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Murni IK, Kato T, Wirawan MT, Arafuri N, Hermawan K, Hartopo AB, Anggrahini DW, Nugroho S, Noormanto N, Emoto N, Dinarti LK. An electrocardiographic score to predict pulmonary hypertension in children with atrial septal defect. BMC Pediatr 2023; 23:288. [PMID: 37301836 PMCID: PMC10257265 DOI: 10.1186/s12887-023-04102-1] [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: 02/20/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND In limited resource settings, identification of factors that predict the occurrence of pulmonary hypertension(PH) in children with atrial septal defect(ASD) is important to decide which patients should be prioritized for defect closure to prevent complication. Echocardiography and cardiac catheterization are not widely available in such settings. No scoring system has been proposed to predict PH among children with ASD. We aimed to develop a PH prediction score using electrocardiography parameters for children with ASD in Indonesia. METHODS A cross-sectional study reviewing medical record including ECG record was conducted among all children with newly diagnosed isolated ASD admitted to Dr Sardjito Hospital in Yogyakarta, Indonesia during 2016-2018. Diagnosis of ASD and PH was confirmed through echocardiography and/or cardiac catheterization. Spiegelhalter Knill-Jones approach was used to develop PH prediction score. Accuracy of prediction score was performed using a receiver operating characteristic (ROC) curve. RESULTS Of 144 children, 50(34.7%) had PH. Predictors of pulmonary hypertension were QRS axis ≥120°, P wave ≥ 3 mm at lead II, R without S at V1, Q wave at V1, right bundle branch block (RBBB), R wave at V1, V2 or aVR > normal limit and S wave at V6 or lead I > normal limit. ROC curve from prediction scores yielded an area under the curve (AUC) 0.908(95% CI 0.85-0.96). Using the cut-off value 3.5, this PH prediction score had sensitivity of 76%(61.8-86.9), specificity 96.8%(91.0-99.3), positive predictive value 92.7%(80.5-97.5), negative predictive value 88.4%(82.2-92.6), and positive likelihood ratio 23.8(7.7-73.3). CONCLUSIONS A presence of PH in children with ASD can be predicted by the simple electrocardiographic score including QRS axis ≥120°, P wave ≥3 mm at lead II, R without S at V1, Q wave at V1, RBBB, R wave at V1, V2 or aVR > normal limit and S wave at V6 or lead I > normal limit. A total score ≥ 3.5 shows a moderate sensitivity and high specificity to predict PH among children with ASD.
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Affiliation(s)
- Indah K Murni
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia.
- Centre for Child Health-Pediatric Research Office (CCH-PRO), Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Taichi Kato
- Department of Pediatrics/Developmental Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Muhammad Taufik Wirawan
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Nadya Arafuri
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Kristia Hermawan
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Anggoro Budi Hartopo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Dyah Wulan Anggrahini
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Sasmito Nugroho
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Noormanto Noormanto
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- Laboratory of Clinical Pharmaceutical Science, Kobe Pharmaceutical University, Kobe, Japan
| | - Lucia Kris Dinarti
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 PMCID: PMC8289457 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
| | - Girija G. Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
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Wadia RS, Bernier ML, Diaz-Rodriguez NM, Goswami DK, Nyhan SM, Steppan J. Update on Perioperative Pediatric Pulmonary Hypertension Management. J Cardiothorac Vasc Anesth 2021; 36:667-676. [PMID: 33781669 DOI: 10.1053/j.jvca.2021.02.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 12/25/2022]
Abstract
Pediatric pulmonary hypertension is a disease that has many etiologies and can present anytime during childhood. Its newly revised hemodynamic definition follows that of adult pulmonary hypertension: a mean pulmonary artery pressure >20 mmHg. However, the pediatric definition stipulates that the elevated pressure must be present after the age of three months. The definition encompasses many different etiologies, and diagnosis often involves a combination of noninvasive and invasive testing. Treatment often is extrapolated from adult studies or based on expert opinion. Moreover, although general anesthesia may be required for pediatric patients with pulmonary hypertension, it poses certain risks. A thoughtful, multidisciplinary approach is needed to deliver excellent perioperative care.
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Affiliation(s)
- Rajeev S Wadia
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Meghan L Bernier
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Natalia M Diaz-Rodriguez
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dheeraj K Goswami
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sinead M Nyhan
- Department of Anesthesiology and Critical Care Medicine, Division of Adult Cardiothoracic Anesthesia, Division of Adult Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Division of Adult Cardiothoracic Anesthesia, Division of Adult Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Inferior Right Ventricular Wall Thickness by Echocardiogram: A Novel Method of Assessing Hypertrophy in Neonates and Infants. Pediatr Cardiol 2020; 41:1617-1622. [PMID: 32715337 DOI: 10.1007/s00246-020-02419-7] [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: 04/20/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
An established echocardiographic (echo) standard for assessing the newborn right ventricle (RV) for hypertrophy has not been thoroughly developed. This is partially due to the RV's complex architecture, which makes quantification of RV mass by echo difficult. Here, we retrospectively evaluate the thickness of the inferior RV wall (iRVWT) by echo in neonates and infants with normal cardiopulmonary physiology. Inferior RVWT was defined at the medial portion of the inferior wall of the RV at the mid-ventricular level, collected from a subxiphoid, short axis view. iRVWT was indexed to body surface area (BSA) to the 0.5 power and normalized to iLVWT to explore the best normalization method. Ninety-eight neonates and 32 infants were included in the final analysis. Mean age for neonates and infants was 2 days and 59 days, respectively. Mean ± SD for neonate and infant end-diastole iRVWT was 2.17 ± 0.35 mm and 1.79 ± 0.28 mm, respectively. There was no residual relationship between the index iRVWT and BSA (r = 0.03, p = NS). In the infant cohort, the iRVWT was significantly lower and iLVWT was significantly higher compared to neonate, consistent with known physiologic changes of RV and LV mass. Thus, iRVWT may serve as a reliable and accurate proxy for RV mass and the parameter warrants further evaluation.
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Sandeep B, Huang X, Xu F, Su P, Wang T, Sun X. Etiology of right ventricular restrictive physiology early after repair of tetralogy of Fallot in pediatric patients. J Cardiothorac Surg 2019; 14:84. [PMID: 31046798 PMCID: PMC6498477 DOI: 10.1186/s13019-019-0909-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Right ventricular restrictive physiology (RVRP) is a common finding after repair of Tetralogy of Fallot (TOF). The characteristic feature of RVRP is the presence of a direct end-diastolic flow (EDFF) during atrial contraction in the main pulmonary artery. This end-diastolic forward flow is caused by increased right ventricular end-diastolic pressure due to right ventricular myocardial stiffness and decreased right ventricular compliance. OBJECTIVE Our main objective is to found out the etiology of RVRP in pediatrics patients who underwent for complete repair of Tetralogy of Fallot (TOF). METHODS A total of 50 TOF patients have registered for this study in our hospital from January 2017 to September 2018. The patients were divided in two groups, group A with restrictive physiology and group B without restrictive physiology. The patients selected for this study includes TOF patients, TOF patients with atrial septal defect (ASD), and TOF patients with patent ductus arteriosus (PDA). Ventricular hypertrophy and right heart enlargement were evaluated by electrocardiogram and echocardiography. The other parameters we used to compare between these two groups were sex, age, weight, cardio pulmonary bypass (CPB) time, aortic cross clamping time, transannular patch, SP02, RV/LV pressure, ventricular hypertrophy, right heart (RH) enlargement, tricuspid annular plane systolic excursion (TAPSE), pulmonary artery systolic pressure (PASP), TAPSE/PASP ratio, pulmonary annular diameter, intubation time, PICU stay and hematocrit (HCT). RESULTS RVRP was identified in 28 patients (58%). Lower SP02 (mean: 84.3 ± 7.9%) with p-value 0.015, transannular patch repair (n = 22, 78.5%) with p-value< 0.001, longer cardiopulmonary bypass (CPB) time (mean: 117.6 ± 23 min) with p-value< 0.001, longer aortic cross clamping time (mean: 91.4 ± 20.26 min) with p-value< 0.001, lower TAPSE, lower PASP,lower TAPSE/PASP ratio and presence of hypertrophy (p-value < 0.001) were identified as etiology for restrictive physiology. It was also found that 77% TOF patients with ASD have a higher risk of RVRP in our study. CONCLUSIONS In TOF patient's etiology for right ventricular restrictive physiology are associated with lower SP02, transannular patch repair, longer CPB and longer aortic cross clamping time, hypertrophy, lower TAPSE, lower PASP and lower TAPSE/PASP ratio.
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Affiliation(s)
- Bhushan Sandeep
- Department of General Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710000, Shanxi, China.
| | - Xin Huang
- Chengdu medical college, Jinniu district, Rondu avenue, Tianzhu road no 611, Chengdu, 610500, China
| | - Fan Xu
- Department of General Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710000, Shanxi, China
| | - Pengxiao Su
- Department of General Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710000, Shanxi, China
| | - Ting Wang
- Department of General Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710000, Shanxi, China
| | - Xiaoke Sun
- Department of General Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710000, Shanxi, China
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Sandeep B, Huang X, Xu F, Su P, Wang T, Sun X. Etiology of right ventricular restrictive physiology early after repair of tetralogy of Fallot in pediatric patients. J Cardiothorac Surg 2019. [DOI: https://doi.org/10.1186/s13019-019-0909-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Characteristics of Infants With Congenital Diaphragmatic Hernia Who Need Follow-Up of Pulmonary Hypertension. Pediatr Crit Care Med 2018; 19:e219-e226. [PMID: 29419603 DOI: 10.1097/pcc.0000000000001464] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Pulmonary hypertension is one of the main causes of mortality and morbidity in patients with congenital diaphragmatic hernia. Currently, it is unknown whether pulmonary hypertension persists or recurs during the first year of life. DESIGN Prospective longitudinal follow-up study. SETTING Tertiary university hospital. PATIENTS Fifty-two congenital diaphragmatic hernia patients admitted between 2010 and 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pulmonary hypertension was measured using echocardiography and electrocardiography at 6 and 12 months old. Characteristics of patients with persistent pulmonary hypertension were compared with those of patients without persistent pulmonary hypertension. At follow-up, pulmonary hypertension persisted in four patients: at 6 months old, in three patients (patients A-C), and at 12 months old, in two patients (patients C and D). Patients with persistent pulmonary hypertension had a longer duration of mechanical ventilation (median 77 d [interquartile range, 49-181 d] vs median 8 d [interquartile range, 5-15 d]; p = 0.002) and hospital stay (median 331 d [interquartile range, 198-407 d) vs median 33 d (interquartile range, 16-59 d]; p = 0.003) than patients without persistent pulmonary hypertension. The proportion of patients with persistent pulmonary hypertension (n = 4) treated with inhaled nitric oxide (100% vs 31%; p = 0.01), sildenafil (100% vs 15%; p = 0.001), and bosentan (100% vs 6%; p < 0.001) during initial hospital stay was higher than that of patients without persistent pulmonary hypertension (n = 48). At 6 months, all patients with persistent pulmonary hypertension were tube-fed and treated with supplemental oxygen and sildenafil. CONCLUSIONS Less than 10% of congenital diaphragmatic hernia patients had persistent pulmonary hypertension at ages 6 and/or 12 months. Follow-up for pulmonary hypertension should be reserved for congenital diaphragmatic hernia patients with echocardiographic signs of persistent pulmonary hypertension at hospital discharge and/or those treated with medication for pulmonary hypertension at hospital discharge.
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Altit G, Dancea A, Renaud C, Perreault T, Lands LC, Sant'Anna G. Pathophysiology, screening and diagnosis of pulmonary hypertension in infants with bronchopulmonary dysplasia - A review of the literature. Paediatr Respir Rev 2017; 23:16-26. [PMID: 27986502 DOI: 10.1016/j.prrv.2016.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is a common complication of extreme prematurity, which has increased over the last 20 years. BPD is associated with increased morbidities and mortality. It has been increasingly recognized that BPD affects overall lung development including the pulmonary vasculature. More recent studies have demonstrated an increased awareness of pulmonary arterial hypertension (PH) in BPD patients and recent international guidelines have advocated for better screening. This review will describe the current understanding of the pathophysiology of PH in infants with BPD, the in-depth assessment of the available literature linking PH and BPD, and propose an approach of screening and diagnosis of PH in infants with BPD.
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Lau KC, Frank DB, Hanna BD, Patel AR. Utility of electrocardiogram in the assessment and monitoring of pulmonary hypertension (idiopathic or secondary to pulmonary developmental abnormalities) in patients≤18 years of age. Am J Cardiol 2014; 114:294-9. [PMID: 24878129 DOI: 10.1016/j.amjcard.2014.04.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/17/2014] [Accepted: 04/17/2014] [Indexed: 11/16/2022]
Abstract
Electrocardiograms have utility in disease stratification and monitoring in adult pulmonary arterial hypertension (PAH). We examined the electrocardiographic findings that are common in pediatric PAH and assessed for correlation with disease severity and progression. We retrospectively identified patients aged≤18 years followed at a single institution from January 2001 to June 2012 with catheterization-confirmed diagnosis of idiopathic PAH and PAH secondary to pulmonary developmental abnormalities. Patients with an electrocardiography performed within 60 days of catheterization were included. Primary and secondary outcomes are the prevalence of abnormal electrocardiographic findings at the time of catheterization and the association between electrocardiographic and hemodynamic findings and electrocardiographic changes with disease progression on follow-up catheterization, respectively. Of the 100 electrocardiography-catheterization pairs derived from the 46 patients identified, 93% had an electrocardiographic abnormality: 78% had right ventricular hypertrophy (RVH) and 52% had right axis deviation (RAD) for age. In patients with idiopathic PAH, the presence of RVH and RAD correlated with pulmonary vascular resistance and transpulmonary gradient. RAD and RVH on baseline electrocardiogram was associated with an increased risk of disease progression on subsequent catheterization (odds ratio 11.0, 95% confidence interval 1.3 to 96.2, p=0.03) after adjusting for PAH subgroup. The sensitivity, specificity, and positive and negative predictive values of RAD and RVH on baseline electrocardiogram for disease progression were 92%, 48%, 33%, and 95%, respectively. In conclusion, electrocardiographic abnormalities are common in pediatric PAH. RAD and RVH on electrocardiogram were associated with worse hemodynamics, whereas their absence is suggestive of a lack of disease progression.
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Affiliation(s)
- Kelvin C Lau
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - David B Frank
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian D Hanna
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Akash R Patel
- Division of Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, California
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Abstract
Pulmonary hypertension (PH) is a common complication of neonatal respiratory diseases, including bronchopulmonary dysplasia (BPD), and recent studies have increased awareness that PH worsens the clinical course, morbidity and mortality of BPD. Recent evidence indicates that up to 18% of all extremely low-birth-weight infants will develop some degree of PH during their hospitalization, and the incidence rises to 25-40% of the infants with established BPD. Risk factors are not yet well understood, but new evidence shows that fetal growth restriction is a significant predictor of PH. Echocardiography remains the primary method for evaluation of BPD-associated PH, and the development of standardized screening timelines and techniques for identification of infants with BPD-associated PH remains an important ongoing topic of investigation. The use of pulmonary vasodilator medications, such as nitric oxide, sildenafil, and others, in the BPD population is steadily growing, but additional studies are needed regarding their long-term safety and efficacy.
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Ra JJ, Lee SM, Eun HS, Park MS, Park KI, Namgung R, Lee C. Risk Factors of Pulmonary Hypertension in Preterm Infants with Chronic Lung Disease. NEONATAL MEDICINE 2013. [DOI: 10.5385/nm.2013.20.1.75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jeong Jin Ra
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Min Lee
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Sun Eun
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Park
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kook In Park
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ran Namgung
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Chul Lee
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
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Chopra S, Badyal DK, Baby PC, Cherian D. Pulmonary arterial hypertension: advances in pathophysiology and management. Indian J Pharmacol 2012; 44:4-11. [PMID: 22345861 PMCID: PMC3271537 DOI: 10.4103/0253-7613.91858] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 09/29/2011] [Accepted: 10/18/2011] [Indexed: 12/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a heterogeneous, hemodynamic, and pathophysiological state which is commonly found throughout the world, but the disease burden is greater in India and in other developing countries. It is a disease characterized by vascular obstruction and vasoconstriction leading to progressive increase in pulmonary vascular resistance and right ventricular failure. PAH is a progressive disorder carrying a poor prognosis; however, dramatic progress has occurred in our knowledge of its pathogenesis and consequently, its treatment over the last two decades. In this article, we attempt to provide an overview of the etiology, pathophysiology, and current therapeutic modalities in the treatment of PAH. Patients suspected to have PAH should be submitted to a battery of investigations which help in establishing the diagnosis, identifying the etiology, guiding in treatment and informing the prognosis. All patients should be considered for standard therapy with oxygen, anticoagulation, and diuretics for right heart failure. Oral calcium channel blockers should be used in patients with a favorable response to acute vasodilator challenge. Disease targeted therapies include prostacyclines, endothelin receptor blockers, and phosphodiesterase-5 inhibitors. A brief mention of new and potential therapeutic strategies is also included.
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Affiliation(s)
- Sandeep Chopra
- Department of Cardiology, Christian Medical College, Ludhiana, India
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Chung HH, Dai ZK, Wu BN, Yeh JL, Chai CY, Chu KS, Liu CP, Chen IJ. The xanthine derivative KMUP-1 inhibits models of pulmonary artery hypertension via increased NO and cGMP-dependent inhibition of RhoA/Rho kinase. Br J Pharmacol 2010; 160:971-86. [PMID: 20590592 DOI: 10.1111/j.1476-5381.2010.00740.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND PURPOSE KMUP-1 is known to increase cGMP, enhance endothelial nitric oxide synthase (eNOS) and suppress Rho kinase (ROCK) expression in smooth muscle. Here, we investigated the mechanism of action of KMUP-1 on acute and chronic pulmonary artery hypertension (PAH) in rats. EXPERIMENTAL APPROACH We measured pulmonary vascular contractility, wall thickening, eNOS immunostaining, expressions of ROCK II, RhoA activation, myosin phosphatase target subunit 1 (MYPT1) phosphorylation, eNOS, soluble guanylyl cyclase (sGC), protein kinase G (PKG) and phosphodiesterase 5A (PDE-5A), blood oxygenation and cGMP/cAMP, and right ventricular hypertrophy (RVH) in rats. KEY RESULTS In rings of intact pulmonary artery (PA), KMUP-1 relaxed the vasoconstriction induced by phenylephrine (10 microM) or the thromboxane A(2)-mimetic U46619 (0.5 microM). In endothelium-denuded PA rings, this relaxation was reduced. In acute PAH induced by U46619 (2.5 microg x kg(-1) x min(-1), 30 min), KMUP-1 relaxed vasoconstriction by enhancing levels of eNOS, sGC and PKG, suppressing those of PDE-5A, RhoA/ROCK II activation and MYPT1 phosphorylation, and restoring oxygenation in blood and cGMP/cAMP in plasma. Incubating smooth muscle cells from PA (PASMCs) with KMUP-1 inhibited thapsigargin-induced Ca(2+) efflux and angiotensin II-induced Ca(2+) influx. In chronic PAH model induced by monocrotaline, KMUP-1 increased eNOS and reduced RhoA/ROCK II activation/expression, PA wall thickening, eNOS immunostaining and RVH. KMUP-1 and sildenafil did not inhibit monocrotaline-induced PDE-5A expression. CONCLUSION AND IMPLICATIONS KMUP-1 decreased PAH by enhancing NO synthesis by eNOS, with consequent cGMP-dependent inhibition of RhoA/ROCK II and Ca(2+) desensitization in PASMCs. KMUP-1 has the potential to reduce vascular resistance, remodelling and RVH in PAH.
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Affiliation(s)
- Hui-Hsuan Chung
- Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Kim GB. Pulmonary hypertension in infants with bronchopulmonary dysplasia. KOREAN JOURNAL OF PEDIATRICS 2010; 53:688-93. [PMID: 21189939 PMCID: PMC2994133 DOI: 10.3345/kjp.2010.53.6.688] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 05/13/2010] [Indexed: 11/27/2022]
Abstract
An increase in the number of preterm infants and a decrease in the gestational age at birth have resulted in an increase in the number of patients with significant bronchopulmonary dysplasia (BPD) and secondary pulmonary hypertension (PH). PH contributes significantly to the high morbidity and mortality in the BPD patients. Therefore, regular monitoring for PH by using echocardiography and B-type natriuretic peptide (BNP) or N-terminal-proBNP must be conducted in the BPD patients with greater than moderate degree to prevent PH and to ensure early treatment if PH is present. In the BPD patients with significant PH, multi-modality treatment, including treatment for correcting an underlying disease, oxygen supply, use of diverse selective pulmonary vasodilators (inhaled nitric oxide, inhaled prostacyclins, sildenafil, and endothelin-receptor antagonist) and other methods, is mandatory.
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Affiliation(s)
- Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
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Leroy PLJM, Knoester H, Cobben NAM. Screening en follow-up van kinderen die voor thuisbeademing in aanmerking komen. ACTA ACUST UNITED AC 2009. [DOI: 10.1007/bf03086371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Khemani E, McElhinney DB, Rhein L, Andrade O, Lacro RV, Thomas KC, Mullen MP. Pulmonary artery hypertension in formerly premature infants with bronchopulmonary dysplasia: clinical features and outcomes in the surfactant era. Pediatrics 2007; 120:1260-9. [PMID: 18055675 DOI: 10.1542/peds.2007-0971] [Citation(s) in RCA: 384] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although abnormal pulmonary vascular structure and function in preterm infants with bronchopulmonary dysplasia may predispose infants to pulmonary artery hypertension, little is known about the characteristics and outcomes of bronchopulmonary dysplasia-associated pulmonary artery hypertension in the surfactant era. METHODS We studied 42 premature infants (< 32 weeks of gestation) with bronchopulmonary dysplasia who were diagnosed as having pulmonary artery hypertension > or = 2 months after birth, between 1998 and 2006, at a median age of 4.8 months. Pulmonary artery hypertension was graded through echocardiography for all patients; 13 patients also underwent cardiac catheterization. RESULTS Eighteen (43%) of 42 patients had severe pulmonary artery hypertension (systemic or suprasystemic right ventricular pressure). Among 13 patients who underwent catheterization, the mean pulmonary artery pressure was 43 +/- 8 mmHg and the pulmonary vascular resistance index was 9.9 +/- 2.8 Wood units. In 12 patients, pulmonary artery pressure and pulmonary vascular resistance improved with 100% oxygen and 80 ppm inhaled nitric oxide but remained elevated. The pulmonary vascular resistance index decreased to 7.9 +/- 3.8 Wood units in 100% oxygen and to 6.4 +/- 3.1 Wood units with the addition of nitric oxide. Sixteen patients (38%) died during the follow-up period. Estimated survival rates were 64% +/- 8% at 6 months and 53% +/- 11% at 2 years after diagnosis of pulmonary artery hypertension. In multivariate analyses, severe pulmonary artery hypertension and small birth weight for gestational age were associated with worse survival rates. Among 26 survivors (median follow-up period: 9.8 months), pulmonary artery hypertension was improved, relative to its most severe level, in 24 patients (89%). CONCLUSION Premature infants with bronchopulmonary dysplasia and severe pulmonary artery hypertension are at high risk of death, particularly during the first 6 months after diagnosis of pulmonary artery hypertension.
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Affiliation(s)
- Ekta Khemani
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA
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Bibliography. Current world literature. Cardiovascular medicine. Curr Opin Pediatr 2007; 19:601-6. [PMID: 17885483 DOI: 10.1097/mop.0b013e3282f12851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Huicho L, Niermeyer S. Cross-sectional study of electrocardiographic pattern in healthy children resident at high altitude. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2007; 133:879-86. [PMID: 17340640 DOI: 10.1002/ajpa.20563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Electrocardiographic studies have reported persistent right ventricle predominance in high altitude children as an adaptive response. No information was provided on ethnicity and environmental factors in those studies. We assessed the electrocardiographic characteristics in healthy high altitude children with mixed ancestry and relatively high mobility to lower altitudes. A cross-sectional study of 321 children aged 2 months through 19 years old and living at high altitude (Tintaya, Peru, 4,100 m) was conducted. Standard 12-lead electrocardiography was performed. Information was obtained on ethnicity, medical history, place and altitude of pregnancy and birth, mobility of children and their parents and grandparents to lower altitudes, and housing conditions. A medical examination, echocardiography, hemoglobin, oxygen saturation, and anthropometric measurements were performed. Means between sexes were compared through Mann-Whitney test for independent samples not normally distributed. Potentially influential variables on electrocardiographic values were controlled through a general linear model. Electrocardiographic parameters including QRS axis, RV1, RSV1, RV1SV5, RSV5, RSV6, and SV1RV5 did not show a right predominance pattern at any age. Values were within sea level norms. None of the genetic or environmental factors controlled showed a consistent influence on the electrocardiographic variables. Our study showed an electrocardiographic pattern similar to that of sea level in high altitude children with some degree of high-altitude ancestry, comparatively well-nourished and with relatively high mobility to low altitudes.
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Affiliation(s)
- Luis Huicho
- Department of Pediatrics, Universidad Nacional Mayor de San Marcos, Lima 05, Peru.
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