1
|
Toyoshima K, Aoki H, Noguchi T, Saito N, Shimizu T, Kemmotsu T, Shimokaze T, Saito T, Shibasaki J, Kawataki M, Asou T, Tachibana T, Masutani S. Biventricular function in preterm infants with patent ductus arteriosus ligation: A three-dimensional echocardiographic study. Pediatr Res 2024:10.1038/s41390-024-03180-w. [PMID: 38615076 DOI: 10.1038/s41390-024-03180-w] [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: 09/05/2023] [Revised: 02/05/2024] [Accepted: 03/23/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND The detailed hemodynamics after patent ductus arteriosus (PDA) ligation in preterm infants remain unknown. We aimed to clarify the effect of surgical ligation on left ventricular (LV) and right ventricular (RV) volume and function. METHODS Echocardiography was performed in 41 preterm infants (median gestational age: 25 weeks) before and after PDA ligation. Global longitudinal strain was determined using three-dimensional speckle-tracking echocardiography. These values were compared with those in 36 preterm infants without PDA (non-PDA). RESULTS Preoperatively, the PDA group had greater end-diastolic volume (EDV) and cardiac output (CO) in both ventricles, a higher LV ejection fraction (LVEF) (53% vs 44%) and LV global longitudinal strain, and a lower RVEF (47% vs 52%) than the non-PDA group. At 4-8 h postoperatively, the two groups had a similar LVEDV and RVEDV. However, the PDA group had a lower EF and CO in both ventricles than the non-PDA group. At 24-48 h postoperatively, the RVEF was increased, but the LVEF remained decreased, and LVCO was increased. CONCLUSIONS PDA induces biventricular loading and functional abnormalities in preterm infants, and they dramatically change after surgery. Three-dimensional echocardiography may be beneficial to understand the status of both ventricles. IMPACT Preterm infants are at high risk of hemodynamic compromise following a sudden change in loading conditions after PDA ligation. Three-dimensional echocardiography enables quantitative and serial evaluation of ventricular function and volume in preterm infants with PDA. PDA induces biventricular loading and functional abnormalities in preterm infants, and they dramatically change after surgery.
Collapse
Affiliation(s)
- Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan.
| | - Hirosato Aoki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Takahiro Noguchi
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Naka Saito
- Department of Clinical Laboratory, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tatsuto Shimizu
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Takahiro Kemmotsu
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomoyuki Shimokaze
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomoko Saito
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jun Shibasaki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Motoyoshi Kawataki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Toshihide Asou
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tsuyoshi Tachibana
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| |
Collapse
|
2
|
Bischoff AR, Stanford AH, McNamara PJ. Short-term ventriculo-arterial coupling and myocardial work efficiency in preterm infants undergoing percutaneous patent ductus arteriosus closure. Physiol Rep 2021; 9:e15108. [PMID: 34806325 PMCID: PMC8606853 DOI: 10.14814/phy2.15108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 01/21/2023] Open
Abstract
Definitive closure of a patent ductus arteriosus (PDA) causes significant changes in loading conditions of the left ventricle (LV) which can lead to cardiorespiratory instability including hypotension, low cardiac output, oxygenation, and ventilation impairment. Physiological insights of the adaptation of the LV can be gained by looking at ventriculo-arterial coupling (VAC) and myocardial work-energetics. We conducted a retrospective cohort study of preterm infants with echocardiographic assessment of VAC parameters, including end-systolic and arterial elastance (EES , EA ), and myocardial work indices derived from longitudinal strain analysis before and 1-h after percutaneous PDA closure. A total of 35 patients were included with mean [±SD] age at intervention of 30.8 ± 9.9 days and median [IQR] weight of 1130 [995, 1318] grams. There was a reduction in preload and stroke volume, an increase in EA (38.6 ± 11.4 vs. 60 ± 15.1 mmHg/ml/kg, p < 0.001) and in EES (72 [61.5, 109.8] vs. 91.6 [72.2, 125.2] mmHg/ml/kg, p = 0.003) post-closure. Myocardial work indices reduced after PDA closure, including global work efficiency (93.9 ± 2.3 vs. 91.1 ± 3.6%, p < 0.001). A total of 17 (48.6%) patients developed post-closure instability which was associated with younger age, lower preload, and higher EA and EES . Percutaneous PDA closure is associated with major short-term changes in VAC and myocardium energetics, which may provide novel insights on the physiology of PDA closure and on the differential vulnerability to changes in loading conditions.
Collapse
Affiliation(s)
- Adrianne R. Bischoff
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
| | - Amy H. Stanford
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
| | - Patrick J. McNamara
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
- Department of Internal MedicineUniversity of IowaIowa CityIowaUSA
| |
Collapse
|
3
|
Levy PT, Pellicer A, Schwarz CE, Neunhoeffer F, Schuhmann MU, Breindahl M, Fumagelli M, Mintzer J, de Boode W. Near-infrared spectroscopy for perioperative assessment and neonatal interventions. Pediatr Res 2021:10.1038/s41390-021-01791-1. [PMID: 34716423 DOI: 10.1038/s41390-021-01791-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 11/08/2022]
Abstract
Perioperative applications of near-infrared spectroscopy (NIRS) to monitor regional tissue oxygenation and perfusion in cardiac and noncardiac surgery are of increasing interest in neonatal care. Complex neonatal surgery can impair adequate oxygen delivery and tissue oxygen consumption and increase the risk of neurodevelopmental delay. Coupled with conventional techniques, NIRS monitoring may enable targeted hemodynamic management of the circulation in both cardiac and noncardiac surgical procedures. In this narrative review, we discuss the application of perioperative NIRS in specific neonatal interventions, including surgical intervention for congenital heart defects, definitive closure of the patent ductus arteriosus, neurological and gastrointestinal disorders, and use of extracorporeal membrane oxygenation. We identified areas for future research within disease-specific indications and offer a roadmap to aid in developing evidence-based targeted diagnostic and management strategies in neonates. IMPACT: There is growing recognition that perioperative NIRS monitoring, used in conjunction with conventional monitoring, may provide critical hemodynamic information that either complements clinical impressions or delivers novel physiologic insight into the neonatal circulatory and perfusion pathways.
Collapse
Affiliation(s)
- Philip T Levy
- Department of Pediatrics, Harvard Medical School and Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christoph E Schwarz
- Department of Neonatology, University Children's Hospital, Tübingen, Germany
- Infant Research centre, University College Cork Ireland, Cork, Ireland
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Morten Breindahl
- Department of Neonatology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Monica Fumagelli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Jonathan Mintzer
- Division of Newborn Medicine, Department of Pediatrics, Mountainside Medical Center, Montclair, NJ, USA
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| |
Collapse
|
4
|
Aldana-Aguirre JC, Deshpande P, Jain A, Weisz DE. Physiology of Low Blood Pressure During the First Day After Birth Among Extremely Preterm Neonates. J Pediatr 2021; 236:40-46.e3. [PMID: 34019882 DOI: 10.1016/j.jpeds.2021.05.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/09/2021] [Accepted: 05/11/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate the circulatory physiology of hypotension during the first day after birth among stable extremely preterm neonates. STUDY DESIGN Case-control study of neonates born at ≤276/7 weeks gestational age with hypotension, defined as mean blood pressure in mmHg less than gestational age in weeks for at least 1 hour during the first 24 hours after birth, who underwent comprehensive echocardiography assessment before commencement of cardiovascular drugs. Neonates with hypotension (n = 14) were matched by gestational age and intensity of respiratory support with normotensive neonates (n = 27) who underwent serial echocardiography during the first day after birth, and relatively contemporaneous echocardiography assessments were used for comparison. RESULTS Neonates with hypotension had a higher frequency of patent ductus arteriosus ≥1.5 mm (71% vs 15%; P < .001) and ductal size (median diameter, 1.6 mm [IQR, 1.4-2.1] vs 1.0 mm [IQR, 0-1.3]; P = .002), higher echocardiography indices of left ventricular systolic function (mean shortening fraction, 34 ± 7% vs 26 ± 4%; P < .001; mean longitudinal strain, -16 ± 5% vs -14 ± 3%; P = .04; and mean velocity of circumferential fiber shortening, 1.24 ± 0.35 circ/s vs 1.01 ± 0.28 circ/s; P = .03), lower estimates of left ventricular afterload (mean end-systolic wall stress, 20 ± 7 g/cm2 vs 30 ± 9 g/cm2; P < .001 and mean arterial elastance, 43 ± 19 mmHg/mL vs 60 ± 22 mmHg/mL; P = .01), without significant difference in stress-velocity index z-score (-0.42 ± 1.60 vs -0.88 ± 1.30; P = .33). Neonates with hypotension had higher rates of any degree of intraventricular hemorrhage (71% vs 22%; P = .006). CONCLUSIONS Low blood pressure in otherwise well extremely low gestational age neonates was associated with low systemic afterload and larger patent ductus arteriosus, but not left ventricular dysfunction.
Collapse
Affiliation(s)
| | - Poorva Deshpande
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| |
Collapse
|
5
|
Rios DR, Bhattacharya S, Levy PT, McNamara PJ. Circulatory Insufficiency and Hypotension Related to the Ductus Arteriosus in Neonates. Front Pediatr 2018; 6:62. [PMID: 29600242 PMCID: PMC5863525 DOI: 10.3389/fped.2018.00062] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/02/2018] [Indexed: 12/12/2022] Open
Abstract
The biological role of the ductus arteriosus (DA) in neonates varies from an innocent bystander role during normal postnatal transition, to a supportive role when there is compromise to either systemic or pulmonary blood flow, to a pathological state in the presence of hemodynamically significant systemic to pulmonary shunts, as occurs in low birth weight infants. Among a wide array of clinical manifestations arising due to the ductal entity, systemic circulatory insufficiency and hypotension are of significant concern as they are particularly challenging to manage. An understanding of the physiologic interplay between the DA and the circulatory system is the key to developing appropriate targeted therapeutic strategies. In this review, we discuss the relationship of systemic hypotension to the DA, emphasizing the importance of critical thinking and a precise individual approach to intensive care support. We particularly focus on the variable states of hypotension arising directly due to a hemodynamically significant DA or seen in the period following successful surgical ligation. In addition, we explore the mechanistic contributions of the ductus to circulatory insufficiency that may manifest during the transitional period, states of maladapted transition (such as acute pulmonary hypertension of the newborn), and congenital heart disease (both ductal dependent and non-ductal dependent lesions). Understanding the dynamic modulator role of the ductus according to the ambient physiology enables a more precise approach to management. We review the pathophysiology, clinical manifestations, diagnosis, monitoring, and therapeutic intervention for the spectrum of DA-related circulatory compromise.
Collapse
Affiliation(s)
- Danielle R. Rios
- Section of Neonatology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Soume Bhattacharya
- Division of Neonatology, Department of Paediatrics, Western University, London, ON, Canada
| | - Philip T. Levy
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, Saint Louis, MI, United States
| | - Patrick J. McNamara
- Division of Neonatology, Department of Paediatrics and Physiology, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
6
|
Carrillo SA. "What we know is little, and what we are ignorant of is immense". J Thorac Cardiovasc Surg 2017; 154:2052-2053. [PMID: 28964490 DOI: 10.1016/j.jtcvs.2017.08.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 08/30/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Sergio A Carrillo
- Children's Heart Center Nevada and the Department of Surgery, University of Nevada, Las Vegas (UNLV), Las Vegas, Nev.
| |
Collapse
|
7
|
Noori S, Kumar SR. Pre-dicting post-ligation syndrome. J Thorac Cardiovasc Surg 2017; 154:2060-2061. [PMID: 28967417 DOI: 10.1016/j.jtcvs.2017.08.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/19/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Shahab Noori
- Fetal and Neonatal Institute, Children's Hospital of Los Angeles, Los Angeles, Calif; Division of Neonatology, Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, Calif
| | - S Ram Kumar
- Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif; Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, Calif.
| |
Collapse
|