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Luedtke S, Tijani OA, Arawiran JM. Preterm Neonate With Dexamethasone-Induced Acute Hypertrophic Cardiomyopathy and Cardiogenic Shock. J Pediatr Pharmacol Ther 2022; 27:760-764. [PMID: 36989000 PMCID: PMC9674354 DOI: 10.5863/1551-6776-27.8.760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/25/2022] [Indexed: 11/18/2022]
Abstract
This case report describes an extremely low birth weight infant, born at 26-week gestational age, who developed hypertrophic cardiomyopathy (HCM) and cardiogenic shock a few hours after administration of a small dose of dexamethasone. Although cases of steroid-induced cardiomyopathy in preterm neonates are known in literature, their adverse effects are insidious and are transient in occurrence. This is the first report of HCM and cardiogenic shock occurring acutely after administration of small-dose dexamethasone. This neonate received small-dose dexamethasone initially to prevent reintubation, and again to facilitate successful extubation. Both occurrences were associated with acute cardiac decompensation with reduction in ejection fraction within hours of administration. Cardiac function subsequently improved with discontinuation of drug and use of inotropic pharmacotherapy. Studies outlined in this report show that steroid-induced HCM is known and not isolated to dexamethasone alone; however, little is known on the adverse effect of small-dose steroid in resulting acute cardiac decompensation. This case is of educational value in clinical practice by highlighting the potential adverse effects even at the smaller doses of dexamethasone currently recommended in extremely low birth weight infants.
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Affiliation(s)
- Sherry Luedtke
- Department of Pharmacy (SL), Texas Tech University Health Sciences Center at Amarillo, TX
| | - Olusola A. Tijani
- Department of Pediatrics (OAT, JMA), Texas Tech University Health Sciences Center at Amarillo, TX
| | - Jenda M. Arawiran
- Department of Pediatrics (OAT, JMA), Texas Tech University Health Sciences Center at Amarillo, TX
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Sehgal A, Nold MF, Roberts CT, Menahem S. Cardiorespiratory adaptation to low-dose dexamethasone for lung disease in extremely preterm infants: A prospective echocardiographic study. J Physiol 2022; 600:4361-4373. [PMID: 36068678 DOI: 10.1113/jp282973] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/19/2022] [Indexed: 11/08/2022] Open
Abstract
The cardiovascular impact of dexamethasone (Dex) is not well understood. Most data are obtained from a 6 week, high-dose regimen, and are limited to findings of hypertension and cardiac hypertrophy. The present study ascertained the impact of low-dose Dex on cardiac indices when administered to extremely preterm infants for lung disease. A pre-post intervention prospective echocardiographic (Echo) study was undertaken, with cardiac assessments performed before and within 24 h after completion of first course of therapy (10 day regimen, cumulative 0.89 mg kg-1 ). Thirty infants with a gestational age of 24.6 ± 1.1 weeks and birthweight of 612 ± 125 g, respectively, were studied. The age at Dex administration was 20 ± 9 days. Fractional inspired oxygen decreased from 0.7 ± 0.23 to 0.35 ± 0.14 (P < 0.001). Patent ductus arteriosus was noted in 20 infants at Echo1. At Echo2, the ductal diameter decreased from 2.16 ± 0.8 to 1.1 ± 0.8 mm (P = 0.0003), with complete closure in 7/20 (35%). A reduction in left pulmonary artery end-diastolic velocity was noted (17 ± 12 to 9 ± 10 cm s-1 , P < 0.001). Pulmonary vascular resistance decreased (increased time to peak velocity/right ventricular ejection time, 0.2 ± 0.03 to 0.23 ± 0.03, P = 0.0001) and right ventricular systolic performance improved (tricuspid annular plane systolic excursion, 4.9 ± 0.8 to 5.5 ± 0.9 mm, P = 0.02). No significant changes in fractional shortening and left ventricular mass were noted. A significant increase in blood pressure was noted. As a percentage of pre-treatment baseline, the mean increase for systolic blood pressure was 20.3% (95% confidence interval = 14-26) on day 2 (P = 0.008). Low-dose Dex influenced cardiovascular parameters related to pulmonary circulation. KEY POINTS: Corticosteroid therapy is frequently used in preterm infants who are dependent on ventilator support. Echocardiographic studies in infants administered a 6 week course of steroids have noted left ventricular hypertrophy, outlet obstruction and hypertension, but no information is available on right heart indices. The cardiopulmonary effects of the current, significantly lesser cumulative dose (10 day regimen, commonly described as 'DART') have not been evaluated. The present study noted a significant influence on ductal and pulmonary circulation indices. Left heart architecture and function was maintained, whereas a significant but transient increase in blood pressure was noted.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Marcel F Nold
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Samuel Menahem
- Emeritus Head, Paediatric and Fetal Cardiac Units, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
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Seok H, Oh JH. Hypertrophic Cardiomyopathy in Infants from the Perspective of Cardiomyocyte Maturation. Korean Circ J 2021; 51:733-751. [PMID: 34327880 PMCID: PMC8424452 DOI: 10.4070/kcj.2021.0153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) in infancy is rare and many fulminant cases are fatal. Infantile HCM shows a rapid progressive clinical course and different characteristics compared with late-onset HCM presenting during the prepubertal age. There are also spontaneously resolving phenotypes of HCM that are diagnosed in neonates being treated for bronchopulmonary dysplasia with corticosteroids or in those with other problems related to maternal endocrine diseases. The pathophysiology of infantile HCM has not been well described. Therefore, this review updates the pathophysiology of infantile HCM and includes molecular studies on maturation of cardiomyocytes from a clinician's point of view. Hypertrophic cardiomyopathy (HCM) is characterized by ventricular wall hypertrophy with diastolic dysfunction. Pediatric HCM is distinguished from the adult in many aspects. Most children with HCM do not present clinically until the adolescent period, even when they are born with genetic mutations. Some infants with early-onset HCM present with massive progressive myocardial hypertrophy in the first few months of life, which is often fatal. The mortality of pediatric HCM peaks during the infantile and adolescent periods. These periods roughly correlate with children's growth spurt. Non-sarcomeric causes of HCM are more frequent in pediatric HCM, while sarcomeric causes are more common in adults. From the perspective of cardiac development, the fetal heart has immature cardiomyocytes, which are characterized by proliferation and exit their cell cycles with a decreased regenerative property after birth. In the perinatal period, there is a dynamic change in maturation of cardiomyocytes from immature to mature cells. Infants who are treated with steroids or born to mothers with diabetes or hyperthyroidism often show phenotypes of HCM, which gradually resolve. With remarkable advancement of molecular biology, understanding on maturation of cardiomyocytes has increased. Neonates undergo abrupt environmental changes during the transitional circulation, which is affected by oxygen, metabolic and hormonal fluctuations. Derangement in physiological transition to the normal postnatal environment may influence maturation of proliferative immature cardiomyocytes during early infancy. This article reviews updates of infantile HCM and recent molecular studies related to maturation of cardiomyocytes from the clinical point of view of identifying distinct characteristics of infantile HCM.
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Affiliation(s)
- Heeyoung Seok
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jin Hee Oh
- Department of Pediatrics, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Jiang J, Zhang J, Kang M, Yang J. Transient hypertrophic cardiomyopathy and hypertension associated with hydrocortisone in preterm infant: A case report. Medicine (Baltimore) 2019; 98:e16838. [PMID: 31415406 PMCID: PMC6831158 DOI: 10.1097/md.0000000000016838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Hypertrophic cardiomyopathy (HCM) is a heterogeneous, usually familial disorder of heart muscle. The hypertrophic form of cardiomyopathy is frequently genetic, or as part of several neuromuscular disorders. In neonates, especially prematurity, HCM could also be secondary to corticosteroid treatment. PATIENT CONCERNS We reported here a 34 weeks gestational age preterm infant presented with profound cardiomegaly after multiple doses of hydrocortisone used to treat blood pressure instability associated with septic shock and persistent pulmonary hypertension (PPHN). DIAGNOSIS Patient presented auscultation of a grade III/IV harsh systolic ejection murmur from day 14, which was absent before. Profound cardiomegaly was indicated at chest film at day 30. Echocardiography showed severe thickening of the IVS (13.8 mm, z score = 8.29) and mild thickening of the posterior left ventricular wall (LVPW, 6 mm). INTERVENTIONS Propranolol and captopril were started along with supportive care. The patient was also admitted to NICU for further treatment with 24-hour Holter electrocardiographic monitoring. OUTCOMES A reversible course was observed without left ventricular outflow tract obstruction nor arrhythmias within 4 weeks. LESSONS The risk/benefit ratio must be carefully considered when corticosteroids are used in prematurity. Monitors such as echocardiography and electrocardiograph should be conducted in order to guide cardiovascular management. Systematic surveys of the incidence of cardiac complications in a larger population of preterm infant treated with corticosteroid are needed in the future.
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Affiliation(s)
- Jingbo Jiang
- Department of Neonatology, Shenzhen Children's Hospital, Shenzhen
| | - Jiawen Zhang
- Department of Neonatology, Guangdong Women and Children's Hospital, Guangzhou, China
| | - Mengmeng Kang
- Department of Neonatology, Guangdong Women and Children's Hospital, Guangzhou, China
| | - Jie Yang
- Department of Neonatology, Guangdong Women and Children's Hospital, Guangzhou, China
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Ventricular remodeling in preterm infants: computational cardiac magnetic resonance atlasing shows significant early remodeling of the left ventricle. Pediatr Res 2019; 85:807-815. [PMID: 30758323 DOI: 10.1038/s41390-018-0171-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/01/2018] [Accepted: 08/27/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Premature birth is associated with ventricular remodeling, early heart failure, and altered left ventricular (LV) response to physiological stress. Using computational cardiac magnetic resonance (CMR) imaging, we aimed to quantify preterm ventricular remodeling in the neonatal period, and explore contributory clinical factors. METHODS Seventy-three CMR scans (34 preterm infants, 10 term controls) were performed to assess in-utero development and preterm ex-utero growth. End-diastolic computational atlases were created for both cardiac ventricles; t statistics, linear regression modeling, and principal component analysis (PCA) were used to describe the impact of prematurity and perinatal factors on ventricular volumetrics, ventricular geometry, myocardial mass, and wall thickness. RESULTS All preterm neonates demonstrated greater weight-indexed LV mass and higher weight-indexed end-diastolic volume at term-corrected age (P < 0.05 for all preterm gestations). Independent associations of increased term-corrected age LV myocardial wall thickness were (false discovery rate <0.05): degree of prematurity, antenatal glucocorticoid administration, and requirement for >48 h postnatal respiratory support. PCA of LV geometry showed statistical differences between all preterm infants at term-corrected age and term controls. CONCLUSIONS Computational CMR demonstrates that significant LV remodeling occurs soon after preterm delivery and is associated with definable clinical situations. This suggests that neonatal interventions could reduce long-term cardiac dysfunction.
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Baud O, Alberti C, Mohamed D, Watterberg K. Low-dose hydrocortisone in extremely preterm infants - Authors' reply. Lancet 2016; 388:1158-9. [PMID: 27650090 DOI: 10.1016/s0140-6736(16)31611-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Olivier Baud
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, CHU Robert Debré, Université Paris Diderot, Sorbone Paris Cité, INSERM U1141, Paris, France.
| | - Corinne Alberti
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, CHU Robert Debré, Université Paris Diderot, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
| | - Damir Mohamed
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, CHU Robert Debré, Université Paris Diderot, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
| | - Kristi Watterberg
- Department of Pediatrics and Neonatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Bonsante F, Iacobelli S. Low-dose hydrocortisone in extremely preterm infants. Lancet 2016; 388:1157. [PMID: 27650088 DOI: 10.1016/s0140-6736(16)31610-5] [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: 03/14/2016] [Accepted: 07/26/2016] [Indexed: 11/21/2022]
Affiliation(s)
- Francesco Bonsante
- Centre d'Etudes Périnatales de l'Océan Indien EA7388, CHU La Réunion, Site Sud, 97448 Saint Pierre, France; Service de Réanimation Néonatale et Pédiatrique, Néonatologie, CHU La Réunion, Site Sud, Saint Pierre, France
| | - Silvia Iacobelli
- Centre d'Etudes Périnatales de l'Océan Indien EA7388, CHU La Réunion, Site Sud, 97448 Saint Pierre, France; Service de Réanimation Néonatale et Pédiatrique, Néonatologie, CHU La Réunion, Site Sud, Saint Pierre, France.
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