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Morales-Demori R, Coleman R, Mallory GB. Pediatric Pulmonary Hypertension. Pediatr Rev 2024; 45:251-259. [PMID: 38689108 DOI: 10.1542/pir.2023-006010] [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] [Indexed: 05/02/2024]
Affiliation(s)
| | | | - George B Mallory
- Section of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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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.
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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.
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Zheng S, Ye L. Hemodynamic Melody of Postnatal Cardiac and Pulmonary Development in Children with Congenital Heart Diseases. BIOLOGY 2024; 13:234. [PMID: 38666846 PMCID: PMC11048247 DOI: 10.3390/biology13040234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024]
Abstract
Hemodynamics is the eternal theme of the circulatory system. Abnormal hemodynamics and cardiac and pulmonary development intertwine to form the most important features of children with congenital heart diseases (CHDs), thus determining these children's long-term quality of life. Here, we review the varieties of hemodynamic abnormalities that exist in children with CHDs, the recently developed neonatal rodent models of CHDs, and the inspirations these models have brought us in the areas of cardiomyocyte proliferation and maturation, as well as in alveolar development. Furthermore, current limitations, future directions, and clinical decision making based on these inspirations are highlighted. Understanding how CHD-associated hemodynamic scenarios shape postnatal heart and lung development may provide a novel path to improving the long-term quality of life of children with CHDs, transplantation of stem cell-derived cardiomyocytes, and cardiac regeneration.
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Affiliation(s)
- Sixie Zheng
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, National Children’s Medical Center, Shanghai 200127, China;
- Shanghai Institute for Pediatric Congenital Heart Disease, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, National Children’s Medical Center, Shanghai 200127, China
| | - Lincai Ye
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, National Children’s Medical Center, Shanghai 200127, China;
- Shanghai Institute for Pediatric Congenital Heart Disease, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, National Children’s Medical Center, Shanghai 200127, China
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Joye S, Bhattacharya S, Kharrat A, Jasani B, Giesinger RE, McNamara PJ, Jain A. Shape of Pulmonary Artery Doppler Flow Profile and Right Ventricular Hemodynamics in Neonates. J Pediatr 2024; 266:113864. [PMID: 38052293 DOI: 10.1016/j.jpeds.2023.113864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVES To characterize pulmonary artery Doppler flow profile (PAFP) patterns among infants receiving care in neonatal intensive care units and to examine the association of PAFP patterns with pulmonary and right ventricular (RV) hemodynamics. STUDY DESIGN This is a retrospective study at 2 tertiary intensive care units over 4 years that included neonates who demonstrated a complete tricuspid regurgitation envelope on targeted neonatal echocardiography. Separate personnel reviewed TNEs to characterize PAFP patterns, divide cohort into PAFP groups, and measure quantitative indices of RV hemodynamics (RV systolic pressure, pulmonary artery acceleration time and its ratio with RV ejection time, tricuspid annular plane systolic excursion, and RV output), for intergroup comparisons. RESULTS We evaluated TNEs from 186 neonates with median gestational age of 28.5 weeks (IQR, 25.9-35.9 weeks). Four distinct PAFP patterns were identified (A) near-isosceles triangle (22%), (B) right-angled triangle (29%), (C) notching (40%), and (D) low peak velocity (<0.4 m/s; 9%). Groups A-C demonstrated a stepwise worsening in all indices of PH, whereas pattern D was associated with lower tricuspid annular plane systolic excursion and RV output. Using common definitions of pulmonary hypertension (PH), pattern A performed best to rule out PH (sensitivity range, 81%-90%) and pattern C for diagnosing PH (specificity range, 63%-78%). CONCLUSIONS Inspection of PAFP is a simple bedside echocardiography measure that provides clinically meaningful information on underlying RV hemodynamics and may aid in screening and monitoring of patients for PH in intensive care units.
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Affiliation(s)
- Sébastien Joye
- Department Woman-Mother-Child, Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Ashraf Kharrat
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Bonny Jasani
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Division of Neonatology, The Hospital of Sick Children, Toronto, ON, Canada
| | | | | | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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Point-of-Care Ultrasound and the Discovery of Pulmonary Arterial Hypertension in a Teenager. Pediatr Emerg Care 2022; 38:702-704. [PMID: 36449741 DOI: 10.1097/pec.0000000000002881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
We present a case of a teenage patient with new-onset cardiac symptoms discovered to have primary pulmonary arterial hypertension. Point-of-care ultrasound used early in the patient's presentation identified significant right-sided heart dilatation and dysfunction despite the patient's relatively unrevealing physical examination. This article emphasizes the utility of performing focused cardiac ultrasound in pediatric patients early in their presentation. We briefly review focused cardiac ultrasound technique and highlight relevant literature.
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Song K, Duan Q, Ren J, Yi J, Yu H, Che H, Yang C, Wang X, Li Q. Targeted metabolomics combined with network pharmacology to reveal the protective role of luteolin in pulmonary arterial hypertension. Food Funct 2022; 13:10695-10709. [PMID: 36172851 DOI: 10.1039/d2fo01424f] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease that significantly endangers human health, where metabolism may drive pathogenesis: a shift from mitochondrial oxidation to glycolysis occurs in diseased pulmonary vessels and the right ventricle. An increase in pulmonary vascular resistance in patients with heart failure with a preserved ejection fraction portends a poor prognosis. Luteolin exists in numerous foods and is marketed as a dietary supplement assisting in many disease treatments. However, little is known about the protective effect of luteolin on metabolism disorders in diseased pulmonary vessels. In this study, we found that luteolin apparently reversed the pulmonary vascular remodeling of PAH rats by inhibiting the abnormal proliferation of pulmonary artery smooth muscle cells (PASMCs). Moreover, network pharmacology and metabolomics results revealed that the arachidonic acid pathway, amino acid pathway and TCA cycle were dysregulated in PAH. A total of 14 differential metabolites were significantly changed during the PAH, including DHA, PGE2, PGD2, LTB4, 12-HETE, 15-HETE, PGF2α, and 8-iso-PGF2α metabolites in the arachidonic acid pathway, and L-asparagine, oxaloacetate, N-acetyl-L-ornithine, butane diacid, ornithine, glutamic acid metabolites in amino acid and TCA pathways. However, treatment with luteolin recovered the LTB4, PGE2, PGD2, 12-HETE, 15-HETE, PGF2α and 8-iso-PGF2α levels close to normal. Meanwhile, we showed that luteolin also downregulated the gene and protein levels of COX 1, 5-LOX, 12-LOX, and 15-LOX in the arachidonic acid pathway. Collectively, this work highlighted the metabolic mechanism of luteolin-protected PAH and showed that luteolin would hold great potential in PAH prevention.
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Affiliation(s)
- Kexin Song
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
| | - Qingya Duan
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
| | - Jiping Ren
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
| | - Jie Yi
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
| | - Hong Yu
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
| | - Haixia Che
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
| | - Chunjuan Yang
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
| | - Xiaotong Wang
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
| | - Qian Li
- Department of Pharmaceutical Analysis and Analytical Chemistry, College of Pharmacy, Harbin Medical University, No. 157 Baojian Road, Nangang District, Harbin 150081, Heilongjiang, China.
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Critser PJ, Collins SL, Elia EG, McSweeney J, Leary B, Sleeper LA, Mullen MP. Factors Determining Change in Treatment for Ambulatory Children With Pulmonary Arterial Hypertension: Implications for Monitoring. Pulm Circ 2022; 12:e12121. [PMID: 35991680 PMCID: PMC9382461 DOI: 10.1002/pul2.12121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/23/2022] [Accepted: 07/24/2022] [Indexed: 11/24/2022] Open
Abstract
While care models adapt to the COVID‐19 pandemic with virtual and hybrid visits, clinical factors associated with treatment changes among ambulatory pediatric pulmonary arterial hypertension (PAH) patients are not well characterized. To understand which data critically altered treatment recommendations, we conducted a retrospective review among ambulatory children with Group 1 PAH to determine optimal visit and diagnostic strategies. Changes in management included: unplanned new treatments, dose modifications of vasodilators or diuretics, unscheduled hospitalizations, or changes to activity recommendations, catheterization schedule, or other testing. Factors prompting management changes were classified as symptoms, exam findings, or diagnostic tests. Across 398 ambulatory visits by 48 patients, 38 patients (79%) at 88 visits (22%) required change in management, most commonly in targeted PH medication. Changes were driven by symptoms alone (15%), diagnostic testing alone (47%), exam only (2%), symptoms and exam (2%), combination of testing and symptoms or testing and exam (25%), and other reasons (9%). Patients with World Health Organization functional Class IV (odds ratio [OR] 9.04 vs. Class I, p = 0.014) or Class III (OR 2.08 vs. Class I, p = 0.050) were more likely to undergo change in management. However, among Class I patients, 18% of visits generated changes in management because of test findings. While multiple factors affect management in ambulatory pediatric PH, neither symptoms nor exam was sufficient for identifying patients warranting clinical change in management. Testing accounted for most changes. Thus, in‐person or hybrid surveillance including history, exam, and diagnostic testing remains essential for optimal management of pediatric PAH.
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Affiliation(s)
- Paul J. Critser
- Department of Cardiology Boston Children's Hospital Boston MA
| | | | - Eleni G. Elia
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Julia McSweeney
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Brienne Leary
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Lynn A. Sleeper
- Department of Cardiology Boston Children's Hospital Boston MA
- Department of Pediatrics, Harvard Medical School Boston MA
| | - Mary P. Mullen
- Department of Cardiology Boston Children's Hospital Boston MA
- Department of Pediatrics, Harvard Medical School Boston MA
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Ye B, Peng X, Su D, Liu D, Huang Y, Huang Y, Pang Y. Effects of YM155 on the proliferation and apoptosis of pulmonary artery smooth muscle cells in a rat model of high pulmonary blood flow-induced pulmonary arterial hypertension. Clin Exp Hypertens 2022; 44:470-479. [PMID: 35507763 DOI: 10.1080/10641963.2022.2071919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Proliferation and apoptosis of pulmonary artery smooth muscle cells (PASMCs) play an important role in the occurrence and development of pulmonary arterial hypertension (PAH). The purpose of this study was to investigate the effects of survivin inhibitor YM155 on the proliferation and apoptosis of PASMCs in rats with PAH induced by high pulmonary blood flow. METHODS Thirty male Sprague-Dawley (SD) rats were randomly divided into control, model, and YM155 intervention groups. A rat model of PAH induced by high pulmonary blood flow was established, and it was confirmed by assessments of right-ventricular pressure (RVP) and right ventricular hypertrophy index (RVHI). Immunohistochemical staining and western blot analysis were used to detect the expression of survivin, and the proliferation and apoptosis of PASMCs. Lastly, the effects of in vivo treatment of YM155 were tested. RESULTS The increased expression of survivin mRNA and protein were observed in the model group, accompanied by pulmonary arteriolar wall thickening, lumen stenosis, and perivascular inflammatory cell infiltration. Elevated expression of survivin and pulmonary vascular remodeling were significantly mitigated after YM155 treatment. Specifically, the YM155 intervention group had a significantly lower PASMC proliferation rate and a higher PASMC apoptotic rate. CONCLUSION YM155 suppressed PASMC proliferation and promoted PASMC apoptosis by inhibiting survivin expression and thereby reducing pulmonary vascular remodeling in high pulmonary blood flow-induced PAH in vivo.
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Affiliation(s)
- Bingbing Ye
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, GX, China
| | - Xiaofei Peng
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, GX, China.,Department of Pediatrics, Hengyang Central Hospital, Hengyang, GX, China
| | - Danyan Su
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, GX, China
| | - Dongli Liu
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, GX, China
| | - Yanyun Huang
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, GX, China
| | - Yuqin Huang
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, GX, China
| | - Yusheng Pang
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, GX, China
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Domingo LT, Ivy DD, Abman SH, Grenolds AM, MacLean JT, Breaux JA, Minford KJ, Frank BS. Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide. Front Pediatr 2022; 10:1014922. [PMID: 36533232 PMCID: PMC9751701 DOI: 10.3389/fped.2022.1014922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/17/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Riociguat, an oral soluble guanylate cyclase stimulator, has been approved for use in adults with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension. However, there is limited data on its therapeutic use in children. CASE PRESENTATION We report the case of two infants with severe suprasystemic pulmonary hypertension who were successfully treated with riociguat after failure to wean off inhaled nitric oxide (iNO) despite combination PAH therapy. Case 1 is a 6-month-old term male with TBX4 deletion who presented with severe hypoxemic respiratory failure and severe PAH immediately after birth. Initial cardiac catheterization showed PVRi 15.5 WU*m2. Marked hypoxemia and PAH persisted despite aggressive therapy with sildenafil, bosentan, intravenous treprostinil, and milrinone. The infant required high doses of inhaled nitric oxide (60 ppm) and manifested significant post-ductal hypoxemia and hemodynamic instability with any attempt at weaning. After discontinuation of sildenafil, initiation, and very slow uptitration of riociguat, the patient was able to maintain hemodynamic stability and wean from nitric oxide over 6 weeks with persistently severe but not worsened pulmonary hypertension. Case 2 is a 4-month-old term male with compound heterozygous SLC25A26 mutation and severe pulmonary hypertension. Initial cardiac catheterization showed PVRi 28.2 WU*m2. After uptitration of sildenafil, bosentan, and IV treprostinil, serial echocardiograms continued to demonstrate near-systemic pulmonary hypertension. He failed multiple attempts to wean off typical doses of iNO (10-20 ppm) over the following weeks with tachypnea, hypoxemia, and worsening pulmonary hypertension on echocardiogram despite continued aggressive combination targeted therapy. After a 24-h sildenafil washout, he was initiated and uptitrated on riociguat with concomitant, successful wean of nitric oxide over one week that was well tolerated. No serious adverse effects in the titration period were observed. CONCLUSION Riociguat may be considered as an adjuvant therapeutic agent in selected children with severe PAH who are poorly responsive to sildenafil therapy and unable to wean from iNO.
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Affiliation(s)
- L T Domingo
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake, UT, United States
| | - D D Ivy
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United States
| | - S H Abman
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United States
| | - A M Grenolds
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United States
| | - J T MacLean
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United States
| | - J A Breaux
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United States
| | - K J Minford
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake, UT, United States
| | - B S Frank
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United States
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Abstract
PURPOSE OF REVIEW Pulmonary arterial hypertension (PAH) causes high morbidity and mortality in children. In this review, we discuss advances in diagnosis and treatment of this disorder. RECENT FINDINGS Proceedings published from the 2018 World Symposium updated the definition of pulmonary hypertension to include all adults and children with mean pulmonary artery pressure more than 20 mmHg. Targeted PAH therapy is increasingly used off-label, but in 2017, bosentan became the first Food and Drug Administration-targeted PAH therapy approved for use in children. SUMMARY In recent years, advanced imaging and clinical monitoring have allowed improved risk stratification of pulmonary hypertension patients. New therapies, approved in adults and used off-label in pediatric patients, have led to improved outcomes for affected children.
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