151
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Malloy KW, Austin ED. Pulmonary hypertension in the child with bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:3546-3556. [PMID: 34324276 PMCID: PMC8530892 DOI: 10.1002/ppul.25602] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/25/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease of prematurity resulting from complex interactions of perinatal factors that often lead to prolonged respiratory support and increased pulmonary morbidity. There is also growing appreciation for the dysmorphic pulmonary bed characterized by vascular growth arrest and remodeling, resulting in pulmonary vascular disease and its most severe form, pulmonary hypertension (PH) in children with BPD. In this review, we comprehensively discuss the pathophysiology of PH in children with BPD, evaluate the current recommendations for screening and diagnosis of PH, discern associated comorbid conditions, and outline the current treatment options.
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Affiliation(s)
- Kelsey W Malloy
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric D Austin
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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152
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Leard LE, Holm AM, Valapour M, Glanville AR, Attawar S, Aversa M, Campos SV, Christon LM, Cypel M, Dellgren G, Hartwig MG, Kapnadak SG, Kolaitis NA, Kotloff RM, Patterson CM, Shlobin OA, Smith PJ, Solé A, Solomon M, Weill D, Wijsenbeek MS, Willemse BWM, Arcasoy SM, Ramos KJ. Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021; 40:1349-1379. [PMID: 34419372 PMCID: PMC8979471 DOI: 10.1016/j.healun.2021.07.005] [Citation(s) in RCA: 318] [Impact Index Per Article: 106.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.
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Affiliation(s)
| | | | | | | | - Sandeep Attawar
- Krishna Institute of Medical Sciences Institute for Heart and Lung Transplantation, Hyderabad, India
| | | | - Silvia V Campos
- Heart Institute (InCor) University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | | | - Göran Dellgren
- Sahlgrenska University Hospital and University of Gothenburg, Sweden
| | | | | | | | | | | | | | | | | | - Melinda Solomon
- Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - David Weill
- Weill Consulting Group, New Orleans, Louisiana
| | | | - Brigitte W M Willemse
- Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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153
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Hansmann G, Diekmann F, Chouvarine P, Ius F, Carlens J, Schwerk N, Warnecke G, Vogel-Claussen J, Hohmann D, Alten T, Jack T. Full recovery of right ventricular systolic function in children undergoing bilateral lung transplantation for severe PAH. J Heart Lung Transplant 2021; 41:187-198. [PMID: 34955331 DOI: 10.1016/j.healun.2021.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/05/2021] [Accepted: 10/17/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND We investigated whether RV function recovers in children with pulmonary arterial hypertension (PAH) and RV failure undergoing lung transplantation (LuTx). METHODS Prospective observational study of 15 consecutive children, 1.9 to 17.6 years old, with PAH undergoing bilateral LuTx. We performed advanced echocardiography (Echo) and cardiac magnetic resonance imaging (MRI), followed by conventional and strain analysis, pre- and ∼6 weeks post-LuTx. RESULTS After LuTx, RV/LV end-systolic diameter ratio (Echo), RV volumes and systolic RV function (RVEF 63 vs 30 %; p < 0.05) by MRI completely normalized, even in children with severe RV failure (RVEF < 40%). The echocardiographic end-systolic LV eccentricity index nearly normalized post-LuTx (1.0 vs 2.0, p < 0.0001) while RV hypertrophy regressed more slowly and was still evident. We found especially the end-systolic RV/LV ratios by Echo (diameter: 0.6 vs 2.6) or MRI (volumes: 0.8 vs 3.4) excellent diagnostic tools (p < 0.05): Together with RVEF by MRI, these ratios were superior to tricuspid annular plane systolic excursion (TAPSE; p = 0.4551) in assessing global systolic RV dysfunction. Moreover, children with severe PAH had reduced RV 2D longitudinal strain (Echo, MRI; p = 0.0450) and decreased RV 2D radial and circumferential strain (MRI; p = 0.0026 and p = 0.0036 respectively), all of which greatly improved following LuTx. CONCLUSION We demonstrate full recovery of RV systolic function in children within two months after LuTx for severe PAH, independently of the patients' age, weight, and hemodynamic compromise preceding the LuTx. Even in end-stage pediatric PAH with poor RV function and low cardiac output, LuTx should be preferred over heart-lung transplantation.
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Affiliation(s)
- Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany; European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany.
| | - Franziska Diekmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany; European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Philippe Chouvarine
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany; European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Julia Carlens
- Department of Pediatric Pulmonology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Department of Pediatric Pulmonology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jens Vogel-Claussen
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Dagmar Hohmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany; European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Tim Alten
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Thomas Jack
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany; European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
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154
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Iablonskii P, Carlens J, Mueller C, Aburahma K, Niehaus A, Boethig D, Franz M, Floethmann K, Sommer W, Optenhoefel J, Tudorache I, Greer M, Koeditz H, Jack T, Hansmann G, Kuehn C, Horke A, Hansen G, Haverich A, Warnecke G, Avsar M, Salman J, Bobylev D, Ius F, Schwerk N. Indications and outcome after lung transplantation in children under 12 years of age: A 16-year single center experience. J Heart Lung Transplant 2021; 41:226-236. [PMID: 34836753 DOI: 10.1016/j.healun.2021.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/23/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE Paediatric lung transplantation poses unique management challenges. Experience regarding indications and outcome is scarce, especially in younger children. The primary aim of this study was to investigate outcome after first lung transplantation in children <12 years of age in comparison to adolescents (12-17 years old). METHODS Records of patients <18 years who underwent first lung transplantation between 01/2005 and 01/2021 were retrospectively reviewed, and compared between children <12 years old and adolescents. Median (IQR) follow-up was 51 (23-91) months. RESULTS Of the 117 patients underwent first lung transplantation at our institution, of whom 42 (35.8%) patients were <12 years and 75 (64.2%) ≥12 years old. Compared to adolescents, children were more often transplanted for interstitial lung disease (33.3% vs 12%, p = 0.005) and precapillary pulmonary hypertension (28.6% vs 12%, p = 0.025), and required more often intraoperative cardiopulmonary bypass (31% vs 14.7%, p = 0.036) and postoperative ECMO support (47.6% vs 13.3%, p < 0.001). Postoperatively, children required longer ventilation times (78 vs 18 hours, p = 0.009) and longer ICU stay (9.5 vs 3 days, p < 0.001) compared to their older counterparts. Primary graft dysfunction grade 3 at 72 hours (9.5% vs 9.3%, p = 0.999), in-hospital mortality (2.4% vs 6.7%, p = 0.418), graft survival (80% vs 62%, p = 0.479) and freedom from chronic lung allograft dysfunction (76% vs 59%, p = 0.41) at 8-year follow-up did not differ between groups. CONCLUSIONS Lung transplantation in children under 12 years is challenging due to underlying medical conditions and operative complexity. Nevertheless, outcomes are comparable to those in older children.
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Affiliation(s)
- Pavel Iablonskii
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany; Medical Faculty, Saint-Petersburg State University, Saint-Petersburg, Russia
| | - Julia Carlens
- Department of Pediatric Pneumology Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Carsten Mueller
- Department of Pediatric Pneumology Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Khalil Aburahma
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Adelheid Niehaus
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Maximilian Franz
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Katharina Floethmann
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Joerg Optenhoefel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Harald Koeditz
- Department of Pediatric Cardiology and Critical Care Medicine, Hannover Medical School, Hannover, Germany
| | - Thomas Jack
- Department of Pediatric Cardiology and Critical Care Medicine, Hannover Medical School, Hannover, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care Medicine, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Horke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Department of Pediatric Pneumology Allergology and Neonatology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany.
| | - Nicolaus Schwerk
- Department of Pediatric Pneumology Allergology and Neonatology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
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155
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Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease in infants and is associated with increased mortality, respiratory morbidity, neurodevelopmental impairment, and increased healthcare costs. In parallel with advances made in the field of neonatal intensive care, the phenotype of BPD has evolved from a fibrocystic disease affecting late preterm infants to one of impaired parenchymal development and dysregulated vascular growth predominantly affecting infants born before 29 weeks' gestational age. BPD has been shown to have significant lifelong consequences. Adults with BPD have been found to have abnormal lung function tests, reduced exercise tolerance, and may be at increased risk for developing chronic obstructive pulmonary disease. Evidence shows that BPD occurs secondary to genetic-environmental interactions in an immature lung. In this review, we evaluate the various clinical definitions, imaging modalities, and biomarker data that are helpful in making an early diagnosis of BPD. In addition, we evaluate recent evidence about the prevention and treatment of BPD. We discuss the invasive and non-invasive ventilation strategies and pharmacological agents used in the early, evolving, and established phases of BPD.
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Affiliation(s)
- Margaret Gilfillan
- Division of Neonatology, St Christopher's Hospital for Children, Philadelphia, PA, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Anita Bhandari
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vineet Bhandari
- Division of Neonatology, The Children's Regional Hospital at Cooper, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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156
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Sun L, Wang C, Zhou Y, Sun W, Wang C. Clinical Efficacy and Safety of Different Doses of Sildenafil in the Treatment of Persistent Pulmonary Hypertension of the Newborn: A Network Meta-analysis. Front Pharmacol 2021; 12:697287. [PMID: 34630080 PMCID: PMC8497971 DOI: 10.3389/fphar.2021.697287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/03/2021] [Indexed: 01/23/2023] Open
Abstract
Objective: To evaluate the efficacy and safety of different doses of sildenafil for persistent pulmonary hypertension of the newborn (PPHN) with Bayesian random effects network meta-analysis. Methods: We searched Chinese and English databases for randomized controlled trials (RCTs) concerning sildenafil in newborns with persistent pulmonary hypertension from 1998 to December 2020. Results: Twenty-two RCTs including over 2131 patients were included. Sildenafil was administered by nasal feeding at 0.3–2 mg/kg every 4–6 h. The network meta-analysis revealed that 1.5 mg/kg of sildenafil led to a significant decrease in pulmonary artery systolic pressure (PASP) compared with 0.3 and 0.6 mg/kg (p < 0.05); 1.5 mg/kg was better than 0.3, 0.5, and 1.0 mg/kg at increasing the partial pressure of oxygen (PaO2) (p < 0.05); 1.5 mg/kg was better than 0.5, 0.6 and 1.0 mg/kg at reducing the partial pressure of carbon dioxide (PaCO2) (p < 0.05); and 1.2 mg/kg was better than 0.3, 0.5 and 1.0 mg/kg at increasing the arterial oxygen saturation (SaO2) (p < 0.05). The surface under the cumulative ranking analysis (SUCRA) results showed that 1.5 mg/kg had the best effect in reducing PASP (SUCRA = 92.0%, moderate certainty evidence) and PaCO2 (91.1%) and increasing PaO2 (SUCRA = 79.3%, moderate certainty evidence), 2.0 mg/kg had the best effect in increasing SaO2 (SUCRA = 88.6%, moderate certainty evidence) and total effective rate (SUCRA = 93.5%, low certainty of evidence)). No severe adverse effects were observed with the different doses of sildenafil. Conclusion: Different doses of sildenafil can significantly improve PPHN, and 1.5 mg/kg of sildenafil has better clinical efficacy and does not increase the probability of adverse reactions.
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Affiliation(s)
- Linli Sun
- Department of General Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chunxia Wang
- Department of Pharmacy, Yinan County People's Hospital, Linyi, China
| | - Yulu Zhou
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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157
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Khugaev GA, Shmalts AA. [Morphological assessment of pulmonary vessels in pulmonary arterial hypertension associated with congenital heart disease]. Arkh Patol 2021; 83:49-57. [PMID: 34609805 DOI: 10.17116/patol20218305149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pulmonary vascular remodeling is the key structural alteration in pulmonary arterial hypertension associated with congenital heart disease (CHD). Changes in the pulmonary vessels in CHD generally occur in the inner and middle coats. This review considers the pathology of these changes and highlights some issues of a stereological approach to the morphometry of pulmonary vasculature. It also touches upon the issues of the morphology of pulmonary vessels in post-capillary and segmental pulmonary hypertension.
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Affiliation(s)
- G A Khugaev
- A.N. Bakulev National Medical Research Center for Cardiovascular Surgery of the Ministry of Health of Russia, Moscow, Russia
| | - A A Shmalts
- A.N. Bakulev National Medical Research Center for Cardiovascular Surgery of the Ministry of Health of Russia, Moscow, Russia.,Russian Medical Academy of Continuing Professional Education of the Ministry of Health of Russia, Moscow, Russia
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158
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Ntiloudi D, Giannakoulas G. Usefulness of acute vasoreactivity testing to decide shunt closure. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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159
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Becker K, Uebing A, Hansen JH. Pulmonary vascular disease in Fontan circulation-is there a rationale for pulmonary vasodilator therapies? Cardiovasc Diagn Ther 2021; 11:1111-1121. [PMID: 34527537 DOI: 10.21037/cdt-20-431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022]
Abstract
The Fontan circulation is a palliative concept for patients with univentricular hearts. The central veins are connected directly to the pulmonary arteries (cavo-pulmonary connection) to separate the pulmonary and the systemic circulation. There is no sub-pulmonary ventricle that generates pressure to drive blood through the pulmonary arteries. Pulmonary blood flow is determined by central venous pressure (CVP) and pulmonary vascular resistance (PVR). The capability of the Fontan circulation to compensate for alterations in PVR is limited, as CVP can only be increased within narrow ranges without adverse clinical consequences. Consequently, systemic ventricular preload and cardiac output are dependent on a healthy lung with low PVR. Failure of the Fontan circulation is relatively common. In addition to ventricular dysfunction, maladaptive pulmonary vascular remodeling resulting in increased pulmonary resistance may play a key role. The pathophysiology of the maladaptive vascular processes remains largely unclear and diagnosis of an increased PVR is challenging in Fontan circulation as accurate measurement of pulmonary arterial blood flow is difficult. In the absence of a sub-pulmonary ventricle, pulmonary artery pressure will almost never reach the threshold conventionally used to define pulmonary arterial hypertension. There is a need for markers of pulmonary vascular disease complementary to invasive hemodynamic data in Fontan patients. In order to treat or prevent failure of the Fontan circulation, pathophysiological considerations support the use of pulmonary vasodilators to augment pulmonary blood flow and systemic ventricular preload and lower CVP. However, to date the available trial data have neither yielded enough evidence to support routine use of pulmonary vasodilators in every Fontan patient nor have they been helpful in defining subgroups of patients that might benefit from such therapies. This review discusses potential pathomechanisms of pulmonary vascular disease; it summarizes the current knowledge of the effects and efficacy of pulmonary vasodilator therapy in Fontan patients and tries to outline areas of potential future research on the diagnosis and treatment of pulmonary vascular disease and Fontan failure.
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Affiliation(s)
- Kolja Becker
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
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160
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Lammers AE, Apitz C. Update from the World Symposium on Pulmonary Hypertension 2018: does the new hemodynamic definition of pediatric pulmonary hypertension have an impact on treatment strategies? Cardiovasc Diagn Ther 2021; 11:1048-1051. [PMID: 34527530 DOI: 10.21037/cdt-20-412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/29/2020] [Indexed: 11/06/2022]
Abstract
Pediatric pulmonary arterial hypertension (PAH) is a progressive life-threatening disease of the pulmonary vasculature and is defined as an elevation of the mean pulmonary arterial pressure. Before the 6th World Symposium on Pulmonary Hypertension (WSPH) in 2018, pulmonary hypertension (PH) used to be defined as a mean pulmonary artery pressure (mPAP) of ≥25 mmHg. On the WSPH a revised hemodynamic definition of PH was introduced lowering the threshold for a normal mPAP from <25 to <21 mmHg. The Pediatric Task Force chose to follow this newly proposed definition of PH in order to speak a uniform language and facilitate transition to adult services. In this opinion paper we discuss the rationale behind the new PH definition and the impact on pediatric PH. We conclude, that to date, there is no evidence in children, suggesting that this decrease of threshold for PH warrants any further measures than clinical outpatient-follow-up. Hitherto, the new definition does not impact on currently applicable treatment strategies in children with PH.
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Affiliation(s)
- Astrid E Lammers
- Department of Pediatric Cardiology and Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Münster, Münster, Germany
| | - Christian Apitz
- Division of Pediatric Cardiology, University Children's Hospital Ulm, Ulm, Germany
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161
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Kaestner M, Apitz C, Lammers AE. Cardiac catheterization in pediatric pulmonary hypertension: a systematic and practical approach. Cardiovasc Diagn Ther 2021; 11:1102-1110. [PMID: 34527536 DOI: 10.21037/cdt-20-395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
Significant progress in the understanding of the etiology, epidemiology, pathobiology and prognosis of pulmonary hypertension (PH) has been made over the last years. Especially in the pediatric patient population the etiology of PH is very heterogeneous. Nevertheless, the most recent change of the definition of PH to a mean pulmonary artery pressure (mPAP) >20 mmHg has been accepted by pediatricians for uniformity and concordance with adult physicians. Based on the diverse underlying medical conditions leading to PH, a comprehensive and systematic approach for diagnosis and treatment is mandatory. Cardiac catheterization remains the gold standard for invasive assessment and acute vasoreactivity testing (AVT) additionally providing detailed information about nature of PH. In most patients repeat cardiac catheterization may be helpful for evaluation of response to targeted PH treatment, risk stratification and indication for lung transplantation. However, the information and results taken from cardiac catheterization should be interpreted by experienced investigators only who are familiar with confounding factors that may influence the results. Here we provide an overview of current recommendations for invasive hemodynamic evaluation in pediatric PH. We point out different patient scenarios and provide a structured approach for AVT and response interpretation.
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Affiliation(s)
- Michael Kaestner
- University Children's Hospital Ulm, Division of Pediatric Cardiology, Ulm, Germany
| | - Christian Apitz
- University Children's Hospital Ulm, Division of Pediatric Cardiology, Ulm, Germany
| | - Astrid Elisabeth Lammers
- University Children's Hospital Münster, Division of Pediatric Cardiology, Albert-Schweitzer-Campus 1, Münster, Germany
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162
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Gorenflo M, Ziesenitz VC. Treatment of pulmonary arterial hypertension in children. Cardiovasc Diagn Ther 2021; 11:1144-1159. [PMID: 34527540 DOI: 10.21037/cdt-20-912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/27/2021] [Indexed: 11/06/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a devastating illness causing already significant morbidity in childhood. Currently approved treatment options for children comprise the endothelin receptor antagonist bosentan, as well as the phosphodiesterase-5 inhibitor sildenafil. But PAH treatment has advanced significantly over the past decade, and new classes of targeted drug therapies, such as stimulators of the soluble guanylate cyclase (riociguat) or prostacyclin receptor agonists (selexipag), are currently evaluated regarding their efficacy and safety in children, in order to limit off-label use. Due to the different etiologies in children, such as PAH-CHD, there is no evidence that initial combination therapy in children is superior to a mono-therapy with respect to survival. Special attention should also be paid to the pharmacology of PAH drugs in children, which might be impacted by ontogeny or drug-drug-interactions. Therapeutic drug monitoring may be useful in pediatric patients. There is a clear need for more controlled studies of PAH medications, alone or in combination therapy in the pediatric age group. Data from clinical trials as well as from patient registries should be pooled to optimize drug development and evaluation, trial design, and evidence-based pharmacotherapy in pediatric patients with PAH. In this review, the current treatment options of pediatric PAH are summarized, and an overview of new treatment concepts, which are already evaluated in adults, is presented.
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Affiliation(s)
- Matthias Gorenflo
- Department of Pediatric Cardiology and Congenital Heart Diseases, Centre of Child and Adolescent Health, University Hospital Heidelberg, Heidelberg, Germany
| | - Victoria C Ziesenitz
- Department of Pediatric Cardiology and Congenital Heart Diseases, Centre of Child and Adolescent Health, University Hospital Heidelberg, Heidelberg, Germany
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163
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Sommer W, Warnecke G. Lung transplantation for pediatric pulmonary arterial hypertension-quo vadis? Cardiovasc Diagn Ther 2021; 11:1178-1189. [PMID: 34527542 DOI: 10.21037/cdt-21-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/23/2021] [Indexed: 11/06/2022]
Abstract
In children with pulmonary arterial hypertension, lung transplantation illustrates a feasible treatment option once pharmacological therapy is exhausted. Timing of listing for lung transplantation in children remains difficult since hemodynamic deterioration often occurs abruptly and the time on the waiting list is usually hard to predict. Clear contraindications for lung transplantation are recent history of malignancies as well as irreversible end-organ failure. Generally, patients with pulmonary arterial hypertension in the absence of structural cardiac defects can safely undergo bilateral lung transplantation, combined heart-lung transplantation remains a procedure with a higher perioperative risk and should only be performed in selected cases with irreversible structural defects. Donor selection in recent years shows donors with extended criteria as well as lobar transplantation with good outcome, having the positive effect of broadening of the donor pool. Bridging to lung transplantation with veno-arterial ECMO treatment is feasible and has a good outcome in experienced transplant centers. Surgical considerations should include the risk of hemodynamic decompensation upon anesthesia induction and the need for extracorporeal support pre-, intra- and postoperative. Lung transplantation should be performed on veno-arterial ECMO support with either peripheral (>20 kg) or central cannulation (<20 kg). The surgical transplantation procedure includes the bronchial anastomosis as well as anastomoses of the pulmonary artery and the left atrium. Postoperative prolonged veno-arterial ECMO treatment for the immediate postoperative period allows for left ventricular remodeling given the new hemodynamic circumstances with lower pulmonary vascular resistance. Standard triple immunosuppression in most lung transplant programs currently includes steroids, mycophenolate mofetil and tacrolimus. Survival after pediatric lung transplantation for IPAH is comparable to pediatric lung transplants for other underlying diseases with a 1-year survival of approx. 80% and a 5-year survival of 64-65%. Therefore, evolving techniques in the field of lung transplantation led to overall improved survival prospects in children with end-stage pulmonary vascular disease.
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Affiliation(s)
- Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
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164
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Selexipag use for paediatric pulmonary hypertension: a single centre report focussed on congenital heart disease patients. Cardiol Young 2021; 31:1513-1515. [PMID: 33781364 DOI: 10.1017/s1047951121000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pulmonary hypertension is a rare and complex disease with poor prognosis. Paediatric cases are infrequent and usually associated with congenital heart disease. Management is problematical due to the limited therapy available and poor evidence of efficacy. Recently a new medication, selexipag (UptraviR), a prostacyclin receptor agonist, has been approved for the treatment of pulmonary artery hypertension in adults. We report our experience using selexipag in four paediatric patients with pulmonary hypertension associated with congenital heart disease.
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165
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Chen X, Cai XM, Zhang MJ, Xu JH, Li H, Xu ZM. Pharmacokinetics of treprostinil in children with functional single-ventricle pulmonary arterial hypertension: a randomized controlled trial. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1163. [PMID: 34430604 PMCID: PMC8350654 DOI: 10.21037/atm-21-3188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/14/2021] [Indexed: 12/22/2022]
Abstract
Background Application of Treprostinil (TRE) in the patients with single ventricle (SV) physiology is very limited, and the optimal dose for children has not been determined. In this study, we aimed to analyze plasma samples to assess the attainment of clinically therapeutic concentrations of TRE and its efficacy and safety in the treatment of pediatric functional SV pulmonary arterial hypertension (FSV-PAH).. Methods Pediatric patients with FSV-PAH were recruited in this study. IV TRE at an initial rate of 5 ng/kg/min was administered through the femoral vein with an increase in rate to 10 ng/kg/min every 30 minuntil the aiming dose of 80 ng/kg/min had been reached. The drug was gradually discontinued after 12 h of treatment at a stable dose. The mean postoperative pulmonary artery pressure (mPAP), pulmonary-to-systemic arterial pressure ratio (Pp/Ps), and the ratio between arterial oxygen partial pressure and inhaled oxygen concentration (PaO2/FiO2) were used to evaluate the efficacy of TRE treatment. A multiple linear regression model was used to explore the relevant factors associated with TRE blood concentration. Results A total of eight patients were enrolled in the investigation, with an age range of 2.5-9.9 years. The median stable dose of TRE was 70 ng/kg/min with a range of 55-75 ng/kg/min. The median subliminal dose was 55 ng/kg/min with a range of 25-75 ng/kg/min. A linear relationship was established between the TRE dose and the plasma concentration. TRE blood concentrations were associated with dose and patient height. After TRE treatment, mPAP, Pp/Ps, and PaO2/FiO2 were significantly improved (P<0.05). Conclusions A linear relationship was found between the blood concentration of TRE and its dose. IV TRE was an effective therapy without serious side effects in pediatric patients with FSV-PAH. Trial Registration ClinicalTrials.gov Identifier: NCT02865733.
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Affiliation(s)
- Xi Chen
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Man Cai
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ming-Jie Zhang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing-Han Xu
- Department of Pharmacy, Clinical Research Center, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Li
- Department of Pharmacy, Clinical Research Center, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhuo-Ming Xu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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166
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Diekmann F, Chouvarine P, Sallmon H, Meyer-Kobbe L, Kieslich M, Plouffe BD, Murthy SK, Lichtinghagen R, Legchenko E, Hansmann G. Soluble Receptor for Advanced Glycation End Products (sRAGE) Is a Sensitive Biomarker in Human Pulmonary Arterial Hypertension. Int J Mol Sci 2021; 22:ijms22168591. [PMID: 34445297 PMCID: PMC8395319 DOI: 10.3390/ijms22168591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 01/31/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive condition with an unmet need for early diagnosis, better monitoring, and risk stratification. The receptor for advanced glycation end products (RAGE) is activated in response to hypoxia and vascular injury, and is associated with inflammation, cell proliferation and migration in PAH. For the adult cohort, we recruited 120 patients with PAH, 83 with idiopathic PAH (IPAH) and 37 with connective tissue disease-associated PAH (CTD-PAH), and 48 controls, and determined potential plasma biomarkers by enzyme-linked immunoassay. The established heart failure marker NTproBNP and IL-6 plasma levels were several-fold higher in both adult IPAH and CTD-PAH patients versus controls. Plasma soluble RAGE (sRAGE) was elevated in IPAH patients (3044 ± 215.2 pg/mL) and was even higher in CTD-PAH patients (3332 ± 321.6 pg/mL) versus controls (1766 ± 121.9 pg/mL; p < 0.01). All three markers were increased in WHO functional class II+III PAH versus controls (p < 0.001). Receiver-operating characteristic analysis revealed that sRAGE has diagnostic accuracy comparable to prognostic NTproBNP, and even outperforms NTproBNP in the distinction of PAH FC I from controls. Lung tissue RAGE expression was increased in IPAH versus controls (mRNA) and was located predominantly in the PA intima, media, and inflammatory cells in the perivascular space (immunohistochemistry). In the pediatric cohort, plasma sRAGE concentrations were higher than in adults, but were similar in PH (n = 10) and non-PH controls (n = 10). Taken together, in the largest adult sRAGE PAH study to date, we identify plasma sRAGE as a sensitive and accurate PAH biomarker with better performance than NTproBNP in the distinction of mild PAH from controls.
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Affiliation(s)
- Franziska Diekmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, 30625 Hannover, Germany; (F.D.); (P.C.); (L.M.-K.); (E.L.)
| | - Philippe Chouvarine
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, 30625 Hannover, Germany; (F.D.); (P.C.); (L.M.-K.); (E.L.)
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, 13353 Berlin, Germany; (H.S.); (M.K.)
| | - Louisa Meyer-Kobbe
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, 30625 Hannover, Germany; (F.D.); (P.C.); (L.M.-K.); (E.L.)
| | - Moritz Kieslich
- Department of Pediatric Cardiology, Charité University Medical Center, 13353 Berlin, Germany; (H.S.); (M.K.)
| | - Brian D. Plouffe
- Department of Chemical Engineering, Northeastern University, Boston, MA 02115, USA; (B.D.P.); (S.K.M.)
- Department of STEM, Regis College, Weston, MA 02493, USA
| | - Shashi K. Murthy
- Department of Chemical Engineering, Northeastern University, Boston, MA 02115, USA; (B.D.P.); (S.K.M.)
- Flaskworks, LLC, Boston, MA 02118, USA
| | - Ralf Lichtinghagen
- Institute of Clinical Chemistry, Hannover Medical School, 30625 Hannover, Germany;
| | - Ekaterina Legchenko
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, 30625 Hannover, Germany; (F.D.); (P.C.); (L.M.-K.); (E.L.)
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, 30625 Hannover, Germany; (F.D.); (P.C.); (L.M.-K.); (E.L.)
- Correspondence: ; Tel.: +49-511-532-9594
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167
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Day RW. Improving guidance for the correctability of congenital cardiovascular shunts with increased pulmonary vascular resistance. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100184] [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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168
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Schranz D. Reverse Potts Shunt for Pulmonary Hypertension: Back to a "Fetal" Circulation in Part? J Am Coll Cardiol 2021; 78:478-480. [PMID: 34325837 DOI: 10.1016/j.jacc.2021.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center Giessen & Frankfurt, Johann-Wolfgang-Goethe University Clinic, Frankfurt, Germany.
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169
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Pulmonary vascular resistance in children and adults. When should we index for body surface area? INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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170
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Hansmann G, Christou H, Koestenberger M, Sallmon H. Off-label use of PAH-targeted medications approved for adults and their financial coverage by health insurances are vital for children with pulmonary hypertension. Eur J Clin Invest 2021; 51:e13571. [PMID: 33834481 DOI: 10.1111/eci.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany.,The European Pediatric Pulmonary Vascular Disease Network (EPPVDN), Berlin, Germany
| | - Helen Christou
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Martin Koestenberger
- The European Pediatric Pulmonary Vascular Disease Network (EPPVDN), Berlin, Germany.,Division of Pediatric Cardiology, Medical University Graz, Graz, Austria
| | - Hannes Sallmon
- The European Pediatric Pulmonary Vascular Disease Network (EPPVDN), Berlin, Germany.,Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
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171
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Apitz C, Girschick H. Systemic sclerosis-associated pulmonary arterial hypertension in children. Cardiovasc Diagn Ther 2021; 11:1137-1143. [PMID: 34527539 PMCID: PMC8410482 DOI: 10.21037/cdt-20-901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/23/2020] [Indexed: 11/06/2022]
Abstract
Systemic sclerosis (SSc) is a rare disease in childhood and is characterized by a combination of vasculopathy, inflammation, autoimmunity, and fibrogenesis with individually varying expression pattern. Pulmonary arterial hypertension (PAH) is a serious complication of SSc and affects approximately 10% of SSc patients. SSc-PAH is complex and difficult to diagnose, as symptoms are non-specific and may be complicated by other SSc-associated diseases such as interstitial lung disease or left heart disease. SSc-PAH patients can deteriorate rapidly, and disease progression can occur even in patients with mild PAH symptoms at diagnosis. Therefore, interdisciplinary care of SSc patients is essential, and treating physicians must be aware of the association between SSc and PAH. In order to detect PAH early, children with SSc should be regularly screened for PAH by pediatric cardiologists. If PAH is detected, a systematic diagnostic approach by trained PH specialists including careful phenotyping of PAH is required. Relevant interstitial lung disease and left heart disease should be ruled out in the differential diagnosis of SSc-PAH before starting any targeted therapy. Due to the progressive character of SSc-PAH known from adult studies, it appears appropriate to initiate targeted PAH-therapy in juvenile SSc-PAH early. Adapted from adult treatment algorithms, combination therapy regimens (addressing at least two pathophysiological pathways) are increasingly used for pediatric PAH patients, and there is growing evidence to support this approach also in SSc-PAH patients.
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Affiliation(s)
- Christian Apitz
- Division of Pediatric Cardiology, University Children’s Hospital Ulm, Ulm, Germany
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172
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Pulmonary-to-Systemic Arterial Shunt to Treat Children With Severe Pulmonary Hypertension. J Am Coll Cardiol 2021; 78:468-477. [PMID: 34325836 DOI: 10.1016/j.jacc.2021.05.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The placement of a pulmonary-to-systemic arterial shunt in children with severe pulmonary hypertension (PH) has been demonstrated, in relatively small studies, to be an effective palliation for their disease. OBJECTIVES The aim of this study was to expand upon these earlier findings using an international registry for children with PH who have undergone a shunt procedure. METHODS Retrospective data were obtained from 110 children with PH who underwent a shunt procedure collected from 13 institutions in Europe and the United States. RESULTS Seventeen children died in-hospital postprocedure (15%). Of the 93 children successfully discharged home, 18 subsequently died or underwent lung transplantation (20%); the mean follow-up was 3.1 years (range: 25 days to 17 years). The overall 1- and 5-year freedom from death or transplant rates were 77% and 58%, respectively, and 92% and 68% for those discharged home, respectively. Children discharged home had significantly improved World Health Organization functional class (P < 0.001), 6-minute walk distances (P = 0.047) and lower brain natriuretic peptide levels (P < 0.001). Postprocedure, 59% of children were weaned completely from their prostacyclin infusion (P < 0.001). Preprocedural risk factors for dying in-hospital postprocedure included intensive care unit admission (hazard ratio [HR]: 3.2; P = 0.02), mechanical ventilation (HR: 8.3; P < 0.001) and extracorporeal membrane oxygenation (HR: 10.7; P < 0.001). CONCLUSIONS A pulmonary-to-systemic arterial shunt can provide a child with severe PH significant clinical improvement that is both durable and potentially free from continuous prostacyclin infusion. Five-year survival is comparable to children undergoing lung transplantation for PH. Children with severely decompensated disease requiring aggressive intensive care are not good candidates for the shunt procedure.
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173
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Arvanitaki A, Januszewska K, Malec E, Baumgartner H, Kehl HG, Lammers AE. Against all odds-late repair of multiple shunt lesions in a patient with Down syndrome: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab234. [PMID: 34377902 PMCID: PMC8343471 DOI: 10.1093/ehjcr/ytab234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/22/2021] [Accepted: 05/27/2021] [Indexed: 11/24/2022]
Abstract
Background Children with congenital heart defects (CHD) usually undergo elective surgical repair of haemodynamically relevant shunt lesions within the first year of life. Due to susceptibility for pulmonary arterial hypertension (PAH) in patients with Down syndrome, repair is usually aimed for no later than 6 months of life. However, with rising immigration from developing countries to Europe, more patients with unrepaired CHD are diagnosed at a later age. Anatomical repair may be precluded, when advanced pulmonary vascular disease has been established. Case summary We report a 39-month-old male patient with Down syndrome with a large non-restrictive perimembranous ventricular septal defect, a large patent ductus arteriosus, and a secundum-type atrial septal defect with a prominent left-to-right shunting. Haemodynamic assessment revealed only a mild increase of pulmonary artery pressures (mPAP) with low pulmonary vascular resistance index (PVRi). Vasodilator testing led to a further increase of the left-to-right shunt and decrease of PVRi, suggesting operability. After careful consideration, the patient underwent complete surgical repair with a good post-operative clinical outcome. Cardiac catheterization 6 months after corrective repair showed a normal mPAP. No signs of PAH have been detected in the medium-term follow-up. Discussion Expertise, increased physician awareness, and a thorough pre-operative multidisciplinary evaluation are paramount to determine the best treatment approach for patients, who may present late with multiple shunts, and—in our case—underlying Down syndrome. Long-term close post-surgical follow-up in an expert centre is warranted to promptly diagnose and treat a possible late presentation of PAH appropriately.
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Affiliation(s)
- Alexandra Arvanitaki
- Division of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.,Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Katarzyna Januszewska
- Division of Paediatric Cardiac Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Edward Malec
- Division of Paediatric Cardiac Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Helmut Baumgartner
- Division of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Hans-Gerd Kehl
- Division of Paediatric Cardiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Astrid Elisabeth Lammers
- Division of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.,Division of Paediatric Cardiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
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174
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Sweatt AJ, Reddy R, Rahaghi FN, Al-Naamani N. What's new in pulmonary hypertension clinical research: lessons from the best abstracts at the 2020 American Thoracic Society International Conference. Pulm Circ 2021; 11:20458940211040713. [PMID: 34471517 PMCID: PMC8404658 DOI: 10.1177/20458940211040713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
In this conference paper, we review the 2020 American Thoracic Society International Conference session titled, "What's New in Pulmonary Hypertension Clinical Research: Lessons from the Best Abstracts". This virtual mini-symposium took place on 21 October 2020, in lieu of the annual in-person ATS International Conference which was cancelled due to the COVID-19 pandemic. Seven clinical research abstracts were selected for presentation in the session, which encompassed five major themes: (1) standardizing diagnosis and management of pulmonary hypertension, (2) improving risk assessment in pulmonary arterial hypertension, (3) evaluating biomarkers of disease activity, (4) understanding metabolic dysregulation across the spectrum of pulmonary hypertension, and (5) advancing knowledge in chronic thromboembolic pulmonary hypertension. Focusing on these five thematic contexts, we review the current state of knowledge, summarize presented research abstracts, appraise their significance and limitations, and then discuss relevant future directions in pulmonary hypertension clinical research.
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Affiliation(s)
- Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Raju Reddy
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Farbod N. Rahaghi
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Nadine Al-Naamani
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - on behalf of the American Thoracic Society Pulmonary Circulation Assembly Early Career Working Group
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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175
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Siefkes HM, Lakshminrusimha S. Management of systemic hypotension in term infants with persistent pulmonary hypertension of the newborn: an illustrated review. Arch Dis Child Fetal Neonatal Ed 2021; 106:446-455. [PMID: 33478959 PMCID: PMC8217132 DOI: 10.1136/archdischild-2020-319705] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 01/03/2023]
Abstract
In persistent pulmonary hypertension of the newborn (PPHN), the ratio of pulmonary vascular resistance to systemic vascular resistance is increased. Extrapulmonary shunts (patent ductus arteriosus and patent foramen value) allow for right-to-left shunting and hypoxaemia. Systemic hypotension can occur in newborns with PPHN due to variety of reasons, such as enhanced peripheral vasodilation, impaired left ventricular function and decreased preload. Systemic hypotension can lead to end organ injury from poor perfusion and hypoxaemia in the newborn with PPHN. Thus, it must be managed swiftly. However, not all newborns with PPHN and systemic hypotension can be managed the same way. Individualised approach based on physiology and echocardiographic findings are necessary to improve perfusion to essential organs. Here we present a review of the physiology and mechanisms of systemic hypotension in PPHN, which can then guide treatment.
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176
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Lv ZC, Li F, Wang L, Zhao QH, Gang GS, Wu Y, Miao YQ, Yuan P. Impact of Parthanatos on the Increased Risk of Onset and Mortality in Male Patients With Pulmonary Hypertension. Am J Mens Health 2021; 15:15579883211029458. [PMID: 34190625 PMCID: PMC8256257 DOI: 10.1177/15579883211029458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
There have been no studies as to whether parthanatos, a poly (adenosine diphosphate-ribose) polymerase-1 (PARP-1)-dependent and apoptosis-inducing factor (AIF)-mediated caspase-independent programmed cell death, is present in pulmonary hypertension (PH). Basic studies have, however, been conducted on several of the key molecules in parthanatos, such as PARP-1, AIF, and macrophage migration inhibitory factor (MIF). For this study, we collected blood samples from 88 incident male patients with PH and 50 healthy controls at the Shanghai Pulmonary Hospital. We measured the key factors of parthanatos (PARP-1, PAR, AIF, and MIF) by enzyme-linked immunosorbent assay and performed a logistic regression, Cox proportional hazards analysis, and Kaplan-Meier test to assess the prognostic value of the key molecules in diagnosing and predicting survival. The patients who ultimately died had a significantly poorer clinical status during the study than those who survived. The PARP-1, PAR, AIF, and MIF levels were significantly higher in the patients than in the controls (all p < .0001), and the PARP-1, PAR, and AIF levels were higher in the nonsurvivors than in the survivors (all p < .0001). PARP-1 and AIF levels served as independent predictors of disease onset and mortality in these patients (all p < .005). Patients with PARP-1 levels <11.24 ng/mL or AIF levels <1.459 pg/mL had significantly better survival than those with higher PARP-1 or AIF levels (p < .0001). Circulating levels of PARP-1 and AIF were independent predictors for PH onset and mortality, which indicated that parthanatos might be associated with the pathogenesis of PH.
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Affiliation(s)
- Zhen-Chun Lv
- Institute of Bismuth Science, University of Shanghai for Science and Technology, Shanghai, China.,Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Fei Li
- Department of Radiology, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Gong-Su Gang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yue Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yu-Qing Miao
- Institute of Bismuth Science, University of Shanghai for Science and Technology, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
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177
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 PMCID: PMC8289457 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
| | - Girija G. Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
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178
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Kurath-Koller S, Koestenberger M, Hansmann G, Cantinotti M, Tissot C, Sallmon H. Subcostal Echocardiographic Imaging in Neonatal and Pediatric Intensive Care. Front Pediatr 2021; 9:471558. [PMID: 34249801 PMCID: PMC8264136 DOI: 10.3389/fped.2021.471558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stefan Kurath-Koller
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hanover, Germany
| | - Massimiliano Cantinotti
- Fondazione Consiglio Nazionale delle Ricerche Area (CNR)-Regione Toscana G. Monasterio (FTGM), Pisa, Italy
| | - Cecille Tissot
- Center de Pediatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité–Universitätsmedizin Berlin, Berlin, Germany
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179
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Baczynski M, Kelly E, McNamara PJ, Shah PS, Jain A. Short and long-term outcomes of chronic pulmonary hypertension in preterm infants managed using a standardized algorithm. Pediatr Pulmonol 2021; 56:1155-1164. [PMID: 33270376 DOI: 10.1002/ppul.25200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is limited data on management strategies for chronic pulmonary hypertension (cPH) in chronic lung disease (CLD) of prematurity. Our objective was to evaluate clinical outcomes following a standardized policy, wherein only cPH with right-ventricular (RV) dilatation was treated and diuretics were employed as first-line therapy; cPH without RV-dilatation was managed expectantly. METHOD In this retrospective cohort study, all infants with CLD were categorized as "CLD-only" or "CLD-cPH," using echocardiography at ≥36 weeks postmenstrual age. Intergroup comparison was performed. Regression analysis examined the association between cPH and primary outcome of death or disability at 18-24 months. RESULTS Of 128 CLD infants, 48 (38%) had cPH, of which 29 (60%) received diuretics. Symptomatic improvement within 1-week was recorded in 90%. Although CLD-cPH had worse in-hospital respiratory course than CLD-only, all post-discharge respiratory and neurodevelopmental outcomes were similar. cPH was not associated with death or disability (adjusted odds ratio, 1.02; 95% confidence interval, 0.32-3.27). Disease progression treated with sildenafil occurred in 2 (4%) cases. There was no death from respiratory or RV failure. CONCLUSION Primary treatment of CLD-cPH with diuretics using RV-dilatation as therapeutic threshold, may result in symptomatic improvement, disease stabilization and post-discharge outcomes comparable to infants without cPH.
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Affiliation(s)
- Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, Canada
| | - Edmond Kelly
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Patrick J McNamara
- Division of Neonatology, University of Iowa Stead Family Children's Hospital, Iowa, USA
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
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180
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Lv Z, Jiang R, Hu X, Zhao Q, Sun Y, Wang L, Li J, Miao Y, Wu W, Yuan P. Dysregulated lncRNA TUG1 in different pulmonary artery cells under hypoxia. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:879. [PMID: 34164513 PMCID: PMC8184498 DOI: 10.21037/atm-21-2040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background At present, the role of lncRNAs in the pathogenesis of hypoxia-induced pulmonary hypertension (HPH) is not fully understood. This study aimed to explore differences in the hypoxia-induced expression of lncRNAs and their potential role in multiple pulmonary artery cells. Methods LncRNA expression in pulmonary artery smooth muscle cells (PASMCs), pulmonary microvascular endothelial cells (PMECs), and pericytes (PCs) was analyzed by high-throughput sequencing and compared between normoxic and hypoxic cells. Bioinformatics analysis was conducted to predict their functions. Results PASMCs, PMECs, and PCs displayed 275 (140 upregulated), 251 (162 upregulated), and 290 (176 upregulated) different lncRNAs, respectively. Among these, lncRNA TUG1 levels increased in PASMCs and PCs but decreased in PMECs. Bioinformatics analysis indicated that lncRNA TUG1 might target miR-145-5p, thereby affecting SOX4 and BMF expression, and could also regulate miR-129-5p levels to affect CYP1B1 and VCP expression. It could also regulate miR-138-5p levels to affect KCNK3 and RHOC expression. Conclusions Hypoxia exposure of vascular cells resulted in differential expression of lncRNAs, especially lncRNA TUG1, which showed significant abnormal expression in all three types of vascular cells under hypoxia. Our results suggested that abnormal expression of lncRNA TUG1 might be involved in the regulation of pulmonary vascular cell function under hypoxia.
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Affiliation(s)
- Zhenchun Lv
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China.,Institute of Bismuth Science, University of Shanghai for Science and Technology, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Xiaoyi Hu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China.,Department of Gastroenterology, the 903rd Hospital of People's Liberation Army, Hangzhou, China
| | - Qinhua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yuanyuan Sun
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Jinling Li
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Yuqing Miao
- Institute of Bismuth Science, University of Shanghai for Science and Technology, Shanghai, China
| | - Wenhui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, Shanghai, China
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181
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Vanhie E, VandeKerckhove K, Haas NA, De Wolf D. Atrial flow regulator for drug-resistant pulmonary hypertension in a young child. Catheter Cardiovasc Interv 2021; 97:E830-E834. [PMID: 33650782 DOI: 10.1002/ccd.29590] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 11/10/2022]
Abstract
This case describes the successful implantation of an Occlutech Atrial Flow Regulator in a young child with idiopathic pulmonary hypertension and recurrent syncope despite targeted combination therapy, with subsequent relief of symptoms.
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Affiliation(s)
- Ellen Vanhie
- Department of Pediatrics, Pediatric Cardiology, Amsterdam University Hospital, Amsterdam, The Netherlands
| | - Kristof VandeKerckhove
- Department of Pediatrics, Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Nikolaus A Haas
- Department of Pediatrics, Pediatric Cardiology, LMU Klinikum, München, Germany
| | - Daniel De Wolf
- Department of Pediatrics, Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium.,Department of Pediatrics, Pediatric Cardiology, Brussel University Hospital, Brussels, Belgium
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Abstract
PURPOSE OF REVIEW Pulmonary arterial hypertension (PAH) causes high morbidity and mortality in children. In this review, we discuss advances in diagnosis and treatment of this disorder. RECENT FINDINGS Proceedings published from the 2018 World Symposium updated the definition of pulmonary hypertension to include all adults and children with mean pulmonary artery pressure more than 20 mmHg. Targeted PAH therapy is increasingly used off-label, but in 2017, bosentan became the first Food and Drug Administration-targeted PAH therapy approved for use in children. SUMMARY In recent years, advanced imaging and clinical monitoring have allowed improved risk stratification of pulmonary hypertension patients. New therapies, approved in adults and used off-label in pediatric patients, have led to improved outcomes for affected children.
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183
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Children with Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension Treated with Pulmonary Vasodilators-The Pediatric Cardiologist Point of View. CHILDREN-BASEL 2021; 8:children8050326. [PMID: 33922327 PMCID: PMC8145230 DOI: 10.3390/children8050326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Abstract
Pulmonary hypertension in children with bronchopulmonary dysplasia (BPD-PH) significantly worsens the prognosis. Pulmonary vasodilators are often used in BPD-PH but the short-term outcome of treatment is not well described. The aim of this study was to evaluate BPD-PH children diagnosed beyond 36 weeks postmenstrual age treated with pulmonary vasodilators (sildenafil, bosentan, or both) and to assess the short and long-term effect of oral pulmonary vasodilators treatment. Twenty patients were included in the study. Cardiology evaluation (WHO-FC, NTproBNP, oxygen saturation, pulmonary to systemic pressure ratio PAP/SAP) was performed at diagnosis and after treatment initiation. In the majority of patients improvement in all evaluated factors was observed. No side effects of vasodilators were observed. PH resolved in 10 patients after a mean of 21.4 months of treatment. Six patients died. The number of poor prognostic factors commonly used to assess patients with pulmonary arterial hypertension (PAH) decreased significantly during BPD-PH treatment. The influence of BPD-PH perinatal risk factors on prognosis was considered but was not confirmed. In conclusion, the treatment of BPD-PH with pulmonary vasodilators was well tolerated and led to a clinical improvement with the possibility of discontinuation without recurrence of PH. Prognostic factors used in pediatric PAH risk stratification also seem to be useful in assessing treatment efficacy and prognosis in patients with BPD-PH.
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184
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Muehlbacher T, Bassler D, Bryant MB. Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2021; 8:298. [PMID: 33924638 PMCID: PMC8069828 DOI: 10.3390/children8040298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. OBJECTIVE The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. METHODS We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. RESULTS Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. DISCUSSION There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.
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Affiliation(s)
- Tobias Muehlbacher
- Department of Neonatology, University Hospital Zurich, 8091 Zurich, Switzerland; (D.B.); (M.B.B.)
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185
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The Impact of COVID-19 Pandemic on Children with Pulmonary Arterial Hypertension. Parental Anxiety and Attitudes. Follow-Up Data from the Polish Registry of Pulmonary Hypertension (BNP-PL). J Clin Med 2021; 10:jcm10081640. [PMID: 33921526 PMCID: PMC8069741 DOI: 10.3390/jcm10081640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/27/2021] [Accepted: 04/08/2021] [Indexed: 12/20/2022] Open
Abstract
The COVID-19 pandemic has impacted healthcare systems worldwide. Little is known about the impact of the pandemic on medical and psycho-social aspects of children with rare diseases such as pulmonary arterial hypertension and their parents. The study is based on children registered in The Database of Pulmonary Hypertension in the Polish Population and a parent-reported survey deployed during the first 6 months of the pandemic. The questionnaire consisted of six question panels: demographic data, fear of COVID-19, General Anxiety Disorder-7 (GAD-7), social impact of pandemic, patients’ medical status, and alarming symptoms (appearance or exacerbation). Out of 80 children registered, we collected 58 responses (72.5% response rate). Responders (parents) were mostly female (n = 55; 94.8%) at a mean age of 40.6 ± 6.9 years. Patients (children) were both females (n = 32; 55%) and males with a mean age of 10.0 ± 5.1 years. Eleven (19%) children had symptoms of potential disease exacerbation. Eight parents (72.7%) decided for watchful waiting while others contacted their GPs or cardiologists (n = 6; 54.5%). Three children had to be hospitalized (27.3%). Most planned hospitalizations (27/48; 56.2%) and out-patient visits (20/35; 57.1%) were cancelled, delayed, or substituted by telehealth services. Among the participating parents, the study shows very high levels of anxiety (n = 20; 34.5%) and concern (n = 55; 94.8%) and the need for detailed information (52; 89.6%) regarding COVID-19 and medical service preparedness during the pandemic. The COVID-19 pandemic has influenced child healthcare and caused high levels of anxiety among parents.
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186
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Kirkpatrick EC. Pulmonary Hypertension as a Complication of Pediatric Cancer. Glob Pediatr Health 2021; 8:2333794X211009094. [PMID: 33889681 PMCID: PMC8040614 DOI: 10.1177/2333794x211009094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 11/16/2022] Open
Abstract
Pediatric cancer is a life threatening disease known to create multi-organ complications that further compromise medical management affecting patient morbidity and mortality. Pulmonary hypertension (PH) is becoming more recognized as a complication of cancer and its therapies but has not been well characterized in pediatrics. Cancer pathophysiology can be uniquely set up to promote pulmonary vascular injury and remodeling that is similar to PH patients without cancer. This highlights the need to evaluate for PH clinically and with routine testing such as echocardiography during the course of a patient's care even into adulthood. This review article will discuss the direct, indirect and therapy related aspects of cancer which can promote PH in these patients. This understanding is essential to target effective treatment options in a potentially fatal complication. Diagnostic and treatment algorithms are presented in relation to the most recent pediatric PH management guidelines.
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187
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Chandrasekharan P, Lakshminrusimha S, Abman SH. When to say no to inhaled nitric oxide in neonates? Semin Fetal Neonatal Med 2021; 26:101200. [PMID: 33509680 DOI: 10.1016/j.siny.2021.101200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Inhaled nitric oxide (iNO) was approved for use in critically ill term and near-term neonates (>34 weeks gestational age) in 1999 for hypoxic respiratory failure (HRF) with evidence of pulmonary hypertension. In 2011 and 2014, the National Institutes of Health and American Academy of Pediatrics respectively recommended against the use of iNO in preterm infants <34 weeks. However, these guidelines were based on trials conducted with varying inclusion criteria and outcomes. Recent guidelines from the American Thoracic Society/American Heart Association, the Pediatric Pulmonary Hypertension Network (PPHNet) and European Pediatric Pulmonary Vascular Disease Network recommend the use of iNO in preterm neonates with HRF with confirmed pulmonary hypertension. This review discusses the available evidence for off-label use of iNO. Preterm infants with prolonged rupture of membranes and pulmonary hypoplasia appear to respond to iNO. Similarly, preterm infants with physiology of pulmonary hypertension with extrapulmonary right-to-left shunts may potentially have an oxygenation response to iNO. An overview of relative and absolute contraindications for iNO use in neonates is provided. Absolute contraindications to iNO use include a ductal dependent congenital heart disease where systemic circulation is supported by a right-to-left ductal shunt, severe left ventricular dysfunction and severe congenital methemoglobinemia. In preterm infants, we do not recommend the routine use of iNO in HRF due to parenchymal lung disease without pulmonary hypertension and prophylactic use to prevent bronchopulmonary dysplasia. Future randomized trials evaluating iNO in preterm infants with pulmonary hypertension and/or pulmonary hypoplasia are warranted. (233/250 words).
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Affiliation(s)
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA.
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA.
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188
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Tamimi O, Mohammed MHA. Pulmonary Vascular Resistance Measurement Remains Keystone in Congenital Heart Disease Management. Front Cardiovasc Med 2021; 8:607104. [PMID: 33869298 PMCID: PMC8044299 DOI: 10.3389/fcvm.2021.607104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/03/2021] [Indexed: 11/13/2022] Open
Abstract
Pulmonary vascular resistance (PVR) plays a major role in congenital heart management and critical decision. The impact of pulmonary vascular disease in the early and late morbidity and mortality after cardiac surgery and interventional catheterization in congenital heart defect (CHD) highlights the importance of critical evaluation for PVR. Currently, PVR is evaluated with invasive cardiac catheterization for hemodynamic data collection, processing, and analysis. Despite the limitation of hemodynamic evaluation in the setting of CHD, accurate data analysis, and interpretation have significant impact on clinical outcome and procedure success. This article reviews the basic calculation of PVR in the setting of congenital heart disease with diagrammatic illustration for easy understanding of the hemodynamic.
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Affiliation(s)
- Omar Tamimi
- Department of Cardiac Sciences, King Salman Cardiac Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed H A Mohammed
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department Pediatric, Faculty of Medicine, Omdurman Islamic University, Omdurman, Sudan
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189
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Foeldvari I, Klotsche J, Kasapcopur O, Adrovic A, Terreri MT, Sakamoto AP, Stanevicha V, Sztajnbok F, Anton J, Feldman B, Alexeeva E, Katsicas M, Smith V, Avcin T, Marrani E, Kostik M, Lehman T, Sifuentes-Giraldo WA, Vasquez-Canizares N, Appenzeller S, Janarthanan M, Moll M, Nemcova D, Patwardhan A, Santos MJ, Sawhney S, Schonenberg-Meinema D, Battagliotti C, Berntson L, Bica B, Brunner J, Costa-Reis P, Eleftheriou D, Harel L, Horneff G, Kaiser D, Kallinich T, Lazarevic D, Minden K, Nielsen S, Nuruzzaman F, Uziel Y, Helmus N, Torok KS. Differences sustained between diffuse and limited forms of juvenile systemic sclerosis in expanded international cohort. www.juvenile-scleroderma.com. Arthritis Care Res (Hoboken) 2021; 74:1575-1584. [PMID: 33787070 DOI: 10.1002/acr.24609] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 03/01/2021] [Accepted: 03/25/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To evaluate the baseline clinical characteristics of juvenile systemic sclerosis (jSSc) patients in the international Juvenile SSc Inception Cohort (jSScC), compare these characteristics between the classically defined diffuse (dcjSSc) and limited cutaneous (lcjSSc) subtypes, and among those with overlap features. METHODS A cross-sectional study was performed using baseline visit data. Demographic, organ system evaluation, treatment, and patient and physician reported outcomes were extracted and summary statistics applied. Comparisons between dcjSSc and lcSSc subtypes and patients with and without overlap features were performed using Chi-square and Mann Whitney U-tests. RESULTS At data extraction 150 jSSc patients were enrolled across 42 centers, 83% were Caucasian, 80% female, dcjSSc predominated (72%), and 17% of the cohort had overlap features. Significant differences were found between dcjSSc and lcjSSc regarding the modified Rodnan Skin Score, presence of Gottron's papules, digital tip ulceration, 6 Minute walk test, composite pulmonary and cardiac involvement. All more frequent in dcSSc except for cardiac involvement. DcjSSc patients had significantly worse scores for physician rated disease activity and damage. A significantly higher occurrence of Gottron's papules, musculoskeletal involvement and composite pulmonary involvement, and significantly lower frequency of Raynaud's phenomenon, were seen in those with overlap features. CONCLUSION Results from a large international jSSc cohort demonstrate significant differences between dcjSSc and lcjSSc patients including more globally severe disease and increased frequency of ILD in dcjSSc patients, while those with lcSSc have more frequent cardiac involvement. Those with overlap features had an unexpected higher frequency of interstitial lung disease.
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Affiliation(s)
- Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | | | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | | | | | - Valda Stanevicha
- Riga Stradins University, Department of Pediatric, University Children Hospital, Riga, Latvia
| | | | - Jordi Anton
- Pediatric Rheumatology, Hospital Sant Joan de Déu, Esplugues (Barcelona), Universitat de Barcelona, Spain
| | - Brian Feldman
- SickKids The Hospital for Sick Children, Toronto, Canada
| | - Ekaterina Alexeeva
- National Medical Research Center of Children's Health, Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Maria Katsicas
- Hospital de Pediatria J.P Garrahan, Buenos Aires, Argentine
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University, Department of Rheumatology, Ghent University Hospital; Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - Tadej Avcin
- University Children's Hospital University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Mikhail Kostik
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | | | | | | | | | | | - Monika Moll
- University Tuebingen, Pediatric Rheumatology, Tuebingen, Germany
| | | | | | | | | | - Dieneke Schonenberg-Meinema
- Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Lillemor Berntson
- Dept. of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Blanca Bica
- Hospital Universitário Clementino Fraga Filho (HUCFF), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jürgen Brunner
- Medical University Innsbruck; Department of Pediatrics, Pediatric Rheumatology, Innsbruck, Austria
| | - Patricia Costa-Reis
- Pediatrics Department, Hospital de Santa Maria, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | - Liora Harel
- Schneider Children's Medical Center of Israel Sackler Faculty of Medicine, Tel Aviv University, Petah-Tikva, Israel
| | - Gerd Horneff
- Asklepios Klnik Sankt Augustin, Sankt Augustin, Germany
| | - Daniela Kaiser
- Luzerner Kantonsspital, Kinderspital, Luzern, Switzerland
| | - Tilmann Kallinich
- Charité University Medicine and German Rheumatism Research Center Berlin, Berlin, Germany
| | - Dragana Lazarevic
- Dept of Pediatric Rheumatology and Immunology Clinical Center Nis, Faculty of Medicine, University of Niš, Nis, Serbia
| | - Kirsten Minden
- Charité University Medicine and German Rheumatism Research Center Berlin, Berlin, Germany
| | | | | | - Yosef Uziel
- Pediatric Rheumatology Unit, Meir Medical Center, Kfar Saba, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nicola Helmus
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - Kathryn S Torok
- University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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190
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Melicoff E, Hayes D, Benden C. Lung transplantation as an intervention for pediatric pulmonary hypertension. Pediatr Pulmonol 2021; 56:587-592. [PMID: 33210834 DOI: 10.1002/ppul.25154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/30/2020] [Accepted: 10/22/2020] [Indexed: 12/24/2022]
Abstract
Lung transplantation is a treatment option for selected children with end-stage lung disease and pulmonary vascular disorders. Overall, pulmonary hypertension (PH) is the second most frequent indication for infants and children requiring lung transplants. In pediatric PH patients, timing for listing remains a difficult decision due to patient heterogeneity and varying allocation policies across different countries. Furthermore, perioperative management can be challenging, making interdisciplinary collaboration among surgical, anesthesiology, critical care, and lung transplant teams essential. Because pediatric PH patients typically have preserved cardiac index and exercise tolerance even with advanced disease, they should be referred early even if they do not meet the criteria for listing of primarily adults by International Society for Heart and Lung Transplantation (ISHLT) published in 2015: New York Heart Association (NYHA) functional class III or IV without improvement, cardiac index < 2 L/min/m2 , mean right atrial pressure of >15 mmHg. Bridging strategies with extracorporeal support should be determined at the time of listing in anticipation of possible clinical deterioration. Bilateral lung transplantation using cardiopulmonary bypass to provide hemodynamic stability is nowadays the standard surgical approach in pediatric centers. The immediate post-transplant period is characterized by dramatic changes in the right ventricle (RV) and and left ventricle (LV) anatomy and physiology, which can be life-threatening. Induction, immunosuppression, prophylaxis, and surveillance are not different from patients without PH. Overall, outcomes in pediatric lung and heart-lung transplant patients for PH are not different from those children undergoing transplantation for other indications. In fact, long-term survival is superior in children with idiopathic PH compared to other diseases, providing most recipients with improved quality of life.
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Affiliation(s)
- Ernestina Melicoff
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Don Hayes
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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191
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Coleman RD, Chartan CA, Mourani PM. Intensive care management of right ventricular failure and pulmonary hypertension crises. Pediatr Pulmonol 2021; 56:636-648. [PMID: 33561307 DOI: 10.1002/ppul.24776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 04/03/2020] [Indexed: 01/22/2023]
Abstract
Pulmonary hypertension (PH), an often unrelenting disease that carries with it significant morbidity and mortality, affects not only the pulmonary vasculature but, in turn, the right ventricle as well. The survival of patients with PH is closely related to the right ventricular function. Therefore, having an understanding of how to manage right ventricular failure (RVF) and acute pulmonary hypertensive crises is imperative for clinicians who encounter these patients. This review addresses the management of these patients in detail, addressing: (a) the pathophysiology of RVF, (b) intensive care monitoring of these patients in the intensive care unit, (c) imaging of the right ventricle, (d) intubation and mechanical ventilation, (e) inotrope and vasopressor selection, (f) pulmonary vasodilator use, (g) interventional and surgical procedures for the acutely failing right ventricle, and (h) mechanical support for RVF.
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Affiliation(s)
- Ryan D Coleman
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Corey A Chartan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Peter M Mourani
- Section of Critical Care Medicine and Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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192
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Chouvarine P, Photiadis J, Cesnjevar R, Scheewe J, Bauer UMM, Pickardt T, Kramer HH, Dittrich S, Berger F, Hansmann G. RNA expression profiles and regulatory networks in human right ventricular hypertrophy due to high pressure load. iScience 2021; 24:102232. [PMID: 33786422 PMCID: PMC7994198 DOI: 10.1016/j.isci.2021.102232] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/28/2021] [Accepted: 02/22/2021] [Indexed: 12/15/2022] Open
Abstract
Right ventricular hypertrophy (RVH) occurs in high pressure afterload, e.g., tetralogy of Fallot/pulmonary stenosis (TOF/PS). Such RVH is associated with alterations in energy metabolism, neurohormonal and epigenetic dysregulation (e.g., microRNA), and fetal gene reprogramming in animal models. However, comprehensive expression profiling of competing endogenous RNA in human RVH has not been performed. Here, we unravel several previously unknown circular, long non-coding, and microRNAs, predicted to regulate expression of genes specific to human RVH in the non-failing heart (TOF/PS). These genes are significantly overrepresented in pathways related to regulation of glucose and lipid metabolism (SIK1, FABP4), cell surface interactions (THBS2, FN1), apoptosis (PIK3IP1, SIK1), extracellular matrix composition (CTGF, IGF1), and other biological events. This is the first unbiased RNA sequencing study of human compensated RVH encompassing coding and non-coding RNA expression and predicted sponging of miRNAs by non-coding RNAs. These findings advance our understanding of adaptive RVH and highlight future therapeutic targets. First comprehensive transcriptomic study of human RVH via RNA expression and network analysis First human RVH study using exclusively freshly isolated myocardium Known hypertrophy genes are regulated the strongest by competing endogenous RNA networks in RVH Epigenetic mRNA regulation in RVH by ncRNAs is dependent on sex and age
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Affiliation(s)
- Philippe Chouvarine
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Joachim Photiadis
- Departments of Pediatric Cardiology and Pediatric Cardiac Surgery, German Heart Institute, German Center for Cardiovascular Research (DZHK) partner site Berlin, Berlin, Germany.,Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany
| | - Robert Cesnjevar
- Departments of Pediatric Cardiology and Pediatric Cardiac Surgery, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany.,Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany
| | - Jens Scheewe
- Divisions of Pediatric Cardiology and Pediatric Cardiac Surgery, Heart Center, University of Kiel, German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Kiel, Germany.,Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany
| | - Ulrike M M Bauer
- Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany.,National Register for Congenital Heart Defects, German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Thomas Pickardt
- Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany.,National Register for Congenital Heart Defects, German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Hans-Heiner Kramer
- Divisions of Pediatric Cardiology and Pediatric Cardiac Surgery, Heart Center, University of Kiel, German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Kiel, Germany.,Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany
| | - Sven Dittrich
- Departments of Pediatric Cardiology and Pediatric Cardiac Surgery, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany.,Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany
| | - Felix Berger
- Departments of Pediatric Cardiology and Pediatric Cardiac Surgery, German Heart Institute, German Center for Cardiovascular Research (DZHK) partner site Berlin, Berlin, Germany.,Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany.,Competence Network for Congenital Heart Defects (CNCHD), Berlin, Germany
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193
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[Research advances in the treatment strategies for severe pertussis in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23. [PMID: 33627217 PMCID: PMC7921532 DOI: 10.7499/j.issn.1008-8830.2010105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
At present, effective antibiotics and comprehensive symptomatic/supportive treatment as early as possible are mainly used for the treatment of severe pertussis in clinical practice. However, some children with severe pertussis have unsatisfactory response to commonly used drugs and treatment measures in the intensive care unit and thus have a high risk of death. Studies have shown that certain treatment measures given in the early stage, such as exchange transfusion, may help reduce deaths, but there is still a lack of uniform implementation norms. How to determine the treatment regimen for severe pertussis and improve treatment ability remains a difficult issue in clinical practice. This article reviews the advances in the treatment of severe pertussis, in order to provide a reference for clinical treatment and research.
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194
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Lakshminrusimha S. Neonatal and Postneonatal Pulmonary Hypertension. CHILDREN-BASEL 2021; 8:children8020131. [PMID: 33670256 PMCID: PMC7918656 DOI: 10.3390/children8020131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 02/09/2021] [Indexed: 11/16/2022]
Abstract
During transition at birth with ventilation of the lungs, pulmonary vascular resistance (PVR) decreases from high fetal values, leading to an 8 to 10-fold increase in pulmonary blood flow (Qp). In some infants, this transition does not occur, resulting in pulmonary hypertension (PH). In infants, PH can present as: (a) primary PH in term neonates (idiopathic), (b) PH secondary to lung disease or hypoplasia in term infants, (c) acute PH in preterm infants with respiratory distress syndrome (RDS), (d) chronic PH with bronchopulmonary dysplasia (BPD) in preterm infants and (e) post-neonatal PH. A hemodynamically significant patent ductus arteriosus (PDA) can exacerbate PH in preterm infants due to increased Qp. Pulmonary vein stenosis (PVS) can complicate BPD with PH. Diagnosis of PH is based on clinical features, echocardiography and, in some intractable cases, cardiac catheterization. Therapy of PH includes oxygen, invasive or non-invasive ventilation, correction of acidosis, surfactant and selective and non-selective pulmonary vasodilators such as inhaled nitric oxide and sildenafil, respectively. Early closure of a hemodynamically significant PDA has the potential to limit pulmonary vascular remodeling associated with BPD and PH. The role of thiamine in pathogenesis of PH is also discussed with the recent increase in thiamine-responsive acute pulmonary hypertension in early infancy. Recognition and prompt therapy of PH can prevent right ventricular dysfunction, uncoupling and failure.
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Affiliation(s)
- Satyan Lakshminrusimha
- Department of Pediatrics, UC Davis Children's Hospital; University of California Davis, Sacramento, CA 95817, USA
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195
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Nawaytou H, Fineman JR, Moledina S, Ivy D, Abman SH, Cerro MJD. Practice patterns of pulmonary hypertension secondary to left heart disease among pediatric pulmonary hypertension providers. Pulm Circ 2021; 11:2045894021991446. [PMID: 33623667 PMCID: PMC7879002 DOI: 10.1177/2045894021991446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/07/2021] [Indexed: 11/16/2022] Open
Abstract
Development of pulmonary hypertension (PH) in patients with left side heart disease (LHD) is a predictor of poor prognosis. The use of pulmonary vasodilators in PH associated with LHD (PH-LHD) is controversial. In this study, we describe the practice patterns regarding the use of pulmonary vasodilators in PH-LHD among a group of international pediatric PH specialists. A survey was distributed to the members of three pediatric PH networks: PPHNet, PVRI, and REHIPED. The survey queried participants on the rationale, indications, and contraindications of the use of pulmonary vasodilators in children with PH-LHD. Forty-seven PH specialists from 39 PH centers completed the survey. Participants included PH specialists from North America (57%), South America (15%), and Europe (19%). The majority of participants (74%) recommended the use of pulmonary vasodilators only in patients with combined pre-capillary and post-capillary pulmonary hypertension. Participants required the presence of clinical symptoms or signs of heart failure (68%) or right ventricular dysfunction by echocardiography (51%) in order to recommend pulmonary vasodilator therapy. There was no agreement regarding hemodynamic criteria used to recommend pulmonary vasodilators or the etiologies of LHD considered contraindications for using pulmonary vasodilators to manage PH-LHD. Of the available PH-targeted drugs, most participants preferred the use of phosphodiesterase-5-inhibitors for this indication. In conclusion, the practice of recommending pulmonary vasodilators in PH-LHD is highly variable among international pediatric PH specialists. Most specialists of those surveyed (57% in North America) would consider the use of pulmonary vasodilators in PH-LHD only if pre-capillary pulmonary hypertension and right ventricular dysfunction are present.
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Affiliation(s)
- Hythem Nawaytou
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Jeffrey R Fineman
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Shahin Moledina
- Department of Pediatrics, University College London, London, UK
| | - Dunbar Ivy
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maria J Del Cerro
- Department of Pediatric Cardiology, Ramon y Cajal University Hospital, Madrid, Spain
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196
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Huang SW, Lee PL, Fan PC, Kuo MF, Chen CA, Chiu SN, Lin MT, Lu CW, Wang JK, Wu MH. Diffuse midline glioma presenting with central sleep apnea and pulmonary hypertension in a 4-year-old patient: a case report. J Clin Sleep Med 2021; 17:325-328. [PMID: 33006310 DOI: 10.5664/jcsm.8854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
NONE Central sleep apnea is a rare disorder in the pediatric population with various initial presentations and is secondary to many underlying diseases. We report on a 4-year-old boy with episodes of syncope. He also had pulmonary hypertension and cardiomegaly. Polysomnography showed the finding for central sleep apnea with a high apnea-hypopnea index (up to 138.1 events/h). Brain magnetic resonance imaging showed an ill-defined area near the medulla oblongata and lower pons. The lesion from a brainstem biopsy confirmed the diagnosis of low-grade glioma. Conservative medical follow-up was suggested, and brain magnetic resonance imaging 6 months later showed no obvious tumor progression. To our best knowledge, this is the first case report that workup on the cause of syncope and pulmonary hypertension led to the final diagnosis of central sleep apnea and a brain neoplasm.
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Affiliation(s)
- Szu-Wei Huang
- Department of Emergency Medicine, Taipei Municipal Wan Fang Hospital, Taipei, Taiwan.,Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Pei-Lin Lee
- Department of Medicine, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Pi-Chuan Fan
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Meng-Fai Kuo
- Department of Surgery, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-An Chen
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Shuenn-Nan Chiu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
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197
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Beghetti M, Berger RMF, Bonnet D, Grill S, Lesage C, Lemarie JC, Ivy DD. Echocardiographic Changes and Long-Term Clinical Outcomes in Pediatric Patients With Pulmonary Arterial Hypertension Treated With Bosentan for 72 Weeks: A Post-hoc Analysis From the FUTURE 3 Study. Front Pediatr 2021; 9:681538. [PMID: 34222150 PMCID: PMC8242164 DOI: 10.3389/fped.2021.681538] [Citation(s) in RCA: 1] [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: 03/16/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022] Open
Abstract
FormUlation of bosenTan in pUlmonary arterial hypeRtEnsion (FUTURE) 3 was a 24-week open-label, prospective, and randomized phase 3 study that assessed the pharmacokinetics of bosentan 2 mg/kg b.i.d. or t.i.d. in children with pulmonary arterial hypertension (PAH). We report findings from a post-hoc analysis that explored the prognostic value of echocardiographic changes during FUTURE 3 in relation to clinical outcomes observed during the 24-week core study and 48-week extension. Patients aged ≥3 months to <12 years (n = 64) received oral doses of bosentan 2 mg/kg b.i.d. or t.i.d. (1:1) for 24 weeks, after which they were eligible to enter the extension with continued bosentan administration. Echocardiographic evaluations were performed at baseline, Week 12, and 24 of the core study via central reading, and analyzed post-hoc for correlation with clinical outcomes (time to PAH worsening, time to death, and vital status). Sixty-four patients were randomized in the core study [median (IQR) age 3.8 (1.7-7.8) years]; and 58 patients (90.6%) entered the 48-week extension. Most of the patients (68.8%) were receiving ≥1 PAH medication at baseline. Echocardiographic changes during the core study were small but with high variability. There were statistically significant associations at Week 24 between worsening of the parameters, systolic left ventricular eccentricity index (LVEIS) and E/A ratio mitral valve flow, and the outcomes of time to death and time to PAH worsening. Additional studies that utilize simple and reproducible echocardiographic assessments are needed to confirm these findings and subsequently identify potential treatment goals in pediatric PAH.
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Affiliation(s)
- Maurice Beghetti
- Paediatric Cardiology Unit, Children's Hospital, Geneva, Switzerland.,Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatriques, University of Lausanne, Lausanne, Switzerland
| | - Rolf M F Berger
- Department of Paediatric Cardiology, Centre for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Damien Bonnet
- M3C-Hospital Necker Enfants Malades, Department of Paediatric Cardiology, Université de Paris, Paris, France
| | - Simon Grill
- Actelion Pharmaceuticals Ltd., Allschwil, Switzerland
| | | | | | - D Dunbar Ivy
- Department of Pediatric Cardiology, Children's Hospital Colorado, Denver, CO, United States
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198
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Hasan BS, Rasheed MA, Wahid A, Kumar RK, Zuhlke L. Generating Evidence From Contextual Clinical Research in Low- to Middle Income Countries: A Roadmap Based on Theory of Change. Front Pediatr 2021; 9:764239. [PMID: 34956976 PMCID: PMC8696471 DOI: 10.3389/fped.2021.764239] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/18/2021] [Indexed: 11/24/2022] Open
Abstract
Along with inadequate access to high-quality care, competing health priorities, fragile health systems, and conflicts, there is an associated delay in evidence generation and research from LMICs. Lack of basic epidemiologic understanding of the disease burden in these regions poses a significant knowledge gap as solutions can only be developed and sustained if the scope of the problem is accurately defined. Congenital heart disease (CHD), for example, is the most common birth defect in children. The prevalence of CHD from 1990 to 2017 has progressively increased by 18.7% and more than 90% of children with CHD are born in Low and Middle-Income Countries (LMICs). If diagnosed and managed in a timely manner, as in high-income countries (HICs), most children lead a healthy life and achieve adulthood. However, children with CHD in LMICs have limited care available with subsequent impact on survival. The large disparity in global health research focus on this complex disease makes it a solid paradigm to shape the debate. Despite many challenges, an essential aspect of improving research in LMICs is the realization and ownership of the problem around paucity of local evidence by patients, health care providers, academic centers, and governments in these countries. We have created a theory of change model to address these challenges at a micro- (individual patient or physician or institutions delivering health care) and a macro- (government and health ministries) level, presenting suggested solutions for these complex problems. All stakeholders in the society, from government bodies, health ministries, and systems, to frontline healthcare workers and patients, need to be invested in addressing the local health problems and significantly increase data to define and improve the gaps in care in LMICs. Moreover, interventions can be designed for a more collaborative and effective HIC-LMIC and LMIC-LMIC partnership to increase resources, capacity building, and representation for long-term productivity.
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Affiliation(s)
- Babar S Hasan
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Muneera A Rasheed
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Asra Wahid
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Liesl Zuhlke
- Division of Pediatric Cardiology, Department of Pediatrics, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa.,Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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199
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Hansmann G, Sallmon H, Roehr CC, Kourembanas S, Austin ED, Koestenberger M. Pulmonary hypertension in bronchopulmonary dysplasia. Pediatr Res 2021; 89:446-455. [PMID: 32521539 PMCID: PMC7979539 DOI: 10.1038/s41390-020-0993-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/24/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is a major complication in prematurely born infants. Pulmonary hypertension (PH) associated with BPD (BPD-PH) is characterized by alveolar diffusion impairment, abnormal vascular remodeling, and rarefication of pulmonary vessels (vascular growth arrest), which lead to increased pulmonary vascular resistance and right heart failure. About 25% of infants with moderate to severe BPD develop BPD-PH that is associated with high morbidity and mortality. The recent evolution of broader PH-targeted pharmacotherapy in adults has opened up new treatment options for infants with BPD-PH. Sildenafil became the mainstay of contemporary BPD-PH therapy. Additional medications, such as endothelin receptor antagonists and prostacyclin analogs/mimetics, are increasingly being investigated in infants with PH. However, pediatric data from prospective or randomized controlled trials are still sparse. We discuss comprehensive diagnostic and therapeutic strategies for BPD-PH and briefly review the relevant differential diagnoses of parenchymal and interstitial developmental lung diseases. In addition, we provide a practical framework for the management of children with BPD-PH, incorporating the modified definition and classification of pediatric PH from the 2018 World Symposium on Pulmonary Hypertension, and the 2019 EPPVDN consensus recommendations on established and newly developed therapeutic strategies. Finally, current gaps of knowledge and future research directions are discussed. IMPACT: PH in BPD substantially increases mortality. Treatment of BPD-PH should be conducted by an interdisciplinary team and follow our new treatment algorithm while still kept tailored to the individual patient. We discuss recent developments in BPD-PH, make recommendations on diagnosis, monitoring and treatment of PH in BPD, and address current gaps of knowledge and potential research directions. We provide a practical framework, including a new treatment algorithm, for the management of children with BPD-PH, incorporating the modified definition and classification of pediatric PH (2018 WSPH) and the 2019 EPPVDN consensus recommendations on established and newly developed therapeutic strategies for BPD-PH.
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Affiliation(s)
- Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany.
| | - Hannes Sallmon
- grid.6363.00000 0001 2218 4662Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | - Charles C. Roehr
- grid.410556.30000 0001 0440 1440Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK ,grid.4991.50000 0004 1936 8948National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Stella Kourembanas
- grid.38142.3c000000041936754XDivision of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Eric D. Austin
- grid.152326.10000 0001 2264 7217Division of Pediatric Pulmonary Medicine, Vanderbilt University, Nashville, TN USA
| | - Martin Koestenberger
- grid.11598.340000 0000 8988 2476Division of Pediatric Cardiology, Medical University of Graz, Graz, Austria
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200
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Toward a standardized multidisciplinary team approach in preterm infants at-risk for pulmonary hypertension. J Perinatol 2021; 41:801-802. [PMID: 33564106 PMCID: PMC8049864 DOI: 10.1038/s41372-021-00949-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/12/2020] [Accepted: 01/21/2021] [Indexed: 12/12/2022]
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