Cause and prevention of central nervous system injury in neonates undergoing cardiac surgery
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Published on: May 26, 2023
Troy E Dominguez1, Gil Wernovsky, J William Gaynor
1Division of Cardiothoracic Surgery, The Cardiac Center at The Childre's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
Insights
Neurologic morbidity is a growing concern in neonates with congenital heart disease. Patient-specific factors, not just surgical management, significantly impact long-term brain health outcomes.
Area of Science:
- Pediatric Cardiology
- Neonatal Neurology
- Neurocritical Care
Background:
- Improved surgical survival in neonates with congenital heart disease has highlighted the challenge of associated neurologic morbidity.
- Congenital brain disease in this population presents a significant obstacle to achieving favorable long-term neurologic outcomes.
Purpose of the Study:
- To review the mechanisms of central nervous system injury in neonates undergoing cardiac surgery.
- To discuss prenatal, intraoperative, and postoperative factors influencing neurologic outcomes.
- To emphasize the role of patient-specific factors in long-term neurologic outcomes.
Main Methods:
- Review of existing literature on neurologic injury in neonates with congenital heart disease.
- Identification of mechanisms of central nervous system injury, including hypoxia-ischemia, emboli, oxidative stress, and inflammatory microvasculopathy.
- Analysis of modifiable perioperative factors (pH, hematocrit, cerebral perfusion, hypothermia) and their impact on neurologic outcomes.
Main Results:
- Key mechanisms of brain injury include hypoxia-ischemia, emboli, reactive oxygen species, and inflammatory microvasculopathy.
- Preoperative focus is on preventing hypoxic-ischemic and thromboembolic events.
- Modifiable intraoperative factors like pH, hematocrit, cerebral perfusion, and deep hypothermic circulatory arrest are critical.
- Postoperative injury can result from altered cerebral autoregulation, further insults, seizures, and prolonged ICU stays.
Conclusions:
- While modifiable perioperative factors are important, patient-specific genetic and environmental factors appear to explain a greater proportion of variability in long-term neurologic outcomes.
- Addressing "congenital brain disease" requires a comprehensive approach considering all contributing factors.
Abstract:
Neurologic morbidity has been identified as increasingly problematic in neonates with congenital heart disease as surgical mortality rates have improved. The presence of "congenital brain disease" in patients with congenital heart disease represents a challenge in improving long-term neurologic outcomes. Mechanisms of central nervous system injury in infants undergoing cardiac surgery include hypoxia-ischemia, emboli, reactive oxygen species, and inflammatory microvasculopathy. Preoperatively, the primary focus is on preventing hypoxic-ischemic injury and thromboembolic insults. Modifiable intraoperative factors associated with central nervous system injury include, but are not limited to, pH management, hematocrit during cardiopulmonary bypass, regional cerebral perfusion, and the use of deep hypothermic circulatory arrest. Postoperatively, secondary neurologic injury may be related to post-cardiopulmonary bypass alterations in cerebral autoregulation and additional hypoxic-ischemic insult, seizures, or other issues associated with prolonged intensive care unit stay. In addition to prenatal and modifiable perioperative factors, genetic and environmental factors are known to be important. Unfortunately, modifiable perioperative factors may explain less of the variability in long-term outcomes than do patient-specific factors.
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