Congenital Heart Surgery

The Burden of Stroke in Neonates Undergoing Congenital Heart Surgery: A Large Multicenter Analysis. Faateh M, Kulshrestha K, Ahmed HF, Lehenbauer D, Carlisle MA, Gaies M, Morales DLS, Ashfaq A. Ann Thorac Surg. 2024 Oct;118(4):908-918. doi: 10.1016/j.athoracsur.2024.05.011. Take Home Points: • Perioperative stroke occurred in 5.6% of neonatal CHS patients, with a significantly higher incidence among those with prematurity, low birth weight, HLHS, or ECMO use. Stroke was associated with a 33.1% in-hospital mortality rate and a greater burden of long-term neurologic complications. • The occurrence of stroke significantly worsens outcomes, including prolonged hospitalization, increased costs, and elevated risks of hydrocephalus, cerebral palsy, and neurodevelopmental disorders. Commentary from Dr. Shinichiro Oda (Kyoto, Japan), section editor of Congenital Heart Surgery Journal Watch Summary: This large multicenter retrospective study analyzed the incidence, risk factors, and outcomes of perioperative stroke in neonates undergoing congenital heart surgery (CHS) with cardiopulmonary bypass (CPB), using the Pediatric Health Information System (PHIS) database from 2004 to 2022, comprising 14,228 patients. The overall incidence of perioperative stroke was 5.6% (n = 800). Among these, 43.9% were preoperative strokes (2.5% of all cases) and 56.1% were postoperative strokes (3.2%). Stroke was associated with markedly higher in-hospital mortality (33.1% vs 8.9%), prolonged hospitalization, increased costs, and a higher rate of non-home discharge. Neonates with prematurity, low birth weight, hypoplastic left heart syndrome (HLHS), or requiring extracorporeal membrane oxygenation (ECMO) were significantly more likely to develop stroke. Among patients who developed stroke, risk factors for in-hospital mortality included prematurity, HLHS, ECMO use, hemorrhagic (vs ischemic) stroke, and need for dialysis. Long-term follow-up showed significantly higher rates of hydrocephalus, cerebral palsy, and autism spectrum disorder among stroke survivors. Importantly, stroke remained an independent predictor of in-hospital mortality and prolonged hospitalization, even after adjusting for key confounders such as ECMO use, prematurity, birth weight, and diagnosis of HLHS. These findings emphasize the need for early identification of high-risk neonates and the implementation of neuroprotective strategies to mitigate both short- and long-term adverse outcomes. Comments: This important multicenter study highlights the significant burden of perioperative stroke in neonates undergoing congenital heart surgery. Although the reported stroke incidence (5.6%) is based on diagnostic coding and not derived from universal neuroimaging of all cases, it likely approximates clinical reality. In most centers, brain imaging—such as MRI or cranial ultrasound—is performed in response to clinical symptoms such as seizures, delayed recovery, or abnormal tone, rather than as part of a routine protocol. While a few institutions may implement routine perioperative brain MRI regardless of symptoms, these are exceptions. Thus, when viewed in the context of how stroke is typically diagnosed in real-world neonatal cardiac care, the incidence reported here may not substantially diverge from clinical experience. For cardiac surgeons, the diagnosis of postoperative stroke is uniquely devastating. Even when the surgical repair is technically successful, the emergence of a neurologic complication like stroke casts a long shadow over the outcome. It is a source of profound frustration and emotional burden, often leaving the team with a lingering sense of defeat. The study identifies key risk factors for stroke, including prematurity, low birth weight, HLHS, and ECMO use, which is highly valuable. Interestingly, while strokes were categorized as preoperative or postoperative, the authors found no significant difference in in-hospital mortality between the two groups after adjustment for confounders. Nevertheless, the underlying causes and implications of stroke may differ depending on timing. Preoperative stroke may reflect antenatal or perinatal factors such as chronic hypoxia or delayed diagnosis [1,2], whereas postoperative stroke is more commonly associated with procedural and hemodynamic stressors, including cardiopulmonary bypass, deep hypothermic circulatory arrest, and ECMO [3,4]. Whether these pathophysiologic differences result in distinct long-term neurodevelopmental outcomes remains unknown and deserves further study. This study is a strong foundation, but we are now left with the pressing question: what can we do to prevent this nightmare? The next critical step will be to explore strategies for stroke prevention, early detection, optimal perioperative management, and perhaps even therapeutic interventions. We look forward to future research that moves us closer to protecting the brains of our most vulnerable patients. References: [1] McQuillen PS, Barkovich AJ, Hamrick SE, et al. Temporal and anatomic risk profile of brain injury with neonatal repair of congenital heart defects. Stroke. 2007;38:736–741. [2] Petit CJ, Rome JJ, Wernovsky G, et al. Preoperative brain injury in transposition of the great arteries is associated with oxygenation and time to surgery. Circulation. 2009;119:709–716. [3] Gilbey T, Milne B, de Somer F, et al. Neurologic complications after cardiopulmonary bypass—a narrative review. Perfusion. 2023;38:1545–1559. [4] Werho DK, Pasquali SK, Yu S, et al. Epidemiology of stroke in pediatric cardiac surgical patients supported with extracorporeal membrane oxygenation. Ann Thorac Surg. 2015;100:1751–1757.