010;90:1586-1592.[Abstract/Free Full Text]
3. Andropoulos DB, Mizrahi EM, Hrachovy RA, et al. Electroencephalographic seizures after neonatal cardiac surgery with high-flow cardiopulmonary bypass Anesth Analg 2010;110:1680-1685.[Abstract/Free Full Text]
4. Hoevels-Guerich HH, Seghaye MC, Ma Q, et al. Long-term neurodevelopmetal outcome in school-aged children after neonatal arterial switch operation J Thorac Cardiovasc Surg 2002;73:601-609.
5. Toet MC, Flinterman A, Laar I, et al. Cerebral oxygen saturation and electrical brain activity before, during and up to 36 hours after arterial switch procedure in neonates without pre-existing brain damage: its relationship to neurodevelopmental outcome Exp Brain Res 2005;165:343-350.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ger Bennink Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bennink, G. Search for Related Content PubMed PubMed Citation Articles by Bennink, G. Related Collections Congenital - acyanotic Related Article