Neurodevelopmental status at eight years in children with dextro-transposition of the great arteries: the Boston Circulatory Arrest Trial.
OBJECTIVE
Our goal was to determine which of the two major methods of vital organ support used in infant cardiac surgery, total circulatory arrest and low-flow cardiopulmonary bypass, results in better neurodevelopmental outcomes at school age.


METHODS
In a single-center trial, infants with dextrotransposition of the great arteries underwent the arterial switch operation after random assignment to either total circulatory arrest or low-flow cardiopulmonary bypass. Developmental, neurologic, and speech outcomes were assessed at 8 years of age in 155 of 160 eligible children (97%).


RESULTS
Treatment groups did not differ in terms of most outcomes, including neurologic status, Full-Scale or Performance IQ score, academic achievement, memory, problem solving, and visual-motor integration. Children assigned to total circulatory arrest performed worse on tests of motor function including manual dexterity with the nondominant hand (P =.003), apraxia of speech (P =.01), visual-motor tracking (P =.01), and phonologic awareness (P =.003). Assignment to low-flow cardiopulmonary bypass was associated with a more impulsive response style on a continuous performance test of vigilance (P <.01) and worse behavior as rated by teachers (P =.05). Although mean scores on most outcomes were within normal limits, neurodevelopmental status in the cohort as a whole was below expectation in many respects, including academic achievement, fine motor function, visual-spatial skills, working memory, hypothesis generating and testing, sustained attention, and higher-order language skills.


CONCLUSIONS
Use of total circulatory arrest to support vital organs during heart surgery in infancy is generally associated with greater functional deficits than is use of low-flow cardiopulmonary bypass, although both strategies are associated with increased risk of neurodevelopmental vulnerabilities.
Bellinger
David C
DC
Department of Neurology, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA. david.bellinger@tch.harvard.edu
Wypij
David
D
duPlessis
Adre J
AJ
Rappaport
Leonard A
LA
Jonas
Richard A
RA
Wernovsky
Gil
G
Newburger
Jane W
JW
D001900:Boston; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods; D002315:Cardiopulmonary Bypass / Q000009:adverse effects* / Q000379:methods; D002648:Child; D002658:Developmental Disabilities / Q000175:diagnosis / Q000209:etiology*; D005260:Female; D005500:Follow-Up Studies; D006324:Heart Arrest, Induced / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D007231:Infant, Newborn; D007361:Intelligence Tests; D008297:Male; D019957:Motor Skills Disorders / Q000175:diagnosis / Q000209:etiology*; D009422:Nervous System Diseases / Q000175:diagnosis / Q000209:etiology*; D009460:Neurologic Examination; D009483:Neuropsychological Tests; D011336:Probability; D011446:Prospective Studies; D012016:Reference Values; D018570:Risk Assessment; D012720:Severity of Illness Index; D014188:Transposition of Great Vessels / Q000175:diagnosis / Q000601:surgery*; D016896:Treatment Outcome