1. Intermediate-term Neuro- Developmental Outcomes after Neonatal Cardiac Surgery: Role of Cortical Iso-Electric Activity Pediatric Cardiac Consortium of Upstate New York University of Rochester Medical Center

2. Disclosures None

3. Objective Neurodevelopmental delay diagnosed 5-7 years following neonatal cardiac surgery Thought to arise from multiple factors – Pre-natal hypoxia – Operative Hypoxia Hypothermia Low flow

4. Objective Continuous intra-operative EEG Hypothermia  Iso-electric activity Recovery from iso-electric activity  seizures – Rhythmic Burst Pattern – Sharp Components – Asynchronous between hemispheres

5. Hypothesis We hypothesized that the duration of iso-electric cortical brain activity would be related to neuro-developmental outcomes

6. Methods Neonates requiring surgery 2006-2009 EEG leads placed – Standard 10-20 Baseline EEG prior to anesthesia Continuous Intra-operative EEG monitoring Lead Placement

7. Methods EEG activity classified as 1.Normal for Age 2.Slow and Continuous Slower frequencies but continuous 3.Moderate Burst Suppression < 30 second intervals between bursts 4.Severe Burst Suppression > 30 second intervals between bursts 5.Iso-Electric Activity Absence of brain activity

8. Methods F7-T7 T7-P7 P7-O1 F3-C3 C3-P3 P3-O1 F2-C2 C2-P2 F4-C4 C4-P4 P4-O2 F8-T8 T8-P8 P8-O2 Normal for Age

9. Methods F7-T7 T7-P7 P7-O1 F3-C3 C3-P3 P3-O1 F2-C2 C2-P2 F4-C4 C4-P4 P4-O2 F8-T8 T8-P8 P8-O2 Moderate Burst Suppression

10. Methods F7-T7 T7-P7 P7-O1 F3-C3 C3-P3 P3-O1 F2-C2 C2-P2 F4-C4 C4-P4 P4-O2 F8-T8 T8-P8 P8-O2 Iso-Electric Activity

11. Methods-VABS-II Parents of neonates with prior EEG recordings contacted Parents completed VABS-II questionnaire at a follow-up of 5.6 ± 1.0 years Investigator trained in the VABS-II validated the parental responses

12. Methods-VABS-II Numeric and percentile scores of overall performance – Communication – AODL – Socialization – Motor skills Scores classified according to percentiles – Low – Moderately low – Adequate – Moderately high – High

13. Original Cohort (n=32) Died during the follow-up (n=6) Did not complete survey correctly (n=3) Lost to Follow-up (n=2) Results EEG’s and ND outcomes (n=21) IE Activity (n=11) Non-IE Activity (n=10)

14. IE (n=11)Non IE (n=10)p value Age at operation (days)7.0 ± 2.27.7 ± 2.50.5 Weight (kg)3.1 ± 0.53.4 ± 0.40.2 HLHS or variant500.03 D-TGA190.003 TOF011.0 CoA/Arch Hypoplasia500.03 DHCA Time (min)24.1 ± 16.30 Regional Perfusion36% (4)0 Results

15. Non IE (n=10) IE (n=11)

16. Results Non IE (n=10) IE (n=11)

17. Results Non IE (n=10) IE (n=11)

18. Results

19. IE (n=11)Non IE (n=10)P value Communication Score43.1±10.150.0±5.10.04 Receptive14.2 ± 4.016.7 ± 2.10.09 Expressive14.5 ± 4.516.5 ± 2.10.2 Written14.5 ± 2.816.8 ± 2.10.04 Daily Living40.5 ± 11.344.3±4.30.7 Personal12.8 ± 4.113.3 ± 2.40.2 Domestic13.9 ± 3.515.8 ± 2.30.3 Community13.8 ± 4.215.5 ± 1.90.3 Socialization43.2 ± 11.945.2 ± 7.90.6 Interpersonal Relations14.9 ± 4.314.8 ± 3.50.9 Play/Leisure12.3 ± 3.813.7 ± 2.40.3 Coping skills16.0 ± 4.616.8 ± 2.80.6 Motor Skills26.5 ± 7.228.5 ± 3.00.4 Gross Motor Skills13.1 ± 3.814.5 ± 1.60.3 Fine Motor Skills13.2 ± 4.114.0 ± 2.10.6 Adaptive Behavior351.1±100.0392±49.00.3 Adequate79 Maladaptive Behavior Index17.5 ± 2.516.9 ± 1.20.5

20. Results

21. R = 0.1 p = 0.7

22. Results IE Time DHCA Time

23. Conclusions Cortical IE is strongly associated with hypothermia < 25 °C Duration of IE activity correlates with neuro- developmental outcomes at an intermediate- term follow-up Intra-operative EEG may be a useful tool to assess neurologic injury Limited hypothermia may improve neuro- developmental outcomes

24. Thank you

25. Results

26. DHCA-Neonates cooled to 18-20 °C Absence of DHCA-Neonates cooled to 32-34 °C Glucose levels maintained 80-200 g/dl PO 2 > 100 PCO 2 < 30 Hemoglobin > 7.0 g/dl Methods-Operative