Effects of prostaglandin E1 infusion in the pre-operative management of critical congenital heart disease

Standardizing Prostaglandin Initiation in Prenatally Diagnosed Ductal-Dependent Neonates; A Quality Initiative

Prostaglandin E1 (PGE) is used in patients with ductal-dependent congenital heart disease (CHD). Side effects of apnea and fever are often dose dependent and occur within 48 h after initiation. We initiated a standardized approach to PGE initiation after our institution recognized a high incidence of side effects and a wide variety of starting doses of PGE. Neonates with prenatally diagnosed ductal-dependent CHD were identified, started on a standardized protocol that started PGE at 0.01 mcg/kg/min, and evaluated for PGE related side effects. Compliance, outcomes and dose adjustments during the first 48 h post-PGE initiation were evaluated. Fifty patients were identified (25 pre-intervention; 25 post-intervention). After intervention, compliance with the protocol was 96%, and apnea or fever occurred in 28% (compared to 63% pre-intervention, p = 0.015). Dose adjustments (either increase or decrease) prior to cardiac surgery were similar in both cohorts (60%, 52%, p = 0.569). There were no mortalities or emergent procedures performed due to ductus arteriosus closure. Standardizing a protocol for initiating PGE in prenatally diagnosed ductal-dependent CHD was successful and reduced the incidence of apnea, fever, and sepsis evaluations. A starting dose of 0.01 mcg/kg/min did not cause increased adverse effects.

Prostaglandin E1 for maintaining ductal patency in neonates with ductal-dependent cardiac lesions

BACKGROUND

Prostaglandin E1 (PGE1) is used to keep the ductus arteriosus patent and can be life-saving in neonates with ductal-dependent cardiac lesions. PGE1 is used to promote mixing of pulmonary and systemic blood flow or improve pulmonary or systemic circulations, prior to balloon atrial septostomy or surgery. PGE1 therapy may cause several short-term and long-term adverse effects. The efficacy and safety of PGE1 in neonates with ductal-dependent cardiac lesions has not been systematically reviewed.

OBJECTIVES

To determine the efficacy and safety of both short-term (< 120 hours) and long-term (≥120 hours) PGE1 therapy in maintaining patency of the ductus arteriosus and decreasing mortality in ductal-dependent cardiac lesions.

SEARCH METHODS

We searched the literature in October 2017, using the search strategy recommended by Cochrane Neonatal. We searched electronic databases (CENTRAL (in the Cochrane Library), MEDLINE, CINAHL, Embase); abstracts of the Pediatric Academic Societies; websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com; and in the reference list of identified articles.

SELECTION CRITERIA

Randomized or quasi-randomized trials using PGE1 at any dose or duration to maintain ductal patency in term or late preterm (≥ 34 weeks' gestation) infants with ductal-dependent cardiac lesions and which reported effectiveness and safety in the short term or long term.

DATA COLLECTION AND ANALYSIS

We followed the standard Cochrane methods for conducting a systematic review. Two review authors (SA and MP) independently assessed the titles and abstracts of studies identified by the search strategy to determine eligibility for inclusion. We obtained the full-text version if eligibility could not be done reliably by title and abstract. We resolved any differences by discussion. We designed electronic forms for trial inclusion/exclusion, data extraction, and for requesting additional published information from authors of the original reports.

MAIN RESULTS

Our search did not identify any completed or ongoing trials that met our inclusion criteria.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomized controlled trials to determine the safety and efficacy of PGE1 in neonates with ductal-dependent cardiac lesions. Evidence from observational trials have informed clinical practice on the use of PGE, which is now considered the standard of care for ductal-dependent cardiac lesions. It is unlikely that randomized controlled studies will be performed for this indication but comparative efficacy of newer formulations of PGE1, different doses of PGE1 and studies comparing PGE with PDA stents or other measures to keep the ductus open may be ethical and necessary.

Reappraisal of the prostaglandin E1 dose for early newborns with patent ductus arteriosus-dependent pulmonary circulation

OBJECTIVES

The usual initial dose of prostaglandin E1 (PGE1) for ductal-dependent congenital heart disease (CHD) is 50-100 ng/kg/minute. The aim of this study was to review our experience of a low initial dose of PGE1 treatment in early newborns with congenital heart disease and patent ductus arteriosus (PDA)-dependent pulmonary flow.

METHODS

We reviewed the clinical data of 33 newborns with CHD and PDA-dependent pulmonary circulation who were admitted from January 2005 to December 2010. Clinical parameters were collected, including, PGE1 dosage, oxygenation condition, vital signs, and other related clinical parameters during admission. Echocardiography was employed to assess the status of the PDA as clinically indicated.

RESULTS

Thirty-three newborns, including 17 males and 16 females, with CHD and PDA-dependent pulmonary circulation were enrolled in the study. Their mean age was 2.9 ± 5.1 (within the range of 1-26) days with a median of 1.0 day. Among the 33 cases, 25 were diagnosed with pulmonary atresia and eight with critical pulmonary stenosis. Twenty-five of our patients were treated with the initial low-dosage regimen of 20.0 ± 7.4 ng/kg/minute in our neonatal intensive care unit. None of these 25 patients with had significant apnea necessitating intubation and none had hypotension, fever, convulsion or cortical hyperostosis. Three of the eight patients who were treated with high-dose PGE1 (39 ± 13.2 ng/kg/minute) before referral to our unit had apnea and intubation after PGE1 use. All patients had adequate PDA patency with a low maintenance dose of 10.5 ± 5.3 ng/kg/minute before operation under our protocol.

CONCLUSION

In our experience, adequate PDA flows in early newborns with CHD and PDA-dependent pulmonary circulation could be achieved at a much lower dose than recommended in the literature. The lower dose of PGE1 also causes much fewer complications, such as apnea, fever, and hypotension. For early newborns with CHD and PDA-dependent pulmonary circulation, treatment with a lower initial dose of PGE1 of 20 ng/kg/minute and a maintenance dose of 10 ng/kg/minute is recommended.

Do predictors exist for a successful withdrawal of preoperative prostaglandin E(1) from neonates with d-transposition of the great arteries and intact ventricular septum?

Prostaglandin E(1) (PGE(1)) is given to neonates with d-transposition of the great arteries (d-TGA) to reduce cyanosis by reopening and maintaining the patency of the ductus arteriosus. To avoid side effects, this medication can be stopped for hemodynamically stable patients after balloon atrial septostomy (BAS). A consecutive series of neonates with d-TGA and an intact ventricular septum (IVS) presenting from 2000 through 2005 was analyzed retrospectively to search for side effects of PGE(1) and to identify predictors for a safe preoperative withdrawal. The medication was stopped for hemodynamically stable patients with transcutaneous oxygen saturations higher than 80% after BAS and reinitiated for patients with an oxygen saturation lower than 65%. Patients successfully weaned were compared with those who had failed weaning in terms of atrial septal defect (ASD) size, ductus arteriosus size, and the transcutaneous oxygen saturation. Prostaglandin E(1) was initiated for all 43 neonates with d-TGA. The median maintenance dose of PGE(1) was 0.00625 μg/kg/min (range, 0.00313-0.050 μg/kg/min) for a median duration of 6 days (range, 1-12 days). For 16 patients, PGE(1) was preoperatively withdrawn but then had to be reinitiated for 7 of the 16 patients. No predictors for a successful weaning of PGE(1) were found based on ASD size, ductus arteriosus size, or oxygen saturation. The adverse effects of PGE(1) were apnea in 10 patients and fever in 19 patients. Neither seizures nor necrotizing enterocolitis was documented. Prostaglandin E(1) was successfully withdrawn for a minority of hemodynamically stable patients with d-TGA. No predictors for a successful weaning could be identified. Because apnea and fever are common side effects, withdrawal of PGE(1) after BAS may improve patient safety and comfort. In this patient group, if PGE(1) withdrawal was not well tolerated, it could be safely reinitiated. There were no serious side effects of PGE(1.).

Pre- and Postoperative Quantitation of Right Ventricular Tissue Doppler Velocities in Infants with Hypoplastic Left Heart Syndrome

BACKGROUND

The purpose of this study was to use tissue Doppler imaging (TDI) to serially quantitate initial and preoperative right ventricular (RV) TDI velocities and compare them to postoperative RV TDI velocities as measures of RV function in newborns with hypoplastic left heart syndrome (HLHS).

METHODS

Twelve consecutive patients were prospectively studied with diagnosis of HLHS. Systolic (Sw) and early diastolic (Ew) velocities were recorded at the tricuspid annulus and the ventricular septum at (1) admission, (2) immediately preoperative, and (3) during recovery. All patients were treated preoperatively with prostaglandins (PGE). Velocities were compared using repeated measure analysis of variance.

RESULTS

Mean age at diagnosis was 1 day (0-4 days). Time from diagnosis to surgery was 4 days (1-9 days), age at surgery 5.3 days (2-10 days), and time from surgery to postoperative echo 12.3 days (5-19 days). Tricuspid annular and septal systolic velocities increased from admission to preoperative. Both tricuspid Sw and Ew and septal Sw velocities decreased postoperatively. No significant changes occurred in the ventricular septal diastolic (Ew) velocities from admission to preoperative.

CONCLUSION

These data indicate that following the institution of PGE and initial medical and ventilatory management, there is an increase in RV annular and septal systolic velocities from the initial to the preoperative period and that these indices as well as RV annular diastolic velocities decline significantly postoperatively. Initial septal diastolic velocities were severely abnormal and did not significantly change pre- and postoperatively. These data may have significance for both postoperative and subsequent long-term RV function.

Mortality from congenital cardiovascular malformations in Japan, 1968 through 1997

Long-term mortality from congenital cardiovascular malformations (CCVM) remains unknown in most countries. Age- and sex-specific mortality rates from CCVM in Japan from 1968 through 1997 were determined from analyses, with official permission, of individual death records held by the Japanese Government. CCVM with chromosomal anomalies were not included. The number of deaths analyzed was 82,919. The mortality rate declined by 64% from 3.36 per 100,000 population in 1968 to 1.22 in 1997, largely because of a decrease in mortality among patients under 20 years of age. Infant mortality remained high until 1978, then sharply declined from 1979 to 1987 with the advent of 2-dimensional echocardiographic diagnosis and prostaglandin El therapy. The cumulative mortality rates in the first 20 years of life were expected to decline among cohort members born after 1978. In contrast, the mortality rates for subjects over 20 years of age increased during the 30-year study period. Mortality rates were higher for males than for females. The mortality rate among young patients with CCVM is expected to decline still further, suggesting that many if not most children with CCVM will survive to adulthood.