Cerebral autoregulation in congenital heart disease

Background: Recent advancements in surgical techniques and perioperative care have improved survival rates for children with congenital heart disease (CHD). Nevertheless, neurodevelopmental impairments remain common. Aim of review: This review examines the interplay between prenatal brain development, cerebral autoregulation (CAR) maturation, and perioperative influences in children with CHD. Key scientific concepts of review: Neurodevelopmental impairments, affecting cognition, motor skills, and behavior in later life, may originate as early as the prenatal stage, linked to placental dysfunction and altered cerebral blood supply, which impairs early brain development. As fetal development progresses, cardiac defects will further compromise cerebral perfusion. Importantly, CAR, the brain's ability to maintain stable blood flow, is often impaired in these fetuses. This altered autoregulatory capacity increases susceptibility to ischemic damage. Postnatally, CAR may be further impaired by surgical interventions and the associated risk factors, e.g., hypotension and hypothermia, exacerbating neurodevelopmental delays. By identifying key mechanisms challenging neurodevelopment in CHD, including placental dysfunction, altered fetal cerebral perfusion, and perioperative risk factors, we aim to improve understanding of the pathways contributing to adverse neurodevelopmental outcomes.