Introduction: The Shifting Paradigm in Congenital Heart Disease
For decades, the primary benchmark for success in pediatric cardiac surgery was survival. As surgical techniques, perioperative care, and mechanical support have advanced, mortality rates for infants with complex congenital heart disease (CHD) have plummeted. However, this success has revealed a new clinical frontier: the long-term neurodevelopmental (ND) morbidity that often follows early life cardiac intervention. Survivors of infant heart surgery are now known to be at significant risk for a range of neurodevelopmental challenges, including motor delays, cognitive impairment, and social-behavioral disorders.
While previous research has established this risk, there has been a lack of large-scale, multi-state data focusing specifically on the most vulnerable populations, such as those covered by public insurance. Publicly insured children often face additional social determinants of health that can compound biological risks. A recent study by O’Meara and colleagues, published in JAMA Network Open, provides a critical look at the neurodevelopmental trajectory of over 3,000 publicly insured children in the five years following infant heart surgery, highlighting both the high prevalence of these disorders and significant gaps in specialized care.
Study Overview: Assessing the Publicly Insured Population
Methodological Rigor and Population Characteristics
The retrospective cohort study utilized the Merative MarketScan Medicaid Claims Database, encompassing deidentified data from 12 states. The researchers focused on children with CHD who underwent their first cardiac surgery during infancy between 2016 and 2020. This resulted in a cohort of 3,147 patients.
The demographic breakdown of the cohort was diverse: 53.6% were male, 19.7% were Black, 7.2% were Hispanic, and 33.4% were White. Notably, nearly half (48.2%) of the surgeries occurred in the neonatal period (under 30 days of age), and 22.5% of the patients had a confirmed genetic diagnosis. Surgical complexity was assessed using the Risk Adjustment for Congenital Heart Surgery (RACHS-2) categories, with approximately 28% of the cohort falling into the highest complexity categories (4 and 5).
Key Findings: A High Prevalence of Neurodevelopmental Challenges
The Escalation of Diagnoses Over Time
The study’s findings are stark. By age three, the cumulative prevalence of at least one neurodevelopmental diagnosis was 43.5%. By age five, this number rose to 51.7%. These figures underscore that neurodevelopmental delay is not a rare complication but rather the majority experience for this high-risk population. The types of diagnoses varied, encompassing everything from speech and motor delays to more complex cognitive and behavioral disorders as the children reached school age.
Service Utilization vs. Comprehensive Evaluation
One of the most striking aspects of the study was the disconnect between service utilization and formal evaluation. The researchers found that 82.9% of children had utilized at least one form of neurodevelopmental service (such as physical, occupational, or speech therapy) by age five. Furthermore, 55.7% had undergone some form of developmental screening.
However, despite recommendations from the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) for formal, multidisciplinary neurodevelopmental evaluations for high-risk CHD survivors, the rates of such evaluations were alarmingly low. Only 6.6% received a psychological or neuropsychological evaluation, and only 8.5% received a comprehensive developmental evaluation. This suggests that while many children are receiving therapies—likely triggered by general screening or obvious delays—they are not receiving the deep-dive diagnostic assessments required to tailor interventions to their specific neuropsychological profiles.
Identifying Risk Factors: Complexity and Disparity
The Role of Surgical Complexity
As expected, the complexity of the initial cardiac surgery was a strong predictor of future neurodevelopmental needs. Patients in RACHS-2 category 5 (the highest complexity) were significantly more likely to receive a neurodevelopmental diagnosis (HR 1.32) and were much more likely to utilize services (HR 2.25) compared to those in category 1. This correlation highlights the physiological toll of prolonged cardiopulmonary bypass, deep hypothermic circulatory arrest, and the inherent fragility of infants requiring complex reconstructions.
Racial and Ethnic Disparities in Diagnosis
The study also identified concerning disparities. Even after adjusting for surgical complexity and genetic factors, Black children (HR 1.14) and Hispanic children (HR 1.24) had a higher hazard ratio for receiving a neurodevelopmental diagnosis compared to White children. These findings suggest that systemic factors, ranging from environmental exposures to inequities in healthcare access and the quality of early intervention services, may play a role in the neurodevelopmental outcomes of minority children with CHD.
Expert Commentary: Closing the ‘Evaluation Gap’
The high utilization of services (over 80%) compared to the low rate of formal evaluation (under 9%) suggests a ‘treatment-first, diagnosis-later’ approach that may be suboptimal. While early intervention (EI) services are vital, they are often general in nature. Formal neuropsychological testing can identify subtle deficits in executive function, social cognition, and higher-order language that general screenings might miss but which become critical as a child enters the educational system.
The low rates of comprehensive evaluation may stem from several factors:
1. Provider Shortages: There is a national shortage of pediatric neuropsychologists and developmental-behavioral pediatricians.
2. Access Barriers: Publicly insured families may face transportation hurdles or long wait times for specialized centers.
3. Referral Knowledge: Primary care providers and even some cardiologists may not be fully aware of the specific AHA/AAP guidelines recommending formal evaluation regardless of screening results for high-risk infants.
Conclusion: Implications for Clinical Practice and Policy
This study serves as a clarion call for clinicians and policymakers. For children with CHD, the heart and the brain are inextricably linked. We can no longer view cardiac surgery as a localized intervention; it is a systemic event with lifelong neurodevelopmental implications.
To improve outcomes, the medical community must move toward a more integrated care model. This includes:
– Automatic Referrals: Establishing ‘Cardiac Neurodevelopmental Programs’ where formal evaluations are scheduled as a standard part of post-operative follow-up.
– Policy Support: Increasing Medicaid reimbursement for comprehensive developmental assessments to encourage provider participation and reduce wait times.
– Health Equity Initiatives: Targeted outreach and support for Black and Hispanic families to ensure they can navigate the complex landscape of neurodevelopmental care.
In summary, while we have become masters at mending the hearts of these infants, our work in supporting their developing minds is only just beginning. Ensuring that the 50% of children who face ND challenges receive the highest standard of evaluation and care is the next great challenge in pediatric cardiology.
References
1. O’Meara D, Henson B, Rollins CK, Gauvreau K, Berry JG, Hall M, Newburger JW. Neurodevelopment Among Publicly Insured Children in the First 5 Years After Infant Heart Surgery. JAMA Netw Open. 2026;9(2):e2556832.
2. Marino BS, et al. Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association. Circulation. 2012;126(9):1143-1172.
3. Gaynor JW, et al. Neurodevelopmental outcomes after cardiac surgery in infancy. Pediatrics. 2015;135(5):816-825.
