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Odackal NJ, Crume M, Naik T, Stiver C. Cardiac Development and Related Clinical Considerations. Neoreviews 2024; 25:e401-e414. [PMID: 38945970 DOI: 10.1542/neo.25-7-e401] [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: 01/03/2024] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 07/02/2024]
Abstract
The anatomy, physiology, and hemodynamics of the premature heart vary along the range of gestational ages cared for in neonatal intensive care units, from 22 weeks to term gestation. Clinical management of the preterm neonate should account for this heterogenous development. This requires an understanding of the impact of ex utero stressors on immature and disorganized cardiac tissue, the different state of hemodynamics across intracardiac shunts impacting the natural transition from fetal to neonatal life, and the effects of intensive pharmacologic and non-pharmacologic interventions that have systemic consequences influencing cardiac function. This article provides a review of the increasing but still limited body of literature on the anatomy, hemodynamics, and electrophysiology of the preterm heart with relevant clinical considerations.
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Affiliation(s)
- Namrita J Odackal
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Mary Crume
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Tanvi Naik
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Corey Stiver
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Cardiology, Nationwide Children's Hospital, Columbus, OH
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2
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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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3
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Rigotti C, Zannin E, Dellacà RL, Ventura ML. Combining lung ultrasound and oscillatory mechanics for assessing lung disease in very preterm infants. Pediatr Res 2024; 95:1022-1027. [PMID: 37857847 DOI: 10.1038/s41390-023-02829-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND We investigated whether combining lung ultrasound scores (LUSs) and respiratory system reactance (Xrs) measured by respiratory oscillometry explains the severity of lung disease better than individual parameters alone. METHODS We performed a prospective observational study in very preterm infants. Forced oscillations (10 Hz) were applied using a neonatal mechanical ventilator (Fabian HFOi, Vyaire). We used the simultaneous respiratory severity score (RSS = mean airway pressure × FIO2) as a primary outcome. We built linear mixed-effect models to assess the relationship between Xrs z-score, LUS and RSS and compared nested models using the likelihood ratio test (LRT). RESULTS We enrolled 61 infants (median (Q1, Q3) gestational age = 30.00 (26.86, 31.00) weeks) and performed 243 measurements at a postnatal age of 26 (13, 41) days and postmenstrual age of 33.14 (30.46, 35.86) weeks. Xrs z-score and LUS were independently associated with simultaneous RSS (p < 0.001 for both). The model including Xrs and LUS explained the RSS significantly better than Xrs (p value LRT < 0.001) or LUS alone (p value LRT < 0.001). CONCLUSIONS Combining LUS and Xrs z-score explains the severity of lung disease better than each parameter alone and has the potential to improve the understanding of the underlying pathophysiology. IMPACT Combining respiratory system reactance by oscillometry and lung ultrasound score explains the respiratory support requirement (e.g., proxy of the severity of lung disease) significantly better than each parameter alone. We assessed the relationship between lung ultrasound and respiratory system reactance in very preterm infants for the first time. Combining respiratory oscillometry and lung ultrasound has the potential to improve the understanding of respiratory pathophysiology.
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Affiliation(s)
- Camilla Rigotti
- Neonatal Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Emanuela Zannin
- Neonatal Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Raffaele L Dellacà
- TechRes Lab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - Maria Luisa Ventura
- Neonatal Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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4
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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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5
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El-Saie A, Varghese NP, Webb MK, Villafranco N, Gandhi B, Guaman MC, Shivanna B. Bronchopulmonary dysplasia - associated pulmonary hypertension: An updated review. Semin Perinatol 2023; 47:151817. [PMID: 37783579 PMCID: PMC10843293 DOI: 10.1016/j.semperi.2023.151817] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is the leading cause of chronic lung disease in infants and the commonest complication of prematurity. Advances in respiratory and overall neonatal care have increased the survival of extremely low gestational age newborns, leading to the continued high incidence of BPD. Pulmonary hypertension (PH) represents the severe form of the pulmonary vascular disease associated with BPD, and affects almost one-third of infants with moderate to severe BPD. PH responds suboptimally to pulmonary vasodilators and increases morbidity and mortality in BPD infants. An up-to-date knowledge of the pathogenesis, pathophysiology, diagnosis, treatment, and outcomes of BPD-PH can be helpful to develop meaningful and novel strategies to improve the outcomes of infants with this disorder. Therefore, our multidisciplinary team has attempted to thoroughly review and summarize the latest advances in BPD-PH in preventing and managing this morbid lung disorder of preterm infants.
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Affiliation(s)
- Ahmed El-Saie
- Section of Neonatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Nidhy P Varghese
- Division of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Melissa K Webb
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Natalie Villafranco
- Division of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Bheru Gandhi
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Milenka Cuevas Guaman
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Binoy Shivanna
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
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6
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Zhu F, Ibarra Rios D, Joye S, Baczynski M, Rios D, Giesinger RE, McNamara PJ, Jain A. Cardiopulmonary physiological effects of diuretic therapy in preterm infants with chronic pulmonary hypertension. J Perinatol 2023; 43:1288-1294. [PMID: 37550529 DOI: 10.1038/s41372-023-01742-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE Using targeted neonatal echocardiography (TNE) to examine cardiopulmonary physiological impact of diuretics in preterm infants with chronic pulmonary hypertension (cPH). STUDY DESIGN Retrospective study comparing TNE indices pre- and ≤2 weeks (post) of initiating diuretic therapy in infants born <32 weeks gestational age with cPH. RESULTS Twenty-seven neonates with mean gestational age, birthweight and interval between pre-post diuretic TNE of 27.0 ± 2.8 weeks, 859 ± 294 grams, and 7.8 ± 3.0 days respectively were studied. Diuretics was associated with improvement in pulmonary vascular resistance [pulmonary artery acceleration time (PAAT); 34.27(9.76) vs. 40.24(11.10)ms, p = 0.01), right ventricular (RV) ejection time:PAAT ratio [5.92(1.66) vs. 4.83(1.14), p < 0.01)], RV fractional area change [41.6(9.8) vs. 46.4(6.5%), p = 0.03)] and left ventricular myocardial performance index [0.55(0.09) vs. 0.41(0.23), p < 0.01)]. Post-treatment, frequency of bidirectional/right-to-left inter-atrial shunts decreased significantly (24% vs. 4%, p = 0.05). CONCLUSION Primary diuretic treatment in neonates with cPH may result in improvement in PVR, RV and LV function and compliance.
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Affiliation(s)
- Faith Zhu
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Daniel Ibarra Rios
- Neonatology Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | | | | | - Danielle Rios
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | | | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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Fraga MV, Dysart KC, Stoller JZ, Huber M, Fedec A, Mercer-Rosa L, Kirpalani H. Echocardiographic Assessment of Pulmonary Arterial Hypertension Following Inhaled Nitric Oxide in Infants with Severe Bronchopulmonary Dysplasia. Neonatology 2023; 120:633-641. [PMID: 37573771 DOI: 10.1159/000531586] [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: 02/06/2023] [Accepted: 06/08/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES Inhaled nitric oxide (iNO) is an effective pulmonary vasodilator. However, the efficacy of iNO in former premature infants with established bronchopulmonary dysplasia (BPD) has not been studied. This study aimed to determine the efficacy of iNO in reducing pulmonary artery pressure in infants with severe BPD as measured by echocardiography. STUDY DESIGN Prospective, observational study enrolling infants born at less than 32 weeks gestation and in whom (1) iNO therapy was initiated after admission to our institution, or (2) at the outside institution less than 48 h before transfer and received an echocardiogram prior to iNO initiation, and (3) had severe BPD. Data were collected at three time-points: (1) before iNO; (2) 12-48 h after initiation of iNO; and (3) 48-168 h after initiation of iNO. The primary outcome was the effect of iNO on pulmonary artery pressure measured by echocardiography in patients with severe BPD between 48 and 168 h after initiating iNO therapy. RESULTS Of 37 enrolled, 81% had echocardiographic evidence of pulmonary arterial hypertension (PAH) before iNO and 56% after 48 h of iNO (p = 0.04). FiO2 requirements were significantly different between time-points (1) and (3) (p = 0.05). There were no significant differences between Tricuspid Annular Plane Systolic Excursion (TAPSE) Z-Scores, time to peak velocity: right ventricular ejection time (TPV:RVET), and ventilator changes. CONCLUSIONS Although we found a statistically significant reduction of PAH between time-point (1) and (3), future trials are needed to further guide clinical care.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, Nemours Children's Health, duPont Hospital for Children, Wilmington, Delaware, USA
| | - Jason Z Stoller
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Matthew Huber
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anysia Fedec
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Emeritus Professor of Pediatrics, Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Emeritus Professor of Pediatrics, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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8
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Rigotti C, Doni D, Zannin E, Abdelfattah AS, Ventura ML. Left ventricular diastolic function and respiratory outcomes in preterm infants: a retrospective study. Pediatr Res 2023; 93:1010-1016. [PMID: 35896704 DOI: 10.1038/s41390-022-02216-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/22/2022] [Accepted: 07/12/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The role of left ventricular (LV) diastolic pressure in the pathophysiology of bronchopulmonary dysplasia (BPD) is unclear. We evaluated the trajectory of echocardiographic parameters of LV diastolic function and the association with respiratory outcomes in preterm infants. METHODS We retrospectively analysed measurements of LV diastolic function (E, e', A, Ee' and E/A ratios) in infants below 32 weeks' gestation (GA). We compared infants with and without BPD by two-way RM ANOVA. We considered Ee' ratio as a proxy of LV filling pressure and identified a cut-off value using ROC analysis. We divided infants using such threshold and compared respiratory outcomes between groups by Mann-Whitney or Chi-square tests. RESULTS We included 72 infants. Ee' ratio at 28 days was significantly associated with the duration of respiratory support (beta (std. error) = 5.32 (1.82), p = 0.005) and BPD (beta = 0.27 (0.10), p = 0.008). Infants with Ee' ratio > 12 at 28 days had longer respiratory support, oxygen requirement, and higher BPD rates than infants with Ee' ratio ≤ 12. CONCLUSION LV diastolic function associated with elevated LV filling pressure may contribute to the pathophysiology of BPD. Serial echocardiographic measurements could identify infants at risk of worse respiratory outcomes. IMPACT In very preterm infants, we assessed the trajectory of left ventricular diastolic function by serial echocardiographic evaluations and evaluated its association with respiratory outcomes. On average, infants who developed bronchopulmonary dysplasia had higher Ee' at 28 postnatal days and 36 weeks postmentrual age than infants who did not develop the disease. Infants with elevated Ee' at 28 postnatal days, suggestive of elevated left atrial pressure, required longer respiratory support.
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Affiliation(s)
- Camilla Rigotti
- Neonatal Intensive Care Unit, Fondazione MBBM-ASST-Monza, Monza, Italy
| | - Daniela Doni
- Neonatal Intensive Care Unit, Fondazione MBBM-ASST-Monza, Monza, Italy
| | - Emanuela Zannin
- Neonatal Intensive Care Unit, Fondazione MBBM-ASST-Monza, Monza, Italy.
| | - Abedulrhman S Abdelfattah
- Neonatal Intensive Care Unit, Fondazione MBBM-ASST-Monza, Monza, Italy
- Pediatric Department, School of Medicine, Hashemite University, Zarqa, Jordan
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9
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Fetal growth restriction and neonatal-pediatric lung diseases: Vascular mechanistic links and therapeutic directions. Paediatr Respir Rev 2022; 44:19-30. [PMID: 36503648 DOI: 10.1016/j.prrv.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 11/18/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common respiratory sequela of prematurity, and infants born with fetal growth restriction (FGR) are disproportionately represented in BPD statistics, as factors which affect somatic growth may also affect pulmonary growth. Effects of in-utero hypoxia underlying FGR on lung parenchymal architecture predisposing to BPD are well documented, but the pulmonary vascular constructs are not well appreciated. Disruption of angiogenesis during critical periods of lung growth impairs alveolarization, contributing to BPD pathogenesis. Pulmonary artery thickness/stiffness has been noted in FGR in the initial postnatal weeks, and also in well-grown infants with established BPD. The lack of waveform cushioning by the major arteries exposes the pulmonary resistance vessels to higher pulsatile stress, thereby accelerating microvascular disease. Reactive oxygen species, increased sympathetic activity and endothelial dysfunction are common mediators in FGR and BPD; each putative targets for prevention and/or therapeutics using interleukin (IL)-1 receptor antagonist (IL-1Ra), melatonin or inhibition of renin-angiotensin-aldosterone system. While BPD is the archetypal respiratory disease of infancy, effects of FGR on pulmonary function are long-term, extending well into childhood. This narrative links FGR in very/extremely preterm infants with BPD through the vascular affliction as a mechanistic and potentially, therapeutic pathway. Our objectives were to depict the burden of disease for FGR and BPD amongst preterm infants, portray vascular involvement in the placenta in FGR and BPD cohorts, provide high resolution vascular ultrasound information in both cohorts with a view to address therapeutic relevance, and lastly, link this information with paediatric age-group lung diseases.
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10
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Bischoff AR, Stanford AH, Aldoss O, Rios DR, McLennan DI, Mohammad Nijres B, Giesinger RE, McNamara PJ. Left ventricular function before and after percutaneous patent ductus arteriosus closure in preterm infants. Pediatr Res 2022:10.1038/s41390-022-02372-6. [PMID: 36380071 DOI: 10.1038/s41390-022-02372-6] [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] [Received: 02/23/2022] [Revised: 10/07/2022] [Accepted: 10/23/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Definitive closure of the patent ductus arteriosus (PDA) is associated with significant changes in the loading conditions of the left ventricle (LV), which may lead to cardiovascular and respiratory instability. The objective of the study was to evaluate targeted neonatal echocardiography (TnECHO) characteristics and the clinical course of preterm infants ≤2 kg undergoing percutaneous PDA closure. METHODS Retrospective cohort study of prospectively acquired pre- and post-closure TnECHOs to assess hemodynamic changes. Cardiorespiratory parameters in the first 24 h following PDA closure were also evaluated. RESULTS Fifty patients were included with a mean age of 30.6 ± 9.6 days and weight of 1188 ± 280 g. LV global longitudinal strain decreased from -20.6 ± 2.6 to -14.9 ± 2.9% (p < 0.001) after 1 h. There was a decrease in LV volume loading, left ventricular output, LV systolic and diastolic parameters. Cardiorespiratory instability occurred in 24 (48%) [oxygenation failure in 44%] but systolic hypotension and/or need for cardiovascular medications was only seen in 6 (12%). Patients with instability had worse baseline respiratory severity score and lower post-closure early diastolic strain rates. CONCLUSIONS Percutaneous PDA closure leads to a reduction in echocardiography markers of LV systolic/diastolic function. Post-closure cardiorespiratory instability is characterized primarily by oxygenation failure and may relate to impaired diastolic performance. IMPACT Percutaneous patent ductus arteriosus closure leads to a reduction in echocardiography markers of left ventricular volume loading, cardiac output, and left ventricular systolic/diastolic function. Post-procedural cardiorespiratory instability is characterized primarily by oxygenation failure. Post-procedural cardiorespiratory instability may relate to impaired diastolic performance.
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Affiliation(s)
| | - Amy H Stanford
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Osamah Aldoss
- Division of Pediatric Cardiology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Danielle R Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Daniel I McLennan
- Section of Pediatric Cardiology, The Herma Heart Institute, Milwaukee, WI, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bassel Mohammad Nijres
- Division of Pediatric Cardiology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA. .,Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
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11
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Sehgal A, Elsayed K, Nugent M, Varma S. Sequelae associated with systemic hypertension in infants with severe bronchopulmonary dysplasia. J Perinatol 2022; 42:775-780. [PMID: 35354941 PMCID: PMC9184283 DOI: 10.1038/s41372-022-01372-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/25/2022] [Accepted: 03/11/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To ascertain correlation between systemic hypertension and respiratory sequelae amongst infants with BPD. STUDY DESIGN Retrospective evaluation of six-year data compared infants with severe BPD to infants with no BPD. 7-day morning blood pressure (BP) (360-366 week) was compared with 95th centile cut-offs. RESULTS 57 infants with BPD were compared with 114 infants with no BPD. Gestation and birthweight were comparable (median [interquartile range], (27 [25, 28] vs. 26.5 weeks [25, 28], p = 0.7 and 706 g [611, 884] vs. 730 [630, 895]), p = 0.1. Number of infants having BP ≥ 95th centile was significantly higher in BPD cohort (systolic BP, 23/57 [40.3%] vs. 3/114 [2.6%], p < 0.001 & mean arterial BP, 26/57 [46%] vs. 3/114 [2.6%], p < 0.001). Amongst BPD infants, higher BP was associated with longer duration of respiratory support (median [range], 109 days [81-138] vs. 87 [58-109], p < 0.001). CONCLUSIONS Infants with severe BPD had higher BP compared to those without BPD.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia. .,Department of Paediatrics, Monash University, Melbourne, Australia.
| | - Kristy Elsayed
- grid.460788.5Monash Newborn, Monash Children’s Hospital, Melbourne, Australia
| | - Matilda Nugent
- grid.1002.30000 0004 1936 7857Department of Paediatrics, Monash University, Melbourne, Australia
| | - Suraj Varma
- grid.419789.a0000 0000 9295 3933MonashHeart, Monash Health, Melbourne, Australia
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12
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Sullivan RT, Tandel MD, Bhombal S, Adamson GT, Boothroyd DB, Tracy M, Moy A, Hopper RK. Role of left atrial hypertension in pulmonary hypertension associated with bronchopulmonary dysplasia. Front Pediatr 2022; 10:1012136. [PMID: 36313896 PMCID: PMC9615143 DOI: 10.3389/fped.2022.1012136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Left atrial hypertension (LAH) may contribute to pulmonary hypertension (PH) in premature infants with bronchopulmonary dysplasia (BPD). Primary causes of LAH in infants with BPD include left ventricular diastolic dysfunction or hemodynamically significant left to right shunt. The incidence of LAH, which is definitively diagnosed by cardiac catheterization, and its contribution to PH is unknown in patients with BPD-PH. We report the prevalence of LAH in an institutional cohort with BPD-PH with careful examination of hemodynamic contributors and impact on patient outcomes. This single-center, retrospective cohort study examined children <2 years of age with BPD-PH who underwent cardiac catheterization at Lucile Packard Children's Hospital Stanford. Patients with unrepaired simple shunt congenital heart disease (CHD) and pulmonary vein stenosis (only 1 or 2 vessel disease) were included. Patients with complex CHD were excluded. From April 2010 to December 2021, 34 patients with BPD-PH underwent cardiac catheterization. We define LAH as pulmonary capillary wedge pressure (PCWP) or left atrial pressure (LAP) of at least 10 mmHg. In this cohort, median PCWP was 8 mmHg, with LAH present in 32% (n = 11) of the total cohort. A majority (88%, n = 30) of the cohort had severe BPD. Most patients had some form of underlying CHD and/or pulmonary vein stenosis: 62% (n = 21) with an atrial septal defect or patent foramen ovale, 62% (n = 21) with patent ductus arteriosus, 12% (n = 4) with ventricular septal defect, and 12% (n = 4) with pulmonary vein stenosis. Using an unadjusted logistic regression model, baseline requirement for positive pressure ventilation at time of cardiac catheterization was associated with increased risk for LAH (odds ratio 8.44, 95% CI 1.46-48.85, p = 0.02). Small for gestational age birthweight, sildenafil use, and CHD were not associated with increased risk for LAH. LAH was associated with increased risk for the composite outcome of tracheostomy and/or death, with a hazard ratio of 6.32 (95% CI 1.72, 22.96; p = 0.005). While the etiology of BPD-PH is multifactorial, LAH is associated with PH in some cases and may play a role in clinical management and patient outcomes.
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Affiliation(s)
- Rachel T Sullivan
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Megha D Tandel
- Quantitative Sciences Unit, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Gregory T Adamson
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Derek B Boothroyd
- Quantitative Sciences Unit, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Michael Tracy
- Division of Pulmonary Medicine, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Amanda Moy
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Rachel K Hopper
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, CA, United States
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13
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Hemodynamic consequences of respiratory interventions in preterm infants. J Perinatol 2022; 42:1153-1160. [PMID: 35690691 PMCID: PMC9436777 DOI: 10.1038/s41372-022-01422-5] [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: 12/19/2021] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 12/14/2022]
Abstract
Advances in perinatal management have led to improvements in survival rates for premature infants. It is known that the transitional period soon after birth, and the subsequent weeks, remain periods of rapid circulatory changes. Preterm infants, especially those born at the limits of viability, are susceptible to hemodynamic effects of routine respiratory care practices. In particular, the immature myocardium and cardiovascular system is developmentally vulnerable. Standard of care (but essential) respiratory interventions, administered as part of neonatal care, may negatively impact heart function and/or pulmonary or systemic hemodynamics. The available evidence regarding the hemodynamic impact of these respiratory practices is not well elucidated. Enhanced diagnostic precision and therapeutic judiciousness are warranted. In this narrative, we outline (1) the vulnerability of preterm infants to hemodynamic disturbances (2) the hemodynamic effects of common respiratory practices; including positive pressure ventilation and surfactant therapy, and (3) identify tools to assess cardiopulmonary interactions and guide management.
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14
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Malloy KW, Austin ED. Pulmonary hypertension in the child with bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:3546-3556. [PMID: 34324276 PMCID: PMC8530892 DOI: 10.1002/ppul.25602] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/25/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease of prematurity resulting from complex interactions of perinatal factors that often lead to prolonged respiratory support and increased pulmonary morbidity. There is also growing appreciation for the dysmorphic pulmonary bed characterized by vascular growth arrest and remodeling, resulting in pulmonary vascular disease and its most severe form, pulmonary hypertension (PH) in children with BPD. In this review, we comprehensively discuss the pathophysiology of PH in children with BPD, evaluate the current recommendations for screening and diagnosis of PH, discern associated comorbid conditions, and outline the current treatment options.
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Affiliation(s)
- Kelsey W Malloy
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric D Austin
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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15
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Stanford AH, Reyes M, Rios DR, Giesinger RE, Jetton JG, Bischoff AR, McNamara PJ. Safety, Feasibility, and Impact of Enalapril on Cardiorespiratory Physiology and Health in Preterm Infants with Systemic Hypertension and Left Ventricular Diastolic Dysfunction. J Clin Med 2021; 10:jcm10194519. [PMID: 34640535 PMCID: PMC8509219 DOI: 10.3390/jcm10194519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/23/2021] [Accepted: 09/25/2021] [Indexed: 11/16/2022] Open
Abstract
Neonatal hypertension has been increasingly recognized in premature infants with bronchopulmonary dysplasia (BPD); of note, a sub-population of these infants may have impaired left ventricular (LV) diastolic function, warranting timely treatment to minimize long term repercussions. In this case series, enalapril, an angiotensin-converting enzyme (ACE) inhibitor, was started in neonates with systemic hypertension and echocardiography signs of LV diastolic dysfunction. A total of 11 patients were included with birth weight of 785 ± 239 grams and gestational age of 25.3 (24, 26.1) weeks. Blood pressure improvement was noticed within 2 weeks of treatment. Improvement in LV diastolic function indices were observed with a reduction in Isovolumic Relaxation Time (IVRT) from 63.1 ± 7.2 to 50.9 ± 7.4 msec and improvement in the left atrium size indexed to aorta (LA:Ao) from1.73 (1.43, 1.88) to 1.23 (1.07, 1.29). Neonatal systemic hypertension is often underappreciated in ex-preterm infants and may be associated with important maladaptive cardiac changes with long term implications. It is biologically plausible that identifying and treating LV diastolic dysfunction in neonates with systemic hypertension may have a positive modulator effect on cardiovascular health in childhood and beyond.
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Affiliation(s)
- Amy H. Stanford
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Melanie Reyes
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Danielle R. Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Regan E. Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Jennifer G. Jetton
- Division of Pediatric Nephrology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA;
| | - Adrianne R. Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Patrick J. McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
- Correspondence: ; Tel.: +1-319-467-7435
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16
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Belfort MB, Sacks SB. Preterm Birth and Heart Failure in Infancy and Beyond: Born With a Broken Heart? JAMA Pediatr 2021; 175:673-675. [PMID: 33818589 DOI: 10.1001/jamapediatrics.2021.0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mandy Brown Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Suzanne Brown Sacks
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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17
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Jobe AH, Bancalari E. An All-Inclusive Perspective on Bronchopulmonary Dysplasia. J Pediatr 2021; 234:257-259. [PMID: 33811871 DOI: 10.1016/j.jpeds.2021.03.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/05/2021] [Accepted: 03/29/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Alan H Jobe
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Eduardo Bancalari
- University of Miami Miller School of Medicine Division of Neonatology, Miami, FL
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18
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Left Ventricle Phenotyping Utilizing Tissue Doppler Imaging in Premature Infants with Varying Severity of Bronchopulmonary Dysplasia. J Clin Med 2021; 10:jcm10102211. [PMID: 34065264 PMCID: PMC8160781 DOI: 10.3390/jcm10102211] [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] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 12/16/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is characterized by alveolar-capillary simplification and is associated with pulmonary hypertension (PH) in preterm infants. The contribution of left ventricle (LV) disease towards this severe BPD-PH phenotype is not well established. We aimed to describe the longitudinal trajectory of the LV function as measured by tissue Doppler imaging (TDI) and its association with BPD-PH. We retrospectively assessed prospectively acquired clinical and echocardiographic data from 77 preterm infants born between 2011 and 2013. We characterized the LV function by measuring systolic and diastolic myocardial velocities (s’, e’, a’), isovolumetric relaxation time (IVRT), and myocardial performance index with TDI at three time periods from 32 and 36 weeks, postmenstrual age through one year of age. We also measured post systolic motion (PSM), a marker of myocardial dysfunction that results from asynchronous movement of the ventricular walls, and not previously described in preterm infants. Patients were stratified into groups according to BPD severity and the presence of PH and compared over time. Conventional TDI measures of the LV function were similar between groups, but the septal PSM was significantly prolonged over the first year of age in patients with BPD-PH. PSM provides a novel objective way to assess the hemodynamic impact of lung and pulmonary vascular disease severity on LV function in preterm infants with BPD and PH.
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