Right and left ventricular function in hospitalized children with respiratory syncytial virus infection

Early elevated NT-proBNP but not troponin I is associated with severe bronchiolitis in infants

BACKGROUND

We aimed to explore and to compare the association between the NT-proBNP and high-sensitivity troponin I (hs-cTnI) at early stages of acute bronchiolitis with echocardiographic alterations, clinical severity and outcomes.

METHODS

A single centre, prospective observational study including previously healthy infants aged 1-12 months with bronchiolitis admitted to a tertiary hospital from April 2019 to March 2020. All patients underwent clinical, laboratory and echocardiographic evaluation at the same time point within 12 h of hospital admission. NT-proBNP > 1121 pg/ml and hs-cTnI > 26 ng/L were considered elevated. The primary outcome measure was the association of raised cardiac biomarkers with the need for PICU admission.

RESULTS

We enrolled 40 infants with median levels of NT-proBNP of 1176 (520-3030) pg/ml and hs-cTnI of 11.5 (5-21) ng/L at the time of hospital admission. Raised levels of NT-proBNP and hs-cTnI in 50% and 20% of cases, respectively. Of them, 15 (37%) required PICU admission during the hospitalization. Increased NT-proBNP was associated with PICU admission (adjusted OR 9.5 (CI95% 1.4-64); p = 0.020), prolonged hospitalization (β = 2.7; p = 0.012) and duration of oxygen administration (β = 2.7; p = 0.004) in the multivariate analysis. There were no differences in hs-cTnI levels regarding PICU admission (p = 0.866). Increased hs-cTnI levels were only associated with oxygen administration duration (Spearman rho = 0.38; p = 0.017), but this association disappeared in the multivariate analysis. Only NT-proBNP was associated with echocardiographic parameters of myocardial dysfunction (p < 0.001), and pulmonary hypertension (p < 0.001) CONCLUSION: Early elevated NT-proBNP but not hs-cTnI could be used as a biomarker for myocardial strain and disease severity in bronchiolitis.

The Assessment of Myocardial Strain by Cardiac Imaging in Healthy Infants with Acute Bronchiolitis: A Systematic Review and Meta-Analysis

This study aims to systematically review the incidence of myocardial strain detected by echocardiography in previously healthy infants with acute bronchiolitis and its role as a predictor for adverse outcomes in this setting.

METHODS

Pubmed/Medline, Excerpta Medica Data Base (EMBASE), and Cochrane Library were searched in April 2020 to identify original observational prospective studies that systematically performed echocardiography for the screening of myocardial strain in healthy infants with acute bronchiolitis. Pooled estimates were generated using random-effects models. Heterogeneity within studies was assessed using Cochran's Q and I² statistics. Funnel plots and Egger´s regression method were constructed to evaluate publication bias. Sensitivity analyses were also conducted to evaluate potential sources of heterogeneity.

RESULTS

After a detailed screening of 305 articles, a total of 10 studies with 395 participants (mean of 40 participants per study) was included. Five of them were classified as high-quality studies. Up to 28% of cases presented adverse outcomes. The echocardiographic screening for myocardial strain was performed within the first 24 h of admission in 92% cases. Tissue Doppler imaging and Speckle-Tracking echocardiography were performed only in 20% of cases. The presence of pulmonary hypertension was evaluated with methods different from the tricuspid regurgitation jet in 64% of cases. Seven studies found some grade of myocardial strain with a pooled incidence of 21% (CI 95%, 11-31%), in the form of pulmonary hypertension (pooled incidence of 20% (CI 95%, 11-30%)), and myocardial dysfunction (pooled incidence of 5% (CI 95%, 1-9%)). The presence of these echocardiographic alterations was associated with adverse outcomes (pooled relative risk = 16; CI 95%, 8.2-31.5). After a subgroup analysis based on the echocardiographic techniques used, no significant heterogeneity across the studies was observed. There was no evidence of publication bias when assessed by Egger´s test. Cardiac biomarkers to assess myocardial strain were used in five studies. Only N-terminal-pro-brain natriuretic peptide accurately predicted the presence of myocardial strain by echocardiography.

CONCLUSIONS

Myocardial strain is not infrequent in previously healthy infants with acute bronchiolitis, and it could be present at the early stages of the disease with prognostic implications. There is a need for sufficiently powered prospective studies with a similar methodology, preferably employing advanced imaging techniques, to conclusively address the usefulness of the assessment of myocardial strain in this setting.

Left Ventricular Dysfunction and Plasmatic NT-proBNP Are Associated with Adverse Evolution in Respiratory Syncytial Virus Bronchiolitis

AIM

To investigate whether the presence of left ventricular myocardial dysfunction (LVMD) assessed by Tei index (LVTX) impacts the outcomes of healthy infants with Respiratory Syncytial Virus Bronchiolitis (RSVB). To explore whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) increases the accuracy of traditional clinical markers in predicting the outcomes.

METHODS

A single-centre, prospective, cohort study including healthy infants aged 1-12 months old admitted for RSVB between 1 October 2016 and 1 April 2017. All patients underwent clinical, laboratory and echocardiographic evaluation within 24 h of admission. Paediatric intensive care unit (PICU) admission was defined as severe disease.

RESULTS

We enrolled 50 cases of RSVB (median age of 2 (1-6.5) months; 40% female) and 50 age-matched controls. We observed higher values of LVTX in infants with RSVB than in controls (0.42 vs. 0.36; p = 0.008). Up to nine (18%) children presented with LVMD (LVTX > 0.5), with a higher incidence of PICU admission (89% vs. 5%; p < 0.001). The diagnostic performance of NT-proBNP in predicting LVMD was high (area under the receiver operator characteristic curve (AUC) 0.95, CI 95% 0.90-1). The diagnostic yield of the predictive model for PICU admission that included NT-proBNP was excellent (AUC 0.945, CI 95% 0.880-1), and significantly higher than the model without NT-proBNP (p = 0.026).

CONCLUSIONS

LVMD could be present in healthy infants with RSVB who develop severe disease. NT-proBNP seems to improve traditional clinical markers for outcomes.