Developmental Outcome After Surgical Versus Interventional Closure of Secundum Atrial Septal Defect in Children Karen J. Visconti, MA; David P. Bichell, MD; Richard A. Jonas, MD; Jane W. Newburger, MD, MPH; David C. Bellinger, PhD, MSc Background—The assessment of the impact of cardiopulmonary bypass (CPB) on developmental outcomes in children who undergo open heart surgery is hampered by the absence of a suitable comparison group. The development of interventional catheterization techniques for the repair of certain types of congenital heart lesions provides the opportunity to study children who have not been exposed to CPB. Methods and Results—We performed standardized neuropsychological testing on children after closure of a secundum atrial septal defect through the use of surgery (n=26) or a transcatheter device (n=19). Device patients, compared with surgical patients, were similar in age at defect closure (mean, 6 years) but older at follow-up testing (12.3 versus 10.6 years). The mean weight percentile at closure was greater and the defect size was smaller in the device patients. Families of device patients tended to have a higher parent IQ, higher level of maternal education, and higher level of maternal occupation. In general, however, children’s IQ and achievement scores were in the normal range for both groups. In regression analyses with adjustment for age at testing and parent IQ, surgical repair was associated with a 9.5-point deficit in Full-Scale IQ (P=0.03) and a 9.7-point deficit in Performance IQ (P=0.05). Block Design was the IQ subtest on which treatment groups differed the most (P=0.01). Surgical patients achieved significantly better scores on errors of commission (P=0.05) and attentiveness index (P=0.03) on a continuous performance test of attention. Scores on tests of achievement and other neuropsychological domains did not differ significantly between the groups. Regression analyses within the surgical group failed to identify significant CPB-related risk factors. Conclusions—A prospective randomized trial or a study that includes prerepair and postrepair assessments is necessary to establish whether the observed advantages of device closure in neuropsychological outcome represent deleterious effects of CPB or a methodological artifact. (Circulation. 1999;100[suppl II]:II-145–II-150.) Key Words: heart diseases  heart defects, congenital  cardiopulmonary bypass  pediatrics R ecent studies from our group indicate that neurological development may be adversely affected in children with transposition of the great arteries who undergo relatively long periods of deep hypothermic cardiopulmonary bypass (CPB) with or without total circulatory arrest. 1,2 A “safe” duration of CPB has not been established. One strategy for addressing this issue would be to evaluate the late development of a group of children with a congenital heart defect whose repair requires only a relatively brief period of mildly hypothermic bypass. One such group is children with secundum atrial septal defect (ASD2). In contrast to children with transposi- tion of the great arteries, these children are rarely symptom- atic or hypoxic. Efforts to determine the developmental impact of CPB on the late development of children have been hampered by several methodological challenges. One of the most critical challenges involves the identification of an appropriate control group of children who are comparable to a patient sample in all important respects except that they did not experience a period of CPB. Various approaches have been used, including the use of healthy children from the community or siblings, children who undergo surgery for noncardiac disease, and children with cardiac disease who undergo a closed surgical procedure. Siblings or other healthy controls may not be suitable because any deficits noted among the children who experi- enced CPB may be due to their underlying disease or to the emotional and physical trauma of surgery and hospitalization rather than specifically to the fact of having experienced CPB. Although the study of noncardiovascular operations might control for the possible developmental impact of hospitalization and surgery, children with noncardiac surgical diagnoses do not have central nervous system risk factors that may be specific to children with certain types of congenital heart lesions. Children with congenital heart disease repaired From the Departments of Cardiac Surgery (K.J.V., D.P.B., R.A.J.), Cardiology (J.W.N.), and Neurology (D.C.B.), Children’s Hospital, Boston, Mass; and Departments of Neurology (D.C.B), Pediatrics (J.W.N.), and Surgery (D.P.B., R.A.J.), Harvard Medical School, Boston, Mass. Correspondence to David C. Bellinger, PhD, Neuroepidemiology Unit, CA-503, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail bellinger@a1.tch.harvard.edu © 1999 American Heart Association, Inc. Circulation is available at http://www.circulationaha.org II-145 Surgery for Congenital Heart Disease by guest on December 9, 2015 http://circ.ahajournals.org/ Downloaded from