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Calcaterra G, Bassareo PP, Barilla F, Martino F, Fanos V, Fedele F, Romeo F. Pulmonary hypertension in paediatrics. A feasible approach to bridge the gap between real world and guidelines. J Matern Fetal Neonatal Med 2019; 34:3820-3826. [PMID: 31744358 DOI: 10.1080/14767058.2019.1695770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pulmonary hypertension (PH) is quite infrequent in paediatric age and its most common aetiologies include idiopathic pulmonary arterial hypertension, PH related to congenital heart diseases, bronchopulmonary dysplasia (chronic lung disease), persistence of pulmonary hypertension of the newborn, and congenital diaphragmatic hernia. The developed for adult patients PH classification shows limitations when applied to paediatric subjects, since the underlying causes are markedly different between the two ages. In 2011, the Pulmonary Vascular Research Institute Panama Task Force outlined the first specific paediatric pulmonary hypertensive vascular disease diagnostic classification, including 10 main categories and 109 subcategories, thus testifying PH complex pathophysiology during newborns/children growth and development. The unique, distinctive features of paediatric PH were recognized also during the fifth World Symposium on Pulmonary hypertension in 2013 and then confirmed in the recent 2018 sixth World Symposium. For the sake of uniformity, an attempt to adapt the adult classification to paediatric patients was made. However, all these commendable classifications are very complex and may be not of quick comprehension for clinicians. A clinical simpler and simplified method is now suggested, comprising only five groups: Neonatal, Cardiac, Developmental, Idiopathic, and Syndromic PH. This approach is not aimed at replacing the already existing classifications, but is mainly based on the kind of specialized physician (neonatologist, paediatric cardiologist, paediatrician, pulmonologist, general practitioner) who first faces and looks after the child with suspected PH. What is dramatically known is that paediatric PH is a severe disease which, when untreated or undertreated, may lead to increased morbidity and mortality.
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Affiliation(s)
| | - Pier Paolo Bassareo
- University College of Dublin, Mater Misericordiae University Hospital and Our Lady's Children's Hospital, Crumlin, Dublin, Republic of Ireland
| | - Francesco Barilla
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, "La Sapienza" University of Rome, Rome, Italy
| | - Francesco Martino
- Department of Pediatrics, Obstetrics-Gynecology and Urology, "La Sapienza" University of Rome, Rome, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, University of Cagliari, Cagliari, Italy
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, "La Sapienza" University of Rome, Rome, Italy
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Perioperative Considerations in Pediatric Patients With Pulmonary Hypertension. Int Anesthesiol Clin 2019; 57:25-41. [PMID: 31503094 DOI: 10.1097/aia.0000000000000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hansmann G, Koestenberger M, Alastalo TP, Apitz C, Austin ED, Bonnet D, Budts W, D'Alto M, Gatzoulis MA, Hasan BS, Kozlik-Feldmann R, Kumar RK, Lammers AE, Latus H, Michel-Behnke I, Miera O, Morrell NW, Pieles G, Quandt D, Sallmon H, Schranz D, Tran-Lundmark K, Tulloh RMR, Warnecke G, Wåhlander H, Weber SC, Zartner P. 2019 updated consensus statement on the diagnosis and treatment of pediatric pulmonary hypertension: The European Pediatric Pulmonary Vascular Disease Network (EPPVDN), endorsed by AEPC, ESPR and ISHLT. J Heart Lung Transplant 2019; 38:879-901. [PMID: 31495407 DOI: 10.1016/j.healun.2019.06.022] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/14/2019] [Accepted: 06/15/2019] [Indexed: 02/03/2023] Open
Abstract
The European Pediatric Pulmonary Vascular Disease Network is a registered, non-profit organization that strives to define and develop effective, innovative diagnostic methods and treatment options in all forms of pediatric pulmonary hypertensive vascular disease, including pulmonary hypertension (PH) associated with bronchopulmonary dysplasia, PH associated with congenital heart disease (CHD), persistent PH of the newborn, and related cardiac dysfunction. The executive writing group members conducted searches of the PubMed/MEDLINE bibliographic database (1990-2018) and held face-to-face and web-based meetings. Ten section task forces voted on the updated recommendations, based on the 2016 executive summary. Clinical trials, meta-analyses, guidelines, and other articles that include pediatric data were searched using the term "pulmonary hypertension" and other keywords. Class of recommendation (COR) and level of evidence (LOE) were assigned based on European Society of Cardiology/American Heart Association definitions and on pediatric data only, or on adult studies that included >10% children or studies that enrolled adults with CHD. New definitions by the World Symposium on Pulmonary Hypertension 2018 were included. We generated 10 tables with graded recommendations (COR/LOE). The topics include diagnosis/monitoring, genetics/biomarkers, cardiac catheterization, echocardiography, cardiac magnetic resonance/chest computed tomography, associated forms of PH, intensive care unit/lung transplantation, and treatment of pediatric PH. For the first time, a set of specific recommendations on the management of PH in middle- and low-income regions was developed. Taken together, these executive, up-to-date guidelines provide a specific, comprehensive, detailed but practical framework for the optimal clinical care of children and young adults with PH.
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Affiliation(s)
- Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany.
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | | | - Christian Apitz
- Division of Pediatric Cardiology, Children's University Hospital Ulm, Ulm, Germany
| | - Eric D Austin
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Damien Bonnet
- Unité Médico-Chirurgicale de Cardiologie Congénital et Pédiatrique, Hôspital Necker Enfants Malades, Université Paris Descartes, Sorbonne, Paris, France
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Michele D'Alto
- Cardiology, University L. Vanvitelli - Monaldi Hospital, Naples, Italy
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, United Kingdom
| | - Babar S Hasan
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - R Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Astrid E Lammers
- Department of Pediatric Cardiology, University of Münster, Münster, Germany
| | - Heiner Latus
- Department of Paediatric Cardiology and Congenital Heart Defects, German Heart Centre, Munich, Germany
| | - Ina Michel-Behnke
- Pediatric Heart Center, Division of Pediatric Cardiology, University Hospital for Children and Adolescents, Medical University Vienna, Vienna, Austria
| | - Oliver Miera
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Institute Berlin (DHZB), Berlin, Germany
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Guido Pieles
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Royal Hospital for Children and Bristol Heart Institute, Bristol, United Kingdom
| | - Daniel Quandt
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dietmar Schranz
- Hessen Pediatric Heart Center Giessen & Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Karin Tran-Lundmark
- The Pediatric Heart Center and the Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Robert M R Tulloh
- Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Håkan Wåhlander
- The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Institution of Clinical Sciences, Gothenburg University, Gothenburg, Sweden
| | - Sven C Weber
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Zartner
- Department of Paediatric Cardiology, German Pediatric Heart Centre, Sankt Augustin, Germany
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Brown ML, DiNardo JA, Nasr VG. Anesthesia in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Surgery: Defining the Risk. J Cardiothorac Vasc Anesth 2019; 34:470-478. [PMID: 31345716 DOI: 10.1053/j.jvca.2019.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/08/2019] [Accepted: 06/10/2019] [Indexed: 01/13/2023]
Abstract
The incidence of moderate to severe congenital heart disease (CHD) in the United States is estimated to be 6 per 1,000 live-born, full-term infants. Recent advances in pediatric cardiology, surgery, and critical care have improved significantly the survival rates of patients with CHD leading to an increase in prevalence in both children and adults. Children with CHD significant enough to require cardiac surgery frequently also undergo noncardiac surgical procedures. With this increased demand for procedures that require anesthesia, all anesthesiologists, and more specifically, pediatric anesthesiologists will encounter patients with repaired or unrepaired CHD and other cardiac diseases in their practice. They often are faced with the question, "Is this patient too high risk for anesthesia?" The objective of this literature review is to provide a greater understanding of patients at high risk and to quantify the risk for patients, their families, and clinicians. In addition, specific high-risk lesions (single ventricle, Williams-Beuren syndrome, pulmonary hypertension, cardiomyopathies, and ventricular assist devices) are described.
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Affiliation(s)
- Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.
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Latham GJ, Yung D. Current understanding and perioperative management of pediatric pulmonary hypertension. Paediatr Anaesth 2019; 29:441-456. [PMID: 30414333 DOI: 10.1111/pan.13542] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/20/2018] [Accepted: 11/02/2018] [Indexed: 11/27/2022]
Abstract
Pediatric pulmonary hypertension is a complex disease with multiple, diverse etiologies affecting the premature neonate to the young adult. Pediatric pulmonary arterial hypertension, whether idiopathic or associated with congenital heart disease, is the most commonly discussed form of pediatric pulmonary hypertension, as it is progressive and lethal. However, neonatal forms of pulmonary hypertension are vastly more frequent, and while most cases are transient, the risk of morbidity and mortality in this group deserves recognition. Pulmonary hypertension due to left heart disease is another subset increasingly recognized as an important cause of pediatric pulmonary hypertension. One aspect of pediatric pulmonary hypertension is very clear: anesthetizing the child with pulmonary hypertension is associated with a significantly heightened risk of morbidity and mortality. It is therefore imperative that anesthesiologists who care for children with pulmonary hypertension have a firm understanding of the pathophysiology of the various forms of pediatric pulmonary hypertension, the impact of anesthesia and sedation in the setting of pulmonary hypertension, and anesthesiologists' role as perioperative experts from preoperative planning to postoperative disposition. This review summarizes the current understanding of pediatric pulmonary hypertension physiology, preoperative risk stratification, anesthetic risk, and intraoperative considerations relevant to the underlying pathophysiology of various forms of pediatric pulmonary hypertension.
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Affiliation(s)
- Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Delphine Yung
- Department of Pediatric Cardiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
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Calcaterra G, Fanos V, Bassareo PP. Still puzzling about a clear definition of pulmonary arterial hypertension in newborns. Eur Respir J 2019; 53:53/3/1900005. [DOI: 10.1183/13993003.00005-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/19/2019] [Indexed: 01/08/2023]
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Rosenzweig EB, Abman SH, Berger RMF. Response: Still puzzling about a clear definition of pulmonary arterial hypertension in newborns. Eur Respir J 2019; 53:53/3/1900135. [PMID: 30923178 DOI: 10.1183/13993003.00135-2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Erika B Rosenzweig
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Steven H Abman
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Dept of Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Huang WC, Hsu CH, Sung SH, Ho WJ, Chu CY, Chang CP, Chiu YW, Wu CH, Chang WT, Lin L, Lin SL, Cheng CC, Wu YJ, Wu SH, Hsieh TY, Hsu HH, Fu M, Dai ZK, Kuo PH, Hwang JJ, Cheng SM. 2018 TSOC guideline focused update on diagnosis and treatment of pulmonary arterial hypertension. J Formos Med Assoc 2019; 118:1584-1609. [PMID: 30926248 DOI: 10.1016/j.jfma.2018.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/14/2018] [Indexed: 01/04/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized as a progressive and sustained increase in pulmonary vascular resistance, which may induce right ventricular failure. In 2014, the Working Group on Pulmonary Hypertension of the Taiwan Society of Cardiology (TSOC) conducted a review of data and developed a guideline for the management of PAH.4 In recent years, several advancements in diagnosis and treatment of PAH has occurred. Therefore, the Working Group on Pulmonary Hypertension of TSOC decided to come up with a focused update that addresses clinically important advances in PAH diagnosis and treatment. This 2018 focused update deals with: (1) the role of echocardiography in PAH; (2) new diagnostic algorithm for the evaluation of PAH; (3) comprehensive prognostic evaluation and risk assessment; (4) treatment goals and follow-up strategy; (5) updated PAH targeted therapy; (6) combination therapy and goal-orientated therapy; (7) updated treatment for PAH associated with congenital heart disease; (8) updated treatment for PAH associated with connective tissue disease; and (9) updated treatment for chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chih-Hsin Hsu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shih-Hsien Sung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Jing Ho
- Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chun-Yuan Chu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chih-Ping Chang
- Division of Cardiology, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Wei Chiu
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chun-Hsien Wu
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ting Chang
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan City, Taiwan
| | - Lin Lin
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan
| | - Shoa-Lin Lin
- Department of Internal Medicine, Yuan's General Hospital, Kaohsiung, Taiwan
| | - Chin-Chang Cheng
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan; Pulmonary Hypertension Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Pulmonary Hypertension Interventional Medicine, Cardiovascular Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Shu-Hao Wu
- Pulmonary Hypertension Interventional Medicine, Cardiovascular Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Tsu-Yi Hsieh
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Morgan Fu
- Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Zen-Kong Dai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; National Taiwan University Hospital Yunlin Branch, Douliu City, Taiwan.
| | - Shu-Meng Cheng
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Sanchez Mejia AA, Rodgers NJ. Evaluation and Monitoring of Pulmonary Hypertension in Neonates With Congenital Diaphragmatic Hernia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:11. [PMID: 30767157 DOI: 10.1007/s11936-019-0711-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW This review aims to describe the assessment of pulmonary hypertension and ventricular function in neonates with congenital diaphragmatic hernia and the long-term follow-up of their pulmonary vascular disease. RECENT FINDINGS In 2015, the pediatric pulmonary hypertension guidelines from the American Heart Association and American Thoracic Society suggested class I level of evidence B guidelines for routine evaluation of patients with congenital diaphragmatic hernia, including longitudinal care in an interdisciplinary pulmonary hypertension program and following the recommendations offered for all children with pulmonary hypertension. Congenital diaphragmatic hernia causes compression of the lungs during critical stages of fetal development and results in lung hypoplasia. As a result, there is abnormal development of pulmonary vasculature that leads to post-natal pulmonary hypertension and increased afterload to the right ventricle. Left ventricular filling is affected by decreased pre-load and mechanical compression by abdominal content leading to decreased systemic perfusion. Persistent pulmonary hypertension after surgical repair of congenital diaphragmatic hernia is associated with increased mortality. Assessment and monitoring of pulmonary hypertension and ventricular function in this population of neonates is crucial to determine response to medical treatment, the need for extracorporeal membrane oxygenation, and the timing of surgical repair.
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Affiliation(s)
- Aura A Sanchez Mejia
- Department of Pediatrics, University of Minnesota, 2450 Riverside Ave, East Building, 5th Floor, Minneapolis, MN, 55454, USA.
| | - Nathan J Rodgers
- Department of Pediatrics, University of Minnesota, 2450 Riverside Ave, East Building, 5th Floor, Minneapolis, MN, 55454, USA
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Abstract
Human diseases are historically categorized into groups based on the specific organ or tissue affected. Over the past two decades, advances in high-throughput genomic and proteomic technologies have generated substantial evidence demonstrating that many diseases are in fact markedly heterogeneous, comprising multiple clinically and molecularly distinct subtypes that simply share an anatomical location. Here, a Bayesian network analysis is applied to study comorbidity patterns that define disease subtypes in pediatric pulmonary hypertension. The analysis relearned established subtypes, thus validating the approach, and identified rare subtypes that are difficult to discern through clinical observations, providing impetus for deeper investigation of the disease subtypes that will enrich current disease classifications. Further advances linking disease subtypes to therapeutic response, disease outcomes, as well as the molecular profiles of individual subtypes will provide impetus for the development of more effective and targeted therapies.
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Handler SS, Hallis BJ, Tillman KA, Krolikowski M, Kuhn EM, Kirkpatrick EC, Brosig CL. Assessment of quality of life in pediatric patients with pulmonary hypertension. Pulm Circ 2018; 9:2045894018822985. [PMID: 30562156 PMCID: PMC6607578 DOI: 10.1177/2045894018822985] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The aim of this study is to evaluate quality of life in four domains (physical,
emotional, social, and school) in pediatric patients with pulmonary hypertension
(PH) using a validated survey (PedsQL). This is a prospective cohort study of
pediatric patients aged 2–18 years with PH. Parents of all children and patients
aged 8–18 years with appropriate developmental capacity completed the PedsQL
survey in the clinic. Results were compared with published norms for pediatric
patients, those with congenital heart disease (CHD) and cancer. Thirty-three
children were enrolled yielding 32 parent and 18 patient self-reports: seven
patients were aged 2–4 years; three were aged 5–7 years; 11 were aged 8–12
years, and 12 were aged 13–18 years. Twenty-one patients were classified as
World Health Organization (WHO) Group I pulmonary arterial hypertension (PAH),
11 WHO Group III PH due to lung disease, and one WHO Group V with segmental PH.
Thirteen patients were NYHA functional class (FC) 1, 12 were FC 2, eight were FC
3, and none were FC 4. The PH cohort had significantly lower scores than healthy
children in all domains on both parent and self-report. The PH cohort also had
significantly lower scores than patients with CHD (parent report: total,
physical, social, school; patient self-report: total, physical, school) and
cancer (parent report: school; patient self-report: physical, school). Close to
50% of participants reported at risk scores in each domain. The quality of life
in pediatric PH patients assessed by PedsQL revealed functional impairment in
multiple domains. Administration of the PedsQL during
outpatient encounters may provide an easy, reproducible method to assess quality
of life and direct referral for interventional services.
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Affiliation(s)
- Stephanie S Handler
- 1 Department of Pediatrics (Division of Pediatric Cardiology), Medical College of Wisconsin, Milwaukee, WI, USA
| | - Brian J Hallis
- 1 Department of Pediatrics (Division of Pediatric Cardiology), Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathryn A Tillman
- 1 Department of Pediatrics (Division of Pediatric Cardiology), Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mary Krolikowski
- 1 Department of Pediatrics (Division of Pediatric Cardiology), Medical College of Wisconsin, Milwaukee, WI, USA
| | - Evelyn M Kuhn
- 2 Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Edward C Kirkpatrick
- 1 Department of Pediatrics (Division of Pediatric Cardiology), Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cheryl L Brosig
- 1 Department of Pediatrics (Division of Pediatric Cardiology), Medical College of Wisconsin, Milwaukee, WI, USA
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Active right atrial emptying fraction predicts reduced survival and increased adverse events in childhood pulmonary arterial hypertension. Int J Cardiol 2018; 271:306-311. [DOI: 10.1016/j.ijcard.2018.04.125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/12/2018] [Accepted: 04/26/2018] [Indexed: 12/16/2022]
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Off-label mesenchymal stromal cell treatment in two infants with severe bronchopulmonary dysplasia: clinical course and biomarkers profile. Cytotherapy 2018; 20:1337-1344. [PMID: 30327248 DOI: 10.1016/j.jcyt.2018.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is the most prevalent sequelae of premature birth, for which therapeutic options are currently limited. Mesenchymal stromal cells (MSCs) are a potential therapy for prevention or reversal of BPD. SERIES OF CASES We report on two infants with severe BPD in whom off-label treatment with repeated intravenous doses of allogeneic bone marrow-derived MSCs were administered. We analyzed the temporal profile of serum and tracheal cytokines and growth factors as well as safety, tolerability and clinical response. The administration of repeated intravenous doses of MSCs in two human babies with severe and advanced BPD was feasible and safe and was associated with a decrease of pro-inflammatory molecules and lung injury biomarkers. Both patients were at very advanced stages of BPD with very severe lung fibrosis and did not survive the disease. CONCLUSIONS MSCs are a promising therapy for BPD, but they should be administered in early stages of the disease.
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Kaemmerer H, Apitz C, Brockmeier K, Eicken A, Gorenflo M, Hager A, de Haan F, Huntgeburth M, Kozlik-Feldmann RG, Miera O, Diller GP. Pulmonary hypertension in adults with congenital heart disease: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:79-88. [PMID: 30195841 DOI: 10.1016/j.ijcard.2018.08.078] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/24/2018] [Indexed: 01/03/2023]
Abstract
In the summer of 2016, delegates from the German Respiratory Society (DGP), the German Society of Cardiology (DGK) and the German Society of Pediatric Cardiology (DGPK) met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary hypertension (PH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines, aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH in adults associated with congenital heart disease (CHD). As such patients are often complex and require special attention, and the general PAH treatment algorithm in the ESC/ERS guidelines appears too unspecific for CHD, the working group proposes an analogous algorithm for the management of PH-CHD which takes the special features of this patient group into consideration, and includes general measures, supportive therapy, targeted PAH drug therapy as well as interventional and surgical procedures. The detailed results and recommendations of the working group on PH in adults with CHD, which were last updated in the spring of 2018, are summarized in this article.
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Affiliation(s)
- Harald Kaemmerer
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich, Germany.
| | - Christian Apitz
- Department of Paediatric Cardiology, University Hospital for Paediatric and Adolescent Medicine, Ulm, Germany
| | - Konrad Brockmeier
- Department for Paediatric Cardiology, Heart Centre, University of Cologne, Germany
| | - Andreas Eicken
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich, Germany
| | - Matthias Gorenflo
- Department for Congenital Heart Defects/Paediatric Cardiology, Heidelberg University Hospital, Germany
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich, Germany
| | | | - Michael Huntgeburth
- Clinic for Internal Medicine III, Department of Cardiology, Heart Centre, University of Cologne, Germany
| | - Rainer G Kozlik-Feldmann
- Department for Paediatric Cardiology, University Heart Centre, University Hospital Eppendorf, Hamburg, Germany
| | - Oliver Miera
- Department for Congenital Heart Disease/Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Gerhard P Diller
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
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Lammers AE, Humpl T. Use of pulmonary vasodilators in Fontan patients: a useful strategy to improve functional status and delay transplantation? Pulm Circ 2018; 8:2045894018798616. [PMID: 30124131 PMCID: PMC6122246 DOI: 10.1177/2045894018798616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Astrid E Lammers
- 1 Department of Paediatric Cardiology, Specialist Service for Paediatric Pulmonary Hypertension, University Hospital Münster, Münster, Germany
| | - Tilman Humpl
- 2 Pediatric Intensive Care & Neonatology Children's Hospital, Inselspital, University of Bern, Bern, Switzerland
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67
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Koestenberger M, Avian A, Gamillscheg A, Sallmon H, Grangl G, Burmas A, Schweintzger S, Kurath-Koller S, Cvirn G, Hansmann G. Right ventricular base/apex ratio in the assessment of pediatric pulmonary arterial hypertension: Results from the European Pediatric Pulmonary Vascular Disease Network. Clin Cardiol 2018; 41:1144-1149. [PMID: 29896859 DOI: 10.1002/clc.22994] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 05/18/2018] [Accepted: 06/10/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Echocardiographic determination of RV end-systolic base/apex (RVES b/a) ratio was proposed to be of clinical value for assessment of pulmonary arterial hypertension (PAH) in adults. HYPOTHESIS We hypothesized that the RVES b/a ratio will be affected in children with PAH and aimed to correlate RVES b/a ratio with conventionally used echocardiographic and hemodynamic variables, and with New York Heart Association (NYHA) functional class. METHODS First we determined normal pediatric values for RVES b/a ratio in 157 healthy children (68 males; age range, 0.5-17.7 years). We then conducted an echocardiographic study in 51 children with PAH (29 males; age range, 0.3-17.8 years). RESULTS RVES b/a ratio was lower compared with age- and sex-matched healthy controls (P < 0.001). In children with PAH, RVES b/a ratio decreased with worsening NYHA class. RVES b/a ratio inversely correlated with RV/LV end-systolic diameter ratio (ρ = -0.450, P = 0.001) but did not correlate with RV systolic function parameters (eg, tricuspid annular plane systolic excursion) and correlated with cardiac catheterization-determined pulmonary vascular resistance index (ρ = -0.571, P < 0.001). ROC analysis unraveled excellent performance of RVES b/a ratio to detect PAH in children (AUC: 0.95, 95% CI: 0.89-1.00, P < 0.001). CONCLUSIONS The RVES b/a ratio decreased in children with PAH compared with age- and sex-matched healthy subjects. The RVES b/a ratio inversely correlated with both echocardiographic and hemodynamic indicators of increased RV pressure afterload and with NYHA class, suggesting that RVES b/a ratio reflects disease severity in PAH children.
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Affiliation(s)
- Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Graz, Austria
| | - Andreas Gamillscheg
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gernot Grangl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Ante Burmas
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Sabrina Schweintzger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Stefan Kurath-Koller
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Gerhard Cvirn
- Centre of Physiological Medicine, Medical University Graz, Graz, Austria
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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68
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Hansmann G. Left Ventricular Diastolic Dysfunction in Pediatric Pulmonary Hypertension. Circ Cardiovasc Imaging 2018; 9:CIRCIMAGING.116.005527. [PMID: 27581954 DOI: 10.1161/circimaging.116.005527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Georg Hansmann
- From the Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Germany.
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69
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Okur V, Nees S, Chung WK, Krishnan U. Pulmonary hypertension in patients with 9q34.3 microdeletion-associated Kleefstra syndrome. Am J Med Genet A 2018; 176:1773-1777. [PMID: 30063093 DOI: 10.1002/ajmg.a.38852] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/23/2018] [Accepted: 05/01/2018] [Indexed: 11/09/2022]
Abstract
Kleefstra Syndrome is a rare genetic disorder caused by mutations in EHMT1, Euchromatin Histone Methyl Transferase 1, or deletions encompassing EHMT1 on 9q34.3. Congenital heart defects are among the major findings in patients with 9q34.3 microdeletion/Kleefstra Syndrome along with recognizable facial appearance, developmental delay/intellectual disability including severely delayed or absent speech, hypotonia, seizures, behavioral and sleep abnormalities. Pulmonary hypertension (PH) is a rare condition associated with increased pulmonary artery and right heart pressures that can lead to right heart failure and death if untreated. PH can be idiopathic, heritable, or associated with co-morbid conditions including congenital heart disease (CHD), lung diseases and other metabolic disorders. Genetic factors play important roles in heritable and idiopathic PH development and are particularly relevant but more diverse in etiology in children. PH is also reported in some chromosomal disorders such as Down syndrome in which congenital heart defects are common; however, PH has rarely been reported in patients with 9q34.3 microdeletion/Kleefstra Syndrome. Here, we present three patients with 9q34.3 microdeletions with CHD and PH along with review of five similar cases reported in the literature and discuss the potential association of PH with Kleefstra syndrome.
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Affiliation(s)
- Volkan Okur
- Department of Pediatrics, Columbia University, New York, New York
| | - Shannon Nees
- Department of Pediatrics, Columbia University, New York, New York
| | - Wendy K Chung
- Department of Pediatrics, Columbia University, New York, New York.,Department of Medicine, Columbia University, New York, New York
| | - Usha Krishnan
- Department of Pediatrics, Columbia University, New York, New York
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Abstract
PURPOSE OF REVIEW Pulmonary vascular disease (PVD) complicates the course of many cardiovascular, pulmonary and other systemic diseases in children. The physiological sequelae (pulmonary hypertension and elevated pulmonary vascular resistance) can overwhelm the right ventricle and lead to circulatory collapse. Despite the common end-point, the preceding pathophysiology is complex and variable and requires a tailored approach to diagnosis and management. In this article, we will review the most recent evidence and explore an approach to current controversies in the diagnosis and management of common or challenging patient subgroups. RECENT FINDINGS New methods of interpreting data derived from echocardiography and cardiac magnetic resonance imaging may assist in risk stratification and response to therapy. In specific patient subgroups, standard pharmacological therapies to reduce right ventricle afterload may be overutilized, ineffective and in some cases harmful. In the patient failing pharmacological therapy, new and novel techniques are being explored including temporary extracorporeal mechanical circulatory support, pumpless lung assist devices and novel surgical and catheterization procedures. SUMMARY PVD is a diverse entity, and attention to the underlying pathophysiology is essential for appropriate management. Despite significant advances in our understanding, the majority of data comes from small uncontrolled studies and must be interpreted with caution.
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71
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Miklashevich IM, Shkolnikova МA, Gorbachevsky SV, Shmalts AA, Groznova ОS, Sadykova DI, Yakovleva LV, Degtyarev DN, Burov AA, Ovsyannikov DY, Volkov AV. CONTEMPORARY STRATEGY OF PULMONARY HYPERTENSION MANAGEMENT IN PEDIATRICS. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2018. [DOI: 10.15829/1728-8800-2018-2-101-124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Pulmonary hypertension (PH) in pediatrics is a polygenic multifactorial condition with extremely adverse prognosis. Selection of optimal management is a severe task. In absence of treatment the mean life duration in children is not higher one year. Last two decades, revolution in approaches to treatment improved the survival of this patients group. Recently, pediatricians and pediatric cardiologists have three drugs groups that act on the main pathogenetic chains of PH: endothelin pathway, nitric oxide pathway and prostacyclin pathway. At the moment, approaches to pediatric PH are based on the data obtained in the trials on adult patients. However, not long ago there were first randomized trials on children performed. The group of authors of current article presents a modern view on the problem of PH in children, and expert recommendations on children management. Class of recommendations and evidence level were set by the data obtained in pediatric population or on adult population with at least 10% of children included. To the strategy, developed by the Russian clinicians, laid the analysis of experience of the pathology treatment in Russian Federation, as the current practics and clinical guidelines on pediatric PH in Europe, and the recent trials published.
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Affiliation(s)
- I. M. Miklashevich
- Veltishchev ScientificResearch Clinical Institute of Pediatrics of the Pirogov RNRMU
| | - М. A. Shkolnikova
- Veltishchev ScientificResearch Clinical Institute of Pediatrics of the Pirogov RNRMU
| | | | | | - О. S. Groznova
- Veltishchev ScientificResearch Clinical Institute of Pediatrics of the Pirogov RNRMU
| | | | | | - D. N. Degtyarev
- Kulakov Scientific Center of Obstetrics, Gynecology and Perinatology
| | - A. A. Burov
- Kulakov Scientific Center of Obstetrics, Gynecology and Perinatology
| | | | - A. V. Volkov
- Nasonova ScientificResearch Center of Rheumatology
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72
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Frank BS, Ivy DD. Diagnosis, Evaluation and Treatment of Pulmonary Arterial Hypertension in Children. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E44. [PMID: 29570688 PMCID: PMC5920390 DOI: 10.3390/children5040044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 02/28/2018] [Accepted: 03/16/2018] [Indexed: 12/23/2022]
Abstract
Pulmonary Hypertension (PH), the syndrome of elevated pressure in the pulmonary arteries, is associated with significant morbidity and mortality for affected children. PH is associated with a wide variety of potential underlying causes, including cardiac, pulmonary, hematologic and rheumatologic abnormalities. Regardless of the cause, for many patients the natural history of PH involves progressive elevation in pulmonary arterial resistance and pressure, right ventricular dysfunction, and eventually heart failure. In recent years, a number of pulmonary arterial hypertension (PAH)-targeted therapies have become available to reduce pulmonary artery pressure and improve outcome. A growing body of evidence in both the adult and pediatric literature demonstrates enhanced quality of life, functional status, and survival among treated patients. This review provides a description of select etiologies of PH seen in pediatrics and an update on the most recent data pertaining to evaluation and management of children with PH/PAH. The available evidence for specific classes of PAH-targeted therapies in pediatrics is additionally discussed.
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Affiliation(s)
- Benjamin S Frank
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
| | - D Dunbar Ivy
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
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73
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De A, Shah P, Szmuszkovicz J, Bhombal S, Azen S, Kato RM. A Retrospective Review of Infants Receiving Sildenafil. J Pediatr Pharmacol Ther 2018; 23:100-105. [PMID: 29720910 PMCID: PMC5916436 DOI: 10.5863/1551-6776-23.2.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The purpose of the study was to assess mortality in an infant population receiving sildenafil. METHODS A retrospective review of hospitalized infants at Children's Hospital Los Angeles who received sildenafil between 2008 and 2012 was conducted. Patient characteristics, comorbidities, and treatment characteristics were analyzed. Primary outcome was mortality at discharge. Sildenafil dosage ranges were based on the Sildenafil in Treatment-Naïve Children, Aged 1-17 Years, With Pulmonary Arterial Hypertension trial and were categorized as small (<1.5 mg/kg/day), medium (1.5-3.75 mg/kg/day), large (3.76-7.5 mg/kg/day), and very large (>7.5 mg/kg/day). RESULTS A total of 147 infants were studied. A total of 82% of patients had severe pulmonary hypertension. Our data revealed 29% mortality at discharge. Mortality increased with increasing sildenafil dosage: 14% (small), 19% (medium), 49% (large), and 90% (very large). On multivariate analysis of sildenafil dosage, other pulmonary hypertension therapies, presence of persistent cardiac shunts, and duration of sildenafil, odds of dying were significantly higher with combined high and very high sildenafil dosage groups compared with combined low and medium dosage groups (OR, 13.2; CI, 4.4-39.5; p < 0.0001). CONCLUSION Sildenafil was given to critically ill infants with multiple risk factors for mortality. Although higher doses cannot be causally related to mortality, there appears to be no added benefit by escalating the sildenafil dose.
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74
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Hopper RK, Mullen MP. Genotypes and Phenotypes: Making Progress Toward a Precision Medicine Approach in Pediatric Pulmonary Hypertension. ACTA ACUST UNITED AC 2018. [DOI: 10.21693/1933-088x-17.4.153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Pediatric pulmonary hypertension (PH) is a heterogeneous disease that includes etiologies related to growth and development that are unique to children. Recent pediatric registry studies have characterized diverse phenotypes even within recognized PH subtypes, including PH associated with congenital heart disease and developmental lung disease. Advances in genetics are resulting in increased understanding of the genetic basis for PH, with recent discoveries such as TBX4 mutations specific for pediatric-onset pulmonary arterial hypertension (PAH) and SOX17 related to congenital heart disease–associated PAH. In addition to potential genetic underpinnings, PAH risk and clinical presentation in children with congenital heart disease may vary by cardiac condition, such as single-ventricle physiology or transposition of the great arteries. Growth and development of the pulmonary vasculature likely plays a role in all pediatric PH, which is highlighted by the disruption of normal lung growth in patients with PH related to prematurity and developmental lung disease. These diverse pediatric genotypes and phenotypes underscore a need for an individualized approach to diagnose and treat the complex pediatric PH population. Magnetic resonance imaging (MRI) is increasingly being used to improve clinical characterization of PH in children, with recent identification of specific MRI biomarkers associated with PH severity and outcomes. While much progress has been made, additional understanding of the important genetic causes and developmental concepts in pediatric PH is needed to develop a precision medicine approach to diagnosis and treatment of children with PH.
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Affiliation(s)
- Rachel K. Hopper
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - Mary P. Mullen
- Department of Cardiology, Boston Children's Hospital, Boston, MA
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75
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Kloesel B, Belani K. Pulmonary Hypertension. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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76
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Bernier ML, Jacob AI, Collaco JM, McGrath-Morrow SA, Romer LH, Unegbu CC. Perioperative events in children with pulmonary hypertension undergoing non-cardiac procedures. Pulm Circ 2017; 8:2045893217738143. [PMID: 28971729 PMCID: PMC5731725 DOI: 10.1177/2045893217738143] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Prior limited research indicates that children with pulmonary hypertension (PH) have higher rates of adverse perioperative outcomes when undergoing non-cardiac procedures and cardiac catheterizations. We examined a single-center retrospective cohort of children with active or pharmacologically controlled PH who underwent cardiac catheterization or non-cardiac surgery during 2006–2014. Preoperative characteristics and perioperative courses were examined to determine relationships between the severity or etiology of PH, type of procedure, and occurrence of major and minor events. We identified 77 patients who underwent 148 procedures at a median age of six months. The most common PH etiologies were bronchopulmonary dysplasia (46.7%), congenital heart disease (29.9%), and congenital diaphragmatic hernia (14.3%). Cardiac catheterizations (39.2%), and abdominal (29.1%) and central venous access (8.9%) were the most common procedures. Major events included failed planned extubation (5.6%), postoperative cardiac arrest (4.7%), induction or intraoperative cardiac arrest (2%), and postoperative death (1.4%). Major events were more frequent in patients with severe baseline PH (P = 0.006) and the incidence was associated with procedure type (P = 0.05). Preoperative inhaled nitric oxide and prostacyclin analog therapies were associated with decreased incidence of minor events (odds ratio [OR] = 0.32, P = 0.046 and OR = 0.24, P = 0.008, respectively), but no change in the incidence of major events. PH etiology was not associated with events (P = 0.24). Children with PH have increased risk of perioperative complications; cardiac arrest and death occur more frequently in patients with severe PH and those undergoing thoracic procedures. Risk may be modified by using preoperative pulmonary vasodilator therapy and lends itself to further prospective studies.
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Affiliation(s)
- Meghan L Bernier
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ariel I Jacob
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Collaco
- 2 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Lewis H Romer
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,2 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,4 Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,5 Center for Cell Dynamics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chinwe C Unegbu
- 6 Division of Anesthesiology, Sedation and Perioperative Medicine, Children's National Health System, Washington, DC, USA
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77
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Pulmonary hypertension associated with bronchopulmonary dysplasia in preterm infants. J Reprod Immunol 2017; 124:21-29. [PMID: 29035757 DOI: 10.1016/j.jri.2017.09.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 09/11/2017] [Accepted: 09/29/2017] [Indexed: 12/12/2022]
Abstract
Bronchopulmonary dysplasia (BPD) and BPD-associated pulmonary hypertension (BPD-PH) are chronic inflammatory cardiopulmonary diseases with devastating short- and long-term consequences for infants born prematurely. The immature lungs of preterm infants are ill-prepared to achieve sufficient gas exchange, thus usually necessitating immediate commencement of respiratory support and oxygen supplementation. These therapies are life-saving, but they exacerbate the tissue damage that is inevitably inflicted on a preterm lung forced to perform gas exchange. Together, air-breathing and necessary therapeutic interventions disrupt normal lung development by aggravating pulmonary inflammation and vascular remodelling, thus frequently precipitating BPD and PH via an incompletely understood pathogenic cascade. BPD and BPD-PH share common risk factors, such as low gestational age at birth, fetal growth restriction and perinatal maternal inflammation; however, these risk factors are not unique to BPD or BPD-PH. Occurring in 17-24% of BPD patients, BPD-PH substantially worsens the morbidity and mortality attributable to BPD alone, thus darkening their outlook; for example, BPD-PH entails a mortality of up to 50%. The absence of a safe and effective therapy for BPD and BPD-PH renders neonatal cardiopulmonary disease an area of urgent unmet medical need. Besides the need to develop new therapeutic strategies, a major challenge for clinicians is the lack of a reliable method for identifying babies at risk of developing BPD and BPD-PH. In addition to discussing current knowledge on pathophysiology, diagnosis and treatment of BPD-PH, we highlight emerging biomarkers that could enable clinicians to predict disease-risk and also optimise treatment of BPD-PH in our tiniest patients.
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78
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Caicedo-Cuenca LM. Enfoque de la hipertensión pulmonar en el paciente pediátrico. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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79
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Bronchopulmonary dysplasia associated pulmonary hypertension: Making the best use of bedside echocardiography. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2016.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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80
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The Pulmonary Circulation in the Single Ventricle Patient. CHILDREN-BASEL 2017; 4:children4080071. [PMID: 28783102 PMCID: PMC5575593 DOI: 10.3390/children4080071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 07/31/2017] [Accepted: 08/03/2017] [Indexed: 02/06/2023]
Abstract
In recent decades, survival of children with complex congenital heart disease has improved considerably. Specifically, children with a variety of congenital heart defects resulting in ‘single ventricle’ physiology can now undergo palliative surgery that allows survival beyond the neonatal period, and in many cases into adulthood, despite having a single functional ventricular pumping chamber supplying both the pulmonary and systemic circulation. Our growing understanding of the functionally univentricular heart has resulted in freedom from Fontan failure of >50% at 25 years post-Fontan. Yet there is still a fair amount of knowledge to be gained, specifically as it relates to the pulmonary circulation in this group of patients. Knowledge gaps relate not only to the pulmonary circulation after Fontan operation, but also at each stage of the single ventricle surgical palliation, including the native physiology prior to any intervention. The pulmonary circulation is affected by multiple issues related to the single ventricle, including specific details of the anatomy unique to each patient, any intervention(s) undertaken, and potential complications such as aortopulmonary collaterals, protein losing enteropathy, plastic bronchitis, venovenous collaterals, pulmonary arteriovenous fistulae, ventricular dysfunction, pulmonary venous stenosis, and more. This chapter will review the current knowledge with regard to the pulmonary circulation in the single ventricle patient, primarily after the Fontan operation. Additionally, it is our hope to help the practitioner assess the pulmonary circulation in the single ventricle patient; we will also discuss the evidence behind and approach to treatment strategies in order to optimize the pulmonary circulation in this complex group of patients.
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81
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Affiliation(s)
- Mardi Gomberg-Maitland
- From the Inova Heart and Vascular Institute, Virginia Commonwealth University, Falls Church (M.G.-M); and Pulmonary Department, Heart Institute, University of Sao Paulo Medical School, Brazil (R.S.)
| | - Rogerio Souza
- From the Inova Heart and Vascular Institute, Virginia Commonwealth University, Falls Church (M.G.-M); and Pulmonary Department, Heart Institute, University of Sao Paulo Medical School, Brazil (R.S.)
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82
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Ong MS, Mullen MP, Austin ED, Szolovits P, Natter MD, Geva A, Cai T, Kong SW, Mandl KD. Learning a Comorbidity-Driven Taxonomy of Pediatric Pulmonary Hypertension. Circ Res 2017; 121:341-353. [PMID: 28611076 PMCID: PMC5559726 DOI: 10.1161/circresaha.117.310804] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/07/2017] [Accepted: 06/12/2017] [Indexed: 11/16/2022]
Abstract
RATIONALE Pediatric pulmonary hypertension (PH) is a heterogeneous condition with varying natural history and therapeutic response. Precise classification of PH subtypes is, therefore, crucial for individualizing care. However, gaps remain in our understanding of the spectrum of PH in children. OBJECTIVE We seek to study the manifestations of PH in children and to assess the feasibility of applying a network-based approach to discern disease subtypes from comorbidity data recorded in longitudinal data sets. METHODS AND RESULTS A retrospective cohort study comprising 6 943 263 children (<18 years of age) enrolled in a commercial health insurance plan in the United States, between January 2010 and May 2013. A total of 1583 (0.02%) children met the criteria for PH. We identified comorbidities significantly associated with PH compared with the general population of children without PH. A Bayesian comorbidity network was constructed to model the interdependencies of these comorbidities, and network-clustering analysis was applied to derive disease subtypes comprising subgraphs of highly connected comorbid conditions. A total of 186 comorbidities were found to be significantly associated with PH. Network analysis of comorbidity patterns captured most of the major PH subtypes with known pathological basis defined by the World Health Organization and Panama classifications. The analysis further identified many subtypes documented in only a few case studies, including rare subtypes associated with several well-described genetic syndromes. CONCLUSIONS Application of network science to model comorbidity patterns recorded in longitudinal data sets can facilitate the discovery of disease subtypes. Our analysis relearned established subtypes, thus validating the approach, and identified rare subtypes that are difficult to discern through clinical observations, providing impetus for deeper investigation of the disease subtypes that will enrich current disease classifications.
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Affiliation(s)
- Mei-Sing Ong
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.).
| | - Mary P Mullen
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.)
| | - Eric D Austin
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.)
| | - Peter Szolovits
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.)
| | - Marc D Natter
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.)
| | - Alon Geva
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.)
| | - Tianxi Cai
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.)
| | - Sek Won Kong
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.)
| | - Kenneth D Mandl
- From the Computational Health Informatics Program (M.-S.O., M.D.N., A.G., S.W.K., K.D.M.), Department of Cardiology (M.P.M.), Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine (A.G.), and Department of Anesthesia (A.G.), Harvard School of Medicine, Boston Children's Hospital, MA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN (E.D.A.); Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge (P.S.); Department of Pediatrics, Massachusetts General Hospital, Boston (M.D.N.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA. (T.C.)
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83
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Abstract
Different treatment options for pulmonary hypertension have emerged in recent years, and evidence-based management strategies have improved quality of life and survival in adults. In children with pulmonary vascular disease, therapeutic algorithms are not so clearly defined; this study determined current treatment initiation in children with pulmonary hypertension in participating centres of a registry. Through the multinational Tracking Outcomes and Practice in Pediatric Pulmonary Hypertension registry, patient demographics, diagnosis, and treatment as judged and executed by the local physician were collected. Inclusion criteria were >3 months and <18 years of age and diagnostic cardiac catheterisation consistent with pulmonary hypertension (mean pulmonary arterial pressure ⩾25 mmHg, pulmonary vascular resistance index ⩾3 Wood units×m2, and mean pulmonary capillary wedge pressure ⩽12 mmHg). At diagnostic catheterisation, 217/244 patients (88.9%) were treatment naïve for pulmonary hypertension-targeted therapy. Targeted therapy was initiated after catheterisation in 170 (78.3%) treatment-naïve patients. A total of 19 patients received supportive therapy, 28 patients were not started on therapy, and 26 patients (10.7%) were on targeted treatment before catheterisation. Among treatment-naïve subjects, treatment was initiated with one targeted drug (n=112, 51.6%), dual therapy (n=39, 18%) or triple-therapy (n=5, 2.3%), and calcium channel blockers with one targeted medication in one patient (0.5%). Phosphodiesterase inhibitors type 5 were used frequently; some patients with pulmonary hypertension related to lung disease received targeted therapy. There is a diverse therapeutic approach for children with pulmonary hypertension with a need of better-defined treatment algorithms based on paediatric consensus for different aetiologies including the best possible diagnostic workup.
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84
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Mahgoub L, Kaddoura T, Kameny AR, Lopez Ortego P, Vanderlaan RD, Kakadekar A, Dicke F, Rebeyka I, Calderone CA, Redington A, Del Cerro MJ, Fineman J, Adatia I. Pulmonary vein stenosis of ex-premature infants with pulmonary hypertension and bronchopulmonary dysplasia, epidemiology, and survival from a multicenter cohort. Pediatr Pulmonol 2017; 52:1063-1070. [PMID: 28152279 DOI: 10.1002/ppul.23679] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/16/2016] [Accepted: 01/13/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pulmonary vein stenosis is emerging as an important clinical problem in ex-premature infants. METHODS We sought to describe the epidemiology of pulmonary vein stenosis affecting ex-premature infants by a multicenter retrospective cohort study of patients from seven children's hospitals diagnosed between 2000-2014. RESULTS We identified 39 ex-premature patients (26 males, median gestational age 28 weeks range 22-36 weeks, birth weight 1.1 kg range 433-2645-g) with pulmonary vein stenosis. Median age at diagnosis was 6.5 months (1 month-6 years). Presentation with pulmonary hypertension occurred in 26/39 (67%) and 29/39 (74%) had bronchopulmonary dysplasia, 15 (39%) were born of twin pregnancies with unaffected twin siblings. A median of 5 (range 1-25) echocardiograms was performed prior to diagnosis. The diagnosis was made using echocardiography in 22/39 (56%), by multi-detector contrast computed tomography scan (CT) in 8/39 (21%), cardiac catheterization in 6/39 (15%) patients, magnetic resonance imaging in 3/39 (8%). Freedom from death or re-stenosis was 73% at 1-year, 55% at 2, 5, and 10 years. Factors associated with shorter survival or re-stenosis were stenosis of ≥3 pulmonary veins (P < 0.01), bilateral pulmonary vein stenosis (P < 0.01) small for gestational age (P = 0.05), aged <6 months at diagnosis (P < 0.01). CONCLUSION Pulmonary vein stenosis of ex-premature infants is a complex problem with poor survival, delayed diagnosis, and unsatisfactory treatment. The lack of concordance in twins suggests epigenetic or environmental factors may play a role in the development of pulmonary vein stenosis. In ex-premature infants with pulmonary hypertension and bronchopulmonary dysplasia a focused echocardiographic assessment of the pulmonary veins is required with further imaging if the echocardiogram is inconclusive.
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Affiliation(s)
- Linda Mahgoub
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Tarek Kaddoura
- Electrical and Computer Engineering, University of Alberta, Edmonton, Canada
| | - A Rebecca Kameny
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | | | | | - Frank Dicke
- Alberta Children's Hospital, Calgary, Canada
| | - Ivan Rebeyka
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | | | | | - Maria Jesus Del Cerro
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Jeff Fineman
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Ian Adatia
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
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85
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Koestenberger M, Hansmann G, Apitz C, Latus H, Lammers A. Diagnostics in Children and Adolescents with Suspected or Confirmed Pulmonary Hypertension. Paediatr Respir Rev 2017; 23:3-15. [PMID: 27964948 DOI: 10.1016/j.prrv.2016.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/20/2016] [Indexed: 12/13/2022]
Abstract
We provide a practical approach on the initial assessment and diagnostic work-up of children and adolescents with pulmonary hypertension (PH). Transthoracic echocardiography (TTE) often serves as initial study tool before invasive cardiac catheterization. Misinterpretation of TTE variables may lead to missed or delayed diagnosis with devastating consequences, or unnecessary invasive diagnostics that have inherited risks. In addition to clinical and biochemical markers, serial examination of patients with PH using a standardized TTE approach, determining conventional and novel echocardiographic variables, may allow early diagnosis and treatment in paediatric PH. Cardiac magnetic resonance imaging and computed tomography represent important non-invasive imaging modalities, that together with TTE may enable comprehensive assessment of ventricular function and pulmonary hemodynamics. Invasive assessment of haemodynamics (ventricular, pulmonary) and testing of acute vasoreactivity in the catheterization laboratory is still the gold standard for the diagnosis of PH and pulmonary hypertensive vascular disease (PHVD) in children and for the initiation of specific PH therapy. We suggest the regular assessment of prognostic TTE variables as part of a standardized approach for initial diagnosis of children with PH. Overreliance on any single TTE variable should be avoided as it detracts from the overall diagnostic potential of a standardized TTE examination for PH.
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Affiliation(s)
- Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Austria.
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Germany
| | - Christian Apitz
- Department of Pediatric Cardiology, University Children's Hospital Ulm, Germany
| | - Heiner Latus
- Pediatric Heart Centre, Justus-Liebig-University, Giessen, Germany
| | - Astrid Lammers
- Department of Paediatric Cardiology, University of Münster, Germany
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86
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Abstract
Congenital diaphragmatic hernia (CDH) is a complex entity wherein a diaphragmatic defect allows intrathoracic herniation of intra-abdominal contents and both pulmonary parenchymal and vascular development are stifled. Pulmonary pathology and pathophysiology, including pulmonary hypoplasia and pulmonary hypertension, are hallmarks of CDH and are associated with disease severity. Pulmonary hypertension (PH) is sustained, supranormal pulmonary arterial pressure, and among patients with CDH (CDH-PH), is driven by hypoplastic pulmonary vasculature, including alterations at the molecular, cellular, and tissue levels, along with pathophysiologic pulmonary vasoreactivity. This review addresses the basic mechanisms, altered anatomy, definition, diagnosis, and management of CDH-PH. Further, emerging therapies targeting CDH-PH and PH are explored.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, Texas 77030.
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87
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Fitzgerald DA, Eber E, Lands LC. Secondary Pulmonary Hypertension: Who to consider, how to confirm and when to follow-up. Paediatr Respir Rev 2017; 23:1-2. [PMID: 27986505 DOI: 10.1016/j.prrv.2016.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 10/25/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales 2145, Australia.
| | - Ernst Eber
- Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Austria
| | - Larry C Lands
- Pediatric Respiratory Medicine, Montreal Children's Hospital-Mcgill University Health Centre, Meakins Christie Laboratories, Montreal, Canada
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88
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Hansmann G. Pulmonary Hypertension in Infants, Children, and Young Adults. J Am Coll Cardiol 2017; 69:2551-2569. [DOI: 10.1016/j.jacc.2017.03.575] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 03/06/2017] [Accepted: 03/10/2017] [Indexed: 12/18/2022]
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89
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Ding X, Zhou S, Li M, Cao C, Wu P, Sun L, Fei G, Wang R. Upregulation of SRF Is Associated With Hypoxic Pulmonary Hypertension by Promoting Viability of Smooth Muscle Cells via Increasing Expression of Bcl-2. J Cell Biochem 2017; 118:2731-2738. [PMID: 28176371 DOI: 10.1002/jcb.25922] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 02/06/2017] [Indexed: 12/11/2022]
Abstract
The aim of study was to investigate the involvement of hypoxia-induced upregulation of serum response factor (SRF) and its downstream effector, B cell leukemia-2 (Bcl-2), in hypoxia-induced pulmonary hypertension (PH). Immunohistochemistry analysis and western blot analysis were used to detect the levels of SRF and Bcl-2 in rats exposed to hypoxia. Furthermore, the regulatory relationship between SRF and Bcl-2 was investigated in PASMCs using real-time PCR and western-blot analysis. We found that mPAP (mean pulmonary arterial pressure) and WA (the ratio of vascular wall area to external diameter) were increased after exposure to hypoxia, while LA (the ratio of vascular lumen area to total area) decreased after exposure to hypoxia. The immunohistochemistry analysis displayed a substantial increase in SRF and Bcl-2 in pulmonary arterial walls after 14 days of hypoxia. And the western blotting showed that SRF and Bcl-2 protein levels were much higher after 7 days of hypoxia and then remained at a high level. And then the levels of SRF and Bcl-2 in pulmonary artery smooth muscle cells (PASMCs) exposed to hypoxia were substantially suppressed following introduction of SRF siRNA, and the level of Bcl-2 was remarkably inhibited by Bcl-2 siRNA, while Bcl-2 siRNA had no effect on SRF level. Finally, SRF siRNA, and Bcl-2 siRNA significantly reduced viability of PASMCs exposed to hypoxia, and enhanced apoptosis of PASMCs exposed to hypoxia. These data validated that SRF responded to hypoxia, which subsequently was involved in pulmonary hypertension by abnormally promoting viability of PASMCs via modulating expression of Bcl-2. J. Cell. Biochem. 118: 2731-2738, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Xing Ding
- Department of Respiratory Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Sijing Zhou
- Department of Occupational Medicine, Hefei Third Clinical College Affiliated to Anhui Medical University, Hefei, China
| | - Min Li
- Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chao Cao
- Department of Respiratory Medicine, Ningbo First Hospital, Ningbo, China
| | - Peipei Wu
- Department of Respiratory Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Li Sun
- Department of Respiratory Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Guanghe Fei
- Department of Respiratory Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ran Wang
- Department of Respiratory Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, China
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90
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[Clinicopathological analysis of pulmonary vascular disease in 38 neonates died of respiratory failure]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017. [PMID: 28446408 PMCID: PMC6744086 DOI: 10.3969/j.issn.1673-4254.2017.04.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
We reviewed the data of 38 neonates who died of respiratory failure. Paraffin sections of the autopsy lung samples were examined with HE staining or immunolabeling for CD34, CD68 and CK to observe the development of the pulmonary vessels and detect potential pulmonary vascular diseases (PVDs). Five cases were identified to have PVDs, including pulmonary hypertensive vascular remodeling in 3 cases and alveolar capillary dysplasia in 2 cases. The result indicated that PVD was one of the important reasons for respiratory failure in these neonates.
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91
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Kula S, Pektaş A. A review of pediatric pulmonary hypertension with new guidelines. Turk J Med Sci 2017; 47:375-380. [PMID: 28425226 DOI: 10.3906/sag-1605-172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 10/02/2016] [Indexed: 11/03/2022] Open
Abstract
This study aims to review pediatric pulmonary hypertension (PH) by comparing the guidelines of the European Society of Cardiology (ESC)/European Respiratory Society (ERS), the American Heart Association (AHA)/American Thoracic Society (ATS), and the European Pediatric Pulmonary Vascular Disease Network (EPPVDN). All three sets of guidelines define PH as having a mean pulmonary artery pressure of ≥25 mmHg and accept the validity of the World Health Organization (WHO) classification system. Every child with a high index of suspicion for PH should undergo an initial work-up of chest X-rays, electrocardiography, and echocardiography. The AHA/ATS guidelines emphasize the necessity of cardiac catheterization and hemodynamic studies. As mentioned in the AHA/ATS guidelines, the symptoms and tests that can detect PH include right ventricle failure, WHO functional class, syncope, echocardiography findings, hemodynamic data, brain natriuretic peptide (BNP)/N-terminal pro-BNP, the 6-min walk test, and cardiopulmonary exercise tests. The EPPVDN guidelines refer to positive acute vasoreactivity test results and growth as risk factors. All three guidelines highlight the importance of treating and following affected children in specialized centers and recommend calcium channel blockers as a first-line treatment in children (aged >12 months) who have a positive acute vasoreactivity test. Children with PH have distinct clinical features. In order to overcome the controversies related to the optimal management of pediatric PH, well-designed clinical studies should be carried out on a large cohort of affected children.
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Affiliation(s)
- Serdar Kula
- Department of Pediatric Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ayhan Pektaş
- Department of Pediatric Cardiology, Faculty of Medicine, Afyon Kocatepe University, Afyon, Turkey
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92
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Kulik TJ, Austin ED. Pulmonary hypertension's variegated landscape: a snapshot. Pulm Circ 2017; 7:67-81. [PMID: 28680566 PMCID: PMC5448531 DOI: 10.1177/2045893216686930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/29/2016] [Indexed: 01/29/2023] Open
Abstract
The many types of pulmonary hypertension (PH) are so protean in their biological origin, histological expression, and natural history that it is difficult to create a summary picture of the disease, or to easily compare and contrast characteristics of one type of PH with another. For newcomers to the field, however, such a picture would facilitate a broad understanding of PH. In this paper, we suggest that four characteristics are fundamental to describing the nature of various types of PH, and that taken together they define a number of patterns of PH expression. These characteristics are histopathology, developmental origin, associated clinical conditions, and potential for resolution. The “snapshot” is a way to concisely display the ways that these signal characteristics intersect in select specific types of PH, and is an effort to summarize these patterns in a way that facilitates a “big picture” comprehension of this disease.
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Affiliation(s)
- Thomas J Kulik
- Department of Cardiology, Division of Cardiac Critical Care, and the Pulmonary Hypertension Program, Boston Children's Hospital, Boston, MA, USA
| | - Eric D Austin
- Vanderbilt Pediatric Pulmonary Hypertension Program, Vanderbilt Medical Center North, Nashville, TN, USA
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93
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Sehgal A, Malikiwi A, Paul E, Tan K, Menahem S. A new look at bronchopulmonary dysplasia: postcapillary pathophysiology and cardiac dysfunction. Pulm Circ 2017; 6:508-515. [PMID: 28090292 DOI: 10.1086/688641] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pulmonary hypertension (PH) and right ventricular function are the focus of cardiovascular effects of bronchopulmonary dysplasia (BPD). We assessed cardiac indexes reflecting systemic afterload and pulmonary venous back pressure as pathophysiologic factors. Cardiac parameters were measured by conventional echocardiography in 20 preterm infants with severe BPD and compared with those of 10 preterm infants with no BPD and 20 healthy term infants. In infants with severe BPD, PH was noted in 5 (25%) by tricuspid regurgitation Doppler jet ≥2.8 m/s and in 15 (75%) by time to peak velocity/right ventricular ejection time <0.34. Among systemic cardiac indexes, significant impairment of diastolic measures was noted in the BPD group compared with infants with no BPD and term infants. The significance persisted after adjusting for gestational age and birth weight. These included transmitral E/A ratio (1.07 ± 0.07 vs. 0.91 ± 0.04 vs. 0.89 ± 0.09; P < 0.0001), isovolumic relaxation time (68.8 ± 3.9 vs. 58.5 ± 7.8 vs. 54.2 ± 5.7 ms ; P < 0.0001), mitral valve stroke volume (4.7 ± 0.7 vs. 5.6 ± 0.6 vs. 5.9 ± 0.1; P = 0.002), and myocardial performance index (0.33 ± 0.05 vs. 0.28 ± 0.01 vs. 0.27 ± 0.05; P = 0.03). Left ventricular output was significantly lower in the BPD cohort (183 ± 45 vs. 189 ± 9 vs. 191 ± 32 mL/kg/min; P = 0.03). Altered systemic (left-sided) cardiac function was noted in infants with BPD, which may lead to pulmonary venous congestion contributing to a continued need for respiratory support.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Monash Health, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia
| | - Andra Malikiwi
- Monash Newborn, Monash Children's Hospital, Monash Health, Melbourne, Australia
| | - Eldho Paul
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; and Clinical Haematology Department, Alfred Hospital, Melbourne, Australia
| | - Kenneth Tan
- Monash Newborn, Monash Children's Hospital, Monash Health, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia
| | - Samuel Menahem
- Department of Paediatrics, Monash University, Melbourne, Australia; Paediatric and Foetal Cardiac Units, Monash Medical Centre, Monash Health, Melbourne, Australia
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94
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Zijlstra WMH, Elmasry O, Pepplinkhuizen S, Ivy DD, Bonnet D, Luijendijk P, Lévy M, Gavilan JL, Torrent-Vernetta A, Mendoza A, del Cerro MJ, Moledina S, Berger RMF. Pulmonary arterial hypertension in children after neonatal arterial switch operation. Heart 2017; 103:1244-1249. [DOI: 10.1136/heartjnl-2016-310624] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 12/11/2016] [Accepted: 12/19/2016] [Indexed: 12/27/2022] Open
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95
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Goss KN, Everett AD, Mourani PM, Baker CD, Abman SH. Addressing the challenges of phenotyping pediatric pulmonary vascular disease. Pulm Circ 2017; 7:7-19. [PMID: 28680562 PMCID: PMC5448545 DOI: 10.1086/689750] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/14/2016] [Indexed: 12/20/2022] Open
Abstract
Pediatric pulmonary vascular disease (PVD) and pulmonary hypertension (PH) represent phenotypically and pathophysiologically diverse disease categories, contributing substantial morbidity and mortality to a complex array of pediatric conditions. Here, we review the multifactorial nature of pediatric PVD, with an emphasis on improved recognition, phenotyping, and endotyping strategies for pediatric PH. Novel tailored approaches to diagnosis and treatment in pediatric PVD, as well as the implications for long-term outcomes, are highlighted.
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Affiliation(s)
- Kara N Goss
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Allen D Everett
- Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter M Mourani
- Section of Pediatric Critical Care, Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Christopher D Baker
- Pediatric Pulmonary Medicine, Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Steven H Abman
- Pediatric Pulmonary Medicine, Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
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96
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Baranov AA, Namazova-Baranova LS, Volodin NN, Davydova IV, Ovsyannikov DU, Ivanov DO, Boytsova EV, Yatsik GV, Antonov AG, Ionov OV, Ryndin AU, Grebennikov VA, Soldatova IG, Chubarova AI. Managing Children with Bronchopulmonary Dysplasia. PEDIATRIC PHARMACOLOGY 2016. [DOI: 10.15690/pf.v13i4.1603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Bronchopulmonary dysplasia is one of the most significant early childhood chronic respiratory diseases. The article features modern approaches to preventing, diagnosing and treating broncho-pulmonary dysplasia, as well as ways of preventing complications and undesirable disease outcomes in patients older than 3 years. Members of professional associations — Union of Pediatricians of Russia and Russian Association of Perinatal Medicine Specialists — have summarized the experience of managing this category of patients at leading Russian pediatric centers according to the principles of evidence-based medicine and have provided scientific and practical data corresponding to the world level of knowledge with regard to the present problem.
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Affiliation(s)
- A. A. Baranov
- Scientific Center of Children’s Health; Pirogov Russian National Research Medical University
| | - L. S. Namazova-Baranova
- Scientific Center of Children’s Health; Pirogov Russian National Research Medical University; Sechenov First Moscow State Medical University
| | - N. N. Volodin
- D. Rogachev Federal Scientific-Clinical Center of Child Hematology, Oncology and Immunology
| | - I. V. Davydova
- Scientific Center of Children’s Health; Sechenov First Moscow State Medical University
| | | | - D. O. Ivanov
- St. Petersburg State Pediatric Medical University
| | - E. V. Boytsova
- Scientific Research Institute of Pulmonology at the I.P. Pavlov St. Petersburg State Medical University
| | | | - A. G. Antonov
- V.I. Kulakov Scientific Center of Obstetrics, Gynaecology and Perinatology
| | - O. V. Ionov
- V.I. Kulakov Scientific Center of Obstetrics, Gynaecology and Perinatology
| | - A. U. Ryndin
- V.I. Kulakov Scientific Center of Obstetrics, Gynaecology and Perinatology
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97
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Abstract
PURPOSE OF REVIEW Pediatric pulmonary vascular disease contributes to morbidities and death in diverse clinical settings, ranging from idiopathic or heritable forms of pediatric arterial hypertension, congenital heart disease, developmental lung disorders, chronic lung disease, left heart disease, sickle cell disease, oncologic disease, and systemic disorders. Despite its impact on the clinical courses in so many diseases, information is limited on how to best approach the diagnosis and evaluation of pediatric pulmonary hypertension. RECENT FINDINGS To address this issue, a group of clinical experts from several subspecialties, including pulmonology, cardiology, neonatology, and others, were selected to form a task force to tackle this topic with support from the American Heart Association and American Thoracic Society. A joint guidelines study presenting their findings was recently published. SUMMARY This review highlights a few key topics underlying guidelines for the care of children with pulmonary hypertension that are especially important for the practicing pediatrician and others, and presents some of the major recommendations from the published guidelines report. Overall, the author emphasizes that these guidelines are based on the best current evidence and clinical experience of experts in the field, yet much more clinical research is needed to improve long-term outcomes in pediatric pulmonary hypertension.
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Affiliation(s)
- Steven H Abman
- Pediatric Heart Lung Center, Section of Pediatric Pulmonary Medicine, Department of Pediatrics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
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98
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Kaddoura T, Vadlamudi K, Kumar S, Bobhate P, Guo L, Jain S, Elgendi M, Coe JY, Kim D, Taylor D, Tymchak W, Schuurmans D, Zemp RJ, Adatia I. Acoustic diagnosis of pulmonary hypertension: automated speech- recognition-inspired classification algorithm outperforms physicians. Sci Rep 2016; 6:33182. [PMID: 27609672 PMCID: PMC5016849 DOI: 10.1038/srep33182] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/19/2016] [Indexed: 12/14/2022] Open
Abstract
We hypothesized that an automated speech- recognition-inspired classification algorithm could differentiate between the heart sounds in subjects with and without pulmonary hypertension (PH) and outperform physicians. Heart sounds, electrocardiograms, and mean pulmonary artery pressures (mPAp) were recorded simultaneously. Heart sound recordings were digitized to train and test speech-recognition-inspired classification algorithms. We used mel-frequency cepstral coefficients to extract features from the heart sounds. Gaussian-mixture models classified the features as PH (mPAp ≥ 25 mmHg) or normal (mPAp < 25 mmHg). Physicians blinded to patient data listened to the same heart sound recordings and attempted a diagnosis. We studied 164 subjects: 86 with mPAp ≥ 25 mmHg (mPAp 41 ± 12 mmHg) and 78 with mPAp < 25 mmHg (mPAp 17 ± 5 mmHg) (p < 0.005). The correct diagnostic rate of the automated speech-recognition-inspired algorithm was 74% compared to 56% by physicians (p = 0.005). The false positive rate for the algorithm was 34% versus 50% (p = 0.04) for clinicians. The false negative rate for the algorithm was 23% and 68% (p = 0.0002) for physicians. We developed an automated speech-recognition-inspired classification algorithm for the acoustic diagnosis of PH that outperforms physicians that could be used to screen for PH and encourage earlier specialist referral.
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Affiliation(s)
- Tarek Kaddoura
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, Canada
| | - Karunakar Vadlamudi
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Shine Kumar
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Prashant Bobhate
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Long Guo
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Shreepal Jain
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Mohamed Elgendi
- Department Computing Science, University of Alberta, Edmonton, Canada
| | - James Y Coe
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Daniel Kim
- Department of Medicine, Division of Cardiology, Cardiac Catheterization Laboratories, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Dylan Taylor
- Department of Medicine, Division of Cardiology, Cardiac Catheterization Laboratories, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Wayne Tymchak
- Department of Medicine, Division of Cardiology, Cardiac Catheterization Laboratories, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Dale Schuurmans
- Department Computing Science, University of Alberta, Edmonton, Canada
| | - Roger J Zemp
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, Canada
| | - Ian Adatia
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
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99
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Zijlstra WMH, Douwes JM, Ploegstra MJ, Krishnan U, Roofthooft MTR, Hillege HL, Ivy DD, Rosenzweig EB, Berger RMF. Clinical classification in pediatric pulmonary arterial hypertension associated with congenital heart disease. Pulm Circ 2016; 6:302-12. [PMID: 27683607 PMCID: PMC5019083 DOI: 10.1086/687764] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 05/26/2016] [Indexed: 11/03/2022] Open
Abstract
Congenital heart disease (CHD) is a frequent cause of pediatric pulmonary arterial hypertension (PAH), with diverse etiology and outcome. We aimed to describe phenotypic heterogeneity in pediatric PAH associated with CHD (PAH-CHD), assess the applicability of the Nice CHD classification, and explore whether this classification accurately reflects patient/disease characteristics and survival. All children with CHD from a contemporary cohort of consecutive pediatric PAH patients followed in three major referral centers (Denver, New York, the Netherlands) were characterized and classified on the basis of the latest proposed clinical classification for PAH-CHD (World Symposium on Pulmonary Hypertension, Nice, 2013). According to this classification, 24% of 134 children were classified into group 1, 14% into group 2, 19% into group 3, and 30% into group 4; 11% could not be classified. Types of CHD and hemodynamic profile differed between groups, with the highest right atrial pressure in group 4 (P < 0.040). Group 3 children had Down syndrome less frequently (P = 0.011) but other (un)defined syndromes most frequently (P = 0.063) and received most intense PAH-targeted therapy (P = 0.003). With 15 deaths and one lung transplant (12%; median follow-up: 4.3 years), survival differences could not be demonstrated between the groups in the Nice CHD classification. Pediatric PAH-CHD is a heterogeneous condition frequently associated with extracardiac, developmental factors that are believed to affect disease development. The Nice CHD classification identifies groups with specific patient/disease characteristics. However, a substantial proportion of children could not be classified. Group 3 forms a distinct disease entity. Its prognostic value could not be determined because of the low number of events. The Nice CHD classification supports clinical characterization of PAH-CHD; however, further refinement is needed to classify all children with PAH-CHD.
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Affiliation(s)
- Willemijn M. H. Zijlstra
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes M. Douwes
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mark-Jan Ploegstra
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Usha Krishnan
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Marcus T. R. Roofthooft
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hans L. Hillege
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Erika B. Rosenzweig
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Rolf M. F. Berger
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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100
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Hansmann G, Apitz C, Abdul-Khaliq H, Alastalo TP, Beerbaum P, Bonnet D, Dubowy KO, Gorenflo M, Hager A, Hilgendorff A, Kaestner M, Koestenberger M, Koskenvuo JW, Kozlik-Feldmann R, Kuehne T, Lammers AE, Latus H, Michel-Behnke I, Miera O, Moledina S, Muthurangu V, Pattathu J, Schranz D, Warnecke G, Zartner P. Executive summary. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK. Heart 2016; 102 Suppl 2:ii86-100. [PMID: 27053701 DOI: 10.1136/heartjnl-2015-309132] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 02/09/2016] [Indexed: 12/25/2022] Open
Abstract
UNLABELLED : The European Paediatric Pulmonary Vascular Disease (PVD) Network is a registered, non-profit organisation that strives to define and develop effective, innovative diagnostic methods and treatment options in all forms of paediatric pulmonary hypertensive vascular disease, including specific forms such as pulmonary arterial hypertension (PAH)-congenital heart disease, pulmonary hypertension (PH) associated with bronchopulmonary dysplasia, persistent PH of the newborn, and related cardiac dysfunction. METHODS The writing group members conducted searches of the PubMed/MEDLINE bibliographic database (1990-2015) and held five face-to-face meetings with votings. Clinical trials, guidelines, and reviews limited to paediatric data were searched using the terms 'pulmonary hypertensioń' and 5-10 other keywords, as outlined in the other nine articles of this special issue. Class of recommendation (COR) and level of evidence (LOE) were assigned based on European Society of Cardiology/American Heart Association definitions and on paediatric data only, or on adult studies that included >10% children. RESULTS A total of 9 original consensus articles with graded recommendations (COR/LOE) were developed, and are summarised here. The topics included diagnosis/monitoring, genetics/biomarker, cardiac catheterisation, echocardiography, cardiac magnetic resonance/chest CT, associated forms of PH, intensive care unit/ventricular assist device/lung transplantation, and treatment of paediatric PAH. CONCLUSIONS The multipaper expert consensus statement of the European Paediatric PVD Network provides a specific, comprehensive, detailed but practical framework for the optimal clinical care of children with PH.
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Affiliation(s)
- Georg Hansmann
- Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Christian Apitz
- Division of Paediatric Cardiology, Children's University Hospital Ulm, Ulm, Germany
| | - Hashim Abdul-Khaliq
- Department of Paediatric Cardiology, Saarland University Hospital, Homburg, Germany
| | - Tero-Pekka Alastalo
- Blueprint Genetics, Biomedicum Helsinki, Helsinki, Finland Department of Paediatric Cardiology, Children's Hospital Helsinki, University of Helsinki, Helsinki, Finland
| | - Phillip Beerbaum
- Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Damien Bonnet
- Unité Médico-Chirurgicale de Cardiologie Congénital et Pédiatrique, Centre de reference Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Necker Enfants Malades, APHP, Université Paris Descartes, Sorbonne Paris, Paris, France
| | - Karl-Otto Dubowy
- Department of Paediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Centre NRW, Bad Oeynhausen, Germany
| | - Matthias Gorenflo
- Department of Paediatric Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich and Technical University, Munich, Germany
| | - Anne Hilgendorff
- Perinatal Center Grosshadern, Dr. von Haunersches Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Michael Kaestner
- Division of Paediatric Cardiology, Children's University Hospital Ulm, Ulm, Germany
| | - Martin Koestenberger
- Divison of Paediatric Cardiology, Department of Paediatrics, Medical University Graz, Graz, Austria
| | - Juha W Koskenvuo
- Blueprint Genetics, Biomedicum Helsinki, Helsinki, Finland Department of Paediatric Cardiology, Children's Hospital Helsinki, University of Helsinki, Helsinki, Finland
| | - Rainer Kozlik-Feldmann
- Division of Paediatric Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Titus Kuehne
- German Heart Institute Berlin (DHZB), Unit of Cardiovascular Imaging, Department of Congenital Heart Disease and Paediatric Cardiology, Berlin, Germany
| | - Astrid E Lammers
- Department of Paediatric Cardiology, University of Münster, Münster, Germany
| | - Heiner Latus
- Justus-Liebig-University Giessen, Pediatric Cardiology, Paediatric Heart Center, Giessen, Germany
| | - Ina Michel-Behnke
- Paediatric Heart Center, Division of Paediatric Cardiology, University Hospital for Children and Adolescents, Medical University Vienna, Austria
| | - Oliver Miera
- German Heart Institute Berlin (DHZB), Department of Congenital Heart Disease and Paediatric Cardiology, Berlin, Germany
| | - Shahin Moledina
- National Paediatric Pulmonary Hypertension Service UK, Great Ormond Street Hospital for Children, London, UK
| | - Vivek Muthurangu
- Cardiovascular MRI Department, Great Ormond Street Hospital for Children, London, UK
| | - Joseph Pattathu
- Department of Paediatric Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Dietmar Schranz
- Justus-Liebig-University Giessen, Pediatric Cardiology, Paediatric Heart Center, Giessen, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany German Centre for Lung Research, BREATH, Hannover, Germany
| | - Peter Zartner
- Department of Paediatric Cardiology, German Paediatric Heart Centre, Sankt Augustin, Germany
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