Closure of the ductus arteriosus and development of pulmonary branch stenosis in babies of less than 32 weeks gestation

Genetic conditions of short stature: A review of three classic examples

Noonan, Turner, and Prader-Willi syndromes are classical genetic disorders that are marked by short stature. Each disorder has been recognized for several decades and is backed by extensive published literature describing its features, genetic origins, and optimal treatment strategies. These disorders are accompanied by a multitude of comorbidities, including cardiovascular issues, endocrinopathies, and infertility. Diagnostic delays, syndrome-associated comorbidities, and inefficient communication among the members of a patient's health care team can affect a patient's well-being from birth through adulthood. Insufficient information is available to help patients and their multidisciplinary team of providers transition from pediatric to adult health care systems. The aim of this review is to summarize the clinical features and genetics associated with each syndrome, describe best practices for diagnosis and treatment, and emphasize the importance of multidisciplinary teams and appropriate care plans for the pediatric to adult health care transition.

Spontaneous Closure of the Ductus Arteriosus in Preterm Infants: A Systematic Review

The optimal management strategy for patent ductus arteriosus in preterm infants remains a topic of debate. Available evidence for a treatment strategy might be biased by the delayed spontaneous closure of the ductus arteriosus in preterm infants, which appears to depend on patient characteristics. We performed a systematic review of all literature on PDA studies to collect patient characteristics and reported numbers of patients with a ductus arteriosus and spontaneous closure. Spontaneous closure rates showed a high variability but were lowest in studies that only included preterm infants with gestational ages below 28 weeks or birth weights below 1,000 g (34% on day 4; 41% on day 7) compared to studies that also included infants with higher gestational ages or higher birth weights (up to 55% on day 3 and 78% on day 7). The probability of spontaneous closure of the ductus arteriosus keeps increasing until at least 1 week after birth which favors delayed treatment of only those infants that do not show spontaneous closure. Better prediction of the spontaneous closure of the ductus arteriosus in the individual newborn is a key factor to find the optimal management strategy for PDA in preterm infants.

A literature review of systemic to pulmonary collaterals in preterm infants to emphasise their existence and clinical importance

AIM

Cardiorespiratory physiology plays an important role in neonatal care with increasing utility of point-of-care ultrasound. This review is to bring to light the importance of systemic to pulmonary collaterals (SPCs) in the preterm population without congenital heart disease (CHD) and provide a useful diagnostic tool to the neonatologist performing a cardiac ultrasound.

METHODS

Medline, PubMed, EMBASE and the Internet were searched up to November 2017 for articles in English which included SPCs in preterm infants without CHD. This comprised title, abstract and full-text screening of relevant data.

RESULTS

A total of 10 studies which included case reports, retrospective observational studies and one small prospective cohort study were identified and analysed in detail. The studies had varying focus such as variable incidence, clinical presentation, association with chronic lung disease, pathophysiology and clinical importance of SPCs. SPCs were overall thought to be prevalent, underdiagnosed and of clinical significance in preterm infants.

CONCLUSION

Systemic to pulmonary collaterals are a potential left-to-right shunt in preterm infants and may contribute to worsening chronic lung disease (CLD) or heart failure. They should be carefully looked for when performing bedside cardiac ultrasound as the findings can mimic those seen in patent ductus arteriosus (PDA).

Catheter closure of the arterial duct in preterm infants

BACKGROUND

When medical treatment of a symptomatic arterial duct in a preterm infant fails, management is surgical.

PATIENTS AND METHODS

10 preterm neonates referred to a tertiary cardiac centre for treatment of a symptomatic patent arterial duct who underwent cardiac catheterisation with the intention of device closure.

RESULTS

Successful catheter device closure of the arterial duct in nine preterm infants is described.

CONCLUSION

In selected cases, catheter device closure may offer an alternative to thoracotomy and surgical ligation.

Transcatheter treatment of "pulmonary artery hypertension" due to patent ductus arteriosus and pulmonary artery stenosis

The association between large, left-sided patent ductus arteriosus and severe, peripheral, right pulmonary artery stenosis with no other cardiac malformation is an unreported condition that might be misdiagnosed as pulmonary hypertension due to long-standing ductal shunt. A 57-year-old man with supposed hypertensive patent ductus arteriosus underwent confirmatory cardiac catheterization. At angiography, a severe pre-hilar right pulmonary artery stenosis (peak pressure gradient, 65 mmHg) was found to complicate the hemodynamic picture of a moderate-to-large patent ductus arteriosus (QP/QS, 1.7:1), by causing pulmonary hypertension (mean pressure, 65 mmHg) and left-to-right pulmonary flow imbalance. Both lesions were treated in a single procedure of right pulmonary artery stenting and patent ductus arteriosus closure, after which the pulmonary artery pressure significantly decreased (mean, 35 mmHg). In our opinion, a thorough hemodynamic evaluation followed by pulmonary angiography should be mandatory before proceeding to patent ductus arteriosus closure in the adult patient who has "hypertensive" ductus, in whom possible associated malformations can be missed due to a poor echocardiographic window.

Evaluation of echocardiography on the neonatal unit

BACKGROUND

Echocardiography is an investigation that is being used increasingly on the neonatal unit. There is some controversy as to whether this service can be provided safely and effectively by neonatologists or whether it should only be performed by paediatric cardiologists.

AIMS

To describe (a) the indications for an echocardiogram, (b) the yield and range of positive findings, (c) the resulting changes in clinical management, and (d) the reliability of echocardiography in the hands of neonatologists when it is performed on the neonatal unit.

METHODS

Information about all echocardiograms performed on the neonatal unit was collected prospectively. Indications for performing echocardiography, echocardiographic findings, and any resulting changes in clinical management were determined. The concordance of findings in infants who underwent echocardiograms performed by both a neonatologist and a paediatric cardiologist was described.

RESULTS

A total of 157 echocardiograms were performed in 82 infants. Echocardiography identified 44 infants with a structural cardiac abnormality and a further 17 infants with a trivial abnormality. In addition, 13 babies were found to have an important functional abnormality. Echocardiography prompted a specific change in clinical management in 64 (78%) babies. In 31 of the 38 infants who had paired scans performed, there was complete concordance between the two examinations. No infants had scans that were completely different. Some discrepancy was identified in seven infants, but this did not prevent appropriate immediate clinical management.

CONCLUSIONS

Echocardiography on the neonatal unit has a high yield for the diagnosis of structural and functional cardiac abnormalities, often results in a change in clinical management, and can be a reliable tool in the hands of neonatologists.

One-step treatment of patent ductus arteriosus and pulmonary artery stenosis by cardiac catheterization

Coexistence of pulmonary artery (PA) stenosis and patent ductus arteriosus (PDA) may lead to overestimating the relative importance of these malformations. This article reports on a patient with a trivial PDA and severe PA stenosis erroneously diagnosed as moderate PDA. He was successfully submitted to simultaneous PA stenting and PDA embolization.

Neonatal murmurs: are senior house officers good enough?

AIM

To show that, given appropriate guidelines, senior house officers (SHOs) have the clinical skills required to assess neonatal murmurs.

METHODS

Neonatal SHOs identified babies with a cardiac murmur at routine neonatal examination. The SHOs assessed whether the murmur was significant or innocent and decided between immediate further assessment or echocardiogram as an outpatient.

RESULTS

A total of 112 babies had murmurs at routine neonatal examination. The incidence of cardiac murmurs was 13.8 per 1000. Twelve babies were referred for immediate further assessment. Eleven had structurally abnormal hearts. One had a normal heart with pulmonary hypoplasia. One hundred babies were referred, and 78 attended for outpatient follow up. Of these, the SHO assessed nine babies as having a significant murmur and 69 as having an innocent murmur. Twenty two babies failed to attend for follow up; all were thought to have innocent murmurs. Of the nine murmurs assessed as significant, four were confirmed as such and five were found to be innocent. Of the 91 murmurs assessed as innocent, 63 were proven to be innocent, six had abnormalities on echocardiogram, and 22 defaulted to follow up. Five of the serious murmurs were small ventricular septal defects, which had resolved by 6 months of age; the other had mild pulmonary stenosis. None of these babies were clinically symptomatic at outpatient review.

CONCLUSION

Given appropriate guidelines, SHOs have the skills to assess the significance of, and decide on appropriate management for, neonatal murmurs. Electrocardiograms and chest radiographs are not necessary.