Early Neurodevelopmental Outcomes After Corrective Cardiac Surgery In Infants

Objective: To assess neurodevelopmental status in Indian infantsundergoing corrective surgery for congenital heart disease (CHD)and to analyze factors associated with neurodevelopmental delay.Design : Cross-sectional study.Setting: Tertiary-care pediatric cardiology facility.Participants: Consecutive infants undergoing corrective surgeryfor CHD (January 2013 –December 2014). Palliative procedures,and patients with known genetic syndromes were excluded.Main outcome measures: Neurodevelopmental evaluation 3months, and one year after surgery using DevelopmentalAssessment Scales for Indian Infants (DASII); scores werecategorized as delayed if ?70.Results: Of the 162 children enrolled, delayed PDI and MDIscores were observed in 33.5% and 19.6% of patients at 3months, respectively; this reduced to 14.5 % on 1-year follow-up.On multivariate analysis, delayed PDI outcome at one year waspredicted by early term birth and one-year postoperative headcircumference Z-score <–2. Delayed MDI was associated withhigher mean perfusion pressure on cardiopulmonary bypass.Cardiac diagnosis and peri-operative factors did not impactneurodevelopmental outcomes.Conclusions: Neurodevelopmental status is delayed in 14.5% ofinfants one year after corrective infant heart surgery

Outcomes of Infants with Prenatally Diagnosed Congenital Heart Disease Delivered in a Tertiary-care Pediatric Cardiac Facility.

Objective: To report short-term outcomes of infants with prenatally diagnosed Congenital Heart Disease (CHD) delivered in a tertiary-care cardiac facility. Design: Retrospective study. Setting: Tertiary-care referral hospital. Participants: Children with prenatally diagnosed CHDs who underwent delivery at study centre during the period January 2008 - December 2013 were included. Outcomes tracked from hospital records and direct follow-up. Results: Of the 552 fetuses diagnosed to have CHD, 121 (22%) were delivered at the study centre. Fetuses undergoing a planned delivery were diagnosed in late gestation (mean gestational age 31.5 + 5.1 wk). 74 fetuses (61.2%) had simple CHD and rest were complex. 96 (79.3%) neonates received cardiac care; 30 (24.8%) required surgery while 5 received catheter-based interventions. 11 patients underwent surgery on follow-up. Neonatal survival in cardiac care group was 93.8%; on follow-up (12.5 + 13.1 mo); 83 (86.4%) of these infants were alive. All infants undergoing neonatal surgery or catheter-based interventions survived. 25 patients (20.6%) received comfort care (Complex CHD, associated co-morbidities); 14 (56%) survived neonatal period and 6 (24%) were alive on follow-up. Conclusions: Infants with prenatal diagnosis of CHD and planned delivery in a cardiac facility had satisfactory immediate outcomes, expecially in those receiving specialized post-natal cardiac care.

Clinical Screening for Congenital Heart Disease at Birth: A Prospective Study in a Community Hospital in Kerala.

Objective: To develop a clinical strategy for detection of Congenital heart disease (CHD) in the newborn through a combination of clinical signs and pulse oximetry. Design: Prospective longitudinal study. Setting: Community level hospital in the city of Kochi, Kerala. Participants and interventions: All consecutive newborns between June 2006 and February 2009 were prospectively screened for CHD, 48 hours after birth. The on-site pediatrician performed clinical screening. A study nurse recorded pulse oximetry in a lower extremity; value of <94% was defined as abnormal. Echocardiography was performed on site by a trained research officer. A 6- week clinical follow-up evaluation was done for all. Main outcome measure: Detection of CHD by echocardiography. Results: Of 5487 babies screened, 425 (7.75%) had CHD. 17 (0.31%) had major CHD, two of whom (one ALCAPA and one large VSD) were missed during the initial evaluation. The rest were minor CHD (408 patients, 7.44%), most of which normalized by 6 weeks. On multivariate analysis, murmur, central cyanosis, abnormal precordial pulsations and abnormal pulse oximetry emerged as significant predictors of CHD. The sensitivity of clinical evaluation and pulse oximetry combined was 19% for all CHDs and 20% for major CHD; specificity was 88%. Conclusions: In the community setting of a developing country, clinical evaluation and pulse oximetry after birth had a very low sensitivity for detection of CHD. Though an abnormal screening warrants prompt echocardiography, a 6-week clinical evaluation is recommended to ensure that major CHD is not missed.

Malnutrition in children with congenital heart disease (CHD) determinants and short term impact of corrective intervention.

OBJECTIVE: To identify determinants of malnutrition in children with congenital heart disease (CHD) and examine the short-term effects of corrective intervention. METHODS: Patients with CHD admitted for corrective intervention were evaluated for nutritional status before and 3 months after surgery. Detailed anthropometry was performed and z-scores calculated. Malnutrition was defined as weight, height and weight/height z-score <or= -2. Determinants of malnutrition were entered into a multivariate logistic regression analysis model. RESULTS: 476 consecutive patients undergoing corrective intervention were included. There were 16 deaths (3.4%; 13 in-hospital, 3 follow-up). The 3-month follow-up data of 358 (77.8%) of remaining 460 patients were analyzed. Predictors of malnutrition at presentation are as summarized: weight z-score <or= -2 (59%): congestive heart failure (CHF), age at correction, lower birth weight and fat intake, previous hospitalizations, >or= 2 children; height z-score <or= -2 (26.3%): small for gestation, lower maternal height and fat intake, genetic syndromes; and weight/height z-score <or= -2 (55.9%): CHF, age at correction, lower birthweight and maternal weight, previous hospitalizations, religion (Hindu) and level of education of father.Comparison of z-scores on 3-month follow-up showed a significant improvement from baseline, irrespective of the cardiac diagnosis. CONCLUSIONS: Malnutrition is common in children with CHD. Corrective intervention results in significant improvement in nutritional status on short-term follow-up.

Stenting the patent arterial duct to increase pulmonary blood flow.

BACKGROUND: Use of surgically created aoropulmonary shunt is well-established for improving pulmonary blood flow in infants with critical reduction in pulmonary blood flow. Recently, stenting the patent ductus arteriosus has emerged as an alternative in selected infants with congenital heart disease and reduced pulmonary blood flow. METHODS AND RESULTS: We reviewed records of consecutive infants undergoing stenting of patent ductus arteriosus between August 2003 and October 2005 at our institution. Two of 12 patients underwent patent ductus arteriosus stenting to facilitate preparation of left ventricle for transposition with intact septum. We report the case selection, technique, immediate and short-term follow-up outcome in the remaining 10 patients [median age: 16 days (range 4-290 days): weight 2.7 kg (range 2-6 kg)] with reduced pulmonary blood flow who underwent stenting of patent ductus arteriosus as an alternative to conventional surgical aortopulmonary shunts. Five of the 6 newborns were prostaglandin-dependent and 4 had previously undergone guidewire perforation of the pulmonary valve (n=2) or balloon dilation (n=2). Successful stent implantation was accomplished in all with no major patient-related complication (median fluoroscopy time: 18.6 min; range: 7.7-72 min). The intensive care unit and hospital stays were prolonged in 3 patients because of sepsis (n=2) and pulmonary over-circulation with sepsis (n=1). On follow-up (median 5.5 months; range 1-19 months) all implanted stents were patent. One patient underwent re-dilation of the implanted stent for declining saturations. CONCLUSIONS: The immediate and short-term follow-up results of stenting of the patent arterial duct, as an alternative to the surgical aortopulmonary shunt in carefully selected newborns and infants is encouraging.