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Avitabile CM, Zhang X, Ampah S, Wang Y, Ash D, Nilan K, Tingo JE, Frank DB, Jensen EA, Lingappan K, Gibbs KA. Elevated pulmonary capillary wedge pressure, higher blood pressure, and lower cardiac index in infants with bronchopulmonary dysplasia. Int J Cardiol 2024; 411:132246. [PMID: 38851539 DOI: 10.1016/j.ijcard.2024.132246] [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: 01/18/2024] [Revised: 05/30/2024] [Accepted: 06/05/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Left ventricular diastolic dysfunction indicated by elevated pulmonary capillary wedge pressure (ePCWP) may worsen cardiorespiratory status in bronchopulmonary dysplasia (BPD), but the scope of ePCWP by cardiac catheterization is not well described. METHODS This single-center retrospective cohort study included infants with BPD without congenital heart disease, significant intracardiac shunts, or pulmonary vein stenosis who underwent cardiac catheterization from 2010 to 2021. ePCWP was defined as >10 mmHg. Quantitative measures of ventricular systolic and diastolic function were performed on existing echocardiograms. Patients with and without ePCWP were compared using the Chi-squared or Wilcoxon rank-sum tests. Associations between catheterization hemodynamics and echocardiographic parameters were assessed by simple linear regression. RESULTS Seventy-one infants (93% Grade 2 or 3 BPD) met inclusion criteria, and 30 (42%) had ePCWP. Patients with ePCWP were older at catheterization (6.7 vs. 4.5 months, p < 0.001), more commonly underwent tracheostomy (66.7% vs. 29.3%, p = 0.003), and had higher mean systemic blood pressure [64.5 (56.0, 75.0) vs. 47.0 (43.0, 55.0) mm Hg, p < 0.001], higher systemic vascular resistance [11.9 (10.4, 15.6) vs. 8.7 (6.7, 11.2) WU*m2, p < 0.001), and lower cardiac index [3.9 (3.8, 4.9) vs. 4.7 (4.0, 6.3) L/min/m2, p = 0.03] at catheterization. Mean pulmonary artery pressure, pulmonary vascular resistance, and mortality were similar between the groups. Echocardiographic indices of left ventricular diastolic dysfunction did not correlate with PCWP. CONCLUSIONS ePCWP was common in infants with severe BPD who underwent cardiac catheterization in this cohort. The association between ePCWP and higher systemic blood pressure supports further study of afterload reduction in this population.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Echocardiography Laboratory Research Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Xuemei Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Steve Ampah
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yan Wang
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Echocardiography Laboratory Research Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Devon Ash
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Echocardiography Laboratory Research Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen Nilan
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer E Tingo
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David B Frank
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Erik A Jensen
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Krithika Lingappan
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen A Gibbs
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Ficial B, Dolce P, Petoello E, Flore AI, Nogara S, Ciarcià M, Brancolini G, Alfarano A, Marzollo R, Bosio I, Raimondi F, Risso FM, Beghini R, Dani C, Benfari G, Ribichini FL, Corsini I. Left atrial strain assessment unveils left ventricular diastolic dysfunction in neonates with transient tachypnea of the newborn: A prospective observational study. Pediatr Pulmonol 2024. [PMID: 38953730 DOI: 10.1002/ppul.27156] [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: 03/04/2024] [Revised: 06/02/2024] [Accepted: 06/20/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION An inadequate clearance of lung fluid plays a key role in the pathogenesis of transient tachypnea of the newborn (TTN). OBJECTIVES To evaluate if left ventricular diastolic dysfunction contributes to reduced clearance of lung fluid in TTN. MATERIALS AND METHODS This was a prospective, observational study. Echocardiography and lung ultrasound were performed at 2, 24 and 48 h of life (HoL) to assess biventricular function and calculate lung ultrasound score (LUS). Left atrial strain reservoir (LASr) provided surrogate measurement of left ventricular diastolic function. RESULTS Twenty-seven neonates with TTN were compared with 27 controls with no difference in gestation (36.1 ± 2 vs. 36.9 ± 2 weeks) or birthweight (2508 ± 667 vs. 2718 ± 590 g). Biventricular systolic function was normal in both groups. LASr was significantly lower in cases at 2 (21.0 ± 2.7 vs. 38.1 ± 4.4; p < 0.01), 24 (25.2 ± 4.5 vs. 40.6 ± 4.0; p < 0.01) and 48 HoL (36.5 ± 5.8 and 41.6 ± 5.2; p < 0.01), resulting in a significant group by time interaction (p < 0.001), after adjusting for LUS and gestational diabetes. A logistic regression model including LUS, birth weight and gestational diabetes as covariates, showed that LASr at 2 HoL was a predictor of respiratory support at 24 HoL, with an adjusted odds ratio of 0.60 (CI 0.36-0.99). CONCLUSIONS LASr was reduced in neonates with TTN, suggesting diastolic dysfunction, that may contribute to the delay in lung fluid clearance.
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Affiliation(s)
- Benjamim Ficial
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Pasquale Dolce
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - Enrico Petoello
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Alice Iride Flore
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Silvia Nogara
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Martina Ciarcià
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giovanna Brancolini
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Angela Alfarano
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Roberto Marzollo
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Ilaria Bosio
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Francesco Raimondi
- Division of Neonatology and Department of Translational Medical Sciences, Università "Federico II" di Napoli, Naples, Italy
| | - Francesco Maria Risso
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Renzo Beghini
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
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Maia PD, Abman SH, Mandell E. Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension: Basing Care on Physiology. Neoreviews 2024; 25:e415-e433. [PMID: 38945971 DOI: 10.1542/neo.25-7-e415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/31/2023] [Accepted: 01/13/2024] [Indexed: 07/02/2024]
Abstract
Bronchopulmonary dysplasia (BPD) is the heterogeneous chronic lung developmental disease of prematurity, which is often accompanied by multisystem comorbidities. Pulmonary vascular disease and pulmonary hypertension (PH) contribute significantly to the pathogenesis and pathophysiology of BPD and dramatically influence the outcomes of preterm infants with BPD. When caring for those patients, clinicians should consider the multitude of phenotypic presentations that fall under the "BPD-PH umbrella," reflecting the need for matching therapies to specific physiologies to improve short- and long-term outcomes. Individualized management based on the patient's prenatal and postnatal risk factors, clinical course, and cardiopulmonary phenotype needs to be identified and prioritized to provide optimal care for infants with BPD-PH.
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Affiliation(s)
- Paula Dias Maia
- Section of Neonatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Steven H Abman
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
- Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Erica Mandell
- Section of Neonatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
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Heidari N, Kumaran K, Pagano JJ, Hornberger LK. Natural History of Secundum ASD in Preterm and Term Neonates: A Comparative Study. Pediatr Cardiol 2024; 45:710-721. [PMID: 38366300 DOI: 10.1007/s00246-023-03403-7] [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: 11/17/2023] [Accepted: 12/29/2023] [Indexed: 02/18/2024]
Abstract
Atrial septal defects (ASDs) are common in neonates. Although past studies suggest ASDs ≥ 3 mm in term neonates (TNs) are less likely to close, there is paucity of data regarding the natural history in preterm neonates (PNs), information that would inform surveillance. We sought to compare spontaneous closure rates and need for intervention for ASDs in TNs/near term (≥ 36 weeks) versus PNs (< 36 weeks). We included all TNs and PNs who underwent echocardiography at ≤ 1 month between 2010 and 2018 in our institution with an ASD ≥ 3 mm, without major congenital heart disease, and with repeat echocardiogram(s). Spontaneous resolution was defined as size diminution to < 3 mm or closure. We included 156 TNs (mean gestational age at birth 38.6 ± 1.4 weeks) and 156 PNs (29.6 ± 3.7 weeks) with a mean age at follow-up of 16 ± 19 and 15 ± 21 months, respectively (p = 0.76). Based on maximum color Doppler diameter, in TNs, ASD resolution occurred in 95% of small (3-5 mm), 87% of moderate (5.1-8 mm), and 60% of large (> 8 mm) defects; whereas, in PNs, resolution occurred in 79% of small, 76% of moderate, and 33% of large ASDs. There was a significant association between size and ASD resolution in TNs (p = 0.003), but not PNs (p = 0.17). Overall, ASD resolution rate was higher in TNs (89%) versus PNs (78%) (p = 0.009), and fewer TNs (1%) compared to PNs (7%) required ASD intervention (p = 0.02). Most ASDs identified in TNs and PNs spontaneously resolve. PNs, however, demonstrate lower ASD resolution and higher intervention rates within all size groups. These data should inform follow-up of affected neonates.
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Affiliation(s)
- Negar Heidari
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, University of Alberta, Women & Children's Health Research Institute, and the Stollery Children's Hospital, WCMC, 8440 112th Street Edmonton, Alberta, T6G 2B7, Canada
| | - Kumar Kumaran
- Division of Neonatology, Department of Pediatrics, University of Alberta, Women & Children's Health Research Institute, and the Stollery Children's Hospital, Alberta, Canada
| | - Joseph J Pagano
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, University of Alberta, Women & Children's Health Research Institute, and the Stollery Children's Hospital, WCMC, 8440 112th Street Edmonton, Alberta, T6G 2B7, Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, University of Alberta, Women & Children's Health Research Institute, and the Stollery Children's Hospital, WCMC, 8440 112th Street Edmonton, Alberta, T6G 2B7, Canada.
- Department of Obstetrics & Gynecology, Lois Hole Hospital for Women, Royal Alexandra Hospital, University of Alberta, 10245 111th Street Edmonton, Alberta, T5G 0B6, Canada.
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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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Abman SH, Lakshminrusimha S. Pulmonary Hypertension in Established Bronchopulmonary Dysplasia: Physiologic Approaches to Clinical Care. Clin Perinatol 2024; 51:195-216. [PMID: 38325941 DOI: 10.1016/j.clp.2023.12.002] [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
Preterm infants with bronchopulmonary dysplasia (BPD) are prone to develop pulmonary hypertension (PH). Strong laboratory and clinical data suggest that antenatal factors, such as preeclampsia, chorioamnionitis, oligohydramnios, and placental dysfunction leading to fetal growth restriction, increase susceptibility for BPD-PH after premature birth. Echocardiogram metrics and serial assessments of NT-proBNP provide useful tools to diagnose and monitor clinical course during the management of BPD-PH, as well as monitoring for such complicating conditions as left ventricular diastolic dysfunction, shunt lesions, and pulmonary vein stenosis. Therapeutic strategies should include careful assessment and management of underlying airways and lung disease, cardiac performance, and systemic hemodynamics, prior to initiation of PH-targeted drug therapies.
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Affiliation(s)
- Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, University of Colorado Anschutz Medical Campus, Mail Stop B395, 13123 East 16th Avenue, Aurora, CO 80045, USA.
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA
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Chen Y, Gong Y, Cai K. Correlations of cardiovascular autonomic neuropathy with urinary albumin excretion rate and cardiac function in patients with type 2 diabetes mellitus. Minerva Endocrinol (Torino) 2024; 49:3-12. [PMID: 33792236 DOI: 10.23736/s2724-6507.21.03358-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The associations of cardiovascular autonomic neuropathy (CAN) with diabetic nephropathy and heart disease remain elusive. The aim of this study was to explore the correlations of CAN with urinary albumin excretion rate (UAER) and cardiac function in patients with type 2 diabetes mellitus (T2DM). METHODS A total of 225 T2DM patients were assigned into CAN and non-CAN groups using cardiovascular reflex tests (CARTs). They were divided into macroalbuminuria, microalbuminuria and normoalbuminuria groups according to urinary albumin/creatinine ratio (UACR), or left ventricular diastolic dysfunction and normal groups based on left ventricular peak E/A velocity ratio (E/A). The correlations of CAN with albuminuria and left ventricular diastolic dysfunction, and the predictive values of UACR and E/A were analyzed. RESULTS Compared with non-CAN group, CAN group had older age, longer T2DM duration, higher serum urine acid (SUA) level, UACR, systolic and diastolic pressure differences between supine and standing positions, and lower other CARTs parameters and E/A (P<0.001). Macroalbuminuria group had largest positional systolic and diastolic pressure differences, and lowest other CARTs parameters (P<0.001). Compared with normal group, left ventricular diastolic dysfunction group had larger positional systolic and diastolic pressure differences, and lower other CARTs parameters (P<0.001). CAN in T2DM patients was positively correlated with albuminuria and left ventricular diastolic dysfunction (P<0.001). Age, SUA, UACR and E/A were independent predictive factors (P=0.031, P=0.005, P<0.001, P<0.001). UACR and E/A had high predictive values. CONCLUSIONS In T2DM patients, CAN is positively correlated with declined UAER and cardiac function. UACR and E/A have high predictive values.
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Affiliation(s)
- Yunjiang Chen
- Department of General Practice, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanchun Gong
- Department of General Practice, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kaiyu Cai
- Department of General Practice, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China -
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Reyes-Hernandez ME, Bischoff AR, Giesinger RE, Rios DR, Stanford AH, McNamara PJ. Echocardiography Assessment of Left Ventricular Function in Extremely Preterm Infants, Born at Less Than 28 Weeks' Gestation, With Bronchopulmonary Dysplasia and Systemic Hypertension. J Am Soc Echocardiogr 2024; 37:237-247. [PMID: 37619910 DOI: 10.1016/j.echo.2023.08.013] [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: 06/02/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND The survival of smaller and more immature premature infants has been associated with lifelong cardiorespiratory comorbidities. Infants with bronchopulmonary dysplasia (BPD) undergo routine screening echocardiography to evaluate for development of chronic pulmonary hypertension, a late manifestation of pulmonary vascular disease. METHODS Our aim was to evaluate left ventricular (LV) performance in infants with BPD and pulmonary vascular disease who developed systemic hypertension. We hypothesized that infants with hypertension were more likely to have impaired LV performance. We present a single-center cross-sectional study of premature infants born at less than 28 0/7 weeks' gestational age with a clinical diagnosis of BPD. Infants were categorized by the systolic arterial pressure (SAP) at time of echocardiography as hypertensive (SAP ≥90 mm Hg) or normotensive (SAP <90 mm Hg). Sixty-four patients were included. RESULTS Infants with hypertension showed altered LV diastolic function with prolonged tissue Doppler imaging-derived isovolumic relaxation time (54.2 ± 5.1 vs 42.9 ± 8.2, P < .001), lower E:A, and higher E:e'. Indices of left heart volume/pressure loading (left atrium:aorta and LV end-diastolic volume [6.1 ± 2 vs 4.2 ± 1.2, P < .001]) were also higher in the hypertensive group. Finally, infants in the hypertensive group had higher pulmonary vascular resistance index (4.42 ± 1.1 vs 3.69 ± 0.8, P = .004). CONCLUSIONS We conclude that extremely preterm infants with BPD who develop systemic hypertension are at risk of abnormal LV diastolic dysfunction. Increased pulmonary vascular resistance index in the hypertensive group may relate to pulmonary venous hypertension secondary to LV dysfunction. This is an important consideration in this cohort when selecting the physiologically most appropriate treatment.
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Affiliation(s)
| | - Adrianne R Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Danielle R Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Amy H Stanford
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa; Department of Internal Medicine, University of Iowa, Iowa City, Iowa.
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de Waal K, Crendal E, Poon ACY, Latheef MS, Sachawars E, MacDougall T, Phad N. The association between patterns of early respiratory disease and diastolic dysfunction in preterm infants. J Perinatol 2023; 43:1268-1273. [PMID: 36823313 PMCID: PMC10541326 DOI: 10.1038/s41372-023-01608-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/04/2023] [Accepted: 01/11/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND This study aims to determine the association between clinical patterns of early respiratory disease and diastolic dysfunction in preterm infants. METHODS Preterm infants <29 weeks' gestation underwent cardiac ultrasounds around day 7 and 14-21. Respiratory dysfunction patterns were classified as stable (ST), respiratory deterioration (RD) or early persistent respiratory dysfunction (EPRD) according to oxygen need. Diastolic dysfunction was diagnosed using a multi-parameter approach including left atrial strain (LASR) to help differentiate between cardiac or pulmonary pathophysiology. RESULTS 98 infants (mean 27 weeks) were included. The prevalence of ST, RD and EPRD was 53%, 21% and 26% respectively. Diastolic dysfunction was more prevalent in the RD and EPRD groups with patent ductus arteriosus and significant growth restriction as risk factors. Not all infants with a PDA developed diastolic dysfunction. LASR was lower in the EPDR group. CONCLUSION Respiratory dysfunction patterns are associated with diastolic dysfunction in preterm infants.
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Affiliation(s)
- Koert de Waal
- John Hunter Children's Hospital, department of neonatology, Newcastle, NSW, Australia.
- University of Newcastle, Newcastle, NSW, Australia.
| | - Edward Crendal
- John Hunter Children's Hospital, department of neonatology, Newcastle, NSW, Australia
- John Hunter Hospital, department of cardiology, Newcastle, NSW, Australia
| | | | | | - Elias Sachawars
- John Hunter Hospital, department of radiology, Newcastle, NSW, Australia
| | - Thomas MacDougall
- John Hunter Hospital, department of radiology, Newcastle, NSW, Australia
| | - Nilkant Phad
- John Hunter Children's Hospital, department of neonatology, Newcastle, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
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10
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Das B, Deshpande S, Akam-Venkata J, Shakti D, Moskowitz W, Lipshultz SE. Heart Failure with Preserved Ejection Fraction in Children. Pediatr Cardiol 2023; 44:513-529. [PMID: 35978175 DOI: 10.1007/s00246-022-02960-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/22/2022] [Indexed: 11/27/2022]
Abstract
Diastolic dysfunction (DD) refers to abnormalities in the mechanical function of the left ventricle (LV) during diastole. Severe LVDD can cause symptoms and the signs of heart failure (HF) in the setting of normal or near normal LV systolic function and is referred to as diastolic HF or HF with preserved ejection fraction (HFpEF). Pediatric cardiologists have long speculated HFpEF in children with congenital heart disease and cardiomyopathy. However, understanding the risk factors, clinical course, and validated biomarkers predictive of the outcome of HFpEF in children is challenging due to heterogeneous etiologies and overlapping pathophysiological mechanisms. The natural history of HFpEF varies depending upon the patient's age, sex, race, geographic location, nutritional status, biochemical risk factors, underlying heart disease, and genetic-environmental interaction, among other factors. Pediatric onset HFpEF is often not the same disease as in adults. Advances in the noninvasive evaluation of the LV diastolic function by strain, and strain rate analysis with speckle-tracking echocardiography, tissue Doppler imaging, and cardiac magnetic resonance imaging have increased our understanding of the HFpEF in children. This review addresses HFpEF in children and identifies knowledge gaps in the underlying etiologies, pathogenesis, diagnosis, and management, especially compared to adults with HFpEF.
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Affiliation(s)
- Bibhuti Das
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Shriprasad Deshpande
- Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, DC, USA
| | - Jyothsna Akam-Venkata
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Divya Shakti
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - William Moskowitz
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Steven E Lipshultz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Oishei Children's Hospital, Buffalo, NY, 14203, USA
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Barišić N. Assessment of Indicators of Left Ventricular Performance Obtained by Tissue Doppler Imaging in Prematurely Born Neonates. J Cardiovasc Dev Dis 2022; 9:jcdd9110364. [PMID: 36354763 PMCID: PMC9693410 DOI: 10.3390/jcdd9110364] [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: 08/30/2022] [Revised: 10/16/2022] [Accepted: 10/21/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: Tissue Doppler imaging techniques (pulsed-wave TDI (pwTDI) and color-coded TDI (cTDI)) allow for the assessment of myocardial performance during the cardiac cycle. The application of such techniques in neonatology is sporadic and poorly studied. Objective: The objective of the present study was to determine average values of pwTDI indicators of left ventricular performance (maximum systolic velocity of the mitral annulus (s’), maximum velocity in early diastole (e’) and maximum velocity in late diastole (a’)) and to examine their dynamics in prematurely born newborns in the first week of life. Methods: Prematurely born newborns of postnatal age up to 7 days were divided by gestational age into Group1 (<28 weeks) and Group 2 (≥28 weeks). Standard pwTDI parameters (s’, e’ and a’) were measured, compared between the groups and correlated with gestational and postnatal age, as well as application of respiratory support. Results: Fifty subjects were included (Group 1: 24; Group 2: 26). Average values of parameters s’, e’ and a’ were: Group 1: 4.06 ± 0.78 cm/s, 3.71 ± 0.40 cm/s and 3.98 ± 1.06 cm/s, respectively; Group 2: 4.18 ± 1.22 cm/s, 4.68 ± 1.04 cm/s and 4.12 ± 0.94 cm/s, respectively. Values of parameter e’ differed significantly between groups (p = 0.001) and strongly correlated with gestational age (p = 0, Pearson’s R = 0.88). There was no significant difference between groups for parameters s’ and a’ (p = 0.42 and 0.31, respectively). The values of s’, e’ and a’ did not differ between patients with an without respiratory support. Conclusion: Parameter e’ depends on gestational age, whereas parameters s’ and a’ are independent of gestational age. pwTDI indicators do not change during the first week of life, nor are all robust to hemodynamic circumstances caused by invasive/non-invasive respiratory support.
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Affiliation(s)
- Nenad Barišić
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; ; Tel.: +381-64-2115233
- Institute For Child and Youth Healthcare of Vojvodina, 21000 Novi Sad, Serbia
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Feasibility, Reproducibility and Reference Ranges of Left Atrial Strain in Preterm and Term Neonates in the First 48 h of Life. Diagnostics (Basel) 2022; 12:diagnostics12020350. [PMID: 35204441 PMCID: PMC8871374 DOI: 10.3390/diagnostics12020350] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
Left atrial strain (LAS) is the most promising technique for assessment of diastolic dysfunction but few data are available in neonates. Our aim was to assess feasibility and reproducibility, and to provide reference ranges of LAS in healthy neonates in the first 48 h of life. We performed one echocardiography in 30 neonates to assess feasibility and develop a standard protocol for image acquisition and analysis. LAS reservoir (LASr), conduit (LAScd) and contraction (LASct) were measured. We performed echocardiography at 24 and 48 h of life in an unrelated cohort of 90 neonates. Median (range) gestational age and weight of the first cohort were 34.4 (26.4–40.2) weeks and 2075 (660–3680) g. LAS feasibility was 96.7%. Mean (SD) gestational age and weight of the second cohort were 34.2 (3.8) weeks and 2162 (833) g. Mean (SD) LASr significantly increased from 24 to 48 h: 32.9 (3.2) to 36.8 (4.6). Mean (SD) LAScd and LASct were stable: −20.6 (8.0) and −20.8 (9.9), −11.6 (4.9) and −13.5 (6.4). Intra and interobserver intraclass correlation coefficient for LASr, LAScd and LASct were 0.992, 0.993, 0.986 and 0.936, 0.938 and 0.871, respectively. We showed high feasibility and reproducibility of LAS in neonates and provided reference ranges.
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13
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de Waal K, Prasad R, Kluckow M. Patent ductus arteriosus management and the drift towards therapeutic nihilism - What is the evidence? Semin Fetal Neonatal Med 2021; 26:101219. [PMID: 33653600 DOI: 10.1016/j.siny.2021.101219] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The published literature on patent ductus arteriosus (PDA) management is challenging to interpret due to poorly designed trials with high rates of open label treatments, homogenisation of patients with varying physiological subtypes, poor treatment efficacy, and spontaneous closure in more mature infants. The perceived lack of clinical benefit has led to a drift away from medical and surgical treatment of all infants with a PDA. This therapeutic nihilism as a default response to PDA management fails to recognise the physiological relevance of a left-to-right shunt with early haemodynamic instability after birth and subsequent pulmonary volume overload with prolonged exposure. Clinicians need to know if therapeutic nihilism is safe. This review will provide an overview of the available data on the efficacy of known PDA treatments, conservative management and supportive care measures that are currently applied.
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Affiliation(s)
- Koert de Waal
- John Hunter Children's Hospital Department of Neonatology and University of Newcastle, Newcastle, NSW, Australia.
| | - Rahul Prasad
- Randwick Children's Hospital Department of Neonatology, Sydney, NSW, Australia
| | - Martin Kluckow
- Royal North Shore Hospital Department of Neonatology and University of Sydney, Sydney, NSW, Australia
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14
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Cohen ED, Yee M, Porter GA, Ritzer E, McDavid AN, Brookes PS, Pryhuber GS, O’Reilly MA. Neonatal hyperoxia inhibits proliferation and survival of atrial cardiomyocytes by suppressing fatty acid synthesis. JCI Insight 2021; 6:140785. [PMID: 33507880 PMCID: PMC8021108 DOI: 10.1172/jci.insight.140785] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Preterm birth increases the risk for pulmonary hypertension and heart failure in adulthood. Oxygen therapy can damage the immature cardiopulmonary system and may be partially responsible for the cardiovascular disease in adults born preterm. We previously showed that exposing newborn mice to hyperoxia causes pulmonary hypertension by 1 year of age that is preceded by a poorly understood loss of pulmonary vein cardiomyocyte proliferation. We now show that hyperoxia also reduces cardiomyocyte proliferation and survival in the left atrium and causes diastolic heart failure by disrupting its filling of the left ventricle. Transcriptomic profiling showed that neonatal hyperoxia permanently suppressed fatty acid synthase (Fasn), stearoyl-CoA desaturase 1 (Scd1), and other fatty acid synthesis genes in the atria of mice, the HL-1 line of mouse atrial cardiomyocytes, and left atrial tissue explanted from human infants. Suppressing Fasn or Scd1 reduced HL-1 cell proliferation and increased cell death, while overexpressing these genes maintained their expansion in hyperoxia, suggesting that oxygen directly inhibits atrial cardiomyocyte proliferation and survival by repressing Fasn and Scd1. Pharmacologic interventions that restore Fasn, Scd1, and other fatty acid synthesis genes in atrial cardiomyocytes may, thus, provide a way of ameliorating the adverse effects of supplemental oxygen on preterm infants.
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Affiliation(s)
| | | | | | | | | | - Paul S. Brookes
- Department of Anesthesiology, School of Medicine and Dentistry, The University of Rochester, Rochester, New York, USA
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15
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de Waal K, Phad N, Stubbs M, Chen Y, Kluckow M. A Randomized Placebo-Controlled Pilot Trial of Early Targeted Nonsteroidal Anti-Inflammatory Drugs in Preterm Infants with a Patent Ductus Arteriosus. J Pediatr 2021; 228:82-86.e2. [PMID: 32858033 DOI: 10.1016/j.jpeds.2020.08.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/28/2020] [Accepted: 08/21/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To establish the feasibility of a future large randomized trial to compare early treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) while awaiting spontaneous patent ductus arteriosus (PDA) closure. STUDY DESIGN Preterm infants at <29 weeks of gestation with a PDA diameter >1.5 mm and <72 hours after birth were randomized to NSAIDs vs placebo. No open-label NSAID treatment was allowed in either arm, but all infants with PDA volume load received supportive management, including optimization of airway pressure, careful fluid management, and diuretics as needed. The pilot outcomes were recruitment rate and incidence of open-label treatment. Secondary clinical outcomes included chronic lung disease or death, the planned primary outcome for a future large trial. RESULTS Overall, 54% of the approached parents consented to participate in the study. The median recruitment rate was 3 infants per month, and a total of 72 infants were randomized. One patient in each arm received open-label treatment. PDA closure rates were 74% for the NSAIDs arm vs 30% for the placebo arm, but this was not associated with significant changes in clinical outcomes. CONCLUSIONS This pilot trial showed that recruitment of more than one-half of eligible infants with a low incidence of open-label treatment is feasible. PDA closure rates and clinical outcomes were similar to those reported in previous PDA trials.
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Affiliation(s)
- Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, NSW, Australia.
| | - Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Michelle Stubbs
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Yan Chen
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
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16
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Abstract
Primary function of cardiovascular system is to meet body's metabolic demands. The aim of inotrope therapy is to minimise adverse impact of cardiovascular compromise. Current use of inotropes is primarily guided by the pathophysiology of cardiovascular compromise and anticipated actions of inotropes. Lack of significant reduction in morbidity and mortality associated with cardiovascular compromise despite inotrope use, highlights major gaps in our understanding of circulatory targets, thresholds and choices of inotrope therapy. Thus far, prevention of cardiovascular compromise remains the most effective strategy to optimize outcomes. Studies of alternative design are needed for further advancement in cardiovascular therapy in neonates.
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Affiliation(s)
- Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia.
| | - Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia
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