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Wacker J, Humpl T, Berger RMF, Ivy D, Bowers D, Bonnet D, Beghetti M. Application of a modified clinical classification for pulmonary arterial hypertension associated with congenital heart disease in children: emphasis on atrial septal defects and transposition of the great arteries. An analysis from the TOPP registry. Front Cardiovasc Med 2024; 11:1344014. [PMID: 38370158 PMCID: PMC10870771 DOI: 10.3389/fcvm.2024.1344014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/16/2024] [Indexed: 02/20/2024] Open
Abstract
Aims A proportion of patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) do not fit in the current classification. We aimed to analyse the applicability of an adapted clinical classification of PAH-CHD to pediatric patients using the TOPP-1 registry (Tracking Outcomes and Practice in Pediatric Pulmonary Hypertension) and focus on atrial septal defects (ASD) and transposition of the great arteries (TGA). Methods and results Hemodynamic and clinical data of all patients with PAH-CHD in the TOPP cohort were reviewed. Patients were classified according to predefined ABCDE categories (A: Eisenmenger syndrome, B: left-to-right shunt, C: coincidental defects, including all ASDs, D: corrected CHD, E: TGA), or as complex CHD (group 5), by 2 independent investigators. In case of disagreement, a third reviewer could either settle a final decision, or the patient was deemed not classifiable. Survival curves were calculated for each group and compared to idiopathic PAH patients of the registry. A total of 223 out of 531 patients in the registry had PAH-CHD, and 193 were categorized to the following groups: A 39(20%), B 27(14%), C 62(32%) including 43 ASDs, D 58(30%), E 7(4%), whereas 6 patients were categorized as group 5, and 10 patients were unable to be classified. No survival difference could be demonstrated between the groups. Conclusions This modified classification seems to be more applicable to pediatric PAH-CHD patients than the previous classification, but some patients with PAH-CHD who never had a shunt remain unclassifiable. The role of ASD in pediatric PH should be reconsidered.
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Affiliation(s)
- Julie Wacker
- Pediatric Cardiology Unit, Department of Women, Child and Adolescent, Children’s University Hospital, and University of Geneva, Geneva, Switzerland
| | - Tilman Humpl
- Pediatric Cardiology and Critical Care Medicine, The Hospital for Sick Children University of Toronto, Toronto, ON, Canada
| | - Rolf M. F. Berger
- Centre for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Dunbar Ivy
- Pediatric Cardiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - David Bowers
- School of Allied Health Sciences, University of Suffolk, Ipswich, United Kingdom
| | - Damien Bonnet
- Centre de Référence Malformations Cardiaques Congénitales Complexes, M3C-Necker Hospital for Sick Children, Assistance Publique des Hôpitaux de Paris, University of Paris Cité, Paris, France
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Women, Child and Adolescent, Children’s University Hospital, and University of Geneva, Geneva, Switzerland
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Ploegstra MJ, Ivy DD, Beghetti M, Bonnet D, Alehan D, Ablonczy L, Mattos S, Bowers D, Humpl T, Berger RMF. Long-term outcome of children with newly diagnosed pulmonary arterial hypertension: results from the global TOPP registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:66-76. [PMID: 36972621 PMCID: PMC10785586 DOI: 10.1093/ehjqcco/qcad020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND AND AIMS The Tracking Outcomes and Practice in Pediatric Pulmonary Hypertension (TOPP) registry is a global network established to gain insights into the disease course and long-term outcomes of paediatric pulmonary arterial hypertension (PAH). Previously published cohorts in paediatric PAH are obscured by survival bias due to the inclusion of both prevalent (previously diagnosed) and incident (newly diagnosed) patients. The current study aims to describe long-term outcome and its predictors in paediatric PAH, exclusively of newly diagnosed patients. METHODS AND RESULTS Five hundred thirty-one children with confirmed pulmonary hypertension, aged ≥3 months and <18 years, were enrolled in the real-world TOPP registry at 33 centres in 20 countries, from 2008 to 2015. Of these, 242 children with newly diagnosed PAH with at least one follow-up visit were included in the current outcome analyses. During long-term follow-up, 42 (17.4%) children died, 9 (3.7%) underwent lung transplantation, 3 (1.2%) atrial septostomy, and 9 (3.7%) Potts shunt palliation (event rates: 6.2, 1.3, 0.4, and 1.4 events per 100 person-years, respectively). One-, three-, and five-year survival free from adverse outcome was 83.9%, 75.2%, and 71.8%, respectively.Overall, children with open (unrepaired or residual) cardiac shunts had the best survival rates. Younger age, worse World Health Organization functional class, and higher pulmonary vascular resistance index were identified as independent predictors of long-term adverse outcome. Younger age, higher mean right atrial pressure, and lower systemic venous oxygen saturation were specifically identified as independent predictors of early adverse outcome (within 12 months after enrolment). CONCLUSION This comprehensive analysis of survival from time of diagnosis in a large exclusive cohort of children newly diagnosed with PAH describes current-era outcome and its predictors.
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Affiliation(s)
- Mark-Jan Ploegstra
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - David Dunbar Ivy
- Department of Pediatrics, Section of Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado Heart Institute, Aurora, CO, USA
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of the Child and Adolescent, Children's University Hospital Geneva, Geneva, Switzerland
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, Université de Paris Cité, Paris, France
| | - Dursun Alehan
- Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Sandra Mattos
- Maternal–Fetal Cardiac Unit, Royal Portuguese Hospital, Recife, Brazil
| | - David Bowers
- School of Engineering, Arts, Science & Technology, University of Suffolk, Ipswich, UK
| | - Tilman Humpl
- The Hospital for Sick Children, Critical Care and Cardiology, University of Toronto, Toronto, Canada
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, The Netherlands
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Liu Y, Li Y, Zhang J, Zhang D, Li J, Zhao Y, Liu K, Ma X, Bai C, Gu H, Fan X, Wang J. Maternal and fetal outcomes of pregnant women with pulmonary arterial hypertension associated with congenital heart disease in Beijing, China: a retrospective study. Pulm Circ 2022; 12:e12079. [PMID: 35514772 PMCID: PMC9063973 DOI: 10.1002/pul2.12079] [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: 11/16/2021] [Revised: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 11/11/2022] Open
Abstract
As pulmonary arterial hypertension associated with congenital heart disease (PAH‐CHD) may increase maternal and fetal risk, this study explored the pregnancy outcomes of Chinese women with PAH‐CHD. The clinical data of pregnant women with PAH‐CHD admitted to the Beijing Anzhen Hospital from 2010 to 2019 were retrospectively analyzed; these patients and their offspring were followed up, with a mean period of 5.9 ± 2.7 years. Overall, 260 patients with PAH‐CHD were included. The mean maternal age was 27.7 ± 4.1 years, and 205 (78.8%) patients were nulliparous. The estimated systolic pulmonary artery pressure was 40–50 mmHg in 34.6% of the patients, 50–70 mmHg in 23.1%, and >70 mmHg in 42.3%. More than 96% of patients were diagnosed with PAH‐CHD before pregnancy. During pregnancy, heart failure occurred in 19.2% of the patients. Cesarean delivery was performed in 88.1% (15.0% emergency) of the patients. Complications included fetal distress (5.8%), preterm delivery (34.2%), and low birth weight (33.8%). A total of 15 mothers (5.8%) died, with the highest mortality rate in those with Eisenmenger syndrome (10/43, 23.3%), and 10 offspring died (3.8%), two (0.8%) following hospital discharge and eight (3.1%) while in hospital. Although most pregnant women with PAH‐CHD were able to have children, PAH increased the maternal and fetal risk. Thus, an individualized risk‐based approach with shared decision‐making may be more appropriate in pregnant women with PAH‐CHD.
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Affiliation(s)
- Yang Liu
- Department of Pediatric Cardiac Center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Yanna Li
- Department of Obstetrics and Gynecology Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Jun Zhang
- Department of Obstetrics and Gynecology Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Dawei Zhang
- Department of Obstetrics and Gynecology Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Jiachen Li
- Department of Pediatric Cardiac Center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Yichen Zhao
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Kemin Liu
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Xiaolong Ma
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Chen Bai
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Hong Gu
- Department of Pediatric Cardiac Center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Xiangming Fan
- Department of Pediatric Cardiac Center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Jiangang Wang
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
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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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Capel A, Lévy M, Szezepanski I, Malekzadeh-Milani S, Vouhé P, Bonnet D. Potts anastomosis in children with severe pulmonary arterial hypertension and atrial septal defect. ESC Heart Fail 2020; 8:326-332. [PMID: 33216469 PMCID: PMC7835613 DOI: 10.1002/ehf2.13074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/26/2022] Open
Abstract
Aims Potts shunt has been proposed as a bridge or alternative to lung transplantation for children with severe and drug‐refractory suprasystemic pulmonary arterial hypertension (PAH). We describe the management of the atrial shunt when a Potts shunt is planned in refractory PAH. Methods and results We report a case series of children in whom a Potts shunt was done for severe PAH associated with an atrial septal defect to illustrate the different clinical and haemodynamic scenarios. Five children (2 to 13 years) underwent a Potts shunt: three surgical, one percutaneous Potts shunt, and one percutaneous stenting of a restrictive arterial duct. All had associated atrial septal defect. Those who had generalized cyanosis before the procedure had a complicated postoperative course and required longer ventilatory and inotropic support, except the one who had atrial septal defect closure before the Potts shunt. One of the three cyanotic patients died. Two patients with left‐to‐right shunt before the Potts shunt had an uncomplicated postoperative course. Conclusions Shunt physiology is only partially predictable after the Potts shunt in children with PAH and atrial septal defect. Abrupt drop in left ventricle preload while the right ventricle is decompressed can potentially be prevented by atrial septal defect closure prior to the Potts shunt.
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Affiliation(s)
- Alice Capel
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Marilyne Lévy
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Isabelle Szezepanski
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Sophie Malekzadeh-Milani
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Pascal Vouhé
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
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6
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Abstract
Pulmonary hypertension (PH), the syndrome of increased pressure in the pulmonary arteries, is associated with significant morbidity and mortality for affected children and is associated with a variety of potential underlying causes. Several pulmonary arterial hypertension-targeted therapies have become available to reduce pulmonary artery pressure and improve outcome, but there is still no cure for most patients. This review provides a description of select causes of PH encountered in pediatrics and an update on the most recent data pertaining to evaluation and management of children with PH. Available evidence for specific classes of PH-targeted therapies in pediatrics is discussed.
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Affiliation(s)
- Benjamin S Frank
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - D Dunbar Ivy
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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7
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Jančauskaitė D, Rudienė V, Jakutis G, Geenen LW, Roos-Hesselink JW, Gumbienė L. Residual Pulmonary Hypertension more than 20 Years after Repair of Shunt Lesions. ACTA ACUST UNITED AC 2020; 56:medicina56060297. [PMID: 32560260 PMCID: PMC7353861 DOI: 10.3390/medicina56060297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 12/04/2022]
Abstract
Background and Objectives: After successful surgical repair of a congenital shunt lesion, pulmonary hypertension (PH) often disappears. However, PH can persist long-term after the closure. This study aimed to assess the prevalence of PH long-term after surgical repair of congenital heart disease (CHD), and to evaluate the outcomes and preoperative factors related to residual PH. Materials and Methods: In this retrospective cohort study, we reviewed patients who underwent right heart catheterisation in Vilnius University Hospital Santaros Klinikos during the period of 1985–2007. Among 4118 right heart catheterisations performed, 160 patients underwent congenital systemic-to-pulmonary shunt repair at a young age (<18 years) and had pre-operative PH. Half of the patients were foreigners whose follow-up data were unavailable. Eventually, 88 patients with available follow-up data were included in this study. Results: The median age at diagnosis of CHD with PH was 0.8 (0.6–3.0) and 1.1 (0.6–3.9) years at surgery (50% females). Residual PH was assessed 9.5 years after surgery and observed in 30.7% (n = 27) of the patients. It was associated with having more than one shunt (44.4% (n = 12), p = 0.016) and higher median pulmonary vascular resistance (3.4 (2.5–6.5) vs. 2.2 (1.0–3.7), p = 0.035) at baseline. After a median follow-up of 21 (15–24) years, 9.1% of the patients were deceased. Kaplan–Meier survival analysis revealed significantly higher mortality in the residual PH group (p = 0.035). Conclusions: Residual PH affects a significant proportion of patients after surgical repair of a shunt lesion and is associated with worse long-term outcome.
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Affiliation(s)
- Dovilė Jančauskaitė
- Centre of Cardiology and Angiology, Vilnius University, LT 08661 Vilnius, Lithuania;
- Correspondence: ; Tel.: +370-5-250-1442
| | - Virginija Rudienė
- Faculty of Medicine, Vilnius University, LT 03101 Vilnius, Lithuania; (V.R.); (G.J.)
| | - Gabrielius Jakutis
- Faculty of Medicine, Vilnius University, LT 03101 Vilnius, Lithuania; (V.R.); (G.J.)
| | - Laurie W Geenen
- Department of Cardiology, Erasmus MC University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (L.WG.); (J.WR.-H.)
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Erasmus MC University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (L.WG.); (J.WR.-H.)
| | - Lina Gumbienė
- Centre of Cardiology and Angiology, Vilnius University, LT 08661 Vilnius, Lithuania;
- Centre of Heart and Chest Surgery, Vilnius University, LT 08661 Vilnius, Lithuania
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8
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Children and Adolescents with Pulmonary Arterial Hypertension: Baseline and Follow-Up Data from the Polish Registry of Pulmonary Hypertension (BNP-PL). J Clin Med 2020; 9:jcm9061717. [PMID: 32503164 PMCID: PMC7356296 DOI: 10.3390/jcm9061717] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/21/2022] Open
Abstract
We present the results from the pediatric arm of the Polish Registry of Pulmonary Hypertension. We prospectively enrolled all pulmonary arterial hypertension (PAH) patients, between the ages of 3 months and 18 years, who had been under the care of each PAH center in Poland between 1 March 2018 and 30 September 2018. The mean prevalence of PAH was 11.6 per million, and the estimated incidence rate was 2.4 per million/year, but it was geographically heterogeneous. Among 80 enrolled children (females, n = 40; 50%), 54 (67.5%) had PAH associated with congenital heart disease (CHD-PAH), 25 (31.25%) had idiopathic PAH (IPAH), and 1 (1.25%) had portopulmonary PAH. At the time of enrolment, 31% of the patients had significant impairment of physical capacity (WHO-FC III). The most frequent comorbidities included shortage of growth (n = 20; 25%), mental retardation (n = 32; 40%), hypothyroidism (n = 19; 23.8%) and Down syndrome (n = 24; 30%). The majority of children were treated with PAH-specific medications, but only half of them with double combination therapy, which improved after changing the reimbursement policy. The underrepresentation of PAH classes other than IPAH and CHD-PAH, and the geographically heterogeneous distribution of PAH prevalence, indicate the need for building awareness of PAH among pediatricians, while a frequent coexistence of PAH with other comorbidities calls for a multidisciplinary approach to the management of PAH children.
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10
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Santoro JD, Lee S, Mlynash M, Mayne EW, Rafii MS, Skotko BG. Diminished Blood Pressure Profiles in Children With Down Syndrome. Hypertension 2020; 75:819-825. [PMID: 31928114 DOI: 10.1161/hypertensionaha.119.14416] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study sought to analyze blood pressure trends in children with Down syndrome at multiple centers. A multicenter, retrospective, cross-sectional study was performed. All patients were <18 years and had a diagnosis of Down syndrome. Existing comorbidities were nonexclusionary. For each patient, 3 blood pressure recordings were obtained from routine clinic visits. In total, 887 patients with 2661 total blood pressure recordings were included in this study. The average blood pressure percentile for patients was 38.87 with a median percentile of 31.5. Age, sex, and race were not predictive of blood pressure percentile. Compared with established data from the National Heart Lung and Blood Institute and National Health and Nutrition Examination Survey cohort (ages 8-18 years), blood pressure in our Down syndrome population was statistically lower by 6.1 percentile points (P<0.001), with the greatest difference at higher blood pressure percentiles (P<0.001). Only 10% of all Down syndrome cohort blood pressure recordings were greater than the National Heart Lung and Blood Institute/National Health and Nutrition Examination Survey 70th percentile, with no patients meeting criteria for prehypertension or hypertension. Additional comparisons against American Academy of Pediatrics data were similar and statistically significant. In children with Down syndrome, there is a 12 percentile point reduction in baseline blood pressure compared with age- and height-matched controls reported in the National Heart Lung and Blood Institute/National Health and Nutrition Examination Survey and American Academy of Pediatrics cohorts. This data can potentially be utilized in the evaluation and care of persons with Down syndrome in their pediatric medical homes.
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Affiliation(s)
- Jonathan D Santoro
- From the Department of Neurology, Children's Hospital Los Angeles, CA (J.D.S.).,Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (J.D.S.).,Department of Neurology, Massachusetts General Hospital, Boston (J.D.S.).,Harvard Medical School, Boston, MA (J.D.S., B.G.S.)
| | - Sarah Lee
- Division of Child Neurology, Stanford University, Palo Alto, CA (S.L., M.M., E.W.M.)
| | - Michael Mlynash
- Division of Child Neurology, Stanford University, Palo Alto, CA (S.L., M.M., E.W.M.)
| | - Elizabeth W Mayne
- Division of Child Neurology, Stanford University, Palo Alto, CA (S.L., M.M., E.W.M.)
| | - Michael S Rafii
- Alzheimer's Therapeutic Research Institute (ATRI), Keck School of Medicine, University of Southern California, San Diego (M.S.R.)
| | - Brian G Skotko
- Harvard Medical School, Boston, MA (J.D.S., B.G.S.).,Down Syndrome Program, Division of Medical Genetics, Department of Pediatrics, Massachusetts General Hospital, Boston (B.G.S.)
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Abstract
PURPOSE OF REVIEW Pediatric pulmonary arterial hypertension (PAH) is associated with significant morbidity and mortality. Herein we review the diagnosis and classification for pediatric PAH and detail the current therapeutic options available for use in the pediatric PAH population. RECENT FINDINGS Classification and treatment of pediatric PAH is guided by adult criteria and treatment algorithms, yet the distribution of factors contributing to PAH in children differs significantly from that seen in adults. It is necessary to understand these differences in order to appropriately tailor therapy to the needs of the child or adolescent. An expanding array of targeted PAH drugs are now approved for use in adults, and many of these drugs are used "off-label" to treat children and adolescents with PAH. Use of these novel therapies has coincided with marked improvement in outcomes, suggesting significant benefit. However, because most of these drugs have not been studied in rigorous randomized, controlled trials in children, it is critical that physicians understand their mechanisms of action, potential benefits, and safety profiles. Pediatric PAH outcomes have improved substantially in the modern era, coinciding with the "off-label" use of targeted PAH drugs in children and adolescents. Ideally, care should be provided at centers with specialized expertise in the diagnosis and treatment of pediatric PAH by providers who understand the appropriate diagnostic algorithms, classification schemes, and treatment approaches.
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Affiliation(s)
- Jordan E Ezekian
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Medical Center, 2301 Erwin Road, DUMC, Box 3090, Durham, NC, 27710, USA
| | - Kevin D Hill
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Medical Center, 2301 Erwin Road, DUMC, Box 3090, Durham, NC, 27710, USA.
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12
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Beghetti M, Gorenflo M, Ivy DD, Moledina S, Bonnet D. Treatment of pediatric pulmonary arterial hypertension: A focus on the NO-sGC-cGMP pathway. Pediatr Pulmonol 2019; 54:1516-1526. [PMID: 31313530 PMCID: PMC6771736 DOI: 10.1002/ppul.24442] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE While pulmonary arterial hypertension (PAH) is rare in infants and children, it results in substantial morbidity and mortality. In recent years, prognosis has improved, coinciding with the introduction of new PAH-targeted therapies, although much of their use in children is off-label. Evidence to guide the treatment of children with PAH is less extensive than for adults. The goal of this review is to discuss the treatment recommendations for children with PAH, as well as the evidence supporting the use of prostanoids, endothelin receptor antagonists (ERAs), and phosphodiesterase type 5 inhibitors (PDE5i) in this setting. DATA SOURCES Nonsystematic PubMed literature search and authors' expertise. STUDY SELECTION Articles were selected concentrating on the nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway in PAH. The methodology of an ongoing study evaluating the sGC stimulator riociguat in children with PAH is also described. RESULTS Despite recent medical advances, improved therapeutic strategies for pediatric PAH are needed. The efficacy and tolerability of riociguat in adults with PAH have been well trialed. CONCLUSION The pooling of data across trials, supplemented by registry data, will help to confirm the safety and tolerability of prostanoids, ERAs, and PDE5i in children. Ongoing studies will clarify the place of sGC stimulators in the treatment strategy for pediatric PAH.
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Affiliation(s)
- Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque PédiatriqueChildren's University HospitalGenevaSwitzerland
| | - Matthias Gorenflo
- Department of Pediatrics II, Pediatric Cardiology and Congenital Heart Defects, Center for PediatricsUniversity Hospital HeidelbergGermany
| | - D. Dunbar Ivy
- Children's Hospital Colorado, Heart InstituteUniversity of Colorado School of MedicineDenverColorado
| | - Shahin Moledina
- Cardiology DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Damien Bonnet
- M3C‐Paediatric Cardiology, Necker Enfants Malades, AP‐HPUniversité Paris DescartesParisFrance
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13
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Hipertensión pulmonar en niños. REVISTA COLOMBIANA DE CARDIOLOGÍA 2019. [DOI: 10.1016/j.rccar.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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14
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Rosenzweig EB, Abman SH, Adatia I, Beghetti M, Bonnet D, Haworth S, Ivy DD, Berger RMF. Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management. Eur Respir J 2019; 53:1801916. [PMID: 30545978 PMCID: PMC6351335 DOI: 10.1183/13993003.01916-2018] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features of adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for the care of children with PAH, as presented by the Paediatric Task Force of the 6th World Symposium on Pulmonary Hypertension. We provide updates of the current definition, epidemiology, classification, diagnostics and treatment of paediatric PAH, and identify critical knowledge gaps. Several features of paediatric PAH including the prominence of neonatal PAH, especially in pre-term infants with developmental lung diseases, and novel genetic causes of paediatric PAH are highlighted. The use of cardiac catheterisation as a diagnostic modality and haemodynamic definitions of PAH, including acute vasoreactivity, are addressed. Updates are provided on issues related to utility of the previous classification system to reflect paediatric-specific aetiologies and approaches to medical and interventional management of PAH, including the Potts shunt. Although a lack of clinical trial data for the use of PAH-targeted therapy persists, emerging data are improving the identification of appropriate targets for goal-oriented therapy in children. Such data will likely improve future clinical trial design to enhance outcomes in paediatric PAH.
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Affiliation(s)
- Erika B Rosenzweig
- Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Steven H Abman
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Ian Adatia
- Glenwood Children's Heart Clinic, Edmonton, AB, Canada
| | - Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque Pédiatrique, University Hospitals of Geneva and Lausanne, Lausanne, Switzerland
| | - Damien Bonnet
- Hôpital Necker Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | | | - D Dunbar Ivy
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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15
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Frank BS, Ivy DD. Diagnosis, Evaluation and Treatment of Pulmonary Arterial Hypertension in Children. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E44. [PMID: 29570688 PMCID: PMC5920390 DOI: 10.3390/children5040044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 02/28/2018] [Accepted: 03/16/2018] [Indexed: 12/23/2022]
Abstract
Pulmonary Hypertension (PH), the syndrome of elevated pressure in the pulmonary arteries, is associated with significant morbidity and mortality for affected children. PH is associated with a wide variety of potential underlying causes, including cardiac, pulmonary, hematologic and rheumatologic abnormalities. Regardless of the cause, for many patients the natural history of PH involves progressive elevation in pulmonary arterial resistance and pressure, right ventricular dysfunction, and eventually heart failure. In recent years, a number of pulmonary arterial hypertension (PAH)-targeted therapies have become available to reduce pulmonary artery pressure and improve outcome. A growing body of evidence in both the adult and pediatric literature demonstrates enhanced quality of life, functional status, and survival among treated patients. This review provides a description of select etiologies of PH seen in pediatrics and an update on the most recent data pertaining to evaluation and management of children with PH/PAH. The available evidence for specific classes of PAH-targeted therapies in pediatrics is additionally discussed.
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Affiliation(s)
- Benjamin S Frank
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
| | - D Dunbar Ivy
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
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16
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Douwes JM, Berger RMF. Pediatric pulmonary arterial hypertension: on the eve of growing up. Curr Opin Pulm Med 2017; 23:398-403. [PMID: 28590293 DOI: 10.1097/mcp.0000000000000406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Current recommendations for diagnosis and treatment of pulmonary arterial hypertension (PAH) during childhood are expert opinion based, because of lacking pediatric data. In recent years, however, important pediatric data have emerged on PAH. RECENT FINDINGS PAH in children shows similarities as well as differences compared to adults. Neonates and children know specific clinical presentations and a hemodynamic profile that differs from adults with PAH. Children identified as acute vasodilator responders according to the criteria proposed for adults rather than the pediatric criteria have better outcome when treated with calcium channel blockers. For nonresponders, combination PAH-targeted therapy leads to improved outcome compared to monotherapy. In pediatric PAH, WHO functional class, N-terminal pro-brain natriuretic peptide and tricuspid annular plane systolic excursion were identified as surrogates for survival and therefore qualify to be treatment goals in a goal-oriented treatment strategy. SUMMARY In order to refine current pediatric treatment guidelines, data on efficacy of specific treatment regiments and strategies are needed. The recently validated composite endpoint of clinical worsening allows for trials that will provide these data. For the first time, evidence-based treatment goals have been identified that will allow for a goal-oriented treatment strategy. Furthermore, various prognostic predictors have been identified that may prove treatment goals in future.
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Affiliation(s)
- Johannes M Douwes
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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17
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Idiopathic Pulmonary Arterial Hypertension in Children: A Review. Pulm Ther 2017. [DOI: 10.1007/s41030-017-0035-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Li L, Jick S, Breitenstein S, Hernandez G, Michel A, Vizcaya D. Pulmonary arterial hypertension in the USA: an epidemiological study in a large insured pediatric population. Pulm Circ 2017; 7:126-136. [PMID: 28680572 PMCID: PMC5448526 DOI: 10.1086/690007] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/22/2016] [Indexed: 01/31/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is rare in children and few data are available in a pediatric general population. This study aims to calculate the annual incidence and prevalence of PAH and to describe these children in a large US population of patients aged under 18 years. Using the US MarketScan claims database we identified 695 children with PAH in 2010-2013. We calculated annual incidence rates and prevalence overall, by age and PAH type (idiopathic and non-idiopathic) using Byar's method. We also described characteristics, co-morbidities, treatment patterns, and diagnostic procedures for these children. In 2010-2013, the annual incidence rates of PAH per 1,000,000 children-years was in the range of 4.8-8.1; 0.5-0.9 for idiopathic PAH and 4.3-7.3 for non-idiopathic PAH. The annual prevalence of PAH was in the range of 25.7-32.6 per 1,000,000 children; 4.4-6.0 for idiopathic PAH and 21.3-27.0 for non-idiopathic PAH. Incidence rates and prevalence were highest in children under age 2 years. Around 36% of affected children were born prematurely. Most (75%) had some type of congenital heart defect and 13% had Down's syndrome. Most patients received PAH monotherapy (83%), while 13% received dual therapy. Phosphodiesterase type 5 inhibitors were the most commonly used treatments. Around 92% had at least one echocardiogram and 37% a right heart catheterization. PAH is very rare in children especially in the absence of etiological factors such as congenital heart defects. A large proportion of diagnoses in children seem to be based on echocardiography rather than right heart catheterization.
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Affiliation(s)
- Lin Li
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA, USA
| | - Susan Jick
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA, USA
| | | | - Gemzel Hernandez
- Clinical Development, Bayer HealthCare Pharmaceuticals Inc., Parsippany, NJ, USA
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