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Determinants of neurological outcome in neonates with congenital heart disease following heart surgery



The objective was to determine the association between perioperative risk factors and brain imaging abnormalities on neurologic outcome in neonates with hypoplastic left heart syndrome (HLHS) or d-Transposition of the great arteries (d-TGA) who underwent cardiac surgery including cardiopulmonary bypass.


A retrospective analysis of neonates with HLHS or d-TGA undergoing cardiac surgery including cardiopulmonary bypass between 2009 and 2017 was performed. Perioperative risk factors and Andropoulos’ Brain Injury Scores from pre- and postoperative brain magnetic resonant images (MRI) were correlated to outcome assessments on patients between 5 and 23 months of age. Neurologic outcome was measured using the Pediatric Stroke Outcome Measure (PSOM) and Pediatric Version of the Glasgow Outcome Scale-Extended (GOS-E).


Fifty-three neonates met our enrollment criteria (24 HLHS, 29 d-TGA). Mechanical ventilation > 12 days and DHCA > 40 min were associated with worse outcome. MRI measures of brain injuries were not associated with worse outcome by PSOM or GOS-E.


For HLHS and d-TGA patients, duration of mechanical ventilation and DHCA are associated with adverse neurologic outcome. Neonatal brain MRI commonly demonstrates acquired brain injuries, but the clinical impact of these abnormalities are not often seen before 2 years of age.


  • Acquired brain injury is common in high-risk neonates with CHD but poor neurological outcome was not predicted by severity of injury or lesion subtype. Longer stay in ICU is associated with postoperative brain injuries on MRI.

  • Total duration of ventilation > 12 days is predictive of adverse neurological outcome scores.

  • DHCA > 40 min is associated with adverse neurological outcome scores.

  • Neurological outcome before 2 years of age is more affected by the clinical course than by cardiac diagnosis.

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Fig. 1: Forest plot of Multivariable predictors of worse PSOM scores (moderate to severe deficits).
Fig. 2: Forest plot of Multivariable predictors of worse GOS-E scores (moderate to severe disabilities).


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V.A.K. was supported by the Kaltenbach doctoral candidate-grant, funded by the German Heart Foundation. This sponsor has no influence on the study design, the collection, analysis, and interpretation of data, the writing of the report or the decision to submit the paper for publication.

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V.A.K.: Study design, initial drafting, project administration, data collection, visualization, critical review, final revision. J.L.C.: Study design, initial drafting, project administration, data collection, data analysis, critical review, final revision, approval of the article. D.Z.: Study design, statistics, data analysis, visualization, critical review, final revision, approval of the article. J.G.R.: Data collection, visualization, critical review. L.T.: Initial drafting, data collection, critical review, approval of the article. M.T.D.: Study design, initial drafting, critical review, approval of the article. R.A.-F.: Initial drafting, critical review, approval of the article. C.L.: Study design, initial drafting, critical review, approval of the article. C.Y.: Supervision, study design, initial drafting, project administration, visualization, data analysis, critical review, final revision, approval of the article.

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Correspondence to Viktoria A. Kuhn.

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Kuhn, V.A., Carpenter, J.L., Zurakowski, D. et al. Determinants of neurological outcome in neonates with congenital heart disease following heart surgery. Pediatr Res 89, 1283–1290 (2021).

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