title: Cerebral tissue oxygenation index and lactate at 24 hours postoperative predict survival and neurodevelopmental outcome after neonatal cardiac surgery.
abstract: OBJECTIVE
  There are no well-established noninvasive biomarkers for identifying patients at risk for poor outcome after surgery for congenital heart disease. Few studies have assessed prognostic accuracy of cerebral tissue oxygenation index (cTOI) measured by near infrared spectroscopy (NIRS).
  
  
  OBJECTIVE
  To assess the utility of noninvasive NIRS monitoring as a predictor of outcomes after neonatal cardiac surgery through measurement of cTOI. To examine the utility of noninvasive NIRS monitoring in combination with lactate concentration and inotropic score in prediction of outcomes after neonatal cardiac surgery.
  
  
  METHODS
  Prospective longitudinal cohort study.
  
  
  METHODS
  Operating room and cardiac intensive care unit, Children's National Heart Institute.
  
  
  METHODS
  Seventy-five patients with complex congenital heart disease undergoing surgical repair within first month of life.
  
  
  METHODS
  Cerebral TOI, blood lactate, and inotropic scores were measured preoperative, intraoperative and up to 24 hours postoperative.
  
  
  METHODS
  Postoperative mortality and neurodevelopmental outcome assessed by the Bayley Scales of Infant Development (BSID II). Mental and motor scores were obtained at 6, 15, and 21 months. Good outcome was defined as survival and BSID mental and motor scores ≥70 points. Poor outcome was defined as death or BSID scores <70 at most recent follow-up.
  
  
  RESULTS
  Cohort of 75 patients prospectively followed including 40 patients with single ventricle and 35 with two ventricles. Four patients died before discharge and ten died within 21 months. Seven patients were lost to follow-up. Among survivors with follow-up (n = 54), BSID was abnormal in 25 (46%). Patients with poor outcome (n = 39) had lower mean cTOI 60 minutes off-CPB (48% vs. 58%, P = .003) and 24 hours postoperative (49% vs. 59%, P < .001), higher lactate (8.2 vs. 5.0 mmol/L, P = .005) and higher inotropic scores (10 vs. 6, P = .02) at 24 hours postoperative. ROC analysis indicated that cTOI had moderate predictive accuracy of outcome (AUC = 0.751, P < .001). Multivariable regression analysis confirmed that predictive accuracy was improved using both cTOI and lactate at 24 hours postoperative (AUC = 0.813, 95% CI: 0.705-0.921, P < .001) with optimal cutoff values <58% and >7.4 mmol/L, respectively (sensitivity = 95%).
  
  
  CONCLUSIONS
  Cerebral TOI combined with lactate at 24 hours postoperative are accurate non-invasive predictive biomarkers of patient survival and neurodevelopmental outcome in neonates with CHD undergoing cardiac surgery.
authors.affiliation: Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia, USA.
authors.forename: Safwat A
authors.initials: SA
authors.lastname: Aly
authors.affiliation: Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: David
authors.initials: D
authors.lastname: Zurakowski
authors.affiliation: Department of Psychiatry and Behavioral Science, Children's National Medical Center, Washington, District of Columbia, USA.
authors.forename: Penny
authors.initials: P
authors.lastname: Glass
authors.affiliation: Division of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA.
authors.forename: Kami
authors.initials: K
authors.lastname: Skurow-Todd
authors.affiliation: Division of Cardiothoracic Surgery, Children's National Medical Center, Washington, District of Columbia, USA.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Jonas
authors.affiliation: Division of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA.
authors.forename: Mary T
authors.initials: MT
authors.lastname: Donofrio
mesh_terms: D000367:Age Factors; D019540:Area Under Curve; D015415:Biomarkers / Q000097:blood; D001921:Brain / Q000098:blood supply*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D002560:Cerebrovascular Circulation; D002657:Child Development; D004219:District of Columbia; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D018730:Infant Behavior; D007231:Infant, Newborn; D019344:Lactic Acid / Q000097:blood*; D016015:Logistic Models; D008137:Longitudinal Studies; D009043:Motor Activity; D015999:Multivariate Analysis; D009420:Nervous System / Q000254:growth & development; D010100:Oxygen / Q000097:blood*; D010101:Oxygen Consumption; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D012307:Risk Factors; D019265:Spectroscopy, Near-Infrared; D013566:Sympathomimetics / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D013566:Sympathomimetics; D019344:Lactic Acid; D010100:Oxygen
keywords: congenital heart disease; lactate; near infrared spectroscopy; neurodevelopmental outcome; pediatric cardiology; tissue oxygenation