Hostname: page-component-cd9895bd7-8ctnn Total loading time: 0 Render date: 2024-12-27T21:48:12.710Z Has data issue: false hasContentIssue false
  • English
  • Français

Clinical neurologic and developmental studies after cardiac surgery utilizing hypothermic circulatory arrest and cardiopulmonary bypass

Published online by Cambridge University Press:  19 August 2008

Gil Wernovsky ,
Richard A. Jonas ,
Paul R. Hickey ,
Adré J. du Plessis  and
Jane W. Newburger
Gil Wernovsky*
Affiliation:
From the Departments of Cardiology, Cardiac Surgery, Anesthesiology and Neurology, Children's Hospital and the Departments of Pediatrics, Surgery, Anesthesiology and Neurology, Harvard Medical School, Boston
Richard A. Jonas
Affiliation:
From the Departments of Cardiology, Cardiac Surgery, Anesthesiology and Neurology, Children's Hospital and the Departments of Pediatrics, Surgery, Anesthesiology and Neurology, Harvard Medical School, Boston
Paul R. Hickey
Affiliation:
From the Departments of Cardiology, Cardiac Surgery, Anesthesiology and Neurology, Children's Hospital and the Departments of Pediatrics, Surgery, Anesthesiology and Neurology, Harvard Medical School, Boston
Adré J. du Plessis
Affiliation:
From the Departments of Cardiology, Cardiac Surgery, Anesthesiology and Neurology, Children's Hospital and the Departments of Pediatrics, Surgery, Anesthesiology and Neurology, Harvard Medical School, Boston
Jane W. Newburger
Affiliation:
From the Departments of Cardiology, Cardiac Surgery, Anesthesiology and Neurology, Children's Hospital and the Departments of Pediatrics, Surgery, Anesthesiology and Neurology, Harvard Medical School, Boston
*
Dr. Gil Wernovsky, Cardiac Intensive Care Unit, Farley 653, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel. (617) 735-7866; Fax. (617) 730-0403.
Get access Rights & Permissions [Opens in a new window]

Extract

The dramatic reduction in surgical mortality associated with repair of congenital heart anomalies in recent decades has been accompanied by a growing recognition of adverse neurologic sequels in some of the survivors. Abnormalities of the central nervous system may be a function of coexisting cerebral abnormalities or acquired events unrelated to surgical management (such as paradoxical embolus, cerebral infection, or effects of chronic cyanosis), but insults to the central nervous system appear to occur most frequently during or immediately after surgery. In particular, techniques of support used during neonatal and infant cardiac surgery—cardiopulmonary bypass, profound hypothermia and circulatory arrest—have been implicated as important causes of cerebral injury. This paper will review the effects of bypass and deep hypothermic circulatory arrest on neurodevelopmental outcome.

Keywords

Management of bypassintelligence quotientelectroencephalographycore cooling
Type
World Forum for Pediatric Cardiology Symposium on Cardiopulmonary Bypass (Part 1)
Information
Cardiology in the Young , Volume 3 , Issue 3 , July 1993 , pp. 308 - 316
Copyright
Copyright © Cambridge University Press 1993

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Berthrong, M, Sabiston, DC. Cerebral lesions in congenital heart disease: A review of autopsies on one hundred and sixty-two cases. Bull John Hopkins Hospital 1951; 89: 384–401.Google Scholar
2.Glauser, TA, Rorke, LB, Weinberg, PM, Clancy, RR. Congeni tal brain anomalies associated with the hypoplastic left heart syndrome. Pediatrics 1990; 85: 984–990.CrossRefGoogle Scholar
3.Terplan, KL. Patterns of brain damage in infants and children with congenital heart disease. Am J Dis Child 1973; 125: 175.CrossRefGoogle Scholar
4.Slogoff, ST, Girgis, KZ, Keats, AS. Etiologic factors in neuro psychiatric complications associated with cardiopulmonary bypass. Anesth Analg 1982; 61: 903–911.CrossRefGoogle Scholar
5.Bellinger, DC, Wernovsky, G, Rappaport, LA. Cognitive devel opment of children following early repair of transposition of the great arteries using deep hypothermic circulatory arrest. Pediatrics 1991; 87: 701–707.CrossRefGoogle Scholar
6.Watanabe, T, Masamichi, M, Onto, H, Kobayasi, M, Washio, M. Brain tissue pH, oxygen tension, and carbon dioxide tension in profoundly hypothermic cardiopulmonary bypass. J Thorac Cardiovasc Surg 1990; 100: 274–280.CrossRefGoogle ScholarPubMed
7.Watanabe, T, Miura, M, Inui, K. Blood and brain tissue gaseous strategy for profoundly hypothermic total circulatory arrest. J Thorac Cardiovasc Surg 1991; 102: 497–504.CrossRefGoogle ScholarPubMed
8.Johnston, WE, Vinten-Johansen, J, De Witt, DS, O'Steen, WK, Stump, DA, Prough, DS. Cerebral perfusion during canine hypothermic cardiopulmonary bypass: effect ofarterial carbon dioxide tension. Ann Thorac Surg 1991; 52: 479–489.CrossRefGoogle Scholar
9.Willford, DC, Moores, WY, Ji, S, Zhung, TC, Palencia, A, Daily, PO. Importance of acid-base strategy in reducing myocardial and whole body oxygen consumption during perfusion hy pothermia. J Thorac Cardiovasc Surg 1990; 100: 699–707.CrossRefGoogle Scholar
10.Jonas, RA, Newburger, JW, Wernovsky, G, Farrell, DM, Rappaport, LA, Bellinger, DC. Alkaline pH strategy during core cooling worsens developmental outcome after circulatory arrest. Circulation 1991; 84 (Suppl II): 121A. [Abstract]Google Scholar
11.Settergren, G, Ohqvist, G, Lundberg, S, Henze, A, Bjork, VO, Persson, B. Cerebral blood flow and cerebral metabolism in children following cardiac surgery with deep hypothermia and circulatory arrest. Clinical course and follow-up of psychomo tor development. Scan J Thor Cardiovasc Surg 1982; 16: 209–215.Google Scholar
12.Wright, JS, Hicks, RG, Newman, DC. Deep hypothermic arrest: observations on later development in children. J Thorac Cardiovasc Surg 1979; 77: 466–468.CrossRefGoogle ScholarPubMed
13.Wells, FC, Coghill, S, Caplan, HL, Lincoln, C. Duration of circulatory arrest does influence the psychological development of children after cardiac operation in early life. J Thorac Cardiovasc Surg 1983; 86: 823–831.CrossRefGoogle ScholarPubMed
14.Muraoka, R, Yokota, M, Aoshima, M. Subclinical changes in brain morphology following cardiac operations as reflected by computed tomographic scans ofthe brain. J Thorac Cardiovasc Surg 1981; 81: 364–369.CrossRefGoogle Scholar
15.Fisk, GC, Wright, JS, Hicks, RG. The influence of duration of circulatory arrest at 20°C on cerebral changes. Anaesth Intens Care 1976; 4: 126–134.CrossRefGoogle Scholar
16.Jonas, RA, Wernovsky, G, Ware, J. The Boston circulatory arrest study: perioperative neurologic outcome after the arterial switch operation. Circulation 1992; 86(Suppl I): 360A. [Abstract]Google Scholar
17.Barry, YA, Labow, RS, Keon, WJ, Tocchi, M, Rock, G. Perioperarive exposure to plasticizers in patients undergoing cardiopulmonary bypass. J Thorac Cardiovasc Surg 1989; 97: 900–905.CrossRefGoogle Scholar
18.Blauth, CI, Smith, PL, Arnold, JV, Jagoe, JR, Wootton, R, Taylor, KM. Influence of oxygenator type on the prevalence and extent of mircroembolic retinal ischemia during cardiopulmo nary bypass. J Thorac Cardiovasc Surg 1990; 99: 61–69.CrossRefGoogle Scholar
19.Fish, KJ. Microembolization: etiology and prevention. In: Hilberman, M (ed). Brain Injury and Protection During Heart Surgery. Martinus Nijhoff Publishing, Boston, 1988, pp 67–84.CrossRefGoogle Scholar
20.Nussmeier, MA, McDermott, JP. Macroembolization: preven tion and outcome modification. In: Hilberman, M (ed). Brain Injury and Protection During Heart Surgery. Martinus Nijhoff Publishing, Boston, 1988, pp 85–108.CrossRefGoogle Scholar
21.Padayachee, TS, Parsons, S, Theobold, R, Gosling, RG, Deverall, PB. The effect of arterial filtration on reduction of gaseous microemboli in the middle cerebral artery during cardiopul monary bypass. Ann Thorac Surg 1988; 45: 647–649.CrossRefGoogle Scholar
22.Wilson, GJ, Rebeyka, IM, Coles, JG. Loss of the somatosensory evoked response as an indicator of reversible cerebral ischemia during hypothermic, low-flow cardiopulmonary bypass. Ann Thorac Surg 1988; 45: 206–209.CrossRefGoogle ScholarPubMed
23.Kern, FH, Jonas, RA, Mayer, JE, Hanley, FL, Castafleda, AR, Hickey, PR. Temperature monitoring during CPB in infants: does it predict efficient brain cooling? Ann Thorac Surg 1992; 54: 749–754.CrossRefGoogle ScholarPubMed
24.Coselli, JS, Crawford, ES, Beall, AC, Mizrahi, EM, Hess, KR, Patel, VM. Determination of brain temperatures for safe circulatory arrest during cardiovascular operation. Ann Thorac Surg 1988; 45: 638–642.CrossRefGoogle ScholarPubMed
25.Busto, R, Dietrich, WD, Globus, MYT, Valdes, I, Scheinberg, P, Gensberg, MD. Small differences in intraischemic brain tem perature critically determine the extent of ischemic neuronal injury. J Cerbr Blood Flow Met 1987; 7: 729–738.CrossRefGoogle Scholar
26.Pulsinelli, WA, Waidman, S, Rawlinson, D, Plum, F. Moderate hyperglycemia augments ischemic brain damage: a pathologic study in the rat. Neur 1982; 32: 1239.Google ScholarPubMed
27.Steward, DJ, DaSilva, CA, Flegel, T. Elevated blood glucose levels may increase the danger of neurological deficit following profoundly hypothermic cardiac arrest. Anesth 1988; 68: 653.CrossRefGoogle ScholarPubMed
28.Whitman, V, Drotar, D, Lambert, S. Effects of cardiac surgery with extracorporeal circulation on intellectual function in children. Circulation 1973; 46: 160–163.CrossRefGoogle Scholar
29.Hammeke, TA, Hastings, JE. Neuropsychologic alterations after cardiac operation. J Thorac Cardiovasc Surg 1989; 96: 326–331.CrossRefGoogle Scholar
30.Grote, CL, Shanahan, PT, Salmon, P, Meyer, RG, Barrett, C, Lansing, A. Cognitive outcome after cardiac operations. J Thorac Cardiovasc Surg 1992; 104: 1405–1409.CrossRefGoogle ScholarPubMed
31.Aberg, T. Cerebral injury during open heart surgery: studies using functional, biochemical, and morphological methods. In: Hilberman, M (ed). Brain Injury and Protection During Heart Surgery. Martinus Nijhoff Publishing, Boston, 1988, pp 1–12.Google Scholar
32.Kirklin, JK, Westaby, S, Blackstone, EH, Kirklin, JW, Chenoweth, DE, Pacifico, AD. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983; 86: 845–857.CrossRefGoogle ScholarPubMed
33.Jonas, RA. Pathophysiology ofcardiopulmonary bypass and its relation to age: metabolic response. In: RA, Jonas, Elliott, EM (eds). Cardiopulmonary Bypass for Neonates, Infants and Small Children. Butterworth-Heinemann, London, 1993. [In press]Google Scholar
34.Mathews, K, Bale, JF, Clark, EB, Marvin, WJ Jr, Dory, DB. Cerebral infarction complicating Fontan surgery for cyanotic congenital heart disease. Pediatr Cardiol 1986; 7: 161–166.CrossRefGoogle ScholarPubMed
35.McConnell, JR, Fleming, WH, Chu, W-K. Magnetic resonance imaging of the brain in infants and children before and after cardiac surgery. A prospective study. Am J Dis Child 1990; 144: 374–378.CrossRefGoogle ScholarPubMed
36.Moody, DM, Bells, MA, Challa, VR, Johnston, WE, Prough, DS. Brain microemboli during cardiac surgery or aortogra phy. Ann Neurol 1990; 28: 477–486.CrossRefGoogle ScholarPubMed
37.Ekroth, R, Thompson, RJ, Lincoln, C, Scallan, M, Rossi, R, Tsang, V. Elective deep hypothermia with total circulatory arrest: changes in plasma creatine kinase BB, blood glucose, and clinical variables. J Thorac Cardiovasc Surg 1989; 97: 30.CrossRefGoogle ScholarPubMed
38.Mezrow, CK, Sadeghi, AM, Gandsas, A. Cerebral blood flow and metabolism in hypothermic circulatory arrest. Ann Thorac Surg 1992; 54: 609–616.CrossRefGoogle ScholarPubMed
39.Greeley, WJ, Kern, FH, Ungerleider, RM. The effect of hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral metabolism in neonates, infants and children. J Thorac Cardiovasc Surg 1991; 101: 783–794.CrossRefGoogle ScholarPubMed
40.Lundar, T, Lindberg, H, Lindegaard, KF. Cerebral perfusion during major cardiac surgery in children. Pediatr Cardiol 1987; 8: 161–165.CrossRefGoogle ScholarPubMed
41.Greeley, W, Ungerleider, RM, Smith, LR, Reves, JG. The effects of deep hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral blood flow in infants and children. J Thorac Cardiovasc Surg 1989; 97: 737–745.CrossRefGoogle ScholarPubMed
42.Greeley, WJ, Ungerleider, RM, Kern, FH, Brusino, FG, Smith, LR, Reves, JG. Effects of cardiopulmonary bypass on cerebral blood flow in neonates, infants, and children. Circulation 1989; 80: 209–215.Google ScholarPubMed
43.Soma, Y, Hirotani, T, Yozu, R. A clinical study of cerebral circulation during extracorporeal circulation. J Thorac Cardiovasc Surg 1989; 97: 187–193.CrossRefGoogle ScholarPubMed
44.Kern, FH, Ungerleider, RM, Quill, TJ. Cerebral blood flow response to changes in arterial carbon dioxide tension during hypothermic cardiopulmonary bypass in children. J Thorac Cardiovasc Surg 1991; 101: 618–622.CrossRefGoogle ScholarPubMed
45.Maul, JR, Ohtake, S, Klingensmith, ME, Heinle, JS, Greeley, WJ, Ungerleider, RM. Cerebral metabolism and circulatory arrest: effects of duration and strategies for protection. Ann Thorac Surg 1993; 55: 57–64.CrossRefGoogle Scholar
46.Folkerth, TL, Angell, WW, Fosburg, RG, Oury, JH. Effect of deep hypothermia, limited cardiopulmonary bypass, and total arrest on growing puppies. In: Recent Advances in Studies on Cardiac Structure, Vol. 10. University Park, Baltimore, 1975, pp 411–421.Google Scholar
47.Kramer, RS, Sanders, AP, Lesage, AM, Woodhall, B, Scaly, WC. The effect of profound hypothermia on preservation of cerebral ATP content during circulatory arrest. J Thorac Cardiovasc Surg 1968; 56: 699.CrossRefGoogle ScholarPubMed
48.Fisk, GC, Wright, JS, Turner, BB: Cerebral effects of circulatory arrest at 20°C in the infant pig. Anaesth Intens Care 1974; 2: 33.CrossRefGoogle Scholar
49.Wolin, LR, Massopust, LC Jr, White, RJ. Behavioral effects of autocerebral perfusion, hypothermia and arrest of cerebral blood flow in the rhesus monkey. Exp Neurol 1973; 39: 336.CrossRefGoogle ScholarPubMed
50.Treasure, T, Naftel, DC, Conger, KA, Garcia, JH, Kirklin, JW, Blackstone, EH. The effect of hypothermic circulatory arrest time on cerebral function, morphology, and biochemistry. J Thorac Cardiovasc Surg 1983; 86: 761.CrossRefGoogle ScholarPubMed
51.Coles, JG, Taylor, MJ, Pearce, JM. Cerebral monitoring of somatosensory evoked potentials during profoundly hypothermic circulatory arrest. Circulation 1984; 70(Suppl I): I 96–I 102.Google ScholarPubMed
52.Weiss, M, Weiss, J, Cotton, J, Nicolas, F, Binet, JP. A study of the electroencephalogram during surgery with deep hypothermia and circulatory arrest in infants. J Thorac Cardiovasc Surg 1975; 70: 316–329.CrossRefGoogle ScholarPubMed
53.Rossi, R, Ekroth, R, Lincoln, C. Detection of cerebral injury after total circulatory arrest and profound hypothermia by estimation of specific creatinine kinase isoenzyme levels using monoclonal antibody techniques. Am J Cardiol 1986; 58: 1236–1241.CrossRefGoogle Scholar
54.Hicks, RG, Poole, JL. Electroencephalographic changes with hypothermia and cardiopulmonary bypass in children. J Thorac Cardiovasc Surg 1992; 81: 781–786.CrossRefGoogle Scholar
55.Nussmeier, NA, Arlund, C, Slogoff, ST. Neuropsychiatric complications after cardiopulmonary bypass: cerebral protection by a barbiturate. Anesth 1986; 64: 165–170.CrossRefGoogle ScholarPubMed
56.Shewmon, DA. What is a neonatal seizure? Problems in definition and quantification for investigative and clinical purposes. J Clin Neurophysiol 1993; 7: 315–368.CrossRefGoogle Scholar
57.Volpe, JJ. Neonatal seizures: current concepts and revised classification. Pediatrics 1989; 84: 422–428.CrossRefGoogle ScholarPubMed
58.Scher, MS, Painter, MJ. Controversies concerning neonatal seizures. Ped Clin N Am 1989; 36: 281–310.CrossRefGoogle ScholarPubMed
59.Zelnik, N, Nir, A, Amit, S, lancu, TC. Autonomic seizures in an infant: unusual cutaneous and cardiac manifestations. Dev Med Child Neurol 1990; 32: 74–78.CrossRefGoogle Scholar
60.Clancy, RR, Legido, A, Lewis, D. Occult neonatal seizures. Epilepsia 1988; 29: 256–261.CrossRefGoogle ScholarPubMed
61.Ehyai, A, Fenichel, GM, Bender, HW Jr. Incidence and prog nosis of seizures in infants after cardiac surgery with profound hypothermia and circulatory arrest. J Am Med Assoc 1984; 252: 3165–3167.CrossRefGoogle Scholar
62.Wernovsky, G, Jonas, RA, Newburger, JW. The Boston circu latory arrest study: hemodynamics and hospital course after the arterial switch operation. Circulation 1992; 86(Suppl I): 237A. [Abstract]Google Scholar
63.Brunberg, JA, Reilly, EL, Dory, DB. Central nervous system consequences in infants of cardiac surgery using deep hypo thermia and circulatory arrest. Circulation 1974; 50(Suppl II): II 60–II 68.Google Scholar
64.Barratt-Boyes, BG. Choreoathetosis as a complication of car diopulmonary bypass. Ann Thorac Surg 1990; 50: 693–694.CrossRefGoogle Scholar
65.Robinson, RO, Samuels, M, Pohl, KRE. Choreic syndrome after cardiac surgery. Arch Dis Child 1988; 63: 1466–1469.CrossRefGoogle ScholarPubMed
66.Smith-Wical, B, Tomasi, LG. A distinctive neurologic syn drome after induced profound hypothermia. Pediatric Neurol 1990; 6: 202–205.CrossRefGoogle Scholar
67.Brunberg, JA, Dory, DB, Reilly, EL. Choreoathetosis in infants following cardiac surgery with deep hypothermia and circula tory arrest. J Pediatr 1974; 84: 232–235.CrossRefGoogle Scholar
68.Chaves, E, Scaltsas-Persson, I. Severe choreoathetosis following congenital heart disease surgery. Neur 1988; 38 (Suppl): 284.Google Scholar
69.DeLeon, S, Ilbawi, M, Archiia, R. Choreoathetosis after deep hypothermia without circulatory arrest. Ann Thorac Surg 1990; 50: 714–719.CrossRefGoogle ScholarPubMed
70.Wong, PC, Barlow, CF, Hickey, PR. Factors associated with choreoathetosis after cardiopulmonary bypass in children with congenital heart disease. Circulation 1992; 86(Suppl II): II 118–II 126.Google ScholarPubMed
71.Messmer, BJ, Schallberger, U, Gattiker, R, Senning, A. Psy chomotor and intellectual development after deep hypothermia and circulatory arrest in early infancy. J Thorac Cardiovasc Surg 1976; 72: 495–502.CrossRefGoogle Scholar
72.Haka-Ikse, K, Blackwood, MJA, Steward, DJ. Psychomotor development of infants and children after profound hypothermia during surgery for congenital heart disease. Develop Med Child Neurol 1978; 20: 62–70.CrossRefGoogle ScholarPubMed
73.Dickinson, DF, Sambrooks, JE. Intellectual performance in children after circulatory arrest with profound hypothermia in infancy. Arch Dis Child 1979; 54: 1–6.CrossRefGoogle ScholarPubMed
74.Clarkson, PM, MacArthur, BA, Barratt-Boyes, BG, Whitlock, RM, Neutze, JM. Developmental progress after cardiac surgery in infancy using hypothermia and circulatory arrest. Circulation 1980; 62: 855–861.CrossRefGoogle ScholarPubMed
75.Blackwood, MJA, Haka-Ikse, K, Steward, DJ. Developmental outcome in children undergoing surgery with profound hypo thermia. Anesth 1986; 65: 437–440.CrossRefGoogle Scholar
76.Ferry, PC. Neurologic sequelae of open-heart surgery in children: an “irritating question”. AmJ Dis Child 1990; 144: 369–373.CrossRefGoogle Scholar
77.Sotaniemi, KA. Cerebral outcome after extracorporeal circulation. Comparison between prospective and retrospective evaluations. Arch Neurol 1989; 40: 75–77.CrossRefGoogle Scholar
78.Kern, FH, Ungerleider, RM, Schulman, S. Comparison of two strategies of CPB cooling on jugular venous oxygen saturation. Anesth 1992; 77: 1136A. [Abstract]CrossRefGoogle Scholar
79.Baraka, AS, Baroody, MA, Haroun, ST. Effect of alpha stat versus pH stat strategy on oxyhemoglobin dissociation and whole-body oxygen consumption during hypothermic cardiopulmonary bypass. Anesth Analg 1992; 74: 32–37.CrossRefGoogle ScholarPubMed
80.Rogers, AT, Prough, DS, Roy, RC. Cerebrovascular and cerebral metabolic effects of alterations in perfusion flow rate during hypothermic cardiopulmonary bypass in man. J Thorac Cardiovasc Surg 1992; 103: 363–368.CrossRefGoogle ScholarPubMed
81.Tuppurainen, T, Settergren, G, Stensved, P. The effect of arterial pH on whole body oxygen uptake during hypothermic cardiopulmonary bypass in man. J Thorac Cardiovasc Surg 1989; 98: 769–773.CrossRefGoogle ScholarPubMed
82.Murkin, JM. Cerebral hyperperfusion during cardiopulmo nary bypass: the influence of PaCO2. In: Hilberman, M (ed). Brain Injury and Protection During Heart Surgery. Martinus Nijhoff Publishing, Boston, 1988, pp 47–66.CrossRefGoogle Scholar