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Michel-Macías C, Hébert A, Altit G. Optimizing management of chronic pulmonary hypertension in preterm infants: strategies for a complex population. Curr Opin Pediatr 2024:00008480-990000000-00200. [PMID: 38957100 DOI: 10.1097/mop.0000000000001383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Pulmonary hypertension (PH) is commonly observed in premature infants with bronchopulmonary dysplasia (BPD) and is associated with poor outcomes and increased mortality. This review explores the management of this intricate condition of the pulmonary vasculature, which exhibits heterogeneous effects and may involve both arterial and postcapillary components. RECENT FINDINGS Current management of BPD-PH should focus on optimizing ventilatory support, which involves treatment of underlying lung disease, transitioning to a chronic phase ventilation strategy and evaluation of the airway. Data on management is limited to observational studies. Diuretics are considered a part of the initial management, particularly in infants with right ventricular dilation. In many cases, pulmonary vasodilator therapy is required to induce pulmonary arterial vasodilation, reduce right ventricular strain, and prevent coronary ischemia and heart failure. Echocardiography plays a pivotal role in guiding treatment decisions and monitoring disease progression. SUMMARY BPD-PH confers a heightened risk of mortality and long-term cardio-respiratory adverse outcomes. Echocardiography has been advocated for screening, while catheterization allows for confirmation in select more complex cases. Successful management of BPD-PH requires a multidisciplinary approach, focusing on optimizing BPD treatment and addressing underlying pathologies.
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Affiliation(s)
- Carolina Michel-Macías
- Universidad Autónoma de Querétaro, Facultad de Medicina, Querérato, Mexico
- Neonatology - McGill University Health Centre - Montreal Children's Hospital; Department of Pediatrics - McGill University, Montreal, Quebec, Canada
| | - Audrey Hébert
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City
| | - Gabriel Altit
- Neonatology - McGill University Health Centre - Montreal Children's Hospital; Department of Pediatrics - McGill University, Montreal, Quebec, Canada
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Varghese NP, Altit G, Gubichuk MM, Siddaiah R. Navigating Diagnostic and Treatment Challenges of Pulmonary Hypertension in Infants with Bronchopulmonary Dysplasia. J Clin Med 2024; 13:3417. [PMID: 38929946 PMCID: PMC11204350 DOI: 10.3390/jcm13123417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
Advances in perinatal intensive care have significantly enhanced the survival rates of extremely low gestation-al-age neonates but with continued high rates of bronchopulmonary dysplasia (BPD). Nevertheless, as the survival of these infants improves, there is a growing awareness of associated abnormalities in pulmonary vascular development and hemodynamics within the pulmonary circulation. Premature infants, now born as early as 22 weeks, face heightened risks of adverse development in both pulmonary arterial and venous systems. This risk is compounded by parenchymal and airway abnormalities, as well as factors such as inflammation, fibrosis, and adverse growth trajectory. The presence of pulmonary hypertension in bronchopulmonary dysplasia (BPD-PH) has been linked to an increased mortality and substantial morbidities, including a greater susceptibility to later neurodevelopmental challenges. BPD-PH is now recognized to be a spectrum of disease, with a multifactorial pathophysiology. This review discusses the challenges associated with the identification and management of BPD-PH, both of which are important in minimizing further disease progression and improving cardiopulmonary morbidity in the BPD infant.
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Affiliation(s)
- Nidhy P. Varghese
- Department of Pediatrics, Division of Pulmonology, Baylor College of Medicine and Texas Children’s Hospital, 6701 Fannin St., Ste 1040, Houston, TX 77030, USA
| | - Gabriel Altit
- Division of Neonatology, Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada;
| | - Megan M. Gubichuk
- Division of Pulmonary and Sleep Medicine, Children’s Mercy Hospital, Kansas City, MO 64108, USA;
| | - Roopa Siddaiah
- Department of Pediatrics, Penn State Health Children’s Hospital, Hershey, PA 17033, USA;
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Kieu V, Handler SS, Mitchell M, Pan AY, Zhang L, Kirkpatrick E. Multimodal Assessment and Intramodal Comparison of Imaging Techniques for Pediatric Pulmonary Vein Stenosis with Pulmonary Hypertension. Pediatr Cardiol 2024:10.1007/s00246-024-03531-8. [PMID: 38842557 DOI: 10.1007/s00246-024-03531-8] [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: 11/20/2023] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
Pulmonary vein stenosis (PVS) is a rare, serious, and progressive disease in the pediatric population. Evaluation is complex and involves multimodality imaging. Diagnosis is important as early treatment to prevent progressive pulmonary hypertension and right ventricular dysfunction is essential. Adult studies have shown good correlation between various imaging modalities; however, there are limited data in children. This is a single-center retrospective pilot study to determine the reliability of measurement of pulmonary vein stenosis and pulmonary hypertension across different imaging modalities-computed tomography angiography (CTA), echocardiography (echo), lung perfusion scan (LPS), and cardiac catheterization (cath). PVS was defined as > 2 mmHg by echo and cath and/or 50% reduction in diameter by CTA. Patients had to have an echo, CTA and cath performed within a 1-month timeframe of one another to be included in the study, with LPS data included if testing was completed at initial evaluation. Fifteen total patients were enrolled; 87% were categorized as primary PVS; a condition not directly related to direct injury or prior surgical intervention. Twenty-seven total stenotic pulmonary veins were identified (mean 1.8, range 1-4). CTA had a slightly better agreement with cath than echo in identifying PVS in different vein locations except in the LLPV. Additionally, echo and CTA had excellent sensitivity (91%) and specificity (100%) compared to cath for diagnosis of PH. We conclude that non-invasive imaging of echo and CTA has an acceptable correlation to cardiac catheterization for screening and initial evaluation of PVS and PH, as directly related to PVS, in pediatrics.
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Affiliation(s)
- Victor Kieu
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
- Herma Heart Institute-Children's Wisconsin, Milwaukee, WI, USA.
- Division of Cardiology, Department of Pediatrics, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, USA.
| | - Stephanie S Handler
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Herma Heart Institute-Children's Wisconsin, Milwaukee, WI, USA
| | - Michael Mitchell
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Herma Heart Institute-Children's Wisconsin, Milwaukee, WI, USA
| | - Amy Y Pan
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Liyun Zhang
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Edward Kirkpatrick
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Herma Heart Institute-Children's Wisconsin, Milwaukee, WI, USA
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Swartz MF, Meagher C, Yoshitake S, Atallah-Yunes N, Angona R, Cholette JM, Alfieris GM. Pulmonary Venous Gradients in Healthy Controls and Following the Repair of Total Anomalous Pulmonary Venous Return. Pediatr Cardiol 2023; 44:325-332. [PMID: 35986764 DOI: 10.1007/s00246-022-02986-x] [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: 06/15/2022] [Accepted: 08/08/2022] [Indexed: 02/07/2023]
Abstract
The percent of children who can achieve a normal and physiologic pulmonary venous gradient and flow following the repair of Total Anomalous Pulmonary Venous Return (TAPVR) is not known. Pulmonary venous confluence gradients from infants with supra-, infra-, or mixed TAPVR, repaired using a direct anastomotic connection were measured. Data from age, weight, and gender-matched controls established the normal pulmonary venous gradient range (0.30-0.94 mmHg). TAPVR subjects were divided into three groups: (I) pulmonary venous gradient < 2 × normal with multiphasic flow (II) pulmonary venous gradient > 2 × normal with multiphasic flow, and (III) pulmonary venous gradient > 2 × normal with monophasic flow. From 63 children following TAPVR repair and 63 matched controls, pulmonary venous gradients were significantly lower [0.5 mmHg (IQR:0.4, 0.6) vs 1.6 mmHg (IQR:1.0, 2.4); p < 0.001], and multiphasic flow more frequent (100 vs. 84.1%; p = 0.001) within the control group. There were 38 children (60.3%) in group I, 15 (23.8%) in group II, and 10 (15.8%) in group III. Children in Group I were significantly older at the time of repair, had shorter cardiopulmonary bypass times, and did not utilize deep hypothermic circulatory arrest (DHCA). Multivariate analysis confirmed that avoiding DHCA [Odds Ratio 0.931 (0.913,0.994; p = 0.002)] and shorter cardiopulmonary bypass times [Odds Ratio 0.962 (0.861,0.968; p = 0.02)] during repair were associated with the lowest pulmonary venous gradients and multiphasic flow. Following TAPVR repair with a direct anastomosis, the majority of children can achieve a gradient two times normal or less with multiphasic pulmonary venous flow.
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Affiliation(s)
- Michael F Swartz
- Pediatric Cardiac Consortium of Central New York, Rochester, USA.
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave Box Card/Surg, Rochester, NY, 14642, USA.
| | - Cecilia Meagher
- Pediatric Cardiac Consortium of Central New York, Rochester, USA
- Department of Pediatrics, University of Rochester Medical Center, Rochester, USA
| | - Shuichi Yoshitake
- Pediatric Cardiac Consortium of Central New York, Rochester, USA
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave Box Card/Surg, Rochester, NY, 14642, USA
| | - Nader Atallah-Yunes
- Pediatric Cardiac Consortium of Central New York, Rochester, USA
- Department of Pediatrics, University of Rochester Medical Center, Rochester, USA
| | - Ron Angona
- Pediatric Cardiac Consortium of Central New York, Rochester, USA
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave Box Card/Surg, Rochester, NY, 14642, USA
| | - Jill M Cholette
- Pediatric Cardiac Consortium of Central New York, Rochester, USA
- Department of Pediatrics, University of Rochester Medical Center, Rochester, USA
| | - George M Alfieris
- Pediatric Cardiac Consortium of Central New York, Rochester, USA
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave Box Card/Surg, Rochester, NY, 14642, USA
- Department of Pediatrics, University of Rochester Medical Center, Rochester, USA
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Frogel J, Navon S, Astbury JC, Augoustides JG, Coleman SR, Fernando RJ, Krishnan S, Desai RG, Patel KM. Echocardiographic Diagnosis and Management of Unexpected Pulmonary Vein Stenosis After Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2023; 37:149-157. [PMID: 36372719 DOI: 10.1053/j.jvca.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Jonathan Frogel
- Department of Anesthesiology, Sheba Medical Center, Ramat Gan, Israel
| | - Shanee Navon
- Sackler School of Medicine at Tel Aviv University, Tel Aviv, Israel
| | - Jeffrey C Astbury
- Department of Anesthesiology, Butler Health System, Lake Erie School of Osteopathic Medicine, Butler, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott R Coleman
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC.
| | - Sandeep Krishnan
- Adult Cardiothoracic Anesthesiology, Wayne State University School of Medicine, Pontiac, MI
| | - Ronak G Desai
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Kinjal M Patel
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
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Callahan R, Morray BH, Hirsch R, Petit CJ. Management of Pediatric Pulmonary Vein Stenosis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100391. [PMID: 39131478 PMCID: PMC11307749 DOI: 10.1016/j.jscai.2022.100391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/27/2022] [Accepted: 06/01/2022] [Indexed: 08/13/2024]
Abstract
Pediatric intraluminal pulmonary vein stenosis has evolved into a chronic illness, with improving survival. Although significant knowledge gaps remain, medical providers have found success in the management of patients with pulmonary vein stenosis using a comprehensive multimodality treatment strategy. This review discusses the core principles employed by 4 centers dedicated to improving pulmonary vein stenosis outcomes, including how to make the diagnosis, educating the family, treatment strategy, the importance of surveillance, and the management of symptoms and comorbidities.
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Affiliation(s)
- Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian H. Morray
- Division of Pediatric Cardiology, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, Washington
| | - Russel Hirsch
- Heart Institute, Cincinnati Children’s Hospital and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christopher J. Petit
- Division of Pediatric Cardiology, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital and Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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