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Tsoi SM, Steurer M, Nawaytou H, Cheung S, Keller RL, Fineman JR. Defining the Typical Course of Persistent Pulmonary Hypertension of the Newborn: When to Think Beyond Reversible Causes. J Pediatr 2024; 273:114131. [PMID: 38823627 DOI: 10.1016/j.jpeds.2024.114131] [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: 03/07/2024] [Revised: 04/17/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVES To describe the typical clinical course of reversible persistent pulmonary hypertension of the newborn (PPHN) from perinatal etiologies and compare that with the clinical course of PPHN due to underlying fetal developmental etiologies. STUDY DESIGN This was a single-center, retrospective cohort study of liveborn newborns either born or transferred to our facility for higher level of care between 2015 and 2020 with gestational age ≥35 weeks and a clinical diagnosis of PPHN in the electronic health record. Newborns with complex congenital heart disease and congenital diaphragmatic hernia were excluded. Using all data available at time of collection, newborns were stratified into 2 groups by PPHN etiology - perinatal and fetal developmental causes. Primary outcomes were age at initiation, discontinuation, and total duration of extracorporeal life support, mechanical ventilation, supplemental oxygen, inhaled nitric oxide, inotropic support, and prostaglandin E1. Our secondary outcome was age at echocardiographic resolution of pulmonary hypertension. Groups were compared by t-test. Time-to-event Kaplan Meier curves described and compared (log-rank test) discontinuation of each therapy. RESULTS Sixty-four (72%) newborns had perinatal etiologies whereas 24 (28%) had fetal developmental etiologies. The resolution of perinatal PPHN was more rapid compared with fetal developmental PPHN. By 10 days of age, more neonates were off inotropes (98% vs 29%, P < .01), decannulated from extracorporeal life support (100% vs 0%, P < .01), extubated (75% vs 37%, P < .01), and had echocardiographic resolution of PH (35% vs 7%, P = .02). CONCLUSIONS An atypical PPHN course, characterized by persistent targeted therapies in the second week of life, warrants further work-up for fetal developmental causes.
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Affiliation(s)
- Stephanie M Tsoi
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA.
| | - Martina Steurer
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA; Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Hythem Nawaytou
- Division of Cardiology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Shannon Cheung
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Roberta L Keller
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Jeffrey R Fineman
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
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Pereira SS, Jacquemyn X, Kutty S. Echocardiographic markers at diagnosis of persistent pulmonary hypertension of the newborn. J Perinat Med 2024:jpm-2023-0346. [PMID: 39275958 DOI: 10.1515/jpm-2023-0346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/26/2024] [Indexed: 09/16/2024]
Abstract
OBJECTIVES Clinical parameters along with echocardiographic markers are used to interrogate the haemodynamics in persistent pulmonary hypertension of the newborn (PPHN). The aim of this study was to compare different echocardiographic markers in recent cohort of newborn infants with and without PPHN. METHODS In this retrospective study, common echocardiographic markers were examined in infants>34 weeks' gestation with PPHN (cases) and without PPHN (controls). Infants with congenital heart disease were excluded. Binary regression testing was used to evaluate echocardiographic markers predicting PPHN and death. In addition, diagnostic accuracy testing of echocardiographic markers using ROC was also performed. Intra-observer reliability for echocardiographic markers was examined using coefficient of variation (CoV) and intraclass correlation. RESULTS Fifty-two infants were studied; 22 (42 %) infants with PPHN had significantly higher oxygen requirement, oxygenation index and ventilation days when compared with controls. Echocardiographic markers such as TR Vmax, S/D TR, PAAT, TAPSE and eccentricity index (EI) were significantly different between cases and controls. Receiver operator characteristics analysis of echocardiographic markers revealed TR Vmax 0.96 (0.9-1.0), S/D TR 0.95 (0.87-1.0) and end systolic EI 0.94 (0.87-1.0). These markers were found to predict death in this cohort of infants. CoV and Intra-observer reliability was good for various echocardiographic markers. CONCLUSIONS Among the various echocardiographic markers studied, TR Vmax when present along with S/D TR and end systolic EI had good intra-observer reliability and were diagnostic of PPHN and predicted death in this cohort. Future trials could use these markers in studies examining PPHN.
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Affiliation(s)
- Sujith S Pereira
- Neonatal Unit, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, UK
- Centre for Genomics and Child Health, Barts and the London School of Medicine, Blizard Institute, London, UK
| | - Xander Jacquemyn
- Department of Pediatrics, Helen B. Taussig Heart Center, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Shelby Kutty
- Department of Pediatrics, Helen B. Taussig Heart Center, Johns Hopkins Hospital, Baltimore, MD, USA
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Boyd SM, Kluckow M, McNamara PJ. Targeted Neonatal Echocardiography in the Management of Neonatal Pulmonary Hypertension. Clin Perinatol 2024; 51:45-76. [PMID: 38325947 DOI: 10.1016/j.clp.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Pulmonary hypertension (PH) in neonates, originating from a range of disease states with heterogeneous underlying pathophysiology, is associated with significant morbidity and mortality. Although the final common pathway is a state of high right ventricular afterload leading to compromised cardiac output, multiple hemodynamic phenotypes exist in acute and chronic PH, for which cardiorespiratory treatment strategies differ. Comprehensive appraisal of pulmonary pressure, pulmonary vascular resistance, cardiac function, pulmonary and systemic blood flow, and extrapulmonary shunts facilitates delivery of individualized cardiovascular therapies in affected newborns.
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Affiliation(s)
- Stephanie M Boyd
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Corner Hawkesbury Road, Hainsworth Street, Westmead, Sydney 2145, Australia; The University of Sydney, Sydney, Australia
| | - Martin Kluckow
- The University of Sydney, Sydney, Australia; Department of Neonatology, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Sydney, Australia
| | - Patrick J McNamara
- Division of Neonatology, The University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Timberline S, Bhatt A, Sunderji S, Tancredi DJ, Lakshminrusimha S, Siefkes H. Novel scoring tool of hypoxemic respiratory failure and pulmonary hypertension for defining severity of persistent pulmonary hypertension of newborn. J Perinatol 2023; 43:1281-1287. [PMID: 37626160 PMCID: PMC10541330 DOI: 10.1038/s41372-023-01762-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE To obtain preliminary validity data for a hypoxemic respiratory failure/pulmonary hypertension (HRF/PH) score for classifying persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN Retrospective chart review of 100 consecutive neonates admitted to a Children's hospital from 2016-2021 with PPHN, gestational age ≥34 weeks, and echocardiograms in the first week. We assessed the correlation between HRF/PH score and short-term outcomes using linear and logistic regressions. RESULTS HRF/PH scores ranged 2-12 (mean 8.5), and were classified mild (0-5), moderate (6-10), and severe (11-15), with 6%, 77% and 17% infants in respective categories. HRF/PH score category correlated with invasive ventilation, nitric oxide, high frequency ventilation, vasoactive infusions, extracorporeal life support and death. HRF/PH score category did not correlate with duration of support or length of stay. CONCLUSION The HRF/PH score offers a promising representation of disease severity for PPHN. The tool requires further validation in prospective studies and evaluation for long-term outcomes.
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Affiliation(s)
- Sage Timberline
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Avni Bhatt
- School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Sherzana Sunderji
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | | | - Heather Siefkes
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA.
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Le Duc K, Rakza T, Baudelet JB, Boukhris MR, Mur S, Houeijeh A, Storme L. Diastolic ventricular function in persistent pulmonary hypertension of the newborn. Front Pediatr 2023; 11:1175178. [PMID: 37435163 PMCID: PMC10331722 DOI: 10.3389/fped.2023.1175178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023] Open
Abstract
Background Persistent pulmonary hypertension of the newborn (PPHN) is usually considered a consequence of impaired pulmonary circulation. However, little is known regarding the role of cardiac dysfunction in PPHN. In this study, we hypothesized that the tolerance for pulmonary hypertension in newborn infants depends on the biventricular function. The aim of this study is to evaluate biventricular cardiac performance by using Tissue Doppler Imaging (TDI) in an healthy newborn infants with asymptomatic pulmonary hypertension and in newborn infants with PPHN. Methods Right and left cardiac function were investigated using conventional imaging and TDI in 10 newborn infants with PPHN ("PPHN") and 10 asymptomatic healthy newborn infants ("asymptomatic PH"). Results Systolic pulmonary artery pressure (PAP) as assessed by TDI and the mean systolic velocity of the right ventricular (RV) free wall were similar in both groups. The isovolumic relaxation time of the right ventricle at the tricuspid annulus was significantly longer in the "PPHN" than in the "asymptomatic PH" group (53 ± 14 ms vs. 14 ± 4 ms, respectively; p < 0.05). Left ventricular (LV) function was normal in both groups with a systolic velocity (S'LV) at the LV free wall groups (6 ± 0.5 cm/s vs. 8.3 ± 5.7 cm/s, p > 0.05). Conclusion The present results suggest that high PAP with or without respiratory failure is not associated with altered right systolic ventricular function and does not affect LV function in newborn infants. PPHN is characterized by a marked right diastolic ventricular dysfunction. These data suggest that the hypoxic respiratory failure in PPHN results, at least in part, from diastolic RV dysfunction and right to left shunting across the foramen ovale. We propose that the severity of the respiratory failure is more related to the RV diastolic dysfunction than the pulmonary artery pressure.
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Affiliation(s)
- Kévin Le Duc
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- University of Lille, CHU Lille, ULR 2694—METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, axe Environnement Périnatal et Santé, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Thameur Rakza
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean Benoit Baudelet
- Department of Pediatric Cardiology, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Mohamed Riadh Boukhris
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Sébastien Mur
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Ali Houeijeh
- University of Lille, CHU Lille, ULR 2694—METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, axe Environnement Périnatal et Santé, Lille, France
- Department of Pediatric Cardiology, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Laurent Storme
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- University of Lille, CHU Lille, ULR 2694—METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, axe Environnement Périnatal et Santé, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
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El-Khuffash A, McNamara PJ, Breatnach C, Bussmann N, Smith A, Feeney O, Tully E, Griffin J, de Boode WP, Cleary B, Franklin O, Dempsey E. The use of milrinone in neonates with persistent pulmonary hypertension of the newborn - a randomised controlled trial pilot study (MINT 1). J Perinatol 2023; 43:168-173. [PMID: 36385642 PMCID: PMC9666925 DOI: 10.1038/s41372-022-01562-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the impact of milrinone administration on time spent on nitric oxide (iNO) in infants with acute pulmonary hypertension (aPH). We hypothesized that intravenous milrinone used in conjunction with iNO would reduce the time on iNO therapy and the time spent on invasive ventilation in infants ≥34 weeks gestation with a diagnosis of aPH. We aimed to assess the practicality of instituting the protocol and contributing to a sample size calculation for a definitive multicentre study. STUDY DESIGN This was a multicentre, randomized, double-blind, two arm pilot study, with a balanced (1:1) allocation. Infants with a gestation ≥34 weeks and a birth weight ≥2000 grams aPH, an oxygenation index of ≥10, and commenced on iNO were eligible. Participants on iNO were assigned to either a milrinone infusion (intervention) or a normal saline infusion (placebo) for up to 35 h. The primary outcome was time on iNO and feasibility of conducting the protocol. RESULTS The trial was terminated early after 4 years of enrollment due to poor recruitment. Four infants were allocated to the intervention arm and 5 to the placebo arm. The groups were well matched for baseline variables. No differences were seen in any of the primary or secondary outcomes. CONCLUSION Conducting an interventional trial in the setting of acute pulmonary hypertension in infants is not feasible using our current approach. Future studies in this area require alternative trial design to improve recruitment as this topic remains understudied in the neonatal field. TRIAL REGISTRATION www.isrctn.com ; ISRCTN:12949496; EudraCT Number:2014-002988-16.
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Affiliation(s)
- Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Patrick J McNamara
- Division of Neonatology, Stead Family Department of Pediatrics, Iowa City, IA, USA
| | - Colm Breatnach
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Oliver Feeney
- Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Elizabeth Tully
- Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Joanna Griffin
- Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Brian Cleary
- Department of Pharmacy, The Rotunda Hospital, Dublin, Ireland
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Eugene Dempsey
- INFANT Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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Butt MU, Jabri A, Hamade H, Abdouh AA, Mhanna M, Haddadin F, Nasser F, Hammad N, Jazar DA, Toumar AJ, Siraj A, Balakumaran K, Ilbawi M. Predicting the Severity and Outcome of Persistent Pulmonary Hypertension of the Newborn Using New Echocardiography Parameters. Curr Probl Cardiol 2022:101181. [PMID: 35341801 DOI: 10.1016/j.cpcardiol.2022.101181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/22/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine echocardiographic (ECHO) parameters correlation with clinical severity indices, Alveolar- arterial gradient (A-a gradient), oxygenation index (OI) and clinical outcomes in newborns with persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN Retrospective cohort study of 67 subjects, >35 weeks' gestation with the diagnosis of PPHN admitted to the University of Kentucky neonatal intensive care unit (NICU) between September 2014 and December 2016. RESULTS High left ventricular end-systolic eccentricity index (EIs) correlates with the overall clinical severity of PPHN as it is associated with higher A-a gradient and OI (p=0.0003 and p<0.0001, respectively). Elevated EIs was also predictive for the use of inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO) (p=0.0004 and p<0.0001, respectively). EIs value of >1.38 provides cutoff value as an objective marker for the need for ECMO. CONCLUSION EIs can be used to assess clinical severity and outcomes and should be reported routinely. Further studies are warranted to confirm these results.
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Affiliation(s)
| | - Ahmad Jabri
- Heart and Vascular Center, Metrohealth Medical Center, Cleveland, OH.
| | - Hani Hamade
- Department of Internal Medicine, Metrohealth Medical Center, Cleveland, OH
| | | | - Mohammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Faris Haddadin
- Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Farhan Nasser
- Heart and Vascular Center, Metrohealth Medical Center, Cleveland, OH
| | - Nour Hammad
- Division of Nephrology, University Hospitals Cleveland Medical Centers, Cleveland, OH
| | - Deaa Abu Jazar
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Ahmad J Toumar
- Department of Internal Medicine, Kent Hospital, Warwick, RI
| | - Aisha Siraj
- Heart and Vascular Center, Metrohealth Medical Center, Cleveland, OH
| | | | - Michel Ilbawi
- Pediatric Cardiac Team, Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, IL
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 PMCID: PMC8289457 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
| | - Girija G. Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
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Bischoff AR, Giesinger RE, Neary E, Weisz DE, Belik J, McNamara PJ. Clinical and echocardiography predictors of response to inhaled nitric oxide in hypoxemic term and near-term neonates. Pediatr Pulmonol 2021; 56:982-991. [PMID: 33434418 DOI: 10.1002/ppul.25252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/23/2020] [Accepted: 12/25/2020] [Indexed: 01/13/2023]
Abstract
Approximately 40% of hypoxemic term/near-term neonates are nonresponders to inhaled nitric oxide (iNO). Phenotypic characterization of patients less likely to respond may improve diagnostic precision and therapeutic decisions. We conducted a retrospective cohort study of neonates born ≥35 weeks gestation with hypoxemia who received iNO in the first 72 h of life and classified them into responders and nonresponders according to changes in the fraction of inspired oxygen, saturations and/or arterial partial pressure of oxygen after 1 h of administration. Comprehensive targeted neonatal echocardiography (TnECHO) data were collected when performed up to 6 h prior or 24 h after iNO initiation. Descriptive statistics, univariate analysis, and binary logistic regression were used to compare the groups. There were 183 patients included (63% responders) and TnECHO was performed in 54 infants. The presence of lung disease, and particularly meconium aspiration syndrome (p = .004), was associated with nonresponse to iNO. Nonresponders were characterized by a higher need for rescue high-frequency ventilation (p < .001), longer duration of mechanical ventilation (p < .001), and need for oxygen support (p = .003). Pulmonary hypertension documented on TnECHO was present in 96.3% of the patients but there was no difference in frequency or severity of pulmonary hypertension, or rates of low cardiac output between the groups. Moderate-to-severe right ventricular systolic dysfunction (p > .05) and lower left ventricular strain (p < .05) were more likely in the nonresponder group. In summary, response to iNO is influenced by lung disease, choice of ventilation strategy, and perhaps underlying cardiovascular physiology. Prospective pre- and post-iNO echocardiography data may provide novel physiologic insights.
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Affiliation(s)
| | | | - Elaine Neary
- Department of Neonatology, Liverpool Women's Hospital, Liverpool, UK
| | - Dany E Weisz
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jaques Belik
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
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10
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Cardiac Function and Ventricular Interactions in Persistent Pulmonary Hypertension of the Newborn. Pediatr Crit Care Med 2021; 22:e145-e157. [PMID: 33044416 DOI: 10.1097/pcc.0000000000002579] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to use a comprehensive imaging protocol to identify echocardiographic correlations of right and left ventricular size, function, and hemodynamics in neonates with persistent pulmonary hypertension of newborn and describe their relationship with key clinical variables. DESIGN Retrospective case-control echocardiography-based study of persistent pulmonary hypertension of newborn. SETTING A tertiary neonatal ICU in Canada. PATIENTS Forty-nine neonates (gestational age ≥ 35 wk old) diagnosed with persistent pulmonary hypertension of newborn within first 3 days after birth and 50 age-matched controls. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The echocardiographic measurements comprised of right ventricular and left ventricular functional markers, including tricuspid annular plane systolic excursion, fractional area change, tissue Doppler imaging, and deformation imaging. Sample size was based on detecting an intergroup difference of 10% in tricuspid annular plane systolic excursion, which was considered the primary outcome. Linear correlations between the right and left ventricular indices, as well as their association with the outcome of death or extracorporeal membrane oxygenation were evaluated. Persistent pulmonary hypertension of newborn was associated with lower tricuspid annular plane systolic excursion (6.81 ± 1.92 vs 9.25 ± 1.30 mm), right-ventricular global longitudinal strain (16.9% ± 5.4% vs -21.6% ± 4.6%); left ventricular ejection fraction (49% ± 7% vs 55% ± 6%), left ventricular global longitudinal strain (-16.7% ± 3.3% vs -21.4% ± 2.0%) (all p < 0.01). Right and left ventricular diastolic and global function was also lower in persistent pulmonary hypertension of newborn, with more pronounced changes seen for the right ventricle. Moderate-to-strong linear correlations were observed between the right and left ventricular functional markers, with right ventricular global longitudinal strain and left ventricular global longitudinal strain being the strongest (r = 0.8). Within persistent pulmonary hypertension of newborn group, hypoxic ischemic encephalopathy was associated with lower right and left ventricular systolic and right ventricular diastolic performance. Tricuspid annular plane systolic excursion (p =0.08) and left ventricular systolic velocity (p = 0.09) tended to be lower in patients who subsequently died/needed extracorporeal membrane oxygenation. CONCLUSIONS Persistent pulmonary hypertension of newborn is characterized by global cardiac dysfunction, involving both the right and left ventricles, with significant interventricular functional correlation. Cardiac dysfunction early in disease course may identify patients at highest risk of adverse outcome.
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Qasim A, Jain SK. Milrinone Use in Persistent Pulmonary Hypertension of the Newborn. Neoreviews 2021; 21:e165-e178. [PMID: 32123121 DOI: 10.1542/neo.21-3-e165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Failure of the normal transition from in utero to ex utero physiology leads to "persistent" pulmonary hypertension of the newborn (PPHN). PPHN is frequently associated with low systemic blood pressure and low cardiac output because of increased right ventricular afterload and myocardial dysfunction. The general management of newborns with PPHN is geared toward maintenance of normothermia, normal serum electrolytes, normal intravascular volume, correction of acidosis, adequate sedation/analgesia, adequate ventilation and oxygenation with optimal lung recruitment, and avoidance of hyperoxia. Inotropic and vasoactive agents are commonly initiated early to increase cardiac output, maintain adequate systemic blood pressure, and enhance oxygen delivery to the tissue. Unfortunately, there is not much evidence on the choice, timing of initiation, dosing, monitoring, and titrating of vasoactive agents in this patient population. In this review, we will discuss the pathophysiology of PPHN and review the use of inotropic, lusitropic, and vasoactive agents in the management of PPHN, with particular attention to milrinone.
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Affiliation(s)
- Amna Qasim
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Sunil K Jain
- Department of Pediatrics, Division of Neonatology, University of Texas Medical Branch, Galveston, TX
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Breinig S, Dicky O, Ehlinger V, Dulac Y, Marcoux MO, Arnaud C. Echocardiographic Parameters Predictive of Poor Outcome in Persistent Pulmonary Hypertension of the Newborn (PPHN): Preliminary Results. Pediatr Cardiol 2021; 42:1848-1853. [PMID: 34331558 PMCID: PMC8324438 DOI: 10.1007/s00246-021-02677-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/30/2021] [Indexed: 12/01/2022]
Abstract
The aim is to conduct a pilot study to prospectively describe echocardiographic parameters in neonates with pulmonary hypertension (PH) managed according to current recommendations and to identify those parameters that could predict worsening of short-term outcomes. All neonates less than 28 days old with a diagnosis of PH were prospectively enrolled in a tertiary care center for 1 year. Two echocardiograms were performed by a trained neonatologist. The first echocardiogram was performed at the time of diagnosis, whereas the second was performed just after basic therapeutic optimization. The cohort included 27 neonates. Mean gestational age at birth was 36.1 weeks gestational age (WGA) (SD: 4) and mean birth weight was 2658 g (SD: 907). Six neonates (22%) died before day 28, with a median age at death of 48 h (IQR [33; 89]). Although the first echocardiogram showed no difference, the second highlighted a strong link between the persistence of right-to left-shunt and death (p = 0.002). We showed a link between right-to-left shunt and a poor outcome (death or morbidity) after therapeutic optimization among premature and full-term neonates suffering from PH. We recommend repeating echocardiography after basic therapeutic optimization and for prognostic purposes, taking into account only the second examination. Larger cohorts are needed to confirm these results.
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Affiliation(s)
- Sophie Breinig
- Neonatal and Pediatric Intensive Care Unit, Children's Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France. .,INSERM, UMR 1027, SPHERE Team, Hôpital Paule de Viguier, 330 Avenue de Grande-Bretagne, TSA 70034, Toulouse, France.
| | - Odile Dicky
- grid.414260.50000 0004 0638 3516INSERM, UMR 1027, SPHERE Team, Hôpital Paule de Viguier, 330 Avenue de Grande-Bretagne, TSA 70034, Toulouse, France ,Neonatal Intensive Care Unit, Children’s Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France
| | - Virginie Ehlinger
- grid.414260.50000 0004 0638 3516INSERM, UMR 1027, SPHERE Team, Hôpital Paule de Viguier, 330 Avenue de Grande-Bretagne, TSA 70034, Toulouse, France
| | - Yves Dulac
- Pediatric Cardiology, Children’s Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France
| | - Marie-Odile Marcoux
- Neonatal and Pediatric Intensive Care Unit, Children’s Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France
| | - Catherine Arnaud
- grid.414260.50000 0004 0638 3516INSERM, UMR 1027, SPHERE Team, Hôpital Paule de Viguier, 330 Avenue de Grande-Bretagne, TSA 70034, Toulouse, France ,grid.411175.70000 0001 1457 2980Clinical Epidemiology Unit, University Hospital Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
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Mat Bah MN, Tan RYH, Razak H, Sapian MH, Abdullah N, Alias EY. Survival and associated risk factors for mortality among infants with persistent pulmonary hypertension of the newborn in Malaysia. J Perinatol 2021; 41:786-793. [PMID: 33589728 PMCID: PMC7883964 DOI: 10.1038/s41372-021-00962-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 11/27/2020] [Accepted: 01/22/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study aims to determine the immediate outcome of persistent pulmonary hypertension of the newborn (PPHN) and risk factors for mortality in the era of inhaled nitric oxide (iNO). STUDY DESIGN This observational cross-sectional study includes 195 confirmed PPHN with a gestational age of ≥34 weeks without congenital heart disease. Multivariable logistic regression was used to identify risk factors for mortality. RESULTS The mortality rate was 16.4%, with the highest mortality with pulmonary hypoplasia. Of 195, 65% received iNO; 18% were iNO non-responders with the majority having pulmonary hypoplasia. Independent risk factors for mortality were the presence of reversal of flow at the descending aorta, pulmonary hypoplasia, APGAR scores ≤ 5 at 5 min, and idiopathic PPHN with an adjusted odds ratio of 15.9, 7.5, 6.7, and 6.4, respectively. CONCLUSIONS Despite the usage of iNO, mortality due to PPHN remains high and is related to etiology and cardiac function.
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Affiliation(s)
- Mohd Nizam Mat Bah
- Department of Pediatrics, Hospital Sultanah Aminah, Ministry of Health, Johor Bahru, Malaysia.
| | - Racine Yuh Hwa Tan
- grid.413461.50000 0004 0621 7083Department of Pediatrics, Hospital Sultanah Aminah, Ministry of Health, Johor Bahru, Malaysia
| | - Hasliza Razak
- grid.413461.50000 0004 0621 7083Department of Pediatrics, Hospital Sultanah Aminah, Ministry of Health, Johor Bahru, Malaysia
| | - Mohd Hanafi Sapian
- grid.413461.50000 0004 0621 7083Department of Pediatrics, Hospital Sultanah Aminah, Ministry of Health, Johor Bahru, Malaysia
| | - Nisah Abdullah
- grid.413461.50000 0004 0621 7083Department of Pediatrics, Hospital Sultanah Aminah, Ministry of Health, Johor Bahru, Malaysia
| | - Emieliyuza Yusnita Alias
- grid.413461.50000 0004 0621 7083Department of Pediatrics, Hospital Sultanah Aminah, Ministry of Health, Johor Bahru, Malaysia
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14
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Smith A, Purna JR, Castaldo MP, Ibarra-Rios D, Giesinger RE, Rios DR, Weisz DE, Jain A, El-Khuffash AF, McNamara PJ. Accuracy and reliability of qualitative echocardiography assessment of right ventricular size and function in neonates. Echocardiography 2019; 36:1346-1352. [PMID: 31246348 DOI: 10.1111/echo.14409] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Subjective assessment of right ventricular (RV) function by neonatal echocardiography lacks validation. Incorrect diagnostic assignment in patients with suspected pulmonary hypertension (PH) may lead to unnecessary treatment or missed treatment opportunities. METHODS Six evaluators (experts [n = 3], novice [n = 3]) were asked to independently rate RV characteristics (global function, dilation, and septal flattening) based on standardized echocardiography images. We randomly selected 60 infants, ≥35 weeks gestation at birth, of whom 30 were clinically unwell with acute pulmonary hypertension (aPH) and 30 were healthy controls. aPH was defined by echocardiography presence of right-left shunting across transitional shunts or elevated right ventricular systolic pressure as estimated by the magnitude of the regurgitant jet across the tricuspid valve with impaired oxygenation. Inter-rater comparative evaluation within groups and between groups was performed using Kappa statistics. RESULTS Global agreement between evaluators for subjective assessment of RV function (0.3 [0.03], P < 0.001), size (0.14 [0.02], P < 0.001), and septal flattening (0.2 [0.02], P < 0.001) was uniformly poor. Agreement in RV function assessment was marginally better for both expert (0.32 [0.08], P < 0.001 vs 0.13 [0.081], and P < 0.001) and novice (0.4 [0.08], P < 0.001 vs 0.06 [0.07], and P < 0.001) evaluators. Overall, the diagnosis of aPH vs control was misclassified in 18% of cases. CONCLUSION This study demonstrated significant variability in qualitative assessment of RV size and function by trained evaluators, regardless of level of expertise attained. The reliability of objective measures of RV hemodynamics requires prospective evaluation.
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Affiliation(s)
- Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Jyothsna R Purna
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michael P Castaldo
- Department of Neonatology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Regan E Giesinger
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | | | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Afif F El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Patrick J McNamara
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
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15
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El-Khuffash A, McNamara PJ, Breatnach C, Bussmann N, Smith A, Feeney O, Tully E, Griffin J, de Boode WP, Cleary B, Franklin O, Dempsey E. The use of milrinone in neonates with persistent pulmonary hypertension of the newborn - a randomised controlled trial pilot study (MINT 1): study protocol and review of literature. Matern Health Neonatol Perinatol 2018; 4:24. [PMID: 30524749 PMCID: PMC6276183 DOI: 10.1186/s40748-018-0093-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/24/2018] [Indexed: 11/10/2022] Open
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a relatively common condition which results in a mortality of up to 33%. Up to 40% of infants treated with nitric oxide (iNO) either have a transient response or fail to demonstrate an improvement in oxygenation. Milrinone, a selective phosphodiesterase 3 (PDE3) inhibitor with inotropic and lusitropic properties may have potential benefit in PPHN. This pilot study was developed to assess the impact of milrinone administration on time spent on iNO in infants with PPHN. This is a multicentre, randomized, double-blind, two arm pilot study, with a balanced (1:1) allocation of 20 infants. In this pilot study, we hypothesise that infants ≥34 weeks gestation and ≥ 2000 g with a clinical and echocardiography diagnosis of PPHN, intravenous milrinone used in conjunction with iNO will result in a reduction in the time spent on iNO. In addition, we hypothesise that milrinone treatment will lead to an improvement in myocardial performance and global hemodynamics when compared to iNO alone. We will also compare the rate of adverse events associated with the milrinone, and the pre-discharge outcomes of both groups. The purpose of this pilot study is to assess the feasibility of performing the trial and to obtain preliminary data to calculate a sample size for a definitive multi-centre trial of milrinone therapy in PPHN. Trial registration: www.isrctn.com; ISRCTN:12949496; EudraCT Number:2014-002988-16.
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Affiliation(s)
- Afif El-Khuffash
- 1Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- 2Department of Paediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Patrick J McNamara
- Division of Neonatology, Stead Family Department of Pediatrics, Iowa City, IA USA
| | - Colm Breatnach
- 1Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Neidin Bussmann
- 1Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Aisling Smith
- 1Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Oliver Feeney
- 4Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Elizabeth Tully
- 4Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Joanna Griffin
- 4Department of Clinical Research, The Rotunda Hospital, Dublin, Ireland
| | - Willem P de Boode
- 5Department of Neonatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Brian Cleary
- 6Department of Pharmacy, The Rotunda Hospital, Dublin, Ireland
- 7School of Pharmacy, Royal College of Surgeons, Dublin, Ireland
| | - Orla Franklin
- 8Department of Paediatric Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Eugene Dempsey
- 9INFANT Centre, University College Cork, Cork, Ireland
- 10Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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de Boode WP, Singh Y, Molnar Z, Schubert U, Savoia M, Sehgal A, Levy PT, McNamara PJ, El-Khuffash A. Application of Neonatologist Performed Echocardiography in the assessment and management of persistent pulmonary hypertension of the newborn. Pediatr Res 2018; 84:68-77. [PMID: 30072805 PMCID: PMC6257221 DOI: 10.1038/s41390-018-0082-0] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pulmonary hypertension contributes to morbidity and mortality in both the term newborn infant, referred to as persistent pulmonary hypertension of the newborn (PPHN), and the premature infant, in the setting of abnormal pulmonary vasculature development and arrested growth. In the term infant, PPHN is characterized by the failure of the physiological postnatal decrease in pulmonary vascular resistance that results in impaired oxygenation, right ventricular failure, and pulmonary-to-systemic shunting. The pulmonary vasculature is either maladapted, maldeveloped, or underdeveloped. In the premature infant, the mechanisms are similar in that the early onset pulmonary hypertension (PH) is due to pulmonary vascular immaturity and its underdevelopment, while late onset PH is due to the maladaptation of the pulmonary circulation that is seen with severe bronchopulmonary dysplasia. This may lead to cor-pulmonale if left undiagnosed and untreated. Neonatologist performed echocardiography (NPE) should be considered in any preterm or term neonate that presents with risk factors suggesting PPHN. In this review, we discuss the risk factors for PPHN in term and preterm infants, the etiologies, and the pathophysiological mechanisms as they relate to growth and development of the pulmonary vasculature. We explore the applications of NPE techniques that aid in the correct diagnostic and pathophysiological assessment of the most common neonatal etiologies of PPHN and provide guidelines for using these techniques to optimize the management of the neonate with PPHN.
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Affiliation(s)
- Willem P. de Boode
- grid.461578.9Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Nijmegen, The Netherlands
| | - Yogen Singh
- 0000 0004 0383 8386grid.24029.3dAddenbrooke′s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Zoltan Molnar
- 0000 0001 2306 7492grid.8348.7John Radcliffe Hospital, Oxford, United Kingdom
| | - Ulf Schubert
- 0000 0004 1937 0626grid.4714.6Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marilena Savoia
- grid.411492.bAzienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy
| | - Arvind Sehgal
- 0000 0004 1936 7857grid.1002.3Department of Pediatrics, Monash University, Melbourne, Australia
| | - Philip T. Levy
- 0000 0001 2355 7002grid.4367.6Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO USA ,grid.429583.1Department of Pediatrics, Goryeb Children’s Hospital, Morristown, NJ USA
| | - Patrick J. McNamara
- 0000 0001 2157 2938grid.17063.33Departments of Pediatrics and Physiology, University of Toronto, Toronto, ON Canada
| | - Afif El-Khuffash
- 0000 0004 0617 7587grid.416068.dDepartment of Neonatology, The Rotunda Hospital, Dublin, Ireland ,0000 0004 0488 7120grid.4912.eDepartment of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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17
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Nakwan N, Chaiwiriyawong P. An international survey on persistent pulmonary hypertension of the newborn: A need for an evidence-based management. J Neonatal Perinatal Med 2016; 9:243-250. [PMID: 27589551 DOI: 10.3233/npm-16915133] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the current practice preferences in diagnosis and management of persistent hypertension of the newborn (PPHN) of neonatologists or pediatricians with expertise in neonatal care. STUDY DESIGN Investigators identified potential participants worldwide through a literature search. They were emailed the URL of an online 25-item questionnaire through the web survey site SurveyMonkey®. Additional respondents were also acquired through a professional online discussion group. The survey was conducted during July - September 2015. RESULTS Overall, there were 200 respondents from 51 different countries. Of these, the average 2014 mortality rate of the 90 respondents who completed this section of the questionnaire was 8.3% (interquartile range (IQR): 0-20.3). Echocardiography together with pre-to-post ductal oxygen pulse oximetry (SpO2) gradient was the most common PPHN diagnostic method. The most frequent first-line pulmonary vasodilator was inhaled nitric oxide (155/199, 77.9%). Oral sildenafil was most commonly used as second-line adjunctive therapy by 46.3% (81/175). Dopamine (139/198, 70.2%) was chosen to be the initial inotropic agent and normal saline (191/199, 96.0%) was the preferred initial fluid resuscitation for hypotension. Sedation and analgesia were routinely used for PPHN treatment. Twenty-one percent (42/199) of respondents also used muscle relaxants to control respiratory distress. The most commonly used targets for partial pressure of oxygen, partial pressure of carbon dioxide, SpO2 and hemoglobin were 71-80 mmHg (60/197, 30.4%), 36-45 mmHg (100/199, 50.2%), 91-95% (111/199, 55.8%), and 13-15 gm/dL (156/196, 79.6%), respectively. CONCLUSIONS This survey shows that the management of PPHN varies widely around the world. The major PPHN diagnostic method is echocardiography together with bedside SpO2 monitoring. The study numbers show the main differences are between developed and developing countries. Further studies exploring evidence-based principles of diagnosis and management in PPHN are warranted.
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The effect of milrinone on right and left ventricular function when used as a rescue therapy for term infants with pulmonary hypertension. Cardiol Young 2016; 26:90-9. [PMID: 25599873 DOI: 10.1017/s1047951114002698] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Milrinone may be an appropriate adjuvant therapy for infants with persistent pulmonary hypertension of the newborn. We aimed to describe the effect of milrinone administration on right and left ventricular function in infants with persistent pulmonary hypertension not responding to inhaled nitric oxide after 4 hours of administration. MATERIALS AND METHODS This is a retrospective review of infants born after or at 34 weeks of gestation with persistent pulmonary hypertension who received milrinone treatment. The primary endpoint was the effect of milrinone on myocardial performance and haemodynamics, including right and left ventricular outputs, tissue Doppler velocities, right ventricle and septal strain, and strain rate. Secondary endpoints examined included duration of inhaled nitric oxide and oxygen support. RESULTS A total of 17 infants with a mean (standard deviation) gestation and birth weight of 39.8 (2.0) weeks and 3.45 (0.39) kilograms, respectively, were included in the study. The first echocardiogram was performed 15 hours after the commencement of nitric oxide inhalation. Milrinone treatment was started at a median time of 1 hour after the echocardiogram and was associated with an increase in left ventricular output (p=0.04), right ventricular output (p=0.004), right ventricle strain (p=0.01) and strain rate (p=0.002), and left ventricle s` (p<0.001) and a` (p=0.02) waves. There was a reduction in nitric oxide dose and oxygen requirement over the subsequent 72 hours (all p<0.05). CONCLUSION The use of milrinone as an adjunct to nitric oxide is worth further exploration, with preliminary evidence suggesting an improvement in both oxygenation and myocardial performance in this group of infants.
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19
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Abman SH, Hansmann G, Archer SL, Ivy DD, Adatia I, Chung WK, Hanna BD, Rosenzweig EB, Raj JU, Cornfield D, Stenmark KR, Steinhorn R, Thébaud B, Fineman JR, Kuehne T, Feinstein JA, Friedberg MK, Earing M, Barst RJ, Keller RL, Kinsella JP, Mullen M, Deterding R, Kulik T, Mallory G, Humpl T, Wessel DL. Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Circulation 2015; 132:2037-99. [PMID: 26534956 DOI: 10.1161/cir.0000000000000329] [Citation(s) in RCA: 706] [Impact Index Per Article: 78.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension.
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MESH Headings
- Cardiovascular Agents/therapeutic use
- Child
- Child, Preschool
- Combined Modality Therapy
- Diagnostic Imaging/methods
- Disease Management
- Extracorporeal Membrane Oxygenation
- Genetic Counseling
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/therapy
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/therapy
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/therapy
- Infant
- Infant, Newborn
- Lung/embryology
- Lung Transplantation
- Nitric Oxide/administration & dosage
- Nitric Oxide/therapeutic use
- Oxygen Inhalation Therapy
- Persistent Fetal Circulation Syndrome/diagnosis
- Persistent Fetal Circulation Syndrome/therapy
- Postoperative Complications/therapy
- Respiration, Artificial/adverse effects
- Respiration, Artificial/methods
- Ventilator-Induced Lung Injury/prevention & control
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20
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Bendapudi P, Rao GG, Greenough A. Diagnosis and management of persistent pulmonary hypertension of the newborn. Paediatr Respir Rev 2015; 16:157-61. [PMID: 25765845 DOI: 10.1016/j.prrv.2015.02.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022]
Abstract
Persistent pulmonary hypertension of new born (PPHN) is associated with mortality and morbidity; it may be idiopathic or secondary to a number of conditions. The mainstay of diagnosis and to exclude structural abnormalities is echocardiography. Brain type natriuretic peptide (BNP) levels are elevated in PPHN, but are insufficiently sensitive to contribute to routine diagnosis. Management includes improving oxygenation by optimising lung volume by ventilatory techniques and/or surfactant and administering pulmonary vasodilator agents. Inhaled nitric oxide (iNO), a selective pulmonary vasodilator, reduces the need for extracorporeal membrane oxygenation in term infants; it does not, however, improve mortality or have any long term positive effects in prematurely born infants or infants with congenital diaphragmatic hernia. Other pulmonary vasodilators have been reported in case series to be efficacious alone or in combination with iNO. Randomised trials with long term follow up are required to identify the optimum therapeutic strategies in PPHN.
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Affiliation(s)
- Perraju Bendapudi
- Division of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in Asthma, King's College London
| | - Gopinath Gangadhara Rao
- Division of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in Asthma, King's College London
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in Asthma, King's College London.
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21
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Malowitz JR, Forsha DE, Smith PB, Cotten CM, Barker PC, Tatum GH. Right ventricular echocardiographic indices predict poor outcomes in infants with persistent pulmonary hypertension of the newborn. Eur Heart J Cardiovasc Imaging 2015; 16:1224-31. [PMID: 25851325 DOI: 10.1093/ehjci/jev071] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 03/05/2015] [Indexed: 11/12/2022] Open
Abstract
AIMS Infants with persistent pulmonary hypertension of the newborn (PPHN) have elevated pulmonary vascular resistance that can lead to right ventricular (RV) failure and death. Clinicians must decide which infants will fail conventional therapy and require transfer to extra corporeal membrane oxygenation (ECMO) centres, but accurate echocardiographic predictors have not been identified. We assessed echocardiographic measurements of RV pressure and function in predicting progression to death or ECMO in infants with PPHN. METHODS AND RESULTS Echocardiograms for infants ≥35-week gestation with a clinical diagnosis of PPHN were retrospectively reviewed. Traditional and strain echocardiographic measures were compared for those with or without the primary outcome of ECMO/cardiovascular death. Receiver operator curves identified cut points for measures that were significantly different. Of the 86 subjects analysed, 25 (29%) of the patients had the primary outcome of ECMO/death. The ECMO/death group had diminished tricuspid annular plane systolic excursion (TAPSE; P = 0.002) and RV global longitudinal peak strain (GLPS; P = 0.03), a predominant right-to-left shunt across the patent ductus arteriosus (PDA; P = 0.05), and an elevated oxygenation index (OI; P < 0.001). Sensitivity/specificity for TAPSE <4 mm was 56 and 85%, and for GLPS greater than or equal to -9% was 52 and 77%. CONCLUSION TAPSE, GLPS, and right-to-left PDA shunting were associated with progression to death/ECMO. RV free wall strain was not associated with the outcome, suggesting that diminished global strain better reflects clinical outcomes in this group. These thresholds may assist in the decision-making to transfer high-risk infants to ECMO centres.
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Affiliation(s)
- Jonathan R Malowitz
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
| | - Daniel E Forsha
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - P Brian Smith
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
| | - C Michael Cotten
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
| | - Piers C Barker
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
| | - Gregory H Tatum
- Duke University Medical Center, 242 Erwin Road, Suite 504, Durham, NC 27710, USA
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22
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Aggarwal S, Natarajan G. Echocardiographic correlates of persistent pulmonary hypertension of the newborn. Early Hum Dev 2015; 91:285-9. [PMID: 25782054 DOI: 10.1016/j.earlhumdev.2015.02.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/20/2015] [Accepted: 02/24/2015] [Indexed: 11/25/2022]
Abstract
AIMS To compare echocardiographic (ECHO) measures of ventricular function and hemodynamics of infants with persistent pulmonary hypertension of the newborn (PPHN) and normal controls; and to examine their association with clinical outcomes in PPHN. DESIGN/SUBJECTS We performed a retrospective review of ECHOs of mechanically ventilated infants (≥ 34 weeks gestational age) with PPHN. Infants with congenital heart disease were excluded. Controls had normal ECHOs within 1 week of age. OUTCOMES ECHOs measures included a) right (RVO) and left ventricular output (LVO) b) RV and LV myocardial performance index (MPI) c) right ventricular systolic to diastolic duration (S/D) ratio and d) eccentricity index in systole (EIs) and diastole (EId). RESULTS Infants with PPHN (n = 117), 63% of whom were males, had mean (SD) GA and birth weights of 38.6 (1.9) weeks and 3.3 (0.65) kg respectively. LVO, RVO and EIs were significantly lower and heart rate, MPI and RV S/D ratio were significantly higher in infants with PPHN, compared to controls (n = 35). The mean RV S/D ratios were significantly higher in infants with PPHN who died or required ECMO (n = 61), compared to survivors without ECMO (n = 56). Increasing RV S/D ratio was independently associated with a reduction in survival without ECMO [0.21; 95% C.I. 0.06-0.74, p = 0.015]. RV S/D ratio >1.3 had a sensitivity of 93 (95% C.I. 85-99) % for death or ECMO. CONCLUSIONS Elevated RV S/D ratio, a marker of global RV dysfunction, was associated with adverse outcomes in PPHN. Its routine measurement in this population may aid risk-identification and targeted interventions.
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Affiliation(s)
- Sanjeev Aggarwal
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA.
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Mydam J, Zidan M, Chouthai NS. A comprehensive study of clinical biomarkers, use of inotropic medications and fluid resuscitation in newborns with persistent pulmonary hypertension. Pediatr Cardiol 2015; 36:233-9. [PMID: 25107548 DOI: 10.1007/s00246-014-0992-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/23/2014] [Indexed: 01/20/2023]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is associated with high morbidity and mortality. This study evaluated clinical outcomes in PPHN in relation to echocardiographic (EC) markers, score of neonatal acute physiology, perinatal extension, version II (SNAPPE II) scores, inotropic agent use, and the amount of fluid received as boluses. In this retrospective chart analysis of 98 neonates with PPHN born at >34 weeks' gestation, we compared two cohorts of newborns: those who received inhaled nitric oxide and mechanical ventilation only, and who survived to discharge (Group 1); and those who required extracorporeal membrane oxygenation (ECMO) or who died (Group 2). Of 21 EC parameters assessed, seven were significantly different between Group 1 and Group 2. Eleven (24.4%) newborns in Group 2 had decreased left ventricular (LV) function, compared with three (5.1%) in Group 1 (p = 0.011). Median SNAPPE II scores were significantly higher in Group 2 than in Group 1 (p < 0.001). Newborns in Group 2 also received a significantly higher amount of fluid as boluses during the first 7 days of hospitalization compared with Group 1 (p = 0.018). Following logistic regression analysis, only the difference in total SNAPPE II score retained statistical significance (p < 0.001); however, the total amount of fluid administered as boluses trended higher (p = 0.087) for newborns in Group 2. Our findings show that SNAPPE II scores may help guide counseling for parents of newborns with PPHN regarding the likelihood of death or the need for ECMO. Limiting fluid boluses may improve outcomes in newborns with high SNAPPE II scores and decreased LV function.
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Affiliation(s)
- Janardhan Mydam
- Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA,
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Cabral JE, Belik J. Persistent pulmonary hypertension of the newborn: Recent advances in pathophysiology and treatment. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2013. [DOI: 10.1016/j.jpedp.2012.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Cabral JEB, Belik J. Persistent pulmonary hypertension of the newborn: recent advances in pathophysiology and treatment. J Pediatr (Rio J) 2013; 89:226-42. [PMID: 23684454 DOI: 10.1016/j.jped.2012.11.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/08/2012] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Although recognized for decades, little is known about the etiology, physiopathology, and prevention of persistent pulmonary hypertension of the newborn (PPHN), and its treatment remains a major challenge for neonatologists. In this review, the clinical features and physiopathology of the syndrome will be addressed, as well as its general and specific treatments. DATA SOURCE A review was carried out in PubMed, Cochrane Library, and MRei consult databases, searching for articles related to the syndrome and published between 1995 and 2011. DATA SYNTHESIS Risk factors and the physiopathological mechanisms of the syndrome are discussed. The clinical presentation depends on the different factors involved. These are related to the etiology and physiopathology of the different forms of the disease. In addition to the measures used to allow for the decrease in pulmonary vascular resistance after birth, in some instances pulmonary vasodilators will be required. Although inhaled nitric oxide has proved effective, other vasodilators have been recently used, but clinical evidence is still lacking to demonstrate their benefits in the treatment of PPHN. CONCLUSIONS Despite recent technological advances and new physiopathological knowledge of this disease, mortality associated with PPHN remains at 10%. More clinical research and evidence-based experimental results are needed to prevent, treat, and reduce the morbidity/mortality associated with this neonatal syndrome.
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Vijlbrief DC, Benders MJNL, Kemperman H, van Bel F, de Vries WB. B-type natriuretic peptide and rebound during treatment for persistent pulmonary hypertension. J Pediatr 2012; 160:111-5.e1. [PMID: 21839472 DOI: 10.1016/j.jpeds.2011.06.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 05/16/2011] [Accepted: 06/23/2011] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate whether serum B-type natriuretic peptide (BNP) is a useful biomarker in evaluating the course of persistent pulmonary hypertension of the newborn (PPHN) and the effectiveness of treatment. STUDY DESIGN Prospective follow-up study of infants with clinical and echocardiographic signs of PPHN, who were treated with inhaled nitric oxide (iNO). Of 24 patients with PPHN who were treated, serum BNP levels were determined longitudinally in 21. BNP levels were compared between infants with (n = 6) and without rebound PPHN (n = 15). RESULTS BNP levels in all infants with PPHN were not significantly different at the initial start of iNO. BNP levels decreased in both groups during iNO treatment. In the infants in whom rebound PPHN developed after weaning from iNO, a significantly higher increase was found in BNP (283 pmol/L to 1232 pmol/L) compared with that in infants without rebound (98 pmol/L to 159 pmol/L). This occurred before the onset of clinical deterioration. BNP again decreased significantly after iNO treatment was restarted. CONCLUSIONS BNP, a biomarker of cardiac ventricular strain, proved to be useful in evaluating the efficacy of PPHN treatment, and moreover, BNP helps to predict a rebound of PPHN.
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Affiliation(s)
- Daniel C Vijlbrief
- Department of Neonatology, University Medical Center, Utrecht, The Netherlands.
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Aggarwal S, Stockmann P, Klein MD, Natarajan G. Echocardiographic measures of ventricular function and pulmonary artery size: prognostic markers of congenital diaphragmatic hernia? J Perinatol 2011; 31:561-6. [PMID: 21311494 DOI: 10.1038/jp.2011.3] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare echocardiographic measures of biventricular function and pulmonary artery size in infants with congenital diaphragmatic hernia (CDH) and normal controls, and examine their correlation, if any, with outcomes in CDH. STUDY DESIGN We included consecutive neonates (<1 month old) with CDH and term controls without structural heart defects. Clinical and outcomes data were recorded and echocardiograms evaluated for right ventricular (RV) and left ventricular (LV) myocardial performance index (MPI), cardiac output index (CI) and McGoon index, among others. Statistical analyses (SPSS version 17, SPSS, Chicago, IL, USA) included between-group comparisons, using analysis of variance and χ(2)-test and binary regression, with significance set at P<0.05. RESULT Infants with CDH (n=34) were comparable with controls (n=35) in their age, weight, gestational age and gender. CDH was left sided in 24 (70%) neonates. Extracorporeal membrane oxygenation (ECMO) was required in 15 (45%) neonates; 18 (53%) infants survived. MPIs, CI and eccentricity index in systole were significantly worse in the CDH group, compared with controls and among CDH infants who died, compared with survivors. Infants with CDH who died or needed ECMO had significantly impaired MPIs and CI than survivors. On regression analyses, LV CI and MPIs were independently associated with mortality. CONCLUSION Infants with CDH had significantly impaired ventricular function and pulmonary hypertension, compared with controls. In the CDH group, LV dysfunction was associated with death and adverse outcomes. Further studies incorporating echocardiographic indices as prognostic markers of CDH are warranted.
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Affiliation(s)
- S Aggarwal
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Michigan, Detroit, MI 48201, USA.
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Abstract
Functional echocardiography (fECHO) is the bedside use of ultrasound to longitudinally assess myocardial function, systemic and pulmonary blood flow, and intra and extracardiac shunts. This review will focus on fECHO as a tool for the clinician to assess the hemodynamic condition of sick neonates and describe situations where fECHO can help determine a pathophysiological choice for cardiovascular support. The very low birth weight infant with hypotension during the first 24h of life, assessment and monitoring of the ductus arteriosus, assessment and response to treatment of infants with pulmonary hypertension, the infant with perinatal asphyxia and the infant with sepsis and cardiovascular compromise are reviewed. Close cooperation with pediatric cardiology, proper logistics and training programs are mandatory to achieve a 24h a day fECHO service run by bedside clinicians.
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Expression of HIF-1 alpha, VEGF and EPO in peripheral blood from patients with two cardiac abnormalities associated with hypoxia. Clin Biochem 2009; 43:234-9. [PMID: 19804771 DOI: 10.1016/j.clinbiochem.2009.09.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 09/21/2009] [Accepted: 09/22/2009] [Indexed: 01/22/2023]
Abstract
OBJECTIVES HIF-1 alpha (hypoxia-inducible factor-1 alpha) mediates the responses of mammalian cells to hypoxia/ischemia by inducing the expression of adaptive gene products (e.g., vascular endothelial growth factor (VEGF) and erythropoietin (EPO)). Persistent pulmonary hypertension of the newborn (PPHN) and cyanotic congenital heart disease (CCHD) are common neonatal diseases considered as paradigms of hypoxemia. Since the expression HIF-1 alpha, VEGF and EPO in newborns diagnosed with these diseases has yet to be studied, we set out to define the expression of these genes in peripheral blood from newborn infants diagnosed with PPHN and CCHD. DESIGN AND METHODS The mRNA transcripts encoding HIF-1 alpha, VEGF and EPO were measured by RT-PCR in healthy newborn infants and infants diagnosed with PPHN and CCHD. RESULTS An important increase in HIF-1 alpha expression was observed in both pathological conditions, accompanied by significant increases in VEGF and EPO expression when compared to healthy infants. CONCLUSIONS HIF-1 alpha mRNA expression increases in newborn infants with PPHN or CCHD, as does the expression of its target genes VEGF and EPO.
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