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Avitabile CM, Zhang X, Ampah S, Wang Y, Ash D, Nilan K, Tingo JE, Frank DB, Jensen EA, Lingappan K, Gibbs KA. Elevated pulmonary capillary wedge pressure, higher blood pressure, and lower cardiac index in infants with bronchopulmonary dysplasia. Int J Cardiol 2024:132246. [PMID: 38851539 DOI: 10.1016/j.ijcard.2024.132246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/30/2024] [Accepted: 06/05/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Left ventricular diastolic dysfunction indicated by elevated pulmonary capillary wedge pressure (ePCWP) may worsen cardiorespiratory status in bronchopulmonary dysplasia (BPD), but the scope of ePCWP by cardiac catheterization is not well described. METHODS This single-center retrospective cohort study included infants with BPD without congenital heart disease, significant intracardiac shunts, or pulmonary vein stenosis who underwent cardiac catheterization from 2010 to 2021. ePCWP was defined as >10 mmHg. Quantitative measures of ventricular systolic and diastolic function were performed on existing echocardiograms. Patients with and without ePCWP were compared using the Chi-squared or Wilcoxon rank-sum tests. Associations between catheterization hemodynamics and echocardiographic parameters were assessed by simple linear regression. RESULTS Seventy-one infants (93% Grade 2 or 3 BPD) met inclusion criteria, and 30 (42%) had ePCWP. Patients with ePCWP were older at catheterization (6.7 vs. 4.5 months, p < 0.001), more commonly underwent tracheostomy (66.7% vs. 29.3%, p = 0.003), and had higher mean systemic blood pressure [64.5 (56.0, 75.0) vs. 47.0 (43.0, 55.0) mm Hg, p < 0.001], higher systemic vascular resistance [11.9 (10.4, 15.6) vs. 8.7 (6.7, 11.2) WU*m2, p < 0.001), and lower cardiac index [3.9 (3.8, 4.9) vs. 4.7 (4.0, 6.3) L/min/m2, p = 0.03] at catheterization. Mean pulmonary artery pressure, pulmonary vascular resistance, and mortality were similar between the groups. Echocardiographic indices of left ventricular diastolic dysfunction did not correlate with PCWP. CONCLUSIONS ePCWP was common in infants with severe BPD who underwent cardiac catheterization in this cohort. The association between ePCWP and higher systemic blood pressure supports further study of afterload reduction in this population.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Echocardiography Laboratory Research Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Xuemei Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Steve Ampah
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yan Wang
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Echocardiography Laboratory Research Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Devon Ash
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Echocardiography Laboratory Research Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen Nilan
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer E Tingo
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David B Frank
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Erik A Jensen
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Krithika Lingappan
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen A Gibbs
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Hernandez BS, Shinozaki RM, Grady RM, Drussa A, Jamro-Comer E, Wang J, Aggarwal M. Improvement in Echocardiographic and Diagnostic Biomarkers after Systemic Glucocorticoid Therapy in Infants with Pulmonary Hypertension. J Pediatr 2024:114116. [PMID: 38815741 DOI: 10.1016/j.jpeds.2024.114116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/09/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To assess the effect of treating pulmonary hypertension (PH) in infants less than 1 year of age with systemic glucocorticoids while using echocardiographic and diagnostic biomarkers as measures of efficacy. STUDY DESIGN A retrospective chart review was performed on 17 hospitalized infants less than one year of age at St. Louis Children's Hospital who received a five- to seven-day course of systemic glucocorticoid treatment followed by a three-week taper with no significant intracardiac shunts from January 1, 2017, to December 31, 2021. Quantitative echocardiographic indices for PH, N-terminal pro b-type natriuretic peptide (NT-proBNP) and/or b-type natriuretic peptide (BNP) levels were collected pre-glucocorticoid treatment, after the glucocorticoid burst, and following the 21-day taper. RESULTS Mean (+/- SD) gestational age was 32.1 (+/-5.8) weeks, 5 infants were (29%) concomitantly treated with sildenafil, and 8 were male. Twelve were classified as World Health Organization (WHO) group 3 PH (71%), and 5 WHO group 1 PH. There were significant improvements 30 days post-glucocorticoid initiation in BNP levels (p=0.008), partial pressure of carbon dioxide (p=0.03), eccentricity index (p=0.005), RV ejection time (p=0.04), pulmonary artery acceleration time (PAAT) (p=0.002), and PAAT to right ventricular ejection time ratio (PAAT/RVET) (p=0.02). Tricuspid regurgitation velocity was not able to be assessed. There were no mortalities during the study timeline. CONCLUSIONS In our retrospective study, systemic glucocorticoid therapy was well tolerated and appeared to be associated with significant improvement in cardio-pulmonary function in infants with PH. Further prospective study in a larger sample is warranted.
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Affiliation(s)
- Brian S Hernandez
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Rod M Shinozaki
- Division of Pediatric Critical Care, Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, California
| | - R Mark Grady
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Andrea Drussa
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Erica Jamro-Comer
- Division of Biostatistics, Washington University in St. Louis, St. Louis, Missouri
| | - Jinli Wang
- Division of Biostatistics, Washington University in St. Louis, St. Louis, Missouri
| | - Manish Aggarwal
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
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Joshi K, Priyadarshi M, Shrivastava Y, Chaurasia S, Singh P, Bhat NK, Basu S. Transitional Hemodynamics in Neonates Born Through Meconium-Stained Amniotic Fluid: A Prospective Observational Study. Pediatr Cardiol 2024:10.1007/s00246-024-03521-w. [PMID: 38782782 DOI: 10.1007/s00246-024-03521-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Neonates born through meconium-stained amniotic fluid (MSAF) are at increased risk of altered cardiopulmonary transition at birth. There is a paucity of literature evaluating the transitional hemodynamics in these neonates. We aimed to evaluate transitional hemodynamics via echocardiography in neonates born through MSAF, compared to healthy neonates. The primary objective was to assess pulmonary vascular resistance using left pulmonary artery-velocity time integral (LPA-VTI). The secondary objectives were to assess other pulmonary vascular parameters and myocardial function. We enrolled 35 MSAF-born and 35 healthy neonates. Echocardiography was performed at 24 and 48 h of life by a pediatric cardiologist. Echocardiographic parameters were compared between MSAF-born and healthy neonates, and between MSAF-born neonates who developed meconium aspiration syndrome (MAS) and who did not (non-MAS). Among 35 MSAF-born neonates, 14 (40%) were non-vigorous, 18 (51%) required admission to neonatal intensive care unit, 8 (23%) developed MAS, 3 (9%) pulmonary hypertension and 1 (3%) air leak. On echocardiography, LPA-VTI (cm; mean ± SD) was significantly decreased at 24 and 48 h in MSAF-born neonates (14.38 ± 2.48; 15.55 ± 2.48), compared to healthy neonates (16.60 ± 2.14; 17.66 ± 2.71), respectively. Further, LPA-VTI was significantly reduced at 24 and 48 h among MAS (11.81 ± 3.0; 12.43 ± 2.5), compared to non-MAS neonates (15.15 ± 1.72; 16.48 ± 1.55), respectively. Other pulmonary vascular and myocardial function parameters were comparable between the two groups. Pulmonary adaptation was significantly delayed in neonates with MSAF, which was more pronounced in MAS neonates. Further studies should explore the utility of these parameters for early prediction of cardiorespiratory morbidities in this population.
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Affiliation(s)
- Kamal Joshi
- Departments of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
- Departments of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mayank Priyadarshi
- Departments of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Yash Shrivastava
- Departments of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Suman Chaurasia
- Departments of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Poonam Singh
- Departments of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nowneet Kumar Bhat
- Departments of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sriparna Basu
- Departments of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
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Niyogi SG, Singh A, Kumar B, Mishra AK, Puri GD. Right Atrial Strain in Pediatric Pulmonary Hypertension-A Prospective Observational Study. Pediatr Cardiol 2024:10.1007/s00246-024-03523-8. [PMID: 38777858 DOI: 10.1007/s00246-024-03523-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Right ventricular (RV) afterload due to elevated pulmonary arterial (PA) pressure in pulmonary hypertension (PH) causes long-term right atrial (RA) remodeling and dysfunction. RA function has been shown to correlate with PA pressures and outcome in both adult and pediatric patients with PH. We studied the role of RA strain in estimating PA pressures in congenital heart disease (CHD)-associated PH. Children below 12 years undergoing elective repair of CHD with left-to-right shunts and echocardiographic evidence of PH were included. RA reservoir, conduit and contractile strain along with conventional measures of RV function and PA pressure were measured using transthoracic echocardiography after induction of anaesthesia. Pre-and post-repair invasive PA pressures were measured after surgical exposure. 51 children with a median age of 24 months (range 4-144 months) were included, most of whom were undergoing VSD closure. Contractile RA strain showed good correlation with pre-repair systolic PA pressure in mmHg (r = 0.59, 95%CI 0.37-0.75) or expressed as a percentage of SBP (r = 0.67, 95%CI 0.49-0.80). It also predicted persistent postoperative PH as well as pre-repair pulmonary artery acceleration time and right ventricular systolic pressure measured from tricuspid regurgitation jet. The trends of correlation observed suggest a possible prognostic role of RA strain in ACHD with PH and potential utility in its echocardiographic assessment. The observed findings merit deeper evaluation in larger cohorts.
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Affiliation(s)
- Subhrashis Guha Niyogi
- Department of Anaesthesia, All India Institute of Medical Sciences, Kalyani, West Bengal, India
| | - Avneet Singh
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Bhupesh Kumar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.
| | - Anand Kumar Mishra
- Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
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Gopagondanahalli KR, Abdul Haium AA, Vora SJ, Sundararaghavan S, Ng WD, Choo TLJ, Ang WL, Binte Mohamad Taib NQ, Wijedasa NHY, Rajadurai VS, Yeo KT, Tan TH. Serial tissue Doppler imaging in the evaluation of bronchopulmonary dysplasia-associated pulmonary hypertension among extremely preterm infants: a prospective observational study. Front Pediatr 2024; 12:1349175. [PMID: 38646509 PMCID: PMC11026596 DOI: 10.3389/fped.2024.1349175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/18/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives To evaluate serial tissue Doppler cardiac imaging (TDI) in the evolution of bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH) among extremely preterm infants. Design Prospective observational study. Setting Single-center, tertiary-level neonatal intensive care unit. Patients Infant born <28 weeks gestation. Main outcome measures Utility of TDI in the early diagnosis and prediction of BPD-PH and optimal timing for screening of BPD-PH. Results A total of 79 infants were included. Of them, 17 (23%) had BPD-PH. The mean gestational age was 25.9 ± 1.1 weeks, and mean birth weight was 830 ± 174 g. The BPD-PH group had a high incidence of hemodynamically significant patent ductus arteriosus (83% vs. 56%, p < 0.018), longer oxygen days (96.16 ± 68.09 vs. 59.35 ± 52.1, p < 0.008), and prolonged hospital stay (133.8 ± 45.9 vs. 106.5 ± 37.9 days, p < 0.005). The left ventricular eccentricity index (0.99 ± 0.1 vs. 1.1 ± 0.7, p < 0.01) and the ratio of acceleration time to right ventricular ejection time showed a statistically significant trend from 33 weeks (0.24 ± 0.05 vs. 0.28 ± 0.05, p < 0.05). At 33 weeks, the BPD-PH group showed prolonged isovolumetric contraction time (27.84 ± 5.5 vs. 22.77 ± 4, p < 0.001), prolonged isovolumetric relaxation time (40.3 ± 7.1 vs. 34.9 ± 5.3, p < 0.003), and abnormal myocardial performance index (0.39 ± 0.05 vs. 0.32 ± 0.03, p < 0.001). These differences persisted at 36 weeks after conceptional gestational age. Conclusions TDI parameters are sensitive in the early evolution of BPD-PH. Diagnostic accuracy can be increased by combining the TDI parameters with conventional echocardiographic parameters. BPD-PH can be recognizable as early as 33-34 weeks of gestation.
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Affiliation(s)
- Krishna Revanna Gopagondanahalli
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Abdul Alim Abdul Haium
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Shrenik Jitendrakumar Vora
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Sreekanthan Sundararaghavan
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
- Department of Paediatric Cardiology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Wei Di Ng
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Tze Liang Jonathan Choo
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
- Department of Paediatric Cardiology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Wai Lin Ang
- Department of Paediatric Cardiology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | | | | | - Victor Samuel Rajadurai
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Kee Thai Yeo
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Teng Hong Tan
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
- Department of Paediatric Cardiology, KK Women’s and Children’s Hospital, Singapore, Singapore
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Singh Y. Echocardiography in the neonatal unit: current status and future prospects. Expert Rev Med Devices 2024; 21:307-316. [PMID: 38526192 DOI: 10.1080/17434440.2024.2334449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/20/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Traditionally echocardiography was used by pediatric cardiologists to diagnose congenital heart defects in neonates. Formalized neonatal hemodynamic fellowships have been established where neonatologists acquire advanced echocardiographic skills to gain anatomical, physiological, and hemodynamic information in real time and utilize this information in making a timely and accurate physiology-based clinical decision. AREA COVERED Differences between a comprehensive formal structural echocardiography, neonatologist performed targeted echocardiography and limited assessment on point-of-care-ultrasonography for specific indications have been covered. This article is focused at providing a comprehensive review of the status of echocardiography in the neonatal units, recent advancements and its future prospects in the neonatal intensive care units. EXPERT OPINION Comprehensive guidelines providing the scope of practice, a framework for training, and robust clinical governance process for the neonatologist performed targeted echocardiography have been established. In the last decade, echocardiography has emerged as essential vital bedside diagnostic tool in providing high-quality care to the sick infants in the neonatal units, and it has proved to improve the outcomes in neonates. It is now being considered as a modern hemodynamic monitoring tool. Advances in technology, machine learning, and application of artificial intelligence in applications of echocardiography seem promising adjunct tools for rapid assessment in emergency situations.
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Affiliation(s)
- Yogen Singh
- Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, USA
- Division of Neonatology, University of Southern California, Los Angeles, USA
- Department of Pediatrics, University of Cambridge Clinical School of Medicine, Cambridge, UK
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Théry G, Gascon V, Fraile V, Ochagavia A, Hamzaoui O. How to use echocardiography to manage patients with shock? Med Intensiva 2024; 48:220-230. [PMID: 38151372 DOI: 10.1016/j.medine.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023]
Abstract
Echocardiography enables the intensivist to assess the patient with circulatory failure. It allows the clinician to identify rapidly the type and the cause of shock in order to develop an effective management strategy. Important characteristics in the setting of shock are that it is non-invasive and can be rapidly applied. Early and repeated echocardiography is a valuable tool for the management of shock in the intensive care unit. Competency in basic critical care echocardiography is now regarded as a mandatory part of critical care training with clear guidelines available. The majority of pathologies found in shocked patients are readily identified using basic level 2D and M-mode echocardiography. The four core types of shock (cardiogenic, hypovolemic, obstructive, and septic) can readily be identified by echocardiography. Echocardiography can differentiate the different pathologies that may be the cause of each type of shock. More importantly, as a result of more complex and elderly patients, the shock may be multifactorial, such as a combination of cardiogenic and septic shock, which emphasises on the added value of transthoracic echocardiography (TTE) in such population of patients. In this review we aimed to provide to clinicians a bedside strategy of the use of TTE parameters to manage patients with shock. In the first part of this overview, we detailed the different TTE parameters and how to use them to identify the type of shock. And in the second part, we focused on the use of these parameters to evaluate the effect of treatments, in different types of shock.
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Affiliation(s)
- Guillaume Théry
- Service de Médecine Intensive - Réanimation Polyvalente, Hôpital Robert Debré, Centre Hospitalo-Universitaire de Reims; Unité HERVI "Hémostase et Remodelage Vasculaire Post-Ischémie" - EA 3801.
| | - Victor Gascon
- Servicio de Medicina Intensiva, Hospital Universitario de la Ribera, Alcira (Valencia)
| | - Virginia Fraile
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Valladolid
| | - Ana Ochagavia
- Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona
| | - Olfa Hamzaoui
- Service de Médecine Intensive - Réanimation Polyvalente, Hôpital Robert Debré, Centre Hospitalo-Universitaire de Reims; Unité HERVI "Hémostase et Remodelage Vasculaire Post-Ischémie" - EA 3801
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Joye S, Bhattacharya S, Kharrat A, Jasani B, Giesinger RE, McNamara PJ, Jain A. Shape of Pulmonary Artery Doppler Flow Profile and Right Ventricular Hemodynamics in Neonates. J Pediatr 2024; 266:113864. [PMID: 38052293 DOI: 10.1016/j.jpeds.2023.113864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVES To characterize pulmonary artery Doppler flow profile (PAFP) patterns among infants receiving care in neonatal intensive care units and to examine the association of PAFP patterns with pulmonary and right ventricular (RV) hemodynamics. STUDY DESIGN This is a retrospective study at 2 tertiary intensive care units over 4 years that included neonates who demonstrated a complete tricuspid regurgitation envelope on targeted neonatal echocardiography. Separate personnel reviewed TNEs to characterize PAFP patterns, divide cohort into PAFP groups, and measure quantitative indices of RV hemodynamics (RV systolic pressure, pulmonary artery acceleration time and its ratio with RV ejection time, tricuspid annular plane systolic excursion, and RV output), for intergroup comparisons. RESULTS We evaluated TNEs from 186 neonates with median gestational age of 28.5 weeks (IQR, 25.9-35.9 weeks). Four distinct PAFP patterns were identified (A) near-isosceles triangle (22%), (B) right-angled triangle (29%), (C) notching (40%), and (D) low peak velocity (<0.4 m/s; 9%). Groups A-C demonstrated a stepwise worsening in all indices of PH, whereas pattern D was associated with lower tricuspid annular plane systolic excursion and RV output. Using common definitions of pulmonary hypertension (PH), pattern A performed best to rule out PH (sensitivity range, 81%-90%) and pattern C for diagnosing PH (specificity range, 63%-78%). CONCLUSIONS Inspection of PAFP is a simple bedside echocardiography measure that provides clinically meaningful information on underlying RV hemodynamics and may aid in screening and monitoring of patients for PH in intensive care units.
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Affiliation(s)
- Sébastien Joye
- Department Woman-Mother-Child, Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Ashraf Kharrat
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Bonny Jasani
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Division of Neonatology, The Hospital of Sick Children, Toronto, ON, Canada
| | | | | | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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Boyd SM, Kluckow M, McNamara PJ. Targeted Neonatal Echocardiography in the Management of Neonatal Pulmonary Hypertension. Clin Perinatol 2024; 51:45-76. [PMID: 38325947 DOI: 10.1016/j.clp.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Pulmonary hypertension (PH) in neonates, originating from a range of disease states with heterogeneous underlying pathophysiology, is associated with significant morbidity and mortality. Although the final common pathway is a state of high right ventricular afterload leading to compromised cardiac output, multiple hemodynamic phenotypes exist in acute and chronic PH, for which cardiorespiratory treatment strategies differ. Comprehensive appraisal of pulmonary pressure, pulmonary vascular resistance, cardiac function, pulmonary and systemic blood flow, and extrapulmonary shunts facilitates delivery of individualized cardiovascular therapies in affected newborns.
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Affiliation(s)
- Stephanie M Boyd
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Corner Hawkesbury Road, Hainsworth Street, Westmead, Sydney 2145, Australia; The University of Sydney, Sydney, Australia
| | - Martin Kluckow
- The University of Sydney, Sydney, Australia; Department of Neonatology, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Sydney, Australia
| | - Patrick J McNamara
- Division of Neonatology, The University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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10
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Gu H, Azukaitis K, Doyon A, Erdem S, Ranchin B, Harambat J, Lugani F, Boguslavskyi A, Cansick J, Finlay E, Gilbert R, Kerecuk L, Lunn A, Maxwell H, Morgan H, Shenoy M, Shroff R, Subramaniam P, Tizard J, Tse Y, Simpson J, Chowienczyk P, Schaefer F, Sinha MD. Decline in Left Ventricular Early Systolic Function with Worsening Kidney Function in Children with Chronic Kidney Disease: Insights from the 4C and HOT-KID Studies. J Am Soc Echocardiogr 2024; 37:356-363.e1. [PMID: 37993063 DOI: 10.1016/j.echo.2023.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/27/2023] [Accepted: 11/08/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Adults with childhood-onset chronic kidney disease (CKD) have an increased risk of cardiovascular disease. First-phase ejection fraction (EF1), a novel measure of early systolic function, may be a more sensitive marker of left ventricular dysfunction than other markers in children with CKD. OBJECTIVE To examine whether EF1 is reduced in children with CKD. METHODS Children from the 4C and HOT-KID studies were stratified according to estimated glomerular filtration rate (eGFR). The EF1 was calculated from the fraction of left ventricular (LV) volume ejected up to the time of peak aortic flow velocity. RESULTS The EF1 was measured in children ages 10.9 ± 3.7 (mean ± SD) years, 312 with CKD and 63 healthy controls. The EF1 was lower, while overall ejection fraction was similar, in those with CKD compared with controls and decreased across stages of CKD (29.3% ± 3.7%, 23.5% ± 4.5%, 19.8% ± 4.0%, 18.5% ± 5.1%, and 16.7% ± 6.6% in controls, CKD 1, 2, 3, and ≥ 4, respectively, P < .001). The relationship of EF1 to eGFR persisted after adjustment for relevant confounders (P < .001). The effect size for association of measures of LV structure or function with eGFR (SD change per unit change in eGFR) was greater for EF1 (β = 0.365, P < .001) than for other measures: LV mass index (β = -0.311), relative wall thickness (β = -0.223), E/e' (β = -0.147), and e' (β = 0.141) after adjustment for confounders in children with CKD. CONCLUSIONS Children with CKD exhibit a marked and progressive decline in EF1 with falling eGFR. This suggests that EF1 is a more sensitive marker of LV dysfunction when compared to other structural or functional measures and that early LV systolic function is a key feature in the pathophysiology of cardiac dysfunction in CKD.
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Affiliation(s)
- Haotian Gu
- King's College London British Heart Foundation Centre, London, United Kingdom
| | - Karolis Azukaitis
- Clinic of Pediatrics, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Anke Doyon
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sevcan Erdem
- Department of Pediatric Cardiology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Jerome Harambat
- Pediatric Nephrology Unit, Department of Pediatrics, Centre de Référence Maladies Rénales Rares, Bordeaux University Hospital, Bordeaux, France
| | - Francesca Lugani
- Division of Nephrology, Dialysis, Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrii Boguslavskyi
- King's College London British Heart Foundation Centre, London, United Kingdom
| | - Janette Cansick
- Department of Paediatrics, Medway Maritime Hospital, Medway, United Kingdom
| | - Eric Finlay
- Department of Paediatric Nephrology, Leeds General Infirmary, Leeds, United Kingdom
| | - Rodney Gilbert
- Department of Paediatric Nephrology, Southampton General Hospital, Southampton, United Kingdom
| | - Larissa Kerecuk
- Department of Paediatric Nephrology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Andrew Lunn
- Department of Paediatric Nephrology, Nottingham University Hospital NHS Trust, Nottingham, United Kingdom
| | - Heather Maxwell
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Henry Morgan
- Department of Paediatric Nephrology, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Rukshana Shroff
- Department of Paediatric Nephrology, UCL Great Ormond Street Hospital and Institute of Child Health, London, United Kingdom
| | - Pushpa Subramaniam
- Department of Paediatrics, St Georges Hospital, Tooting, London, United Kingdom
| | - Jane Tizard
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Yincent Tse
- Department of Paediatric Nephrology, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - John Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, United Kingdom
| | - Phil Chowienczyk
- King's College London British Heart Foundation Centre, London, United Kingdom
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Manish D Sinha
- King's College London British Heart Foundation Centre, London, United Kingdom; Department of Paediatric Nephrology, Evelina London Children's Hospital, London, United Kingdom.
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11
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Geisinger R, Rios DR, McNamara PJ, Levy PT. Asphyxia, Therapeutic Hypothermia, and Pulmonary Hypertension. Clin Perinatol 2024; 51:127-149. [PMID: 38325938 DOI: 10.1016/j.clp.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Neonates with a perinatal hypoxic insult and subsequent neonatal encephalopathy are at risk of acute pulmonary hypertension (aPH) in the transitional period. The phenotypic contributors to aPH following perinatal asphyxia include a combination of hypoxic vasoconstriction of the pulmonary vascular bed, right heart dysfunction, and left heart dysfunction. Therapeutic hypothermia is the standard of care for neonates with moderate-to-severe hypoxic ischemic encephalopathy. This review summarizes the underlying risk factors, causes of aPH in neonates with perinatal asphyxia, discusses the unique phenotypical contributors to disease, and explores the impact of the initial insult and subsequent therapeutic hypothermia on aPH.
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Affiliation(s)
- Regan Geisinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Danielle R Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Hunnewell 436, Boston, MA 02115, USA.
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12
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Reyes-Hernandez ME, Bischoff AR, Giesinger RE, Rios DR, Stanford AH, McNamara PJ. Echocardiography Assessment of Left Ventricular Function in Extremely Preterm Infants, Born at Less Than 28 Weeks' Gestation, With Bronchopulmonary Dysplasia and Systemic Hypertension. J Am Soc Echocardiogr 2024; 37:237-247. [PMID: 37619910 DOI: 10.1016/j.echo.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND The survival of smaller and more immature premature infants has been associated with lifelong cardiorespiratory comorbidities. Infants with bronchopulmonary dysplasia (BPD) undergo routine screening echocardiography to evaluate for development of chronic pulmonary hypertension, a late manifestation of pulmonary vascular disease. METHODS Our aim was to evaluate left ventricular (LV) performance in infants with BPD and pulmonary vascular disease who developed systemic hypertension. We hypothesized that infants with hypertension were more likely to have impaired LV performance. We present a single-center cross-sectional study of premature infants born at less than 28 0/7 weeks' gestational age with a clinical diagnosis of BPD. Infants were categorized by the systolic arterial pressure (SAP) at time of echocardiography as hypertensive (SAP ≥90 mm Hg) or normotensive (SAP <90 mm Hg). Sixty-four patients were included. RESULTS Infants with hypertension showed altered LV diastolic function with prolonged tissue Doppler imaging-derived isovolumic relaxation time (54.2 ± 5.1 vs 42.9 ± 8.2, P < .001), lower E:A, and higher E:e'. Indices of left heart volume/pressure loading (left atrium:aorta and LV end-diastolic volume [6.1 ± 2 vs 4.2 ± 1.2, P < .001]) were also higher in the hypertensive group. Finally, infants in the hypertensive group had higher pulmonary vascular resistance index (4.42 ± 1.1 vs 3.69 ± 0.8, P = .004). CONCLUSIONS We conclude that extremely preterm infants with BPD who develop systemic hypertension are at risk of abnormal LV diastolic dysfunction. Increased pulmonary vascular resistance index in the hypertensive group may relate to pulmonary venous hypertension secondary to LV dysfunction. This is an important consideration in this cohort when selecting the physiologically most appropriate treatment.
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Affiliation(s)
| | - Adrianne R Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Danielle R Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Amy H Stanford
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa; Department of Internal Medicine, University of Iowa, Iowa City, Iowa.
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13
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McNamara PJ, Jain A, El-Khuffash A, Giesinger R, Weisz D, Freud L, Levy PT, Bhombal S, de Boode W, Leone T, Richards B, Singh Y, Acevedo JM, Simpson J, Noori S, Lai WW. Guidelines and Recommendations for Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit: An Update from the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:171-215. [PMID: 38309835 DOI: 10.1016/j.echo.2023.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Targeted neonatal echocardiography (TNE) involves the use of comprehensive echocardiography to appraise cardiovascular physiology and neonatal hemodynamics to enhance diagnostic and therapeutic precision in the neonatal intensive care unit. Since the last publication of guidelines for TNE in 2011, the field has matured through the development of formalized neonatal hemodynamics fellowships, clinical programs, and the expansion of scientific knowledge to further enhance clinical care. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus, evaluation of acute and chronic pulmonary hypertension, evaluation of right and left ventricular systolic and/or diastolic function, and screening for pericardial effusions and/or malpositioned central catheters. Neonatal cardiac point-of-care ultrasound (cPOCUS) is a limited cardiovascular evaluation which may include line tip evaluation, identification of pericardial effusion and differentiation of hypovolemia from severe impairment in myocardial contractility in the hemodynamically unstable neonate. This document is the product of an American Society of Echocardiography task force composed of representatives from neonatology-hemodynamics, pediatric cardiology, pediatric cardiac sonography, and neonatology-cPOCUS. This document provides (1) guidance on the purpose and rationale for both TNE and cPOCUS, (2) an overview of the components of a standard TNE and cPOCUS evaluation, (3) disease and/or clinical scenario-based indications for TNE, (4) training and competency-based evaluative requirements for both TNE and cPOCUS, and (5) components of quality assurance. The writing group would like to acknowledge the contributions of Dr. Regan Giesinger who sadly passed during the final revisions phase of these guidelines. Her contributions to the field of neonatal hemodynamics were immense.
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Affiliation(s)
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Afif El-Khuffash
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Regan Giesinger
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Dany Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Lindsey Freud
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Shazia Bhombal
- Department of Pediatrics, Division of Neonatology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Tina Leone
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Yogen Singh
- Loma Linda University School of Medicine, Loma Linda, California
| | - Jennifer M Acevedo
- Department of Pediatrics-Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Simpson
- Department of Pediatrics, Evelina London Children's Hospital, London, United Kingdom
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Wyman W Lai
- CHOC Children's Hospital, Orange, California; University of California, Irvine, Orange, California
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14
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Li Q, Zhang M. Echocardiography assessment of right ventricular-pulmonary artery coupling: Validation of surrogates and clinical utilities. Int J Cardiol 2024; 394:131358. [PMID: 37704177 DOI: 10.1016/j.ijcard.2023.131358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 09/15/2023]
Abstract
Right ventricular-pulmonary artery (RV-PA) coupling indicates efficiency of energy transfer from the right ventricle to the pulmonary circulation. The gold standard measurement, end-systolic elastance/arterial elastance ratio (Ees/Ea), is derived from invasive pressure-volume loop, which is technically demanding, expensive and limited in clinical practice. Recent studies have proposed various non-invasive surrogates of Ees/Ea based on echocardiography assessment, of which TAPSE/PASP ratio is an easily-obtained and validated parameter in severe pulmonary hypertension and rapidly applicated in the diagnosis and risk evaluation of various diseases and cardiac intervention. In this review, we summarized principles and validations of echocardiographic surrogates, and their clinical utilities and also limitations. The goal is to systematically review the research advances of echocardiography assessment of RV-PA coupling and help to guide clinical practice.
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Affiliation(s)
- Qimou Li
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Mei Zhang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China.
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15
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Stanford AH, Chatmethakul T, Rios DR, Giesinger RE, Thomas B, Bischoff AR, Weiner L, McNamara PJ. Postnatal cytomegalovirus infection and pulmonary vascular disease in extremely premature infants: A case series. J Neonatal Perinatal Med 2024; 17:275-284. [PMID: 38728205 DOI: 10.3233/npm-230078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND Pulmonary vascular disease (PVD) is a major determinant of both morbidity and mortality in extremely low birth weight infants. It is biologically plausible that postnatal cytomegalovirus (pCMV) infection may lead to PVD in premature infants secondary to pneumonitis or via derangement of pulmonary vascular development directly through endothelial dysfunction. Uncertainty remains, however, regarding thresholds for intervention in premature infants with cardiorespiratory instability and presumed CMV infection likely secondary to the limited understanding of the natural history of the disease. METHODS/RESULTS We describe four cases of premature infants with clinical and echocardiography features of PVD, in the setting of postnatally acquired CMV. All patients had atypical PVD trajectories, refractory to vasodilator treatment, which improved after initiation of CMV treatment. CONCLUSION We highlight the need to consider postnatally acquired CMV infection in patients with PVD non-responsive to standard pulmonary vasodilator therapies or disease severity which is out of proportion of the usual clinical trajectory. Treatment of extremely premature infants with CMV-associated PVD may have positive impact on cardiorespiratory health, although duration of therapy remains uncertain.
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Affiliation(s)
- A H Stanford
- Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
| | - T Chatmethakul
- Department of Pediatrics, Neonatal-Perinatal Medicine Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - D R Rios
- Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
| | - R E Giesinger
- Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
| | - B Thomas
- Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
| | - A R Bischoff
- Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
| | - L Weiner
- Department of Pediatrics, Division of Pediatric Infectious Disease, University of Iowa, Iowa City, IA, USA
| | - P J McNamara
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
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16
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Loar RW, Tsao C, Ogunyankin F, Wilkes JK, VanLoozen D, Schutte D, Dyer A. Mid-Systolic Notching of the Pulmonary Valve Doppler Signal is Highly Associated with Pulmonary Hypertension. Pediatr Cardiol 2023; 44:1667-1673. [PMID: 37676274 DOI: 10.1007/s00246-023-03285-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/21/2023] [Indexed: 09/08/2023]
Abstract
Mid-systolic notching (MSN) of the pulmonary valve Doppler signal represents a reflected systolic pressure wave from the pulmonary vasculature and is often seen in pulmonary hypertension (PH). We hypothesize that MSN is associated with a higher pulmonary vascular resistance (PVR) and mean pulmonary artery pressure (mPAP), and a diagnosis of PH in pediatric patients. This was a retrospective study of patients ≤ 18 years who had an echocardiogram obtained ≤ 30 days before catheterization for suspected PH. MSN was defined as an indentation in the initial two thirds of the systolic Doppler signal. PH was defined as mPAP > 20 mmHg and PVR ≥ 3.0 Wu m2. Subgroups (MSN vs. normal) were compared. Receiver operator characteristic determined a continuous variable's discriminatory ability for a diagnosis of PH. Reproducibility of MSN was assessed. In total, 90 patients (73 with congenital heart disease) were included, of which 36 had MSN and 54 were normal. MSN patients were more likely to have PH, and had significantly higher mPAP, PVR, and lower pulmonary stroke volume. The presence of MSN had good discriminatory ability for PH diagnosis. The presence of MSN had high specificity (96%) for PH, whereas sensitivity was lower (54%). Reproducibility was 100% for MSN. MSN is a simple, highly reproducible echocardiographic metric associated with higher mPAP and PVR. When present, there is a high likelihood a diagnosis of PH confirmed by catheterization. Incorporation of MSN into imaging protocols may be useful. MSN appears worthy of further investigation in pediatric patients with suspected PH.
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Affiliation(s)
- Robert W Loar
- Pediatric Cardiology, Cook Children's Medical Center, 1500 Cooper St., Fort Worth, TX, 76104, USA.
- Department of Pediatrics, TCU Burnett School of Medicine, Fort Worth, TX, USA.
| | - Christopher Tsao
- Pediatric Cardiology, Cook Children's Medical Center, 1500 Cooper St., Fort Worth, TX, 76104, USA
| | - Fadeke Ogunyankin
- Pediatric Cardiology, Cook Children's Medical Center, 1500 Cooper St., Fort Worth, TX, 76104, USA
| | - J Kevin Wilkes
- Pediatric Cardiology, Cook Children's Medical Center, 1500 Cooper St., Fort Worth, TX, 76104, USA
| | - Dennis VanLoozen
- Pediatric Cardiology, Cook Children's Medical Center, 1500 Cooper St., Fort Worth, TX, 76104, USA
| | - Deborah Schutte
- Pediatric Cardiology, Cook Children's Medical Center, 1500 Cooper St., Fort Worth, TX, 76104, USA
| | - Adrian Dyer
- Pediatric Cardiology, Cook Children's Medical Center, 1500 Cooper St., Fort Worth, TX, 76104, USA
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17
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Smith A, Franklin O, McCallion N, Breathnach F, El-Khuffash A. Assessment of Myocardial Function in Infants of Mothers with Gestational Diabetes Mellitus Using Deformation Imaging over the First Year of Age. J Pediatr 2023; 263:113645. [PMID: 37517648 DOI: 10.1016/j.jpeds.2023.113645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To assess serial myocardial performance and pulmonary vascular resistance (PVR) in infants of mothers with gestational diabetes mellitus (GDM) over the first year of life. STUDY DESIGN This was a prospective, observational study. Echocardiography was performed at birth, 6 months, and 1 year of age. Pulmonary artery acceleration time and left ventricular (LV) eccentricity index provided surrogate measurements of PVR. Biventricular function was assessed by tissue Doppler imaging and deformation analysis. RESULTS Fifty infants of mothers with GDM were compared with 50 controls with no difference in gestation (38.9 ± 0.8 weeks vs 39.3 ± 0.9 weeks; P = .05) or birthweight (3.55 ± 0.49 kg vs 3.56 ± 0.41 kg; P = .95). At 1 year of age, the pulmonary artery acceleration time was lower (70 ± 11 vs 79 ± 10; P = .01) in the GDM group. LV global longitudinal strain (24.7 ± 1.9 vs 28.8 ± 1.8 %; P < .01), LV systolic strain rate (1.8 ± 0.2 vs 2.1 ± 0.3 1/s; P < .01), and RV free wall strain (31.1 ± 4.8 vs 34.6 ± 3.9 %; P < .01) were lower in the GDM cohort at 1 year of age (all P values adjusted for gestation, mode of delivery, and maternal body mass index). CONCLUSIONS Our findings demonstrate higher indices of PVR and lower biventricular function in infants of mothers with GDM compared with controls at each time point assessed in this study over the first year of life.
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Affiliation(s)
- Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.
| | - Orla Franklin
- Department of Pediatric Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Naomi McCallion
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; Department of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fionnuala Breathnach
- Department of Obstetrics & Gynaecology, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; Department of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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18
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El-Saie A, Varghese NP, Webb MK, Villafranco N, Gandhi B, Guaman MC, Shivanna B. Bronchopulmonary dysplasia - associated pulmonary hypertension: An updated review. Semin Perinatol 2023; 47:151817. [PMID: 37783579 PMCID: PMC10843293 DOI: 10.1016/j.semperi.2023.151817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is the leading cause of chronic lung disease in infants and the commonest complication of prematurity. Advances in respiratory and overall neonatal care have increased the survival of extremely low gestational age newborns, leading to the continued high incidence of BPD. Pulmonary hypertension (PH) represents the severe form of the pulmonary vascular disease associated with BPD, and affects almost one-third of infants with moderate to severe BPD. PH responds suboptimally to pulmonary vasodilators and increases morbidity and mortality in BPD infants. An up-to-date knowledge of the pathogenesis, pathophysiology, diagnosis, treatment, and outcomes of BPD-PH can be helpful to develop meaningful and novel strategies to improve the outcomes of infants with this disorder. Therefore, our multidisciplinary team has attempted to thoroughly review and summarize the latest advances in BPD-PH in preventing and managing this morbid lung disorder of preterm infants.
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Affiliation(s)
- Ahmed El-Saie
- Section of Neonatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Nidhy P Varghese
- Division of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Melissa K Webb
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Natalie Villafranco
- Division of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Bheru Gandhi
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Milenka Cuevas Guaman
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Binoy Shivanna
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
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19
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Avitabile CM, Flohr S, Mathew L, Wang Y, Ash D, Frank DB, Tingo JE, Rintoul NE, Hedrick HL. Quantitative Measures of Right Ventricular Size and Function by Echocardiogram Correlate with Cardiac Catheterization Hemodynamics in Congenital Diaphragmatic Hernia. J Pediatr 2023; 261:113564. [PMID: 37329980 PMCID: PMC11164033 DOI: 10.1016/j.jpeds.2023.113564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE To evaluate associations between cardiac catheterization (cath) hemodynamics, quantitative measures of right ventricular (RV) function by echocardiogram, and survival in patients with congenital diaphragmatic hernia (CDH). STUDY DESIGN This single-center retrospective cohort study enrolled patients with CDH who underwent index cath from 2003 to 2022. Tricuspid annular plane systolic excursion z score, RV fractional area change, RV free wall and global longitudinal strain, left ventricular (LV) eccentricity index, RV/LV ratio, and pulmonary artery acceleration time were measured from preprocedure echocardiograms. Associations between hemodynamic values, echocardiographic measures, and survival were evaluated by Spearman correlation and Wilcoxon rank sum test, respectively. RESULTS Fifty-three patients (68% left-sided, 74% liver herniation, 57% extracorporeal membrane oxygenation, 93% survival) underwent cath (39 during index hospitalization, 14 later) including device closure of a patent ductus arteriosus in 5. Most patients (n = 31, 58%) were on pulmonary hypertension treatment at cath, most commonly sildenafil (n = 24, 45%) and/or intravenous treprostinil (n = 16, 30%). Overall, hemodynamics were consistent with precapillary pulmonary hypertension. Pulmonary capillary wedge pressure was >15 mm Hg in 2 patients (4%). Lower fractional area change and worse ventricular strain were associated with higher pulmonary artery pressure while higher LV eccentricity index and higher RV/LV ratio were associated with both higher pulmonary artery pressure and higher pulmonary vascular resistance. Hemodynamics did not differ based on survival status. CONCLUSIONS Worse RV dilation and dysfunction by echocardiogram correlate with higher pulmonary artery pressure and pulmonary vascular resistance on cath in this CDH cohort. These measures may represent novel, noninvasive clinical trial targets in this population.
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Affiliation(s)
- Catherine M Avitabile
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Sabrina Flohr
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Leny Mathew
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yan Wang
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Devon Ash
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David B Frank
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer E Tingo
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Natalie E Rintoul
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Holly L Hedrick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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20
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Zhu F, Ibarra Rios D, Joye S, Baczynski M, Rios D, Giesinger RE, McNamara PJ, Jain A. Cardiopulmonary physiological effects of diuretic therapy in preterm infants with chronic pulmonary hypertension. J Perinatol 2023; 43:1288-1294. [PMID: 37550529 DOI: 10.1038/s41372-023-01742-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE Using targeted neonatal echocardiography (TNE) to examine cardiopulmonary physiological impact of diuretics in preterm infants with chronic pulmonary hypertension (cPH). STUDY DESIGN Retrospective study comparing TNE indices pre- and ≤2 weeks (post) of initiating diuretic therapy in infants born <32 weeks gestational age with cPH. RESULTS Twenty-seven neonates with mean gestational age, birthweight and interval between pre-post diuretic TNE of 27.0 ± 2.8 weeks, 859 ± 294 grams, and 7.8 ± 3.0 days respectively were studied. Diuretics was associated with improvement in pulmonary vascular resistance [pulmonary artery acceleration time (PAAT); 34.27(9.76) vs. 40.24(11.10)ms, p = 0.01), right ventricular (RV) ejection time:PAAT ratio [5.92(1.66) vs. 4.83(1.14), p < 0.01)], RV fractional area change [41.6(9.8) vs. 46.4(6.5%), p = 0.03)] and left ventricular myocardial performance index [0.55(0.09) vs. 0.41(0.23), p < 0.01)]. Post-treatment, frequency of bidirectional/right-to-left inter-atrial shunts decreased significantly (24% vs. 4%, p = 0.05). CONCLUSION Primary diuretic treatment in neonates with cPH may result in improvement in PVR, RV and LV function and compliance.
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Affiliation(s)
- Faith Zhu
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Daniel Ibarra Rios
- Neonatology Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | | | | | - Danielle Rios
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | | | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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21
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Wu Q, Zou S, Liu W, Liang M, Chen Y, Chang J, Liu Y, Yu X. A novel onco-cardiological mouse model of lung cancer-induced cardiac dysfunction and its application in identifying potential roles of tRNA-derived small RNAs. Biomed Pharmacother 2023; 165:115117. [PMID: 37406509 DOI: 10.1016/j.biopha.2023.115117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/28/2023] [Accepted: 07/01/2023] [Indexed: 07/07/2023] Open
Abstract
An increasing body of research suggests cancer-induced cardiovascular diseases, leading to the appearance of an interdisciplinary study known as onco-cardiology. Lung cancer has the highest incidence and mortality. Cardiac dysfunction constitutes a major cause of death in lung cancer patients. However, its mechanism has not been elucidated because suitable animal models that adequately mimic clinical features are lacking. Here, we established a novel chemically induced lung cancer mouse model using benzo[a]pyrene and urethane to recapitulate the general characteristics of cardiac dysfunction caused by lung cancer, the cardiac disorders in the context of the progression of lung cancer were evaluated using echocardiographic and histological approaches. The pathological changes included myocardial ischaemia, pericarditis, cardiac pre-cachexia, and pulmonary artery hypertension. We performed sequencing to detect the tRNA-derived fragments and tRNA-derived stress-induced RNAs (tRFs/tiRNAs) expressions in mouse heart tissue. 22 upregulated and 16 downregulated tRFs/tiRNAs were identified. Subsequently, the top 10 significant results of Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were presented. The in vitro model was established by exposing neonatal rat cardiomyocytes and myocardial fibroblasts to lung tumour cell-conditioned medium, respectively. Western blotting revealed significant changes in cardiac failure markers (atrial natriuretic peptide and α-myosin heavy chain) and cardiac fibrosis markers (Collagen-1 and Collagen-3). Our model adequately reflects the pathological features of lung cancer-induced cardiac dysfunction. Furthermore, the altered tRF/tiRNA profiles showed great promise as novel targets for therapies. These results might pave the way for research on therapeutic targets in onco-cardiology.
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Affiliation(s)
- Qian Wu
- Department of Pharmacology, the Municipal & Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, National Medical Products Administration & State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences & The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, PR China
| | - Shiting Zou
- Department of Pharmacology, the Municipal & Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, National Medical Products Administration & State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences & The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, PR China
| | - Wanjie Liu
- Department of Pharmacology, the Municipal & Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, National Medical Products Administration & State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences & The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, PR China
| | - Miao Liang
- Department of Pharmacology, the Municipal & Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, National Medical Products Administration & State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences & The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, PR China
| | - Yuling Chen
- Department of Pharmacology, the Municipal & Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, National Medical Products Administration & State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences & The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, PR China
| | - Jishuo Chang
- Department of Pharmacology, the Municipal & Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, National Medical Products Administration & State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences & The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, PR China
| | - Yinghua Liu
- Department of Pharmacology, the Municipal & Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, National Medical Products Administration & State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences & The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, PR China.
| | - Xiyong Yu
- Department of Pharmacology, the Municipal & Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, National Medical Products Administration & State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences & The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou 511436, PR China.
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22
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Gavotto A, Amedro P, Cambonie G. Think out of the box: association of left congenital diaphragmatic hernia and abnormal origin of the right pulmonary artery : A train can hide another. BMC Pediatr 2023; 23:349. [PMID: 37434143 DOI: 10.1186/s12887-023-04164-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND We report the occurrence of a severe pulmonary hypertension (PH) in a neonate affected by a left congenital diaphragmatic hernia (CDH). PH in this patient was associated with an abnormal origin of the right pulmonary artery from the right brachiocephalic artery. This malformation, sometimes named hemitruncus arteriosus, has to the best of our knowledge never been reported in association with a CDH. CASE PRESENTATION A male newborn was hospitalized from birth in the neonatal intensive care unit after prenatal diagnosis of a left CDH. Ultrasound examination at 34 weeks of gestational age evaluated the observed-to-expected lung-to-head ratio at 49%. Birth occurred at 38+ 5 weeks of gestational age. Soon after admission, severe hypoxemia, i.e., preductal pulse oximetry oxygen saturation (SpO2) < 80%, prompted therapeutic escalation including the use of high frequency oscillatory ventilation with fraction of inspired oxygen (FiO2) 100% and inhaled nitric oxide (iNO). Echocardiography assessment revealed signs of severe PH and normal right ventricle function. Despite administration of epoprostenolol, milrinone, norepinephrine, and fluid loadings with albumin and 0.9% saline, hypoxemia remained severe, preductal SpO2 inconsistently greater than or equal to 80-85% and post ductal SpO2 lower on average by 15 points. This clinical status remained unchanged during the first 7 days of life. The infant's clinical instability was incompatible with surgical intervention, while chest X-ray showed a relatively preserved lung volume, especially on the right side. This prompted an additional echocardiography, aimed at searching an explanation of this unusual evolution and found an abnormal origin of the right pulmonary artery, which was confirmed on computed tomography angiography subsequently. A change in the medical strategy was decided, with the suspension of pulmonary vasodilator treatments, the administration of diuretics, and the decrease in norepinephrine dose to decrease the systemic-to-pulmonary shunt. Progressive improvement in the infant respiratory and hemodynamic status enabled to perform CDH surgical repair 2 weeks after birth. CONCLUSIONS This case recalls the interest of systematic analysis of all potential causes of PH in a neonate with CDH, a condition frequently associated with various congenital malformations.
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Affiliation(s)
- Arthur Gavotto
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, 371 Avenue du Doyen Giraud, 34295, Montpellier, France.
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France.
| | - Pascal Amedro
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France
- IHU Liryc, INSERM 1045, Bordeaux University, Bordeaux, France
| | - Gilles Cambonie
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, 371 Avenue du Doyen Giraud, 34295, Montpellier, France
- Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France
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23
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Smith A, Franklin O, Mocanu E, McCallion N, El-Khuffash A. Assessment of myocardial function in infants conceived by assisted reproductive technologies using deformation imaging over the first year of age: A cohort study. Echocardiography 2023. [PMID: 37129268 DOI: 10.1111/echo.15585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 03/28/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND AND AIM There is emerging evidence of cardiovascular remodeling and functional impairment in individuals conceived via Assisted Reproductive Technologies (ART). The aim of this study was to serially assess myocardial function and pulmonary hemodynamic measurements in infants conceived via ART over the first year of age and to compare them to a cohort of spontaneously conceived controls. METHODS This was a prospective, observational study. Echocardiography was performed at Day 2, 6 months and 1 year of age. Biventricular function was assessed by deformation analysis. Pulmonary artery acceleration time (PAAT) and left ventricular (LV) eccentricity index (LVEI) provided surrogate measures of pulmonary vascular resistance (PVR). RESULTS Fifty infants conceived via ART were compared to 50 spontaneously conceived controls. There were no differences in baseline infant demographics between the two groups. At 1 year of age right ventricular (RV) basal and RV mid cavity diameters were higher in the ART group. PAATi was lower and LVEI higher in the ART group at 6 months and 1 year. In the ART group, LV global longitudinal strain, LV systolic strain rate, LV early diastolic strain rate and RV free wall strain were lower on Day 2, 6 months, and 1 year of age in comparison to the control group (all p < .05). Within the ART group, on linear regression, maternal age, the type of ART treatment or egg characteristics did not influence PAAT or deformation measurements. CONCLUSION Our findings suggest that greater cardiovascular surveillance of ART conceived infants may be warranted.
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Affiliation(s)
- Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Edgar Mocanu
- Department of Obstetrics, School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Naomi McCallion
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- Department of Paediatrics, School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- Department of Paediatrics, School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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24
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Fike CD, Aschner JL. Pharmacotherapy for Pulmonary Hypertension in Infants with Bronchopulmonary Dysplasia: Past, Present, and Future. Pharmaceuticals (Basel) 2023; 16:503. [PMID: 37111262 PMCID: PMC10141152 DOI: 10.3390/ph16040503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023] Open
Abstract
Approximately 8-42% of premature infants with chronic lung disease of prematurity, bronchopulmonary dysplasia (BPD), develop pulmonary hypertension (PH). Infants with BPD-PH carry alarmingly high mortality rates of up to 47%. Effective PH-targeted pharmacotherapies are desperately needed for these infants. Although many PH-targeted pharmacotherapies are commonly used to treat BPD-PH, all current use is off-label. Moreover, all current recommendations for the use of any PH-targeted therapy in infants with BPD-PH are based on expert opinion and consensus statements. Randomized Control Trials (RCTs) are needed to determine the efficacy of PH-targeted treatments in premature infants with or at risk of BPD-PH. Prior to performing efficacy RCTs, studies need to be conducted to obtain pharmacokinetic, pharmacodynamic, and safety data for any pharmacotherapy used in this understudied and fragile patient population. This review will discuss current and needed treatment strategies, identify knowledge deficits, and delineate both challenges to be overcome and approaches to be taken to develop effective PH-targeted pharmacotherapies that will improve outcomes for premature infants with or at risk of developing BPD-PH.
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Affiliation(s)
- Candice D. Fike
- Department of Pediatrics, University of Utah Health, Salt Lake City, UT 84108, USA
| | - Judy L. Aschner
- Department of Pediatrics, Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center, Hackensack, NJ 07601, USA
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
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25
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Saha AK, Ghosh M, Sardar S, Pal S. Assessment of myocardial function in late preterm and term infants with transient tachypnea of the newborn using tissue Doppler imaging - a pilot observational study. Eur J Pediatr 2023:10.1007/s00431-023-04941-1. [PMID: 36959315 DOI: 10.1007/s00431-023-04941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/08/2023] [Accepted: 03/19/2023] [Indexed: 03/25/2023]
Abstract
The aim of this study was to compare conventional and tissue Doppler echocardiography parameters between transient tachypnea of the newborn (TTN) and healthy control infants. This cross sectional pilot observational study was conducted in a level 3 neonatal care unit of India. Consecutively born late preterm and term infants (LPTI) with TTN were eligible for enrollment. Control group was selected from healthy LPTI. Conventional and tissue Doppler (myocardial velocities, myocardial performance index (MPI)) echocardiography was done within first 12 h (D1) and 48-72 h (D3) of life. Conventional echocardiography parameters were fractional shortening (FS), ejection fraction (EF), ventricular output, E/A ratio, fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), pulmonary artery systolic pressure (PASP), and pulmonary artery acceleration to ejection time ratio (PATET). Baseline characteristics and echocardiography images were compared between TTN and control groups. Out of 60 infants enrolled, 34 from TTN and 20 from control group were finally analyzed. Mean (SD) gestational age and birth weight of the study population was 366/7(1.8) weeks and 2398(376) g respectively. Left ventricular (LV) parameters were similar between both groups. On D1, right ventricular (RV)e' was smaller (6.42(1) cm/s vs. 7.68(1.68) cm/s, p 0.022), and E/e' (7.79(1.51) vs. 6.08(2.59), p 0.037) was larger in TTN group, indicating RV diastolic dysfunction. RV MPI (0.61(0.11) vs. 0.44(0.12), p < 0.001) was also larger, signifying RV global myocardial dysfunction. Similar findings were observed on D3. PATET was lower in TTN group on both D1 (0.34 (0.05) vs. 0.42 (0.05), p < 0.001) and D3 (0.38 (0.05) vs. 0.43 (0.02), p 0.004) suggesting persistently raised pulmonary arterial pressure, although only 2 infants developed pulmonary hypertension identified by standard echocardiography. Conclusion: Myocardial tissue Doppler imaging of TTN infants revealed occult right ventricular diastolic dysfunction secondary to persistently raised pulmonary arterial pressure. What is Known: •Transient tachypnea of the newborn may be associated with pulmonary arterial hypertension. What is New: •Tissue Doppler imaging in infants with transient tachypnea of the newborn revealed occult right ventricular diastolic dysfunction secondary to raised pulmonary arterial pressure, not detected by standard echocardiography.
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Affiliation(s)
- Anindya Kumar Saha
- Department of Neonatology, IPGME&R, 244 AJC Bose Road, Kolkata-700020, India
| | - Moumita Ghosh
- Department of Pediatrics, Medical College & Hospital, Kolkata, India
| | - Syamal Sardar
- Department of Neonatology, IPGME&R, 244 AJC Bose Road, Kolkata-700020, India
| | - Somnath Pal
- Department of Neonatology, IPGME&R, 244 AJC Bose Road, Kolkata-700020, India.
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26
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Wang L, Liu Z, Zhang F, Xu H, Wang H, Zhao X. The value of pulmonary artery acceleration time in evaluating pulmonary vascular disease in preterm infants with bronchopulmonary dysplasia. Echocardiography 2023; 40:180-187. [PMID: 36691732 DOI: 10.1111/echo.15513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/15/2022] [Accepted: 11/30/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Early screening and dynamic monitoring of pulmonary vascular disease (PVD) in bronchopulmonary dysplasia (BPD) high-risk infants is of great clinical significance. Pulmonary artery acceleration time (PAAT) is a reliable and non-invasive method for assessing PVD in children over 1 year, but to date, few studies have used PAAT to assess pulmonary hemodynamics of preterm infants, especially those with BPD. Through dynamic monitoring the main hemodynamic indicators reflected PVD after birth, this study aimed to assess the value of PAAT in evaluating early PVD in BPD infants. METHODS All 81 preterm infants at risk of BPD were divided into BPD and non-BPD groups according to whether BPD occurred. Clinical characteristics, PAAT, right ventricular ejection time (RVET) and other main hemodynamic indicators at four different time points after birth were studied and compared. RESULTS PAAT and PAAT/RVET increased gradually within 72 h after birth in the BPD group (p < .05), but the curve tended to be flat over time after 72 h (p > .05). At PMA32 and 36 weeks, the PAAT (49.7 ± 4.8 vs. 54.8 ± 5.7, p = .001; 50.0 ± 5.3 vs. 57.0 ± 5.3, p = .001) and PAAT/RVET (.33 ± .04 vs. .35 ± .03, p = .001; .34 ± .03 vs. .37 ± .04, p = .001) in BPD group were significantly lower than those in the non-BPD group. CONCLUSIONS PAAT and PAAT/RVET in the BPD group infants showed different change patterns compared to non-BPD group infants. PAAT can be used as a noninvasive and reliable screening method for screening and dynamic monitoring of PVD in BPD high-risk infants.
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Affiliation(s)
- Liling Wang
- Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Zhijie Liu
- Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Fengjuan Zhang
- Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Haiyan Xu
- Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Haiyan Wang
- Department of Medical Ultrasound, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Xueqiang Zhao
- Department of Cardiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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27
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Cardiopulmonary Ultrasound Patterns of Transient Acute Respiratory Distress of the Newborn: A Retrospective Pilot Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020289. [PMID: 36832418 PMCID: PMC9955778 DOI: 10.3390/children10020289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/20/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023]
Abstract
Acute transient respiratory distress in the first hours of life is usually defined as transient tachypnea of the newborn (TTN). TTN is a respiratory self-limiting disorder consequent to delayed lung fluid clearance at birth. While TTN is the most common etiology of respiratory distress near term, its pathogenesis and diagnostic criteria are not well-defined. Lung ultrasound and targeted neonatal echocardiography are increasingly being used to assess critically ill infants, although their combined use to improve diagnostic precision in neonatal intensive care units has not yet been described. This retrospective pilot analysis aimed to identify possible cardiopulmonary ultrasound (CPUS) patterns in term and late preterm infants suffering from transient respiratory distress and requiring non-invasive respiratory support. After retrospectively revising CPUS images, we found seven potential sonographic phenotypes of acute neonatal respiratory distress. Up to 50% of the patients presented with signs of increased pulmonary vascular resistance, suggesting that those patients may be diagnosed with mild forms of persistent pulmonary hypertension of the newborn. Approximately 80% of the infants with a history of meconium-stained amniotic fluid displayed irregular atelectasis, indicating that they may have suffered from mild meconium aspiration syndrome. CPUS evaluation may improve accuracy in the approach to the infants presenting with transient acute respiratory distress, supporting communication with the parents and carrying important epidemiological consequences.
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28
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El-Khuffash A, McNamara PJ, Breatnach C, Bussmann N, Smith A, Feeney O, Tully E, Griffin J, de Boode WP, Cleary B, Franklin O, Dempsey E. The use of milrinone in neonates with persistent pulmonary hypertension of the newborn - a randomised controlled trial pilot study (MINT 1). J Perinatol 2023; 43:168-173. [PMID: 36385642 PMCID: PMC9666925 DOI: 10.1038/s41372-022-01562-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the impact of milrinone administration on time spent on nitric oxide (iNO) in infants with acute pulmonary hypertension (aPH). We hypothesized that intravenous milrinone used in conjunction with iNO would reduce the time on iNO therapy and the time spent on invasive ventilation in infants ≥34 weeks gestation with a diagnosis of aPH. We aimed to assess the practicality of instituting the protocol and contributing to a sample size calculation for a definitive multicentre study. STUDY DESIGN This was a multicentre, randomized, double-blind, two arm pilot study, with a balanced (1:1) allocation. Infants with a gestation ≥34 weeks and a birth weight ≥2000 grams aPH, an oxygenation index of ≥10, and commenced on iNO were eligible. Participants on iNO were assigned to either a milrinone infusion (intervention) or a normal saline infusion (placebo) for up to 35 h. The primary outcome was time on iNO and feasibility of conducting the protocol. RESULTS The trial was terminated early after 4 years of enrollment due to poor recruitment. Four infants were allocated to the intervention arm and 5 to the placebo arm. The groups were well matched for baseline variables. No differences were seen in any of the primary or secondary outcomes. CONCLUSION Conducting an interventional trial in the setting of acute pulmonary hypertension in infants is not feasible using our current approach. Future studies in this area require alternative trial design to improve recruitment as this topic remains understudied in the neonatal field. TRIAL REGISTRATION www.isrctn.com ; ISRCTN:12949496; EudraCT Number:2014-002988-16.
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Affiliation(s)
- Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Patrick J McNamara
- Division of Neonatology, Stead Family Department of Pediatrics, Iowa City, IA, USA
| | - Colm Breatnach
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Oliver Feeney
- Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Elizabeth Tully
- Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Joanna Griffin
- Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Brian Cleary
- Department of Pharmacy, The Rotunda Hospital, Dublin, Ireland
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Eugene Dempsey
- INFANT Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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29
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Labuz DF, Whitlock AE, Kycia I, Zurakowski D, Fauza DO. Early functional analysis on the pulmonary hemodynamic effects of Transamniotic Stem Cell Therapy (TRASCET) in the nitrofen model of congenital diaphragmatic hernia. J Pediatr Surg 2023; 58:8-13. [PMID: 36280468 DOI: 10.1016/j.jpedsurg.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/16/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE Transamniotic stem cell therapy (TRASCET) with mesenchymal stem cells (MSCs) has been shown to impact pulmonary vascular development and remodeling in experimental congenital diaphragmatic hernia (CDH), with secondary structural cardiac effects. We sought to determine whether TRASCET has any functional impact on term fetal pulmonary hemodynamics in the nitrofen model. METHODS Time-dated pregnant rat dams (n = 13) received nitrofen on gestational day 9 (E9) to induce fetal CDH. Fetuses (n = 155) were divided into three groups: untreated (n = 45), and two groups receiving volume-matched intra-amniotic injections on E17 of either saline (sham; n = 46), or a suspension of amniotic fluid-derived MSCs (afMSCs) (TRASCET; n = 64). Donor afMSCs were syngeneic, phenotyped by flow cytometry, and "primed" by exposure to interferon-gamma and interleukin-1beta prior to administration in vivo. At term (E21), fetuses underwent Doppler flow assessment at the mid-pulmonary artery and 4-chamber echocardiogram. Pulmonary vascular resistance was estimated by pulmonary artery acceleration time (PAAT), max velocity (MaxV) and velocity time integral (VTI). Cardiac function was assessed by global longitudinal strain (GLS) and ejection fraction (EF) using speckle analyses. Healthy fetuses (n = 11) served as additional controls. Statistical analysis was by the Mann-Whitney U test RESULTS: High resolution ultrasound data could be obtained from 8 to 13 fetuses per group. The PAAT and the PAAT normalized to cardiac cycle time were significantly improved by TRASCET compared to both untreated and sham-treated CDH (p = 0.004 to <0.001 in all pairwise comparisons). The flow profile sharpness (MaxV:VTI) was increased in untreated (p = 0.06) and sham (p = 0.01) groups but normalized by TRASCET (p<0.01). There was no difference in GLS between TRASCET and either the untreated or sham groups (p = 0.25 to p = 0.93). CONCLUSION Transamniotic stem cell therapy improves pulmonary vascular resistance in early term fetuses in the Nitrofen model of congenital diaphragmatic hernia. Further focus on the functional pulmonary hemodynamic impact of this therapy is justified. LEVEL OF EVIDENCE N/A (animal and laboratory study).
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Affiliation(s)
- Daniel F Labuz
- Department of Surgery, Boston Children's Hospital/ Harvard Medical School, Boston, MA, United States
| | - Ashlyn E Whitlock
- Department of Surgery, Boston Children's Hospital/ Harvard Medical School, Boston, MA, United States
| | - Ina Kycia
- Department of Surgery, Boston Children's Hospital/ Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital/ Harvard Medical School, Boston, MA, United States
| | - Dario O Fauza
- Department of Surgery, Boston Children's Hospital/ Harvard Medical School, Boston, MA, United States.
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Rossi ML, Escobar-Diaz MC, Hadley SM, Randanne PC, Sanchez-de-Toledo J, Jordan I. Echocardiographic Markers of Mild Pulmonary Hypertension are not Correlated with Worse Respiratory Outcomes in Infants with Bronchiolitis. Pediatr Cardiol 2023; 44:237-244. [PMID: 36401628 DOI: 10.1007/s00246-022-03043-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/01/2022] [Indexed: 11/21/2022]
Abstract
Pulmonary hypertension has been reported as a crucial factor in the pathophysiology of severe bronchiolitis. The aim of this study was to evaluate pulmonary artery pressure (PAP) in patients with bronchiolitis and to analyze their correlation with clinical outcomes. This prospective cohort study examined children admitted for bronchiolitis. PAP was assessed by right ventricle (RV) acceleration/ejection time ratio (AT/ET), isovolumic relaxation time, eccentricity index, and the presence of a pulmonary systolic notch. Pulmonary hypertension (PH) was considered if at least two altered parameters were present. Severity of clinical course was established by higher N-terminal (NT)-prohormone BNP (NT-proBNP) values, the need for positive pressure respiratory support (PPRS), and the duration of hospital admission. One hundred sixty-nine children were included in analysis. Sixty-eight patients (40%) required PPRS, and those patients had increased NT-proBNP values and worse tricuspid annular systolic excursion (TAPSE) compared to mild cases (p < 0.001and p < 0.001, respectively). Twenty-two (13%) cases had at least two altered parameters of PAP and met criteria for presumed PH, with no differences in NT-proBNP values, TAPSE, need for PPRS or hospital length of stay compared to normal PAP group (p = 0.98, p = 0.07, p = 0.94 and p = 0.64, respectively). We found no correlation between altered RV AT/ET and worse cardiac function, NT-proBNP values or hospital length of stay. In our cohort, the presence of echocardiographic findings of PH were not associated with worse clinical outcomes. Patients with severe bronchiolitis had higher values of NT-proBNP but, interestingly, no clear association with PH.
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Affiliation(s)
- Maria Lucia Rossi
- Department of Pediatric Cardiology, Sant Joan de Deu Hospital, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain. .,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain.
| | - Maria Clara Escobar-Diaz
- Department of Pediatric Cardiology, Sant Joan de Deu Hospital, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain.,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain
| | | | - Paula Cecilia Randanne
- Department of Pediatric Cardiology, Sant Joan de Deu Hospital, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
| | - Joan Sanchez-de-Toledo
- Department of Pediatric Cardiology, Sant Joan de Deu Hospital, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain.,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Iolanda Jordan
- Pediatric Intensive Care Unit. Hospital Sant Joan de Déu, Barcelona, Spain.,Institut de Recerca Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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31
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Sánchez-Becerra JC, Guillén-Torres R, Becerra-Becerra R, Márquez-González H, Ibarra-Ríos D. Targeted neonatal echocardiography and lung ultrasound in preterm infants with chronic lung disease with and without pulmonary hypertension, screened using a standardized algorithm. Front Pediatr 2023; 11:1104940. [PMID: 37033165 PMCID: PMC10076703 DOI: 10.3389/fped.2023.1104940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction Increased recognition of the development of chronic pulmonary hypertension (cPH) in preterm infants with chronic lung disease (CLD) has prompted enhanced monitoring for the identification of different phenotypes. Methods All newborns consulted for oxygen/respiratory support dependency (CLD assessment) from January 2018 to December 2021 were included. TnECHO and LUS screening for cPH-CLD were performed at 36 weeks postmenstrual age. Cases of cPH related to increased pulmonary blood flow (cPH-IPBF) were referred to Pediatric Cardiology. The objective of the study was to identify all cases of cPH (cPH-CLD/IPBF) in the CLD patients screened and to compare outcomes. Following a standardized algorithm, cPH-CLD patients were treated with diuretics; ultrasounds taken before and after treatment were analyzed. Results Seventy-two patients with CLD were screened. Twenty-two (30%) had cPH-CLD, and nine (12%) had cPH-IPBF. cPH infants underwent more days of mechanical ventilation, were more likely to have retinopathy of prematurity, and showed increased mortality. The LUS pattern observed in the 72 CLD patients consisted of a thickened pleural line and a B-line interstitial heterogeneous pattern; 29% of patients were found to have lung consolidations. After diuretic therapy, step-down in respiratory support occurred in 59% of neonates with cPH-CLD. A decrease in respiratory rate (RR), right ventricular output (RVO), markers of pulmonary vascular resistance (PVR), and B-line pattern was observed. In tissue Doppler imaging, biventricular diastolic function was found to be modified after diuretics. Conclusions CLD infants with cPH showed increased morbidity and mortality. In cPH-CLD patients, a decrease in RR and step-down in respiratory support was observed after diuretic treatment. Follow-up ultrasound showed a decrease in RVO, markers of PVR, and B-lines.
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Affiliation(s)
| | - Rogelio Guillén-Torres
- Neonatology Department, National Institute of Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Rosario Becerra-Becerra
- Cardiology Department, National Institute of Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Horacio Márquez-González
- Clinical Investigation Department, National Institute of Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Daniel Ibarra-Ríos
- Neonatology Department, National Institute of Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
- Correspondence: Daniel Ibarra-Ríos
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32
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Rossi ML, Hadley SM, Randanne PC, Escobar-Diaz MC, Camprubi MC, Jordan I, Sanchez-de-Toledo J. Cardiac function in bronchiolitis: Not only a right ventricle matter. Pediatr Pulmonol 2023; 58:288-296. [PMID: 36226478 DOI: 10.1002/ppul.26199] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/24/2022] [Accepted: 10/06/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Extrapulmonary manifestations of bronchiolitis have been previously studied, with some identifying right ventricle (RV) diastolic/systolic dysfunction. We hypothesized that severe cases of bronchiolitis would have cardiac dysfunction resulting an increase in N-terminal pro-hormone B-type natriuretic peptide (NT-proBNP) values and worse outcomes. Therefore, the objective was to evaluate the existence of cardiac dysfunction and to determine its association with severe bronchiolitis. METHODS This prospective cohort study included children hospitalized for bronchiolitis under 1-year old between January 2019 and March 2020. At admission, an echocardiography was performed and plasma levels of NT-proBNP were measured. To analyze outcomes, the cohort was divided into two groups based on the need for positive pressure respiratory support (PPRS), and both were compared to healthy infants. STATISTICS bivariant analysis, significant differences p < 0.05. RESULTS One hundred eighty-one patients were included; median age was 2 months. Seventy-three patients required PPRS. Compared to controls, patients requiring PPRS showed worse RV systolic function, with lower tricuspid annular-plane systolic excursion (p = 0.002) and parameters of worse right and left diastolic function (trans-tricuspid E and A wave [p = 0.004 and p = 0.04, respectively] and tricuspid tissue doppler imaging [TDI] e' [p = 0.003], trans-mitral E and mitral TDI a' [p = 0.02 and p = 0.005, respectively]). An NT-ProBNP greater than 3582 pg/dl predicts the need for longer necessity of PPRS in patients younger than 2 months. CONCLUSIONS In addition to the expected RV systolic dysfunction, patients with severe bronchiolitis have parameters of global diastolic worse function possibly secondary to intrinsic myocardial involvement. NT-ProBNP values at admission had strong discriminatory power to predict worse outcomes.
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Affiliation(s)
- Maria L Rossi
- Department of Pediatric Cardiology, Hospital Sant Joan de Déu, Barcelona, Spain.,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain
| | - Stephanie M Hadley
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Paula C Randanne
- Department of Pediatric Cardiology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Maria C Escobar-Diaz
- Department of Pediatric Cardiology, Hospital Sant Joan de Déu, Barcelona, Spain.,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain
| | - Marta C Camprubi
- Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain.,BCNatal - Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Sant Joan de Déu - Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Barcelona, Spain.,Institut de Recerca Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
| | - Joan Sanchez-de-Toledo
- Department of Pediatric Cardiology, Hospital Sant Joan de Déu, Barcelona, Spain.,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Bartnik A, Pepke-Zaba J, Hoole SP, White P, Garbi M, Coghlan JG, Taghavi F, Tsui S, Weir-McCall J. Right ventricular-pulmonary artery coupling in chronic thromboembolic pulmonary hypertension. Heart 2022; 109:898-904. [PMID: 36549680 DOI: 10.1136/heartjnl-2022-321770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension occurs in a proportion of patients with prior acute pulmonary embolism and is characterised by breathlessness, persistently raised pulmonary pressures and right heart failure. Surgical pulmonary endarterectomy (PEA) offers significant prognostic and symptomatic benefits for patients with proximal disease distribution. For those with inoperable disease, management options include balloon pulmonary angioplasty (BPA) and medical therapy. Current clinical practice relies on the evaluation of pulmonary haemodynamics to assess disease severity, timing of and response to treatment. However, pulmonary haemodynamics correlate poorly with patient symptoms, which are influenced by right ventricular tolerance of the increased afterload. How best to manage symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension is not resolved.Right ventricular-pulmonary artery coupling (RV-PAC) describes the energy transfer within the whole cardiopulmonary unit. Thus, it can identify the earliest signs of decompensation even before pulmonary hypertension is overt. Invasive measurement of coupling using pressure volume loop technology is well established in research settings. The development of efficient and less invasive measurement methods has revived interest in coupling as a viable clinical tool. Significant improvement in RV-PAC has been demonstrated after both PEA and BPA. Further studies are required to understand its clinical utility and prognostic value, in particular, its potential to guide management in patients with CTEPD. Finally, given the reported differences in coupling between sexes in pulmonary arterial hypertension, further work is required to understand the applicability of proposed thresholds for decoupling in therapeutic decision making.
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Affiliation(s)
- Aleksandra Bartnik
- Radiology, Royal Papworth Hospital, Cambridge, UK .,University of Cambridge, Cambridge, UK.,Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Paul White
- Medical Physics and Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Medical Technology Research Centre, Anglia Ruskin University, Cambridge, UK
| | | | | | | | - Steven Tsui
- Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Jonathan Weir-McCall
- Radiology, Royal Papworth Hospital, Cambridge, UK.,University of Cambridge, Cambridge, UK
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Singh GK, McClenaghan C, Aggarwal M, Gu H, Remedi MS, Grange DK, Nichols CG. A Unique High-Output Cardiac Hypertrophy Phenotype Arising From Low Systemic Vascular Resistance in Cantu Syndrome. J Am Heart Assoc 2022; 11:e027363. [PMID: 36515236 PMCID: PMC9798820 DOI: 10.1161/jaha.122.027363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022]
Abstract
Background Cardiomegaly caused by left ventricular hypertrophy is a risk factor for development of congestive heart failure, classically associated with decreased systolic and/or diastolic ventricular function. Less attention has been given to the phenotype of left ventricular hypertrophy with enhanced ventricular function and increased cardiac output, which is potentially associated with high-output heart failure. Lack of recognition may pose diagnostic ambiguity and management complexities. Methods and Results We sought to systematically characterize high-output cardiac hypertrophy in subjects with Cantu syndrome (CS), caused by gain-of-function variants in ABCC9, which encodes cardiovascular KATP (ATP-sensitive potassium) channel subunits. We studied the cardiovascular phenotype longitudinally in 31 subjects with CS with confirmed ABCC9 variants (median [interquartile range] age 8 years [3-32 years], body mass index 19.9 [16.5-22.9], 16 male subjects). Subjects with CS presented with significant left ventricular hypertrophy (left ventricular mass index 86.7 [57.7-103.0] g/m2 in CS, n=30; 26.6 [24.1-32.8] g/m2 in controls, n=17; P<0.0001) and low blood pressure (systolic 94.5 [90-103] mm Hg in CS, n=17; 109 [98-115] mm Hg in controls, n=17; P=0.0301; diastolic 60 [56-66] mm Hg in CS, n=17; 69 [65-72] mm Hg in control, n=17; P=0.0063). Most (21/31) subjects with CS exhibited eccentric hypertrophy with normal left ventricular wall thickness. Congestive heart failure symptoms were evident in 4 of the 5 subjects with CS aged >40 years on long-term follow-up. Conclusions The data define the natural history of high-output cardiac hypertrophy resulting from decreased systemic vascular resistance in subjects with CS, a defining population for long-term consequences of high-output hypertrophy caused by low systemic vascular resistance, and the potential for progression to high-output heart failure.
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Affiliation(s)
- Gautam K. Singh
- Division of Cardiology, Department of PediatricsWashington University School of MedicineSt. LouisMO
- Center for the Investigation of Membrane Excitability Diseases (CIMED)Washington University School of MedicineSt. LouisMO
| | - Conor McClenaghan
- Center for the Investigation of Membrane Excitability Diseases (CIMED)Washington University School of MedicineSt. LouisMO
- Department of Cell Biology and PhysiologyWashington University School of MedicineSt. LouisMO
| | - Manish Aggarwal
- Division of Cardiology, Department of PediatricsWashington University School of MedicineSt. LouisMO
| | - Hongjie Gu
- Division of StatisticsWashington University School of MedicineSt. LouisMO
| | - Maria S. Remedi
- Center for the Investigation of Membrane Excitability Diseases (CIMED)Washington University School of MedicineSt. LouisMO
- Department of Medicine, Division of EndocrinologyWashington University School of MedicineSt. LouisMO
| | - Dorothy K. Grange
- Center for the Investigation of Membrane Excitability Diseases (CIMED)Washington University School of MedicineSt. LouisMO
- Department of Pediatrics, Division of GeneticsWashington University School of MedicineSt. LouisMO
| | - Colin G. Nichols
- Center for the Investigation of Membrane Excitability Diseases (CIMED)Washington University School of MedicineSt. LouisMO
- Department of Cell Biology and PhysiologyWashington University School of MedicineSt. LouisMO
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Zi-Yang Y, Hezhi L, Nanshan X, Yin Z, Dongling L, Hongwen F, Caojin Z. Model for screening adult congenital heart disease surgery eligibility with echocardiography parameters. J Heart Lung Transplant 2022; 41:1831-1838. [PMID: 36150995 DOI: 10.1016/j.healun.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/30/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES This study aimed to screen for the eligibility of correction in cases of adult congenital heart disease (CHD). Pulmonary to systemic flow ratios (Qp/Qs) > 1.5 and pulmonary to systemic vascular resistance ratios (Rp/Rs) < 1/3, acquired by right heart catheterization (RHC), are two essential parameters. Nonetheless, performing RHC at every follow-up is impractical and even harmful. Thus, it is important to establish a model to predict Qp/Qs and Rp/Rs status before a RHC confirmation, using echocardiography parameters. METHODS A total of 1,785 patients with adult CHD were enrolled and randomly assigned to the derivation or validation groups. Echocardiogram parameters of the 974 patients in the derivation group were considered candidate predictors for surgery eligibility (Qp/Qs > 1.5 and Rp/Rs < 1/3). Binary logistic regression analyses were performed to identify the independent predictors and establish a scoring system. The scoring system was further examined in the validation group using a receiver operating characteristic (ROC) analysis. RESULTS Estimated pulmonary artery systolic pressure, velocity through the pulmonary valve, and diameters of the left and right atria were identified as independent predictors. The area under the ROC curve of the predictive value in the validation group and its pre- and post-tricuspid valve malformation subgroups were 0.87 (95% confidence interval [CI]: 0.84-0.90, p < 0.01), 0.86 (95% CI: 0.82-0.91, p < 0.01), and 0.85 (95% CI: 0.79-0.90, p < 0.01), respectively. CONCLUSIONS This scoring system could augment flexibility and convenience for pre-screening CHD patients' eligibility for surgery, before RHC.
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Affiliation(s)
- Yang Zi-Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Southern Medical University, The Second School of Clinical Medicine, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Li Hezhi
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Xie Nanshan
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Southern Medical University, The Second School of Clinical Medicine, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Zhou Yin
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Luo Dongling
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Fei Hongwen
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Southern Medical University, The Second School of Clinical Medicine, Guangzhou, Guangdong, China.
| | - Zhang Caojin
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Southern Medical University, The Second School of Clinical Medicine, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China.
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36
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Woo JL, DiLorenzo MP, Rosenzweig E, Pasumarti N, Villeda GV, Berman-Rosenzweig E, Krishnan U. Correlation Between Right Ventricular Echocardiography Measurements and Functional Capacity in Patients With Pulmonary Arterial Hypertension. Tex Heart Inst J 2022; 49:488231. [PMID: 36350291 PMCID: PMC9809095 DOI: 10.14503/thij-21-7719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Accelerometry is an emerging option for real-time evaluation of functional capacity in patients with pulmonary arterial hypertension (PAH). This prospective pilot study assesses the relationship between functional capacity by accelerometry and right ventricular measurements on echocardiography for this high-risk cohort. METHODS Patients with PAH were prospectively enrolled and underwent 6-Minute Walk Test and cardiopulmonary exercise testing. They were given a Fitbit, which collected steps and sedentary time per day. Echocardiographic data included right ventricular global longitudinal, free wall, and septal strain; tricuspid regurgitant peak velocity; tricuspid annular plane systolic excursion; tricuspid annular plane systolic velocity; right ventricular myocardial performance index; and pulmonary artery acceleration time. Pairwise correlations were performed. RESULTS The final analysis included 22 patients aged 13 to 59 years. Tricuspid regurgitant peak velocity had a negative correlation with 6-Minute Walk Test (r = -0.58, P = .02), peak oxygen consumption on exercise testing (r = -0.56, P = .03), and average daily steps on accelerometry (r = -0.59, P = .03), but a positive correlation with median sedentary time on accelerometry (r = 0.64, P = .02). Pulmonary artery acceleration time positively correlated with peak oxygen consumption on exercise testing (r = 0.64, P = .002). There was no correlation between right ventricular strain measurements and functional capacity testing. CONCLUSION In this pilot study, tricuspid regurgitant jet and pulmonary artery acceleration time were the echocardiographic variables that correlated most with accelerometry data. With further echocardiographic validation, accelerometry can be a useful, noninvasive, and cost-effective tool to monitor disease progression in patients with PAH.
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Affiliation(s)
- Joyce L. Woo
- Department of Pediatrics, Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael P. DiLorenzo
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - Eliana Rosenzweig
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - Nikhil Pasumarti
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | | | - Erika Berman-Rosenzweig
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - Usha Krishnan
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
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Sehgal A, Nold MF, Roberts CT, Menahem S. Cardiorespiratory adaptation to low-dose dexamethasone for lung disease in extremely preterm infants: A prospective echocardiographic study. J Physiol 2022; 600:4361-4373. [PMID: 36068678 DOI: 10.1113/jp282973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/19/2022] [Indexed: 11/08/2022] Open
Abstract
The cardiovascular impact of dexamethasone (Dex) is not well understood. Most data are obtained from a 6 week, high-dose regimen, and are limited to findings of hypertension and cardiac hypertrophy. The present study ascertained the impact of low-dose Dex on cardiac indices when administered to extremely preterm infants for lung disease. A pre-post intervention prospective echocardiographic (Echo) study was undertaken, with cardiac assessments performed before and within 24 h after completion of first course of therapy (10 day regimen, cumulative 0.89 mg kg-1 ). Thirty infants with a gestational age of 24.6 ± 1.1 weeks and birthweight of 612 ± 125 g, respectively, were studied. The age at Dex administration was 20 ± 9 days. Fractional inspired oxygen decreased from 0.7 ± 0.23 to 0.35 ± 0.14 (P < 0.001). Patent ductus arteriosus was noted in 20 infants at Echo1. At Echo2, the ductal diameter decreased from 2.16 ± 0.8 to 1.1 ± 0.8 mm (P = 0.0003), with complete closure in 7/20 (35%). A reduction in left pulmonary artery end-diastolic velocity was noted (17 ± 12 to 9 ± 10 cm s-1 , P < 0.001). Pulmonary vascular resistance decreased (increased time to peak velocity/right ventricular ejection time, 0.2 ± 0.03 to 0.23 ± 0.03, P = 0.0001) and right ventricular systolic performance improved (tricuspid annular plane systolic excursion, 4.9 ± 0.8 to 5.5 ± 0.9 mm, P = 0.02). No significant changes in fractional shortening and left ventricular mass were noted. A significant increase in blood pressure was noted. As a percentage of pre-treatment baseline, the mean increase for systolic blood pressure was 20.3% (95% confidence interval = 14-26) on day 2 (P = 0.008). Low-dose Dex influenced cardiovascular parameters related to pulmonary circulation. KEY POINTS: Corticosteroid therapy is frequently used in preterm infants who are dependent on ventilator support. Echocardiographic studies in infants administered a 6 week course of steroids have noted left ventricular hypertrophy, outlet obstruction and hypertension, but no information is available on right heart indices. The cardiopulmonary effects of the current, significantly lesser cumulative dose (10 day regimen, commonly described as 'DART') have not been evaluated. The present study noted a significant influence on ductal and pulmonary circulation indices. Left heart architecture and function was maintained, whereas a significant but transient increase in blood pressure was noted.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Marcel F Nold
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Samuel Menahem
- Emeritus Head, Paediatric and Fetal Cardiac Units, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
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Trittmann JK, Almazroue H, Nelin LD, Shaffer TA, Celestine CR, Green HW, Malbrue RA. PATET ratio by Doppler echocardiography: noninvasive detection of pediatric pulmonary arterial hypertension. Pediatr Res 2022; 92:631-636. [PMID: 34795389 PMCID: PMC9114166 DOI: 10.1038/s41390-021-01840-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/09/2021] [Accepted: 10/28/2021] [Indexed: 11/12/2022]
Abstract
Pulmonary artery acceleration time (PAT) and PAT: ejection time (PATET) ratio are echocardiographic measurements of pulmonary arterial hypertension (PAH). These noninvasive quantitative measurements are ideal to follow longitudinally through the clinical course of PAH, especially as it relates to the need for and/or response to treatment. This review article focuses on the current literature of PATET measurement for infants and children as it relates to the shortening of the PATET ratio in PAH. At the same time, further development of PATET as an outcome measure for PAH in preclinical models, particularly mice, such that the field can move forward to human clinical studies that are both safe and effective. Here, we present what is known about PATET in infants and children and discuss what is known in preclinical models with particular emphasis on neonatal mouse models. In both animal models and human disease, PATET allows for longitudinal measurements in the same individual, leading to more precise determinations of disease/model progression and/or response to therapy. IMPACT: PATET ratio is a quantitative measurement by a noninvasive technique, Doppler echocardiography, providing clinicians a more precise/accurate, safe, and longitudinal assessment of pediatric PAH. We present a brief history/state of the art of PATET ratio to predict PAH in adults, children, infants, and fetuses, as well as in small animal models of PAH. In a preliminary study, PATET shortened by 18% during acute hypoxic exposure compared to pre-hypoxia. Studies are needed to establish PATET, especially in mouse models of disease, such as bronchopulmonary, as a routine measure of PAH.
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Affiliation(s)
- Jennifer K. Trittmann
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, The Ohio State University, College of Medicine, Columbus, OH,Jennifer K. Trittmann, MD, MPH, Center for Perinatal Research, Abigail Wexner Research Institute at, Nationwide Children’s Hospital and, The Ohio State University, College of Medicine, Columbus, OH, USA,
| | - Hanadi Almazroue
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Leif D. Nelin
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, The Ohio State University, College of Medicine, Columbus, OH
| | - Terri A. Shaffer
- Animal Resources Core, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Charanda R. Celestine
- Louisiana State University, School of Veterinary Medicine, Department of Veterinary Clinical Sciences, Baton Rouge, LA, USA
| | - Henry W. Green
- Louisiana State University, School of Veterinary Medicine, Department of Veterinary Clinical Sciences, Baton Rouge, LA, USA
| | - Raphael A. Malbrue
- Animal Resources Core, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,The Ohio State University, College of Veterinary Medicine, Columbus, OH
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Factors associated with discontinuation of pulmonary vasodilator therapy in children with bronchopulmonary dysplasia-associated pulmonary hypertension. J Perinatol 2022; 42:1246-1254. [PMID: 35676536 DOI: 10.1038/s41372-022-01421-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/25/2022] [Accepted: 05/24/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate factors associated with discontinuation of pulmonary vasodilator therapy in bronchopulmonary dysplasia-related pulmonary hypertension (BPD-PH). STUDY DESIGN Retrospective study of neonatal, echocardiographic, and cardiac catheterization data in 121 infants with BPD-PH discharged on pulmonary vasodilator therapy from 2009-2020 and followed into childhood. RESULT After median 4.4 years, medications were discontinued in 58%. Those in whom medications were discontinued had fewer days of invasive support, less severe BPD, lower incidence of PDA closure or cardiac catheterization, and higher incidence of fundoplication or tracheostomy decannulation (p < 0.05). On multivariable analysis, likelihood of medication discontinuation was lower with longer period of invasive respiratory support [HR 0.95 (CI:0.91-0.99), p = 0.01] and worse RV dilation on pre-discharge echocardiogram [HR 0.13 (CI:0.03-0.70), p = 0.017]. In those with tracheostomy, likelihood of medication discontinuation was higher with decannulation [HR 10.78 (CI:1.98-58.59), p < 0.001]. CONCLUSION In BPD-PH, childhood discontinuation of pulmonary vasodilator therapy is associated with markers of disease severity.
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Smith A, Bussmann N, Breatnach C, Levy P, Molloy E, Miletin J, Curley A, McCallion N, Franklin Mrcpch O, El-Khuffash A. Serial Assessment of Cardiac Function and Pulmonary Hemodynamics in Infants with Down Syndrome. J Am Soc Echocardiogr 2022; 35:1176-1183.e5. [PMID: 35868547 DOI: 10.1016/j.echo.2022.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND There is a dearth of longitudinal data describing the evolution of cardiopulmonary haemodynamics in infants with Down Syndrome (DS) beyond infancy. We hypothesized that babies with DS, independent of the presence of congenital heart disease (CHD), demonstrate biventricular systolic and diastolic impairment and sustained elevation of pulmonary pressures compared to controls over the first two years of age. METHODS This was a prospective observational cohort study of 70 infants with DS (48 with CHD and 22 without CHD) and 60 controls carried out in three tertiary neonatal intensive care units in Dublin, Ireland. Infants with DS with and without CHD and non-DS controls underwent serial echocardiograms at birth, 6 months, 1 year and 2 years of age to assess biventricular systolic and diastolic function using deformation analysis. Pulmonary vascular resistance (PVR) was assessed using pulmonary artery acceleration time (PAAT) and left ventricular (LV) eccentricity index. RESULTS Infants with DS exhibited smaller LV (Birth: 27±4 vs. 31±2 mm, p<0.01; 2 years: 43±5 vs. 48±4 mm, p<0.01) and RV (Birth: 28±3 vs. 31±2 mm, p<0.01; 2 years: 40±4 vs. 44±3 mm, p<0.01) lengths and lower LV (Birth: -19±3 vs. -22±2 %, p<0.01; 2 years: -24±2 vs. -26±2 %, p<0.01) and RV (Birth: -19±4 vs. -22±3 %, p<0.01; 2 years: -29±6 vs. -33±4 %, p<0.01) systolic strain over the two year period. PAAT was lower in the DS group throughout the study period (Birth: 44±10 vs. 62±14 ms, p<0.01; 2 years 71±12 vs. 83±11 ms, p<0.01). No differences were observed between DS infants with and without CHD (all p >0.05). CONCLUSIONS Infants with DS exhibit impaired maturational changes in myocardial function and PVR. Such novel findings provide valuable insights into the pathophysiology affecting cardiorespiratory morbidity in this population.
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Affiliation(s)
- Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Colm Breatnach
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Philip Levy
- Boston Children's Hospital Department of Pediatrics, Boston, Massachusetts, USA; Department of Paediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Eleanor Molloy
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland; Department of Paediatrics and Child Health, Trinity College Dublin, Dublin, Ireland
| | - Jan Miletin
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Anna Curley
- Department of Neonatology, The National Maternity Hospital, Dublin, Dublin, Ireland
| | - Naomi McCallion
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; Department of Paediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Franklin Mrcpch
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; Department of Paediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland.
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Tai C, Hsieh A, Moon-Grady AJ, Keller RL, Teitel D, Nawaytou HM. Pulmonary artery acceleration time in young children is determined by heart rate and transpulmonary gradient but not by pulmonary blood flow: A simultaneous echocardiography-cardiac catheterization study. Echocardiography 2022; 39:895-905. [PMID: 35690918 DOI: 10.1111/echo.15397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 04/06/2022] [Accepted: 05/21/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Pulmonary artery acceleration time (PAAT) is considered useful for the non-invasive evaluation of pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR). PAAT is dependent on PAP, PVR, pulmonary artery compliance, stroke volume, and heart rate. Its relative dependency on these determinants may differ between young and older children, raising uncertainty regarding its utility in young children. We aim to identify the primary determinants of the PAAT in children less than 36 months undergoing cardiac catheterization and its utility for the diagnosis of elevated PVR. METHODS We prospectively studied 42 children undergoing cardiac catheterization and simultaneous echocardiography. We determined the correlations of PAAT to the above-mentioned determinants and evaluated receiver operator characteristic (ROC) curves for diagnosis of PVR indexed to body surface area (PVRi) ≥3 Wu*m2 . RESULTS Median age was 11.5 (IQR 5.2, 21.2) months. Moderate correlations were found between PAAT and mean PAP (R = -.66, p < .001), PVRi (R = -.54, p = .004), pulmonary artery compliance (R = .65, p < .001), transpulmonary gradient (R = -.67, p < .001), stroke volume (R = .61, p = .002), and heart rate (R = -.63, p < .001). In multivariate regression modeling, only transpulmonary gradient and heart rate were independent determinants of PAAT. PAAT ≤77 msec had acceptable utility for diagnosing PVRi ≥ 3 Wu*m2 (AUC .8 [.64, .95], n = 36), low sensitivity (59%), and excellent specificity (94%). CONCLUSION Transpulmonary gradient and heart rate, but not pulmonary blood flow, are important determinants of PAAT in children <36 months undergoing cardiac catheterization. PAAT has low sensitivity for diagnosing elevated PVRi, therefore, should not be solely relied upon in screening for elevated PVRi in young children.
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Affiliation(s)
- Christiana Tai
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Anyir Hsieh
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Anita J Moon-Grady
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Roberta L Keller
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - David Teitel
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Hythem M Nawaytou
- Department of Pediatrics, University of California, San Francisco, California, USA
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Carpenter RJ, Srdanovic N, Rychlik K, Sen SK, Porta NFM, Hamvas AE, Murthy K, Hauck AL. The association between pulmonary vascular disease and respiratory improvement in infants with type I severe bronchopulmonary dysplasia. J Perinatol 2022; 42:788-795. [PMID: 35397644 DOI: 10.1038/s41372-022-01386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/14/2022] [Accepted: 03/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the association between echocardiographic measures of pulmonary vascular disease and time to respiratory improvement among infants with Type I severe bronchopulmonary dysplasia (sBPD). STUDY DESIGN We measured the pulmonary artery acceleration time indexed to the right ventricular ejection time (PAAT/RVET) and right ventricular free wall longitudinal strain (RVFWLS) at 34-41 weeks' postmenstrual age. Cox-proportional hazards models were used to estimate the relationship between the PAAT/RVET, RVFWLS, and the outcome: days from 36 weeks' postmenstrual age to room-air or discharge with oxygen (≤0.5 L/min). RESULT For 102 infants, the mean PAAT/RVET and RVFWLS were 0.27 ± 0.06 and -22.63 ± 4.23%. An abnormal measurement was associated with an increased time to achieve the outcome (PAAT/RVET: 51v24, p < 0.0001; RVFWLS; 62v38, p = 0.0006). A normal PAAT/RVET was independently associated with a shorter time to outcome (aHR = 2.04, 1.11-3.76, p = 0.02). CONCLUSION The PAAT/RVET may aid in anticipating timing of discharge in patients with type I severe BPD.
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Affiliation(s)
- Ryan J Carpenter
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Nina Srdanovic
- Biostatistics Collaboration Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Karen Rychlik
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shawn K Sen
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nicolas F M Porta
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Aaron E Hamvas
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Karna Murthy
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amanda L Hauck
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Smith A, Bussmann N, Breatnach C, Levy PT, Molloy E, Miletin J, Curley A, McCallion N, Franklin O, El-Khuffash AF. Relationship Between Postnatal Pulmonary Arterial Pressure and Altered Diastolic Function in Neonates with Down Syndrome. J Pediatr 2022; 245:172-178.e5. [PMID: 35176311 DOI: 10.1016/j.jpeds.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/30/2022] [Accepted: 02/09/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess the influence of diastolic dysfunction on the evolution of pulmonary hypertension in neonates with Down Syndrome over the early newborn period. STUDY DESIGN This was a prospective observational cohort study. Echocardiography was performed three times over the first week of life in both Down syndrome and control cohorts. Measurements of pulmonary arterial pressure in addition to left ventricular (LV) and right ventricular systolic and diastolic function were collected. RESULTS Seventy babies with Down syndrome and 60 control infants were enrolled. Forty-eight of the infants with Down syndrome (69%) were born with congenital heart disease (CHD). Echocardiography surrogates of pulmonary hypertension and myocardial function remained significantly impaired in the Down syndrome group in comparison with control infants (all P < .01). In the Down syndrome group, LV early diastolic strain rate was independently associated with measures of pulmonary hypertension while controlling for gestational age, cesarean delivery, and the presence of CHD (P < .01). CONCLUSIONS Intrinsic LV diastolic impairment is directly associated with higher indices of pulmonary hypertension in infants with Down syndrome and may be a contributing factor to its evolution.
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Affiliation(s)
- Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.
| | - Neidin Bussmann
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Colm Breatnach
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Eleanor Molloy
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland; Department of Paediatrics and Child Health, Trinity College Dublin, Dublin, Ireland
| | - Jan Miletin
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Anna Curley
- Department of Neonatology, The National Maternity Hospital, Dublin, Ireland
| | - Naomi McCallion
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; Department of Paediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Afif F El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; Department of Paediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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Heath-Freudenthal A, Toledo-Jaldin L, von Alvensleben I, Lazo-Vega L, Mizutani R, Stalker M, Yasini H, Mendizabal F, Madera JD, Mundo W, Castro-Monrroy M, Houck JA, Moreno-Aramayo A, Miranda-Garrido V, Su EJ, Giussani DA, Abman SH, Moore LG, Julian CG. Vascular Disorders of Pregnancy Increase Susceptibility to Neonatal Pulmonary Hypertension in High-Altitude Populations. Hypertension 2022; 79:1286-1296. [PMID: 35437031 PMCID: PMC9098686 DOI: 10.1161/hypertensionaha.122.19078] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Preeclampsia and fetal growth restriction increase cardiopulmonary disease risk for affected offspring and occur more frequently at high-altitude (≥2500 m). Retrospective studies indicate that birth to a preeclampsia woman at high altitude increases the risk of pulmonary hypertension (PH) in later life. This prospective study asked whether preeclampsia with or without fetal growth restriction exaggerated fetal hypoxia and impaired angiogenesis in the fetal lung, leading to neonatal cardiopulmonary circulation abnormalities and neonatal or infantile PH. METHODS AND RESULTS We studied 79 maternal-infant pairs (39 preeclampsia, 40 controls) in Bolivia (3600-4100 m). Cord blood erythropoietin, hemoglobin, and umbilical artery and venous blood gases were measured as indices of fetal hypoxia. Maternal and cord plasma levels of angiogenic (VEGF [vascular endothelial growth factor]) and antiangiogenic (sFlt1 [soluble fms-like tyrosine kinase]) factors were determined. Postnatal echocardiography (1 week and 6-9 months) assessed pulmonary hemodynamics and PH. Preeclampsia augmented fetal hypoxia and increased the risk of PH in the neonate but not later in infancy. Pulmonary abnormalities were confined to preeclampsia cases with fetal growth restriction. Maternal and fetal plasma sFlt1 levels were higher in preeclampsia than controls and positively associated with PH. CONCLUSIONS The effect of preeclampsia with fetal growth restriction to increase fetal hypoxia and sFlt1 levels may impede normal development of the pulmonary circulation at high altitude, leading to adverse neonatal pulmonary vascular outcomes. Our observations highlight important temporal windows for the prevention of pulmonary vascular disease among babies born to highland residents or those with exaggerated hypoxia in utero or newborn life.
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Affiliation(s)
| | | | | | | | | | | | - Hussna Yasini
- College of Liberal Arts and Sciences, University of Colorado Denver, Denver, Colorado
| | | | - Jesus Dorado Madera
- College of Liberal Arts and Sciences, University of Colorado Denver, Denver, Colorado
| | - William Mundo
- University of Colorado School of Medicine, Aurora, Colorado
| | | | - Julie A. Houck
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Emily J. Su
- Departments of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Dino A. Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Steven H. Abman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Lorna G. Moore
- Departments of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Colleen G. Julian
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Echocardiographic Assessment of Pulmonary Hypertension in Neonates with Congenital Diaphragmatic Hernia Using Pulmonary Artery Flow Characteristics. J Clin Med 2022; 11:jcm11113038. [PMID: 35683426 PMCID: PMC9181044 DOI: 10.3390/jcm11113038] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Assessment of pulmonary hypertension (PH) is essential in neonates with congenital diaphragmatic hernia (CDH). Echocardiography is widely established to quantify PH severity, but currently used parameters have inherent limitations. The aim of our study was to investigate the prognostic utility of the index of the pulmonary artery acceleration time to the right ventricular ejection time (PAAT:ET) in CDH neonates assessed using echocardiography. Methods: PAAT:ET values were prospectively measured in CDH neonates on admission, on day of life (DOL) 2 and DOL 5−7. Optimal cut-off values to predict mortality and need for ECMO were calculated and PAAT:ET values were compared between non-ECMO survivors, ECMO-survivors, and ECMO-non-survivors. Results: 87 CDH neonates were enrolled and 39 patients required ECMO therapy. At baseline, PAAT:ET values were significantly lower in ECMO patients compared to non-ECMO patients (p < 0.001). ECMO survivors and ECMO non-survivors had similar values at baseline (p = 0.967) and DOL 2 (p = 0.124) but significantly higher values at DOL 5−7 (p = 0.003). Optimal PAAT:ET cut-off for predicting ECMO was 0.290 at baseline and 0.310 for predicting non-survival in patients on ECMO at DOL 5−7. Conclusion: PAAT:ET is a feasible parameter for early risk assessment in CDH neonates.
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Knutsen RH, Gober LM, Kronquist EK, Kaur M, Donahue DR, Springer D, Yu ZX, Chen MY, Fu YP, Choobdar F, Nguyen ML, Osgood S, Freeman JL, Raja N, Levin MD, Kozel BA. Elastin Insufficiency Confers Proximal and Distal Pulmonary Vasculopathy in Mice, Partially Remedied by the KATP Channel Opener Minoxidil: Considerations and Cautions for the Treatment of People With Williams-Beuren Syndrome. Front Cardiovasc Med 2022; 9:886813. [PMID: 35665242 PMCID: PMC9160528 DOI: 10.3389/fcvm.2022.886813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Williams Beuren syndrome (WBS) is a recurrent microdeletion disorder that removes one copy of elastin (ELN), resulting in large artery vasculopathy. Early stenosis of the pulmonary vascular tree is common, but few data are available on longer-term implications of the condition. Methods Computed tomography (CT) angiogram (n = 11) and echocardiogram (n = 20) were performed in children with WBS aged 3.4–17.8 years. Controls (n = 11, aged 4.4–16.8 years) also underwent echocardiogram. Eln+/− mice were analyzed by invasive catheter, echocardiogram, micro-CT (μCT), histology, and pressure myography. We subsequently tested whether minoxidil resulted in improved pulmonary vascular endpoints. Results WBS participants with a history of main or branch pulmonary artery (PA) stenosis requiring intervention continued to exhibit increased right ventricular systolic pressure (RVSP, echocardiogram) relative to their peers without intervention (p < 0.01), with no clear difference in PA size. Untreated Eln+/− mice also show elevated RVSP by invasive catheterization (p < 0.0001), increased normalized right heart mass (p < 0.01) and reduced caliber branch PAs by pressure myography (p < 0.0001). Eln+/− main PA medias are thickened histologically relative to Eln+/+ (p < 0.0001). Most Eln+/− phenotypes are shared by both sexes, but PA medial thickness is substantially greater in Eln+/− males (p < 0.001). Eln+/− mice showed more acute proximal branching angles (p < 0.0001) and longer vascular segment lengths (p < 0.0001) (μCT), with genotype differences emerging by P7. Diminished PA acceleration time (p < 0.001) and systolic notching (p < 0.0001) were also observed in Eln+/− echocardiography. Vascular casting plus μCT revealed longer generation-specific PA arcade length (p < 0.0001), with increased PA branching detectable by P90 (p < 0.0001). Post-weaning minoxidil decreased RVSP (p < 0.01) and normalized PA caliber (p < 0.0001) but not early-onset proximal branching angle or segment length, nor later-developing peripheral branch number. Conclusions Vascular deficiencies beyond arterial caliber persist in individuals with WBS who have undergone PA stenosis intervention. Evaluation of Eln+/− mice reveals complex vascular changes that affect the proximal and distal vasculatures. Minoxidil, given post-weaning, decreases RVSP and improves lumen diameter, but does not alter other earlier-onset vascular patterns. Our data suggest additional therapies including minoxidil could be a useful adjunct to surgical therapy, and future trials should be considered.
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Affiliation(s)
- Russell H. Knutsen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Leah M. Gober
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Elise K. Kronquist
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Maninder Kaur
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Danielle R. Donahue
- Mouse Imaging Facility, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Danielle Springer
- Murine Phenotyping Core, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Zu Xi Yu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Marcus Y. Chen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Yi-Ping Fu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Feri Choobdar
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - My-Le Nguyen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Sharon Osgood
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Joy L. Freeman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Neelam Raja
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Mark D. Levin
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Beth A. Kozel
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Beth A. Kozel
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sPAP/PAAT Ratio as a New Index of Pulmonary Vascular Load: A Study in Normal Subjects and Ssc Patients with and without PH. PATHOPHYSIOLOGY 2022; 29:134-142. [PMID: 35366295 PMCID: PMC8949923 DOI: 10.3390/pathophysiology29010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
In pulmonary hypertension (PH), the development of right ventricular (RV) dilatation and RV failure are signs of accelerated progression of the disease, resulting in an increased risk of cardiac death. Even the noninvasive assessment of systolic blood pressure in the pulmonary artery undertaken by echocardiography does not provide a measure of ventricle–pulmonary interaction. Some studies have shown the potential for echocardiography to indirectly evaluate pulmonary vascular resistance (PVR) and the acceleration time of pulmonary outflow (PAAT). We used systolic pulmonary artery pressure (sPAP) and pulmonary vascular resistance to develop an sPAP/PAAT ratio (strength/surface unit)/(time) for this study. From January 2017 to December 2018, 60 healthy subjects and 63 patients with systemic scleroderma (Ssc) (60 females, 3 males), 27 with PH and 36 without PH at two-dimensional echocardiographic/Doppler, were screened. In normal subjects, the mean sPAP/PAAT ratio was 0.26 ± 0.063, which indicated optimal pulmonary arterial ventricle coupling and biventricular function. The data derived from the analysis of the Ssc patients showed that those presenting pre-capillary PH at cardiac catheterization had an sPAP/PAAT ratio of 0.40 ± 0.05. There was a significant correlation between sPAP/PAAT with Walk Distance (WD) and PVR, but not with TAPSE. Interobserver variability was less than 5%. The sPAP/PAAT ratio is a new parameter that may indicate pulmonary vascular afterload and interaction, both in normal subjects and in patients with Ssc and PH.
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Hocq C, Vanhoutte L, Guilloteau A, Massolo AC, Van Grambezen B, Carkeek K, Piersigilli F, Danhaive O. Early diagnosis and targeted approaches to pulmonary vascular disease in bronchopulmonary dysplasia. Pediatr Res 2022; 91:804-815. [PMID: 33674739 DOI: 10.1038/s41390-021-01413-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/25/2021] [Indexed: 01/31/2023]
Abstract
Pulmonary hypertension has emerged as a life-threatening disease in preterm infants suffering from bronchopulmonary dysplasia (BPD). Its development is closely linked to respiratory disease, as vasculogenesis and alveologenesis are closely interconnected. Once clinically significant, BPD-associated pulmonary hypertension (BPD-PH) can be challenging to manage, due to poor reversibility and multiple comorbidities frequently associated. The pulmonary vascular disease process underlying BPD-PH is the result of multiple innate and acquired factors, and emerging evidence suggests that it progressively develops since birth and, in certain instances, may begin as early as fetal life. Therefore, early recognition and intervention are of great importance in order to improve long-term outcomes. Based on the most recent knowledge of BPD-PH pathophysiology, we review state-of-the-art screening and diagnostic imaging techniques currently available, their utility for clinicians, and their applicability and limitations in this specific population. We also discuss some biochemical markers studied in humans as a possible complement to imaging for the detection of pulmonary vascular disease at its early stages and the monitoring of its progression. In the second part, we review pharmacological agents currently available for BPD-PH treatment or under preclinical investigation, and discuss their applicability, as well as possible approaches for early-stage interventions in fetuses and neonates. IMPACT: BPD-associated PH is a complex disease involving genetic and epigenetic factors, as well as environmental exposures starting from fetal life. The value of combining multiple imaging and biochemical biomarkers is emerging, but requires larger, multicenter studies for validation and diffusion. Since "single-bullet" approaches have proven elusive so far, combined pharmacological regimen and cell-based therapies may represent important avenues for research leading to future cure and prevention.
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Affiliation(s)
- Catheline Hocq
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Laetitia Vanhoutte
- Division of Pediatric Cardiology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Axelle Guilloteau
- Division of Clinical Pharmacy, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Anna Claudia Massolo
- Department of Surgical and Medical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Bénédicte Van Grambezen
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Kate Carkeek
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Fiammetta Piersigilli
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Olivier Danhaive
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium. .,Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.
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Lalitha R, Bitar E, Hicks M, Hyderi A, Kumaran K. Pulmonary artery dopplers for early prediction of risk for bronchopulmonary dysplasia in extremely low birth weight babies. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:385-392. [PMID: 35218035 DOI: 10.1002/jcu.23161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The early abnormal pulmonary vasoreactivity observed in babies at risk of Bronchopulmonary dysplasia (BPD) increases the pulmonary vascular resistance. This can be assessed non-invasively using Time to Peak Velocity:Right Ventricular Ejection Time ratio (TPV:RVET) measured from pulmonary artery Doppler waveform obtained using echocardiogram. We postulate that screening for this early can predict BPD in this cohort. The objective of the study was to determine the utility of TPV:RVET in early prediction of BPD in Extremely Low Birth Weight (ELBW) babies born less than 1250grams Birth Weight. METHODS This was a single-center retrospective cohort study of ELBW babies born<29 weeks over 4 year period who had echocardiogram between 7-21 days of life. TPV:RVET ratio was measured from pulmonary artery Doppler waveform obtained using echocardiogram. The main outcome was BPD at 36 weeks corrected gestation. The predictive ability of TPV:RVET (cut off 0.34) for subsequent development of BPD was analyzed using ROC. RESULTS Of 589 ELBW<29 weeks, 207 babies were eligible. BPD was found in 60.4%. The TPV:RVET at 0.34 had sensitivity 76.8% (95%CI 68.4-83.9), specificity 85.4% (95%CI 75.8-92.2), positive predictive value 88.9% (95%CI 81.4-94.1), negative predictive value 70.7% (95%CI 60.7-79), and ROC area 0.811 (95%CI 0.757-0.864). Odds ratio of having BPD for TPV:RVET at 0.34 was 19.9 (95%CI 8.19-48.34) and increased by 1.07 (95%CI 1.05-1.09) with every additional days of mechanical ventilation. TPV:RVET ratio had 92.75% inter-observer agreement with kappa 0.83. CONCLUSION TPV:RVET ratio is a good and reliable early screening tool for subsequent development of BPD in ELBW babies with substantial inter-observer agreement.
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Affiliation(s)
- Renjini Lalitha
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
| | - Eyad Bitar
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew Hicks
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Abbas Hyderi
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Kumar Kumaran
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Smith A, Armstrong S, Dempsey E, El-Khuffash A. The impact of a PDA on tissue oxygenation and haemodynamics following a blood transfusion in preterm infants. Pediatr Res 2022; 93:1314-1320. [PMID: 35152266 DOI: 10.1038/s41390-022-01967-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND To examine the impact of PRBC transfusion on pulmonary vascular resistance (PVR), systemic vascular resistance and myocardial function using echocardiography and cerebral and splanchnic tissue oxygenation using near-infrared spectroscopy (NIRS) in premature babies with and without a PDA. METHODS A prospective observational study of premature infants born <1500 g in receipt of PRBC transfusions beyond 10 days of age. Echocardiography and NIRS monitoring were performed at baseline, during the transfusion and 24 h after transfusion. RESULTS Thirty infants with a median gestation of 26.4 [24.8-28.0] weeks were enrolled. Ten infants had a PDA. Following transfusion, a significant decrease in PVR markers occurred in all infants. Right ventricular (RV) function increased following transfusion in the PDA closed group only. Cerebral oxygen saturation increased following transfusion in all infants. Babies in the PDA open group had significantly lower splanchnic oxygen saturations at baseline compared to the PDA closed group which persisted over the study period and were unaltered by transfusion. CONCLUSIONS PRBC transfusion lowers PVR irrespective of PDA status. Those with a PDA demonstrated a lack of improvement in RV function and splanchnic oxygenation highlighting the impact a PDA has on the neonatal circulation. IMPACT The presence or absence of the PDA imposes differential effects on splanchnic oxygenation during red blood cell (PRBC) transfusion in the premature population. This is the first study to assess the impact of the PDA on splanchnic oxygenation via near-infrared spectroscopy (NIRS) during red blood cell transfusion in premature neonates. New insights have been found into the impact of PRBC transfusion on pulmonary vascular resistance, right ventricular function, cerebral and splanchnic oxygenation in the presence and absence of a PDA and emphasises the ongoing impact of ductal patency on gut oxygenation.
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Affiliation(s)
- Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.
| | - Sean Armstrong
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,INFANT Centre, University College Cork, Cork, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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