Developmental and Neurologic Status of Children after Heart Surgery with Hypothermic Circulatory Arrest or Low-Flow Cardiopulmonary Bypass
David C. Bellinger, Ph.D., Richard A. Jonas, M.D., Leonard A. Rappaport, M.D., David Wypij, Ph.D., Gil Wernovsky, M.D., Karl C.K. Kuban, M.D., Patrick D. Barnes, M.D., Gregory L. Holmes, M.D., Paul R. Hickey, M.D., Roy D. Strand, M.D., Amy Z. Walsh, R.N., B.S.N., Sandra L. Helmers, M.D., Jules E. Constantinou, F.R.A.C.P., Enrique J. Carrazana, M.D., John E. Mayer, M.D., Frank L. Hanley, M.D., Aldo R. Castaneda, M.D., James H. Ware, Ph.D., and Jane W. Newburger, M.D., M.P.H.
Background Deep hypothermia with either total circulatory arrestor low-flow cardiopulmonary bypass is used to support vitalorgans during heart surgery in infants. We compared the developmentaland neurologic sequelae of these two strategies one year aftersurgery.
Methods Infants with D-transposition of the great arteries whounderwent an arterial-switch operation were randomly assignedto a method of support consisting predominantly of circulatoryarrest or a method consisting predominantly of low-flow bypass.Developmental and neurologic evaluations and magnetic resonanceimaging (MRI) were performed at one year of age.
Results Of the 171 patients enrolled in the study, 155 wereevaluated. After adjustment for the presence or absence of aventricular septal defect, the infants assigned to circulatoryarrest, as compared with those assigned to low-flow bypass,had a lower mean score on the Psychomotor Development Indexof the Bayley Scales of Infant Development (a 6.5-point deficit,P = 0.01) and a higher proportion had scores <80 (i.e., 2SD or more below the population mean) (27 percent vs. 12 percent,P = 0.02). The score on the Psychomotor Development Index wasinversely related to the duration of circulatory arrest (P =0.02). The risk of neurologic abnormalities increased with theduration of circulatory arrest (P = 0.04). The method of supportwas not associated with the prevalence of abnormalities on MRIscans of the brain, scores on the Mental Development Index ofthe Bayley Scale, or scores on a test of visual-recognitionmemory. Perioperative electroencephalographic seizure activitywas associated with lower scores on the Psychomotor DevelopmentIndex (P = 0.002) and an increased likelihood of abnormalitieson MRI scans of the brain (P<0.001).
Conclusions Heart surgery performed with circulatory arrestas the predominant support strategy is associated with a higherrisk of delayed motor development and neurologic abnormalitiesat the age of one year than is surgery with low-flow bypassas the predominant support strategy.
Source Information
From the Departments of Neurology (D.C.B., K.C.K.K., G.L.H., S.L.H., J.E.C., E.J.C.), Cardiovascular Surgery (R.A.J., J.E.M., F.L.H., A.R.C.), Medicine (L.A.R.), Cardiology (G.W., A.Z.W., J.W.N.), Anesthesia (P.R.H.), and Radiology (P.D.B., R.D.S.), Children's Hospital; the Departments of Neurology (D.C.B., K.C.K.K., G.L.H., S.L.H., J.E.C., E.J.C.), Surgery (R.A.J., J.E.M., F.L.H., A.R.C.), Pediatrics (L.A.R., G.W., J.W.N.), and Radiology (P.D.B., R.D.S.), Harvard Medical School; and the Department of Biostatistics, Harvard School of Public Health (D.W., J.H.W.) — all in Boston.
Address reprint requests to Dr. Newburger at the Department of Cardiology, Children's Hospital, 300 Longwood Ave., Boston, MA 02115.
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