Use of Limited Periods of Deep Hypothermic Circulatory Arrest is Not Associated with Worse Neurodevelopmental Outcome at One-Year of Age
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Objective:
Use of deep hypothermic circulatory arrest (DHCA) during neonatal and infant cardiac surgery remains controversial. Recent studies have suggested that the neurodevelopmental sequelae of limited periods of DHCA (< 40 - 45 minutes) are similar to continuous cardiopulmonary bypass (CPB).
Methods:
Analysis of infants ≤ 6 months enrolled in a study of apolipoprotein E (APOE) genotype and neurodevelopmental outcomes after infant cardiac surgery who underwent repair of 2-ventricle cardiac defects with 1 operation with CPB and no more than 1 episode of DHCA. Neurodevelopmental outcomes at 1-year of age were assessed with the Bayley Scales of Infant Development-II which yield 2 indices, the Mental Developmental Index (MDI) and the Psychomotor Developmental Index (PDI).
Results:
Two hundred and forty-eight infants underwent surgical repair between 10/1998 and 4/2003 with 1 hospital death and 3 deaths prior to 1-year of age. Neurodevelopmental evaluation was performed in 188/244 survivors (77%); including 56 patients with tetralogy of Fallot, 39 with transposition of the great arteries with intact ventricular septum, 34 with ventricular septal defects, and 59 with other defects. The median age at surgery was 56 days (1-186), including 72 neonates (38%). Confirmed or suspected genetic syndromes were present in 60/188 infants (32%). DHCA was utilized in 67 infants (36%) with a median duration of 34 minutes (1-80), and was > 50 minutes in 4 patients (2%). For the entire cohort, the mean MDI was 91 ± 15 and the mean PDI was 82 ± 17. For patients without genetic syndromes, the mean MDI was 94 ± 14 and the mean PDI was 85 ± 15.
Stepwise logistic regression was used to evaluate 25 preoperative and operative factors as potential predictors of the MDI and PDI. For the entire cohort (n =188), predictors of a both lower MDI and PDI were presence of a confirmed or suspected genetic syndrome, lower birth weight, presence of the APOE ε2 allele, and lower weight at surgery (all p<0.03). Apgar at 1 minute improved prediction of PDI (p=0.05), but not MDI. For patients without genetic syndromes (n = 128), the only predictor of a lower MDI was either younger gestational age or the highly correlated lower birth weight, p = 0.002. Predictors of a lower PDI score were lower Apgar score at 1-minute and Caucasian ethnicity, both p ≤ 0.001, and younger gestational age (p=0.02). Conclusions:
In this cohort of infants undergoing repair of 2-ventricle cardiac defects with limited periods of DHCA; the strongest predictors of a worse neurodevelopmental outcome at 1-year of age were patient specific factors including presence of a genetic syndrome, low birth weight, presence of the APOE ε2 allele, weight at surgery, and 1 minute Apgar score. Neither the use nor the duration of DHCA was predictive of a worse outcome.
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