intermediate-term neuro- developmental outcomes after neonatal cardiac surgery: role of cortical...
TRANSCRIPT
Intermediate-term Neuro-Developmental Outcomes after Neonatal Cardiac Surgery:
Role of Cortical Iso-Electric Activity
Pediatric Cardiac Consortium of Upstate New York
University of Rochester Medical Center
Disclosures
• None
Objective
• Neurodevelopmental delay diagnosed 5-7 years following neonatal cardiac surgery
• Thought to arise from multiple factors– Pre-natal hypoxia– Operative
• Hypoxia• Hypothermia• Low flow
Objective
• Continuous intra-operative EEG• Hypothermia Iso-electric activity• Recovery from iso-electric activity seizures
– Rhythmic Burst Pattern– Sharp Components– Asynchronous between hemispheres
Hypothesis
• We hypothesized that the duration of iso-electric cortical brain activity would be related to neuro-developmental outcomes
Methods
• Neonates requiring surgery 2006-2009
• EEG leads placed– Standard 10-20
• Baseline EEG prior to anesthesia
• Continuous Intra-operative EEG monitoring
Lead Placement
Methods
• EEG activity classified as1. Normal for Age2. Slow and Continuous
Slower frequencies but continuous
3. Moderate Burst Suppression < 30 second intervals between bursts
4. Severe Burst Suppression > 30 second intervals between bursts
5. Iso-Electric Activity Absence of brain activity
Methods
F7-T7T7-P7P7-O1F3-C3C3-P3P3-O1F2-C2C2-P2F4-C4C4-P4P4-O2F8-T8T8-P8P8-O2
Normal for Age
Methods
F7-T7T7-P7P7-O1F3-C3C3-P3P3-O1F2-C2C2-P2F4-C4C4-P4P4-O2F8-T8T8-P8P8-O2
Moderate Burst Suppression
Methods
F7-T7T7-P7P7-O1F3-C3C3-P3P3-O1F2-C2C2-P2F4-C4C4-P4P4-O2F8-T8T8-P8P8-O2
Iso-Electric Activity
Methods-VABS-II
• Parents of neonates with prior EEG recordings contacted
• Parents completed VABS-II questionnaire at a follow-up of 5.6 ± 1.0 years
• Investigator trained in the VABS-II validated the parental responses
Methods-VABS-II
• Numeric and percentile scores of overall performance– Communication– AODL– Socialization– Motor skills
• Scores classified according to percentiles– Low– Moderately low– Adequate– Moderately high– High
Original Cohort (n=32)
Died during the follow-up (n=6)
Did not complete survey correctly (n=3)
Lost to Follow-up (n=2)
Results
EEG’s and ND outcomes (n=21)
IE Activity (n=11) Non-IE Activity (n=10)
IE (n=11) Non IE (n=10) p value
Age at operation (days) 7.0 ± 2.2 7.7 ± 2.5 0.5
Weight (kg) 3.1 ± 0.5 3.4 ± 0.4 0.2
HLHS or variant 5 0 0.03
D-TGA 1 9 0.003
TOF 0 1 1.0
CoA/Arch Hypoplasia 5 0 0.03
DHCA Time (min) 24.1 ± 16.3 0
Regional Perfusion 36% (4) 0
Results
Results
S/Con
MBS S/Con
MBS SBS IE SBS MBS20
30
40
50
60
MA
P (
mm
Hg
)
Non IE (n=10)
IE (n=11)
Results
MBS MBS SBS IE SBS MBS1.5
1.8
2.1
2.4
2.7
Flo
w (
L/m
in)
Non IE (n=10)
IE (n=11)
Results
S/Con
MBS S/Con
MBS SBS IE SBS MBS15
20
25
30
35
40
Te
mp
era
ture
°C
Non IE (n=10)
IE (n=11)
IE Time DHCA Time0
50
100
150
200
Tim
e (
min
)
*
* Denotes Statistical Significance
Results
Results IE (n=11) Non IE (n=10) P valueCommunication Score 43.1±10.1 50.0±5.1 0.04 Receptive 14.2 ± 4.0 16.7 ± 2.1 0.09 Expressive 14.5 ± 4.5 16.5 ± 2.1 0.2 Written 14.5 ± 2.8 16.8 ± 2.1 0.04 Daily Living 40.5 ± 11.3 44.3±4.3 0.7 Personal 12.8 ± 4.1 13.3 ± 2.4 0.2 Domestic 13.9 ± 3.5 15.8 ± 2.3 0.3 Community 13.8 ± 4.2 15.5 ± 1.9 0.3 Socialization 43.2 ± 11.9 45.2 ± 7.9 0.6 Interpersonal Relations 14.9 ± 4.3 14.8 ± 3.5 0.9 Play/Leisure 12.3 ± 3.8 13.7 ± 2.4 0.3 Coping skills 16.0 ± 4.6 16.8 ± 2.8 0.6 Motor Skills 26.5 ± 7.2 28.5 ± 3.0 0.4 Gross Motor Skills 13.1 ± 3.8 14.5 ± 1.6 0.3 Fine Motor Skills 13.2 ± 4.1 14.0 ± 2.1 0.6 Adaptive Behavior 351.1±100.0 392±49.0 0.3Adequate 7 9 Maladaptive Behavior Index 17.5 ± 2.5 16.9 ± 1.2 0.5
Results
0.00 50.00 100.00 150.00 200.000.00
200.00
400.00
600.00
IE Time (min)
VA
BS
-II
Sc
ore
R = - 0.7p = 0.03
Results
0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.000.00
200.00
400.00
600.00
DHCA Time (min)
VA
BS
-II
Sc
ore
R = 0.1p = 0.7
Results
IE TimeDHCA Time
Conclusions
• Cortical IE is strongly associated with hypothermia < 25 °C
• Duration of IE activity correlates with neuro-developmental outcomes at an intermediate-term follow-up
• Intra-operative EEG may be a useful tool to assess neurologic injury
• Limited hypothermia may improve neuro-developmental outcomes
Thank you
Results
0.00 50.00 100.00 150.00 200.000.00
200.00
400.00
600.00
IE Time (min)
VA
BS
-II
Sc
ore
R = - 0.7p = 0.03
• DHCA-Neonates cooled to 18-20 °C• Absence of DHCA-Neonates cooled to 32-34 °C• Glucose levels maintained 80-200 g/dl• PO2 > 100
• PCO2 < 30• Hemoglobin > 7.0 g/dl
Methods-Operative