Long-term behavioral and emotional outcomes after congenital heart surgery can be predicted by medical history and therapeutic intervention, according to a study of 114 congenital heart disease patients.
Patients who received cardiac medication (diuretics or prostaglandin E1) before surgery or intervention had significantly worse long-term psychological outcomes compared with those who received palliative treatment (a Rashkind procedure) before undergoing surgery or intervention.
As long-term survival from congenital heart interventions becomes more and more common, outcomes beyond mortality and physical morbidity are receiving more attention; these outcomes include behavioral and emotional well-being, according to Dr. Alinda W. Spijkerboer of the Erasmus Medical Centre – Sophia Children’s Hospital, Rotterdam, The Netherlands, and her colleagues.
The researchers used the Child Behavior Checklist (CBC) to determine the extent of behavioral and emotional problems in 7- to 17-year-old participants (64 boys, 50 girls) with congenital heart disease who underwent invasive treatment between 1990 and 1995.
Analyses were performed to correlate the behavioral and emotional outcomes with medical history; therapeutic intervention and direct postinterventional course; long-term medical course; present contact with physicians; and present medical status. The participants were also assessed as to whether problems were internalizing or externalizing. The General Health Questionnaire (GHQ) was used to assess parental distress, especially anxiety.
The CBC includes a section with 120 items for which parents rate their child’s behavior in the preceding 6 months on a 3-point scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true). A total problems score was obtained by adding all scores in this section, with higher scores indicating a higher level of problems. The 28-item GHQ was used to assess parental level of psychological distress. The scale score on anxiety and sleeplessness and the total score were used (J. Ped. Surg.2010;45:2146-53).
The four diagnostic categories of congenital heart disease were surgical closure of atrial septal defect (27 patients), surgical closure of a ventricular septal defect (43 patients), arterial switch operation of transposition of the great arteries (31 patients), and balloon dilatation for pulmonary stenosis (13 patients).
"The only significant predictors found in this study all seemed to originate from the cluster medical history," the authors stated. Use of cardiac medication before therapeutic intervention significantly predicted a higher CBC total problems score. Earlier palliative intervention with the Rashkind procedure before treatment was significantly associated with lower scores in total problems and externalizing (the Rashkind procedure is a catheter-based intervention to enlarge an opening in the cardiac septum between the right and left atria for improved blood oxygenation).
The variable scar from treatment judged by the physician as moderately or poorly healed was significantly associated with a higher internalizing score on the CBC. The diagnostic categories of atrial septal defect and pulmonary stenosis were associated with lower externalizing scores.
Mothers who reported more long-term behavioral and emotional problems for their children also showed significantly more anxiety and psychological distress in their own scores. Fathers showed a similar trend, but it did not reach significance. No parental score differences were found between parents of the four diagnostic groups or between those of children undergoing surgery versus catheter intervention.
One limitation of the study, according to the authors, was the fact that the sample contained only four diagnostic groups, and therefore was not representative of all congenital heart disease anomalies. Also, medical outcomes and parent-reported behavioral and emotional problems were not assessable in all eligible patients/parents. In addition, few fathers were represented in the parental data.
The authors speculated that because cardiac medication before therapeutic intervention is usually related to the severity of an infant’s clinical state, this could be one explanation for their results. However, if patients received both prior cardiac medications and palliative treatment, they did not show increased problems, something which they could not explain.
"Our results indicate that, overall, the use of cardiac medication before surgical or interventional treatment was associated with unfavorable long-term behavioral and emotional outcomes. A palliative intervention before therapeutic intervention was associated with favorable long-term outcomes," the researchers stated, although they concluded that causal relationships need to be established.
The study was financially supported by Doctors for Children. The authors reported having no conflicts which the journal deemed relevant.