Evaluation of Cardiac Manifestations in Neonates With Hypoxic İschemic Encephalopathy Received Therapeutic Hypothermia

Öz

Objective: The aim of this study is to evaluate the severity of cardiac complications of hypoxic ischemic encephalopathy (HIE) according to the degree of hypoxia and to evaluate the efficacy of cardiac biomarkers, electrocardiography (ECG) and echocardiography (ECHO) for myocardial injury.

Material and Methods: Fifty term babies with HIE without any additional disease were selected. Myocardial dysfunction was evaluated using clinical examination, serum CK-MB, troponin-I and ECG and ECHO.

Results: According to Sarnat and Sarnat classificiation, 24 neonates were diagnosed stage II and 26 neonates were diagnosed stage III HIE. Among these 50 cases, 11 (22%) had evidence of myocardiac dysfunction. All the cases had normal sinus rhythm. ECG changes (ST depression, T wave inversion, pathological Q wave as signs of ischemia) were present in 2 (8.3%) cases in the stage II, and 5 (19.8%) cases in the stage HIE group. ECG showed. Serum levels of troponin-I and CK-MB were increased in 30 (60%) patients. Moderate tricuspid regurgitation was present in 5 (10%), severe tricuspid regurgitation in 1 (2%), right ventricular hypokinesia in 4 (8%), left ventricular hypokinesia in 6 (12%) and biventricular hypokinesia in 1 (2%) neonate among all the cases. Enzyme levels were higher, ECG and ECHO abnormalities were more common in the neonates with stage III HIE (p<0.05).

Conclusion: Cardiac involvement is extremely important in terms ofprognosis in the neonates with HIE. Cardiac evaluation and close followup should be performed for the better management of HIE. Cardiac biomarkers, ECG and ECHO are useful in the early recognition and evaluating the severity of myocardial damage in perinatal asphyxia.

Anahtar Kelimeler

• Cardiovascular instability
• Myocardial damage
• Perinatal asphyxia

Terapötik Hipotermi Uygulanan Hipoksik İskemik Ensefalopatili Yenidoğanların Kardiyak Bulgularının Değerlendirilmesi

Öz

Amaç: Terapötik hipotermi tedavisi alan hipoksik iskemik ensefalopatili (HİE) yenidoğanların kardiyak bulgularının; biyobelirteçler, EKG ve ekokardiyografi ile değerlendirilmesi ve bu belirteçlerin hipoksik myokard hasarı şiddetinin belirlenmesindeki etkisinin araştırılması amaçlanmıştır.

Gereç ve Yöntemler: Evre II ve III HİE tanısı alan ve terapötik hipotermi uygulanmış 50 yenidoğan bebeğin verileri retrospektif olarak incelendi. Demografik özellikler, sistemik ve kardiyak muayene bulguları, serum CK-MB, troponin-I, EKG ve ekokardiyografi raporları kaydedildi. Evre II ve Evre III HİE’li hastaların bulguları karşılaştırıldı.

Bulgular: Elli olgunun 11’inde (%22) miyokardiyal disfonksiyon saptandı. EKG kayıtlarında tüm olgular normal sinüs ritmine sahipti. EKG’de patolojik bulgu evre II’de 2 (%8.3) olguda, evre III’de ise 5 (%19.8) olguda mevcuttu. Serum CK-MB ve troponin-I olguların 30’unda (%60) yüksek izlendi. Tüm olguların 5’inde (%10) orta derecede triküspit yetersizliği, 1’inde (%2) şiddetli triküspit yetersizliği, 4’ünde (%8) sağ ventrikül hipokinezisi, 6’sında (%12) sol ventrikül hipokinezi ve 1’inde (%2) biventriküler hipokinezi mevcuttu. Evre III HİE’li olgularda enzim düzeylerinin daha yüksek, EKG ve EKO anormalliklerinin daha yaygın olduğu görüldü (p<0.05).

Sonuç: Hipoksik iskemik ensefalopatili yenidoğanlarda kardiyak etkilenme prognoz açısından son derece önemlidir. Olgularda tedavinin daha iyi yönetilmesi için kardiyak değerlendirme ve yakın takip çok önemlidir. Kardiyak biyobelirteçler, EKG ve EKO perinatal asfikside miyokardiyal hasarın ciddiyetinin erken tanı ve değerlendirilmesinde faydalıdır.

Anahtar Kelimeler

• Perinatal asfiksi
• Miyokardiyal hasar
• Kardiyovasküler insitabilite

Kaynakça

1. 1. Nestaas E, Walsh BH. Hypothermia and Cardiovascular Instability. Clin Perinatol 2020 Sep;47(3):575-592. doi: 10.1016/j.clp.2020.05.012.
2. 2. Habib S, Saini J, Amendoeira S, McNair C. Hemodynamic Instability in Hypoxic Ischemic Encephalopathy: More Than Just Brain Injury-Understanding Physiology, Assessment, and Management. Neonatal Netw 2020; ;39(3):129-136. doi: 10.1891/0730-0832.39.3.129.
3. 3. Kanik E, Ozer EA, Bakiler AR, Aydinlioglu H, Dorak C, Dogrusoz B, et al. Assessment of myocardial dysfunction in neonates with hypoxicischemic encephalopathy: is it a significant predictor of mortality? J Matern Fetal Neonatal Med 2009;22(3):239–242.
4. 4. Popescu MR, Panaitescu AM, Pavel B, Zagrean L, Peltecu G, Zagrean AM. Getting an Early Start in Understanding Perinatal Asphyxia Impact on the Cardiovascular System. Front Pediatr 2020; 26;8:68. doi: 10.3389/fped.2020.00068.
5. 5. Sobeih AA, El-Baz MS, El-Shemy DM, Abu El-Hamed WA. Tissue Doppler imaging versus conventional echocardiography in assessment of cardiac diastolic function in full term neonates with perinatal asphyxia. J Matern Fetal Neonatal Med 2020;6:1-6. doi: 10.1080/14767058.2019.1702640.
6. 6. Executive summary: Neonatal encephalopathy and neurologic outcome, second edition. Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Encephalopathy. Obstet Gynecol 2014;123(4):896-901.
7. 7. Sarnat HB. Neonatal encephalopathy following fetal distress. Arch Neurol 1976;33:696–705.
8. 8. Sadoh WE, Eregie CO, Nwaneri DU, Sadoh AE. The diagnostic value of both troponin T and creatinine kinase isoenzyme (CK-MB) in detecting combined renal and myocardial injuries in asphyxiated infants. PLoS One 2014; 9(3):e91338. doi: 10.1371/journal.pone.0091338.

9. 9. Singh V, Vohra R, Bansal M. Cardiovascular involvement in birth asphyxia. J Clin Neonatol 2018;7:20–24.
10. 10. Rajakumar PS, Vishnu Bhat B, Sridhar MG, Balachander J, Konar BC, Narayanan P, et al. Electrocardiographic and echocardiographic changes in perinatal asphyxia. Indian J Pediatr 2009;76(3):261-4. doi: 10.1007/s12098-008-0221-4.
11. 11. Ökten A, Kamacı R, Mocan H. Hipoksik iskemik ensefalopatili 37 yenidoğanın bir yıllık izlemi ve nörolojik sekel oranları. Çocuk Sağlığı ve Hastalıkları Dergisi 1997;40:61-71. 12. Acunas B, Çeltik C, Garipardıç M, Karasalihoğlu S. Perinatal asfiksili yenidoğanların etyoloji, klinik ve prognoz açısından değerlendirilmesi. Türkiye Klinikleri J. Pediatr 1999; 8: 21-26.
12. 13. Türk Neonatoloji Derneği Hipoksik İskemik Ensefalopati Çalışma Grubu. Türkiye’de yenidoğan yoğun bakım ünitelerinde izlenen hipoksik iskemik ensefalopatili olgular, risk faktörleri, insidans ve kısa dönem prognozları. Çocuk Sağlığı ve Hastalıkları Dergisi 2008;51:123-9.
13. 14. Simovic AM, Prijic SM, Knezevic JB, Igrutinovic ZR, Vujic AJ, Kosutic JL. Predictive value of biochemical, echocardiographic and electrocardiographic markers in nonsurviving and surviving asphyxiated full-term newborns. Turk J Pediatr 2014;56:243–9.
14. 15. Dattilo G, Tulino V, Tulino D, Lamari A, Falanga G, Marte F, et al. Perinatal asphyxia and cardiac abnormalities. Int J Cardiol 2011;147(2):e39–e40.
15. 16. Merchant S, Meshram RM, Khairnar D. Myocardial ischemia in neonate with perinatal asphyxia: electrocardiographic, echocardiographic and enzymatic correlation. Indian J Child Health 2017;4(1):2–6.
16. 17. Shah P, Riphagen S, Beyene J, Perlman M. Multiorgan dysfunction in infants with post-asphyxial hypoxicischaemic encephalopathy. Arch Dis Child Fetal Neonatal Ed 2004;89(2):152–55.
17. 18. Papneja K, Chan AK, Mondal TK, Paes B. Myocardial infarction in neonates: a review of an entity with significant morbidity and mortality. Pediatr Cardiol 2017;38:427–41.
18. 19. Wei Y, Xu J, Xu T, Fan J, Tao S. Left ventriküler systolic function of newborns with asphyxia evaluated by tissue dopler imaging. Pediatr Cardiol 2009;30:741-46.
19. 20. Matter M, Abdel-Hady H, Attia G, Hafez M, Seliem W, Al-Arman M. Myocardial performance in asphyxiated full-term infants assessed by Doppler tissue imaging. Pediatr Cardiol 2010;31:634–42.
20. 21. Teixeira RP, Neves AL, Guimarães H. Cardiac biomarkers in neonatology: BNP/NTproBNP, troponin I/T, CK-MB and myoglobin–a systematic review. JPNIM 2017;6:e06021.
21. 22. Bhasin H, Kohli C. Myocardial dysfunction as a predictor of the severity and mortality of hypoxic ischaemic encephalopathy in severe perinatal asphyxia: a case-control study. Paediatr Int Child Health 2019;39(4):259-64. doi: 10.1080/20469047.2019.1581462.
22. 23. Mandal Ravi RN, Ruchi Gupta, Kapoor AK. Evaluation of activity of creatine Phosphokinase (CPK) and its Isoenzyme CPK-MB in perinatal asphyxia and its implications for myocardial involvement. Bull NNF 1999;13:2-7.
23. 24. Herdy GV, Lopes VG, Aragão ML, Pinto CA, Tavares Júnior PA, Azeredo FB, et al. Perinatal asphyxia and heart problems. Arq Bras Cardiol 1998;71:121-26.
24. 25. Gunes T, Ozturk MA, Koklu SM, Narin N, Koklu E. Troponin-T levels in perinatally asphyxiated infants during the first 15 days of life. Acta Paediatr 2005;94:1638–43.
25. 26. Montaldo P, Cuccaro P, Caredda E, Pugliese U, De Vivo M, Orbinato F, et al. Electrocardiographic and echocardiographic changes during therapeutic hypothermia in encephalopathic infants with long-term adverse outcome. Resuscitation 2018;130:99-104. doi: 10.1016/j.resuscitation.2018.07.014.
26. 27. Turker G, Babaoglu K, Gokalp AS, Sarpen N, Zengin E, Arisoy AE. Cord Blood Cardiac Troponin I as an Early Predictor of Short-Term Outcome in Perinatal Hypoxia. Biology of the Neonate 2004; 86:131-37.
27. 28. Joseph S, Kumar S, Ahamed MZ, Lakshmi S. Cardiac troponin-T as a marker of myocardial dysfunction in term neonates with perinatal asphyxia. Indian J Pediatr 2018;85:877–84.
28. 29. Szymankiewicz M, Matuszczak-Wleklak M, Hodgman JE, Gadzinowski J. Usefulness of cardiac troponin T and echocardiography in the diagnosis of hypoxic myocardial injury of full-term neonates. Biol Neonate 2005;88:19–23.
29. 30. Yildirim A, Ozgen F, Ucar B, Alatas O, Tekin N, Kilic Z. The Diagnostic Value of Troponin T Level in the Determination of Cardiac Damage in Perinatal Asphyxia Newborns. Fetal Pediatr Pathol 2016;35(1):29-36. doi: 10.3109/15513815.2015.1122128.
30. 31. Barberi I, Calabro MP, Cordaro S, Gitto E, Sottile A, Prudente D, et al. Myocardial ischaemia in neonates with perinatal asphyxia: electrographic, echocardiographic and enzymatic correlations. Eur J Pediatr 1999;158:742–747.
31. 32. Perlman JM. Intrapartum hypoxic-ischemic cerebral injury and subsequent cerebral palsy: medicolegal issues. Pediatrics 1997;99(6):851–59.
32. 33. Martin-Ancel A, Garcia-Alix A, GayaÁ F, Cabanas F, Burgu- eros M, Quero J. Multiple organ involvement in perinatal asphyxia. J Pediatr 1995;127:786-93.
33. 34. Flores-Nava G, Echevarría-Ybargüengoitia JL, Navarro- Barrón JL, García-Alonso A. Transient myocardial ischemia in newborn babies with perinatal asphyxia (hypoxic cardiomyopathy). Biol Med Hosp Infant Mex 1990;47:809-14.