1
|
Hosking M, Bates A. Therapy in Pediatric Pulmonary Hypertension: Memoir of an Unfinished Journey. Can J Cardiol 2024; 40:622-624. [PMID: 38373582 DOI: 10.1016/j.cjca.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 02/21/2024] Open
Affiliation(s)
- Martin Hosking
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Angela Bates
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
2
|
He Y, Li Q, Zhang C, Keller BB, Gu H. Treprostinil Effectiveness in Higher-Risk Pediatric Patients With Idiopathic and Heritable Pulmonary Arterial Hypertension. Can J Cardiol 2024; 40:613-621. [PMID: 37944814 DOI: 10.1016/j.cjca.2023.11.004] [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: 08/27/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Little is known about the effectiveness of treprostinil in higher-risk paediatric patients with various pulmonary arterial hypertension genotypes. This study was designed to investigate the prognosis of higher-risk paediatric patients with idiopathic or heritable pulmonary arterial hypertension (IPAH/HPAH) after treprostinil therapy. METHODS Children with IPAH/HPAH who were stratified as higher risk and treated with treprostinil in our centre were included as the study cohort. Those who received only oral medications were included as the reference cohort. All patients in the study cohort received PAH-related genotyping. Survival was defined as no death. Event-free survival was defined as no death, Potts shunt, or atrial septostomy. RESULTS Forty-nine children (median age 7.7 years [interquartile range (IQR) 4.2-11.5 years], 65% female) were included in the study cohort and 48 children were included in the reference cohort; 84% of the study cohort had genetic disorders after genetic testing with a dominance of BMPR2 and ACVRL1 mutations. After a median therapy duration of 5.56 months (IQR 2.66-11.12 months), all patients were alive with significant improvements in clinical characteristics. One-, 2-, and 3-year survival rates were 91%, 84%, and 69%, respectively with a median follow-up duration of 19.17 months (IQR 9.7-29.79 months), which was significantly superior to the reference cohort (P = 0.038). Multivariate Cox regression analysis identified World Health Organisation functional class after therapy as a predictor for survival. There was no significant difference in survival among patients with different genotypes. CONCLUSIONS Treprostinil can significantly improve the prognosis in children with IPAH/HPAH who are at higher risk, despite genetic backgrounds.
Collapse
Affiliation(s)
- Yuan He
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiangqiang Li
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chen Zhang
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bradley B Keller
- Cincinnati Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hong Gu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
3
|
Carroll J, Rao R, Steinhorn RH. Targeted Therapies for Neonatal Pulmonary Hypertension: Beyond Nitric Oxide. Clin Perinatol 2024; 51:113-126. [PMID: 38325937 DOI: 10.1016/j.clp.2023.11.008] [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 in the neonatal population can be acute or chronic and carries significant risk for morbidity and mortality. It can be idiopathic but more often is associated with comorbid pulmonary and heart disease. There are several pharmacotherapeutics aimed at pulmonary vasodilation. This review highlights the most common agents as well as those on the horizon for the treatment of pulmonary hypertension in the neonate.
Collapse
Affiliation(s)
- Jeanne Carroll
- Division of Neonatology, Department of Pediatrics, University of California, San Diego, Rady Children's Hospital-San Diego, 3030 Children's Way, San Diego, CA 92123, USA
| | - Rohit Rao
- Division of Cardiothoracic Critical Care, Department of Pediatrics, University of California, San Diego, Rady Children's Hospital-San Diego, 3030 Children's Way, San Diego, CA 92123, USA
| | - Robin H Steinhorn
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital-San Diego, 3020 Children's Way, San Diego, CA 92123, USA.
| |
Collapse
|
4
|
Kochanski JJ, Feinstein JA, Ogawa M, Ritter V, Hopper RK, Adamson GT. Younger age at initiation of subcutaneous treprostinil is associated with better response in pediatric Group 1 pulmonary arterial hypertension. Pulm Circ 2024; 14:e12328. [PMID: 38348195 PMCID: PMC10860541 DOI: 10.1002/pul2.12328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/31/2023] [Accepted: 11/24/2023] [Indexed: 02/15/2024] Open
Abstract
Children with severe Group 1 pulmonary arterial hypertension (PAH) have an unpredictable response to subcutaneous treprostinil (TRE) therapy, which may be influenced by age, disease severity, or other unknown variables at time of initiation. In this retrospective single-center cohort study, we hypothesized that younger age at TRE initiation, early hemodynamic response (a decrease in pulmonary vascular resistance by ≥30% at follow-up catheterization), and less severe baseline hemodynamics (Rp:Rs < 1.1) would each be associated with better clinical outcomes. In 40 pediatric patients with Group I PAH aged 17 days-18 years treated with subcutaneous TRE, younger age (cut-off of 6-years of age, AUC 0.824) at TRE initiation was associated with superior 5-year freedom from adverse events (94% vs. 39%, p = 0.002), better WHO functional class (I or II: 88% vs. 39% p = 0.003), and better echocardiographic indices of right ventricular function at most recent follow-up. Neither early hemodynamic response nor less severe baseline hemodynamics were associated with better outcomes. Patients who did not have a significant early hemodynamic response to TRE by first follow-up catheterization were unlikely to show subsequent improvement in PVRi (1/8, 13%). These findings may help clinicians counsel families and guide clinical decision making regarding the timing of advanced therapies.
Collapse
Affiliation(s)
- Justin J. Kochanski
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Jeffrey A. Feinstein
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Michelle Ogawa
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Victor Ritter
- Stanford University School of MedicineQuantitative Sciences UnitPalo AltoCaliforniaUSA
| | - Rachel K. Hopper
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Gregory T. Adamson
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| |
Collapse
|
5
|
Ball MK, Seabrook RB, Bonachea EM, Chen B, Fathi O, Nankervis CA, Osman A, Schlegel AB, Magers J, Kulpa T, Sharpin P, Snyder ML, Gajarski RJ, Nandi D, Backes CH. Evidence-Based Guidelines for Acute Stabilization and Management of Neonates with Persistent Pulmonary Hypertension of the Newborn. Am J Perinatol 2023; 40:1495-1508. [PMID: 34852367 DOI: 10.1055/a-1711-0778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN. KEY POINTS: · PPHN is associated with several unique diagnoses; the associated pathophysiology is different for each unique diagnosis.. · PPHN is a challenging, dynamic, and labile process for which optimal care requires frequent reassessment.. · Key management goals are adequate tissue oxygen delivery, avoiding harm..
Collapse
Affiliation(s)
- Molly K Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ruth B Seabrook
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Elizabeth M Bonachea
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Bernadette Chen
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics Pulmonary Hypertension Group, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Omid Fathi
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Craig A Nankervis
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ahmed Osman
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Amy B Schlegel
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jacqueline Magers
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio
| | - Taylor Kulpa
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Paula Sharpin
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Mary Lindsay Snyder
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Robert J Gajarski
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Deipanjan Nandi
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Carl H Backes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Department of Pediatrics, Columbus, Ohio
| |
Collapse
|
6
|
Li L, Zhu X, Chen X, Gao J, Ding C, Zhang M, Ma S. Advances in targeted therapy for pulmonary arterial hypertension in children. Eur J Pediatr 2023; 182:2067-2076. [PMID: 36527480 DOI: 10.1007/s00431-022-04750-y] [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: 08/13/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare and devastating disease of the pulmonary vasculature with a high morbidity and mortality rate in infants and children. Currently, treatment approaches are mostly based on adult guidelines and pediatrician clinical experience, focusing on specific pulmonary antihypertensive therapy and conventional supportive care. The advent of targeted drugs has led to significant advances in the treatment of PAH in children, including endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and prostacyclins, which have been studied and proven to improve hemodynamics and functional class in children PAH. A new targeted drug, riociguat, is assessing its safety and efficacy in clinical trials. However, more randomized controlled studies are needed to evaluate the combination of drugs, treatment strategies, and clinical endpoints of targeted therapy in children PAH. In this review, we summarize the research advances of PAH-targeted therapy in children over the last decade in order to provide a theoretical basis for future studies. CONCLUSION Pulmonary arterial hypertension (PAH) is a rare and devastating pulmonary vascular disease that is associated with a variety of diseases of any age in childhood onset. WHAT IS KNOWN • Therapeutic strategies for targeted drugs for PAH in children are based almost exclusively on data from adult studies and clinical experience of pediatric specialists. • Due to the complex etiology of PAH in children and the relative lack of clinical trial data, the selection of appropriate targeted drug therapy remains difficult. WHAT IS NEW • We redefine the definition of pulmonary arterial hypertension in children and summarize the progress of targeted therapy of pulmonary arterial hypertension in children in the past ten years. • The dosage and adverse reactions were summarized, and the mechanism of action was drawn according to the available targeted drugs. It can provide theoretical support for the development of guidelines and treatment strategies for the diagnosis and treatment of pulmonary arterial hypertension in children.
Collapse
Affiliation(s)
- Li Li
- Department of Scientific Research, Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, 730000, China
| | - Xinyu Zhu
- Department of Scientific Research, Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, 730000, China
| | - Xiaojie Chen
- Department of Scientific Research, Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, 730000, China
| | - Jieyun Gao
- Department of Scientific Research, Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, 730000, China
| | - Chunchun Ding
- Department of Pharmacy, Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, 730000, China
| | - Min Zhang
- Department of Scientific Research, Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, 730000, China.
| | - Shixun Ma
- First Clinical College of Medicine, Lanzhou University, 1st West Donggang R.D., Lanzhou, 730000, China.
- General Surgery, Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, 730000, China.
| |
Collapse
|
7
|
McSweeney J, Colglazier E, Becerra J, Leary B, Miller‐Reed K, Walker S, Tillman K, Magness M, Ogawa M, Bannon W, Kivett T, Jackson EO, Davis A, Shepard C, Richards S, Whalen E, Engstrand S, DiPasquale Z, Connor JA. Failure to tolerate continuous subcutaneous treprostinil in pediatric pulmonary hypertension patients. Pulm Circ 2023; 13:e12224. [PMID: 37143765 PMCID: PMC10151594 DOI: 10.1002/pul2.12224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 05/06/2023] Open
Abstract
Continuous subcutaneous (SubQ) treprostinil is an effective therapy for pediatric patients diagnosed with pulmonary hypertension (PH). To date, the clinical characteristics and factors associated with failure to tolerate this therapy have not been described. The purpose was to describe patient-reported factors contributing to SubQ treprostinil intolerance in pediatric patients with PH. A retrospective descriptive study was performed at 11 participating sites in the United States and Canada for patients younger than 21 years of age diagnosed with PH who failed treatment to tolerate SubQ treprostinil between January 1, 2009, and December 31, 2019. All data were summarized using descriptive statistics. Forty-one patients met the inclusion criteria. The average age at SQ treprostinil initiation, and length of treatment, was 8.6 years and 22.6 months, respectively. The average maximum dose, concentration, and rate were 95.8 ng/kg/min, 6.06 mg/mL, and 0.040 mL/h, respectively. The reasons for failure to tolerate SubQ treprostinil included intractable site pain (73.2%), frequent site changes (56.1%), severe site reactions (53.7%), infections (26.8%), and noncompliance/depression/anxiety (17.1%). Thirty-nine (95.1%) patients transitioned to a prostacyclin therapy with 23 patients transitioning to intravenous prostacyclin, 5 to inhaled prostacyclin, 5 to oral prostacyclin, and 7 to a prostacyclin receptor agonist. A subset of pediatric PH patients failed to tolerate SubQ treprostinil infusions despite advances in SubQ site maintenance and pain management strategies. Intractable site pain, frequent SubQ site changes, and severe localized skin reactions were the most common reasons for failure.
Collapse
Affiliation(s)
- Julia McSweeney
- Department of Cardiology and Patient Care OperationsBoston Children's HospitalBostonMassachusettsUSA
| | | | - Jasmine Becerra
- Department of PediatricsUCSF Benioff Children's HospitalOaklandCaliforniaUSA
| | - Brienne Leary
- Department of Cardiology and Patient Care OperationsBoston Children's HospitalBostonMassachusettsUSA
| | | | - Stephen Walker
- Department of CardiologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Katy Tillman
- Department of CardiologyChildren's Hospital of WisconsinMilwaukeeWisconsinUSA
| | - Melissa Magness
- Department of CardiologyCincinnati Children's HospitalCincinnatiOhioUSA
| | - Michelle Ogawa
- Department of CardiologyLucille Packard Children's HospitalPalo AltoCaliforniaUSA
| | - Whitney Bannon
- Pulmonary DepartmentRiley Hospital for Children at Indiana University HealthIndianapolisIndianaUSA
| | - Tisha Kivett
- Pulmonary DepartmentRiley Hospital for Children at Indiana University HealthIndianapolisIndianaUSA
| | - Emma O. Jackson
- Department of CardiologySeattle Children's HospitalSeattleWashingtonUSA
| | - Anne Davis
- Department of CardiologySeattle Children's HospitalSeattleWashingtonUSA
| | - Cathy Shepard
- Department of Pediatric Cardiac Intensive CareStollery Children's HospitalEdmontonAlbertaCanada
| | - Susan Richards
- Department of CardiologyStollery Children's HospitalAlbertaEdmontonCanada
| | - Elise Whalen
- Department of PediatricsTexas Children's HospitalHoustonTexasUSA
| | - Shannon Engstrand
- Department of CardiologyBoston Children's HospitalBostonMassachusettsUSA
| | - Zachary DiPasquale
- Department of CardiologyBoston Children's HospitalBostonMassachusettsUSA
| | - Jean A. Connor
- Department of Cardiology and Patient Care OperationsBoston Children's HospitalBostonMassachusettsUSA
- Department of Critical CareHarvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|
8
|
Subcutaneous use of treprostinil in pediatric pulmonary hypertension patients: A report of three cases. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:145-148. [PMID: 36926146 PMCID: PMC10012979 DOI: 10.5606/tgkdc.dergisi.2023.23748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 01/06/2023] [Indexed: 03/18/2023]
Abstract
Treprostinil was approved by the United States Food and Drug Administration for use in the treatment of pulmonary arterial hypertension in 2002. Intravenous or subcutaneous treprostinil is used in pulmonary arterial hypertension patients in the functional classes of II-IV to alleviate exercise-related symptoms, or in cases where epoprostenol treatment should be reduced due to side effects. In this article, we describe three pediatric cases of pulmonary arterial hypertension in whom subcutaneous treprostinil was used.
Collapse
|
9
|
Colglazier E, Stevens L, Parker C, Nawaytou HM, Amin EK, Becerra J, Steurer M, Fineman JR. Hemodynamic assessment of transitioning from parenteral prostacyclin to selexipag in pediatric pulmonary hypertension. Pulm Circ 2022; 12:e12159. [PMID: 36514390 PMCID: PMC9732384 DOI: 10.1002/pul2.12159] [Citation(s) in RCA: 2] [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: 07/13/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022] Open
Abstract
Despite the increase in therapeutic options, parenteral prostacyclins remain the cornerstone in the medical management of pulmonary arterial hypertension (PAH). While the use of parenteral prostacyclins in pediatric patients is well documented, less is known about alternative drug delivery methods such as enteral administration. Given that parenteral routes of prostacyclin administration (IV or SC) are invariably accompanied by complicated logistics and lifestyle compromises, enteral prostacyclin administration represents an attractive treatment option. Selexipag (Uptravi®) was approved for adults PAH in 2015. There is limited data on the hemodynamic efficacy of transitioning from parenteral prostacyclins to selexipag, particularly in the pediatric population. We report 11 pediatric PAH patients who underwent this transition, in which 10 had complete cardiac catheterization data before and following the transition to selexipag. All patients/families reported an improvement in quality of life, and the transitions occurred without adverse effects. However, 3 of the 11 (27%) did not tolerate the transition; two for worsening hemodynamics, and one for acute right ventricular failure in the setting of an intercurrent illness. In addition, the transition to selexipag was associated with a modest increase in pulmonary vascular resistance index (6/10) and decrease in cardiac index (6/10) in some patients. Selexipag use in pediatric PAH represents a significant addition to our therapeutic arsenal, and its use provides a meaningful improvement in quality of life compared with other prostacyclin formulations. However, when goals of care include aggressive disease management, a decision between improved quality of life and possible adverse outcomes must be considered, and its substitution should include cautious, close, long-term follow-up.
Collapse
Affiliation(s)
- Elizabeth Colglazier
- Department of PediatricsUCSF Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Leah Stevens
- Department of PediatricsUCSF Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Claire Parker
- Department of PediatricsUCSF Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Hythem M. Nawaytou
- Department of PediatricsUCSF Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Elena K. Amin
- Department of PediatricsUCSF Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Jasmine Becerra
- Department of PediatricsUCSF Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Martina Steurer
- Department of PediatricsUCSF Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Jeffrey R. Fineman
- Department of PediatricsUCSF Benioff Children's HospitalSan FranciscoCaliforniaUSA,UCSF Cardiovascular Research InstituteSan FranciscoCaliforniaUSA
| |
Collapse
|
10
|
Ohuchi H, Kawata M, Uemura H, Akagi T, Yao A, Senzaki H, Kasahara S, Ichikawa H, Motoki H, Syoda M, Sugiyama H, Tsutsui H, Inai K, Suzuki T, Sakamoto K, Tatebe S, Ishizu T, Shiina Y, Tateno S, Miyazaki A, Toh N, Sakamoto I, Izumi C, Mizuno Y, Kato A, Sagawa K, Ochiai R, Ichida F, Kimura T, Matsuda H, Niwa K. JCS 2022 Guideline on Management and Re-Interventional Therapy in Patients With Congenital Heart Disease Long-Term After Initial Repair. Circ J 2022; 86:1591-1690. [DOI: 10.1253/circj.cj-22-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Masaaki Kawata
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi
| | - Hideki Uemura
- Congenital Heart Disease Center, Nara Medical University
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Atsushi Yao
- Division for Health Service Promotion, University of Tokyo
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Morio Syoda
- Department of Cardiology, Tokyo Women’s Medical University
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University
| | | | - Syunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomoko Ishizu
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yumi Shiina
- Cardiovascular Center, St. Luke’s International Hospital
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital
| | - Aya Miyazaki
- Division of Congenital Heart Disease, Department of Transition Medicine, Shizuoka General Hospital
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiko Mizuno
- Faculty of Nursing, Tokyo University of Information Sciences
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital
| | - Ryota Ochiai
- Department of Adult Nursing, Yokohama City University
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Koichiro Niwa
- Department of Cardiology, St. Luke’s International Hospital
| | | |
Collapse
|
11
|
Sullivan RT, Handler SS, Feinstein JA, Ogawa M, Liu E, Ma M, Hopper RK, Norris J, Hollander SA, Chen S. Subcutaneous Treprostinil Improves Surgical Candidacy for Next Stage Palliation in Single Ventricle Patients With High-Risk Hemodynamics. Semin Thorac Cardiovasc Surg 2022; 35:733-743. [PMID: 35931345 DOI: 10.1053/j.semtcvs.2022.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/11/2022]
Abstract
Single ventricle (SV) patients with pulmonary vascular disease (SV-PVD) are considered poor surgical candidates for Glenn or Fontan palliation. Given limited options for Stage 1 (S1) and Stage 2 (S2) SV patients with SV-PVD, we report on the use of subcutaneous treprostinil (TRE) to treat SV-PVD in this population. This single-center, retrospective cohort study examined SV patients who were not candidates for subsequent surgical palliation due to SV-PVD and were treated with TRE. The primary outcome was ability to progress to the next surgical stage; secondary outcomes included changes in hemodynamics after TRE initiation. Between 3/2014 and 8/2021, 17 SV patients received TRE for SV-PVD: 11 after S1 and 6 after S2 (median PVR 4.1 [IQR 3.2-4.8] WU*m2 and 5.0 [IQR 1.5-6.1] WU*m2, respectively). Nine of 11 (82%) S1 progressed to S2, and 2 (18%) underwent heart transplant (HTx). Three of 6 (50%) S2 progressed to Fontan, 1 underwent HTx and 2 are awaiting Fontan on TRE. TRE significantly decreased PVR in S1 patients with median post-treatment PVR of 2.0 (IQR 1.5-2.6) WU*m2. TRE can allow for further surgical palliation in select pre-Fontan patients with SV-PVD, obviating the need for HTx. Improvement in PVR was significant in S1 patients and persisted beyond discontinuation of therapy for most patients.
Collapse
Affiliation(s)
- Rachel T Sullivan
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Stephanie S Handler
- Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeffrey A Feinstein
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Michelle Ogawa
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Esther Liu
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Michael Ma
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Rachel K Hopper
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Jana Norris
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Seth A Hollander
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Sharon Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California..
| |
Collapse
|
12
|
Numata R, Takigiku K, Takei K. Clinical impact of subcutaneous treprostinil in trisomy 21 patient with pulmonary arterial hypertension associated with CHD. Cardiol Young 2022; 32:1-3. [PMID: 35000655 DOI: 10.1017/s1047951121005096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Subcutaneous treprostinil is commonly used to improve idiopathic pulmonary arterial hypertension in children. However, its effectiveness has not been reported in trisomy 21. We report the case of 9-year-old boy in trisomy 21 with CHD-pulmonary artery hypertension after surgical correction of CHD. Haemodynamics and exercise capacity dramatically improved with a transition from oral selexipag to subcutaneous treprostinil.
Collapse
Affiliation(s)
- Ryusuke Numata
- Department of Pediatric Cardiology, Nagano Children's Hospital, Nagano, Japan
| | - Kiyohiro Takigiku
- Department of Pediatric Cardiology, Nagano Children's Hospital, Nagano, Japan
| | - Kouta Takei
- Department of Pediatric Cardiology, Nagano Children's Hospital, Nagano, Japan
| |
Collapse
|
13
|
Colglazier E, Ng AJ, Parker C, Nawaytou H, Fineman JR. Safety and Tolerability of a Rapid Transition From Intravenous Treprostinil to Oral Selexipag in Three Adolescent Patients With Pulmonary Arterial Hypertension. J Pediatr Pharmacol Ther 2021; 26:512-516. [PMID: 34239406 DOI: 10.5863/1551-6776-26.5.512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/22/2020] [Indexed: 11/11/2022]
Abstract
There is limited published experience with transitioning pediatric patients from parenteral treprostinil to oral selexipag therapy. In addition, published transitions have typically been protracted, taking several weeks to complete. We present a case series of 3 adolescent patients who were transitioned from parenteral treprostinil to oral selexipag over a 5- to 7-day period. Their clinical courses leading up to the transitions are summarized and their outcomes are described. The 3 patients were successfully rapidly transitioned during an inpatient hospitalization without any observed adverse events or prostacyclin-related side effects. We conclude that when indicated rapid transition of parenteral to oral prostacyclin therapy may be performed safely in adolescents in an inpatient setting.
Collapse
|
14
|
Parenteral Prostanoids in Pediatric Pulmonary Arterial Hypertension: Start Early, Dose High, Combine. Ann Am Thorac Soc 2021; 19:227-237. [PMID: 34181866 PMCID: PMC8867364 DOI: 10.1513/annalsats.202012-1563oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Rationale There are currently no data supporting specific dosing and weaning strategies for parenteral prostanoid therapy in children with pulmonary arterial hypertension (PAH). Objectives To describe the clinical practice of intravenous (IV) or subcutaneous (SC) prostanoid therapy in pediatric PAH and identify dosing strategies associated with favorable outcome. Methods From an international multicenter cohort of 275 children with PAH, 98 patients who received IV/SC prostanoid therapy were retrospectively analyzed. Results IV/SC prostanoids were given as monotherapy (20%) or combined with other PAH-targeted drugs as dual (46%) or triple therapy (34%). The median time-averaged dose was 37 ng/kg/min, ranging 2–136 ng/kg/min. During follow-up, IV/SC prostanoids were discontinued and transitioned to oral or inhaled PAH-targeted therapies in 29 patients. Time-dependent receiver operating characteristic analyses showed specific hemodynamic criteria at discontinuation of IV/SC prostanoids (mean pulmonary arterial pressure < 35 mm Hg and/or pulmonary vascular resistance index < 4.4 Wood units [WU]⋅m2) identified children with favorable long-term outcome after IV/SC prostanoid discontinuation, compared with patients who do not meet those criteria (P = 0.027). In the children who continued IV/SC prostanoids until the end of follow-up, higher dose (>25 ng/kg/min), early start after diagnosis, and combination with other PAH-targeted drugs were associated with better transplant-free survival. Conclusions Early initiation of IV/SC prostanoids, higher doses of IV/SC prostanoids, and combination with additional PAH-targeted therapy were associated with favorable outcome. Transition from IV/SC prostanoid therapy to oral or inhaled therapies is safe in the long term in selected children, identified by reaching hemodynamic criteria for durable IV/SC prostanoid discontinuation while on IV/SC prostanoid therapy.
Collapse
|
15
|
Jackson EO, Brown A, McSweeney J, Parker C. Pediatric subcutaneous treprostinil site maintenance and pain control strategies from the Pediatric Pulmonary Hypertension Network. Pulm Circ 2021; 11:2045894021994450. [PMID: 33738093 PMCID: PMC7934043 DOI: 10.1177/2045894021994450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/24/2021] [Indexed: 11/25/2022] Open
Abstract
Pulmonary arterial hypertension is a chronic, progressive, and life-threatening disease in children with diverse causes of pulmonary arterial hypertension. The most severe cases of pulmonary arterial hypertension require aggressive treatments with systemic administration of continuous prostacyclin therapy, including treprostinil and epoprostenol. The successful use of continuous subcutaneous treprostinil therapy eliminates the need for an indwelling central venous catheter and its associated risks. However, pain at the subcutaneous infusion site, an expected side effect of this therapy, is often a deterrent to its widespread use. Effective subcutaneous treprostinil site maintenance and pain management is essential to achieve success with this therapy, but strategies surrounding site maintenance and pain control vary significantly between pediatric pulmonary hypertension treatment centers. In an attempt to standardize practice, a survey on the use of subcutaneous treprostinil and site maintenance and pain management strategies, as well as its perceived effectiveness, was disseminated to 13 pediatric pulmonary hypertension centers of the Pediatric Pulmonary Hypertension Network. Responses to the survey were collected and analyzed and were developed into a set of formalized strategies to facilitate knowledge sharing and standardization of practice.
Collapse
Affiliation(s)
- Emma O Jackson
- Department of Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Anna Brown
- Division of Pulmonary Medicine, Department of Pediatrics, Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Julia McSweeney
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Claire Parker
- Department of Nursing, University of California, San Francisco Benioff Children's Hospital, San Francisco CA, USA
| |
Collapse
|
16
|
Kam CW, Ruiz FE. Opportunities and challenges of pharmacotherapy for pulmonary arterial hypertension in children. Pediatr Pulmonol 2021; 56:593-613. [PMID: 33002306 DOI: 10.1002/ppul.25101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/15/2020] [Accepted: 09/27/2020] [Indexed: 12/13/2022]
Abstract
Pediatric pulmonary hypertension (PAH) is a rare disease that carries a poor prognosis if left untreated. Although there are published guidelines for the treatment of children with pulmonary hypertension, due to the limited number of robust pediatric clinical trials, recommendations are often based on limited data or clinical experience. Furthermore, many practical aspects of care, particularly for the pediatric patient, are learned through experience and best navigated with a multidisciplinary team. While newer PAH therapies have been approved for adults, there is still limited but expanding experience in pediatrics. This new information will help improve the targets of goal-oriented therapy. Lastly, this review highlights practical aspects in the use of the different therapies available for the treatment of pediatric pulmonary hypertension.
Collapse
Affiliation(s)
- Charissa W Kam
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas, USA
| | - Fadel E Ruiz
- Department of Pulmonology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
17
|
Tella JB, Kulik TJ, McSweeney JE, Sleeper LA, Lu M, Mullen MP. Prostanoids in pediatric pulmonary hypertension: clinical response, time-to-effect, and dose-response. Pulm Circ 2020; 10:2045894020944858. [PMID: 33343879 DOI: 10.1177/2045894020944858] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022] Open
Abstract
For pediatric pulmonary arterial hypertension (PAH) patients treated with parenteral prostanoids, response predictors, and the dose-effect relationship are ill defined. We determined the following: (1) which pulmonary vascular hemodynamic variable, after initiating prostanoids, best correlates with a significant clinical response; (2) the time interval after treatment when if no pulmonary hemodynamic improvement has occurred, none is ever likely to; and (3) the relationship between the prostanoid dose and its hemodynamic effects. This is a retrospective cohort study of 31 pediatric patients with Group 1 PAH treated with parenteral prostanoids. We found the following: (1) A fall in mean pulmonary arterial pressure (mPAP) of ≥25% predicted freedom from adverse clinical events with 80.7% accuracy and was also associated with improved functional class. (2) Thirty-three percent of patients who avoided an adverse clinical event demonstrated a ≥25% reduction in mPAP after 1 year of treatment, and 65% by 2 years. (3) Lower mPAP was seldom seen with doses of epoprostenol >60 ng/kg/min (100 ng/kg/min for treprostinil). Cardiac index was positively correlated with the dose of epoprostenol but not treprostinil; cardiac index >4 l/min/m2 was seen at modest as well as high doses. We conclude that a ≥25% fall in mPAP on prostanoids indicates a positive clinical response which, if validated in other studies, may be useful for patient management or clinical trials. Some patients take more than 2 years for this change. Exceptionally high doses were generally not more effective than lower, although we could not determine whether lower doses would have been as effective.
Collapse
Affiliation(s)
- Joseph B Tella
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Thomas J Kulik
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Julia E McSweeney
- Cardiovascular Nursing Patient Services, Boston Children's Hospital, Boston, MA, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
18
|
Xu N, Huang ST, Sun KP, Wang ZC, Cao H, Chen Q. Midterm postoperative prognosis of patients with severe left heart valvular disease combined with moderate or severe pulmonary hypertension treated with treprostinil. BMC Cardiovasc Disord 2020; 20:472. [PMID: 33143649 PMCID: PMC7641841 DOI: 10.1186/s12872-020-01759-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 10/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the midterm postoperative prognosis of patients with severe left heart valvular disease combined with moderate or severe pulmonary hypertension (PAH) using subcutaneous injection of treprostinil. METHODS A retrospective study was conducted on 61 patients with severe left heart valvular disease combined with moderate or severe PAH who had undergone mechanical mitral and/or aortic valve replacement from April 2018 to October 2018. The patients were divided into the treprostinil group and the conventional treatment group according to whether they received treprostinil. The patients were assessed by SwanGanz catheterization, echocardiography, the 6-min walk test (6-MWT), the Borg dyspnoea score and the SF-36 questionnaire. RESULTS Compared with the preoperative data, the mPAP measured by SwanGanz catheterization, the results of the 6-MWT and the Borg score were significantly improved in both groups during the 1 year follow-up (P < 0.05). Regarding the comparison between the groups, the results in group T were significantly better than those in group C, including the results of the 6-MWT and the general health, vitality and mental health of SF-36 during the 1 year follow-up (P < 0.05). CONCLUSIONS Continuous subcutaneous infusion of treprostinil was not capable of decreasing pulmonary pressures in patients with severe left heart valvular disease combined with moderate or severe PAH during 1 year follow-up, although which some of our data suggest that might improve the symptoms and quality of life of these patients.
Collapse
Affiliation(s)
- Ning Xu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Shu-Ting Huang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Kai-Peng Sun
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Zeng-Chun Wang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China. .,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China.
| |
Collapse
|
19
|
Huang ST, Xu N, Sun KP, Chen LW, Cao H, Chen Q. The Effect of Perioperative Administration of Treprostinil in Infants with Non-restrictive Ventricular Septal Defect and Severe Pulmonary Arterial Hypertension. Pediatr Cardiol 2020; 41:1334-1339. [PMID: 32468125 DOI: 10.1007/s00246-020-02387-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/23/2020] [Indexed: 01/09/2023]
Abstract
This study investigated the efficacy and safety of intravenous treprostinil during the perioperative period in infants with non-restrictive ventricular septal defect (VSD) and severe pulmonary arterial hypertension (PAH) undergoing surgical VSD repair. This was a retrospective study. There were 79 infants with non-restrictive VSD and severe PAH receiving surgical treatment from January to December 2019 in our cardiac center. The patients were divided into the treprostinil group and control group according to whether intravenous treprostinil was used during the perioperative period. There were no significant differences in the preoperative characteristics, including age, sex, weight, ventricular size, or preoperative pulmonary artery pressure, between the two groups. Although the pulmonary artery pressure in both groups was significantly lower postoperatively than preoperatively, the postoperative pulmonary artery systolic pressure was significantly lower in group T than in group C. The postoperative mechanical ventilation time, ICU stay, and hospital stay in group T were shorter than those in group C. Treprostinil can be used effectively and safely to reduce the perioperative pulmonary artery pressure in infants with non-restrictive VSD and severe PAH undergoing surgical VSD repair.
Collapse
Affiliation(s)
- Shu-Ting Huang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Ning Xu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Kai-Peng Sun
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China.
| |
Collapse
|
20
|
Bravo-Valenzuela NJM, Navarro F, Silva SP. Use of selexipag in a teenage patient with pulmonary arterial hypertension. Ann Pediatr Cardiol 2020; 14:75-78. [PMID: 33679065 PMCID: PMC7918021 DOI: 10.4103/apc.apc_63_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/24/2019] [Accepted: 07/08/2020] [Indexed: 12/01/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic, progressive, multifactorial disease. Currently, combination therapy is an attractive option for PAH management because three pathways (endothelin, nitric oxide, and prostacyclin) are involved in this disease. Selexipag is a novel oral prostacyclin pathway drug and is a highly selective IP prostacyclin receptor agonist with vasodilatory and antiproliferative effects. We report the case of a teenage patient with idiopathic PAH who presented in World Health Organization functional Class IV and showed no clinical improvement with dual therapy. We added oral selexipag to the treatment regimen and observed substantial improvement in her quality of life at the short-time follow-up. Despite the lack of childhood data regarding the use of selexipag in pediatric patients with PAH, the use of this drug in the current teenage patient improved her quality of life and exercise capacity.
Collapse
Affiliation(s)
- Nathalie Jeanne Magioli Bravo-Valenzuela
- Department of Pediatrics, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.,PEDICOR-Pediatric and Perinatal Cardiology Center, Sao José dos Campos, SP, Brazil
| | - Flavia Navarro
- Pulmonary Hypertension Center, Faculty of Medical Sciences, Santa Casa de Sao Paulo, Sao Paulo, SP, Brazil
| | | |
Collapse
|
21
|
Using the upper buttocks as a subcutaneous site for treprostinil infusion in children with pulmonary artery hypertension. Cardiol Young 2020; 30:1024-1025. [PMID: 32452334 DOI: 10.1017/s1047951120001237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 14-year-old boy was receiving subcutaneous infusions of treprostinil for pulmonary artery hypertension. Because he had severe infusion site pain in the lower abdomen, we changed his infusion site to the upper buttocks, adding some analgesics. His pain improved gradually. This change may be an effective method for reducing infusion site pain in subcutaneous treprostinil therapy, particularly in children.
Collapse
|
22
|
Olguntürk FR. An update on the diagnosis and treatment of pediatric pulmonary hypertension. Expert Opin Pharmacother 2020; 21:1253-1268. [PMID: 32401622 DOI: 10.1080/14656566.2020.1757071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a heterogeneous disease that mainly affects the pulmonary arterioles, leading to significant morbidity and mortality. Pulmonary hypertension in children from birth to adolescence presents important differences from that of adults. The majority of pediatric pulmonary arterial hypertension (PAH) cases are idiopathic or associated with congenital heart disease. However, the management of pediatric PAH mainly depends on the results of evidence-based adult studies and the clinical experiences of pediatric experts. AREAS COVERED This article briefly reviews the recent updates on the definition, classification, and diagnostic evaluation of pediatric PAH and their impact on treatment strategies. The main purpose of this review is to discuss the current pediatric therapies, as well as the prospective therapies, in terms of therapeutic targets, actions, side effects, and dosages. EXPERT OPINION Although there is no cure for PAH, recent advances in the form of new treatment options have improved the quality of life and survival rates of PAH patients. PAH-targeted drugs and treatment strategies for adult PAH have not been sufficiently studied in children. However, the growing scientific activity in that field will surely change the treatment option recommendations in pediatric PH from experience-based to evidence-based in the near future.
Collapse
Affiliation(s)
- F Rana Olguntürk
- Professor of Pediatrics and Pediatric Cardiology, PhD in medical physiology, Former Head of Pediatrics and Pediatric Cardiology in Gazi University Faculty of Medicine. Founder of Pediatric Cardiology and PAH center in Gazi University. Former President of Turkish Association of Pediatric Cardiology and Surgery, Gazi University , Ankara, Turkiye
| |
Collapse
|
23
|
Álvarez-Fuente M, Garrido-Lestache E, Rivero N, Centella T, Lamas MJ, Pérez-Caballero C, Vázquez JL, Del Cerro MJ. Implantable LENUS pro pump for treprostinil infusion in three pediatric patients. Pediatr Pulmonol 2020; 55:1254-1258. [PMID: 32149476 DOI: 10.1002/ppul.24707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prostanoid treatment in patients with severe pulmonary arterial hypertension (PAH) has been proven safe and effective. Subcutaneous administration of treprostinil has side effects, which limits their use and acceptance. An implantable pump for continuous intravenous treprostinil infusion has been recently approved. We describe our experience with the implantable pump in three pediatric patients. DESCRIPTION OF CASES The LENUS pro pump was implanted in three adolescents with severe PAH, who were treated with tadalafil, ambrisentan, and subcutaneous treprostinil. The indication of the Lenus pro pump implantation was the local side effects of subcutaneous treprostinil (pain, inflammation, and local infection) that were not well tolerated and that severely decreased their quality of life. The pump was surgically implanted under general anesthesia.One patient, in functional class IV, suffered postoperative hemodynamic instability and small pneumothorax, requiring an increase in treprostinil dose up to 85 ng/kg/min and a decrease 9 days after the pump implantation. The second patient who was discharged 4 days after surgery with treprostinil at 60 ng/kg/min reported improvement in his quality of life, but the dose requirement increased up to 92 ng/kg/min. After a 21-month follow-up, this patient received a lung transplant. The third patient presented a hematoma at the pump site with no other complications and had a follow-up of 9 months with an improvement in her quality of life. COMMENTS Implantable pumps for continuous parenteral prostanoid infusion in pediatric patients are an alternative to external pumps, especially when familiar psychological or psychomotor issues hinder the use of external pumps.
Collapse
Affiliation(s)
| | | | - Natalia Rivero
- Department of Pediatric Cardiology, Ramon y Cajal Hospital, Madrid, Spain
| | - Tomasa Centella
- Department of Pediatric Cardiac Surgery, Ramon y Cajal Hospital, Madrid, Spain
| | - Maria J Lamas
- Department of Pediatric Cardiac Surgery, Ramon y Cajal Hospital, Madrid, Spain
| | | | - Jose L Vázquez
- Pediatric Intensive Care Unit, Ramon y Cajal Hospital, Madrid, Spain
| | - Maria J Del Cerro
- Department of Pediatric Cardiology, Ramon y Cajal Hospital, Madrid, Spain
| |
Collapse
|
24
|
Use of Treprostinil in Pediatric Pulmonary Hypertension: Case Reports and Review of the Literature. J Cardiovasc Pharmacol 2020; 76:23-31. [PMID: 32168152 DOI: 10.1097/fjc.0000000000000820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Add-on therapy with prostacyclin in pediatric refractory pulmonary hypertension (PH) poses a challenge, especially when considering continuous intravenous administration in younger children. A search for alternate routes of drug delivery has led to the clinical investigation of stable and long-acting prostacyclin analogues, such as subcutaneous treprostinil. We reported 2 pediatric cases of PH treated with subcutaneous treprostinil and reviewed the literature on treprostinil use in children. METHOD The literature review used 3 electronic databases and a combination of terms (treprostinil, pediatric, PH, prostanoid, etc). We also searched for pediatric clinical trials on treprostinil registered on international clinical trial registries. RESULTS The reported cases highlighted the multifactorial nature of PH in pediatrics: a female child with a giant omphalocele, and intracardiac and extracardiac shunts; and a male premature child with a congenital diaphragmatic hernia and long-term PH. The literature review identified 19 studies reporting treprostinil use in 421 children with various types of PH (groups 1 and 3). Subcutaneous treprostinil was the most administered formulation, at a mean dose of 40 ng/kg/min. Overall, 12 clinical trials on treprostinil for children with PH were registered on the clinical trial registries. Most authors concluded that subcutaneous treprostinil was effective, well tolerated, and represented an alternative to intravenous epoprostenol. CONCLUSIONS Subcutaneous treprostinil may be a useful adjunct in the therapeutic algorithm for children with severe PH, refractory to oral drugs, and after a complete check-up for all PH etiologies.
Collapse
|
25
|
Jiang H, Yu X, Zhang L, Wang M. Effects of treprostinil on pulmonary arterial hypertension during surgery for congenital heart disease complicated with severe pulmonary arterial hypertension. Minerva Cardiol Angiol 2020; 69:154-160. [PMID: 32138501 DOI: 10.23736/s2724-5683.20.05085-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study is to evaluate the effects of treprostinil injection on the control of pulmonary blood pressure in children with congenital heart disease (CHD) complicated by severe pulmonary arterial hypertension (PAH). METHODS Eighty children with CHD complicated by severe pulmonary arterial hypertension admitted to our hospital from January 2015 to June 2018 were selected and randomly divided into a control group (N.=40) and a treatment group (N.=40). Based on standard treatment, the treatment group was intravenously infused with 8-12 ng/kg·min treprostinil, while the control group received the same dose of normal saline. Hemodynamic parameters such as BP, AP, P and SpO<inf>2</inf>% were monitored before anesthesia induction (T0), before cardiopulmonary bypass (T1), 1 h after cardiopulmonary bypass (T2) and at the end of cardiopulmonary bypass (T3). Pulmonary arterial pressure parameters (PASP, PADP and PAMP) were measured at T1, T2 and T3 by transesophageal echocardiography. RESULTS For the treatment group, the HR values at T2 and T3 were lower than that at T0 (P<0.05). For the control group, HR at T3 was lower than that at T0 (P<0.05). HR at T3 of the treatment group was lower than that of the control group (P<0.05). SpO<inf>2</inf> of the treatment group was higher than that of the control group at T3 (P<0.05). At T2 and T3, PASP, PADP and PAMP of both groups were lower than those before surgery (P<0.05), and the values of the treatment group were lower than those of the control group (P<0.05). CONCLUSIONS Treprostinil can improve cardiac function and reduce pulmonary circulation resistance in PAH children.
Collapse
Affiliation(s)
- Huiwen Jiang
- Department of Ultrasonography, Weihai Central Hospital, Weihai, China
| | - Xiaodan Yu
- Blood Purification Center, Weihai Central Hospital, Weihai, China
| | - Lina Zhang
- Penglai People's Hospital, Yantai, China
| | - Minxin Wang
- Department of Ultrasonography, Weihai Central Hospital, Weihai, China -
| |
Collapse
|
26
|
Beghetti M, Gorenflo M, Ivy DD, Moledina S, Bonnet D. Treatment of pediatric pulmonary arterial hypertension: A focus on the NO-sGC-cGMP pathway. Pediatr Pulmonol 2019; 54:1516-1526. [PMID: 31313530 PMCID: PMC6771736 DOI: 10.1002/ppul.24442] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE While pulmonary arterial hypertension (PAH) is rare in infants and children, it results in substantial morbidity and mortality. In recent years, prognosis has improved, coinciding with the introduction of new PAH-targeted therapies, although much of their use in children is off-label. Evidence to guide the treatment of children with PAH is less extensive than for adults. The goal of this review is to discuss the treatment recommendations for children with PAH, as well as the evidence supporting the use of prostanoids, endothelin receptor antagonists (ERAs), and phosphodiesterase type 5 inhibitors (PDE5i) in this setting. DATA SOURCES Nonsystematic PubMed literature search and authors' expertise. STUDY SELECTION Articles were selected concentrating on the nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway in PAH. The methodology of an ongoing study evaluating the sGC stimulator riociguat in children with PAH is also described. RESULTS Despite recent medical advances, improved therapeutic strategies for pediatric PAH are needed. The efficacy and tolerability of riociguat in adults with PAH have been well trialed. CONCLUSION The pooling of data across trials, supplemented by registry data, will help to confirm the safety and tolerability of prostanoids, ERAs, and PDE5i in children. Ongoing studies will clarify the place of sGC stimulators in the treatment strategy for pediatric PAH.
Collapse
Affiliation(s)
- Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque PédiatriqueChildren's University HospitalGenevaSwitzerland
| | - Matthias Gorenflo
- Department of Pediatrics II, Pediatric Cardiology and Congenital Heart Defects, Center for PediatricsUniversity Hospital HeidelbergGermany
| | - D. Dunbar Ivy
- Children's Hospital Colorado, Heart InstituteUniversity of Colorado School of MedicineDenverColorado
| | - Shahin Moledina
- Cardiology DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Damien Bonnet
- M3C‐Paediatric Cardiology, Necker Enfants Malades, AP‐HPUniversité Paris DescartesParisFrance
| |
Collapse
|
27
|
Transition from intravenous treprostinil to enteral selexipag in an infant with pulmonary arterial hypertension. Cardiol Young 2019; 29:849-851. [PMID: 31379316 DOI: 10.1017/s1047951119001082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Selexipag is an enteral, selective prostacyclin IP receptor agonist approved for pulmonary hypertension in adults. There are few reports of its use in children and none in infants. We report the first transition of an infant (11.5 months, 8.6 kg) from intravenous treprostinil (40 ng/kg/minute) to enteral selexipag (400 mcg twice daily) with a good response and no adverse effects.
Collapse
|
28
|
Farhat N, Lador F, Beghetti M. Diagnosis and treatment of pediatric pulmonary arterial hypertension. Expert Rev Cardiovasc Ther 2019; 17:161-175. [PMID: 30698043 DOI: 10.1080/14779072.2019.1576523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Pediatric pulmonary arterial hypertension (PAH) remains a rare and severe disease with a poor prognosis. PAH may be idiopathic, heritable or associated with systemic conditions in particular associated with congenital heart disease. Areas covered: A thorough and extensive diagnostic approach is required for a correct diagnosis. The outcome has improved over the last decade with a better diagnostic approach and with the initiation of new targeted therapies. However, there is still significant progress to achieve as there is still no cure for this devastating disease. Expert opinion: Adapted clinical studies to define the best therapeutic approach are needed. Even if the treatment approach is still mainly derived from adult data and expert consensus, several studies and registries are currently underway and should deliver important information in the next future. This review aims to give an overview of the current diagnosis and treatment strategies of PAH.
Collapse
Affiliation(s)
- Nesrine Farhat
- a Pediatric Cardiology Unit , University Children's Hospital of Geneva , Geneva , Switzerland
| | - Frederic Lador
- b Pulmonary Hypertension Program , University Hospital of Geneva , Geneva , Switzerland.,c Service de Pneumologie , University Hospital of Geneva , Geneva , Switzerland
| | - Maurice Beghetti
- a Pediatric Cardiology Unit , University Children's Hospital of Geneva , Geneva , Switzerland.,c Service de Pneumologie , University Hospital of Geneva , Geneva , Switzerland.,d Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique , University of Geneva and Lausane Switzerland , Geneva , Switzerland
| |
Collapse
|
29
|
Wacker J, Weintraub R, Beghetti M. An update on current and emerging treatments for pulmonary arterial hypertension in childhood and adolescence. Expert Rev Respir Med 2019; 13:205-215. [DOI: 10.1080/17476348.2019.1565998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Julie Wacker
- Department of Cardiology, Royal Children’s Hospital, Melbourne, Australia
- Pediatric Cardiology Unit, University Children’s Hospital HUG, Pulmonary Hypertension Program HUG, Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique (CURCCCP), University of Geneva and Lausanne, Geneva and Lausanne, Switzerland
| | - Robert Weintraub
- Department of Cardiology, Royal Children’s Hospital, Melbourne, Australia
- Cardiology research, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Maurice Beghetti
- Pediatric Cardiology Unit, University Children’s Hospital HUG, Pulmonary Hypertension Program HUG, Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique (CURCCCP), University of Geneva and Lausanne, Geneva and Lausanne, Switzerland
| |
Collapse
|
30
|
Rosenzweig EB, Abman SH, Adatia I, Beghetti M, Bonnet D, Haworth S, Ivy DD, Berger RMF. Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management. Eur Respir J 2019; 53:1801916. [PMID: 30545978 PMCID: PMC6351335 DOI: 10.1183/13993003.01916-2018] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features of adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for the care of children with PAH, as presented by the Paediatric Task Force of the 6th World Symposium on Pulmonary Hypertension. We provide updates of the current definition, epidemiology, classification, diagnostics and treatment of paediatric PAH, and identify critical knowledge gaps. Several features of paediatric PAH including the prominence of neonatal PAH, especially in pre-term infants with developmental lung diseases, and novel genetic causes of paediatric PAH are highlighted. The use of cardiac catheterisation as a diagnostic modality and haemodynamic definitions of PAH, including acute vasoreactivity, are addressed. Updates are provided on issues related to utility of the previous classification system to reflect paediatric-specific aetiologies and approaches to medical and interventional management of PAH, including the Potts shunt. Although a lack of clinical trial data for the use of PAH-targeted therapy persists, emerging data are improving the identification of appropriate targets for goal-oriented therapy in children. Such data will likely improve future clinical trial design to enhance outcomes in paediatric PAH.
Collapse
Affiliation(s)
- Erika B Rosenzweig
- Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Steven H Abman
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Ian Adatia
- Glenwood Children's Heart Clinic, Edmonton, AB, Canada
| | - Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque Pédiatrique, University Hospitals of Geneva and Lausanne, Lausanne, Switzerland
| | - Damien Bonnet
- Hôpital Necker Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | | | - D Dunbar Ivy
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|