2019 updated consensus statement on the diagnosis and treatment of pediatric pulmonary hypertension: The European Pediatric Pulmonary Vascular Disease Network (EPPVDN), endorsed by AEPC, ESPR and ISHLT

Hansmann G, Koestenberger M, Alastalo TP, Apitz C, Austin ED, Bonnet D, Budts W, D’Alto M, Gatzoulis MA, Hasan BS, Kozlik-Feldmann R, Kumar RK, Lammers AE, Latus H, Michel-Behnke I, Miera O, Morrell NW, Pieles G, Quandt D, Sallmon H, Schranz D, Tran-Lundmark K, Tulloh RMR, Warnecke G, Wåhlander H, Weber SC, Zartner P.
J Heart Lung Transplant. 2019 Sep;38(9):879-901. doi: 10.1016/j.healun.2019.06.022. Epub 2019 Jun 21.
PMID: 31495407
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Take-Home Points:

  • Based on the World Symposium of Pulmonary Hypertension WSPH ( Nice, 2018) PH is now defined as mean Pulmonary Artery Pressure (mPAP) > 20mm in children > 3 months of age at sea level. The limit was decreased from 24 to 20mm hg based on adult studies where even mild elevation of mPAP between 20-24mm Hg was found to be independent predictor of poor survival.
  • Children with suspected PH should be evaluated, treated and monitored in specialized pediatric centers. The initial evaluation should include a comprehensive medical history, physical examination, assignment to the functional class, assessment of cardiac function by ECG, Echocardiogram. Further testing and advance imaging is guided by the key findings in the history and include but are not limited to cardiac catheterization, HR-Chest CT with angiography, V/Q scan, Sleep study, Blood gas analysis, Lung function test, etc.
  • Some determinants of higher risk in pediatric PH include clinical evidence of RV failure, progressive symptoms, presence of syncope, growth failure, severely elevated Serum NT-proBNP (> 1200 pg/ml (>1 yr. old).
  • Transthoracic Echocardiogram (TTE) cannot establish a definite diagnosis of PH or determine WHO PH group. PH diagnosed by TTE should be confirmed by catheterization before initiation of targeted PH therapy except in infants with PPHN, BPD and those with high risk. We should rely on a multiparametric approach other than single parameters. Echo or CMR variables that are determinants of high risk include evidence of severe RA/RV enlargement, RV systolic dysfunction, RV/LV end systolic ratio of >1.5, TAPSE ¯¯ (Z-score , -3). Systolic/Diastolic ratio > 1.4 (TR jet ), Pulmonary Artery Acceleration Time PAAT < 70ms and  Pericardial effusion.

 

  • Cardiac catheterization is indicated in all pediatric patients with PH to confirm a diagnosis and determine severity, especially when considering pharmacotherapy except in infants and Low body weight or those presenting critically ill where it can be omitted until more stable. The cardiac catheterization should include Acute Vasoreactivity testing. In children with IPAH/HPAH, the hemodynamic change that defines a positive response to AVT in PH without CV shunt is > 20% fall in mPAP and PVR/SVR ratio without a decrease in CI. Invasive hemodynamics that portend high risk include Cardiac Index < 2.5. mRAP> 15, mPAP/mSAP> 0.75, PVRi> 15 Wu-m
  • In centers equipped to perform advanced pediatric cardiac magnetic resonance imaging, CMR without anesthesia /sedation is recommended as a part of diagnostic evaluation and follow up to assess changes in ventricular function and chamber dimensions.
  • Several Pulmonary Arterial Hypertension (PAH) associated genes have been identified and genetic testing can allow the definition of PAH etiology, estimation of prognosis and identification of families at risk. Hence genetic counseling by trained personnel before genetic testing is recommended for families with children diagnosed with Idiopathic PAH or Heritable PAH. Children who are asymptomatic PAH mutation carriers, asymptomatic first-degree relatives of patients with HPAH without an associated gene mutation should be screened by serial echocardiograms every 1-3 yrs. for the presence of elevated RV pressure and undergo additional diagnostic evaluation if clinically indicated.
  • In patients with PAH associated with congenital heart disease a complete diagnostic workup should be performed to determine whether PAH is associated with or causally related to concomitant CHD. Children with simple shunt defects beyond the typical timing of surgery (> 6 months old ) and with severe cyanosis should undergo comprehensive right and left heart catheterization before any intervention or surgery. Standard management is adopted for PVR1< 6 Wu-m2 and PVR/SVR < 0.3. For patients in gray zone PVRi 6-8 Wu -m2 – a treat and repair approach is reasonable using PAH targeted pharmacotherapy with 1-2 medications. A shunt defect must not be closed in when PVRi > 8 Wu- m2 in children.
  • The term and preterm newborn infant with PPHN should receive oxygen, ventilatory support, surfactant with a goal preductal sat of 91-95 %. Inhaled Nitric Oxide is indicated to improve oxygenation and to reduce the need for ECMO if PaO2 < 100 on 100% oxygen or OI index > 25. In the presence of right heart failure preterm and term infants with PPHN should receive PGE infusion to maintain ductal patency in the absence of post tricuspid unrestrictive shunt.
  • In the pediatric ICU, oxygen is administered when the SaO2 < 95% in children with PH and normal anatomy. iNO may be considered for postoperative PH treatment in mechanically ventilated patients to improve oxygenation and reduce PHT crises. Concomitant sildenafil should be administered to prevent rebound PH while weaning iNO. Inhaled iloprost can be as effective as iNO in children with postoperative PH.
  • The diagnosis and management of PH in middle and low-income regions should be done with specialized centers and endemic diseases should be considered in etiology. Schistosomiasis, Rheumatic heart disease, HIV infection, high altitude, chronic hepatitis, etc. should be considered. Treatment should be based on individual case assessment and PAH targeted medications may help especially when pursued at centers specialized in PH.
  • Treatment of PH should be under expert guidance. Supportive therapy with oxygen, Diuretic therapy, anticoagulation should be based on a specific type of PH, CCB should be considered in those patients who are acutely reactive to iNO with or without oxygen. They should be avoided in AVT nonresponders and children with right heart failure regardless of AVT response.

 


Commentary from Dr. Venugopal Amula (Salt Lake City, UT), section editor of Pediatric Cardiology Journal Watch:  To provide a specific, comprehensive, detailed and practical framework for the clinical care of children and young adults with Pulmonary Hypertension, the European Pediatric Pulmonary Vascular Disease Network constituted an executive writing group. The executive writing group members conducted a thorough scientific review and generated tables with graded recommendations based on the European Society of Cardiology/ American Heart Association definitions. They included studies with pediatric data only,  adult studies that included> 10% of children or studies that enrolled adults with CHD. Although the majority of recommendations on pediatric PH are based on the level of evidence B or C,  much effort has been made to obtain pediatric data from registries and clinical studies. A summary of such recommendations is provided below.

 Updated Clinical Classification of Pulmonary Hypertension, WSPH, Nice, 2018

Diagnostic algorithm for a child or young adult with suspected pulmonary hypertension

 Algorithm for management of patients with CHD associated with PAH/Pulmonary Hypertensive Vascular Disease and congenital shunt lesions.

 Treatment algorithm for Pediatric PAH

    

 

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