Significant advances have been made in the treatment of CHD, either surgically or non-surgically, which led to decreased mortality and increased life expectancy in children with CHD [1–2].
In this regard, we detect more neurodevelopmental disorders in both surgically and interventionaly treated groups, and the most important of that is the low level of cognitive skills [8]. These patients appear to have more impaired memory and task organization. These children also have behavioral disorders in the areas of hyperactivity, impulsivity, conduct, antisocial behavior, isolation, depression, and anxiety [9].
Medical treatment aims are not just to increase life expectancy; quality of life is a priority. Executive dysfunction is an important predictor of academic achievement, social communication, employment, and treatment adherence [19].
Some studies focused on intellectual quotient (I.Q.); Carmen Ryberg et al. examined two groups of congenital heart patients who underwent surgery and catheterization treatments for I.Q. Totally 228 children were classified according to age and severity of the disease. The results showed that 83% of children with congenital heart disease had expected or even higher intelligence [8]. Low I.Q. was associated with the family's economic level and severity of heart disease. Although intelligence is one of the predictors of a child's performance at school, executive performance also should be considered [8].
J.W.ray et al. compared 45 patients with congenital heart disease who underwent heart surgery with 51 patients who underwent bone marrow transplantation and 51 normal individuals. I.Q. in patients with heart disorders was generally in the normal range, but these patients were less well in data analysis and data processing speed [20]. Chronic illness can be one of the causes of poor performance, but the patients with congenital heart defects were lower in information processing and academic achievement than other chronic diseases [20].
In this study, executive performance has been considered. Also, according to their parents' point of view, children who had been included in this study had a normal I.Q. and no particular need for education. The surgically treated patients had lower performance in memory span and sustained attention than the interventional group. The severity of CHD can explain this difference. The surgical group had more complex CHD (single ventricle, tetralogy of Fallot, aortic coarctation) than the catheterization group (ASD, VSD.PDA).
In some studies, patients with complex CHD have impaired in various areas such as memory, academic status, visual-spatial perception, executive function, and attention [11, 12, 21]. In complex CHD patients, more brain abnormalities have been found in magnetic resonance imaging (MRI), although most of these disorders appear to be acquired, and there is no significant relationship between abnormal findings in MRI and neurodevelopmental tests [22]. Impairment of information processing speed, reaction rate, attention, selective attention, fine movements, working memory, and spatial-visual skills is more common in patients with complex heart abnormalities than patients with simpler abnormalities [10]. A study by Klouda L et al. showed that patients with more severe congenital heart defects had more surgeries associated with more executive dysfunction. The risk of acquired brain injuries during surgery, such as strokes, should also be considered [11]. On the other hand, overprotection, inactivity, parental dependency, and high parental anxiety levels in patients undergoing surgery, especially in cyanotic patients, appear to lead to a lack of cognitive skills. [8]. Patients with severe CHD appear to have a greater risk for congenital brain abnormalities [20], which are also related to physiological events due to fetal and chromosomal abnormalities [23–24]. Also, these patients are exposed to acquired executive dysfunctions due to multiple surgeries, hypoxia during and after surgery, seizures, and physical inactivity [25–26–27]. Complex congenital heart defects can predict neurodevelopmental disorders in adults. Although children with simple congenital anomalies such as atrial septal defect (ASD) also have defects compared to the normal population [28].
In our study, both groups of patients in the areas of attention, set-shifting, memory span, working memory, and visual memory had lower performance.
Some research focused on surgical factors explaining developmental neurological disorders in patients with congenital heart abnormalities [28–29]. Prolonged deep hypothermic circulatory arrest and extracorporeal membrane oxygenation are still considered risk factors for developing neurodevelopmental disorders [28]. Interestingly, complications during surgery can only justify 5–8% of developmental disorders [30–31]. Despite the advances in surgical procedures, there is no reduction in neurodevelopmental disorders. The nature of the disease, a group of preoperative factors, and factors during surgery are responsible for neurodevelopmental disorders in treated CHD, and surgical treatment does not seem to play a role in improving EF [20].
The present study results also confirm that patients with congenital heart disease, regardless of the type of intervention or the severity of the disease, have a lower performance in executive function than average. However, in the meta-analyzed Petra et al., the executive function in patients with simple heart disease is not significantly different from normal [32].
In this study, the SDQ parent questionnaire form was used to assess emotional symptoms, behavioral problems, communication problems, hyperactivity, and desirable behavior and the impact of behavioral disorders on a patient's life [18]. In comparing the two surgical and non-surgical groups, the family reporting about the effect of behavioral disorders on life was significantly higher in the surgical group (P˂0.0001).
In comparing the patients' group and the normal population, the patients' group had higher scores in emotional symptoms, behavioral problems, and communicational problems than the control group and lower scores in desirable behavior than the control group. There was no difference in the area of hyperactivity in both patients' groups. Similar research suggests that people with chronic illnesses are more prone to behavioral disorders [33–34–35–36]. Also, behavioral and emotional disorders are higher in patients with congenital heart defects than in the normal population, and these disorders are not related to the severity of the disease [37–38].
Kramer. H.H. et al. compared 128 patients with congenital heart disease with 89 normal people in the control group. They found that children with heart disease had more behavioral problems and higher feelings of inferiority and anxiety [39].
In one randomized control trial, Blinger et al. Compared 155 children who underwent arterial switch operation and were in the 4 to 8 age range compared with the control group. The behavioral checklist of parents 'children, Connor's parent scoring scale, and Connor teachers' scoring scale was used in their study. The score for behavioral disorders and children's behavioral checklists, and teacher checklists in the patient group were higher than in the normal group. This study suggests that patients with congenital heart disease are at risk for behavioral disorders [34].
Our study showed more behavioral problems in CHD patients than normal children except attention-deficit hyperactivity disorder because we exclude these patients from this study.
The analysis of the impact of the above behavioral problems on the child's daily life from the parents' point of view showed that 45% of parents believe that they have been affected by one of the family domains, school friendships or recreational activities, and 55% of parents not believe in this. The effect was unbelievably much lower than expected. This issue can be due to more parents' attention to physical illness than behavioral problems, the level of tolerance of the family with the sick child is higher, families refused to express behavioral disorders due to cultural issues, and the participants' average age.
Some studies, including the study of meta-analysis in Norway, which looked at the executive and psychological functioning in children and adolescents with congenital heart disease, had shown that psycho-behavioral disorders appear in older children, and they show more internal disorders such as depression and anxiety than external disorders such as hyperactivity and behavioral problems [32].