Original article
Long-term outcome of speech and language in children after corrective surgery for cyanotic or acyanotic cardiac defects in infancy

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Abstract

The purpose of this prospective study was to assess whether outcome of speech and language in children 5–10 years after corrective surgery for tetralogy of Fallot (TOF) or ventricular septal defect (VSD) in infancy was influenced by the preoperative condition of hypoxemia or cardiac insufficiency and whether it was associated with perioperative risk factors and neurodevelopmental outcome.

A total of 35 unselected children, 19 with TOF and hypoxemia and 16 with VSD and cardiac insufficiency, operated with combined deep hypothermic circulatory arrest and low-flow cardiopulmonary bypass at mean age 0.7±0.3 (mean±standard deviation) years, underwent, at mean age 7.4±1.6 years, standardized evaluation of speech and language functions. Results were compared between subgroups and related to perioperative factors, sociodemographic and neurodevelopmental status.

Age at testing, socioeconomic status and history of speech and language development were not different between the subgroups. In contrast, total scores on oral and speech motor control functions (TFS) as well as on oral and speech apraxia (Mayo Test) were significantly reduced (p<0.02 to <0.05), and scores on anatomical oral structures tended to be lower (p<0.09) in the TOF group as compared to the VSD group. No differences were found for auditory word recognition and phonological awareness as assessed by the Auditory Closure subtest of the Illinois Test of Psycholinguistic Abilities and the test of auditory analysis skills, respectively. In all children, higher age at testing and better socioeconomic status were associated with better results in all domains of assessment (p<0.001 to <0.04). Consistent impairments of all oral and speech motor control functions (TFS and Mayo Test) were present in 29% of all children with a mean age of 6.5 years in contrast to 43% with normal performance and a mean age of 8.3 years. On the receptive speech tasks, only 6% scored below the normal range of their age group. TFS subscores were significantly correlated with age, bypass duration and motor function, but not correlated with socioeconomic status, duration of cardiac arrest, intelligence and academic achievement.

Children with preoperative hypoxemia due to cyanotic cardiac defects in infancy are at higher risk for dysfunction in speech and language than those with cardiac insufficiency due to acyanotic heart defects. Age at testing, socioeconomic status, and duration of cardiopulmonary bypass influenced test results. Long-term outcome in speech and language functions can be considered as a sensitive indicator of overall child development after cardiac surgery.

Introduction

Children after cardiac operations for congenital heart defects with cardiopulmonary bypass (CPB) with or without hypothermic cardiac arrest generally are at risk of later neurodevelopmental impairment in the domains of motor functions, intelligence, academic achievement, attention, speech, language and behavior.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 In particular, we recently showed that corrective surgery in infancy for tetralogy of Fallot (TOF) or ventricular septal defect (VSD) with combined circulatory arrest and low flow bypass is associated with reduced neurodevelopmental outcome with respect to motor function, formal intelligence and academic achievement.14 We additionally demonstrated that children with preoperative hypoxemia in infancy due to cyanotic heart defects are at higher risk for motor dysfunction14 and attentional dysfunction in the field of executive control15 than are children with cardiac insufficiency due to acyanotic heart defects.

As a milestone of child development, speech and language functions are of special interest with respect to the long-term follow-up of children after cardiac surgery. However, detailed systematic studies are rare in this field.2, 3, 11, 16 Given the high prevalence of speech and language dysfunctions in association with motor, cognitive and academic disabilities, speech and language dysfunctions are considered to be an important indicator of general developmental impairment.2, 17, 18, 19

The present prospective study was designed to test the hyposthesis that (1) the preoperative condition of hypoxemia in infancy is associated with worse outcomes in speech and language later in childhood, when compared to the condition of preoperative cardiac insufficiency; furthermore, (2) the relationship between speech and language outcomes and perioperative management, neurodevelopmental outcomes and sociodemographic status should be evaluated in a uniform cohort of children with TOF or VSD at age 5–11 years after corrective surgery in infancy.

Section snippets

Patient population

Between 1993 and 1999, 24 consecutive infants with a regular form of TOF and hypoxemia and 26 consecutive infants with a VSD and cardiac insufficiency had undergone primary corrective cardiac surgery in our institution at a mean age of 0.7 years with a standard deviation (SD) of 0.3. There was no early or late mortality. All patients with TOF had normal chromosomal status (46, XY and XX, respectively), and microdeletion 22q11.2 had been excluded by fluorescence in situ hybridization (FISH)

Parental report on speech and language history

Table 2 shows the results of the parents’ interview with respect to familial disposition for speech problems and to several aspects of speech development of their children. The proportions of reported developmental risks and disorders were high in most instances and exceeded the typical prevalence rates of 2–10% that are estimated for the global population.27 Almost half of the TOF children in contrast to 25% of the VSD children received speech/language therapy. However, none of the differences

Discussion

Our data are based on two homogeneous groups of infants with preoperative hypoxemia caused by TOF or with preoperative cardiac failure caused by a VSD, respectively, in whom preoperative, perioperative, and postoperative care was conducted according to standardized protocols. Follow-up examination of language and speech at mean age 7.6 years after corrective surgery in infancy was performed in 35 children who account for 70% of the operated patients. The outcome data were compared between the

Acknowledgments

The study was supported by grants of “Bundesverband Herzkranke Kinder e.V.” and “Herzkrankes Kind Aachen e.V.”, Aachen, Germany.

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