Neuropsychological Development in Children after Surgical Treatment of Congenital Heart Diseases

Research Article

Austin Crit Care Case Rep. 2020; 4(1): 1015.

Neuropsychological Development in Children after Surgical Treatment of Congenital Heart Diseases

Lin S1, Liang Y1, Wang X1, Wei X1, Yao J1, Li D2, Zhang H2, Hei F1, Long C1, Jiang F1 and Guan Y1*

¹Department of Extracorporeal Circulation, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China

²Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China

*Corresponding author: Yulong Guan, Department of Extracorporeal Circulation, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing 100037, China

Received: February 07, 2020; Accepted: March 09, 2020; Published: March 16, 2020


Objective: This study was implemented to assess neuropsychological development status in children after surgical treatment of Congenital Heart Diseases (CHDs).

Methods: 89 children (median age 24 months, range 7-78 months) who received follow-up visit in Fuwai Hospital from September 2015 to March 2016 after surgical treatment of CHDs were recruited and 90 normal children (median age 41 months, range 16 - 68 months) without any CHDs were recruited as the control group. The patients were classified into simple CHDs group (RACHS-1 score ≤2) and complex CHDs group (RACHS-1 score ≥3). Neuropsychological development status was measured according to Pediatric-psychological mental test scale developed by Capital institute of pediatrics, Beijing and statistical analysis was compared.

Results: The results of neuropsychological development showed the normal children behaved better than the children with CHDs (p ≺0.05). The simple CHDs group had better distribution of development quotient than the complex CHDs group (p=0.032) and there was no difference between the normal control group and the simple CHDs group (p=0.420). Multivariate regression analysis indicated that younger age at cardiac surgery, lower preoperative Blood Urea Nitrogen (BUN), higher preoperative Creatinine (Cr) and prolonged duration of Cardiopulmonary Bypass (CPB) accounted for lower scores in the subscales of neuropsychological development (p ≺0.05).

Conclusions: Distinct neuropsychological deficits could be present especially in the children with complex CHDs following surgical treatment. Younger age at cardiac surgery, preoperative BUN, Cr and CPB duration could be used as good predictors for midterm neuropsychological development.

Keywords: Congenital Heart Diseases; Child; Neuropsychological Development; Pediatric Cardiac Surgery


It is reported that Congenital Heart Disease (CHD) influences 7-9 per 1000 births in Europe, Asia, and North America, and approximately 25% require surgery in the first year of life. New surgical techniques and optimization in Cardiopulmonary Bypass (CPB), intensive care, and interventional cardiac catheterization have significantly lowered mortality rates for children and adolescents with various CHDs [1-3]. Improved survival of children with congenital heart disease has led to increasing focus on neurodevelopmental outcome, as close to half of the infants undergoing cardiac surgery are affected by neurodevelopmental disability [4].

It is also obvious that at the age of school entry, deficits in cognition, memory, language, reading, mathematics, visual-motor integration and executive function, which are more frequent in the neonates undergoing complex open heart surgery than in the general population [5]. However, just some scattered reports on neuropsychological development in children with CHDs after surgery treatment occurred and there is no recommendations evolved in the guidelines for pediatric cardiac surgery. More importantly, neuropsychological development in children with CHDs after surgery treatment has not been elaborated in China. This study was implemented in Fuwai Hospital to assess neuropsychological development status in these particular children after surgical treatment of CHDs and the results may provide evidence for further intervention. Perioperative factors which may affect neuropsychological development were investigated.

Materials and Methods


From September 2015 to March 2016, 100 children (56 males, 44 females; range 7 to 78 months) who received follow-up visit in Fuwai Hospital after surgical treatment of CHDs were eligible to participate in neuropsychological examination. Exclusion criteria for enrollment were as follows: genetic abnormalities; extremely low gestational age newborns and premature infant; history of perinatal asphyxia and hyperbilirubinemia; history of central nervous system diseases, such as ischemic encephalopathy, encephalitis, meningitis and epilepsy, cerebral dysplasia; surgery not requiring CPB; preoperative cardiac arrest. 90 normal children (55 males, 35 females; range 16 to 68 months) were chosen from nursery schools or kindergartens at the same time period and the neuropsychological examination results of them were regarded as control. The normal children were free from congenital heart diseases and the exclusion criteria were the same as above. Informed consent was obtained from all parents and the examination was performed under parental supervision.

Data collection

The perioperative data of children with CHDs following surgical treatment were obtained from hospital records. Preoperative parameters included month age at surgery, body weight, gender, hemoglobin, platelet count, blood glucose, Blood Urea Nitrogen (BUN), serum albumin, serum Creatinine (Cr) and Left Ventricular Ejection Fraction (LVEF). Intraoperative perfusion data included CPB time, aortic cross-clamping time, nadir nasopharyngeal temperature and the lowest Central Venous Pressure (CVP) before CPB. Postoperative parameters were collected including mechanical ventilation time, postoperative nadir pulse Oxygen Saturation (SpO2), Postoperative Pediatric Intensive Care Unit (PICU) stay time and postoperative hospital stay time. All of the operations were performed with full-flow non-pulsatile extracorporeal circulation under mild (32 to 34°C) or moderate hypothermia (26 to 28°C) according to the surgeon’s preference and cardiac diagnosis.

Neurodevelopmental examination

The same trained and licensed examiner assessed all these children following cardiac surgical treatment and normal control children with Infants Neuropsychological Examination Table for children aged between 0 and 6 (hereunder referred to INET) developed by the Capital Pediatrics Research Institute, Beijing. It comprises five subscales: gross motor, fine motor, adaptability, language and social behavior. Mental age is calculated as one fifth of overall five subscales scores. Development Quotient (DQ) is originally defined as the ratio of mental age to chronological age multiplied by 100. Neuropsychological development was classified according to the score of DQ: supernormal, =130; excellent, 120-129; smart, 110-119; medium, 90-109; slow, 80-89; borderline mental retardation, 70-79; hypophrenia, ≺70.

Classification of CHDs surgeries

The Risk Adjustment for Congenital Heart Surgery (RACHS-1) method is commonly used among pediatric population clinically and the congenital heart surgeries are classified into 1 to 6 according to this method [6]. In this study, there was no surgery ranked equal or greater than 5, so the children received CHD surgeries were divided into simple CHDs group (RACHS-1 score less than or equal to 2) and complex CHDs group (RACHS-1 score equal or greater than 3).

Statistical analysis

Data analysis was performed using IBM SPSS Statistics version 22 (IBM SPSS Statistics, IBM Corporation, Chicago, IL). Continuous variables were presented as mean with Standard Deviation (SD) and categorical variables were presented as counts and percentages. Normally distributed data were compared with the Student t test. When a normal distribution for continuous data was not assumed, Kruskal-Wallis correlation was selected to analyze the correlation between different variables. ANOVA analysis was performed to analyze the differences of neuropsychological development among simple CHDs group, complex CHDs group and normal group. Relationships between INET subscales and perioperative parameters were evaluated by forward stepwise multivariable regression analysis. Probability values are two-sided with a p value less than 0.05 considered statistically significant.


Characteristics of Children with CHDs

Of 100 children with CHDs after surgical treatment recruited in this study, 11 refused to cooperate with the examiner and did not fulfill the neuropsychological test. Finally 89 children with CHDs after surgical procedure in FuWai Hospital received examination between September 2015 and March 2016. According to classification of RACHS-1 method, 53 subjects were classified in the simple CHDs group and 36 were in the complex CHDs group. Demographic and clinical data of the simple CHDs group and the complex CHDs group are presented in Table 1.