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Brain maturation is delayed in infants with complex congenital heart defects
Open accessAbstract
Objective Small head circumferences and white matter injury in the form of periventricular leukomalacia have been observed in populations of infants with severe forms of congenital heart defects. This study tests the hypothesis that congenital heart defects delay in utero structural brain development.Methods Full-term infants with hypoplastic left heart syndrome or transposition of the great arteries were prospectively evaluated with preoperative brain magnetic resonance imaging. Patients with independent risk factors for abnormal brain development (shock, end-organ injury, or intrauterine growth retardation) were excluded. Outcome measures included head circumferences and the total maturation score on magnetic resonance imaging. Total maturation score is a previously validated semiquantitative anatomic scoring system used to assess whole brain maturity. The total maturation score evaluates 4 parameters of maturity: (1) myelination, (2) cortical infolding, (3) involution of glial cell migration bands, and (4) presence of germinal matrix tissue.Results The study cohort included 29 neonates with hypoplastic left heart syndrome and 13 neonates with transposition of the great arteries at a mean gestational age of 38.9 +/- 1.1 weeks. Mean head circumference was 1 standard deviation below normal. The mean total maturation score for the cohort was 10.15 +/- 0.94, significantly lower than reported normative data in infants without congenital heart defects, corresponding to a delay of 1 month in structural brain development.Conclusion Before surgery, term infants with hypoplastic left heart syndrome and transposition of the great arteries have brains that are smaller and structurally less mature than expected. This delay in brain development may foster susceptibility to periventricular leukomalacia in the preoperative, intraoperative, and postoperative periods.
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“Reports from a number of investigators have documented a high prevalence of anatomic and functional neurologic abnormalities prior to surgery in newborns with CHD [9-17], and an association of such abnormalities with childhood developmental status [11,13,18,19].”
From Brain Volume and Metabolism in Fetuses With Congenital Heart Disease: Evaluation With Quantitative Magnetic Resonance Imaging and Spectroscopy (2010) · cites this paper as [17]
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“However, there is increasing evidence that adverse neurodevelopmental outcomes in children with complex CHD are due not only perioperative insult, but to inborn factors as well.”
From Brain Volume and Metabolism in Fetuses With Congenital Heart Disease: Evaluation With Quantitative Magnetic Resonance Imaging and Spectroscopy (2010) · cites this paper as [17]
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“Studies have documented a high prevalence of peri-operative brain injury and delayed brain development in neonates with CHD (7–10).”
From Neonatal Brain Injury and Timing of Neurodevelopmental Assessment in Patients With Congenital Heart Disease (2018) · cites this paper as [9]
In the citing paper
“Similar findings have been observed in human newborns with congenital heart disease (CHD) at autopsy and on brain-imaging studies.[27][28][29][30]”
From Associations Between Age at Arterial Switch Operation, Brain Growth, and Development in Infants With Transposition of the Great Arteries (2019) · cites this paper as [29]
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1 retracted
Dent, C., Spaeth, J., Jones, B., Schwartz, S. M., Glauser, T., Hallinan, B., Pearl, J., Khoury, P., & Kurth, C. (2005) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2005.07.051 · Cited by 194
RetractedVolpe, J. J. (1981) · PubMed · Cited by 2,859
Back, S. A., Luo, N. L., Borenstein, N. S., Levine, J. M., Volpe, J. J., & Kinney, H. C. (2001) · Journal of Neuroscience · doi:10.1523/jneurosci.21-04-01302.2001 · Cited by 936
Abnormal brain development in newborns with congenital heart disease
Miller, S. P., McQuillen, P. S., Hamrick, S., Xu, D., Glidden, D. V., Charlton, N., Karl, T., Azakie, A., Ferriero, D. M., Barkovich, A. J., et al. (2007) · New England Journal of Medicine · doi:10.1056/nejmoa067393 · Cited by 860
Bellinger, D. C., Wypij, D., duPlessis, A. J., Rappaport, L. A., Jonas, R. A., Wernovsky, G., & Newburger, J. W. (2003) · The Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/s0022-5223(03)00711-6 · Cited by 681
Self-citationAn MRI Study of Neurological Injury Before and After Congenital Heart Surgery
Mahle, W. T., Tavani, F., Zimmerman, R. A., Nicolson, S. C., Galli, K. K., Gaynor, J. W., Clancy, R. R., Montenegro, L. M., Spray, T. L., Chiavacci, R. M., et al. (2002) · Circulation · doi:10.1161/01.cir.0000032908.33237.b1 · Cited by 541
Self-citationTemporal and anatomic risk profile of brain injury with neonatal repair of congenital heart defects
McQuillen, P. S., Barkovich, A. J., Hamrick, S. E. G., Perez, M., Ward, P., Glidden, D. V., Azakie, A., Karl, T., & Miller, S. P. (2007) · Stroke · doi:10.1161/01.str.0000247941.41234.90 · Cited by 379
Donofrio, M. T., Bremer, Y. A., Schieken, R. M., Gennings, C., Morton, L. D., Eidem, B. W., Cetta, F., Falkensammer, C. B., Huhta, J. C., & Kleinman, C. S. (2003) · Pediatric Cardiology · doi:10.1007/s00246-002-0404-0 · Cited by 364
Periventricular leukomalacia is common after neonatal cardiac surgery
Galli, K. K., Zimmerman, R. A., Jarvik, G. P., Wernovsky, G., Kuypers, M., Clancy, R. R., Montenegro, L. M., Mahle, W. T., Newman, M. F., Saunders, A. M., et al. (2004) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2003.09.053 · Cited by 352
Self-citationShillingford, A. J., Glanzman, M. M., Ittenbach, R. F., Clancy, R. R., Gaynor, J. W., & Wernovsky, G. (2008) · Pediatrics · doi:10.1542/peds.2007-1066 · Cited by 348
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Marino, B. S., Lipkin, P. H., Newburger, J. W., Peacock, G., Gerdes, M., Gaynor, J. W., Mussatto, K. A., Uzark, K., Goldberg, C. S., Johnson, W. H., et al. (2012) · Circulation · doi:10.1161/cir.0b013e318265ee8a · Cited by 1,608
Self-citationRychik, J. R., Atz, A. M., Celermajer, D. S., Deal, B. J., Gatzoulis, M. Α., Gewillig, M. H. M. L., Hsia, T., Hsu, D. T., Kovacs, A. H., McCrindle, B. W., et al. (2019) · Circulation · doi:10.1161/cir.0000000000000696 · Cited by 1,055
Limperopoulos, C., Tworetzky, W., McElhinney, D. B., Newburger, J. W., Brown, D. W., Robertson, R. L., Guizard, N., McGrath, E., Geva, J., Annese, D., et al. (2010) · Circulation · doi:10.1161/circulationaha.109.865568 · Cited by 663
Neurodevelopmental Outcomes After Cardiac Surgery in Infancy
Gaynor, J. W., Stopp, C., Wypij, D., Andropoulos, D. B., Atallah, J., Atz, A. M., Beca, J., Donofrio, M. T., Duncan, K., Ghanayem, N. S., et al. (2015) · Pediatrics · doi:10.1542/peds.2014-3825 · Cited by 518
Self-citationWhite matter injury in the preterm infant: pathology and mechanisms
Back, S. A. (2017) · Acta Neuropathologica · doi:10.1007/s00401-017-1718-6 · Cited by 473
Metadata
- Authors
- Licht, D. J., Shera, D. M., Clancy, R. R., Wernovsky, G., Montenegro, L. M., Nicolson, S. C., Zimmerman, R. A., Spray, T. L., Gaynor, J. W., & Vossough, A.
- Affiliations
- Children's Hospital of Philadelphia (US)
- Corresponding author
- Licht, Daniel J.
- ORCID
- Venue
- The Journal of Thoracic and Cardiovascular Surgery
- Publisher
- Elsevier BV
- Published
- 2009-03
- Volume
- 137
- Issue
- 3
- Pages
- 529-537
- ISSN
- 0022-5223 (ISSN-L)
- PMC
- PMC2701902
- OpenAlex
- W2105478587
- Cited by
- 629
- References
- 31
- Citations by year
- 2026: 34 · 2025: 30 · 2024: 30 · 2023: 47 · 2022: 40 · 2021: 41 · 2020: 42 · 2019: 49 · 2018: 39 · 2017: 42 · 2016: 49 · 2015: 33 · 2014: 32 · 2013: 30 · 2012: 36
- FWCI
- 20.01
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Thoracic and Cardiovascular Surgery (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Neurological Disorders and Stroke (K23NS052380)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Congenital Heart Disease Studies
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Neonatal and fetal brain pathology
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Fetal and Pediatric Neurological Disorders
- Keywords
- congenital heart disease, brain maturation, hypoplastic left heart syndrome, transposition of the great arteries, head circumference, periventricular leukomalacia, white matter injury, germinal matrix, myelination, neonates
- MeSH terms
- Brain, Female, Fetal Growth Retardation, Heart Defects, Congenital, Humans, Infant, Newborn, Male, Prospective Studies, Time Factors, Transposition of Great Vessels, Hypoplastic Left Heart Syndrome
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