Congenital Heart Disease Requiring Maintenance of Ductus Arteriosus in Critically Ill Newborns Admitted at a Tertiary Neonatal Intensive Care Unit

Predictors of high maintenance prostaglandin E1 doses in neonates with critical congenital heart disease-ductal-dependent pulmonary circulation during preoperative care

BACKGROUND

Neonates with critical congenital heart disease of the ductal-dependent pulmonary circulation type (CCHD-DDPC) require prostaglandin E1 (PGE1) to maintain oxygen saturation until surgery. However, the factors contributing to the maintenance doses of PGE1 remain unclear. This study aimed to determine the predictors of high maintenance PGE1 doses in these neonates.

METHODS

This retrospective cohort study included neonates with CCHD-DDPC at Songklanagarind Hospital between January 1, 2006, and December 31, 2021. Factors associated with high maintenance PGE1 doses (> 0.01 mcg/kg/min) were analyzed to identify predictors. Odds ratios were calculated using tabulation and logistic regression analysis. A prediction score was developed for high maintenance PGE1 doses.

RESULTS

Among 96 neonates with CCHD-DDPC, 55 % required high maintenance doses of PGE1. Three factors significantly associated with high maintenance PGE1 doses were patent ductus arteriosus (PDA) size-to-birthweight ratio ≤1.3 mm/kg, initial PGE1 dose >0.03 mcg/kg/min, and preoperative invasive mechanical ventilation. The area under the receiver operating characteristic curve for these three predictors was 0.7409. A predictive score of 0-3 was created based on these factors. The probabilities of receiving a high maintenance dose of PGE1 for patients with overall scores of 0, 1, 2, and 3 were 0.19 (95 % CI: 0.04-0.33), 0.42 (95 % CI: 0.30-0.54), 0.69 (95 % CI: 0.57-0.81), and 0.87 (95 % CI: 0.76-0.99), respectively.

CONCLUSIONS

In neonates with CCHD-DDPC, a PDA size-to-birth weight ratio ≤1.3 mm/kg, an initial dose of PGE1 > 0.03 mcg/kg/min, and preoperative invasive mechanical ventilation were predictors of high maintenance PGE1 doses during the preoperative period.

Effectiveness of Alprostadil for Ductal Patency

OBJECTIVES

This study aims to describe the effectiveness of low initial alprostadil dosages to maintain a patent ductus arteriosus (PDA) in infants with ductal-dependent congenital heart disease (DDCHD). Secondary objectives were to describe any adverse drug events, describe prescribing trends, describe ductus arteriosus diameter changes, and compare the safety and efficacy of very low and low initial alprostadil dosage regimens.

METHODS

This retrospective observational cohort study at the British Columbia's Women's and Children's Hospital neonatal intensive care unit and pediatric intensive care unit examined neonates admitted with DDCHD who received alprostadil to maintain ductal patency. Very low-dose alprostadil (less than 0.01 mcg/kg/min) versus low-dose alprostadil (equal to or greater than 0.01 mcg/kg/min) was examined. Effectiveness was defined as survival and infants not requiring a resuscitation event (cardiac arrest, cardiogenic shock, code blue, extracorporeal life support, requirement for emergent cardiac surgery, and respiratory acidosis). Adverse drug events with a Naranjo score of 3 or more were included.

RESULTS

Alprostadil was effective for 88% of patients, with no difference between the very low-dose and low-dose groups. Of the 75 patients included, 25 received very low-dose alprostadil. Adverse drug events were common (51%) with neonates in the low-dose group experiencing more apnea and pyrexia than neonates in the very low-dose group.

CONCLUSIONS

Alprostadil therapy was effective in maintaining the PDA in neonates with DDCHD with low-dosage regimens. Adverse drug events were common with both dosage regimens; however, the very low dosage appeared to have less apnea and pyrexia.

Perinatal Management of Pregnancies with Fetal Congenital Anomalies: A Guide to Obstetricians and Pediatricians

BACKGROUND

Congenital anomalies are responsible for approximately 20% of all neonatal deaths worldwide. Improvements in antenatal screening and diagnosis have significantly improved the prenatal detection of birth defects; however, these improvements have not translated into the improved neonatal prognosis of babies born with congenital anomalies.

OBJECTIVES

An attempt has been made to summarise the prenatal interventions, if available, the optimal route, mode and time of delivery and discuss the minimum delivery room preparations that should be made if expecting to deliver a fetus with a congenital anomaly.

METHODS

The recent literature related to the perinatal management of the fetus with prenatally detected common congenital anomalies was searched in English peer-reviewed journals from the PubMed database to work out an evidence-based approach for their management.

RESULTS

Fetuses with prenatally detected congenital anomalies should be delivered at a tertiary care centre with facilities for neonatal surgery and paediatric intensive care if needed. There is no indication for preterm delivery in the majority of cases. Only a few congenital malformations, like highrisk sacrococcygeal teratoma, congenital lung masses with significant fetal compromise, fetal cerebral lesions or neural tube defects with Head circumference >40 cm or the biparietal diameter is ≥12 cm, gastroschisis with extracorporeal liver, or giant omphaloceles in the fetus warrant caesarean section as the primary mode of delivery.

CONCLUSION

The prognosis of a fetus with congenital anomalies can be significantly improved if planning for delivery, including the place and time of delivery, is done optimally. A multidisciplinary team should be available for the fetus to optimize conditions right from when it is born.

Cumulative Dose of Prostaglandin E1 Determines Gastrointestinal Adverse Effects in Term and Near-Term Neonates Awaiting Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

This study aimed to assess the association between treatment characteristics of prostaglandin E1 including initiation time and duration, maximal and cumulative doses, and adverse effects.

DESIGN

A retrospective cohort study in which medical records of neonates with duct-dependent lesions were studied for treatment parameters and adverse effects. Multivariable logistic regression model was applied for testing the effect PGE1 variables on outcomes.

MAIN OUTCOME MEASURES

The primary outcomes of this study were association of adverse effects of PGE1 treatment with maximal dose, cumulative dose, and treatment duration. The secondary outcomes included safety of feeding in infants treated with PGE1.

RESULTS

Eighty-two infants with duct-dependent lesions receiving PGE1 were included. Several infants who received early PGE1 treatment required ventilation support. Feeds were ceased more often as the cumulative dose and duration of PGE1 treatment increased. Gastrointestinal adverse effects were significantly associated with the cumulative dose of PGE1 and treatment duration. Apneas, hyperthermia, and tachycardia were associated with maximal dose. Our data did not demonstrate a difference in the incidence of NEC associated with characteristics of PGE1 treatment.

CONCLUSION

Cumulative PGE1 dose is associated with gastrointestinal adverse effects in neonates. Lower doses should be considered in neonates expecting prolonged PGE1 treatment.

Management of tetralogy of Fallot in the pediatric intensive care unit

Tetralogy of Fallot (ToF) is one of the most common congenital cyanotic heart lesions and can present to a variety of health care professionals, including teams working in pediatric intensive care. Pediatric intensive care teams may care for a child with ToF pre-operatively, peri-operatively, and post-operatively. Each stage of management presents its own unique challenges. In this paper we discuss the role of pediatric intensive care in each stage of management.

Clinical challenges to the concept of ectogestation

Since the publication of the successful animal trials of the Biobag, a prototypical extrauterine support for extremely premature neonates, numerous ethicists have debated the potential implications of such a device. Some have argued that the Biobag represents a natural evolution of traditional newborn intensive care, while others believe that the Biobag would create a new class of being for the patients housed within. Kingma and Finn argued in Bioethics for making a categorical distinction between fetuses, newborns and 'gestatelings' in a Biobag on the basis of a conceptual distinction between ectogenesis versus ectogestation. Applying their arguments to the clinical realities of newborn intensive care, however, demonstrates the inapplicability of their ideas to the practice of medicine. Here, I present three clinical examples of the difficulty and confusion their argument would create for clinicians and offer a possible remedy: namely, discarding the term 'artificial womb' in favour of 'Biobag'.

Management of ductal spasm in a neonate with pulmonary atresia and an intact ventricular septum during cardiac catheterization: A case report

BACKGROUND

Ductal spasm is a rare but life-threatening complication of cardiac catheterization in neonates with pulmonary atresia and an intact ventricular septum. In patients with ductal-dependent pulmonary blood flow, ductal spasm may lead to refractory hypoxemia and severe hemodynamic instability, which need to be treated in perfect order.

CASE SUMMARY

We present a male infant with a gestational age of 39 wk, and his fetal echocardiography showed pulmonary atresia. At 28 d of age, transcatheter pulmonary valvuloplasty with balloon dilatation was performed. Two hours after the operation, the patient's pulse oxygen saturation continued to decrease. The patient was then transferred to receive cardiac catheterization. During catheterization, the invasive blood pressure and pulse oxygen saturation suddenly decreased, and repeated aortography revealed partial occlusion of the ductus arteriosus. It no longer changed when pulse oxygen saturation rose to 51% after approximately 20 min of maintenance therapy. Therefore, a ductal stent was used for implantation. Hemodynamics and hypoxemia were improved.

CONCLUSION

We should know that ductal spasm may occur during pulmonary atresia and intact ventricular septum cardiac catheterization. Understand the pathophysiology of ductal-dependent pulmonary blood flow and make comprehensive perioperative preparations essential to deal with hemodynamic disorders caused by ductal spasm.

The ductus arteriosus in neonates with critical congenital heart disease

The ductus arteriosus (DA) has a paradoxical biological role in neonates with congenital heart disease (CHD) and can present with significant management challenges. Critical congenital cardiac lesions rely on the patency of the DA to provide either systemic or pulmonary blood flow. A patent DA (PDA) that remains open can also have adverse consequences depending on the degree of systemic to-pulmonary shunting and volume of ductal steal. As such, the presence of a PDA may pose a challenge in the medical management and timing of surgical repair. In this perspective article, we provide an understanding of the role of the DA in the circulatory system in neonates with CHD and discuss traditional and emerging approaches to support the pulmonary and systemic circulations with manipulation of the DA.

Increasing Alprostadil Requirements in a Neonate With Cardiac Anomalies and Co-administration of Rectal and Oral Acetaminophen

A patent ductus arteriosus (PDA) results from the failure of the ductus arteriosus to close within 72 hours after birth. In most neonates, a PDA can lead to significant morbidities and often warrants pharmacologic intervention for closure. Common pharmacologic interventions include indomethacin, ibuprofen, and acetaminophen. In cases of ductal-dependent congenital heart defects (CHDs), such as hypoplastic left heart syndrome, it is imperative to keep the ductus arteriosus patent to maintain adequate pulmonary or systemic circulation until surgical intervention can be performed. The only proven pharmacologic agent used for this indication is prostaglandin E1 (PGE1) commonly in the form of intravenous alprostadil. This case report describes a neonate with multiple cardiac and genetic anomalies that required increased alprostadil infusion after exposure to rectal and oral acetaminophen. The patient initially presented with a large PDA on echocardiogram (ECHO); however, after an incidental finding of a small PDA on ECHO, the administration of as needed rectal acetaminophen was discontinued out of concern for its effects on patency. After a few days of increased prostaglandin therapy and 2 reassuring ECHO results, the patient was given oral acetaminophen on an as needed basis. Within 24 hours of restarting the acetaminophen, the repeated ECHO showed a reduction in PDA and flow. In patients with ductal-dependent cardiac lesions, it is important to maintain PDA patency and, therefore, introducing a medication with antiprostaglandin properties should be avoided.

Diagnostic performance of 320 cardiac MDCT angiography in assessment of PDA either isolated or associated with duct dependent congenital heart disease

Background

Patent ductus arteriosus (PDA) is one of most common congenital heart defects, it's a unique vascular structure that provides direct communication between pulmonary and systemic circulation. MDCT angiography is a good imaging modality for evaluation of the PDAs and detection of their exact morphological type; course and diameters, which is important before percutaneous closure or stenting procedure of the PDA, also for selection of closure hardware. The aim of this study was to assess the role of MDCT angiography in qualitative and quantitative evaluation of PDA and associated cardiac and\or extracardiac anomalies.

Results

Echocardiography detected PDA in 28\30 cases while cardiac MDCT detected PDA in all studied 30 cases confirmed by cardiac catheterization and/or operation. MDCT angiography had sensitivity 100% and specificity 100% for PDA detection. PDA originated from aortic isthmus in 15 cases, inferior surface of aortic arch in 11 cases and innominate artery in 4 cases. The most common morphological type of PDA was type A (cone\46.67%) followed by type C (tubular\23.3%), type D (complex\10%), type E (elongated\13.33%) and type B (window\6.67%). The spearman correlation coefficient test demonstrated poor correlation between size of aortic end and MPA (P = 0.75), and between size of pulmonary end and diameter of MPA (P = 0.99) and also demonstrated fair correlation between length of PDA and MPA (P = 0.018). PDA was isolated in 4\30 cases and associated with cardiac and\or extra cardiac anomalies in 26\30 cases included; ASD (n = 18), VSD (n = 16), pulmonary atresia (n = 7), transposition of great arteries (n = 5), teratology of Fallot (n = 4), aortic coarctation (n = 4), persistent truncus arteriosus (n = 3), tricuspid atresia (n = 3), anomalous of pulmonary venous return (n = 3), hypoplastic segment of aorta (n = 2), Ebstein's anomaly (n = 1), bicuspid aortic arch (n = 1) and left hypoplastic heart syndrome (n = 1).

Conclusion

Cardiac MDCT angiography was superior to Echocardiography in detection, quantitative and qualitative evaluation of PDA either isolated or associated with congenital cardiac and\or extracardiac anomalies and was superior to Echocardiography in detection of associated extracardiac anomalies rather than associated intra cardiac anomalies.

Low-dose prostaglandin E1 is safe and effective for critical congenital heart disease: is it time to revisit the dosing guidelines?

INTRODUCTION

Prostaglandin E1 is used to maintain ductal patency in critical congenital heart disease (CHD). The standard starting dose of prostaglandin E1 is 0.05 µg/kg/minute. Lower doses are frequently used, but the efficacy and safety of a low-dose regimen of prostaglandin E1 has not been established.

METHODS

We investigated neonates with critical CHD who were started on prostaglandin E1 at 0.01 µg/kg/minute. We reviewed 154 consecutive patients who were separated into three anatomical groups: obstruction to systemic circulation, obstruction to pulmonary circulation, and inadequate mixing (d-transposition of the great arteries). Treatment failure rates and two commonly reported side effects, respiratory depression and seizure, were studied.

RESULTS

A total of 26 patients (17%) required a dose increase in prostaglandin E1. Patients with pulmonary obstruction were more likely to require higher doses than patients with systemic obstruction (15/49, 31% versus 9/88, 10%, p = 0.003). Twenty-eight per cent of patients developed respiratory depression and 8% of patients needed mechanical ventilation. Prematurity (<37 week gestation) was the primary risk factor for respiratory depression. No patient required dose escalation or tracheal intubation while on transport. No patient had a seizure attributed to prostaglandin E1.

CONCLUSIONS

Prostaglandin E1 at an initial and maintenance dose of 0.01 µg/kg/minute was sufficient to maintain ductal patency in 83% of our cohort. The incidence of respiratory depression requiring mechanical ventilation was low and was mostly seen in premature infants. Starting low-dose prostaglandin E1 at 0.01 µg/kg/minute is a safe and effective therapy for critical CHD.

Diagnosis and Management of Critical Congenital Heart Diseases in the Newborn

Congenital heart disease (CHD) has been one of the most important contributors to neonatal mortality in the western world for the past 2 decades. With improvement in basic neonatal medical care in most parts of our country, the traditional contributors to neonatal mortality such as birth asphyxia and infections have reduced in numbers. This has hence thrust greater focus on CHD. Facilities with capability to diagnose and intervene on neonates with critical CHD are available in most states. Refinements in surgical techniques and advances in post-operative care have ensured that most neonates with critical CHD can undergo surgical or interventional procedures with very low mortality and can be expected to survive to adulthood with a reasonable quality of life. Unrecognized critical CHD could however result in death in the neonatal period. Focus has hence shifted towards sensitizing pediatricians about timely recognition of neonates with CHD. In this article, authors discuss the presentation and initial stabilization of neonates with CHD and attempt to provide practical solutions which can aid early diagnosis of CHD in the Indian scenario.

Case Series of COVID-19 Asymptomatic Newborns With Possible Intrapartum Transmission of SARS-CoV-2

Background: Despite the pandemic, data are limited regarding COVID-19 infection in pregnant women and newborns. This report aimed to bring new information about presentation that could modify precautionary measures for infants born of mothers with a remote history of COVID-19. Methods: We report two infants with possible maternofetal transmission, and four mothers without immunologic reactions. Data were collected from the patient files. Results: One mother exhibited infection signs 10 days before uncomplicated delivery, with negative RT-PCR and no antibody detection thereafter. Another mother exhibited infection 6 weeks pre-delivery, confirmed by nasopharyngeal swab testing with positive RT-PCR, and positive antibody detection (IgM and IgG). Both newborns were asymptomatic but tested positive for nasopharyngeal and stool RT-PCR at 1 and 3 days of age for the first one and at 1 day of age for stool analysis for the second one. Two additional mothers exhibited infection confirmed by positive RT-PCR testing at 28- and 31-days pre-delivery but did not present detectable antibody reaction at the time of delivery. Conclusion: These observations raise concerns regarding contamination risk by asymptomatic newborns and the efficacy of immunologic reactions in pregnant mothers, questioning the reliability of antibody testing during pregnancy.