Perioperative Cerebral Near-Infrared Spectroscopy Variability and Neurodevelopmental Outcomes in Congenital Heart Patients

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I came across this interesting study published in a recent issue of Pediatric Critical Care Medicine by Spaeder et al (1), where they report that variability in cerebral tissue oxygenation index measured by near-infrared spectroscopy (NIRS) during perioperative period is associated with neurodevelopmental outcome in neonates with congenital heart diseases undergoing cardiac surgery. However, the authors do not mention if the patients had seizures, which are not uncommon during the postoperative period, and which have been associated with adverse neurodevelopmental outcome in children undergoing cardiac surgery (2, 3). This might be a very important confounding factor for neurodevelopment in children. Additionally, whether there is any association between seizure episodes and cerebral NIRS and its variability might be important to consider as well.
Second, d-transposition of great arteries (d-TGA) represents the majority of the two-ventricle patient population in this study. An important factor for NIRS would be the systemic arterial saturations. Usually, balloon atrial septostomy improves mixing at the atrial level significantly increasing their saturations. In this cohort, did d-TGA patients undergo balloon atrial septostomy? Furthermore, septostomy in this age group has been associated with white matter MRI changes (4), which could have adverse neurologic outcomes (5). Thus, it would be important to consider this factor while discussing the pre- and postsurgical morbidities and outcomes in this patient population, as they are quite different from other groups of two ventricular repairs as their fetal and postnatal physiology are very different.
Third, the authors have placed all the patients with neuroimaging into one group for the neurodevelopmental outcome, without separating them into different congenital heart disease groups, which I think is not fair, as there are significant differences in the physiology among different groups of congenital heart diseases. The number of neuro MRIs and cranial ultrasounds is small, but even observing a trend in different groups would be relevant given the limitations of the data.

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