Bidirectional Ductal Shunting and Preductal to Postductal Oxygenation Gradient in Persistent Pulmonary Hypertension of the Newborn

Abstract

Background: The aim was to evaluate the relationship between the direction of the patent ductus arteriosus (PDA) shunt and the pre- and postductal gradient for arterial blood gas (ABG) parameters in a lamb model of meconium aspiration syndrome (MAS) with persistent pulmonary hypertension of the newborn (PPHN). Methods: PPHN was induced by intermittent umbilical cord occlusion and the aspiration of meconium through the tracheal tube. After delivery, 13 lambs were ventilated and simultaneous 129 pairs of pre- and postductal ABG were drawn (right carotid and umbilical artery, respectively) while recording the PDA and the carotid and pulmonary blood flow. Results: Meconium aspiration resulted in hypoxemia. The bidirectional ductal shunt had a lower postductal partial arterial oxygen tension ([PaO2] with lower PaO2/FiO2 ratio—97 ± 36 vs. 130 ± 65 mmHg) and left pulmonary flow (81 ± 52 vs. 133 ± 82 mL/kg/min). However, 56% of the samples with a bidirectional shunt had a pre- and postductal saturation gradient of < 3%. Conclusions: The presence of a bidirectional ductal shunt is associated with hypoxemia and low pulmonary blood flow. The absence of a pre- and postductal saturation difference is frequently observed with bidirectional right-to-left shunting through the PDA, and does not exclude a diagnosis of PPHN in this model.

Respiratory Support: How not to Harm Hemodynamics?

“…Венозная кровь из верхней полой вены (ВПВ) проходит через артериальный проток и кровоснабжает нижнюю половину тела, включая плаценту [2]. Важно отметить, что быстрое снижение ЛСС и шунтирования «справа налево» через открытый артериальный проток после рождения являются ключевыми элементами, которые делают легкие основным местом газообмена у доношенных детей [4]. Транзиторный период включает в себя серьезные изменения в нагрузке на сердце и направлении кровотока, что подвергает наиболее уязвимую когорту пациентов (глубоко недоношенные новорожденные, младенцы с врожденными пороками сердца и легких) высокому риску развития нарушений кровообращения.…”

Neonatal and Postneonatal Pulmonary Hypertension

“…Secondary to shunting across the PDA, many of these infants present with differential cyanosis with higher SpO 2 in the preductal regions (right hand) compared to postductal (any foot). In a lamb model of asphyxia, MAS and PH, Lesneski et al demonstrate an association between the presence of a preductal to postductal SpO 2 gradient of ≥3% with a higher proportion (89%) of samples associated with bidirectional shunting at PDA [ 5 ]. More importantly, low preductal to postductal SpO 2 gradient (<3%) was still associated with bidirectional shunting at PDA in 56% of samples.…”