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Timberline S, Bhatt A, Sunderji S, Tancredi DJ, Lakshminrusimha S, Siefkes H. Novel scoring tool of hypoxemic respiratory failure and pulmonary hypertension for defining severity of persistent pulmonary hypertension of newborn. J Perinatol 2023; 43:1281-1287. [PMID: 37626160 PMCID: PMC10541330 DOI: 10.1038/s41372-023-01762-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE To obtain preliminary validity data for a hypoxemic respiratory failure/pulmonary hypertension (HRF/PH) score for classifying persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN Retrospective chart review of 100 consecutive neonates admitted to a Children's hospital from 2016-2021 with PPHN, gestational age ≥34 weeks, and echocardiograms in the first week. We assessed the correlation between HRF/PH score and short-term outcomes using linear and logistic regressions. RESULTS HRF/PH scores ranged 2-12 (mean 8.5), and were classified mild (0-5), moderate (6-10), and severe (11-15), with 6%, 77% and 17% infants in respective categories. HRF/PH score category correlated with invasive ventilation, nitric oxide, high frequency ventilation, vasoactive infusions, extracorporeal life support and death. HRF/PH score category did not correlate with duration of support or length of stay. CONCLUSION The HRF/PH score offers a promising representation of disease severity for PPHN. The tool requires further validation in prospective studies and evaluation for long-term outcomes.
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Affiliation(s)
- Sage Timberline
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Avni Bhatt
- School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Sherzana Sunderji
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | | | - Heather Siefkes
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA.
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Prasad R, Saha B, Kumar A. Ventricular function in congenital diaphragmatic hernia: a systematic review and meta-analysis. Eur J Pediatr 2022; 181:1071-1083. [PMID: 34725730 DOI: 10.1007/s00431-021-04303-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/19/2021] [Accepted: 10/23/2021] [Indexed: 10/20/2022]
Abstract
There is emerging evidence supporting ventricular function as a prognostic factor in congenital diaphragmatic hernia (CDH). The present systematic review and meta-analysis aimed to determine the predictive value of early ventricular function for survival and extracorporeal membrane oxygenation (ECMO) requirement in newborns with CDH. PubMed, Google Scholar, Cochrane Central Register, Clinical Trial Registry, and Opengrey were accessed. Studies evaluating associations between echocardiographic ventricular function measured ≤ 48 h after birth and survival or ECMO requirement were included. Two independent authors extracted the following data: study and participant characteristics, prognostic factors, and outcome-related data. Eleven studies met the inclusion criteria. Five studies reported on survival, two on ECMO, and four on both outcomes. A moderate risk of bias was found in most of the studies, mainly because of selection, prognostic factors, and confounding biases. For survival (899 participants), pooled sensitivity and specificity were 86% (95% confidence interval [CI], 77-92%) and 44% (95% CI, 25-65%), respectively, in normal left ventricular function. For ECMO need (815 participants), pooled sensitivity and specificity were 39.8% (95% CI, 27-52%) and 88% (95% CI, 80-96%), respectively, in left ventricular dysfunction. Overall certainty of the evidence was graded very low for survival and low for ECMO. Inconsistent reporting of echocardiographic measurements and lack of adjustment for confounding factors were major limitations.Conclusion: Early ventricular dysfunction is a potential prognostic factor in CDH. Standardized echocardiographic measurement reporting and high-quality studies are needed to further elucidate its prognostic significance. What is Known: • Evidence supports the predictive value of echocardiographic measurements in CDH ≤ 24-48 h post-birth. • Ventricular dysfunction has been proposed as a prognostic risk factor. What is New: • Right and left ventricular functions were promising predictors of survival and ECMO requirement in neonates with CDH. • Test characteristics of ventricular function were determined as predictors of survival or need for ECMO. Specific echocardiographic markers of ventricular function can be valuable in determining prognosis.
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Affiliation(s)
- Rameshwar Prasad
- Department of Neonatology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India.
| | - Bijan Saha
- Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Amit Kumar
- Department of Neurology, Rajendra Institute of Medical Sciences, Ranchi Jharkhand, India
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Breinig S, Dicky O, Ehlinger V, Dulac Y, Marcoux MO, Arnaud C. Echocardiographic Parameters Predictive of Poor Outcome in Persistent Pulmonary Hypertension of the Newborn (PPHN): Preliminary Results. Pediatr Cardiol 2021; 42:1848-1853. [PMID: 34331558 PMCID: PMC8324438 DOI: 10.1007/s00246-021-02677-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/30/2021] [Indexed: 12/01/2022]
Abstract
The aim is to conduct a pilot study to prospectively describe echocardiographic parameters in neonates with pulmonary hypertension (PH) managed according to current recommendations and to identify those parameters that could predict worsening of short-term outcomes. All neonates less than 28 days old with a diagnosis of PH were prospectively enrolled in a tertiary care center for 1 year. Two echocardiograms were performed by a trained neonatologist. The first echocardiogram was performed at the time of diagnosis, whereas the second was performed just after basic therapeutic optimization. The cohort included 27 neonates. Mean gestational age at birth was 36.1 weeks gestational age (WGA) (SD: 4) and mean birth weight was 2658 g (SD: 907). Six neonates (22%) died before day 28, with a median age at death of 48 h (IQR [33; 89]). Although the first echocardiogram showed no difference, the second highlighted a strong link between the persistence of right-to left-shunt and death (p = 0.002). We showed a link between right-to-left shunt and a poor outcome (death or morbidity) after therapeutic optimization among premature and full-term neonates suffering from PH. We recommend repeating echocardiography after basic therapeutic optimization and for prognostic purposes, taking into account only the second examination. Larger cohorts are needed to confirm these results.
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Affiliation(s)
- Sophie Breinig
- Neonatal and Pediatric Intensive Care Unit, Children's Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France. .,INSERM, UMR 1027, SPHERE Team, Hôpital Paule de Viguier, 330 Avenue de Grande-Bretagne, TSA 70034, Toulouse, France.
| | - Odile Dicky
- grid.414260.50000 0004 0638 3516INSERM, UMR 1027, SPHERE Team, Hôpital Paule de Viguier, 330 Avenue de Grande-Bretagne, TSA 70034, Toulouse, France ,Neonatal Intensive Care Unit, Children’s Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France
| | - Virginie Ehlinger
- grid.414260.50000 0004 0638 3516INSERM, UMR 1027, SPHERE Team, Hôpital Paule de Viguier, 330 Avenue de Grande-Bretagne, TSA 70034, Toulouse, France
| | - Yves Dulac
- Pediatric Cardiology, Children’s Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France
| | - Marie-Odile Marcoux
- Neonatal and Pediatric Intensive Care Unit, Children’s Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France
| | - Catherine Arnaud
- grid.414260.50000 0004 0638 3516INSERM, UMR 1027, SPHERE Team, Hôpital Paule de Viguier, 330 Avenue de Grande-Bretagne, TSA 70034, Toulouse, France ,grid.411175.70000 0001 1457 2980Clinical Epidemiology Unit, University Hospital Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
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Malowitz JR, Forsha DE, Smith PB, Cotten CM, Barker PC, Tatum GH. Right ventricular echocardiographic indices predict poor outcomes in infants with persistent pulmonary hypertension of the newborn. Eur Heart J Cardiovasc Imaging 2015; 16:1224-31. [PMID: 25851325 DOI: 10.1093/ehjci/jev071] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 03/05/2015] [Indexed: 11/12/2022] Open
Abstract
AIMS Infants with persistent pulmonary hypertension of the newborn (PPHN) have elevated pulmonary vascular resistance that can lead to right ventricular (RV) failure and death. Clinicians must decide which infants will fail conventional therapy and require transfer to extra corporeal membrane oxygenation (ECMO) centres, but accurate echocardiographic predictors have not been identified. We assessed echocardiographic measurements of RV pressure and function in predicting progression to death or ECMO in infants with PPHN. METHODS AND RESULTS Echocardiograms for infants ≥35-week gestation with a clinical diagnosis of PPHN were retrospectively reviewed. Traditional and strain echocardiographic measures were compared for those with or without the primary outcome of ECMO/cardiovascular death. Receiver operator curves identified cut points for measures that were significantly different. Of the 86 subjects analysed, 25 (29%) of the patients had the primary outcome of ECMO/death. The ECMO/death group had diminished tricuspid annular plane systolic excursion (TAPSE; P = 0.002) and RV global longitudinal peak strain (GLPS; P = 0.03), a predominant right-to-left shunt across the patent ductus arteriosus (PDA; P = 0.05), and an elevated oxygenation index (OI; P < 0.001). Sensitivity/specificity for TAPSE <4 mm was 56 and 85%, and for GLPS greater than or equal to -9% was 52 and 77%. CONCLUSION TAPSE, GLPS, and right-to-left PDA shunting were associated with progression to death/ECMO. RV free wall strain was not associated with the outcome, suggesting that diminished global strain better reflects clinical outcomes in this group. These thresholds may assist in the decision-making to transfer high-risk infants to ECMO centres.
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Affiliation(s)
- Jonathan R Malowitz
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
| | - Daniel E Forsha
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - P Brian Smith
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
| | - C Michael Cotten
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
| | - Piers C Barker
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
| | - Gregory H Tatum
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
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Platts DG, Hilton A, Diab S, McDonald C, Tunbridge M, Chemonges S, Dunster KR, Shekar K, Burstow DJ, Fraser JF. A novel echocardiographic imaging technique, intracatheter echocardiography, to guide veno-venous extracorporeal membrane oxygenation cannulae placement in a validated ovine model. Intensive Care Med Exp 2014; 2:2. [PMID: 26266903 PMCID: PMC4512982 DOI: 10.1186/2197-425x-2-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 12/09/2013] [Indexed: 11/24/2022] Open
Abstract
Background Echocardiography plays a fundamental role in cannulae insertion and positioning for extracorporeal membrane oxygenation (ECMO). Optimal access and return cannulae orientation is required to prevent recirculation. The aim of this study was to compare a novel imaging technique, intracatheter echocardiography (iCATHe), with conventional intracardiac echocardiography (ICE) to guide placement of ECMO access and return venous cannulae. Methods Twenty sheep were commenced on veno-venous ECMO (VV ECMO). Access and return ECMO cannulae were positioned using an ICE-guided technique. Following the assessment of cannulae position, the ICE probe was then introduced inside the cannulae, noting location of the tip. After 24 h, the sheep were euthanized and cannulae position was determined at post mortem. The two-tailed McNemar test was used to compare iCATHe with ICE cannulae positioning. Results ICE and iCATHe imaging was possible in all 20 sheep commenced on ECMO. There was no significant difference between the two methods in assessing access cannula position (proportion correct for each 90%, incorrect 10%). However, there was a significant difference between ICE and iCATHe success rates for the return cannula (p = 0.001). Proportion correct for iCATHe and ICE was 80% and 15% respectively. iCATHe was 65% more successful (95% CI 27% to 75%) at predicting the placement of the return cannula. There were no complications related to the ICE or iCATHe imaging. Conclusion iCATHe is a safe and feasible imaging technique to guide real-time VV ECMO cannulae placement and improves accuracy of return cannula positioning compared to ICE. Electronic supplementary material The online version of this article (doi:10.1186/2197-425X-2-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David G Platts
- Department of Echocardiography, Cardiac Investigations Unit, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Queensland, 4032, Australia,
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Stone DM, Frattarelli DAC, Karthikeyan S, Johnson YR, Chintala K. Altered prostaglandin E1 dosage during extracorporeal membrane oxygenation in a newborn with ductal-dependent congenital heart disease. Pediatr Cardiol 2006; 27:360-3. [PMID: 16565906 DOI: 10.1007/s00246-005-1189-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We describe a neonate with ductal-dependent congenital heart disease on extracorporeal membrane oxygenation (ECMO) for persistent pulmonary hypertension, who required markedly high doses of prostaglandin E1 (PGE1) to maintain patency of the ductus arteriosus: The effects of ECMO on the pharmacokinetics of PGE1 are discussed.
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Affiliation(s)
- D M Stone
- Division of Cardiology, Carman Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, 3901 Beaubien, Detroit, MI 48201, USA.
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Longin E, Schaible T, Demirakca S, Lenz T, König S. Heart rate variability during extracorporeal membrane oxygenation and recovery in severe neonatal disease. Early Hum Dev 2006; 82:135-42. [PMID: 16209914 DOI: 10.1016/j.earlhumdev.2005.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 09/23/2004] [Accepted: 07/06/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Heart rate variability (HRV) reveals information on the functional state of the autonomic nervous system (ANS) in neonates. During severe illness, heart rate variability is impaired. AIM This study was initiated to measure the changes in HRV in neonates during extracorporeal membrane oxygenation (ECMO) and recovery from severe respiratory and circulatory failure. Moreover, we compared our data with HRV data of healthy newborns and we investigated the differences in HRV parameters between ECMO-survivors and non-survivors. STUDY DESIGN This study is of an observational character. We performed short-term recordings of heart rate variability in 14 neonates during ECMO and recovery. We computed time- and frequency-domain HRV parameters. RESULTS ECMO significantly affects time-domain HRV parameters. Severe neonatal illness causes a significant reduction of all calculated HRV parameters; clinical recovery is accompanied by an increase of HRV. In comparison with normative data of healthy newborns, however, HRV remains impaired. The ECMO-development ratio separated the non-survivors from the survivors during ECMO therapy. CONCLUSIONS During severe neonatal illness, HRV is impaired. It remains to be clarified whether the impairment of HRV during severe illness can predict the neurological outcome. The ability of the E/D ratio as an HRV parameter to serve as a predictive tool has to be corroborated in larger group of patients.
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Affiliation(s)
- Elke Longin
- Children's Hospital, University of Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Abstract
BACKGROUND/PURPOSE Pulmonary hypertension is an integral part of the pathophysiology of the respiratory failure associated with congenital diaphragmatic hernia. Hypothesizing that the evolution of the pulmonary hypertension would determine clinical outcome, the authors examined pulmonary artery pressures in relation to survival in their CDH patients. METHODS The authors performed a retrospective chart review of all neonates with the CDH from 1991 to 2002 at their institution eliminating infants with complex congenital heart disease, prematurity, or limited treatment. Cardiac ECHO data were used to estimate pulmonary artery pressures as a ratio to systemic pressure. Statistical analyses of estimated pulmonary pressure ratios stratified by survival status and time were performed using chi2 and Fisher's Exact Test methods. RESULTS Forty-seven full-term CDH infants with 428 cardiac ECHO evaluations were studied. Long-term survival rate was 74%. Forty-nine percent of patients had normal pulmonary artery pressure estimates within the first 3 weeks of life. All patients survived. Seventeen percent had persistent systemic or suprasystemic pressure estimates unrelieved by treatment interventions resulting in 100% mortality rate. Thirty-four percent had intermediate reductions in pressure estimates over time with 75% survival rate. Systemic pulmonary artery pressures were associated with decreased survival at all time-points when compared with normal-pressure survivors: week 1, 60% (P <.003); week 3, 38% (P <.007); week 6, 0% (P <.02). CONCLUSIONS The evolution of pulmonary hypertension is a critical determinant of survival in CDH patients with current treatment strategies. Three groups can be modeled with markedly different clinical performance patterns. Using serial cardiac ECHO examinations, pulmonary artery pressure estimations can be used to predict clinical outcome.
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Affiliation(s)
- Peter W Dillon
- Division of Pediatric Surgery, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
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Abstract
The outcome of congenital diaphragmatic hernia (CDH) differs for different stages of the fetus or infant's life (i.e., antenatal, immediate postnatal, and postoperative). Assessing combined data from nonrandomized studies is technically difficult. Following recognized methods of reviewing such trials, we aimed to review the available literature on the outcome of CDH to provide a guide to clinicians when counselling parents who have a fetus/infant with this condition. Thirty-five studies reporting data for CDH from 1985 to March 1998 were identified using a high sensitive search strategy, hand-searching journals, and reviewing references of relevant studies. These were systematically reviewed. The median overall mortality was 58% (interquartile range (IQR), 43-65%) for babies diagnosed in utero, 48% (IQR, 35-55%) if born alive, and 33% (IQR, 18-54%) postoperatively. Diagnosis before 25 weeks of gestation is not a uniformly bad prognostic indicator (median mortality, 60%). Outcome was worse for those fetuses with other anomalies (median mortality, 93%). The median percentage mortality for all infants born alive and treated in extracorporeal membrane oxygenation (ECMO) centers was 34% (IQR, 26-47%). Median percentage mortality for all ECMO-treated infants was 44% (IQR, 35-50%). Different treatment strategies may have a variable impact on outcome. These figures, together with local data, may help in parental counselling on prognosis for fetuses/infants with CDH.
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Affiliation(s)
- M W Beresford
- Regional Neonatal Unit, Liverpool Women's Hospital, Liverpool, UK
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