Editorial comment
Congenital heart disease: New challenges
Cardiopatias congénitas: novos desafios
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Mortality from severe forms of CHD in infancy and childhood has declined markedly in recent decades, mostly driven by advances in pre- and postnatal diagnostics, early corrective surgery and improved postoperative care.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Gains in survival until adulthood and increased life expectancy represent a new challenge, since inadequate cerebral blood flow and hypoxia during critical phases of fetal brain development may have irreversible consequences, leading to lifelong cognitive impairment. Recent studies have accordingly aimed to characterize neurocognitive performance and related impacts on psychosocial achievements in these patients, in order to identify their relationship with neonatal and clinical variables that could be the target of intervention.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The paper by Areias et al. published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> is noteworthy as the first holistic and interdisciplinary study between psychology and cardiology carried out in this country. The authors compared the cognitive performance of a cohort of 217 Portuguese CHD patients (cyanotic and noncyanotic forms) with a matched control group (n=80), using a comprehensive neuropsychological test battery to explore the major cognitive domains: memory, executive function, processing speed, attention and visuoconstructive ability. The examination was complemented with behavioral and psychological assessment instruments and a semi-structured interview covering areas of social support, family educational style, environment, self-image, functional limitations and educational achievements. The results confirm a profile of poor performance in all the explored cognitive domains, which is similar to that resulting from the encephalopathy first described in premature infants. As in the latter condition, studies using conventional fetal brain magnetic resonance imaging (MRI) have shown findings compatible with cerebral white matter immaturity that correlated with the severity of the underlying CHD. Furthermore, advanced MRI techniques reveal disorganization of neuronal networks that is associated with the attention deficit hyperactivity disorder seen in adolescents with severe congenital CHD.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Research in which imaging data is correlated with clinical outcomes for risk stratification is increasingly used in CHD and should also be considered by this Portuguese group.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Another strength of the current paper<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> is the identification of neurocognitive phenotypes (clusters) which were further correlated with sociodemographic, neonatal, clinical and psychological adjustment variables. The authors identified three phenotypes that differed in all cognitive dimensions: non-impaired (NI), moderately impaired (MI) and globally impaired (GI). As anticipated, the MI and GI clusters included more cyanotic forms of disease, including tetralogy of Fallot and transposition of the great arteries. Of particular interest, compared to the NI cluster, the GI cluster showed worse neonatal indicators (smaller head circumference and lower birth weight and length and Apgar scores), as well as poorer psychosocial achievements, including fewer years of schooling and more psychological adjustment problems and aggressive behavior.</p><p id="par0020" class="elsevierStylePara elsevierViewall">These findings highlight the impact of antenatal impairment in brain growth and underline the importance of identifying parameters of cardiac and circulatory function that can be used as surrogates of brain development, particularly in these high-risk patients. For instance, prenatal autonomic activity has been investigated as a marker of early childhood development, which was confirmed in a recent study showing that fetal heart rate variability parameters at 34 to 38 weeks gestational age correlated with 18-month cognition and motor scores.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> The same applies to the cerebral-to-placental resistance ratio, which has been assessed as a measure of cerebral autoregulation (brain sparing).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">With regard to treatment, the establishment of clusters of cognitive functioning like those proposed by Areias et al. may be useful, providing guidance for more personalized and tailored interventions. For less serious conditions, a more conservative approach should be recommended focusing on prevention of further brain insults (particularly during delivery and surgical procedures) and early cognitive stimulation as well as educational support. For severe forms of CHD, besides those described above, new neuroprotective approaches, such as maternal hyperoxygenation at 28 to 41 weeks of gestational age to increase cerebral oxygen delivery during pregnancy,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> may be considered. Furthermore, these new strategies of intervention should be tested using specific clinical outcomes such as those analyzed in the paper by Areias et al., including psychosocial adjustment, educational performance, quality of life, and independence in adulthood.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Frequency and spectrum of congenital heart defects among live births in Germany: a study of the Competence Network for Congenital Heart Defects" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. 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Ordonez-Retamar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/jp.2017.59" "Revista" => array:6 [ "tituloSerie" => "J Perinatol" "fecha" => "2017" "volumen" => "37" "paginaInicial" => "953" "paginaFinal" => "957" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28471442" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoregulation of cerebral blood flow in fetuses with congenital heart disease: the brain sparing effect" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.T. Donofrio" 1 => "Y.A. Bremer" 2 => "R.M. Schieken" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00246-002-0404-0" "Revista" => array:6 [ "tituloSerie" => "Pediatr Cardiol" "fecha" => "2003" "volumen" => "24" "paginaInicial" => "436" "paginaFinal" => "443" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14627309" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cerebrovascular response to maternal hyperoxygenation in fetuses with hypoplastic left heart syndrome depends on gestational age and baseline cerebrovascular resistance" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Szwast" 1 => "M. Putt" 2 => "J.W. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 6 | 11 |
| 2024 October | 28 | 32 | 60 |
| 2024 September | 33 | 25 | 58 |
| 2024 August | 28 | 29 | 57 |
| 2024 July | 30 | 30 | 60 |
| 2024 June | 23 | 28 | 51 |
| 2024 May | 23 | 21 | 44 |
| 2024 April | 25 | 21 | 46 |
| 2024 March | 25 | 34 | 59 |
| 2024 February | 19 | 32 | 51 |
| 2024 January | 18 | 25 | 43 |
| 2023 December | 15 | 27 | 42 |
| 2023 November | 19 | 27 | 46 |
| 2023 October | 16 | 13 | 29 |
| 2023 September | 15 | 19 | 34 |
| 2023 August | 16 | 22 | 38 |
| 2023 July | 21 | 13 | 34 |
| 2023 June | 15 | 11 | 26 |
| 2023 May | 27 | 29 | 56 |
| 2023 April | 24 | 1 | 25 |
| 2023 March | 18 | 18 | 36 |
| 2023 February | 20 | 16 | 36 |
| 2023 January | 11 | 25 | 36 |
| 2022 December | 27 | 17 | 44 |
| 2022 November | 26 | 32 | 58 |
| 2022 October | 22 | 18 | 40 |
| 2022 September | 21 | 27 | 48 |
| 2022 August | 22 | 28 | 50 |
| 2022 July | 24 | 42 | 66 |
| 2022 June | 20 | 16 | 36 |
| 2022 May | 17 | 29 | 46 |
| 2022 April | 23 | 29 | 52 |
| 2022 March | 24 | 37 | 61 |
| 2022 February | 17 | 25 | 42 |
| 2022 January | 25 | 19 | 44 |
| 2021 December | 24 | 38 | 62 |
| 2021 November | 25 | 31 | 56 |
| 2021 October | 31 | 38 | 69 |
| 2021 September | 17 | 26 | 43 |
| 2021 August | 16 | 27 | 43 |
| 2021 July | 15 | 24 | 39 |
| 2021 June | 20 | 19 | 39 |
| 2021 May | 24 | 41 | 65 |
| 2021 April | 33 | 55 | 88 |
| 2021 March | 28 | 39 | 67 |
| 2021 February | 40 | 17 | 57 |
| 2021 January | 19 | 17 | 36 |
| 2020 December | 22 | 10 | 32 |
| 2020 November | 14 | 15 | 29 |
| 2020 October | 15 | 14 | 29 |
| 2020 September | 25 | 9 | 34 |
| 2020 August | 16 | 15 | 31 |
| 2020 July | 21 | 10 | 31 |
| 2020 June | 24 | 8 | 32 |
| 2020 May | 19 | 5 | 24 |
| 2020 April | 8 | 8 | 16 |
| 2020 March | 17 | 9 | 26 |
| 2020 February | 22 | 10 | 32 |
| 2020 January | 11 | 6 | 17 |
| 2019 December | 12 | 4 | 16 |
| 2019 November | 15 | 7 | 22 |
| 2019 October | 9 | 2 | 11 |
| 2019 September | 9 | 6 | 15 |
| 2019 August | 11 | 7 | 18 |
| 2019 July | 10 | 4 | 14 |
| 2019 June | 15 | 17 | 32 |
| 2019 May | 19 | 4 | 23 |
| 2019 April | 14 | 11 | 25 |
| 2019 March | 11 | 12 | 23 |
| 2019 February | 12 | 10 | 22 |
| 2019 January | 8 | 4 | 12 |
| 2018 December | 11 | 16 | 27 |
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