The persistence of cognitive deficits into adulthood after the arterial switch procedure: Can we change things?

Abstract

Central MessageAlthough cognitive deficits persist in adults later after the arterial switch procedure, subsequent research should seek to understand modifiable risk factors than may mitigate the risk.See Article page 1028. Although cognitive deficits persist in adults later after the arterial switch procedure, subsequent research should seek to understand modifiable risk factors than may mitigate the risk. See Article page 1028. As early survival after surgical treatment of congenital heart disease (CHD) has improved, the population reaching adulthood has increased.1Benziger C.P. Stout K. Zaragoza-Macias E. Bertozzi-Villa A. Flaxman A.D. Projected growth of the adult congenital heart disease population in the United States to 2050: an integrative systems modeling approach.Popul Health Metr. 2015; 13: 29Crossref PubMed Scopus (44) Google Scholar Little is known, however, regarding the long-term morbidities associated with early surgical repair and how those morbidities affect the life of survivors into adulthood. Evaluating neurocognitive outcomes in adults with CHD is an important emerging research direction.2Gurvitz M. Burns K.M. Brindis R. Broberg C.S. Daniels C.J. Fuller S.M. et al.Emerging research directions in adult congenital heart disease: a report from an NHLBI/ACHA Working Group.J Am Coll Cardiol. 2016; 67: 1956-1964Crossref PubMed Scopus (65) Google Scholar Thus, the study by Kalfa and colleagues3Kalfa D. Kasmi L. Geronikola N. Calderon J. Lambert V. Belli E. et al.Cognitive outcomes and health-related quality of life in adults two decades after the arterial switch operation for transposition of the great arteries.J Thorac Cardiovasc Surg. 2017; 154: 1028-1035Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar in this issue of the Journal is a timely and important contribution to the literature. The central finding of the manuscript is that the neurodevelopmental deficits identified early in childhood after surgery for CHD persist into adulthood. Although not surprising, it provides objective data to support the importance of early childhood deficits. Although the pessimist might note the persistence of the deficits, there are also more heartening conclusions to be reached. Although approximately 30% of adult patients have cognitive deficits (≥1 standard deviation below population norms), fully 70% do not. Good cognitive outcomes are achievable. There are important limitations to the methodology used here. Both the study and the control cohorts are highly selected. The evaluated group appears to have been a lower-risk, higher-functioning subset of all arterial switch operation patients (shorter circulatory arrest times, greater educational achievement). Any study of late survivors who return for elective follow-up also is biased inherently against those with the poorest outcomes: death, but also poor cognitive function and poor psychosocial support. The selection of the control group includes bias that may have both maximized (cognitive function above the population norms) and minimized (matching on educational level) the differences with the study group. The generalizability of the results to all children with transposition may be limited. Although the data here cannot be used to predict cognitive outcomes among all children decades after the arterial switch operation, it does demonstrate the outcomes achievable in some children. Moving forward, future studies must gather sufficient data (and sufficient patients) to understand how high cognitive outcomes are achieved. Modifiable factors may exist both during the perioperative stage (perfusion strategies, intensive care management) and over the longer term (early neurocognitive assessments and interventions). There are findings within this study that may point the way. Greater parental socioeconomic status and income are associated with improved cognitive performance. We cannot provide every child with equivalent parental resources, but this does suggest that investment in early intervention and education may pay long-term dividends. Studies are required that evaluate the impact of specific interventions and identify modifiable factors within the developmental environment of children without the advantage of parental resources. Similarly, although providers should not limit arbitrarily the length of stay in the intensive care unit to improve cognitive outcomes, research directed at understanding the causal connections between length of stay and cognitive deficits may elucidate modifiable factors (including developmental interventions) that may mitigate the impact. Kalfa and colleagues may leave more questions than answers, but that should not lessen the import of the findings. They have shown that the neurodevelopmental deficits seen early in children with CHD persist into adulthood. There are also hints here as to where interventions may be effective in ameliorating those deficits. This is an important start, and the authors should be congratulated on tackling an important, timely, and challenging topic. Cognitive outcomes and health-related quality of life in adults two decades after the arterial switch operation for transposition of the great arteriesThe Journal of Thoracic and Cardiovascular SurgeryVol. 154Issue 3PreviewThe study objective was to evaluate the cognitive and psychosocial outcomes of young adults who underwent an arterial switch operation for transposition of the great arteries. Full-Text PDF Open Archive