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Towards optimization of cardiovascular stability in neonates with hypertrophic cardiomyopathy: uniqueness of the neonatal cardiovascular system

Journal of Perinatology volume 41, pages 907–908 (2021)Cite this article

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The rapid improvement in efficacy of oxygenation, with no additional volume or pulmonary vasodilator support, endorses the likelihood of enhanced oxygen delivery after vasopressin administration. This may have been due to reduced PVR or related to increased transductal pressure gradient due to increased SVR:PVR ratio. Regardless of the mechanism, this is an important change due to the positive effect of increased pulmonary blood flow (PBF) on left heart filling. The increase in right ventricular output (Fig. 1B), used as a surrogate for systemic blood flow (SBF) among patients with left-to-right ductal shunt, argues against the author’s suggestion that PBF solely increased at the expense of SBF. We acknowledge our oversight in leaving out the timing of the echocardiography re-evaluation, which was conducted following a median of 10.5 [6, 18] hours. Although HOCM related to maternal diabetes is typically asymptomatic by 1 month of age [4], natural evolution of the disease is unlikely to have occurred over the short time-course in which clinical improvement was noted.

The author’s comments related to rate pressure product (RPP) are very interesting. HR is proportionally related to myocardial oxygen consumption (MVO2). Gobel et al. suggest RPP to be superior in settings whereby HR and SAP are not expected to increase proportionally [5]. They demonstrate that both HR and RPP are positively correlated to MVO2 among adults with ischemic heart disease undergoing exercise testing. Similarly, Verma et al. describe a weak association between change in RPP and death or re-hospitalization of adults with a diagnosis of heart failure with preserved ejection fraction [OR 1.02 (1.01, 1.04), p < 0.001] [6]. Increase in HR was also associated with negative outcome. There is no neonatal literature describing the use of RPP, therefore caution is advised regarding the extrapolation of concepts to neonates whose myocardium is unique in structure, response to loading conditions, and the force frequency relationship. The independent association of HR with MVO2, the intent of the measurement to account for asynchronous increase in SAP with increased HR and the lack of neonatal literature describing the use of RPP limit its applicability to our patients in whom VO2 can be expected to have declined with the reduction in HR observed. In addition, myocardial oxygen supply can be expected to have increased due to normalization of coronary perfusion pressure with the increase in SAP seen following vasopressin use. Finally, the fall in lactate seen in our patients would suggest that myocardial consumption was not excessive.

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Fig. 1: Patient level data.

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Authors and Affiliations

  1. Division of Neonatology, The University of Iowa, Iowa City, IA, USA

    R. E. Giesinger, D. R. Rios & P. J. McNamara

  2. Grace Centre for Newborn Intensive Care, Children’s Hospital at Westmead, Westmead, NSW, Australia

    S. M. Boyd

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  1. R. E. Giesinger
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  2. S. M. Boyd
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Correspondence to P. J. McNamara.

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Giesinger, R.E., Boyd, S.M., Rios, D.R. et al. Towards optimization of cardiovascular stability in neonates with hypertrophic cardiomyopathy: uniqueness of the neonatal cardiovascular system. J Perinatol 41, 907–908 (2021). https://doi.org/10.1038/s41372-021-00926-w

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