Original article: cardiovascular
Preoperative brain injury in newborns with transposition of the great arteries

Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.
https://doi.org/10.1016/j.athoracsur.2003.10.084Get rights and content

Abstract

Background

The objective was to determine the timing and mechanism of brain injury using preoperative and postoperative magnetic resonance imaging (MRI) and three-dimensional MR spectroscopic imaging (MRSI) in newborns with transposition of the great arteries (TGA) repaired with full-flow cardiopulmonary bypass.

Methods

Ten term newborns with TGA undergoing an arterial switch operation were studied with MRI, MRSI, and neurologic examination preoperatively and postoperatively at a median of 5 days (2 to 9 days) and 19 days (14 to 26 days) of age, respectively. Five term historical controls were studied at a median of 4 days (3 to 9 days). Lactate/choline (marker of cerebral oxidative metabolism) and N-acetylaspartate (NAA)/choline (marker of cerebral metabolism and density) were measured bilaterally from the basal ganglia, thalamus, and corticospinal tracts.

Results

Four TGA newborns had brain injury on the preoperative MRI. The only new lesion detected on the postoperative study was a focal white matter lesion in one newborn with a normal preoperative MRI. The MRSI of age-adjusted lactate/choline was quantitatively higher in newborns with TGA compared with those without heart disease (p < 0.0001), even in newborns without MRI evidence of preoperative brain injury. Lactate/choline decreased after surgery but remained elevated compared with controls. In newborns with TGA, those with preoperative brain injury on MRI had lower NAA/choline globally (p = 0.04) than those with normal preoperative MRI. Five newborns had a decline in NAA/choline from the preoperative to postoperative studies.

Conclusions

Abnormal brain metabolism and injury was observed preoperatively in newborns with TGA. Brain injury is not solely related to the operative course.

Section snippets

Patients

Ten consecutive newborns with TGA and intact ventricular septum, or small restrictive ventricular septal defects, born in or transferred to our institution since September 2001 were studied with preoperative and postoperative MRI and MRSI. Newborns were excluded from the study if gestational age at birth was less than 36 weeks, if there was clinical evidence of a congenital malformation or syndrome, or if there was congenital infection. If a balloon atrial septostomy was clinically indicated,

Clinical and MRI characteristics

The clinical characteristics of the three groups, historical controls, TGA newborns without preoperative brain injury, and TGA newborns with preoperative brain injury, including perinatal and preoperative cardiac indices, were similar (Table 1). All newborns with TGA underwent an arterial switch operation with full-flow CPB, without deep hypothermic circulatory arrest or low-flow CPB. The intraoperative and postoperative indices of the TGA newborns with and without preoperative brain injury

Brain injury occurs preoperatively in infants with TGA

Using preoperative and postoperative MRI and MRSI in hemodynamically stable newborns with TGA, we found preoperative brain injury on MRI in 4 of 10 patients. This is consistent with the observation that more than half of newborns with CHD have evidence of neurobehavioral and neurologic abnormalities before surgery 2, 9. We also found a high incidence of abnormalities on preoperative neurologic examination, including abnormalities of tone and reflexes. The focal lesions identified on

Acknowledgements

The authors thank Dr George Gregory and the neonatal nurses of the Pediatric Clinical Research Center (PCRC) for their expertise, and gratefully acknowledge the assistance of Mary Ann Bohland and Srivathsa Veeraraghavan in acquiring and processing the MR data. This research is supported by the Larry L. Hillblom Foundation (Start-Up Grant) and the American Heart Association (Beginning Grant-In-Aid 0365018Y; SPM), the Pediatric Clinical Research Center at UCSF (National Institutes of Health

References (22)

  • C Limperopoulos et al.

    Neurologic status of newborns with congenital heart defects before open heart surgery

    Pediatrics

    (1999)
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    *These authors contributed equally to this manuscript.

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