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Hébert A, McNamara PJ, Carvalho Nunes GD, Maltais-Bilodeau C, Leclerc MÈ, Wutthigate P, Simoneau J, Drolet C, Altit G. PDA management strategies and pulmonary hypertension in extreme preterm infants with bronchopulmonary dysplasia. Pediatr Res 2024:10.1038/s41390-024-03321-1. [PMID: 38898108 DOI: 10.1038/s41390-024-03321-1] [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: 01/23/2024] [Revised: 04/11/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Premature infants are at risk for developing pulmonary hypertension (PH) in the context of bronchopulmonary dysplasia (BPD). Studies suggest a potential link between prolonged patent ductus arteriosus (PDA) exposure and BPD-PH, though management strategies remain controversial. METHODS Retrospective echocardiographic evaluation of newborns <29 weeks gestational age with BPD at two distinct centers. Primary objective was to evaluate the relationship between center-specific PDA management strategies (interventional or conservative) and the prevalence of BPD-PH. BPD was defined as oxygen or respiratory support at 36 weeks post-menstrual age (PMA). The presence of PH was defined as either an estimated sPAP of ≥40 mmHg or sEI ≥1.3. Center A has a conservative PDA policy. Center B has a targeted interventional policy. RESULTS PH rates were similar between sites (21% vs 17%), while rates of PDA treatment was different (7% vs 81). Adjusted models did not demonstrate an association for center or PDA treatment exposure for PH and EI, although infants from Center A had echocardiography evidence of higher systolic eccentricity index (EI; 1.12 ± 0.19 vs 1.06 ± 0.15, p = 0.04). Markers of RV function (TAPSE and RV-FAC) were similar between groups. CONCLUSION In preterm infants <29 weeks with BPD, conservative PDA treatment policy was not associated with higher rate of pulmonary hypertension diagnosis. IMPACT The association between PDA-management approaches and the occurrence of BPD-associated pulmonary vascular disease in premature infants has sparsely been described. We found that a conservative policy, regarding the PDA, was not associated with an increase in pulmonary hypertension diagnosis. We identified that, in patients with BPD, echocardiographic metrics of LV performance were lower.
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Affiliation(s)
- Audrey Hébert
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, QC, Canada.
| | - Patrick J McNamara
- Division of Neonatology, University of Iowa Children's Hospital, University of Iowa, Iowa city, IA, USA
| | | | | | - Marie-Ève Leclerc
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, QC, Canada
| | - Punnanee Wutthigate
- Division of Neonatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Jessica Simoneau
- Division of Neonatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Christine Drolet
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, QC, Canada
| | - Gabriel Altit
- Division of Neonatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
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Li T, Xia B, Liang S, He Q, Zhang S, Chen X, Xu N. Right ventricular function indices and platelet parameters for early prediction value of bronchopulmonary dysplasia: a retrospective study. BMC Pediatr 2024; 24:391. [PMID: 38862972 PMCID: PMC11167767 DOI: 10.1186/s12887-024-04868-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/31/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND To examine the value of early echocardiographic indices for the right ventricular function combined with platelet(PLT) parameters for predicting bronchopulmonary dysplasia (BPD) in preterm infants. METHODS This retrospective study included infants with gestational age (GA) below 32 weeks, who were admitted to the neonatal intensive care unit(NICU). The detection rate of tricuspid regurgitation jet velocity (TRVJ), ventricular septal flattening, pulmonary artery widening, right ventricular dilation, and right atrial enlargement on the 7th day of life (DOL 7) were compared between BPD and non-BPD infants. Echocardiographic indices of the right ventricular function including tricuspid annular plane systolic excursion (TAPSE) and right ventricular index of myocardial performance (RIMP) were measured on 1 day of life (DOL 1)、on DOL 7 and on 14 day of life (DOL 14) respectively. The PLT parameters including the PLT count, mean platelet volume (MPV), platelet hematocrit (PCT) level, and platelet distribution width (PDW) were measured on the DOL 1,DOL 7, and DOL 14. Multivariate logistic regression was used to analyze the relationship between these parameters and BPD. Receiver operating characteristic curve analysis was performed to assess the predictive value of the right ventricular function indices and PLT parameters for BPD. RESULTS A total of 220 preterm infants were included in this study, and of these, 85 infants developed BPD among them. The RIMP of the BPD group on DOL 14 was higher than that of the non-BPD group (P < 0.05). The TAPSE of the BPD group on DOL 14 was lower than that of the non-BPD group (P < 0.05). The PLT count of the BPD group on DOL 1 was lower than that of the non-BPD group (P < 0.05), and the MPV of the BPD group on DOL 1 was higher than that of the non-BPD group (P < 0.05). Using multivariate logistic regression, GA、invasive mechanical ventilation duration ≥ 7 days、 PLT、 MPV、 TAPSE and RIMP were found to be independent risk factors for BPD. The area under the receiver operating characteristic curve was 0.846 (95CI: 0.794∼0.899), which improved when using right ventricular function indices combined with platelet parameters. CONCLUSION TAPSE and RIMP combined with PLT count and MPV can help identify preterm infants at an increased risk of developing BPD.
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Affiliation(s)
- Tianzi Li
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, Guangdong, China
| | - Bei Xia
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, Guangdong, China
| | - Suixin Liang
- Department of neonatology, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen, Guangdong, China
| | - Qiancheng He
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, Guangdong, China
| | - Shuangshuang Zhang
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, Guangdong, China
| | - Xiaoyi Chen
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, Guangdong, China
| | - Na Xu
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, Guangdong, China.
- Department of Ultrasound, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen, Guangdong, China.
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Varghese NP, Altit G, Gubichuk MM, Siddaiah R. Navigating Diagnostic and Treatment Challenges of Pulmonary Hypertension in Infants with Bronchopulmonary Dysplasia. J Clin Med 2024; 13:3417. [PMID: 38929946 PMCID: PMC11204350 DOI: 10.3390/jcm13123417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
Advances in perinatal intensive care have significantly enhanced the survival rates of extremely low gestation-al-age neonates but with continued high rates of bronchopulmonary dysplasia (BPD). Nevertheless, as the survival of these infants improves, there is a growing awareness of associated abnormalities in pulmonary vascular development and hemodynamics within the pulmonary circulation. Premature infants, now born as early as 22 weeks, face heightened risks of adverse development in both pulmonary arterial and venous systems. This risk is compounded by parenchymal and airway abnormalities, as well as factors such as inflammation, fibrosis, and adverse growth trajectory. The presence of pulmonary hypertension in bronchopulmonary dysplasia (BPD-PH) has been linked to an increased mortality and substantial morbidities, including a greater susceptibility to later neurodevelopmental challenges. BPD-PH is now recognized to be a spectrum of disease, with a multifactorial pathophysiology. This review discusses the challenges associated with the identification and management of BPD-PH, both of which are important in minimizing further disease progression and improving cardiopulmonary morbidity in the BPD infant.
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Affiliation(s)
- Nidhy P. Varghese
- Department of Pediatrics, Division of Pulmonology, Baylor College of Medicine and Texas Children’s Hospital, 6701 Fannin St., Ste 1040, Houston, TX 77030, USA
| | - Gabriel Altit
- Division of Neonatology, Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada;
| | - Megan M. Gubichuk
- Division of Pulmonary and Sleep Medicine, Children’s Mercy Hospital, Kansas City, MO 64108, USA;
| | - Roopa Siddaiah
- Department of Pediatrics, Penn State Health Children’s Hospital, Hershey, PA 17033, USA;
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Sikdar O, Harris C, Greenough A. Improving early diagnosis of bronchopulmonary dysplasia. Expert Rev Respir Med 2024; 18:283-294. [PMID: 38875260 DOI: 10.1080/17476348.2024.2367584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 06/10/2024] [Indexed: 06/16/2024]
Abstract
INTRODUCTION Bronchopulmonary disease (BPD) is associated with long-term neurodevelopmental and cardiorespiratory complications, often requiring significant use of resources. To reduce this healthcare burden, it is essential that those at high risk of BPD are identified early so that strategies are introduced to prevent disease progression. Our aim was to discuss potential methods for improving early diagnosis in the first week after birth. AREAS COVERED A narrative review was undertaken. The search strategy involved searching PubMed, Embase and Cochrane databases from 1967 to 2024. The results of potential biomarkers and imaging modes are discussed. Furthermore, the value of scoring systems is explored. EXPERT OPINION BPD occurs as a result of disruption to pulmonary vascular and alveolar development, thus abnormal levels of factors regulating those processes are promising avenues to explore with regard to early detection of high-risk infants. Data from twin studies suggests genetic factors can be attributed to 82% of the observed difference in moderate to severe BPD, but large genome-wide studies have yielded conflicting results. Comparative studies are required to determine which biomarker or imaging mode may most accurately diagnose early BPD development. Models which include the most predictive factors should be evaluated going forward.
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Affiliation(s)
- Oishi Sikdar
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Christopher Harris
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Gopagondanahalli KR, Abdul Haium AA, Vora SJ, Sundararaghavan S, Ng WD, Choo TLJ, Ang WL, Binte Mohamad Taib NQ, Wijedasa NHY, Rajadurai VS, Yeo KT, Tan TH. Serial tissue Doppler imaging in the evaluation of bronchopulmonary dysplasia-associated pulmonary hypertension among extremely preterm infants: a prospective observational study. Front Pediatr 2024; 12:1349175. [PMID: 38646509 PMCID: PMC11026596 DOI: 10.3389/fped.2024.1349175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/18/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives To evaluate serial tissue Doppler cardiac imaging (TDI) in the evolution of bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH) among extremely preterm infants. Design Prospective observational study. Setting Single-center, tertiary-level neonatal intensive care unit. Patients Infant born <28 weeks gestation. Main outcome measures Utility of TDI in the early diagnosis and prediction of BPD-PH and optimal timing for screening of BPD-PH. Results A total of 79 infants were included. Of them, 17 (23%) had BPD-PH. The mean gestational age was 25.9 ± 1.1 weeks, and mean birth weight was 830 ± 174 g. The BPD-PH group had a high incidence of hemodynamically significant patent ductus arteriosus (83% vs. 56%, p < 0.018), longer oxygen days (96.16 ± 68.09 vs. 59.35 ± 52.1, p < 0.008), and prolonged hospital stay (133.8 ± 45.9 vs. 106.5 ± 37.9 days, p < 0.005). The left ventricular eccentricity index (0.99 ± 0.1 vs. 1.1 ± 0.7, p < 0.01) and the ratio of acceleration time to right ventricular ejection time showed a statistically significant trend from 33 weeks (0.24 ± 0.05 vs. 0.28 ± 0.05, p < 0.05). At 33 weeks, the BPD-PH group showed prolonged isovolumetric contraction time (27.84 ± 5.5 vs. 22.77 ± 4, p < 0.001), prolonged isovolumetric relaxation time (40.3 ± 7.1 vs. 34.9 ± 5.3, p < 0.003), and abnormal myocardial performance index (0.39 ± 0.05 vs. 0.32 ± 0.03, p < 0.001). These differences persisted at 36 weeks after conceptional gestational age. Conclusions TDI parameters are sensitive in the early evolution of BPD-PH. Diagnostic accuracy can be increased by combining the TDI parameters with conventional echocardiographic parameters. BPD-PH can be recognizable as early as 33-34 weeks of gestation.
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Affiliation(s)
- Krishna Revanna Gopagondanahalli
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Abdul Alim Abdul Haium
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Shrenik Jitendrakumar Vora
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Sreekanthan Sundararaghavan
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
- Department of Paediatric Cardiology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Wei Di Ng
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Tze Liang Jonathan Choo
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
- Department of Paediatric Cardiology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Wai Lin Ang
- Department of Paediatric Cardiology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | | | | | - Victor Samuel Rajadurai
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Kee Thai Yeo
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
| | - Teng Hong Tan
- Yong Loo Ling Schoolof Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke—NUS Medical School, Singapore, Singapore
- Department of Paediatric Cardiology, KK Women’s and Children’s Hospital, Singapore, Singapore
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6
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Boyd SM, Kluckow M, McNamara PJ. Targeted Neonatal Echocardiography in the Management of Neonatal Pulmonary Hypertension. Clin Perinatol 2024; 51:45-76. [PMID: 38325947 DOI: 10.1016/j.clp.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Pulmonary hypertension (PH) in neonates, originating from a range of disease states with heterogeneous underlying pathophysiology, is associated with significant morbidity and mortality. Although the final common pathway is a state of high right ventricular afterload leading to compromised cardiac output, multiple hemodynamic phenotypes exist in acute and chronic PH, for which cardiorespiratory treatment strategies differ. Comprehensive appraisal of pulmonary pressure, pulmonary vascular resistance, cardiac function, pulmonary and systemic blood flow, and extrapulmonary shunts facilitates delivery of individualized cardiovascular therapies in affected newborns.
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Affiliation(s)
- Stephanie M Boyd
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Corner Hawkesbury Road, Hainsworth Street, Westmead, Sydney 2145, Australia; The University of Sydney, Sydney, Australia
| | - Martin Kluckow
- The University of Sydney, Sydney, Australia; Department of Neonatology, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Sydney, Australia
| | - Patrick J McNamara
- Division of Neonatology, The University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Moore SS, De Carvalho Nunes G, Dancea A, Wutthigate P, Simoneau J, Beltempo M, Sant'Anna G, Altit G. Early cardiac function and death, severe bronchopulmonary dysplasia and pulmonary hypertension in extremely preterm infants. Pediatr Res 2024; 95:293-301. [PMID: 37726544 DOI: 10.1038/s41390-023-02817-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 07/15/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Association between early cardiac function and neonatal outcomes are scarcely reported. The aim of the current study was to describe this association with death, severe bronchopulmonary dysplasia (BPD) and BPD-related pulmonary hypertension (PH). METHODS Retrospective cohort study of infants <29 weeks born between 2015 and 2019. Infants with clinically acquired echocardiography at ≤21 days after birth were included and data were extracted by an expert masked to outcomes. RESULTS A total of 176 infants were included. Echocardiogram was performed at a median of 9 days (IQR 5-13.5). Of these, 31 (18%) had death/severe BPD and 59 (33.5%) had death/BPD-related PH. Infants with death/severe BPD were of lower birth weight (745 [227] vs 852 [211] grams, p = 0.01) and more exposed to invasive ventilation, late-onset sepsis, inotropes and/or postnatal steroids. Early echocardiograms demonstrated decreased right ventricular [Tricuspid Annular Plane Systolic Excursion: 5.2 (1.4) vs 6.2 (1.5) cm, p = 0.03] and left ventricular function [Ejection fraction 53 (14) vs 58 (10) %, p = 0.03]. Infants with death/BPD-related PH had an increased Eccentricity index (1.35 [0.20] vs 1.26 [0.19], p = 0.02), and flat/bowing septum (19/54 [35%] vs 20/109 [18%], p = 0.021). CONCLUSIONS In extremely premature infants, altered ventricular function and increased pulmonary pressure indices within the first 21 days after birth, were associated with the combined outcome of death/severe BPD and death/BPD-related PH. IMPACT Decreased cardiac function on echocardiography performed during first three weeks of life is associated with severe bronchopulmonary dysplasia in extremely premature infants. In extreme preterm infants, echocardiographic signs of pulmonary hypertension in early life are associated with later BPD-related pulmonary hypertension close to 36 weeks post-menstrual age. Early cardiac markers should be further studied as potential intervention targets in this population. Our study is adding comprehensive analysis of echocardiographic data in infants born below 29 weeks gestational age.
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Affiliation(s)
- Shiran S Moore
- Neonatology-McGill University Health Centre-Montreal Children's Hospital; Department of Pediatrics-McGill University, Montreal, QC, Canada
- Neonatology-Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gabriela De Carvalho Nunes
- Neonatology-McGill University Health Centre-Montreal Children's Hospital; Department of Pediatrics-McGill University, Montreal, QC, Canada
| | - Adrian Dancea
- Pediatric Cardiology-McGill University Health Centre-Montreal Children's Hospital; Department of Pediatrics-McGill University, Montreal, QC, Canada
| | | | - Jessica Simoneau
- Pediatric Cardiology-McGill University Health Centre-Montreal Children's Hospital; Department of Pediatrics-McGill University, Montreal, QC, Canada
| | - Marc Beltempo
- Neonatology-McGill University Health Centre-Montreal Children's Hospital; Department of Pediatrics-McGill University, Montreal, QC, Canada
| | - Guilherme Sant'Anna
- Neonatology-McGill University Health Centre-Montreal Children's Hospital; Department of Pediatrics-McGill University, Montreal, QC, Canada
| | - Gabriel Altit
- Neonatology-McGill University Health Centre-Montreal Children's Hospital; Department of Pediatrics-McGill University, Montreal, QC, Canada.
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Moore SS, De Carvalho Nunes G, Villegas Martinez D, Dancea A, Wutthigate P, Simoneau J, Beltempo M, Sant'Anna G, Altit G. Association of Gestational Age at Birth With Left Cardiac Dimensions at Near-Term Corrected Age Among Extremely Preterm Infants. J Am Soc Echocardiogr 2023; 36:867-877. [PMID: 37044171 DOI: 10.1016/j.echo.2023.04.003] [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: 11/21/2022] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Remodeling and altered ventricular geometry have been described in adults born preterm. Although they seem to have an adverse cardiac phenotype, the impact of various degrees of prematurity on cardiac development has been scarcely reported. In this study, we evaluated the impact of gestational age (GA) at birth on cardiac dimensions and function at near-term age among extremely preterm infants. METHODS This is a retrospective single-center cohort study of infants born at <29 weeks of GA between 2015 and 2019. Infants with available clinically acquired echocardiography between 34 and 43 weeks were included. Two groups were investigated: those born <26 weeks and those born ≥26 weeks. All measurements were done by an expert masked to clinical data using the raw images. The primary outcome was measurements of cardiac dimensions and function based on GA group. Secondary outcomes were the association between cardiac dimensions and postnatal steroid exposure and with increments of GA at birth. RESULTS A total of 205 infants were included (<26 weeks, n = 102; ≥26 weeks, n = 103). At time of echocardiography, weight (2.4 ± 0.5 vs 2.5 ± 0.5 kg, P = .86) and age (37.2 ± 1.6 vs 37.1 ± 1.9 weeks, P = .74) were similar between groups. There was no difference in metrics of right-sided dimensions and function. However, left-sided dimensions were decreased in infants born <26 weeks, including systolic left ventricle (LV) diameter (1.06 ± 0.20 cm vs 1.12 ± 0.18 cm, P = .02), diastolic LV length (2.85 ± 0.37 vs 3.02 ± 0.57 cm, P = .02), and estimated LV end-diastolic volume (5.36 ± 1.69 vs 6.01 ± 1.79 mL, P = .02). CONCLUSIONS In our cohort of very immature infants, birth at the extreme of prematurity was associated with smaller left cardiac dimensions around 36 weeks of corrected age. Future longitudinal prospective studies should evaluate further the impact of prematurity on LV development and performance and their long-term clinical impact.
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Affiliation(s)
- Shiran Sara Moore
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gabriela De Carvalho Nunes
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Daniela Villegas Martinez
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Adrian Dancea
- Department of Pediatric Cardiology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Punnanee Wutthigate
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jessica Simoneau
- Department of Pediatric Cardiology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Marc Beltempo
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Guilherme Sant'Anna
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Gabriel Altit
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada.
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Sánchez-Becerra JC, Guillén-Torres R, Becerra-Becerra R, Márquez-González H, Ibarra-Ríos D. Targeted neonatal echocardiography and lung ultrasound in preterm infants with chronic lung disease with and without pulmonary hypertension, screened using a standardized algorithm. Front Pediatr 2023; 11:1104940. [PMID: 37033165 PMCID: PMC10076703 DOI: 10.3389/fped.2023.1104940] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction Increased recognition of the development of chronic pulmonary hypertension (cPH) in preterm infants with chronic lung disease (CLD) has prompted enhanced monitoring for the identification of different phenotypes. Methods All newborns consulted for oxygen/respiratory support dependency (CLD assessment) from January 2018 to December 2021 were included. TnECHO and LUS screening for cPH-CLD were performed at 36 weeks postmenstrual age. Cases of cPH related to increased pulmonary blood flow (cPH-IPBF) were referred to Pediatric Cardiology. The objective of the study was to identify all cases of cPH (cPH-CLD/IPBF) in the CLD patients screened and to compare outcomes. Following a standardized algorithm, cPH-CLD patients were treated with diuretics; ultrasounds taken before and after treatment were analyzed. Results Seventy-two patients with CLD were screened. Twenty-two (30%) had cPH-CLD, and nine (12%) had cPH-IPBF. cPH infants underwent more days of mechanical ventilation, were more likely to have retinopathy of prematurity, and showed increased mortality. The LUS pattern observed in the 72 CLD patients consisted of a thickened pleural line and a B-line interstitial heterogeneous pattern; 29% of patients were found to have lung consolidations. After diuretic therapy, step-down in respiratory support occurred in 59% of neonates with cPH-CLD. A decrease in respiratory rate (RR), right ventricular output (RVO), markers of pulmonary vascular resistance (PVR), and B-line pattern was observed. In tissue Doppler imaging, biventricular diastolic function was found to be modified after diuretics. Conclusions CLD infants with cPH showed increased morbidity and mortality. In cPH-CLD patients, a decrease in RR and step-down in respiratory support was observed after diuretic treatment. Follow-up ultrasound showed a decrease in RVO, markers of PVR, and B-lines.
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Affiliation(s)
| | - Rogelio Guillén-Torres
- Neonatology Department, National Institute of Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Rosario Becerra-Becerra
- Cardiology Department, National Institute of Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Horacio Márquez-González
- Clinical Investigation Department, National Institute of Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Daniel Ibarra-Ríos
- Neonatology Department, National Institute of Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
- Correspondence: Daniel Ibarra-Ríos
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Martini S, Corsini I, Corvaglia L, Suryawanshi P, Chan B, Singh Y. A scoping review of echocardiographic and lung ultrasound biomarkers of bronchopulmonary dysplasia in preterm infants. Front Pediatr 2023; 11:1067323. [PMID: 36846161 PMCID: PMC9950276 DOI: 10.3389/fped.2023.1067323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/18/2023] [Indexed: 02/12/2023] Open
Abstract
Despite recent improvements in neonatal care, moderate to severe bronchopulmonary dysplasia (BPD) is still associated with high mortality and with an increased risk of developing pulmonary hypertension (PH). This scoping review provides an updated overview of echocardiographic and lung ultrasound biomarkers associated with BPD and PH, and the parameters that may prognosticate their development and severity, which could be clinically helpful to undertake preventive strategies. A literature search for published clinical studies was conducted in PubMed using MeSH terms, free-text words, and their combinations obtained through appropriate Boolean operators. It was found that the echocardiography biomarkers for BPD, and especially those assessing right ventricular function, are reflective of the high pulmonary vascular resistance and PH, indicating a strong interplay between heart and lung pathophysiology; however, early assessment (e.g., during the first 1-2 weeks of life) may not successfully predict later BPD development. Lung ultrasound indicating poor lung aeration at day 7 after birth has been reported to be highly predictive of later development of BPD at 36 weeks' postmenstrual age. Evidence of PH in BPD infants increases risk of mortality and long-term PH; hence, routine PH surveillance in all at risk preterm infants at 36 weeks, including an echocardiographic assessment, may provide useful information. Progress has been made in identifying the echocardiographic parameters on day 7 and 14 to predict later development of pulmonary hypertension. More studies on sonographic markers, and especially on echocardiographic parameters, are needed for the validation of the currently proposed parameters and the timing of assessment before recommendations can be made for the routine clinical practice.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Pradeep Suryawanshi
- Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, India
| | - Belinda Chan
- Division of Neonatology, University of Utah, Salt Lake City, UT, United States
| | - Yogen Singh
- Department of Pediatrics - Division of Neonatology, Loma Linda University School of Medicine, Loma linda, CA, United States.,Neonatology/Pediatric Cardiology, Cambridge University Hospitals, Cambridge, United Kingdom
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11
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Screening Echocardiography Identifies Risk Factors for Pulmonary Hypertension at Discharge in Premature Infants with Bronchopulmonary Dysplasia. Pediatr Cardiol 2022; 43:1743-1751. [PMID: 35488130 DOI: 10.1007/s00246-022-02911-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
HYPOTHESIS Premature infants with bronchopulmonary dysplasia (BPD) are at increased risk of secondary pulmonary hypertension (BPD-PH). Prior studies yielded mixed results on the utility of echocardiographic screening at 36 weeks post-menstrual age (PMA). We present our experience using echocardiographic screening at the time of BPD diagnosis to identify infants at highest risk of BPD-PH at discharge. MATERIALS AND METHODS Retrospective cohort analysis of clinical/ demographic data and screening echocardiograms in patients with BPD. Discharge echocardiograms identified infants with or without BPD-PH at discharge. 36 weeks PMA screening echocardiograms and clinical data were then reviewed to identify which factors were associated with increased odds of BPD-PH at discharge. Associations between echocardiographic findings were evaluated with 2- and 3-variable models to predict increased risk of BPD-PH at discharge. RESULTS In our cohort of 64 infants with severe BPD, BPD-PH was present in 22/64 (34%) infants at discharge. There were no clinical differences at time of 36 weeks PMA screening evaluation (mean PMA 36.6 ± 2.9 weeks). PH at screening was poorly predictive of PH at discharge as PH at screening resolved in 49% of patients. However, having an ASD, RV dilation, hypertrophy, or reduced function on screening, especially in combination, were associated with BPD-PH at discharge. CONCLUSION In our cohort of premature infants with BPD, 36 weeks PMA screening echocardiogram identified patients at increased risk for BPD-PH at discharge when ASD, RVH, or impaired RV function were present. Larger prospective studies are indicated to validate these findings.
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12
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Fetal growth restriction and neonatal-pediatric lung diseases: Vascular mechanistic links and therapeutic directions. Paediatr Respir Rev 2022; 44:19-30. [PMID: 36503648 DOI: 10.1016/j.prrv.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 11/18/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common respiratory sequela of prematurity, and infants born with fetal growth restriction (FGR) are disproportionately represented in BPD statistics, as factors which affect somatic growth may also affect pulmonary growth. Effects of in-utero hypoxia underlying FGR on lung parenchymal architecture predisposing to BPD are well documented, but the pulmonary vascular constructs are not well appreciated. Disruption of angiogenesis during critical periods of lung growth impairs alveolarization, contributing to BPD pathogenesis. Pulmonary artery thickness/stiffness has been noted in FGR in the initial postnatal weeks, and also in well-grown infants with established BPD. The lack of waveform cushioning by the major arteries exposes the pulmonary resistance vessels to higher pulsatile stress, thereby accelerating microvascular disease. Reactive oxygen species, increased sympathetic activity and endothelial dysfunction are common mediators in FGR and BPD; each putative targets for prevention and/or therapeutics using interleukin (IL)-1 receptor antagonist (IL-1Ra), melatonin or inhibition of renin-angiotensin-aldosterone system. While BPD is the archetypal respiratory disease of infancy, effects of FGR on pulmonary function are long-term, extending well into childhood. This narrative links FGR in very/extremely preterm infants with BPD through the vascular affliction as a mechanistic and potentially, therapeutic pathway. Our objectives were to depict the burden of disease for FGR and BPD amongst preterm infants, portray vascular involvement in the placenta in FGR and BPD cohorts, provide high resolution vascular ultrasound information in both cohorts with a view to address therapeutic relevance, and lastly, link this information with paediatric age-group lung diseases.
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13
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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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14
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Kang SJ, Jung H, Hwang SJ, Kim HJ. Right Atrial Strain in Preterm Infants With a History of Bronchopulmonary Dysplasia. J Cardiovasc Imaging 2022; 30:112-122. [PMID: 35505500 PMCID: PMC9058635 DOI: 10.4250/jcvi.2021.0126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/20/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Few studies have utilized right atrial (RA) strain to evaluate right ventricular (RV) diastolic dysfunction in preterm infants with bronchopulmonary dysplasia (BPD). We aimed to evaluate the associations of RA strain with BPD severity and respiratory outcomes in preterm infants with BPD. METHODS We retrospectively studied 153 infants with BPD born before 32 weeks of gestational age at CHA Bundang Medical Center. Peak longitudinal right atrial strain (PLRAS) was obtained using velocity vector imaging and compared among infants across BPD severity. Conventional echocardiographic parameters and clinical characteristics were also evaluated. RESULTS In infants with severe BPD, mean gestational age (27.4 ± 2.1 weeks) and mean birth weight (971.3 ± 305.8 g) were significantly smaller than in those with mild BPD (30.0 ± 0.9 weeks, 1,237.3 ± 132.2 g) and moderate BPD (29.6 ± 1.3 weeks, 1,203.2 ± 214.4 g). PLRAS was significantly lower in infants with severe BPD (26.3 ± 10.1%) than in those in the moderate BPD group (32.4 ± 10.9%) or mild BPD group (31.9 ± 8.3%). Tricuspid E/e′ and maximum RA volume index were similar across BPD severity. A decrease in PLRAS was significantly correlated with increased duration of mechanical ventilation duration; however, tricuspid E/e′ and maximum RA volume index were not. CONCLUSIONS Evaluating PLRAS with other parameters in infants with BPD might detect RV diastolic dysfunction. Longer follow-up and larger study populations may elucidate the association between PLRAS and respiratory outcomes in infants with BPD.
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Affiliation(s)
- Soo Jung Kang
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyemi Jung
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Seo Jung Hwang
- Department of Diagnostic Laboratory Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyo Jin Kim
- Department of Diagnostic Laboratory Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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15
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Rodriguez MJ, Martinez-Orgado J, Corredera A, Serrano I, Arruza L. Diastolic Dysfunction in Neonates With Hypoxic-Ischemic Encephalopathy During Therapeutic Hypothermia: A Tissue Doppler Study. Front Pediatr 2022; 10:880786. [PMID: 35692972 PMCID: PMC9174686 DOI: 10.3389/fped.2022.880786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Diastolic dysfunction often complicates myocardial ischemia with increased mortality rates. However, less is known about diastolic function after perinatal asphyxia in neonates with hypoxic-ischemic encephalopathy (HIE) during therapeutic hypothermia (TH) and rewarming. AIM The aim of this study was to assess diastolic function with tissue Doppler imaging (TDI) in neonates with moderate-severe HIE during TH and rewarming. METHOD Newborns at >36 weeks' gestation with moderate-severe HIE treated with TH were evaluated with targeted neonatal echocardiography (TNE), including TDI, within 24 h of TH initiation (T1), at 48-72 h of treatment (T2), and after rewarming (T3). These retrospective data were collected and compared with a control group of healthy babies at >36 weeks' gestation that was prospectively evaluated following the same protocol. RESULTS A total of 21 patients with HIE + TH and 15 controls were included in the study. Myocardial relaxation before the onset of biventricular filling was prolonged in the HIE + TH group during TH with significantly longer isovolumic relaxation time (IVRT') in the left ventricle (LV), the septum, and the right ventricle (RV). This was associated with slower RV early diastolic velocity (e') and prolonged filling on T1. Total isovolumic time (t-IVT; isovolumic contraction time [IVCT'] + IVRT') and myocardial performance index (MPI') were globally increased in asphyxiated neonates. All these differences persisted after correction for heart rate (HR) and normalized after rewarming. TDI parameters assessing late diastole (a' velocity or e'/a' and E/e' ratios) did not differ between groups. CONCLUSION TDI evaluation in our study demonstrated a pattern of early diastolic dysfunction during TH that normalized after rewarming, whereas late diastole seemed to be preserved. Our data also suggest a possible involvement of impaired twist/untwist motion and dyssynchrony. More studies are needed to investigate the impact and therapeutic implication of diastolic dysfunction in these babies, as well as to clarify the role of TH in these findings.
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Affiliation(s)
- Maria Jose Rodriguez
- Division of Neonatology, Instituto del Niño y del Adolescente, Hospital Clinico San Carlos-IdISSC, Madrid, Spain
| | - Jose Martinez-Orgado
- Division of Neonatology, Instituto del Niño y del Adolescente, Hospital Clinico San Carlos-IdISSC, Madrid, Spain
| | - Araceli Corredera
- Division of Neonatology, Instituto del Niño y del Adolescente, Hospital Clinico San Carlos-IdISSC, Madrid, Spain
| | - Irene Serrano
- Research Methodology Unit, Hospital Clínico San Carlos-IdISSC, Madrid, Spain
| | - Luis Arruza
- Division of Neonatology, Instituto del Niño y del Adolescente, Hospital Clinico San Carlos-IdISSC, Madrid, Spain
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16
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Hemodynamic consequences of respiratory interventions in preterm infants. J Perinatol 2022; 42:1153-1160. [PMID: 35690691 PMCID: PMC9436777 DOI: 10.1038/s41372-022-01422-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 12/14/2022]
Abstract
Advances in perinatal management have led to improvements in survival rates for premature infants. It is known that the transitional period soon after birth, and the subsequent weeks, remain periods of rapid circulatory changes. Preterm infants, especially those born at the limits of viability, are susceptible to hemodynamic effects of routine respiratory care practices. In particular, the immature myocardium and cardiovascular system is developmentally vulnerable. Standard of care (but essential) respiratory interventions, administered as part of neonatal care, may negatively impact heart function and/or pulmonary or systemic hemodynamics. The available evidence regarding the hemodynamic impact of these respiratory practices is not well elucidated. Enhanced diagnostic precision and therapeutic judiciousness are warranted. In this narrative, we outline (1) the vulnerability of preterm infants to hemodynamic disturbances (2) the hemodynamic effects of common respiratory practices; including positive pressure ventilation and surfactant therapy, and (3) identify tools to assess cardiopulmonary interactions and guide management.
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17
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Neumann RP, Schulzke SM, Pohl C, Wellmann S, Metze B, Burdensky AK, Boos V, Barikbin P, Bührer C, Czernik C. Right ventricular function and vasoactive peptides for early prediction of bronchopulmonary dysplasia. PLoS One 2021; 16:e0257571. [PMID: 34550991 PMCID: PMC8457497 DOI: 10.1371/journal.pone.0257571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 09/03/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To assess the prognostic value of early echocardiographic indices of right ventricular function and vasoactive peptides for prediction of bronchopulmonary dysplasia (BPD) or death in very preterm infants. METHODS Prospective study involving 294 very preterm infants (median [IQR] gestational age 28.4 [26.4-30.4] weeks, birth weight 1065 [800-1380] g), of whom 57 developed BPD (oxygen supplementation at 36 weeks postmenstrual age) and 10 died. Tricuspid annular plane systolic excursion (TAPSE), right ventricular index of myocardial performance (RIMP), plasma concentrations of mid-regional pro-atrial natriuretic peptide (MR-proANP) and C-terminal pro-endothelin-1 (CT-proET1) were measured on day 7 of life. RESULTS RIMP was significantly increased (median [IQR] 0.3 [0.23-0.38] vs 0.22 [0.15-0.29]), TAPSE decreased (median [IQR] 5.0 [5.0-6.0] vs 6.0 [5.4-7.0] mm), MR-proANP increased (median [IQR] 784 [540-936] vs 353 [247-625] pmol/L), and CT-proET1 increased (median [IQR] 249 [190-345] vs 199 [158-284] pmol/L) in infants who developed BPD or died, as compared to controls. All variables showed significant but weak correlations with each other (rS -0.182 to 0.359) and predicted BPD/death with similar accuracy (areas under receiver operator characteristic curves 0.62 to 0.77). Multiple regression revealed only RIMP and birth weight as independent predictors of BPD or death. CONCLUSIONS Vasoactive peptide concentrations and echocardiographic assessment employing standardized measures, notably RIMP, on day 7 of life are useful to identify preterm infants at increased risk for BPD or death.
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Affiliation(s)
- Roland P. Neumann
- Department of Neonatology, University Children’s Hospital Basel UKBB, University of Basel, Basel, Switzerland
- * E-mail:
| | - Sven M. Schulzke
- Department of Neonatology, University Children’s Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Christian Pohl
- Department of Neonatology, University Children’s Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Sven Wellmann
- Department of Neonatology, University Children’s Hospital Basel UKBB, University of Basel, Basel, Switzerland
- Department of Neonatology, University Regensburg Children’s Hospital (KUNO), University of Regensburg, Regensburg, Germany
| | - Boris Metze
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ann-Katrin Burdensky
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vinzenz Boos
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Neonatology, Hospital Zollikerberg, Zollikerberg, Switzerland
| | - Payman Barikbin
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Pediatrics, Vivantes Hospital Friedrichshain, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Czernik
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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18
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Aldana-Aguirre JC, Eckersley L, Hyderi A, Hirose A, Boom JVD, Kumaran K, Hornberger LK. Influence of extreme prematurity and bronchopulmonary dysplasia on cardiac function. Echocardiography 2021; 38:1596-1603. [PMID: 34505310 DOI: 10.1111/echo.15178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/30/2021] [Accepted: 08/06/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Prematurity and bronchopulmonary dysplasia (BPD) are associated with poorly understood abnormalities of ventricular function. We therefore comprehensively compared biventricular function in infants with and without BPD. METHODS Prospective observational study in extremely preterm infants with (n = 20) and without (n = 38) BPD using conventional and advanced echocardiography at 28 days (T1) and near-term (T2). RESULTS Infants with BPD had lower birth gestational age (26.7±1.9 vs 27.4±1.1 weeks, p = 0.047) and weight (884±207 vs 1108±190 g, p = 0.0001). BPD was associated with larger right ventricles (RV) and reduced RV systolic strain rate at T1 and pulmonary hypertensive indicators at T2 (pulmonary artery acceleration time BPD 51±17 vs no BPD 63±12 ms, p = 0.017). At T1/T2, infants with BPD had lower RV tissue Doppler velocities (e', a' and s) and higher E/e' ratios (T1: BPD 10.4±2.4 vs no BPD 6.2±3.1 cm/sec, p = 0.001; T2: BPD 8.0±3.1 vs no BPD 5.6±2.6 cm/sec, p = 0.02), altered LV diastolic function (apical circumferential T1 early diastolic strain rate BPD 2.8±0.8 vs no BPD 3.6±1.0 /sec, p = 0.04; T2 late diastolic strain rate, BPD 2.29 ± 0.99 vs no BPD 1.67±0.84 /sec, p = 0.03) and LV rotational mechanics (T1: twist rate BPD 90±16 vs no BPD 130±48 deg/sec, p = 0.008; untwist rate (UTR) BPD -69±90 vs no BPD -147±68 deg/sec, p = 0.008; torsion BPD 2.78±0.56 vs no BPD 4.48±1.74 deg/cm, p = 0.009; and T2: UTR BPD -132±69 vs no BPD -179±57 deg/sec, p = 0.013). CONCLUSION BPD is associated with altered RV diastolic function that persists near term, with elevated pulmonary vascular resistance, and with persistent alterations in LV apical strain rate and rotational mechanics.
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Affiliation(s)
- Jose Carlos Aldana-Aguirre
- Division of Neonatology, Stollery Children's Hospital, Edmonton, Alberta, Canada.,SickKids Hospital, Toronto, Ontario, Canada
| | - Luke Eckersley
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada.,Women's & Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Abbas Hyderi
- Division of Neonatology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Akiko Hirose
- Division of Neonatology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jutta van den Boom
- Division of Neonatology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Kumar Kumaran
- Division of Neonatology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada.,Women's & Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
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19
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Left Ventricle Phenotyping Utilizing Tissue Doppler Imaging in Premature Infants with Varying Severity of Bronchopulmonary Dysplasia. J Clin Med 2021; 10:jcm10102211. [PMID: 34065264 PMCID: PMC8160781 DOI: 10.3390/jcm10102211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 12/16/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is characterized by alveolar-capillary simplification and is associated with pulmonary hypertension (PH) in preterm infants. The contribution of left ventricle (LV) disease towards this severe BPD-PH phenotype is not well established. We aimed to describe the longitudinal trajectory of the LV function as measured by tissue Doppler imaging (TDI) and its association with BPD-PH. We retrospectively assessed prospectively acquired clinical and echocardiographic data from 77 preterm infants born between 2011 and 2013. We characterized the LV function by measuring systolic and diastolic myocardial velocities (s’, e’, a’), isovolumetric relaxation time (IVRT), and myocardial performance index with TDI at three time periods from 32 and 36 weeks, postmenstrual age through one year of age. We also measured post systolic motion (PSM), a marker of myocardial dysfunction that results from asynchronous movement of the ventricular walls, and not previously described in preterm infants. Patients were stratified into groups according to BPD severity and the presence of PH and compared over time. Conventional TDI measures of the LV function were similar between groups, but the septal PSM was significantly prolonged over the first year of age in patients with BPD-PH. PSM provides a novel objective way to assess the hemodynamic impact of lung and pulmonary vascular disease severity on LV function in preterm infants with BPD and PH.
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20
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Sehgal A, Blank D, Roberts CT, Menahem S, Hooper SB. Assessing pulmonary circulation in severe bronchopulmonary dysplasia using functional echocardiography. Physiol Rep 2021; 9:e14690. [PMID: 33400859 PMCID: PMC7785052 DOI: 10.14814/phy2.14690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 12/18/2022] Open
Abstract
Pulmonary hypertension (PH) is common in infants with severe bronchopulmonary dysplasia (BPD) and increases the risk of death. The objectives of this preliminary study were to compare responses of pulmonary circulation parameters to 100% oxygen (O2) and inhaled nitric oxide (iNO) in infants with BPD and PH using echocardiography. Responses between fetal growth restriction (FGR) and appropriate for gestational age infants were compared. Ten infants <28 weeks GA at birth were assessed at ≥36 weeks corrected gestation. Baseline echocardiography1 was performed which was repeated (echocardiography2) after 30 minutes of O2. After a gap of 2–3 hours, iNO was administered for 15 minutes and echocardiography3 was performed, followed by iNO weaning. The gestation and birthweight of the cohort were 25.9 ± 1.6 weeks and 612 ± 175 g. Assessments were performed at 38.7 ± 1.4 weeks corrected gestational age. Baseline time to peak velocity: right ventricular ejection time (TPV/RVETc) increased from 0.24 ± 0.02 to 0.27 ± 0.02 (O2, p = .01) and 0.31 ± 0.03 (iNO, p < .001), indicating a decrease in pulmonary vascular resistance [PVR]. Baseline tricuspid annular plane systolic excursion (TAPSE) increased from 8.1 ± 0.6 mm to 9.3 ± 0.7 mm (O2, p = .01) and 10.5 ± 1.1 mm (iNO, p = .0004), indicating improved ventricular systolic performance. Percentage change for all parameters was greater with iNO. Significant correlations between cardiac performance and PVR were noted. FGR infants noted higher baseline PVR (TPV/RVETc, 0.21 ± 0.02 vs. 0.25 ± 0.01, p = .002), lower ventricular performance (TAPSE, 7 ± 1.2 mm vs. 8.6 ± 6 mm, p = .003), and lower percentage change with O2 and iNO. A reactive component of pulmonary circulation provides real‐time physiological information, which could rationalize treatment decisions.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Monash University, Clayton, VIC., Australia.,Department of Paediatrics, Monash University, Clayton, VIC., Australia
| | - Douglas Blank
- Monash Newborn, Monash Children's Hospital, Monash University, Clayton, VIC., Australia.,Department of Paediatrics, Monash University, Clayton, VIC., Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Monash University, Clayton, VIC., Australia.,Department of Paediatrics, Monash University, Clayton, VIC., Australia
| | - Samuel Menahem
- Paediatric and Fetal Cardiac Units, Monash Health, Clayton, VIC., Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC., Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC., Australia
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21
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Sehgal A, Steenhorst JJ, Mclennan DI, Merkus D, Ivy D, McNamara PJ. The Left Heart, Systemic Circulation, and Bronchopulmonary Dysplasia: Relevance to Pathophysiology and Therapeutics. J Pediatr 2020; 225:13-22.e2. [PMID: 32553872 DOI: 10.1016/j.jpeds.2020.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Arvind Sehgal
- Monash Children's Hospital, Monash University, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| | - Jarno J Steenhorst
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Daniel I Mclennan
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
| | - Daphne Merkus
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands; Institut für Chirurgische Forschung, Klinikum Universität München, Ludwig Maximillian Universität München, München, Germany
| | - Dunbar Ivy
- Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
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22
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Sehgal A, Nitzan I, Jayawickreme N, Menahem S. Impact of Skin-to-Skin Parent-Infant Care on Preterm Circulatory Physiology. J Pediatr 2020; 222:91-97.e2. [PMID: 32389414 DOI: 10.1016/j.jpeds.2020.03.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/28/2020] [Accepted: 03/18/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To ascertain the impact of skin-to-skin care between parents and infants on cardiac function and cerebral blood flow in preterm infants. STUDY DESIGN We undertook a prospective study of 40 self-ventilating preterm infants at a quaternary center and assessed cardiac performance and cerebral blood flow. Assessments were carried out two hours before skin-to-skin care and then 60 minutes after skin-to-skin care (with the infant still on parent and turned supine). RESULTS Infants were 30.5 ± 0.6 weeks' gestational age and 1378 ± 133 g birthweight. Axillary temperature noted a nonsignificant increase during skin-to-skin care from 36.7 ± 0.07°C to 36.9 ± 0.07°C (P = .07). Cardiac contractility (right ventricular fractional area change [26.5% ± 0.3% vs 27.8% ± 0.4; P < .001] and tricuspid annular plane systolic excursion [0.73 ± 0.03 cm vs 0.77 ± 0.03 cm; P = .02]) increased significantly, coincident with decreased measures of pulmonary vascular resistance. An increase in systemic cardiac output was associated with increased cerebral blood flow and reduced middle cerebral artery resistive index (0.81 ± 0.02 vs 0.74 ± 0.02; P = .0001). CONCLUSIONS We documented a significant circulatory beneficial adaptation to a common neonatal practice. These findings align with previously documented physiologic benefits in cardiorespiratory stability and cardiac rhythm in preterm infants, and may be mediated through modulation of the autonomic nervous system.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| | - Itamar Nitzan
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
| | | | - Samuel Menahem
- Pediatric and Fetal Cardiac Units, Monash Medical Centre, Monash Health, Melbourne, Australia
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23
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Mohlkert L, Sjöberg G, Rydberg A, Pegelow Halvorsen C, Tufvesson E, Hallberg J, Domellöf M, Norman M. Lung function and pulmonary vascular resistance are not associated in 6-year-old children born extremely preterm. Acta Paediatr 2020; 109:746-753. [PMID: 31557349 DOI: 10.1111/apa.15030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/21/2019] [Accepted: 09/24/2019] [Indexed: 12/27/2022]
Abstract
AIM Children born preterm are at increased risk of reduced lung function. The aim was to test whether lung function was associated with pulmonary vascular resistance. METHODS Participants were recruited from a population-based cohort born in 2004-2007. Lung function was assessed with spirometry after administration of a beta2-agonist. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1 ) were determined. Estimations of pulmonary vascular resistance, arterial dimensions, right ventricular wall thickness, sphericity, and systolic (TAPSE) and diastolic functions were performed with echocardiography. Adjusted regression analyses were used to study associations. RESULTS Sixty-six children (33 boys) born at 22-26 weeks of gestational age (birthweights 460-1134 g) were assessed at a mean age of 6.7 years. Despite large variations in lung function with FVC z-scores ranging from -4.6 to +2.8, there were no associations between lung function and pulmonary arterial pressure, right ventricular structure or function. Children with higher FVC z-scores (r = .52, β = .55 mm, P = .015) and higher FEV1 z-scores (r = .58, β = .73 mm, P = .001) exhibited larger pulmonary arteries. CONCLUSION In children born extremely preterm, lung function was not associated with pulmonary vascular resistance. Routine echocardiographic evaluation of extremely preterm children may not be indicated at age 6.5 years.
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Affiliation(s)
- Lilly‐Ann Mohlkert
- Division of Paediatrics Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
| | - Gunnar Sjöberg
- Department of Women’s and Children’s Health Karolinska Institutet Stockholm Sweden
| | - Annika Rydberg
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | - Cecilia Pegelow Halvorsen
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education Karolinska Institutet Stockholm Sweden
| | - Ellen Tufvesson
- Department of Clinical Sciences Lund, Respiratory Medicine and Allergology Lund University Lund Sweden
| | - Jenny Hallberg
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | - Mikael Norman
- Division of Paediatrics Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
- Department of Neonatal Medicine Karolinska University Hospital Stockholm Sweden
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24
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Aggarwal S, Agarwal P, Natarajan G. Echocardiographic prediction of severe pulmonary hypertension in neonates undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy. J Perinatol 2019; 39:1656-1662. [PMID: 31471580 DOI: 10.1038/s41372-019-0442-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/25/2019] [Accepted: 03/25/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Among neonates undergoing whole body cooling for hypoxic-ischemic encephalopathy (HIE), to compare ventricular function in the presence and absence of pulmonary hypertension (PPHN) needing inhaled nitric oxide (iNO)/ECMO. DESIGN This retrospective study included infants with HIE who underwent cooling. ECHO (<24 h age) measures, RV fractional area change (FAC), RV Tricuspid annular plane systolic excursion (TAPSE), myocardial performance indices (MPI), and the RV systolic to diastolic duration (S/D) ratio were evaluated. RESULTS The iNO/ECMO group (n = 26) had lower TAPSE and RV FAC and higher RV MPI and S/D, compared with controls (n = 39). Area under the curve was highest for RV S/D, with fair sensitivity (95% CI) [76.9 (56.3-91%)] and negative predictive value [78.6 (63.3-88.6%)] for subsequent iNO/ECMO at cutoff >1.45. CONCLUSIONS Infants with HIE undergoing cooling who progressed to iNO/ECMO for PPHN had RV dysfunction on early ECHO; S/D had the best predictive performance. RV S/D may be a useful early marker of PPHN in HIE.
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Affiliation(s)
- Sanjeev Aggarwal
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Prashant Agarwal
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA.
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25
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Méndez-Abad P, Zafra-Rodríguez P, Lubián-López S, Benavente-Fernández I. Myocardial Function Maturation in Very-Low-Birth-Weight Infants and Development of Bronchopulmonary Dysplasia. Front Pediatr 2019; 7:556. [PMID: 32010652 PMCID: PMC6978685 DOI: 10.3389/fped.2019.00556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/19/2019] [Indexed: 01/07/2023] Open
Abstract
Background: Myocardial function in very-low-birth-weight infants (VLBWIs) develops during early postnatal life, but different patterns of temporal evolution that might be related to the development of bronchopulmonary dysplasia (BPD) are not completely understood. Methods: A prospective cohort study including VLBWIs admitted to our NICU from January 2015 to 2017 was conducted. Plasma N-terminal pro B type natriuretic peptide (NTproBNP) levels were measured, and echocardiograms were performed at 24 and 72 h of life and weekly thereafter until 36 weeks of postmenstrual age (PMA). We measured the tricuspid annular plane systolic excursion (TAPSE) by M-mode; the lateral tricuspid E', A', and S' waves; and the myocardial performance index (MPI) by tissue doppler imaging (TDI). The subjects were divided into non-BPD and BPD groups. Results: We included 101 VLBWIs. The TAPSE and E', A', and S' waves increased while MPI-TDI decreased over time. Birth gestational age (GA) and postnatal PMA impacted these parameters, which evolved differently in those who developed BPD compared to those in the non-BPD group. The NTproBNP levels at 14 days of life and different echocardiographic parameters were associated with the development of BPD in different multivariate models. Conclusion: TAPSE and TDI values depend on GA and PMA and follow a different temporal evolution that is related to the later development of BPD. Combined biochemical and echocardiographic biomarkers can help identify which VLBWIs are at higher risk of developing BDP.
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Affiliation(s)
- Paula Méndez-Abad
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Pamela Zafra-Rodríguez
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Simón Lubián-López
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Isabel Benavente-Fernández
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
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26
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Echocardiographic Measurements of Right Ventricular Mechanics in Infants with Bronchopulmonary Dysplasia at 36 Weeks Postmenstrual Age. J Pediatr 2018; 203:210-217.e1. [PMID: 30244987 PMCID: PMC6252141 DOI: 10.1016/j.jpeds.2018.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/19/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To test the hypothesis that specific echocardiographic measurements of right ventricular (RV) mechanics at 36 weeks postmenstrual age (PMA) are associated with the severity of bronchopulmonary dysplasia (BPD). STUDY DESIGN A subset of 93 preterm infants (born between 27 and 29 weeks of gestation) was selected retrospectively from a prospectively enrolled cohort. BPD was defined using the National Institutes of Health workshop definition, with modifications for oxygen reduction testing and altitude. The cohort was divided into no-BPD and BPD groups using previously published methodology for analyses. Echocardiographic measurements of RV function (ie, tricuspid annular plane systolic excursion, fractional area of change, systolic-to-diastolic ratio, tissue Doppler myocardial performance index, and RV strain), RV remodeling/morphology (end-systolic left ventricular eccentricity index), and RV afterload (pulmonary artery acceleration time measure) were evaluated at 36 weeks PMA. Multivariable logistic regression determined associations between RV measurements and BPD severity. RESULTS Compared with the no-BPD cohort, the BPD group had lower birth weight z-scores (P = .04) and trended toward a male predominance (P = .08). After adjusting for birth weight z-score, gestational age, and sex, there were no between-group differences in echocardiographic measurements except for the eccentricity index (scaled OR [0.1-unit increase], 1.49; 95% CI, 1.13-2.12; P = .01). CONCLUSIONS Among conventional and emerging echocardiographic measurements of RV mechanics, eccentricity index was the sole variable independently associated with BPD severity in this study. The eccentricity index may be a useful echocardiographic measurement for characterizing RV mechanics in patients with BPD at 36 weeks PMA.
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27
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Gautheyrou L, Durand S, Jourdes E, De Jonckheere J, Combes C, Cambonie G. Facilitated tucking during early neonatologist-performed echocardiography in very preterm neonates. Acta Paediatr 2018; 107:2079-2085. [PMID: 30144169 DOI: 10.1111/apa.14555] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 08/04/2018] [Accepted: 08/22/2018] [Indexed: 11/27/2022]
Abstract
AIM To assess the effect of facilitated tucking (FT), a nonpharmacologic nursing intervention, on echocardiographic parameters and infant comfort collected prospectively during neonatologist-performed echocardiography. METHODS Echocardiography was performed twice, in standard conditions and with FT; the order was randomised by computer. Echocardiography provided data on pulmonary artery flow and pressure, right and left ventricular function, and persistent ductus arteriosus. Comfort was assessed by a behavioural scale of pain, variations in heart rate (HR) and SpO2 , and a newborn infant parasympathetic evaluation index based on the high-frequency variability in HR. RESULTS Fifty newborns, with mean gestational age of 28 [26.6-29.0] weeks and mean birthweight of 950 [780-1190] g, were studied at a postnatal age of 13 [9-27] hours. FT was associated with longer acceleration time/right ventricular ejection time in the main pulmonary artery (p = 0.006), reduced averaged HR variations (p = 0.03) and lower pain scores (p < 0.001). The other haemodynamic parameters and the parasympathetic index were not influenced by FT. CONCLUSION Echocardiography performed soon after birth in very premature neonates may generate mild discomfort. FT during echocardiography is associated with lower pulmonary artery pressures and improves infant's comfort during this examination.
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Affiliation(s)
- Laurène Gautheyrou
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
| | - Sabine Durand
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
| | - Emilie Jourdes
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
| | - Julien De Jonckheere
- EA 4489, Perinatal Growth and Environment; Lille University; Montpellier Cedex 5 France
- CIC-IT 1403; Lille University Hospital; Lille France
| | - Clémentine Combes
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
| | - Gilles Cambonie
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
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28
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Sehgal A, Krishnamurthy MB, Clark M, Menahem S. ACE inhibition for severe bronchopulmonary dysplasia - an approach based on physiology. Physiol Rep 2018; 6:e13821. [PMID: 30187692 PMCID: PMC6125606 DOI: 10.14814/phy2.13821] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 07/16/2018] [Indexed: 12/02/2022] Open
Abstract
Premature infants have a high incidence of bronchopulmonary dysplasia (BPD). Systemic hypertension, arterial thickness and stiffness, and increased systemic afterload may all contribute to BPD pathophysiology by altering left ventricular (LV) function and increasing pulmonary venous congestion by lowering end-diastolic compliance. This case series studied the usefulness of angiotensin-converting enzyme (ACE) inhibition by measuring clinical and echocardiographic improvements in six consecutive infants with "severe" BPD unresponsive to conventional therapy. The range of gestation and birthweight were 23-29 weeks and 505-814 g, respectively. All required mechanical ventilation (including high-frequency oscillation) and all but one were administered postnatal corticosteroids. Other treatments including sildenafil and diuretics made no clinical improvements. Captopril was started for systemic hypertension after cardiac and vascular ultrasounds which were repeated 5 weeks later. A significant reduction in oxygen (55 ± 25 to 29 ± 3%, two-tailed P = 0.03) and ventilator requirements, and improved cardiovascular parameters were noted. This included a trend toward reduction in aorta intima media thickness [840 ± 94 to 740 ± 83 μm, P = 0.07] and an increased pulsatile diameter [36 ± 14 to 63 ± 25 μm, P = 0.04]). Improvements were observed for both systolic (increased LV output, 188 ± 13 to 208 ± 13 mL/kg/min, P = 0.046 and mean velocity of circumferential fiber shortening, 1.6 ± 0.2 to 2.5 ± 0.3 [circ/sec], P = 0.0004) and diastolic (decreased isovolumic relaxation time, 69.6 ± 8.2 to 59.4 ± 5 msec, P = 0.044) function which was accompanied by increased pulmonary vein flow. Right ventricular output increased accompanied by a significant lowering of pulmonary vascular resistance. These findings suggest that improving respiratory and cardiac indices (especially diastolic function) warrants further exploration of ACE inhibition in BPD infants unresponsive to conventional therapy.
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Affiliation(s)
- Arvind Sehgal
- Monash NewbornMonash Children's HospitalMelbourneVictoriaAustralia
- Department of PediatricsMonash UniversityMelbourneVictoriaAustralia
| | | | - Megan Clark
- PharmacyMonash HealthClaytonMelbourneVictoriaAustralia
| | - Samuel Menahem
- Emeritus HeadPaediatric and Foetal Cardiac UnitsMonash Medical CentreMonash HealthMelbourneVictoriaAustralia
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29
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Sehgal A, Gwini SM, Menahem S, Allison BJ, Miller SL, Polglase GR. Preterm growth restriction and bronchopulmonary dysplasia: the vascular hypothesis and related physiology. J Physiol 2018; 597:1209-1220. [PMID: 29746007 DOI: 10.1113/jp276040] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/27/2018] [Indexed: 12/12/2022] Open
Abstract
KEY POINTS Approximately 5-10% pregnancies are affected by fetal growth restriction. Preterm infants affected by fetal growth restriction have a higher incidence of bronchopulmonary dysplasia. The present study is the first to measure pulmonary artery thickness and stiffness. The findings show that impaired vasculogenesis may be a contributory factor in the higher incidence of bronchopulmonary dysplasia in preterm growth restricted infants. The study addresses the mechanistic link between fetal programming and vascular architecture and mechanics. ABSTRACT Bronchopulmonary dysplasia is the most common respiratory sequelae of prematurity and histopathologically features fewer, dysmorphic pulmonary arteries. The present study aimed to characterize pulmonary artery mechanics and cardiac function in preterm infants with fetal growth restriction (FGR) compared to those appropriate for gestational age (AGA) in the early neonatal period. This prospective study reviewed 40 preterm infants between 28 to 32 weeks gestational age (GA). Twenty infants had a birthweight <10th centile and were compared with 20 preterm AGA infants. A single high resolution echocardiogram was performed to measure right pulmonary arterial and right ventricular (RV) indices. The GA and birthweight of FGR and AGA infants were 29.8 ± 1.3 vs. 30 ± 0.9 weeks (P = 0.78) and 923.4 g ± 168 vs. 1403 g ± 237 (P < 0.001), respectively. Assessments were made at 10.5 ± 1.3 days after birth. The FGR infants had significantly thicker right pulmonary artery inferior wall (843.5 ± 68 vs. 761 ± 40 μm, P < 0.001) with reduced pulsatility (51.6 ± 7.6 μm vs. 59.7 ± 7.5 μm, P = 0.001). The RV contractility [fractional area change (28.7 ± 3.8% vs 32.5 ± 3.1%, P = 0.001), tricuspid annular peak systolic excursion (TAPSE) (5.2 ± 0.3% vs. 5.9 ± 0.7%, P = 0.0002) and myocardial performance index (0.35 ± 0.03 vs. 0.28 ± 0.02, P < 0.001)] was significantly impaired in FGR infants. Significant correlation between RV longitudinal contractility (TAPSE) and time to peak velocity/RV ejection time (measure of RV afterload) was noted (r2 = 0.5, P < 0.001). Altered pulmonary vascular mechanics and cardiac performance reflect maladaptive changes in response to utero-placental insufficiency. Whether managing pulmonary vascular disease will alter clinical outcomes remains to be studied prospectively.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.,Department of Pediatrics, Monash University, Melbourne, VIC, Australia
| | - Stella M Gwini
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - Samuel Menahem
- Emeritus Head, Paediatric and Foetal Cardiac Units, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
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30
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Kang SJ, Cho YS, Hwang SJ, Kim HJ. Outcomes of Left Ventricular Function According to Treatment Response for a Patent Ductus Arteriosus in Preterm Infants. J Cardiovasc Ultrasound 2018; 25:131-137. [PMID: 29333220 PMCID: PMC5762696 DOI: 10.4250/jcu.2017.25.4.131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/16/2017] [Accepted: 12/16/2017] [Indexed: 11/22/2022] Open
Abstract
Background To evaluate the outcomes of left ventricular (LV) function according to treatment response for a hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants. Methods Echocardiograms of 21 preterm infants born at gestational age < 31 weeks obtained at term-equivalent age were retrospectively studied. Among preterm infants with a hsPDA, 9 underwent ligation after failure of pharmacological closure (ligation group) and 6 experienced successful pharmacological closure (medication group). Six preterm infants without hsPDA (no-hsPDA group) were studied as controls. LV peak longitudinal systolic strain (ε) of each infant was retrospectively obtained from echocardiograms using velocity vector imaging, along with neonatal outcomes. Results Pharmacological closures were attempted at postnatal day 2-3. In the ligation group, the median postnatal age at ligation was 20 days. In the ligation group, LV peak longitudinal systolic ε was significantly decreased at term-equivalent age compared to the other groups. Between the medication and no-hsPDA groups, LV peak longitudinal systolic ε did not differ significantly. Among the neonatal outcomes, infants who experienced necrotizing enterocolitis (NEC) showed significantly decreased LV peak longitudinal systolic ε compared to the infants who did not experience NEC . Conclusion We speculate that in preterm infants with an hsPDA, in cases of medical treatment failure, early PDA ligation at less than 20 days of postnatal age would be beneficial for preserving LV systolic function.
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Affiliation(s)
- Soo Jung Kang
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Young Sun Cho
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Seo Jung Hwang
- Department of Diagnostic Laboratory Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyo Jin Kim
- Department of Diagnostic Laboratory Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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31
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Nestaas E, Schubert U, de Boode WP, El-Khuffash A. Tissue Doppler velocity imaging and event timings in neonates: a guide to image acquisition, measurement, interpretation, and reference values. Pediatr Res 2018; 84:18-29. [PMID: 30072806 PMCID: PMC6257218 DOI: 10.1038/s41390-018-0079-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Neonatologists can use echocardiography for real-time assessment of the hemodynamic state of neonates to support clinical decision-making. There is a large body of evidence showing the shortcomings of conventional echocardiographic indices in neonates. Newer imaging modalities have evolved. Tissue Doppler imaging is a new technique that can provide measurements of myocardial movement and timing of myocardial events and may overcome some of the shortcomings of conventional techniques. The high time resolution and its ability to assess left and right cardiac function make tissue Doppler a favorable technique for assessing heart function in neonates. The aim of this review is to provide an up-to-date overview of tissue Doppler techniques for the assessment of cardiac function in the neonatal context, with focus on measurements from the atrioventricular (AV) plane. We discuss basic concepts, protocol for assessment, feasibility, and limitations, and we report reference values and give examples of its use in neonates.
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Affiliation(s)
- Eirik Nestaas
- 0000 0004 1936 8921grid.5510.1Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway ,0000 0004 0389 8485grid.55325.34Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway ,0000 0004 0627 3659grid.417292.bDepartment of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Ulf Schubert
- 0000 0004 1937 0626grid.4714.6Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Willem P. de Boode
- grid.461578.9Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Nijmegen, The Netherlands
| | - Afif El-Khuffash
- 0000 0004 0617 7587grid.416068.dDepartment of Neonatology, The Rotunda Hospital, Dublin, Ireland ,0000 0004 0488 7120grid.4912.eDepartment of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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Seo YH, Choi HJ. Clinical Utility of Echocardiography for Early and Late Pulmonary Hypertension in Preterm Infants: Relation with Bronchopulmonary Dysplasia. J Cardiovasc Ultrasound 2017; 25:124-130. [PMID: 29333219 PMCID: PMC5762695 DOI: 10.4250/jcu.2017.25.4.124] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 11/22/2022] Open
Abstract
Background We evaluated early and late pulmonary hypertension (PH) in preterm infants and its relation with bronchopulmonary dysplasia (BPD). Methods Sixty-seven preterm infants < 30 weeks' gestation underwent echocardiography within 14 days after birth for early PH and over 28 days after birth for late PH. We measured tricuspid regurgitation (TR) peak velocity, pulse Doppler-derived myocardial performance index (MPI) of right ventricle (RV) (RV MPI), eccentricity index (EI), and tricuspid annular plane systolic excursion (TAPSE). Results The median gestation age of patients was 27 weeks (range, 23–30 weeks) and median birth weight was 1030 g (range, 450–1780 g). TR peak velocity was measured only in 19 patients (28.4%). Patients with symptomatic early PH (n = 11) showed a significantly lower systolic EI and a significantly higher incidence of RV MPI > 0.38 and TAPSE < 0.5 cm than patients without PH. The incidence of symptomatic early PH was highest in severe BPD, although this was not statistically significant. Early echocardiographic parameters are not associated with BPD development. Patients with severe BPD showed a significantly higher RV MPI and a significantly higher incidence of RV MPI > 0.38 than patients with mild BPD, and a significantly lower systolic EI and a significantly higher incidence of systolic EI < 0.81 than patients without BPD. Conclusion Systolic EI, RV MPI, and TAPSE were well represented symptomatic early PH, while systolic EI and RV MPI could be useful parameters for identifying late PH in preterm infants with BPD, even if they did not present PH symptoms.
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Affiliation(s)
- Yo Han Seo
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Hee Joung Choi
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
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Kang SJ, Kim M, Hwang SJ, Kim HJ. Progression of Right Ventricular Systolic Dysfunction Detected by Myocardial Deformation Imaging in Asymptomatic Preterm Children. J Cardiovasc Ultrasound 2017; 25:98-104. [PMID: 29093772 PMCID: PMC5658295 DOI: 10.4250/jcu.2017.25.3.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 01/25/2023] Open
Abstract
Background To detect progression of right ventricular (RV) systolic dysfunction (RVSD) in asymptomatic preterm children from infancy to 24-month corrected age, using velocity vector imaging (VVI). Methods Retrospective study comparing sequential RV longitudinal peak systolic strain (LPSS) from 24 children born at < 33 weeks of gestational age and 10 term infants recruited as controls, obtained at a mean of 4-month (first exam) and 24-month corrected age (second exam). Results In 7/24 (29.2%) of preterm children, RV LPSS of < 16%, defined as RVSD, was detected at the second exam; 5/7 of these children had RV LPSS > 16% at the first exam, and only 2/7 of these children had a history of moderate or severe bronchopulmonary dysplasia. Conclusion In asymptomatic preterm children, routine echocardiographic screening using VVI could detect RVSD which could progress from 4–24 month corrected age.
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Affiliation(s)
- Soo Jung Kang
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Mira Kim
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Seo Jung Hwang
- Department of Diagnostic Laboratory Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyo Jin Kim
- Department of Diagnostic Laboratory Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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Pulmonary hypertension associated with bronchopulmonary dysplasia in preterm infants. J Reprod Immunol 2017; 124:21-29. [PMID: 29035757 DOI: 10.1016/j.jri.2017.09.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 09/11/2017] [Accepted: 09/29/2017] [Indexed: 12/12/2022]
Abstract
Bronchopulmonary dysplasia (BPD) and BPD-associated pulmonary hypertension (BPD-PH) are chronic inflammatory cardiopulmonary diseases with devastating short- and long-term consequences for infants born prematurely. The immature lungs of preterm infants are ill-prepared to achieve sufficient gas exchange, thus usually necessitating immediate commencement of respiratory support and oxygen supplementation. These therapies are life-saving, but they exacerbate the tissue damage that is inevitably inflicted on a preterm lung forced to perform gas exchange. Together, air-breathing and necessary therapeutic interventions disrupt normal lung development by aggravating pulmonary inflammation and vascular remodelling, thus frequently precipitating BPD and PH via an incompletely understood pathogenic cascade. BPD and BPD-PH share common risk factors, such as low gestational age at birth, fetal growth restriction and perinatal maternal inflammation; however, these risk factors are not unique to BPD or BPD-PH. Occurring in 17-24% of BPD patients, BPD-PH substantially worsens the morbidity and mortality attributable to BPD alone, thus darkening their outlook; for example, BPD-PH entails a mortality of up to 50%. The absence of a safe and effective therapy for BPD and BPD-PH renders neonatal cardiopulmonary disease an area of urgent unmet medical need. Besides the need to develop new therapeutic strategies, a major challenge for clinicians is the lack of a reliable method for identifying babies at risk of developing BPD and BPD-PH. In addition to discussing current knowledge on pathophysiology, diagnosis and treatment of BPD-PH, we highlight emerging biomarkers that could enable clinicians to predict disease-risk and also optimise treatment of BPD-PH in our tiniest patients.
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Sehgal A, Allison BJ, Gwini SM, Miller SL, Polglase GR. Cardiac Morphology and Function in Preterm Growth Restricted Infants: Relevance for Clinical Sequelae. J Pediatr 2017; 188:128-134.e2. [PMID: 28662946 DOI: 10.1016/j.jpeds.2017.05.076] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 04/27/2017] [Accepted: 05/30/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess cardiac morphology and function in preterm infants with fetal growth restriction (FGR) compared with an appropriate for gestational age cohort, and to ascertain clinical correlation with neonatal sequelae. STUDY DESIGN With informed consent, 20 infants born between 28 and 32 weeks of gestational age and birthweight (BW) <10th percentile were compared using conventional and tissue Doppler echocardiography with 20 preterm appropriate for gestational age infants. Total duration of respiratory support was recorded. RESULTS The gestational age and BW of the infants with FGR and appropriate for gestational age infants were 29.8 ± 1.3 weeks vs 30 ± 0.9 weeks (P = .78) and 923.4 ± 168 g vs 1403 ± 237 g (P < .001), respectively. Preterm infants with FGR had significantly greater interventricular septal hypertrophy, greater free wall thickening, and lower sphericity indices (1.53 ± 0.15 vs 1.88 ± 0.2; P < .001), signifying globular and hypertrophied hearts. The transmitral E/A ratio and isovolumic relaxation time, markers of diastolic function, were significantly increased in the FGR cohort (0.84 ± 0.05 vs 0.78 ± 0.03 [P < .001] and 61.4 ± 4.1 ms vs 53.2 ± 3.2 ms [P < .001], respectively). Ejection fraction, as measured by the rate corrected mean velocity of circumferential fiber shortening was reduced (1.93 ± 0.4 circ/second vs 2.77 ± 0.5 circ/second; P < .001) in the FGR cohort. On follow-up, the total duration of respiratory support was significantly longer in the FGR cohort, and correlated with tissue Doppler E/E' (r = 0.65; P = .001), mean velocity of circumferential fiber shortening (r = -0.64; P = .001) and mitral annular peak systolic excursion (r = -0.57; P = .008). CONCLUSIONS Preterm infants with FGR have altered cardiac function evident within days after birth, which is associated with respiratory sequelae.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| | - Beth J Allison
- The Ritchie Center, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Stella M Gwini
- Department of Epidemiology & Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Center, Hudson Institute of Medical Research, Clayton, Victoria, Australia; Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Center, Hudson Institute of Medical Research, Clayton, Victoria, Australia; Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
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Haque U, Stiver C, Rivera BK, Richards B, Ma N, Cua CL, Smith CV, Backes CH. Right ventricular performance using myocardial deformation imaging in infants with bronchopulmonary dysplasia. J Perinatol 2017; 37:81-87. [PMID: 27711043 DOI: 10.1038/jp.2016.173] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/24/2016] [Accepted: 08/30/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Right ventricular (RV) performance among infants with bronchopulmonary dysplasia (BPD) remains poorly understood. We tested the hypothesis that myocardial deformation imaging (MDI) strain and strain rate would allow for differentiation between infants with severe and milder forms of BPD, independent of tissue Doppler imaging (TDI) and superior to conventional echocardiographic measurements. STUDY DESIGN Infants with various severities of BPD (11 with none or mild, 13 with moderate and 10 with severe) underwent conventional echocardiography, TDI and MDI assessments at >36 weeks of corrected gestational age. BPD severity grading was determined according to the National Institutes of Child Health and Disease workshop rating scale by physicians blinded to the echocardiogram results. Group data were compared with one-way analysis of variance or Kruskal-Wallis tests, with post hoc multiple comparisons. RESULTS No differences in traditional echocardiographic parameters or TDI among the three BPD severity groups were observed; none of the infants had evidence of pulmonary hypertension. Using MDI, infants with severe BPD had lower peak global systolic strain than did infants with moderate BPD (P<0.01) or mild/none BPD (P<0.01). Early and late diastolic strain rate measurements were similar across the three groups. CONCLUSIONS Among infants with severe forms of BPD, evidence of abnormal RV systolic function was detected with MDI, but not traditional echocardiographic or TDI measurements. Infants with severe forms of BPD may represent a particularly high-risk subgroup for decreased RV performance warranting cardiac surveillance. MDI should be considered as a method to quantitate RV function in this population.
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Affiliation(s)
- U Haque
- Nationwide Children's Hospital Center for Perinatal Research, Columbus, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - C Stiver
- Nationwide Children's Hospital Heart Center, Columbus, OH, USA.,The Ohio State University Wexner College of Medicine, Columbus, OH, USA
| | - B K Rivera
- Nationwide Children's Hospital Center for Perinatal Research, Columbus, OH, USA
| | - B Richards
- Nationwide Children's Hospital Heart Center, Columbus, OH, USA
| | - N Ma
- The Ohio State University Wexner College of Medicine, Columbus, OH, USA
| | - C L Cua
- Nationwide Children's Hospital Heart Center, Columbus, OH, USA.,The Ohio State University Wexner College of Medicine, Columbus, OH, USA
| | - C V Smith
- Seattle Children's Research Institute, Center for Developmental Therapeutics, Seattle, WA, USA
| | - C H Backes
- Nationwide Children's Hospital Center for Perinatal Research, Columbus, OH, USA.,Nationwide Children's Hospital Heart Center, Columbus, OH, USA.,The Ohio State University Wexner College of Medicine, Columbus, OH, USA
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