Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA.
Department of Radiology, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA.
J Am Coll Cardiol. 2023 Jan 24;81(3):253-266. doi: 10.1016/j.jacc.2022.10.029.
Brain injury is common in neonates with complex neonatal congenital heart disease (CHD) and affects neurodevelopmental outcomes.
Given advancements in perioperative care, we sought to determine if the rate of preoperative and postoperative brain injury detected by using brain magnetic resonance imaging (MRI) and associated clinical risk factors have changed over time in complex CHD.
A total of 270 term newborns with complex CHD were prospectively enrolled for preoperative and postoperative brain MRIs between 2001 and 2021 with a total of 466 MRI scans. Brain injuries in the form of white matter injury (WMI) or focal stroke and clinical factors were compared across 4 epochs of 5-year intervals with logistic regression.
Rates of preoperative WMI and stroke did not change over time. After adjusting for timing of the postoperative MRI, site, and cardiac group, the odds of newly acquired postoperative WMI were significantly lower in Epoch 4 compared with Epoch 1 (OR: 0.29; 95% CI: 0.09-1.00; P = 0.05). The adjusted probability of postoperative WMI declined significantly by 18.7% from Epoch 1 (24%) to Epoch 4 (6%). Among clinical risk factors, lowest systolic, mean, and diastolic blood pressures in the first 24 hours after surgery were significantly higher in the most recent epoch.
The prevalence of postoperative WMI has declined, whereas preoperative WMI rates remain constant. More robust postoperative blood pressures may explain these findings by minimizing periods of ischemia and supporting cerebral perfusion. These results suggest potential modifiable clinical targets in the postoperative time period to minimize the burden of WMI.
脑损伤在患有复杂新生儿先天性心脏病（CHD）的新生儿中很常见，并且会影响神经发育结局。
鉴于围手术期护理的进步，我们试图确定在复杂 CHD 中，通过脑磁共振成像（MRI）检测到的术前和术后脑损伤的发生率以及相关临床危险因素是否随时间发生了变化。
共有 270 名患有复杂 CHD 的足月新生儿在 2001 年至 2021 年期间前瞻性地接受了术前和术后脑 MRI 检查，共进行了 466 次 MRI 扫描。使用逻辑回归比较了 4 个 5 年间隔时期的脑白质损伤（WMI）或局灶性卒中的形式的脑损伤和临床因素。
术前 WMI 和卒中的发生率并未随时间而改变。在调整术后 MRI 的时间、部位和心脏组后，与第 1 时期相比，第 4 时期新发生的术后 WMI 的可能性明显较低（OR：0.29；95%CI：0.09-1.00；P=0.05）。术后 WMI 的调整后概率从第 1 时期（24%）显著下降到第 4 时期（6%），下降了 18.7%。在临床危险因素中，术后 24 小时内的最低收缩压、平均血压和舒张压在最近的时期明显较高。
术后 WMI 的患病率有所下降，而术前 WMI 率保持不变。更强的术后血压可能通过最小化缺血期和支持脑灌注来解释这些发现。这些结果表明，在术后时间段内，存在潜在的可改变的临床目标，以最大限度地减少 WMI 的负担。
