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CLINICAL RESEARCH: CONGENITAL HEART DISEASE

Pre-Operative Brain Injury in Newborn Infants With Transposition of the Great Arteries Occurs at Rates Similar to Other Complex Congenital Heart Disease and Is Not Related to Balloon Atrial Septostomy

John Beca, MB, ChB^_*,_*, Julia Gunn, MBBS^_**, Lee Coleman, MB, ChB^¶, Ayton Hope, MB, ChB, Laura-Clare Whelan, BNurs^_*, Thomas Gentles, MB, ChB, Terrie Inder, MD, Rod Hunt, MMed, PhD^# and Lara Shekerdemian, MD^||,_**

^_* Department of Paediatric Intensive Care, Starship Children's Hospital, Auckland, New Zealand
Department of Paediatric Cardiology, Starship Children's Hospital, Auckland, New Zealand
Department of Radiology, Starship Children's Hospital, Auckland, New Zealand
Departments of Pediatrics, Radiology and Neurology, Washington University School of Medicine, St. Louis, Missouri
^|| Department of Paediatric Intensive Care, The Royal Children's Hospital, Melbourne, Australia
^¶ Department of Radiology, The Royal Children's Hospital, Melbourne, Australia
^# Department of Neonatology, The Royal Children's Hospital, Melbourne, Australia
^_** The Murdoch Children's Research Institute, Melbourne, Australia

Manuscript received November 17, 2008; revised manuscript received January 7, 2009, accepted January 19, 2009.

^_* Reprint requests and correspondence: Dr. John Beca, Paediatric Intensive Care Unit, Starship Children's Hospital, Private Bag 92024, Auckland, New Zealand (Email: johnbeca{at}adhb.govt.nz).

Objectives: The goal of this study was to determine the prevalence and pattern of pre-operative brain injury in infants with transposition of the great arteries (TGA) compared with other complex congenital heart disease (CHD) and to define the risk of balloon atrial septostomy (BAS) for the development of brain injury.

Background: It has recently been suggested that infants with TGA are at increased risk of pre-operative brain injury, in particular, stroke, and that this is strongly associated with having a BAS.

Methods: Sixty-four newborn infants with TGA (n = 44), hypoplastic left heart syndrome (n = 13), or pulmonary atresia (n = 7) had magnetic resonance imaging (MRI) scans performed before surgery.

Results: Thirty-three (75%) of the infants with TGA had a BAS. Brain injury occurred in 19 (30%) infants: white matter injury (WMI) in 17 (27%), and stroke in 3 (5%). There was no difference in the prevalence or pattern of brain injury between diagnostic groups. There was no association between BAS and brain injury in infants with TGA. There was a trend toward increased brain injury in TGA with an intact interventricular septum compared with TGA with a ventricular septal defect (38% vs. 8%, p = 0.075). There was no association between brain injury and any clinical variables.

Conclusions: Pre-operative brain injury on MRI scan was present in 30% of infants with CHD. The predominant pattern was WMI. The rates and patterns of pre-operative brain injury are similar in infants with TGA compared with other complex CHD, and BAS does not increase the risk of pre-operative brain injury.

Key Words: transposition of the great vessels • heart defects congenital • brain injuries • magnetic resonance imaging • balloon septostomy

Abbreviations and Acronyms   ASO = arterial switch operation   BAS = balloon atrial septostomy   CHD = congenital heart disease   CI = confidence interval   HLHS = hypoplastic left heart syndrome   MRI = magnetic resonance imaging   PA = pulmonary atresia   TGA = transposition of the great arteries   VSD = ventricular septal defect   WMI = white matter injury

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