Intermediate-term NeuroDevelopmental Outcomes after
Neonatal Cardiac Surgery:
Role of Cortical Iso-Electric
Activity
Pediatric Cardiac Consortium of Upstate New York
University of Rochester Medical Center
Disclosures
• None
Objective
• Neurodevelopmental delay diagnosed 5-7
years following neonatal cardiac surgery
• Thought to arise from multiple factors
– Pre-natal hypoxia
– Operative
• Hypoxia
• Hypothermia
• Low flow
Objective
• Continuous intra-operative EEG
• Hypothermia  Iso-electric activity
• Recovery from iso-electric activity  seizures
– Rhythmic Burst Pattern
– Sharp Components
– Asynchronous between hemispheres
Hypothesis
• We hypothesized that the
duration of iso-electric cortical
brain activity would be related
to neuro-developmental
outcomes
Methods
Lead Placement
• Neonates requiring surgery
2006-2009
• EEG leads placed
– Standard 10-20
• Baseline EEG prior to
anesthesia
• Continuous Intra-operative
EEG monitoring
Methods
• EEG activity classified as
1. Normal for Age
2. Slow and Continuous
Slower frequencies but continuous
3. Moderate Burst Suppression
< 30 second intervals between bursts
4. Severe Burst Suppression
> 30 second intervals between bursts
5. Iso-Electric Activity
Absence of brain activity
Methods
Normal for Age
F7-T7
T7-P7
P7-O1
F3-C3
C3-P3
P3-O1
F2-C2
C2-P2
F4-C4
C4-P4
P4-O2
F8-T8
T8-P8
P8-O2
Methods
Moderate Burst Suppression
F7-T7
T7-P7
P7-O1
F3-C3
C3-P3
P3-O1
F2-C2
C2-P2
F4-C4
C4-P4
P4-O2
F8-T8
T8-P8
P8-O2
Methods
Iso-Electric Activity
F7-T7
T7-P7
P7-O1
F3-C3
C3-P3
P3-O1
F2-C2
C2-P2
F4-C4
C4-P4
P4-O2
F8-T8
T8-P8
P8-O2
Methods-VABS-II
• Parents of neonates with prior EEG recordings
contacted
• Parents completed VABS-II questionnaire at a
follow-up of 5.6 ± 1.0 years
• Investigator trained in the VABS-II validated
the parental responses
Methods-VABS-II
• Numeric and percentile scores of overall
performance
–
–
–
–
Communication
AODL
Socialization
Motor skills
• Scores classified according to percentiles
–
–
–
–
–
Low
Moderately low
Adequate
Moderately high
High
Results
Original Cohort (n=32)
Died during the follow-up (n=6)
Lost to Follow-up (n=2)
Did not complete survey correctly (n=3)
EEG’s and ND outcomes (n=21)
IE Activity (n=11)
Non-IE Activity (n=10)
Results
IE (n=11)
Age at operation (days)
Weight (kg)
HLHS or variant
D-TGA
TOF
CoA/Arch Hypoplasia
DHCA Time (min)
Regional Perfusion
7.0 ± 2.2
3.1 ± 0.5
5
1
0
5
24.1 ± 16.3
36% (4)
Non IE (n=10) p value
7.7 ± 2.5
3.4 ± 0.4
0
9
1
0
0
0
0.5
0.2
0.03
0.003
1.0
0.03
Results
MAP (mmHg)
70
60
50
40
30
20
Non IE
(n=10)
IE
(n=11)
Results
Flow (L/min)
3
Non IE
(n=10)
IE
(n=11)
2.7
2.4
2.1
1.8
1.5
MBS
MBS
SBS
IE
SBS
MBS
Results
Temperature °C
40
Non IE
(n=10)
IE
(n=11)
35
30
25
20
15
S/ConMBS
S/ConMBS SBS
IE
SBS MBS
Results
200
Time (min)
*
150
100
50
0
IE Time
* Denotes Statistical Significance
DHCA Time
Results
Communication Score
Receptive
Expressive
Written
IE (n=11)
43.1±10.1
14.2 ± 4.0
14.5 ± 4.5
14.5 ± 2.8
Non IE (n=10)
50.0±5.1
16.7 ± 2.1
16.5 ± 2.1
16.8 ± 2.1
P value
0.04
0.09
0.2
0.04
Daily Living
Personal
Domestic
Community
40.5 ± 11.3
12.8 ± 4.1
13.9 ± 3.5
13.8 ± 4.2
44.3±4.3
13.3 ± 2.4
15.8 ± 2.3
15.5 ± 1.9
0.7
0.2
0.3
0.3
Socialization
Interpersonal Relations
Play/Leisure
Coping skills
43.2 ± 11.9
14.9 ± 4.3
12.3 ± 3.8
16.0 ± 4.6
45.2 ± 7.9
14.8 ± 3.5
13.7 ± 2.4
16.8 ± 2.8
0.6
0.9
0.3
0.6
Motor Skills
Gross Motor Skills
Fine Motor Skills
26.5 ± 7.2
13.1 ± 3.8
13.2 ± 4.1
28.5 ± 3.0
14.5 ± 1.6
14.0 ± 2.1
0.4
0.3
0.6
351.1±100.0
7
17.5 ± 2.5
392±49.0
9
16.9 ± 1.2
0.3
Adaptive Behavior
Adequate
Maladaptive Behavior Index
0.5
Results
VABS-II Score
600.00
R = - 0.7
p = 0.03
400.00
200.00
0.00
0.00
50.00
100.00
IE Time (min)
150.00
200.00
Results
VABS-II Score
600.00
R = 0.1
p = 0.7
400.00
200.00
0.00
0.00
20.00
40.00
60.00
DHCA Time (min)
80.00
Results
IE Time
DHCA Time
Conclusions
• Cortical IE is strongly associated with
hypothermia < 25 °C
• Duration of IE activity correlates with neurodevelopmental outcomes at an intermediateterm follow-up
• Intra-operative EEG may be a useful tool to
assess neurologic injury
• Limited hypothermia may improve neurodevelopmental outcomes
Thank you
Results
VABS-II Score
600.00
R = - 0.7
p = 0.03
400.00
200.00
0.00
0.00
50.00
100.00
IE Time (min)
150.00
200.00
Methods-Operative
•
•
•
•
•
•
DHCA-Neonates cooled to 18-20 °C
Absence of DHCA-Neonates cooled to 32-34 °C
Glucose levels maintained 80-200 g/dl
PO2 > 100
PCO2 < 30
Hemoglobin > 7.0 g/dl