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Risk Factors for Perioperative Brain Lesions in Infants With Congenital Heart Disease: A European Collaboration
Alexandra F Bonthrone1, Raymond Stegeman2,3, Maria Feldmann4
1Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (A.F.B., K.P., C.J.K., S.A., M.A.R., S.J.C.).
Insights
Delivery method and surgery timing are key factors influencing brain injury in infants with congenital heart disease. Understanding these risks can help personalize treatment and improve neurodevelopmental outcomes.
Area of Science:
- Pediatric Cardiology
- Neonatal Neurology
- Cardiothoracic Surgery
Background:
- Infants with congenital heart disease (CHD) face significant risks of brain injury and impaired neurodevelopment.
- Perioperative brain lesions are a critical concern in neonates undergoing cardiac surgery for CHD.
- Identifying modifiable risk factors is essential for improving outcomes in this vulnerable population.
Purpose of the Study:
- To investigate risk factors associated with perioperative brain lesions in infants with severe CHD.
- To analyze the incidence of arterial ischemic stroke, cerebral sinus venous thrombosis, and white matter injury.
- To identify potential targets for intervention to minimize brain injury during neonatal cardiac surgery.
Main Methods:
- A combined analysis of three European cohorts (Utrecht, Zurich, London) involving infants with transposition of the great arteries, single ventricle physiology, or left ventricular outflow tract/aortic arch obstruction.
- Infants underwent cardiac surgery within 6 weeks of birth.
- Preoperative and postoperative magnetic resonance imaging (MRI) were used to assess brain lesions and analyze risk factors.
Main Results:
- Preoperatively, induced vaginal delivery and balloon atrial septostomy were associated with white matter injury and arterial ischemic stroke.
- Postoperatively, younger age at surgery and selective cerebral perfusion (especially at ≤20°C) increased the risk of new arterial ischemic stroke.
- Single ventricle physiology was linked to new white matter injury, while transposition of the great arteries was associated with new cerebral sinus venous thrombosis. Delayed sternal closure and lower intraoperative temperatures also increased the risk of cerebral sinus venous thrombosis.
Conclusions:
- Delivery planning and timing of cardiac surgery are potentially modifiable risk factors for perioperative brain injury in infants with CHD.
- Optimizing cerebral perfusion techniques during neonatal surgery is crucial.
- Further research is needed to confirm the relationship between cerebral sinus venous thrombosis and perioperative risk factors.
Background:
Infants with congenital heart disease are at risk of brain injury and impaired neurodevelopment. The aim was to investigate risk factors for perioperative brain lesions in infants with congenital heart disease.
Methods:
Infants with transposition of the great arteries, single ventricle physiology, and left ventricular outflow tract and/or aortic arch obstruction undergoing cardiac surgery <6 weeks after birth from 3 European cohorts (Utrecht, Zurich, and London) were combined. Brain lesions were scored on preoperative (transposition of the great arteries N=104; single ventricle physiology N=35; and left ventricular outflow tract and/or aortic arch obstruction N=41) and postoperative (transposition of the great arteries N=88; single ventricle physiology N=28; and left ventricular outflow tract and/or aortic arch obstruction N=30) magnetic resonance imaging for risk factor analysis of arterial ischemic stroke, cerebral sinus venous thrombosis, and white matter injury.
Results:
Preoperatively, induced vaginal delivery (odds ratio [OR], 2.23 [95% CI, 1.06-4.70]) was associated with white matter injury and balloon atrial septostomy increased the risk of white matter injury (OR, 2.51 [95% CI, 1.23-5.20]) and arterial ischemic stroke (OR, 4.49 [95% CI, 1.20-21.49]). Postoperatively, younger postnatal age at surgery (OR, 1.18 [95% CI, 1.05-1.33]) and selective cerebral perfusion, particularly at ≤20 °C (OR, 13.46 [95% CI, 3.58-67.10]), were associated with new arterial ischemic stroke. Single ventricle physiology was associated with new white matter injury (OR, 2.88 [95% CI, 1.20-6.95]) and transposition of the great arteries with new cerebral sinus venous thrombosis (OR, 13.47 [95% CI, 2.28-95.66]). Delayed sternal closure (OR, 3.47 [95% CI, 1.08-13.06]) and lower intraoperative temperatures (OR, 1.22 [95% CI, 1.07-1.36]) also increased the risk of new cerebral sinus venous thrombosis.
Conclusions:
Delivery planning and surgery timing may be modifiable risk factors that allow personalized treatment to minimize the risk of perioperative brain injury in severe congenital heart disease. Further research is needed to optimize cerebral perfusion techniques for neonatal surgery and to confirm the relationship between cerebral sinus venous thrombosis and perioperative risk factors.
