March
2007 VOLUME
4, NUMBER 7
In this issue...
Congenital heart disease (CHD) is the most common life-threatening
birth defect encountered in the NICU. While the incidence of these lesions
has remained constant at around 8 per 1000, the methods of diagnosis
and treatment have undergone tremendous change over the past several
decades.
In this issue, we look at several
recent articles that raise important questions for the perinatal care
of these infants, reviewing subjects that are of broad scope and implication,
but, in most cases, remain controversial. Four topics are highlighted:
1) the effect of prenatal diagnosis on outcomes in congenital heart
disease, 2) fetal intervention for hypoplastic left heart syndrome,
3) prematurity, necrotizing enterocolitis and congenital heart disease,
and 4) balloon atrial septostomy and neonatal stroke.
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Course Directors
Edward E, Lawson, M.D.
Professor
Department of Pediatrics
Neonatology
The Johns Hopkins University
School of Medicine
Lawrence M. Nogee, M.D.
Associate Professor
Department of Pediatrics
Neonatology
The Johns Hopkins University
School of Medicine
Christoph U. Lehmann, M.D.
Assistant Professor
Department of Pediatrics,
Health Information
Science and Dermatology
The Johns Hopkins University
School of Medicine
Mary Terhaar, RN
Assistant Professor
Undergraduate Instruction,
The Johns Hopkins University
School of Nursing
Robert J. Kopotic, MSN, RRT, FAARC
Director of Clinical Programs
ConMed Corporation
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Learning
Objectives |
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The
Johns Hopkins University School of Medicine and The Institute for
Johns Hopkins Nursing take responsibility for the content, quality,
and scientific integrity of this CME/CE activity.
At
the conclusion of this activity, participants should be able to:
- Describe the rationale for fetal intervention for Hypoplastic Left
Heart Syndrome (HLHS).
- Discuss the risk factors for the development of necrotizing enterocolitis
(NEC) in patients with congenital heart disease.
- Describe the risk factors for neonatal stroke in patients with
transposition of the great arteries (TGA).
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Commentary |
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Fetal
echocardiography at 18-22 weeks gestation has proven to be an extremely
accurate screen for the detection of serious congenital heart disease,
and an increasing percentage of cases are now diagnosed prenatally. Many
newborn infants with CHD have already been examined several times by the
cardiologist while in utero, and plans for medical or surgical interventions,
once the diagnosis has been confirmed by postnatal echocardiogram, are
often discussed in detail with parents well in advance of delivery. Potential
benefits of fetal diagnosis include the identification of lesions that
may require specific, life-saving interventions immediately after birth,
the opportunity for parental counseling and education, and possibly, recognition
of diseases that might benefit from medical or surgical interventions
in utero. Four of the articles reviewed herein discuss the impact of prenatal
diagnosis on outcome. In some regions, birth incidence of certain lesions
has declined because of increased termination rates following prenatal
diagnosis. With some diagnoses, such as transposition of the great arteries
(TGA), prenatal diagnosis does not appear to confer significantly improved
medical outcomes. However, for other lesions, fetal diagnosis appears
to have a positive impact. These lesions, such as hypoplastic left heart
syndrome (HLHS), have high potential for death if the infant discharged
from the hospital prior to recognition of symptoms and referral for diagnosis
and treatment. However, because of the changes in management and outcomes
it provides, prenatal diagnosis by fetal echocardiography reduces the
opportunities for pediatric residents to learn the signs and symptoms
of critical CHD in the newborn, and may thus have an impact on training.
A trend in the treatment of congenital heart
disease since the late 1980s has been to perform definitive, corrective
repairs on younger and smaller infants, with the goal of establishing normal
physiology as soon as possible to avoid co-morbidities resulting from palliative
approaches or delayed interventions. The logical progression of this trend
from child to newborn to premature infant has now taken the next step to
the fetus. One particularly troublesome lesion complex has been the hypoplastic
left heart syndrome (HLHS), in which the mitral valve, left ventricle,
aortic valve, and aortic arch may all be critically small, and result in
only one viable ventricle. The current therapeutic strategy for HLHS is
extensive surgical palliation that eventually achieves an acceptable, though
distinctly disadvantageous, univentricular circulation. It has long been
speculated that at least part of the syndrome is the result of decreased
flow across the left side of the heart in utero, resulting in hypoplasia
of “downstream” structures. Due to the limited capacity for hyperplasia
of myocardial cells after birth, there is relatively limited growth potential
of a truly hypoplastic left ventricle after the first few months of life,
even with improved flow. Fetal echocardiography has documented in several
cases the development of HLHS from a relatively normal appearing left ventricle
(LV) beginning at about 17-18 weeks gestation, most commonly noted when
there is severe limitation of LV flow, such as in critical aortic stenosis[1].
Tworetzky and co-workers at The Children’s Hospital in Boston have now
reported their initial experience with fetal intervention on stenotic aortic
valves in an effort to avoid the development of HLHS by improving flow
through the left heart during fetal life. The technique involves the collaboration
of the interventional cardiologist, fetal echocardiographer, high-risk
obstetrician, and perinatologist. One difficulty in evaluating the ultimate
success of the strategy is in knowing which cases of fetal aortic stenosis
are indeed destined to result in HLHS, and at what stage of development
the fetal intervention must be performed in order to achieve the desired
outcome. Other potential targets of fetal balloon interventions include
restrictive patent foramen ovale in certain lesions, and critical pulmonary
stenosis with resulting hypoplastic right ventricle. Infants born following
these procedures will likely have unique medical needs in the NICU and,
if eventually adopted as standard therapy, prenatal intervention may change
the birth incidence of certain lesions.
Unfortunately, the combination of severe congenital heart disease and prematurity is commonplace. The specific issues that complicate the management of these infants
include lower birth weight, which may negatively impact the surgical and
interventional catheter options available; higher risk of lung disease,
which can have a deleterious effect, particularly on the univentricular
heart; and a higher risk of neurological and gastrointestinal complications.
While several studies have shown acceptable survival rates for cardiac
surgery done on low birth weight critically ill neonates, morbidity is
high[2-4]. On the other hand, delaying surgery to achieve weight
gain has not been shown to lessen mortality or morbidity, although it is
often attempted. Enteral feeds, while usually given in this setting to
maximize somatic growth, can result in gastrointestinal injury, particularly
in the setting of decreased gut perfusion, as is often the case in CHD
with increased pulmonary blood flow at the expense of systemic flow. Dees
et al reviewed the outcomes of premature infants with congenital heart
disease and found a high percentage of associated syndromes and risk of
NEC, while McElhinney et al found certain types of cardiac lesions to have
a higher risk than others, particularly in the setting of prematurity.
These data support the theory that decreased gut perfusion results in a
higher risk of NEC.
The most common cause of severe cyanosis
in the neonate is transposition of the great arteries, a condition in which
the aorta arises from the right ventricle and the pulmonary artery from
the left ventricle. The advent of the balloon atrial septostomy (BAS) procedure
to improve systemic oxygenation (by Dr. William Rashkind in 1965) resulted
in a dramatic increase in early survival of infants with TGA, and the procedure
remains a standard technique, now often done in the NICU with echocardiographic
guidance. Neurological outcomes in patients following repair of TGA have
been extensively researched via several large, prospective studies that
focused mainly on intraoperative and postoperative variables as predictors
of outcome[5-7]. While these studies show generally favorable
outcomes, they also report a higher prevalence of learning disabilities
and behavioral problems. In a pair of articles by Miller et al and McQuillen
et al, BAS was noted to be associated with abnormal findings on preoperative
brain MRI. It is unclear why neurological injury may result from BAS, but
presumably small thrombotic or air emboli, either from the septostomy itself
or associated with placement of the venous sheath, may be involved. Whether
the routine application of this common, life-saving practice should continue
unmodified is now in question.
References:
| 1. |
Hornberger LK, Sanders SP, Rein AJ,
Spevak PJ, Parness IA, Colan SD. Left
heart obstructive lesions and left ventricular growth in the midtrimester
fetus. A longitudinal study. Circulation. 1995 Sep 15;92(6):1531-8. |
| 2. |
Chang AC, Hanley FL, Lock JE, Castaneda
AR, Wessel DL. Management
and outcome of low birth weight neonates with congenital heart disease.
J Pediatr. 1994 Mar;124(3):461-6. |
| 3. |
Oppido G, Napoleone CP, Formigari R,
Gabbieri D, Pacini D, Frascaroli G, Gargiulo G. Outcome
of cardiac surgery in low birth weight and premature infants. Eur
J Cardiothorac Surg. 2004 Jul;26(1):44-53. |
| 4. |
Bove T, Francois K, De Groote K, Suys
B, De Wolf D, Verhaaren H, Matthys D, Moerman A, Poelaert J, Vanhaesebroeck
P, Van Nooten G. Outcome
analysis of major cardiac operations in low weight neonates. Ann
Thorac Surg. 2004 Jul;78(1):181-7. |
| 5. |
Newburger JW, Jonas RA, Wernovsky G,
Wypij D, Hickey PR, Kuban KC, Farrell DM, Holmes GL, Helmers SL, Constantinou
J, et al. A
comparison of the perioperative neurologic effects of hypothermic circulatory
arrest versus low-flow cardiopulmonary bypass in infant heart surgery.
N Engl J Med. 1993 Oct 7;329(15):1057- |
| 6. |
Bellinger DC, Jonas RA, Rappaport LA,
Wypij D, Wernovsky G, Kuban KC, Barnes PD, Holmes GL, Hickey PR, Strand
RD, et al. Developmental
and neurologic status of children after heart surgery with hypothermic
circulatory arrest or low-flow cardiopulmonary bypass. N Engl J
Med. 1995 Mar 2;332(9):549-55. |
| 7. |
Bellinger DC, Wypij D, Kuban KC, Rappaport LA, Hickey PR, Wernovsky
G, Jonas RA, Newburger JW. Developmental
and neurological status of children at 4 years of age after heart surgery
with hypothermic circulatory arrest or low-flow cardiopulmonary bypass.
Circulation. 1999 Aug 3;100(5):526-32. |
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EFFECT
OF PRENATAL DIAGNOSIS ON OUTCOMES IN CONGENITAL HEART DISEASE |
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(For
non-journal subscribers, an additional fee may apply for full text articles.) |
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| Bartlett
JM, Wypij D, Bellinger DC et al. Effect of Prenatal Diagnosis
on Outcomes in D-Transposition of the Great Arteries. Pediatrics.
2004; 113: 335-340. |
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| Khoshnood
B, De Vigan C, Vodovar V et al. Trends in Prenatal Diagnosis,
Pregnancy Termination, and Perinatal Mortality of Newborns With Congenital
Heart Disease in France, 1983-2000: A Population-Based Evaluation. Pediatrics 2005;
115: 95-101. |
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| Tworetzhy
W, McElhinney DB, Reddy VM et al. Improved Surgical Outcome
After Fetal Diagnosis of Hypoplastic Left Heart Syndrome. Circulation 2001;
103: 1269-1273. |
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| Mahle
WT, Clancy RR, McGaurn SP et al. Impact of Prenatal Diagnosis
on Survival and Early Neurologic Morbidity in Neonates with the Hypoplastic
Left Heart Syndrome. Pediatrics. 2001; 107: 1277-1282. |
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Ultrasonography
has become the standard of care in the United States for screening of fetal
anomalies. This technology has developed rapidly, such that many cardiac
lesions are now easily identified during routine obstetrical screening,
and mothers suspected of having a fetus with CHD are typically referred
to the pediatric cardiologist for further delineation of cardiac anatomy
and counseling. Many lesions are now fully defined with surprising accuracy
in utero. These trends might be expected to have a major impact on the
care of patients with congenital heart disease.
While prenatal diagnosis has affected the
management and outcomes of CHD, it has done so in a disease-specific manner.
Bartlett et al describe the experience at Children’s Hospital Boston, where
prenatal diagnosis for patients with d-transposition of the great arteries
has not been shown to greatly affect management. Although there were mild
differences in infant characteristics and earlier surgery in the prenatally
diagnosed group, there were no differences in operative mortality or in
neurological outcomes at one year. Therefore, prenatal diagnosis from a
purely medical outcomes standpoint did not show a great advantage. However,
this finding does not take into account the potential benefit to families
from knowing about and anticipating surgery. The international experience
is somewhat different: as described by Khoshnood et al, a prenatal diagnosis
of d-TGA was found to lower the risk of mortality in the first week of
life by 15% in France.
For more challenging lesions such as the
hypoplastic left heart syndrome (HLHS), prenatal
diagnosis has more substantially affected
both the decision to terminate pregnancy
as well as the outcomes of infants brought
to term. The experience of several centers
has recently been published. Tworetzky et
al from the University of California, San
Francisco found that patients who were diagnosed
prenatally were less likely to undergo surgery
than patients who were diagnosed postnatally.
Since the rate of intervention of live born
infants is similar among prenatally versus
postnatally diagnosed children, the difference
is solely due to the rate of pregnancy termination
(which was 33% in their study). The researchers
found a similar trend internationally: in
France, during 1995 to 2000, 63% of pregnancies
having fetuses with a prenatal diagnosis
of HLHS were terminated. This same study found that pregnancy termination
in France for simpler lesions such as tetralogy of Fallot, coarctation
of the aorta, and d-TGA was quite uncommon. All fourteen prenatally diagnosed
infants who went to surgery survived, compared to survival of only 25 of
38 postnatally diagnosed children. Further, prenatally diagnosed children
were less likely to have preoperative acidosis, tricuspid regurgitation,
and ventricular dysfunction.
Mahle et al at the Children’s Hospital of Philadelphia published their
experience with 216 patients with HLHS. Children with a prenatal diagnosis
were delivered more often in a tertiary care hospital and were started
on prostaglandins sooner. Although overall hospital mortality rates were
similar, multivariate analysis demonstrated that prenatal diagnosis was
associated with fewer adverse neurologic events (odds ratio 0.46), defined
as seizure or coma.
In summary, the weight of evidence from these
studies seems to indicate that prenatal diagnosis has had a positive effect
on preoperative management, operative mortality, and neurological outcomes
in patients with CHD, especially in high risk lesions such as HLHS. |
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FETAL
INTERVENTION FOR HYPOPLASTIC LEFT HEART SYNDROME |
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(For
non-journal subscribers, an additional fee may apply for full text articles.) |
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| Tworetzky
W, Wilkins-Haug LE, Jennings RW et al. Balloon Dilation of Severe
Aortic Stenosis in the Fetus; Potential for Prevention of Hypoplastic
Left Heart Syndrome, Candidate Selection, Technique, and Results of
Successful Intervention. Circulation. 2004; 110: 2125-2131. |
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The
hypoplastic left heart syndrome is one of the most challenging and devastating
congenital heart malformations: even with optimal surgical management the
mortality rate for HLHS approaches 25-30% for the first five years of life.
In addition, those children who do survive have lifetime cardiac disability.
Increased surveillance of fetal heart disease has lead to the recognition
that HLHS progresses from equal ventricular size to left ventricular hypoplasia
during the late second to early third trimester. This observation has led
a small group of physicians to attempt to alter the natural history of
HLHS by in utero dilation of the severely stenotic aortic valve.
Tworetzky et al recently published their
report on the largest program for fetal intervention for HLHS undertaken.
Fetal aortic valvular dilation was offered to 24 mothers whose fetuses
had severe aortic stenosis. Intervention was only offered to fetuses after
three independent echocardiographers assigned a high probability of progression
to HLHS. Twenty fetuses underwent attempted balloon dilation of aortic
stenosis; the report describes the initial findings as well as the technical
advances made during the time of the study.
The procedure involves entry of a small catheter
through the maternal abdominal wall, through the fetal chest wall, and
directly into the left ventricular apex. If successful, a guide wire is
passed directly out the left ventricular outflow tract, a small balloon
is deployed over the wire, and the stenotic aortic valve is balloon dilated.
The authors reported a technically successful procedure in fourteen out
of twenty patients. Complications to the fetus were relatively common.
There was demise in two fetuses within days after successful intervention
and one demise a day after an unsuccessful intervention. There was one
pre-viable delivery in a fetus 3 weeks after the procedure. There were
no significant maternal complications.
Analysis of the successful interventions
provided some promising data. Growth of the mitral valve, aortic valve,
and ascending aorta occurred in successfully dilated fetuses, compared
to the unsuccessfully dilated and no intervention control cases. On the
other hand, there was not significant growth in the left ventricular dimensions
when averaged among successfully intervened patients. The authors emphasize
that three infants of the fourteen with successful interventions were born
with two ventricles as proof of principle. Although there were no infants
born with two ventricles among either the unsuccessful interventions or
those who declined procedures, the total numbers were small. There were
only six live born infants in the latter group versus nine successfully
dilated live born infants (three were still in utero at the time of the
report). In order to evaluate these data, a larger group of fetuses with
an early echocardiographic assignment of HLHS would need to be followed.
Despite the inherent shortcomings of this
observational study, this report provides promising data for fetal interventional
cardiology. As these types of technologies progress, neonatologists will
likely encounter patients on whom fetal cardiac procedures have been performed.
These infants may well have new complications and pose new challenges in
the neonatal period. |
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PREMATURITY,
NECROTIZING ENTEROCOLITIS, AND CONGENITAL HEART DISEASE |
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(For
non-journal subscribers, an additional fee may apply for full text articles.) |
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| Dees
E, Lin H, Cotton RB, et al. Outcome of Preterm Infants with
Congenital Heart Disease. J. Pediatrics 2000; 137:
653-9. |
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| McElhinney
DB, Hedrick HL, Bush DM et al. Necrotizing Enterocolitis in
Neonates With Congenital Heart Disease: Risk Factors and Outcomes. Pediatrics 2000;
106: 1080-1087. |
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An
unfortunately common scenario encountered by neonatologists and pediatric
cardiologists is the dilemma of the child with CHD who also has the misfortune
of being born prematurely. A study by Dees et al nicely summarizes the
outcomes of a large group of premature neonates with congenital heart disease.
Associated congenital and genetic malformations were common in this group
of patients, with 32% having associated congenital syndromes. In terms
of morbidity, premature neonates with congenital heart disease were almost
twice (1.7) as likely to develop necrotizing enterocolitis (NEC). Interestingly,
the rate of intraventricular hemorrhage was lower by half than in neonates
without congenital heart disease. Perhaps unsurprisingly, the rate of in-hospital
mortality was higher for preterm patients with congenital heart disease
than for premature infants or infants with congenital heart disease alone.
Although NEC occurs more frequently in premature
infants with congenital heart disease, term infants with congenital heart
disease are also at risk from this disease. McElhinney et al reviewed 643
neonates admitted to their institution with a diagnosis of congenital heart
disease. Among these neonates the rate of NEC was 3.3%, a ten-fold increase
over the general population of newborns, but a lower risk than prematurity.
Not every neonate was equally at risk: using multivariate analysis, the
diagnosis of hypoplastic left heart syndrome, truncus arteriosus, or aortopulmonary
window were independently associated with the diagnosis of NEC. The data
were analyzed in a case control manner, finding earlier gestational age
at birth (36.7 +/- 2.7 weeks versus 38.1 +/- 2.3 weeks) and episodes of
low cardiac output or clinical shock to be significantly associated with
NEC by multivariate analysis. Although high dose prostaglandin was significantly
associated in univariate analysis with NEC, this association became nonsignificant
upon controlling for other factors. These data strongly imply that NEC
within the population of congenital heart disease patients is a perfusion
phenomenon. Patients with the diagnoses of HLHS, truncus arteriosus, and
aortopulmonary window all share the characteristics of widened pulse pressure
and low diastolic pressure due to large amounts of systemic runoff into
the pulmonary vascular bed. Doppler of the descending aorta in these patients
often shows reversal of flow in diastole, a risk factor for mesenteric
hypoperfusion. Importantly, preoperative feeding, timing of feeding, and
type of feeding (breast milk or formula) had no influence on the incidence
of NEC in this population. Hospital mortality was not found to be greater
with the diagnosis of NEC, likely due to the stronger influence that congenital
heart disease had on overall mortality. However, among patients who developed
NEC and died, the deaths were attributable directly to NEC -- implying
that NEC is an important cause of mortality in neonates with CHD.
The authors report that, in general, infants
with CHD born prematurely had worse outcomes and were more likely to develop
necrotizing enterocolitis than infants with prematurity alone. In addition
to the risk that prematurity confers, infants with CHD seem to have a propensity
for developing NEC even when born at term. This risk may be related to
specific hemodynamic features which place the mesentery at high risk of
hypoperfusion. Neonatologists must therefore be vigilant in monitoring
and treatment of NEC in this patient population. |
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BALLOON
ATRIAL SEPTOSTOMY AND NEONATAL STROKES |
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(For
non-journal subscribers, an additional fee may apply for full text articles.) |
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| Miller
SP, McQuillen PS, Vigneron DB et al. Preoperative Brain Injury
in Newborns with Transposition of the Great Arteries. Ann
Thor Surg 2004; 77: 1698-706. |
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| McQuillen
PS, Hamrick SE, Perez MJ, et al. Balloon Atrial Septostomy is
Associated With Preoperative Stroke in Neonates With Transposition of
the Great Arteries. Circulation 2006; 113: 280-285. |
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A
lower level of cognitive ability and various aspects of developmental delay
have long been observed in children who survive surgery for congenital
heart disease, and the mechanisms of neurological insult in these patients
have been the subject of intense research. Preoperative conditions such
as cyanosis and respiratory distress, operative insults of bypass and circulatory
arrest, and postoperative instability with disturbances in ventilation
and oxygenation have all been implicated in neurological trauma.
Two reports have recently shed light onto
the amount of neurologic injury that occurs in the preoperative period,
typically during time spent in the NICU. In the report by Miller et al,
10 consecutive neonates were subjected to preoperative and postoperative
MRI scans to assess the sequence of neurologic injury in surgical repair
of TGA. Also performed was MR spectroscopic imaging (MRSI) of the basal
ganglia, thalamus, and corticospinal tracts. The authors report that MRSI
of lactate/choline, a measure of oxidative metabolism, was higher in newborns
with TGA versus normal newborns, a finding consistent with the hypoxic
condition of the preoperative brain in TGA physiology. Not anticipated
was a 40% rate of focal injury discovered preoperatively, with only one
neonate having new damage documented after surgery. The focal findings
on MRI were infarct, white matter damage, intraventricular hemorrhage,
and/or a combination of these lesions. The data in this study were quite
surprising, as conventional wisdom would have held that major neurologic
morbidity would be associated with surgery and the immediate post-surgical
period.
An intriguing study recently published by
McQuillen et al sought to extend these findings by analyzing the risk factors
involved in preoperative neurological damage among a group of 29 newborns
with transposition of the great arteries, studied using MRI before corrective
surgery. Twelve patients were found to have preoperative brain injury.
Although severe desaturation occurred in these patients, no patients had
evidence of basal ganglia damage or watershed infarcts. Birth weight, Apgar
score, resuscitation score, PGE1 use, lowest oxygen saturation recorded,
and lowest base deficit were not associated with preoperative brain injury.
The only factor found to be significantly associated with preoperative
neurological injury was the performance of balloon atrial septostomy (BAS).
Of the 29 neonates studied, all 12 with brain injury were among the 19
patients who underwent preoperative BAS. The injuries were apparently unrelated
to the BAS technique, including site of cannulation (umbilical versus femoral)
as well as duration of catheterization before MRI.
This useful information, if confirmed in
larger studies, will likely change the preoperative management of many
cyanotic neonates. While the precise clinical prognostic value of these
MRI changes is not fully understood at this time, it is generally agreed
that these are pathologic changes. Pediatric cardiologists may therefore
be more likely to accept somewhat lower postnatal saturations in order
to avoid performing BAS in selected patients. In addition, some interventionalists
may consider anticoagulation during BAS in order to lessen the risk of
thromboembolic events. Whether this strategy will have a positive impact
on long-term neurological outcomes is unknown. |
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The Johns Hopkins University School of Medicine designates
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Physicians should only claim credit commensurate with the extent of their
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Target Audience • back
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This activity has been developed for Neonatologists, NICU Nurses
and Respiratory Therapists working with Neonatal patients. There are no fees
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Learning Objectives • back
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At the conclusion of this activity, participants should be able
to:
- Describe the rationale for fetal intervention for Hypoplastic Left Heart
Syndrome (HLHS).
- Discuss the risk factors for the development of necrotizing enterocolitis
(NEC) in patients with congenital heart disease.
- Describe the risk factors for neonatal stroke in patients
with transposition of the great arteries (TGA).
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