201
|
Evers PD, Critser PJ, Cash M, Magness M, Hirsch R. Prognostic Value of Change in Cardiac Index After Prostacyclin Initiation in Pediatric Pulmonary Hypertension. Pediatr Cardiol 2021; 42:116-122. [PMID: 32974724 DOI: 10.1007/s00246-020-02460-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
Invasive hemodynamic assessment remains the gold standard for the diagnosis of pediatric pulmonary hypertension and for longitudinal assessment of response to therapy. This analysis sought to describe the changes in hemodynamic variables after initiation of prostacyclin therapy and determine which changes bear predictive power of adverse clinical outcomes. A retrospective chart review of established patients at Cincinnati Children's Hospital with pulmonary arterial hypertension (PAH) who required prostacyclin therapy between 2004 and 2018 was performed. The baseline hemodynamic parameters at diagnosis as well as change in those parameters between initial catheterization and post-prostacyclin initiation catheterization were independent variables. Cox proportional hazard regression and recursive partitioning analysis were used to characterize which hemodynamic factors predicted the composite adverse outcome (CAO) defined as death, lung transplantation, or reverse Pott's shunt surgery. During the study period, 29 patients met inclusion criteria in which there were 7 CAOs: 4 deaths, 3 lung transplants, and 2 reverse Pott's shunts. Median time between catheterizations was 86 days and between the initiation of prostacyclin therapy and the second catheterization was 54 days. Cox regression revealed that only baseline pulmonary artery pressure (> 51 mmHg) and a failure to increase cardiac index illustrated statistically significant hazard for occurrence of the CAO (p < 0.01). These criteria significantly dichotomized the population in a Kaplan-Meier analysis into likelihoods of experiencing the CAO. While controlling for other hemodynamic variables, the absence of augmentation of cardiac index after the initiation of prostacyclin therapy is a valuable prognostic indicator of adverse PAH outcomes in pediatrics.
Collapse
Affiliation(s)
- Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Sciences University, 707 SW Gaines St. CDRC-P, Portland, OR, 97239, USA.
| | - Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michelle Cash
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melissa Magness
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Russel Hirsch
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
202
|
Meinel K, Koestenberger M, Sallmon H, Hansmann G, Pieles GE. Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young. Diagnostics (Basel) 2020; 11:diagnostics11010049. [PMID: 33396225 PMCID: PMC7823322 DOI: 10.3390/diagnostics11010049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022] Open
Abstract
While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.
Collapse
Affiliation(s)
- Katharina Meinel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, 8036 Graz, Austria; (K.M.); (M.K.)
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, 8036 Graz, Austria; (K.M.); (M.K.)
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
| | - Hannes Sallmon
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
- Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin (DHZB), 13353 Berlin, Germany
| | - Georg Hansmann
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, 30625 Hannover, Germany
| | - Guido E. Pieles
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Royal Hospital for Children and Bristol Heart Institute, Bristol BS2 8HW, UK
- Institute of Sport Exercise and Health (ISEH), University College London, London W1T 7HA, UK
- Correspondence:
| |
Collapse
|
203
|
Hasan B, Hansmann G, Budts W, Heath A, Hoodbhoy Z, Jing ZC, Koestenberger M, Meinel K, Mocumbi AO, Radchenko GD, Sallmon H, Sliwa K, Kumar RK. Challenges and Special Aspects of Pulmonary Hypertension in Middle- to Low-Income Regions: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75:2463-2477. [PMID: 32408981 DOI: 10.1016/j.jacc.2020.03.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 01/19/2023]
Abstract
Challenges and special aspects related to the management and prognosis of pulmonary hypertension (PH) in middle- to low-income regions (MLIRs) range from late presentation to comorbidities, lack of resources and expertise, cost, and rare options of lung transplantation. Expert consensus recommendations addressing the specific challenges for prevention and therapy of PH in MLIRs with limited resources have been lacking. To date, 6 MLIR-PH registries containing mostly adult patients with PH exist. Importantly, the global prevalence of PH is much higher in MLIRs compared with high-income regions: group 2 PH (left heart disease), pulmonary arterial hypertension associated with unrepaired congenital heart disease, human immunodeficiency virus, or schistosomiasis are highly prevalent. This consensus statement provides selective, tailored modifications to the current PH guidelines to address the specific challenges faced in MLIRs, resulting in the first pragmatic and cost-effective consensus recommendations for PH care providers, patients, and their families.
Collapse
Affiliation(s)
- Babar Hasan
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan.
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany.
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Alexandra Heath
- Division of Pediatric Cardiology, Kardiozentrum, La Paz, Bolivia
| | - Zahra Hoodbhoy
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Zhi-Cheng Jing
- Department of Cardiology, Peking Union Medical College Hospital & Key Lab of Pulmonary Vascular Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Katharina Meinel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Ana Olga Mocumbi
- Instituto Nacional de Saúde, Vila de Marracuene, Maputo, Mozambique
| | - Ganna D Radchenko
- Secondary Hypertension Department with Pulmonary Hypertension Center, State Institute National Scientific Center, MD Strazhesko Institute of Cardiology of Ukrainian National Academy of Medical Science, and Bogomolets National Medical University, Kyiv, Ukraine
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Departments of Medicine and Cardiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - R Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | | |
Collapse
|
204
|
Das BB. COVID-19 and Pulmonary Hypertension in Children: What Do We Know So Far? MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E716. [PMID: 33352654 PMCID: PMC7765781 DOI: 10.3390/medicina56120716] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/01/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022]
Abstract
The interplay between coronavirus disease 2019 (COVID-19) and pulmonary hypertension (PH) in children is unknown. Adults with PH are at potential risk for severe complications and high mortality due to associated comorbidities. It is difficult to extrapolate the outcomes of COVID-19 in adults to pediatric PH patients. Overall, a small number of COVID-19 cases is reported in patients with preexisting PH. Several factors may be responsible for the low incidence of COVID-19 in children with PH. Pulmonary hypertension is a rare disease, testing is not universal, and patients may have followed more rigorously the Center for Disease Control's guidelines recommended for personal protection with mask-wearing, social distancing, and hand sanitization through ongoing health education. The small number of COVID-19 cases in patients with preexisting PH does not support that PH is protective for COVID-19. However, medications used to treat PH may have some protection against COVID-19. This review discusses the pathophysiology of PH occurring with COVID-19, differences between children and adults with COVID-19, strategies for management of preexisting PH in children during the ongoing pandemic, and its impact within the field of PH.
Collapse
Affiliation(s)
- Bibhuti B Das
- Department of Pediatric, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital Austin Specialty Care, Austin, TX 78759, USA
| |
Collapse
|
205
|
Critser PJ, Evers PD, McGovern E, Cash M, Hirsch R. Balloon atrial septostomy as initial therapy in pediatric pulmonary hypertension. Pulm Circ 2020; 10:2045894020958970. [PMID: 33282186 PMCID: PMC7682233 DOI: 10.1177/2045894020958970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/08/2020] [Indexed: 11/23/2022] Open
Abstract
Balloon atrial septostomy is a palliative procedure currently used to bridge medically refractory pulmonary hypertension patients to lung transplantation. In the current report, we present balloon atrial septostomy as an initial therapy for high-risk pediatric pulmonary hypertension patients at our institution. Nineteen patients with median age of 4.3 years (range 0.1–14.3 years) underwent balloon atrial septostomy during initial admission for pulmonary hypertension. There were no procedural complications or deaths within 24 h of balloon atrial septostomy. Patients were followed for a median of 2.6 years (interquartile range 1.0–4.8 years). Three (16%) patients died, 3 (16%) underwent lung transplantation, and 1 (5%) underwent reverse Potts shunt. Transplant-free survival at 30 days, 1 year, and 3 years was 84%, 76%, and 67% respectively. This single-center experience suggests early-BAS in addition to pharmacotherapy is safe and warrants consideration in high-risk pediatric pulmonary hypertension patients.
Collapse
Affiliation(s)
- Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Science University, Portland, OR, USA
| | - Eimear McGovern
- Division of Pediatric Cardiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Michelle Cash
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Russel Hirsch
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
206
|
Hayashi T, Ono H, Kaneko Y. Association of Preoperative Mixed Venous Oxygen Saturation with Postoperative Segmental Pulmonary Hypertension in Pulmonary Atresia with Ventricular Septal Defect and Major Aortopulmonary Collaterals. Pediatr Cardiol 2020; 41:1689-1696. [PMID: 32710283 DOI: 10.1007/s00246-020-02428-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Abstract
In patients with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCAs), segmental pulmonary hypertension is common; however, its pathophysiology remains to be elucidated. This study aimed to identify preoperative hemodynamic factors associated with segmental pulmonary hypertension after intracardiac repair in patients with PA/VSD/MAPCAs. This study included 12 patients with PA/VSD/MAPCAs who underwent unifocalization and intracardiac repair from 2009 at our institution. Hemodynamic measurements of preoperative and postoperative cardiac catheterization were collected. Patients were considered to have pulmonary hypertension if the mean pulmonary pressure measured postoperatively at any peripheral pulmonary artery was ≥ 20 mmHg. The data were compared between patients with and without postoperative segmental pulmonary hypertension; p value < 0.05 was considered statistically significant. Intracardiac repair was performed at the age of 2.1 years (range 0.5-28.2 years). Unifocalization was performed separately prior to intracardiac repair in two patients and concomitantly in 10 patients. Postoperative cardiac catheterization, performed 1.2 years (range 0.2-8.7 years) after intracardiac repair, revealed that five patients had segmental pulmonary hypertension. Patients with postoperative pulmonary hypertension had significantly lower preoperative mixed venous oxygen saturation than those without pulmonary hypertension (57% [55-63%] vs. 65% [53-75%], p < 0.05). No significant differences were found between the groups in terms of age at intracardiac repair, preoperative arterial oxygen saturation, and preoperative peripheral pulmonary arterial mean pressure. Lower preoperative mixed venous oxygen saturation was associated with segmental pulmonary hypertension after intracardiac repair in patients with PA/VSD/MAPCAs.
Collapse
Affiliation(s)
- Taiyu Hayashi
- Division of Cardiology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 1578535, Japan.
| | - Hiroshi Ono
- Division of Cardiology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 1578535, Japan
| | - Yukihiro Kaneko
- Division of Cardiovascular Surgery, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
207
|
Reddy SRV, Arar Y, Hussain T, Greil G, Zabala L, Das BB. Interventional Cardiovascular Magnetic Resonance Imaging (iCMR) in an Adolescent with Pulmonary Hypertension. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:medicina56120636. [PMID: 33255307 PMCID: PMC7760170 DOI: 10.3390/medicina56120636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/11/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023]
Abstract
The interventional cardiac magnetic resonance imaging (iCMR) catheterization procedure is feasible and safe for children and adults with pulmonary hypertension and congenital heart defects (CHD). With iCMR, the calculation of pulmonary vascular resistance (PVR) in children with complex CHD with multilevel shunt lesions is accurate. In this paper, we describe the role of the MRI-guided right-sided cardiac catheterization procedure to accurately estimate PVR in the setting of multiple shunt lesions (ventricular septal defect and patent ductus arteriosus) and to address the clinical question of operability in an adolescent with trisomy 21 and severe pulmonary hypertension.
Collapse
Affiliation(s)
- Surendranath R. Veeram Reddy
- Division of Cardiology, Department of Pediatrics, Children’s Medical Center Dallas, UTSW Medical Center, Dallas, TX 75235, USA; (S.R.V.R.); (Y.A.); (T.H.); (G.G.); (L.Z.)
| | - Yousef Arar
- Division of Cardiology, Department of Pediatrics, Children’s Medical Center Dallas, UTSW Medical Center, Dallas, TX 75235, USA; (S.R.V.R.); (Y.A.); (T.H.); (G.G.); (L.Z.)
| | - Tarique Hussain
- Division of Cardiology, Department of Pediatrics, Children’s Medical Center Dallas, UTSW Medical Center, Dallas, TX 75235, USA; (S.R.V.R.); (Y.A.); (T.H.); (G.G.); (L.Z.)
| | - Gerald Greil
- Division of Cardiology, Department of Pediatrics, Children’s Medical Center Dallas, UTSW Medical Center, Dallas, TX 75235, USA; (S.R.V.R.); (Y.A.); (T.H.); (G.G.); (L.Z.)
| | - Luis Zabala
- Division of Cardiology, Department of Pediatrics, Children’s Medical Center Dallas, UTSW Medical Center, Dallas, TX 75235, USA; (S.R.V.R.); (Y.A.); (T.H.); (G.G.); (L.Z.)
| | - Bibhuti B. Das
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Austin Specialty Care, Austin, TX 78759, USA
| |
Collapse
|
208
|
Capel A, Lévy M, Szezepanski I, Malekzadeh-Milani S, Vouhé P, Bonnet D. Potts anastomosis in children with severe pulmonary arterial hypertension and atrial septal defect. ESC Heart Fail 2020; 8:326-332. [PMID: 33216469 PMCID: PMC7835613 DOI: 10.1002/ehf2.13074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/26/2022] Open
Abstract
Aims Potts shunt has been proposed as a bridge or alternative to lung transplantation for children with severe and drug‐refractory suprasystemic pulmonary arterial hypertension (PAH). We describe the management of the atrial shunt when a Potts shunt is planned in refractory PAH. Methods and results We report a case series of children in whom a Potts shunt was done for severe PAH associated with an atrial septal defect to illustrate the different clinical and haemodynamic scenarios. Five children (2 to 13 years) underwent a Potts shunt: three surgical, one percutaneous Potts shunt, and one percutaneous stenting of a restrictive arterial duct. All had associated atrial septal defect. Those who had generalized cyanosis before the procedure had a complicated postoperative course and required longer ventilatory and inotropic support, except the one who had atrial septal defect closure before the Potts shunt. One of the three cyanotic patients died. Two patients with left‐to‐right shunt before the Potts shunt had an uncomplicated postoperative course. Conclusions Shunt physiology is only partially predictable after the Potts shunt in children with PAH and atrial septal defect. Abrupt drop in left ventricle preload while the right ventricle is decompressed can potentially be prevented by atrial septal defect closure prior to the Potts shunt.
Collapse
Affiliation(s)
- Alice Capel
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Marilyne Lévy
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Isabelle Szezepanski
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Sophie Malekzadeh-Milani
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Pascal Vouhé
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| |
Collapse
|
209
|
Management of chronic pulmonary hypertension in neonates with bronchopulmonary dysplasia: perspectives of neonatologists with hemodynamic expertise and pediatric cardiologists. J Perinatol 2020; 40:1726-1728. [PMID: 32801352 DOI: 10.1038/s41372-020-00791-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/18/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022]
|
210
|
Truong U, Meinel K, Haddad F, Koestenberger M, Carlsen J, Ivy D, Jone PN. Update on noninvasive imaging of right ventricle dysfunction in pulmonary hypertension. Cardiovasc Diagn Ther 2020; 10:1604-1624. [PMID: 33224776 DOI: 10.21037/cdt-20-272] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pulmonary hypertension (PH) is a progressive disease affecting patients across the life span. The pathophysiology primarily involves the pulmonary vasculature and right ventricle (RV), but eventually affects the left ventricular (LV) function as well. Safe, accurate imaging modalities are critical for diagnosis, serial monitoring, and tailored therapy. While cardiac catheterization remains the conventional modality for establishing diagnosis and serial monitoring, noninvasive imaging has gained considerable momentum in providing accurate assessment of the entire RV-pulmonary axis. In this state-of-the-art review, we will discuss the most recent developments in echocardiography, magnetic resonance imaging, and computed tomography in PH evaluation from pediatric to adult population.
Collapse
Affiliation(s)
- Uyen Truong
- Division of Pediatric Cardiology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Katharina Meinel
- Division of Pediatric Cardiology, Medical University of Graz, Graz, Austria
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dunbar Ivy
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Pei-Ni Jone
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
211
|
Giagnorio R, Hansmann G. Mineralocorticoid receptor blockade improves pulmonary hypertension and right ventricular function in bronchopulmonary dysplasia: a case report. Cardiovasc Diagn Ther 2020; 10:1686-1690. [PMID: 33224781 DOI: 10.21037/cdt.2020.02.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is a combined pulmonary vascular and parenchymal disease, representing the most common cause of chronic lung disease (CLD) in infancy. Pulmonary hypertension (PH) is frequently associated with BPD and-if persistent-substantially increases mortality. We report on a 4-month-old, former preterm infant with BPD, severe PH and right heart failure who greatly and rapidly improved clinical status and right ventricular (RV) function by means of blood biomarkers [N-terminal prohormone of brain natriuretic peptide (NT-pro-BNP), cardiac troponin T] and transthoracic echocardiography, following the addition of spironolactone and hydrochlorothiazide to the treatment regimen.
Collapse
Affiliation(s)
- Roberto Giagnorio
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| |
Collapse
|
212
|
Navaratnam M, DiNardo JA. Peri-operative right ventricular dysfunction-the anesthesiologist's view. Cardiovasc Diagn Ther 2020; 10:1725-1734. [PMID: 33224786 PMCID: PMC7666948 DOI: 10.21037/cdt-20-426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/13/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Manchula Navaratnam
- Department of Anesthesia and Perioperative Medicine, Stanford Children’s Hospital, Stanford University Medical Center, Palo Alto, CA, USA
| | - James A. DiNardo
- Department of Anesthesia, Harvard Medical School, Division of Cardiac Anesthesia, Francis X. McGowan Jr, MD Chair in Cardiac Anesthesia, Boston Children’s Hospital, Boston, MA, USA
| |
Collapse
|
213
|
Rawat M, Chandrasekharan P, Gugino SF, Koenigsknecht C, Nielsen L, Wedgwood S, Mathew B, Nair J, Steinhorn R, Lakshminrusimha S. Optimal Oxygen Targets in Term Lambs with Meconium Aspiration Syndrome and Pulmonary Hypertension. Am J Respir Cell Mol Biol 2020; 63:510-518. [PMID: 32609558 PMCID: PMC7528912 DOI: 10.1165/rcmb.2019-0449oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/01/2020] [Indexed: 12/13/2022] Open
Abstract
Optimal oxygen saturation as measured by pulse oximetry (SpO2) in neonatal lung injury, such as meconium aspiration syndrome (MAS) and persistent pulmonary hypertension of newborn (PPHN), is not known. Our goal was to determine the SpO2 range in lambs with MAS and PPHN that results in the highest brain oxygen delivery (bDO2) and pulmonary blood flow (Qp) and the lowest pulmonary vascular resistance and oxidative stress. Meconium was instilled into endotracheal tubes in 25 near-term gestation lambs, and the umbilical cord was occluded to induce asphyxia and gasping, causing MAS and PPHN. Lambs were randomized into four groups and ventilated for 6 hours with fixed fraction of inspired oxygen (FiO2) = 1.0 irrespective of SpO2, and three groups had FiO2 titrated to keep preductal SpO2 between 85% and 89%, 90% and 94%, and 95% and 99%, respectively. Tissues were collected to measure nitric oxide synthase activity, 3-nitrotyrosine, and 8-isoprostanes. Throughout the 6-hour exposure period, lambs in the 95-99% SpO2 target group had the highest Qp, lowest pulmonary vascular resistance, and highest bDO2 but were exposed to higher FiO2 (0.5 ± 0.21 vs. 0.29 ± 0.17) with higher lung 3-nitrotyrosine (0.67 [interquartile range (IQR), 0.43-0.73] ng/mcg protein vs. 0.1 [IQR, 0.09-0.2] ng/mcg protein) and lower lung nitric oxide synthase activity (196 [IQR, 192-201] mMol nitrite/mg protein vs. 270 [IQR, 227-280] mMol nitrite/mg protein) compared with the 90-94% target group. Brain 3-nitrotyrosine was lower in the 85-89% target group, and brain/lung 8-isoprostane levels were not significantly different. In term lambs with MAS and PPHN, Qp and bDO2 through the first 6 hours are higher with target SpO2 in the 95-99% range. However, the 90-94% target range is associated with significantly lower FiO2 and lung oxidative stress. Clinical trials comparing the 90-94% versus the 95-99% SpO2 target range in term infants with PPHN are warranted.
Collapse
Affiliation(s)
| | | | - Sylvia F. Gugino
- Department of Pediatrics and
- Department of Physiology and Biophysics, University at Buffalo, Buffalo, New York
| | | | - Lori Nielsen
- Department of Pediatrics and
- Department of Physiology and Biophysics, University at Buffalo, Buffalo, New York
| | - Stephen Wedgwood
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; and
| | | | | | - Robin Steinhorn
- Department of Pediatrics, Rady Children’s Hospital, University of California San Diego, California
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; and
| |
Collapse
|
214
|
Santens B, Van De Bruaene A, De Meester P, D'Alto M, Reddy S, Bernstein D, Koestenberger M, Hansmann G, Budts W. Diagnosis and treatment of right ventricular dysfunction in congenital heart disease. Cardiovasc Diagn Ther 2020; 10:1625-1645. [PMID: 33224777 DOI: 10.21037/cdt-20-370] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Right ventricular (RV) function is important for clinical status and outcomes in children and adults with congenital heart disease (CHD). In the normal RV, longitudinal systolic function is the major contributor to global RV systolic function. A variety of factors contribute to RV failure including increased pressure- or volume-loading, electromechanical dyssynchrony, increased myocardial fibrosis, abnormal coronary perfusion, restricted filling capacity and adverse interactions between left ventricle (LV) and RV. We discuss the different imaging techniques both at rest and during exercise to define and detect RV failure. We identify the most important biomarkers for risk stratification in RV dysfunction, including abnormal NYHA class, decreased exercise capacity, low blood pressure, and increased levels of NTproBNP, troponin T, galectin-3 and growth differentiation factor 15. In adults with CHD (ACHD), fragmented QRS is independently associated with heart failure (HF) symptoms and impaired ventricular function. Furthermore, we discuss the different HF therapies in CHD but given the broad clinical spectrum of CHD, it is important to treat RV failure in a disease-specific manner and based on the specific alterations in hemodynamics. Here, we discuss how to detect and treat RV dysfunction in CHD in order to prevent or postpone RV failure.
Collapse
Affiliation(s)
- Béatrice Santens
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Pieter De Meester
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Michele D'Alto
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | | | - Georg Hansmann
- Department of Pediatric Cardiology and Critical care, Hannover Medical School, Hannover, Germany
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| |
Collapse
|
215
|
Bakas AM, Healy HM, Bell KA, Brown DW, Mullen M, Scheid A. Prenatal duct closure leading to severe pulmonary hypertension in a preterm neonate-a case report. Cardiovasc Diagn Ther 2020; 10:1691-1695. [PMID: 33224782 DOI: 10.21037/cdt-20-123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Prenatal closure of the ductus arteriosus (DA) can lead to cardiovascular dysfunction resulting in pulmonary hypertension (PH), progressive right heart failure, fetal hydrops, and fetal or neonatal demise. Supportive therapies-including mechanical ventilation, oxygen, and nitric oxide (NO)-have been employed with variable success among infants born full term, but there is no widely accepted management of prenatal closure of the DA, particularly for preterm infants. We present the case of an infant born at 31 weeks' gestation with right ventricular (RV) dysfunction and PH due to prenatal ductal closure, who was successfully treated with milrinone, resulting in full recovery of cardiac function. Prenatal ductal closure is rare, particularly under 32 weeks gestation, but should be suspected in cases of postnatal hypoxemia in the absence of significant lung disease or structural heart disease. Milrinone may be considered as a therapeutic agent to treat both PH and RV dysfunction in preterm infants status post in utero closure of the DA.
Collapse
Affiliation(s)
- Anna M Bakas
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Helen M Healy
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katherine A Bell
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Mullen
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Annette Scheid
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
216
|
Schweintzger S, Koestenberger M, Schlagenhauf A, Grangl G, Burmas A, Kurath-Koller S, Pocivalnik M, Sallmon H, Baumgartner D, Hansmann G, Gamillscheg A. Safety and efficacy of the endothelin receptor antagonist macitentan in pediatric pulmonary hypertension. Cardiovasc Diagn Ther 2020; 10:1675-1685. [PMID: 33224780 DOI: 10.21037/cdt.2020.04.01] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Macitentan, a dual endothelin receptor antagonist (ERA), was approved in 2014 for the treatment of adults with idiopathic pulmonary arterial hypertension (PAH). Once-per-day dosing and low potential hepatic toxicity make macitentan an appealing therapeutic option for children with PAH, but reports on its use in pediatric patients are still lacking. Methods Prospective observational study of 18 children [10 male; median age: 8.5, minimum (min.): 0.6, maximum (max.): 16.8 years] with pulmonary hypertension (PH). Four of these 18 patients were treatment-naïve and started on a de novo macitentan therapy. The remaining 14/18 children were already on a PH-targeted pharmacotherapy (sildenafil or bosentan as monotherapy or in combination). Nine children who were on bosentan were switched to macitentan. We analyzed the 6-minute walking distance (6MWD), NYHA functional class (FC)/modified ROSS score, invasive hemodynamics, echocardiographic variables and the biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP). Results The median follow up was 6 months (min.: 0.5, max.: 30). Macitentan treatment was associated with improvement of invasive hemodynamics, e.g., the ratio of mean pulmonary arterial pressure/mean systemic arterial pressure decreased from a median of 62% (min.: 30%, max.: 87%) to 49% (min.: 30%, max.: 69%), P<0.05; pulmonary vascular resistance index (PVRi) decreased from a median of 7.6 (min.: 3.3, max.: 11.5) to 4.8 Wood units × m2 body surface area (min.: 2.5, max.: 10), P<0.05. The tricuspid annular plane systolic excursion (TAPSE) increased from a median of 1.4 (min.: 0.8, max.: 2.8) to 1.9 (min.: 0.8, max.: 2.7) cm, (P<0.05). NT-proBNP values decreased from a median of 272 (min.: 27, max.: 2,010) to 229 (min.: 23, max.: 814) pg/mL under macitentan therapy (P<0.05). The 6MWD and NYHA FC/modified ROSS score did not change significantly. Conclusions This is the first prospective study of macitentan pharmacotherapy in infants and children with PH <12 years of age. Except in one patient, macitentan treatment was well tolerated and was associated with improvements in invasive hemodynamics, longitudinal systolic RV function (TAPSE) and serum NT-proBNP values.
Collapse
Affiliation(s)
- Sabrina Schweintzger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, Austria.,European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, Austria.,European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Axel Schlagenhauf
- Division of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gernot Grangl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, Austria
| | - Ante Burmas
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, Austria
| | - Stefan Kurath-Koller
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, Austria
| | - Mirjam Pocivalnik
- Pediatric Intensive Care Unit, Department of Pediatrics, Medical University of Graz, Graz, Austria
| | - Hannes Sallmon
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany.,Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | - Daniela Baumgartner
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, Austria
| | - Georg Hansmann
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany.,Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Andreas Gamillscheg
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, Austria
| |
Collapse
|
217
|
Sallmon H, Berger F, Weber SC, Fischer HS, Hansmann G, Opgen-Rhein B. Interventional creation of an endogenous reverse Potts shunt in an infant with pulmonary hypertension and genetic surfactant disorder-a case report. Cardiovasc Diagn Ther 2020; 10:1696-1700. [PMID: 33224783 DOI: 10.21037/cdt.2020.03.11] [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: 11/06/2022]
Abstract
Reverse Potts shunt is a palliative procedure aimed at decompressing the pressure-overloaded right ventricle in severe pulmonary hypertension (PH). We, herein, report the first case of an interventional creation of an "endogenous" reverse Potts shunt by stenting a pre-existing small but patent ductus arteriosus (PDA) in a 2 months old female infant with severe, supra-systemic PH, associated with a novel combination of a compound heterozygous ABCA3 mutation and additional heterozygous genetic variants of surfactant protein B (SFTPB) and C (SFTPC). The aforementioned combination of human genetic mutations has not been described before in viable infants, children or adults. The catheter intervention was performed via percutaneous femoral arterial access and was well-tolerated. Subsequently, the infant improved by means of clinical status, echocardiographic systolic right ventricular (RV) function, and serum NT-proBNP levels as biomarker of right atrial and RV pressure load. In conclusion, this single case report suggests that interventional stenting of a pre-existing PDA to create an "endogenous" reverse Potts shunt is feasible and efficacious in infants less than 3 months old with severe PH and impending RV failure associated with developmental lung disease.
Collapse
Affiliation(s)
- Hannes Sallmon
- Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Berger
- Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany.,Deutsches Zentrum für Herz- und Kreislaufforschung, Partnersite Berlin (DZHK), Berlin, Germany
| | - Sven C Weber
- Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hendrik S Fischer
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Bernd Opgen-Rhein
- Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
218
|
Hansmann G, Rich S, Maron BA. Cardiac catheterization in pulmonary hypertension: doing it right, with a catheter on the left. Cardiovasc Diagn Ther 2020; 10:1718-1724. [PMID: 33224785 DOI: 10.21037/cdt-20-483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Georg Hansmann
- Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Stuart Rich
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Department of Cardiology, Boston VA Healthcare System, Boston, MA, USA
| |
Collapse
|
219
|
Koestenberger M, Bogaard HJ, Hansmann G. Getting to the bottom of right heart failure. Cardiovasc Diagn Ther 2020; 10:1517-1521. [PMID: 33224771 PMCID: PMC7666963 DOI: 10.21037/cdt-20-565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 08/27/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Harm-Jan Bogaard
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Georg Hansmann
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| |
Collapse
|
220
|
Bernardo RJ, Haddad F, Couture EJ, Hansmann G, de Jesus Perez VA, Denault AY, de Man FS, Amsallem M. Mechanics of right ventricular dysfunction in pulmonary arterial hypertension and heart failure with preserved ejection fraction. Cardiovasc Diagn Ther 2020; 10:1580-1603. [PMID: 33224775 PMCID: PMC7666917 DOI: 10.21037/cdt-20-479] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Abstract
Right ventricular (RV) dysfunction is the most important determinant of survival in patients with pulmonary hypertension (PH). The manifestations of RV dysfunction not only include changes in global RV systolic function but also abnormalities in the pattern of contraction and synchrony. The effects of PH on the right ventricle have been mainly studied in patients with pulmonary arterial hypertension (PAH). However, with the demographic shift towards an aging population, heart failure with preserved ejection fraction (HFpEF) has become an important etiology of PH in recent years. There are significant differences in RV mechanics, function and adaptation between patients with PAH and HFpEF (with or without PH), which are related to different patterns of remodeling and dysfunction. Due to the unique features of the RV chamber, its connection with the main pulmonary artery and the pulmonary circulation, an understanding of the mechanics of RV function and its clinical significance is mandatory for both entities. In this review, we describe the mechanics of the pressure overloaded right ventricle. We review the different mechanical components of RV dysfunction and ventricular dyssynchrony, followed by insights via analysis of pressure-volume loop, energetics and novel blood flow patterns, such as vortex imaging. We conduct an in-depth comparison of prevalence and characteristics of RV dysfunction in HFpEF and PAH, and summarize key outcome studies. Finally, we provide a perspective on needed and expected future work in the field of RV mechanics.
Collapse
Affiliation(s)
- Roberto J. Bernardo
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Francois Haddad
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Etienne J. Couture
- Department of Anesthesiology, Quebec Heart and Lung Institute, Quebec, Canada
- Intensive Care Medicine Division, Department of Medicine, Quebec Heart and Lung Institute, Quebec, Canada
- Research Center, Quebec Heart and Lung Institute, Quebec, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Vinicio A. de Jesus Perez
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - André Y. Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada
- Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal, Canada
| | - Frances S. de Man
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, PHEniX laboratory, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Myriam Amsallem
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| |
Collapse
|
221
|
Customized Massive Parallel Sequencing Panel for Diagnosis of Pulmonary Arterial Hypertension. Genes (Basel) 2020; 11:genes11101158. [PMID: 33007923 PMCID: PMC7650688 DOI: 10.3390/genes11101158] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023] Open
Abstract
Pulmonary arterial hypertension is a very infrequent disease, with a variable etiology and clinical expressivity, making sometimes the clinical diagnosis a challenge. Current classification based on clinical features does not reflect the underlying molecular profiling of these groups. The advance in massive parallel sequencing in PAH has allowed for the describing of several new causative and susceptibility genes related to PAH, improving overall patient diagnosis. In order to address the molecular diagnosis of patients with PAH we designed, validated, and routinely applied a custom panel including 21 genes. Three hundred patients from the National Spanish PAH Registry (REHAP) were included in the analysis. A custom script was developed to annotate and filter the variants. Variant classification was performed according to the ACMG guidelines. Pathogenic and likely pathogenic variants have been found in 15% of the patients with 12% of variants of unknown significance (VUS). We have found variants in patients with connective tissue disease (CTD) and congenital heart disease (CHD). In addition, in a small proportion of patients (1.75%), we observed a possible digenic mode of inheritance. These results stand out the importance of the genetic testing of patients with associated forms of PAH (i.e., CHD and CTD) additionally to the classical IPAH and HPAH forms. Molecular confirmation of the clinical presumptive diagnosis is required in cases with a high clinical overlapping to carry out proper management and follow up of the individuals with the disease.
Collapse
|
222
|
Bidirectional Ductal Shunting and Preductal to Postductal Oxygenation Gradient in Persistent Pulmonary Hypertension of the Newborn. CHILDREN-BASEL 2020; 7:children7090137. [PMID: 32942726 PMCID: PMC7552678 DOI: 10.3390/children7090137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/06/2020] [Accepted: 09/14/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim was to evaluate the relationship between the direction of the patent ductus arteriosus (PDA) shunt and the pre- and postductal gradient for arterial blood gas (ABG) parameters in a lamb model of meconium aspiration syndrome (MAS) with persistent pulmonary hypertension of the newborn (PPHN). METHODS PPHN was induced by intermittent umbilical cord occlusion and the aspiration of meconium through the tracheal tube. After delivery, 13 lambs were ventilated and simultaneous 129 pairs of pre- and postductal ABG were drawn (right carotid and umbilical artery, respectively) while recording the PDA and the carotid and pulmonary blood flow. RESULTS Meconium aspiration resulted in hypoxemia. The bidirectional ductal shunt had a lower postductal partial arterial oxygen tension ([PaO2] with lower PaO2/FiO2 ratio-97 ± 36 vs. 130 ± 65 mmHg) and left pulmonary flow (81 ± 52 vs. 133 ± 82 mL/kg/min). However, 56% of the samples with a bidirectional shunt had a pre- and postductal saturation gradient of < 3%. CONCLUSIONS The presence of a bidirectional ductal shunt is associated with hypoxemia and low pulmonary blood flow. The absence of a pre- and postductal saturation difference is frequently observed with bidirectional right-to-left shunting through the PDA, and does not exclude a diagnosis of PPHN in this model.
Collapse
|
223
|
Rodriguez-Gonzalez M, A Perez-Reviriego A, Castellano-Martinez A. Current role of cardiac biomarkers in extra-cardiac diseases in children. Biomark Med 2020; 14:1183-1187. [PMID: 33021387 DOI: 10.2217/bmm-2020-0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Moises Rodriguez-Gonzalez
- Pediatric Cardiology Department of Puerta del Mar University Hospital, Cadiz, Spain
- Biomedical Research & Innovation Institute of Cadiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, Spain
| | - Alvaro A Perez-Reviriego
- Pediatric Cardiology Department of Puerta del Mar University Hospital, Cadiz, Spain
- Biomedical Research & Innovation Institute of Cadiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, Spain
| | - Ana Castellano-Martinez
- Pediatric Nephrology Department of Puerta del Mar University Hospital, Cadiz, Spain
- Biomedical Research & Innovation Institute of Cadiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, Spain
| |
Collapse
|
224
|
Albinni S, Marx M, Lang IM. Focused Update on Pulmonary Hypertension in Children-Selected Topics of Interest for the Adult Cardiologist. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E420. [PMID: 32825190 PMCID: PMC7559541 DOI: 10.3390/medicina56090420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 11/16/2022]
Abstract
Pulmonary hypertensive vascular disease (PHVD), and pulmonary hypertension (PH), which is a broader term, are severe conditions associated with high morbidity and mortality at all ages. Treatment guidelines in childhood are widely adopted from adult data and experience, though big differences may exist regarding aetiology, concomitant conditions and presentation. Over the past few years, paediatric aspects have been incorporated into the common guidelines, which currently address both children and adults with pulmonary hypertension (PH). There are multiple facets of PH in the context of cardiac conditions in childhood. Apart from Eisenmenger syndrome (ES), the broad spectrum of congenital heart disease (CHD) comprises PH in failing Fontan physiology, as well as segmental PH. In this review we provide current data and novel aspects on the pathophysiological background and individual management concepts of these conditions. Moreover, we focus on paediatric left heart failure with PH and its challenging issues, including end stage treatment options, such as mechanical support and paediatric transplantation. PH in the context of rare congenital disorders, such as Scimitar Syndrome and sickle cell disease is discussed. Based on current data, we provide an overview on multiple underlying mechanisms of PH involved in these conditions, and different management strategies in children and adulthood. In addition, we summarize the paediatric aspects and the pros and cons of the recently updated definitions of PH. This review provides deeper insights into some challenging conditions of paediatric PH in order to improve current knowledge and care for children and young adults.
Collapse
Affiliation(s)
- Sulaima Albinni
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Manfred Marx
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Irene M. Lang
- AKH-Vienna, Department of Cardiology, Medical University of Vienna, 1090 Wien, Austria;
| |
Collapse
|
225
|
Dringende Notwendigkeit des Off-label-Einsatzes von PAH-Medikamenten und deren Erstattung bei Kindern mit pulmonaler Hypertonie (Lungenhochdruck). Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00924-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
ZusammenfassungDie pulmonale Hypertonie (PH, Lungenhochdruck), und insbesondere die pulmonalarterielle Hypertonie (PAH), ist eine chronisch-progressive, fatale Erkrankung, für die aktuell – abgesehen von einer bilateralen Lungentransplantation – kein kurativer Therapieansatz besteht. Durch die jüngste Entwicklung und Verfügbarkeit von neuen „zielgerichteten“ PAH-Medikamenten („advanced“ oder „targeted therapies“), die mittlerweile für PAH im Erwachsenenalter zugelassen sind, haben sich allerdings die Lebenserwartung und -qualität von Erwachsenen und Kindern mit PAH erheblich verbessert.Wegen (1) des Mangels an für Kinder zugelassenen PAH-Medikamenten, (2) der gut begründeten Rationale für eine PAH-Pharmakokombinationstherapie im Kindesalter und (3) dem Fehlen schwerwiegender unerwünschter Wirkungen, sollten gerade jungen PH-Patienten die vorhandenen modernen pharmakologischen Therapiemöglichkeiten nicht vorenthalten bleiben. Ein solcher „Off-label“-Einsatz und dessen unbürokratische Erstattung (Finanzierung) durch die Kostenträger sind dringend erforderlich. Die Entscheidung zur spezifischen Therapie der pulmonalen Hypertonie mit Möglichkeit der Kombination von Medikamenten aller Substanzklassen – auch unter Einschluss von „Off-label-Präparaten“ – sollte durch einen Kinderkardiologen erfolgen, der ausreichend Erfahrung mit der Behandlung von Kindern mit pulmonaler Hypertonie – insbesondere mit vasoaktiven Medikamenten – hat, gefolgt von einer engmaschigen ambulanten Anbindung und Nachsorge dieser Patienten. Die mangelnde Zulassung moderner, gegen PAH gerichteter Arzneimittel oder die relativ dünne, evidenzbasierte Datenlage bei Kindern sollte die behandelnden Ärzte nicht davon abhalten, den jungen Patienten diese Therapien anbieten zu können.
Collapse
|
226
|
PPARγ is a gatekeeper for extracellular matrix and vascular cell homeostasis: beneficial role in pulmonary hypertension and renal/cardiac/pulmonary fibrosis. Curr Opin Nephrol Hypertens 2020; 29:171-179. [PMID: 31815758 DOI: 10.1097/mnh.0000000000000580] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Pulmonary arterial hypertension (PAH) is characterized by pulmonary arterial endothelial cell (PAEC) dysfunction and apoptosis, pulmonary arterial smooth muscle cell (PASMC) proliferation, inflammation, vasoconstriction, and metabolic disturbances that include disrupted bone morphogenetic protein receptor (BMPR2)-peroxisome proliferator-activated receptor gamma (PPARγ) axis and DNA damage. Activation of PPARγ improves many of these mechanisms, although erroneous reports on potential adverse effects of thiazolidinedione (TZD)-class PPARγ agonists reduced their clinical use in the past decade. Here, we review recent findings in heart, lung, and kidney research related to the pathobiology of vascular remodeling and tissue fibrosis, and also potential therapeutic effects of the PPARγ agonist pioglitazone. RECENT FINDINGS Independent of its metabolic effects (improved insulin sensitivity and fatty acid handling), PPARγ activation rescues BMPR2 dysfunction, inhibits TGFβ/Smad3/CTGF and TGFβ/pSTAT3/pFoxO1 pathways, and induces the PPARγ/apoE axis, inhibiting vascular remodeling. PPARγ activation dampens mtDNA damage via PPARγ/UBR5/ATM pathway, improves function of endothelial progenitor cells (EPCs), and decrease renal fibrosis by repressing TGFβ/pSTAT3 and TGFβ/EGR1. SUMMARY Pharmacological PPARγ activation improves many hallmarks of PAH, including dysfunction of BMPR2-PPARγ axis, PAEC, PASMC, EPC, mitochondria/metabolism, and inflammation. Recent randomized controlled trials, including IRIS (Insulin Resistance Intervention After Stroke Trial), emphasize the beneficial effects of PPARγ agonists in PAH patients, leading to recent revival for clinical use.
Collapse
|
227
|
Children and Adolescents with Pulmonary Arterial Hypertension: Baseline and Follow-Up Data from the Polish Registry of Pulmonary Hypertension (BNP-PL). J Clin Med 2020; 9:jcm9061717. [PMID: 32503164 PMCID: PMC7356296 DOI: 10.3390/jcm9061717] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/21/2022] Open
Abstract
We present the results from the pediatric arm of the Polish Registry of Pulmonary Hypertension. We prospectively enrolled all pulmonary arterial hypertension (PAH) patients, between the ages of 3 months and 18 years, who had been under the care of each PAH center in Poland between 1 March 2018 and 30 September 2018. The mean prevalence of PAH was 11.6 per million, and the estimated incidence rate was 2.4 per million/year, but it was geographically heterogeneous. Among 80 enrolled children (females, n = 40; 50%), 54 (67.5%) had PAH associated with congenital heart disease (CHD-PAH), 25 (31.25%) had idiopathic PAH (IPAH), and 1 (1.25%) had portopulmonary PAH. At the time of enrolment, 31% of the patients had significant impairment of physical capacity (WHO-FC III). The most frequent comorbidities included shortage of growth (n = 20; 25%), mental retardation (n = 32; 40%), hypothyroidism (n = 19; 23.8%) and Down syndrome (n = 24; 30%). The majority of children were treated with PAH-specific medications, but only half of them with double combination therapy, which improved after changing the reimbursement policy. The underrepresentation of PAH classes other than IPAH and CHD-PAH, and the geographically heterogeneous distribution of PAH prevalence, indicate the need for building awareness of PAH among pediatricians, while a frequent coexistence of PAH with other comorbidities calls for a multidisciplinary approach to the management of PAH children.
Collapse
|
228
|
Abstract
Pulmonary hypertension, despite specific therapies, remains an incurable disease with a dreadful prognosis. A systemic-to-pulmonary shunt, if left unrepaired, can cause pulmonary arterial hypertension. With time, pulmonary vascular disease develops, and closure of the shunt becomes contraindicated. Operability criteria are not well defined and rely mainly on hemodynamic values that fail to predict long-term survival. Shunts can also be created in selected cases of advanced pulmonary hyper-tension, in view of off-loading the right ventricle and improving cardiac output at the cost of cyanosis. Shunt creation is not without risks and remains indicated only in selected severe cases.
Collapse
Affiliation(s)
- Julie Wacker
- Pediatric Cardiology Unit, University Children's Hospital HUG, Pulmonary Hypertension Program HUG, Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique, University of Geneva and Lausanne, Geneva and Lausanne, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, University Children's Hospital HUG, Pulmonary Hypertension Program HUG, Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique, University of Geneva and Lausanne, Geneva and Lausanne, Switzerland
| |
Collapse
|
229
|
Das BB, Jadotte MM, Chan KC. Use of selexipag in a child with pulmonary hypertension associated with sickle cell disease. J Heart Lung Transplant 2020; 39:990-993. [PMID: 32418865 DOI: 10.1016/j.healun.2020.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Bibhuti B Das
- Joe DiMaggio Children's Hospital Heart institute, Memorial Healthcare, Hollywood, Florida; Department of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Specialty Care Clinic, Austin, Texas.
| | - Michelle Marie Jadotte
- Joe DiMaggio Children's Hospital Heart institute, Memorial Healthcare, Hollywood, Florida
| | - Kak-Chen Chan
- Joe DiMaggio Children's Hospital Heart institute, Memorial Healthcare, Hollywood, Florida
| |
Collapse
|
230
|
Burkett DA, Patel SS, Mertens L, Friedberg MK, Ivy DD. Relationship Between Left Ventricular Geometry and Invasive Hemodynamics in Pediatric Pulmonary Hypertension. Circ Cardiovasc Imaging 2020; 13:e009825. [PMID: 32408829 DOI: 10.1161/circimaging.119.009825] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Ventricular septal flattening, frequently present in pulmonary hypertension (PH), can be quantified using eccentricity index (EI). EI has not been evaluated by concurrent echocardiography and cardiac catheterization and traditionally does not account for postsystolic septal flattening, often seen in PH. We evaluated left ventricular shape, including a novel measure of maximal EI to account for postsystolic septal flattening, to establish the relationship with concurrent invasive hemodynamics. Methods Echocardiography was performed at 2 institutions in 78 pediatric PH patients during cardiac catheterization and in 78 matched controls. From midpapillary parasternal short-axis views, EI and right-to-left ventricular diameter ratio were assessed. Results EI and right-to-left ventricular measures were significantly increased in PH compared with controls. Shape measures correlated with invasive hemodynamics and PH outcome measures (PH-related hospitalization, functional class, medical therapy escalation, and BNP [brain natriuretic peptide]). End-systolic EI of 1.16 best identified the presence of PH, whereas a maximal EI of 1.42 and 1.94 best identified half-systemic and systemic PH, respectively. A maximal EI of 1.27 was associated with an odds ratio of 16.16 (95% CI, 6.62-39.46) for PH-related hospitalization or escalation of therapy. Conclusions Using simultaneous echocardiography and catheterization in the largest study population to date, we demonstrate that EI and right-to-left ventricular ratio correlate with invasive hemodynamics and outcomes measures, and EI can accurately define those with clinically important PH. These measures strengthen the ability of echocardiography to identify and follow pediatric PH patients, especially in the absence of methods to quantify right ventricular systolic pressures.
Collapse
Affiliation(s)
- Dale A Burkett
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora (D.A.B., S.S.P., D.D.I)
| | - Sonali S Patel
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora (D.A.B., S.S.P., D.D.I)
| | - Luc Mertens
- Division of Cardiology, Labatt Family Heart Center, Hospital for Sick Children, University of Toronto, Ontario, Canada (L.M., M.K.F.)
| | - Mark K Friedberg
- Division of Cardiology, Labatt Family Heart Center, Hospital for Sick Children, University of Toronto, Ontario, Canada (L.M., M.K.F.)
| | - D Dunbar Ivy
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora (D.A.B., S.S.P., D.D.I)
| |
Collapse
|
231
|
Koestenberger M, Hansmann G. Left Ventricular Geometry and Near-Simultaneous Invasive Hemodynamics in Pediatric Pulmonary Hypertension. CIRCULATION. CARDIOVASCULAR IMAGING 2020; 13:e010787. [PMID: 32408826 DOI: 10.1161/circimaging.120.010787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Austria (M.K.).,European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany (M.K., G.H.)
| | - Georg Hansmann
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany (M.K., G.H.).,Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Germany (G.H.)
| |
Collapse
|
232
|
Olguntürk FR. An update on the diagnosis and treatment of pediatric pulmonary hypertension. Expert Opin Pharmacother 2020; 21:1253-1268. [PMID: 32401622 DOI: 10.1080/14656566.2020.1757071] [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] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a heterogeneous disease that mainly affects the pulmonary arterioles, leading to significant morbidity and mortality. Pulmonary hypertension in children from birth to adolescence presents important differences from that of adults. The majority of pediatric pulmonary arterial hypertension (PAH) cases are idiopathic or associated with congenital heart disease. However, the management of pediatric PAH mainly depends on the results of evidence-based adult studies and the clinical experiences of pediatric experts. AREAS COVERED This article briefly reviews the recent updates on the definition, classification, and diagnostic evaluation of pediatric PAH and their impact on treatment strategies. The main purpose of this review is to discuss the current pediatric therapies, as well as the prospective therapies, in terms of therapeutic targets, actions, side effects, and dosages. EXPERT OPINION Although there is no cure for PAH, recent advances in the form of new treatment options have improved the quality of life and survival rates of PAH patients. PAH-targeted drugs and treatment strategies for adult PAH have not been sufficiently studied in children. However, the growing scientific activity in that field will surely change the treatment option recommendations in pediatric PH from experience-based to evidence-based in the near future.
Collapse
Affiliation(s)
- F Rana Olguntürk
- Professor of Pediatrics and Pediatric Cardiology, PhD in medical physiology, Former Head of Pediatrics and Pediatric Cardiology in Gazi University Faculty of Medicine. Founder of Pediatric Cardiology and PAH center in Gazi University. Former President of Turkish Association of Pediatric Cardiology and Surgery, Gazi University , Ankara, Turkiye
| |
Collapse
|
233
|
Mohamed AA, Louis D, Surak A, Weisz DE, McNamara PJ, Jain A. Vasopressin for refractory persistent pulmonary hypertension of the newborn in preterm neonates - a case series. J Matern Fetal Neonatal Med 2020; 35:1475-1483. [PMID: 32349572 DOI: 10.1080/14767058.2020.1757642] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective: To describe the clinical outcomes following treatment with vasopressin for a sub-cohort of critically ill preterm neonates who have refractory persistent pulmonary hypertension of the newborn (PPHN).Design: Case seriesSetting: Tertiary neonatal intensive care unit, Toronto, Canada.Population: Neonates born <37 weeks gestational age (GA) who received vasopressin for refractory PPHN (lack of response to inhaled nitric oxide) over a 4-year period.Measurements: Changes in physiological indices of cardio-pulmonary stability during vasopressin therapy were analyzed using one-way repeated measures ANOVA, compared to pretreatment values. Data regarding survival to discharge and neurodevelopmental outcomes at 18-24 months were described.Main Results: Thirteen neonates with a mean GA of 31.4 ± 3.3 weeks were included. Vasopressin was initiated at 28.5 ± 4.5 h of age. Overall, oxygenation and hemodynamic variables improved significantly following vasopressin therapy (p < .05 at 24 h vs. pretreatment). Oxygenation failure resolved in 8 cases, of which 7 patients survived (6 without disability). Among the 5 cases where oxygenation failure persisted despite vasopressin, 4 died while one survived with disability.Conclusions: Vasopressin offers promise as a therapy for preterm neonates with refractory PPHN and hemodynamic instability, but prospective investigation is needed.
Collapse
Affiliation(s)
- Adel A Mohamed
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Deepak Louis
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Aimann Surak
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Dany E Weisz
- Department of Pediatrics, Sunnybrook Hospital, Toronto, Canada
| | | | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| |
Collapse
|
234
|
AlSalman F, Howlett M, Breatnach C, Kelly H, O'Brien F. Supporting the use of sildenafil infusions in paediatric and neonatal intensive care - A compatibility study. Eur J Pharm Biopharm 2020; 151:153-161. [PMID: 32289494 DOI: 10.1016/j.ejpb.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/02/2020] [Accepted: 04/09/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Intravenous (IV) sildenafil, a phosphodiesterase type 5 inhibitor, is increasingly being used for the treatment of pulmonary hypertension (PH) in the paediatric population. Sildenafil (Revatio®) is approved for the treatment of pH in adults where it is administered as a bolus injection. However, in paediatrics it is used off-label and administered by continuous IV infusion. In the critically unwell child, limited IV access necessitates the administration of multiple IV infusions through a single IV lumen. The absence of compatibility data between sildenafil and other IV medications commonly used in this context necessitates the use of a dedicated IV line for sildenafil. The overall aim of this study was to establish the physical and chemical compatibility of sildenafil with commonly administered infusions in the paediatric and neonatal intensive care setting. DESIGN This study evaluated the chemical and physical compatibility of binary and multiple combinations (n = 42) of sildenafil with adrenaline, noradrenaline, milrinone, vasopressin and heparin. These were tested using three diluents (NaCl 0.9%w/v, Glucose 5%w/v, and Glucose 10%w/v) and two environmental conditions (room temperature and 37 °C) frequently encountered in paediatric or neonatal intensive care units. Prior to drug combination analysis, HPLC methods were developed and optimised to allow for the quantification of drugs in accordance with current pharmaceutical guidance. Binary and multiple drug mixtures of sildenafil were examined for physical and chemical compatibility to establish compatibility. MEASUREMENTS AND MAIN RESULTS Of the drug combinations not containing heparin, all were deemed compatible with the exception of the five drug mix of Sildenafil 800 μg/mL, Milrinone 200 μg/mL, Vasopressin 0.4Units/mL, Noradrenaline 60 μg/mL, Adrenaline 60 μg/mL at 37 °C, in 10%w/v glucose. All binary or multi drug combinations containing heparin were deemed incompatible. CONCLUSIONS This research provides support and information to clinicians looking to co-administer sildenafil with other IV medicines thus removing the requirement to subject their patients to multiple intravenous cannula insertion points where IV access is restricted. ARTICLE TWEET New evidence to support administration of sildenafil infusions in #PedsICU and #nicu- collaboration between @RCSIPharBioMol@FionaSOBrien1 and @OLCHCrumlin @RCSI_Irl @MoninneHowlett #CHI.
Collapse
Affiliation(s)
- Fatemah AlSalman
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | | | | | - Helena Kelly
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Fiona O'Brien
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| |
Collapse
|
235
|
Selexipag for the treatment of children with pulmonary arterial hypertension: First multicenter experience in drug safety and efficacy. J Heart Lung Transplant 2020; 39:695-706. [PMID: 32362477 DOI: 10.1016/j.healun.2020.03.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/25/2020] [Accepted: 03/27/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The European Pediatric Pulmonary Vascular Disease Network (EPPVDN) investigated the safety and efficacy of add-on selexipag, an oral prostacyclin receptor agonist approved for pulmonary arterial hypertension (PAH) in adults, in the largest, exploratory pediatric cohort to date. METHODS This is a prospective observational study of 15 consecutive children with PAH, treated with oral add-on selexipag at 3 centers. Most patients underwent cardiac catheterizations at baseline and median of 8 months follow-up. All patients had clinical, echocardiographic, and N-terminal pro b-type natriuretic peptide studies, including the EPPVDN pediatric pulmonary hypertension (PH) risk score. RESULTS There was no death during the use of selexipag. Two of 15 patients ultimately underwent lung transplantation. One patient with heritable PAH died on intravenous treprostinil (off selexipag). The mean right atrial pressure, the ratio of pulmonary arterial pressure (PAP) to systemic arterial pressure (SAP) (mean PAP/mean SAP, diastolic PAP/diastolic SAP: -17%), and transpulmonary pressure gradients (TPG) (mean TPG: -17%; p < 0.01; diastolic TPG: -6 mm Hg; p < 0.05) were improved after the therapy (n = 10). Selexipag therapy was associated with a better right ventricular systolic function (tricuspid annular plane systolic excursion: +14.5%; p < 0.01) and functional class. Improvement was seen in non-invasive and combined invasive/non-invasive PH risk scores (lower risk: +18%-22%, higher risk: -35%-37%; p < 0.05). Overall, the efficacy of selexipag was variable, often with a better response in less sick patients. CONCLUSIONS Oral selexipag use in children with PAH is well tolerated and safe when closely monitored. Add-on selexipag therapy improved several outcome-relevant variables in about 50% of patients and prevented disease progression in additional 27% of patients. The novel EPPVDN pediatric PH risk score indicated these drug effects properly, can be useful in clinical follow-up, and should be validated in larger prospective studies.
Collapse
|
236
|
MicroRNA as a Biomarker in Pediatric Pulmonary Hypertension: A Step Closer to the Holy Grail? Pediatr Crit Care Med 2020; 21:393-394. [PMID: 32251186 DOI: 10.1097/pcc.0000000000002219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
237
|
Trans-Right-Ventricle and Transpulmonary MicroRNA Gradients in Human Pulmonary Arterial Hypertension. Pediatr Crit Care Med 2020; 21:340-349. [PMID: 31876555 DOI: 10.1097/pcc.0000000000002207] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES We investigated whether concentrations of circulating microRNAs differ across the hypertensive right ventricle and pulmonary circulation, and correlate with hemodynamic/echocardiographic variables in patients with pulmonary arterial hypertension versus nonpulmonary arterial hypertension controls. DESIGN Prospective blood collection during cardiac catheterization from the superior vena cava, pulmonary artery, and ascending aorta in 12 children with pulmonary arterial hypertension and nine matched nonpulmonary arterial hypertension controls, followed by an unbiased quantitative polymerase chain reaction array screen for 754 microRNAs in plasma. SETTING Children's hospital at a medical school. PATIENTS Twelve pulmonary arterial hypertension patients included as follows: idiopathic pulmonary arterial hypertension (5), pulmonary arterial hypertension (2), pulmonary arterial hypertension-repaired congenital heart disease (4), portopulmonary pulmonary hypertension (1). Nine nonpulmonary arterial hypertension controls included as follows: mild/moderate left ventricular outflow tract obstruction (7), mediastinal teratoma (1), portal vein stenosis (1). INTERVENTIONS Standard pulmonary arterial hypertension treatment. MEASUREMENTS AND MAIN RESULTS Analysis of differential concentrations (false discovery rate < 0.05) revealed two trans-right-ventricle microRNA gradients (pulmonary artery vs superior vena cava): miR-193a-5p (step-up in pulmonary arterial hypertension and step-down in control) and miR-423-5p (step-down in pulmonary arterial hypertension and step-up in control) and two transpulmonary microRNA gradients (ascending aorta vs pulmonary artery): miR-26b-5p (step-down only in control) and miR-331-3p (step-up only in pulmonary arterial hypertension). Between-group comparison revealed miR-29a-3p, miR-26a-5p, miR-590-5p, and miR-200c-3p as upregulated in pulmonary arterial hypertension-superior vena cava and miR-99a-5p as downregulated in pulmonary arterial hypertension-pulmonary artery. The differential microRNA-concentrations correlated with prognostic hemodynamic variables (pulmonary vascular resistance, tricuspid annular plane systolic excursion, etc.). CONCLUSIONS We identified for the first time in human disease (pulmonary arterial hypertension) trans-right-ventricle and transpulmonary microRNA gradients in blood plasma. Several of these microRNAs regulate transcripts that drive cardiac remodeling and pulmonary arterial hypertension and are now emerging as epigenetic pulmonary arterial hypertension biomarkers and targets for therapy.
Collapse
|
238
|
Use of Treprostinil in Pediatric Pulmonary Hypertension: Case Reports and Review of the Literature. J Cardiovasc Pharmacol 2020; 76:23-31. [PMID: 32168152 DOI: 10.1097/fjc.0000000000000820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Add-on therapy with prostacyclin in pediatric refractory pulmonary hypertension (PH) poses a challenge, especially when considering continuous intravenous administration in younger children. A search for alternate routes of drug delivery has led to the clinical investigation of stable and long-acting prostacyclin analogues, such as subcutaneous treprostinil. We reported 2 pediatric cases of PH treated with subcutaneous treprostinil and reviewed the literature on treprostinil use in children. METHOD The literature review used 3 electronic databases and a combination of terms (treprostinil, pediatric, PH, prostanoid, etc). We also searched for pediatric clinical trials on treprostinil registered on international clinical trial registries. RESULTS The reported cases highlighted the multifactorial nature of PH in pediatrics: a female child with a giant omphalocele, and intracardiac and extracardiac shunts; and a male premature child with a congenital diaphragmatic hernia and long-term PH. The literature review identified 19 studies reporting treprostinil use in 421 children with various types of PH (groups 1 and 3). Subcutaneous treprostinil was the most administered formulation, at a mean dose of 40 ng/kg/min. Overall, 12 clinical trials on treprostinil for children with PH were registered on the clinical trial registries. Most authors concluded that subcutaneous treprostinil was effective, well tolerated, and represented an alternative to intravenous epoprostenol. CONCLUSIONS Subcutaneous treprostinil may be a useful adjunct in the therapeutic algorithm for children with severe PH, refractory to oral drugs, and after a complete check-up for all PH etiologies.
Collapse
|
239
|
|
240
|
Chouvarine P, Giera M, Kastenmüller G, Artati A, Adamski J, Bertram H, Hansmann G. Trans-right ventricle and transpulmonary metabolite gradients in human pulmonary arterial hypertension. Heart 2020; 106:1332-1341. [PMID: 32079620 PMCID: PMC7476282 DOI: 10.1136/heartjnl-2019-315900] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/26/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE While metabolic dysfunction occurs in several pulmonary arterial hypertension (PAH) animal models, its role in the human hypertensive right ventricle (RV) and lung is not well characterised. We investigated whether circulating metabolite concentrations differ across the hypertensive RV and/or the pulmonary circulation, and correlate with invasive haemodynamic/echocardiographic variables in patients with PAH. METHODS Prospective EDTA blood collection during cardiac catheterisation from the superior vena cava (SVC), pulmonary artery (PA) and ascending aorta (AAO) in children with PAH (no shunt) and non-PAH controls (Con), followed by unbiased screens of 427 metabolites and 836 lipid species and fatty acids (FAs) in blood plasma (Metabolon and Lipidyzer platforms). Metabolite concentrations were correlated with echocardiographic and invasive haemodynamic variables. RESULTS Metabolomics/lipidomics analysis of differential concentrations (false discovery rate<0.15) revealed several metabolite gradients in the trans-RV (PA vs SVC) setting. Notably, dicarboxylic acids (eg, octadecanedioate: fold change (FC)_Control=0.77, FC_PAH=1.09, p value=0.044) and acylcarnitines (eg, stearoylcarnitine: FC_Control=0.74, FC_PAH=1.21, p value=0.058). Differentially regulated metabolites were also found in the transpulmonary (AAO vs PA) setting and between-group comparisons, that is, in the SVC (PAH-SVC vs Con-SVC), PA and AAO. Importantly, the differential PAH-metabolite concentrations correlated with numerous outcome-relevant variables (e.g., tricuspid annular plane systolic excursion, pulmonary vascular resistance). CONCLUSIONS In PAH, trans-RV and transpulmonary metabolite gradients exist and correlate with haemodynamic determinants of clinical outcome. The most pronounced differential trans-RV gradients are known to be involved in lipid metabolism/lipotoxicity, that is, accumulation of long chain FAs. The identified accumulation of dicarboxylic acids and acylcarnitines likely indicates impaired β-oxidation in the hypertensive RV and represents emerging biomarkers and therapeutic targets in PAH.
Collapse
Affiliation(s)
- Philippe Chouvarine
- Department of Pediatric Cardiology and Critical care, Hannover Medical School, Hannover, Germany
| | - Martin Giera
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, The Netherlands
| | - Gabi Kastenmüller
- Institute of Bioinformatics and Systems Biology, Helmholtz Zentrum München, Deutsches Forschungszentrum für Gesundheit und Umwelt, Neuherberg, Germany
| | - Anna Artati
- Research Unit Molecular Endocrinology and Metabolism, Helmholtz Zentrum München, Deutsches Forschungszentrum für Gesundheit und Umwelt, Neuherberg, Germany
| | - Jerzy Adamski
- Research Unit Molecular Endocrinology and Metabolism, Genome Analysis Center, Helmholtz Zentrum München, Deutsches Forschungszentrum für Gesundheit und Umwelt, Neuherberg, Germany.,Department of Biochemistry, National University Singapore Yong Loo Lin School of Medicine, Singapore
| | - Harald Bertram
- Department of Pediatric Cardiology and Critical care, Hannover Medical School, Hannover, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical care, Hannover Medical School, Hannover, Germany
| |
Collapse
|
241
|
Hansmann G, Calvier L, Risbano MG, Chan SY. Activation of the Metabolic Master Regulator PPARγ: A Potential PIOneering Therapy for Pulmonary Arterial Hypertension. Am J Respir Cell Mol Biol 2020; 62:143-156. [PMID: 31577451 PMCID: PMC6993553 DOI: 10.1165/rcmb.2019-0226ps] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/02/2019] [Indexed: 12/24/2022] Open
Abstract
Translational research is essential to the development of reverse-remodeling strategies for the treatment of pulmonary vascular disease, pulmonary hypertension, and heart failure via mechanistic in vivo studies using animal models resembling human pulmonary arterial hypertension (PAH), cardiovascular remodeling, and progressive right heart failure. Since 2007, peroxisome proliferator-activated receptor γ (PPARγ) agonists have emerged as promising novel, antiproliferative, antiinflammatory, insulin-sensitizing, efficient medications for the treatment of PAH. However, early diabetes study results, their subsequent misinterpretations, errors in published review articles, and rumors regarding potential adverse effects in the literature have dampened enthusiasm for considering pharmacological PPARγ activation for the treatment of cardiovascular diseases, including PAH. Most recently, the thiazolidinedione class PPARγ agonist pioglitazone underwent a clinical revival, especially based on the IRIS (Insulin Resistance Intervention After Stroke) study, a randomized controlled trial in 3,876 patients without diabetes status post-transient ischemic attack/ischemic stroke who were clinically followed for 4.8 years. We discuss preclinical basic translational findings and randomized controlled trials related to the beneficial and adverse effects of PPARγ agonists of the thiazolidinedione class, with a particular focus on the last 5 years. The objective is a data-driven approach to set the preclinical and clinical study record straight. The convincing recent clinical trial data on the lack of significant toxicity in high-risk populations justify the timely conduct of clinical studies to achieve "repurposing" or "repositioning" of pioglitazone for the treatment of clinical PAH.
Collapse
Affiliation(s)
- Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany; and
| | - Laurent Calvier
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany; and
| | - Michael G. Risbano
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, and
| | - Stephen Y. Chan
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, and
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
242
|
El-Saie A, Shivanna B. Novel Strategies to Reduce Pulmonary Hypertension in Infants With Bronchopulmonary Dysplasia. Front Pediatr 2020; 8:201. [PMID: 32457857 PMCID: PMC7225259 DOI: 10.3389/fped.2020.00201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/02/2020] [Indexed: 01/10/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a developmental lung disorder of preterm infants primarily caused by the failure of host defense mechanisms to prevent tissue injury and facilitate repair. This disorder is the most common complication of premature birth, and its incidence remains unchanged over the past few decades. Additionally, BPD increases long-term cardiopulmonary and neurodevelopmental morbidities of preterm infants. Pulmonary hypertension (PH) is a common morbidity of BPD. Importantly, the presence of PH increases both the short- and long-term morbidities and mortality in BPD infants. Further, there are no curative therapies for this complex disease. Besides providing an overview of the pathogenesis and diagnosis of PH associated with BPD, we have attempted to comprehensively review and summarize the current literature on the interventions to prevent and/or mitigate BPD and PH in preclinical studies. Our goal was to provide insight into the therapies that have a high translational potential to meaningfully manage BPD patients with PH.
Collapse
Affiliation(s)
- Ahmed El-Saie
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Binoy Shivanna
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| |
Collapse
|
243
|
Jeremiasen I, Tran-Lundmark K, Idris N, Tran PK, Moledina S. Pulmonary Vasodilator Therapy in Children with Single Ventricle Physiology: Effects on Saturation and Pulmonary Arterial Pressure. Pediatr Cardiol 2020; 41:1651-1659. [PMID: 32734529 PMCID: PMC7695650 DOI: 10.1007/s00246-020-02424-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022]
Abstract
In children with single ventricle physiology, increased pulmonary vascular resistance may impede surgical progression or result in failing single ventricle physiology. The use of pulmonary vasodilators has been suggested as a potential therapy. However, knowledge on indication, dosage, and effect is limited. A retrospective case notes review of all (n = 36) children with single ventricle physiology, treated with pulmonary vasodilators by the UK Pulmonary Hypertension Service for Children 2004-2017. Therapy was initiated in Stage 1 (n = 12), Glenn (n = 8), or TCPC (n = 16). Treatment indications were high mean pulmonary arterial pressure, cyanosis, reduced exercise tolerance, protein-losing enteropathy, ascites, or plastic bronchitis. Average dose of sildenafil was 2.0 mg/kg/day and bosentan was 3.3 mg/kg/day. 56% had combination therapy. Therapy was associated with a reduction of the mean pulmonary arterial pressure from 19 to 14 mmHg (n = 17, p < 0.01). Initial therapy with one or two vasodilators was associated with an increase in the mean saturation from 80 to 85%, (n = 16, p < 0.01). Adding a second vasodilator did not give significant additional effect. 5 of 12 patients progressed from Stage 1 to Glenn, Kawashima, or TCPC, and 2 of 8 from Glenn to TCPC during a mean follow-up time of 4.7 years (0-12.8). Bosentan was discontinued in 57% and sildenafil in 14% of treated patients and saturations remained stable. Pulmonary vasodilator therapy was well tolerated and associated with improvements in saturation and mean pulmonary arterial pressure in children with single ventricle physiology. It appears safe to discontinue when no clear benefit is observed.
Collapse
Affiliation(s)
- Ida Jeremiasen
- Department of Experimental Medical Science, Lund University, BMC C12, 221 84, Lund, Sweden. .,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden.
| | - Karin Tran-Lundmark
- Department of Experimental Medical Science, Lund University, BMC C12, 221 84 Lund, Sweden ,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Nikmah Idris
- Great Ormond Street Hospital for Children, London, UK
| | - Phan-Kiet Tran
- The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Shahin Moledina
- Great Ormond Street Hospital for Children, London, UK ,University College London, London, UK
| |
Collapse
|
244
|
Yang MC, Liu HK, Wu HY, Tey SL, Yang YN, Wu CY, Wu JR. Initial Experience With Patent Ductus Arteriosus Ligation in Pre-term Infants With Bidirectional Shunt Pattern. Front Pediatr 2020; 8:591441. [PMID: 33194925 PMCID: PMC7649389 DOI: 10.3389/fped.2020.591441] [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: 08/04/2020] [Accepted: 09/28/2020] [Indexed: 01/09/2023] Open
Abstract
Background: Patent ductus arteriosus (PDA) with a bidirectional shunt reflects critical clinical conditions. The operability of PDA with a bidirectional shunt in pre-term infants is still not clearly clarified. This study aimed to investigate the feasibility and the outcomes of PDA ligation in pre-term infants with a bidirectional shunt PDA. Methods: All pre-term infants receiving PDA ligation between 2013 and 2019 were enrolled in this prospective study. Patients were allocated into two groups based on the shunting direction of PDA, which were the left-to-right group (group A) and the bidirectional group (group B). Clinical characteristics and pre-op comorbidities were analyzed. Intraoperative complications, post-op neurological sequelae, necrotizing enterocolitis, survival, and mortality were compared between these two groups. Results: Thirty-seven pre-term infants were enrolled (18 in group A, 19 in group B). The mean post-menstrual age at PDA surgery was 32.0 ± 1.3 and 32.8 ± 1.5 weeks, respectively. Before surgery, 44.4 and 89.5% (group A vs. B) of the patients were using invasive mechanical ventilator (p < 0.01). The requirement of high-frequency oscillatory ventilatory support was significantly higher in group B. PDA rupture-related bleeding during exposing PDA or ligating PDA occurred in four infants, and all were all in group B, including one with delayed hemothorax. Early surgical mortality within 30 days of surgery was higher in group B (0 vs. 21.1%, p < 0.05), but only one death could be attributed to the surgery, which was caused by a pain-induced pulmonary hypertension crisis. The 5-year survival was 100% in group A, and 73.7% in group B (p < 0.05). Conclusion: We did not recommend routine PDA ligation in pre-term infants with a bidirectional shunt. However, a bidirectional shunt should not be an absolute contraindication if they fulfill indications of PDA closure. Unexpected intraoperative PDA rupture and delayed hemothorax in a bidirectional shunt PDA should be carefully monitored. Aggressive post-op pain control is also warranted to avoid pulmonary hypertension crisis. The post-op early mortality rate was higher in the bidirectional group, which could be inherent to their poor pre-operative lung condition. Only one death was directly related to the surgery.
Collapse
Affiliation(s)
- Ming-Chun Yang
- Department of Pediatrics, E-Da Hospital, Kaohsiung City, Taiwan.,School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung City, Taiwan.,School of Medicine for International Students, I-Shou University, Kaohsiung City, Taiwan
| | - Hsien-Kuan Liu
- Department of Pediatrics, E-Da Hospital, Kaohsiung City, Taiwan.,School of Medicine for International Students, I-Shou University, Kaohsiung City, Taiwan
| | - Hsuan-Yin Wu
- School of Medicine for International Students, I-Shou University, Kaohsiung City, Taiwan.,Division of Cardiovascular Surgery, Department of Surgery, E-Da Hospital, Kaohsiung City, Taiwan
| | - Shu-Leei Tey
- Department of Pediatrics, E-Da Hospital, Kaohsiung City, Taiwan.,School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung City, Taiwan
| | - Yung-Ning Yang
- Department of Pediatrics, E-Da Hospital, Kaohsiung City, Taiwan.,School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung City, Taiwan.,School of Medicine for International Students, I-Shou University, Kaohsiung City, Taiwan
| | - Chien-Yi Wu
- Department of Pediatrics, E-Da Hospital, Kaohsiung City, Taiwan.,School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung City, Taiwan
| | - Jiunn-Ren Wu
- Department of Pediatrics, E-Da Hospital, Kaohsiung City, Taiwan
| |
Collapse
|
245
|
Calcaterra G, Bassareo PP, Barilla F, Martino F, Fanos V, Fedele F, Romeo F. Pulmonary hypertension in paediatrics. A feasible approach to bridge the gap between real world and guidelines. J Matern Fetal Neonatal Med 2019; 34:3820-3826. [PMID: 31744358 DOI: 10.1080/14767058.2019.1695770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pulmonary hypertension (PH) is quite infrequent in paediatric age and its most common aetiologies include idiopathic pulmonary arterial hypertension, PH related to congenital heart diseases, bronchopulmonary dysplasia (chronic lung disease), persistence of pulmonary hypertension of the newborn, and congenital diaphragmatic hernia. The developed for adult patients PH classification shows limitations when applied to paediatric subjects, since the underlying causes are markedly different between the two ages. In 2011, the Pulmonary Vascular Research Institute Panama Task Force outlined the first specific paediatric pulmonary hypertensive vascular disease diagnostic classification, including 10 main categories and 109 subcategories, thus testifying PH complex pathophysiology during newborns/children growth and development. The unique, distinctive features of paediatric PH were recognized also during the fifth World Symposium on Pulmonary hypertension in 2013 and then confirmed in the recent 2018 sixth World Symposium. For the sake of uniformity, an attempt to adapt the adult classification to paediatric patients was made. However, all these commendable classifications are very complex and may be not of quick comprehension for clinicians. A clinical simpler and simplified method is now suggested, comprising only five groups: Neonatal, Cardiac, Developmental, Idiopathic, and Syndromic PH. This approach is not aimed at replacing the already existing classifications, but is mainly based on the kind of specialized physician (neonatologist, paediatric cardiologist, paediatrician, pulmonologist, general practitioner) who first faces and looks after the child with suspected PH. What is dramatically known is that paediatric PH is a severe disease which, when untreated or undertreated, may lead to increased morbidity and mortality.
Collapse
Affiliation(s)
| | - Pier Paolo Bassareo
- University College of Dublin, Mater Misericordiae University Hospital and Our Lady's Children's Hospital, Crumlin, Dublin, Republic of Ireland
| | - Francesco Barilla
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, "La Sapienza" University of Rome, Rome, Italy
| | - Francesco Martino
- Department of Pediatrics, Obstetrics-Gynecology and Urology, "La Sapienza" University of Rome, Rome, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, University of Cagliari, Cagliari, Italy
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, "La Sapienza" University of Rome, Rome, Italy
| | | |
Collapse
|
246
|
Recommendations from the Association for European Paediatric and Congenital Cardiology for training in pulmonary hypertension. Cardiol Young 2019; 29:1323-1327. [PMID: 31554525 DOI: 10.1017/s104795111900235x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulmonary hypertension is a complex and progressive condition that is either idiopathic or heritable, or associated with one or multiple health conditions, with or without congenital or acquired cardiovascular disease. Recent developments have tremendously increased the armamentarium of diagnostic and therapeutic approaches in children and young adults with pulmonary hypertension that is still associated with a high morbidity and mortality. These modalities include non-invasive imaging, pharmacotherapy, interventional and surgical procedures, and supportive measures. The optimal, tailored diagnostic and therapeutic strategies for pulmonary hypertension in the young are rapidly evolving but still face enormous challenges: Healthcare providers need to take the patient's age, development, disease state, and family concerns into account when initiating advanced diagnostics and treatment. Therefore, there is a need for guidance on core and advanced medical training in paediatric pulmonary hypertension. The Association for European Paediatric and Congenital Cardiology working group "pulmonary hypertension, heart failure and transplantation" has produced this document as an expert consensus statement; however, all recommendations must be considered and applied in the context of the local and national infrastructure and legal regulations.
Collapse
|
247
|
Apitz C, Abdul-Khaliq H, Albini S, Beerbaum P, Dubowy KO, Gorenflo M, Hager A, Hansmann G, Hilgendorff A, Humpl T, Kaestner M, Koestenberger M, Kozlik-Feldmann R, Latus H, Michel-Behnke I, Miera O, Quandt D, Sallmon H, Schranz D, Schulze-Neick I, Stiller B, Warnecke G, Pattathu J, Lammers AE. Neue hämodynamische Definition der pulmonalen Hypertonie. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00792-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Zusammenfassung
Eine pathologische Druckerhöhung im pulmonalen Gefäßsystem (pulmonale Hypertonie, PH) wurde bisher definiert durch einen invasiv gemessenen mittleren pulmonalarteriellen Druck (mPAP) ≥25 mm Hg in Ruhe. Auf dem 6th World Symposium on Pulmonary Hypertension (WSPH) in Nizza 2018 wurde eine neue Definition der PH vorgeschlagen, die die Senkung der Obergrenze des normalen mPAP von 24 auf 20 mm Hg beinhaltet.
Obwohl keine Evidenz aus pädiatrischen Studien hierfür vorliegt, wurde diese neue PH-Definition (mPAP >20 mm Hg) aus Gründen der Einheitlichkeit auch von der pädiatrischen „Task Force“ des WSPH 2018 übernommen.
Die vorliegende Stellungnahme der Arbeitsgemeinschaft Pulmonale Hypertonie (AGPH) der Deutschen Gesellschaft für Pädiatrische Kardiologie und angeborene Herzfehler e. V. (DGPK) erläutert die zugrunde liegende Rationale und mögliche Konsequenzen dieser Definitionsänderung. Insbesondere stellt sie klar, dass diese Änderung der Definition aktuell keinen Einfluss auf die Verschreibung von Medikamenten zur gezielten spezifischen Therapie der pulmonalarteriellen Hypertonie hat.
Collapse
|