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Neurologic sequelae of open-heart surgery in children. An 'irritating question'
1Developmental Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Md.
Insights
Pediatric open-heart surgery can lead to neurologic sequelae, including seizures and cognitive deficits. Further research is needed to understand and prevent these adverse outcomes in children.
Area of Science:
- Pediatric Neurology
- Cardiothoracic Surgery
- Neurodevelopmental Disabilities
Background:
- Improved pediatric cardiac surgical techniques have reduced mortality.
- Focus is shifting to residual morbidity, particularly neurologic sequelae.
- Congenital heart defect repair can result in permanent neurologic injury.
Purpose of the Study:
- To survey current approaches for detecting and managing neurologic sequelae after pediatric open-heart surgery.
- To understand the incidence and types of neurologic complications.
- To identify potential pathogenic factors.
Main Methods:
- A survey of six major North American pediatric cardiac surgery units was conducted.
- Data collected on postoperative neurologic symptoms and neuroimaging findings.
- Inquiry into current detection and management strategies.
Main Results:
- All surveyed units reported a small but definite incidence of postoperative neurologic symptoms.
- Symptoms included altered consciousness, seizures, and focal deficits.
- Neuroimaging revealed hypoxic-ischemic encephalopathy, cerebral atrophy, and subdural hematomas.
Conclusions:
- Neurologic sequelae are a recognized complication of pediatric open-heart surgery.
- Potential causes include preoperative anomalies, hypoxic insults, cardiopulmonary bypass, embolization, and low cardiac output.
- Further research is essential to elucidate mechanisms and develop preventative strategies for lifelong disability.
Abstract:
As pediatric cardiac surgical techniques have improved in recent years, mortality rates have dropped and attention has turned to residual morbidity, especially neurologic sequelae. Although the majority of children undergoing open-heart surgery for correction of congenital heart defects apparently emerge with no adverse consequences, a small percentage suffer permanent neurologic injury (seizures, motor disorders). Another small and not well-defined population may be left with disorders of higher cortical function, such as mental retardation or learning disabilities. A survey of six major pediatric cardiac surgery units in North America was undertaken in 1988-1989 to ascertain current approaches to the detection and management of neurologic sequelae of pediatric open-heart surgery. All units reported seeing a small but definite incidence of postoperative neurologic symptoms, including alterations of consciousness, seizures, and localized abnormalities such as hemiparesis or delayed choreoathetoid syndromes. Postoperative neuroimaging procedures have shown a disturbing incidence of hypoxic-ischemic encephalopathy, unsuspected cerebral atrophy, and subdural hematomas. Pathogenesis may include factors related to preoperative brain anomalies and/or hypoxic insults, altered cerebral blood flow and metabolism during hypothermic cardiopulmonary bypass with or without total circulatory arrest, embolization, and low cardiac output states postoperatively. Further studies are needed to examine the mechanisms of injury and to develop techniques to minimize the occurrence of these sequelae, as they may be associated with life-long neurologic disability and reduced quality of life.