Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego.
Division of Pediatric Cardiac Surgery (S.G., J.N.), Rady Children's Hospital/University of California, San Diego.
Circ Cardiovasc Interv. 2022 May;15(5):e011664. doi: 10.1161/CIRCINTERVENTIONS.121.011664. Epub 2022 Apr 29.
Neonatal myocardial infarction is rare and is associated with a high mortality of 40% to 50%. We report our experience with neonatal myocardial infarction, including presentation, management, outcomes, and our current patient management algorithm.
We reviewed all infants admitted with a diagnosis of coronary artery thrombosis, coronary ischemia, or myocardial infarction between January 2015 and May 2021.
We identified 21 patients (median age, 1 [interquartile range (IQR), 0.25-9.00] day; weight, 3.2 [IQR, 2.9-3.7] kg). Presentation included respiratory distress (16), shock (3), and murmur (2). Regional wall motion abnormalities by echocardiogram were a key criterion for diagnosis and were present in all 21 with varying degrees of depressed left ventricular function (severe [8], moderate [6], mild [2], and low normal [5]). Ejection fraction ranged from 20% to 54% (median, 43% [IQR, 34%-51%]). Mitral regurgitation was present in 19 (90%), left atrial dilation in 15 (71%), and pulmonary hypertension in 18 (86%). ECG was abnormal in 19 (90%). Median troponin I was 0.18 (IQR, 0.12-0.56) ng/mL. Median BNP (B-type natriuretic peptide) was 2100 (IQR, 924-2325) pg/mL. Seventeen had documented coronary thrombosis by cardiac catheterization. Seventeen (81%) were treated with intracoronary tPA (tissue-type plasminogen activator) followed by systemic heparin, AT (antithrombin), and intravenous nitroglycerin, and 4 (19%) were treated with systemic heparin, AT, and intravenous nitroglycerin alone. Nineteen of 21 recovered. One died (also had infradiaphragmatic total anomalous pulmonary venous return). One patient required a ventricular assist device and later underwent heart transplant; this patient was diagnosed late at 5 weeks of age and did not respond to tPA. Nineteen of 21 (90%) regained normal left ventricular function (ejection fraction, 60%-74%; mean, 65% [IQR, 61%-67%]) at latest follow-up (median, 6.8 [IQR, 3.58-14.72] months). Two of 21 (10%) had residual trivial mitral regurgitation. After analysis of these results, we present our current algorithm, which developed and matured over time, to manage neonatal myocardial infarction.
We experienced a lower mortality rate for infants with neonatal infarction than that reported in the literature. We propose a post hoc algorithm that may lead to improvement in patient outcomes following coronary artery thrombus.
新生儿心肌梗死很少见，死亡率高达 40%至 50%。我们报告了我们在新生儿心肌梗死方面的经验，包括临床表现、治疗、结局以及我们目前的患者管理算法。
我们回顾了 2015 年 1 月至 2021 年 5 月期间所有被诊断为冠状动脉血栓形成、冠状动脉缺血或心肌梗死的婴儿的病历。
我们共发现 21 例患者（中位年龄 1 天[四分位距（IQR），0.25-9.00]；体重 3.2kg[IQR，2.9-3.7]）。临床表现包括呼吸窘迫（16 例）、休克（3 例）和杂音（2 例）。超声心动图显示的区域性壁运动异常是诊断的关键标准，21 例患者均存在不同程度的左心室功能抑制（严重[8]、中度[6]、轻度[2]和低正常[5]）。射血分数范围为 20%至 54%（中位数，43%[IQR，34%-51%]）。19 例（90%）存在二尖瓣反流，15 例（71%）存在左心房扩张，18 例（86%）存在肺动脉高压。19 例（90%）心电图异常。中位肌钙蛋白 I 为 0.18ng/mL（IQR，0.12-0.56）。中位 BNP（B 型利钠肽）为 2100pg/mL（IQR，924-2325）。17 例经心导管检查证实存在冠状动脉血栓形成。17 例（81%）接受了冠状动脉内 tPA（组织型纤溶酶原激活物）治疗，随后给予全身肝素、AT（抗凝血酶）和静脉硝酸甘油治疗，4 例（19%）仅接受全身肝素、AT 和静脉硝酸甘油治疗。21 例中有 19 例恢复。1 例死亡（还伴有膈下完全性肺静脉异常回流）。1 例患者需要心室辅助装置，随后进行了心脏移植；该患者在 5 周龄时被诊断为晚期，对 tPA 无反应。21 例中有 19 例（90%）在最近的随访中恢复了正常的左心室功能（射血分数 60%-74%；平均值 65%[IQR，61%-67%]）。21 例中有 2 例（10%）存在残余的轻度二尖瓣反流。在对这些结果进行分析后，我们提出了目前的算法，该算法在不断发展和完善，以管理新生儿心肌梗死。
与文献报道相比，我们发现新生儿梗死患儿的死亡率较低。我们提出了一种事后算法，可能会改善冠状动脉血栓形成后患者的结局。
