Risk of seizures in survivors of newborn heart surgery using deep hypothermic circulatory arrest.
OBJECTIVE
To identify pre- and intraoperative variables associated with postoperative acute neurologic events (ANEs), including seizures and coma, in newborn survivors of congenital heart surgery undergoing deep hypothermic circulatory arrest (DHCA), and to risk-stratify this population on the basis of preoperative risk variables for the purpose of designing future neuroprotection trials.


METHODS
Survivors of newborn heart surgery who were enrolled in a neuroprotection trial provided a comprehensive database for the evaluation of pre- and intraoperative variables that influence the postoperative occurrence of ANEs (seizures or coma). Patients with hypoplastic heart syndrome were excluded. After characterization of the study population, stepwise logistic regression, combined with clinical judgment, was used to identify variables that were most likely to be associated with an increased risk of seizures in the study sample and that were most likely to be generalized to other populations.


RESULTS
Data were available on 164 nonhypoplastic left heart syndrome survivors who underwent newborn heart surgery using DHCA. ANEs occurred in 31 (18.9%) including "seizures alone" (n = 28), "coma alone" (n = 2) or "seizures and coma" (n = 1). A preoperative risk model was constructed demonstrating that infants with a genetic condition and aortic arch obstruction had a 47.8% risk of ANEs compared with all other remaining infants, who had a 9.9% risk. It was also found that prolonged DHCA time (>or=60 minutes) can be a significant risk for infants who have a preexisting genetic condition; however, infants who have genetic conditions and do not undergo prolonged DHCA time or have an aortic arch obstruction are not at increased risk of ANEs.


CONCLUSIONS
This study provides new information about the occurrence of ANEs after newborn heart surgery. Seizures or coma, which appeared in approximately 19% of all non-hypoplastic left heart syndrome survivors, were not random events but were significantly associated with specific types of congenital heart disease, the presence of genetic conditions, and prolonged DHCA time. The 3 identified variables permitted individual cases to be assigned to low-, intermediate-, or high-risk categories. Because neonatal seizures are a good surrogate marker of long-term neurologic outcome, these models provide useful information to stratify individual patients for risk of seizures in future neuroprotection trials.
Clancy
Robert R
RR
Division of Neurology and the Cardiac Center, Children's Hospital of Philadelphia, PA 19104, USA. clancy@email.chop.edu
McGaurn
Susan A
SA
Wernovsky
Gil
G
Gaynor
J William
JW
Spray
Thomas L
TL
Norwood
William I
WI
Jacobs
Marshall L
ML
Goin
James E
JE
D001015:Aortic Arch Syndromes / Q000235:genetics / Q000601:surgery; D003128:Coma / Q000453:epidemiology / Q000209:etiology*; D005260:Female; D006324:Heart Arrest, Induced / Q000379:methods* / Q000706:statistics & numerical data; D006330:Heart Defects, Congenital / Q000235:genetics / Q000601:surgery*; D006801:Humans; D007036:Hypothermia, Induced / Q000379:methods*; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D015233:Models, Statistical; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology*; D011300:Preoperative Care; D018570:Risk Assessment; D012307:Risk Factors; D012640:Seizures / Q000453:epidemiology / Q000209:etiology*; D017741:Survivors / Q000706:statistics & numerical data*; D013997:Time Factors