الفهرس 
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Abstract
T
he transition from fetal life to extra–uterine life is a highly complicated physiological process as, the hemodynamic changes after the first few breaths are probably the most significant adaptation in the human life. Physiological transition is accomplished by DROP in PVR after expansion of lungs. Persistent pulmonary hypertension of the newborn (PPHN) is characterized by elevated pulmonary vascular resistance resulting in right-to-left shunting of blood and hypoxemia.
Hemodynamics can be defined as the dynamics of blood flow in the body. The main goals of hemodynamic monitoring are to alert the health‐care team about systemic performances that may affect the treatment.
A bedside echocardiography can provide information about real-time hemodynamic function by assessing cardiac function, loading conditions (preload and afterload) and cardiac output, hence real–time functional echocardiography is considered to be an ideal tool for monitoring hemodynamic assessment in neonates and children.
Cerebral pulsatility index (CPI) is used as a surrogate marker of distal cerebrovascular resistance. Technique of Transcranial Doppler (TCD) can be used for estimation of pulsatility index (PI) that is correlated with changes at distal cerebrovascular resistance (CVR). So, the relationship between PI and CVR should be monitored as a part of basic hemodynamic assessment.
The aim of this study is to correlate between the hemodynamic assessment of neonates with Pulmonary Hypertension depending on bedside echocardiography and concomitant assessment of Cerebral Pulsatility index as a marker of change in cerebral blood flow using Trans-cranial Doppler among this group of patients compared to control.
The study population included 108 neonates; 54 patients represent the patients group with PPHN which was subdivided according to severity grading into: mild, moderate and severe compared to 54 age and sex–matched control group.
All data from patients and control groups were collected in pre-structured questionnaire to fulfill the following: Full medical history, clinical examination that includes: estimation of gestational age using new ballard score, measurement of birth weight, assessment of respiratory distress using Downes’ score. Measurement of vital data including heart rate, systolic, diastolic and mean blood pressure. Assessment of oxygenation status by pre-ductal and post-ductal pulse oximetry readings, with measurement of urine output,
Laboratory investigations include Complete blood count with differential count, C- reactive protein (Quantitative measurement), capillary blood gases, blood culture and Prothrombin time–partial thromboplastin time. Radiological investigations include chest x – ray are done to assess the presence of pneumonic patches and to assess the heart size.
All patients were evaluated with two-dimensional and color Doppler echocardiography with multiple sub-costal, Apical and Supra-sternal windows for exclusion of congenital heart disease and hemodynamic assessment of pulmonary hypertension. It was done on 3rd, 7th days of life and pre – discharge. Trans - cranial ultrasound and Doppler was done in the same days of echocardiography to measure CPI of the MCA.
There was no statistically significant difference found between cases and control groups regarding gender, BSA, antenatal risk factors.
In our study, patients of the cases group had significantly lower platelets count, higher total leucocytic count and higher CRP together with higher number of positive blood culture.
Patients with PPHN were subdivided into mild (33.3%), moderate (27.8%) and severe (38.9%) according to measurement of pulmonary artery pressure.
Trans–thoracic echocardiography was used for assessment of pre-load and Fluid responsiveness by examining: Variation in left ventricular outflow tract Velocity Time Integral (VTI), Inferior Vena Cava (IVC) Collapsibility Index (IVCCI) and Inferior Vena Cava (IVC) Distensibility Index (IVCDI).
We have found that cases group had statistical significant increase in IVCDI at 3rd day, 7th day and pre – discharge day when compared with control group. While, there was no significant difference regarding the LV VTI and IVCCI between cases and control groups
Assessment of parameters of LV function was done by measurement of Fraction Shortening (FS), Ejection Fraction (EF). we found that there was no statistical significant difference between cases and control groups as regards FS at 3rd, 7th and pre – discharge days
Also, assessment of right ventricle function was done by estimation of pulmonary artery pressure (PAP), assessment of ductal and atrial Shunts, assessment of inter–Ventricular Septum (IVS) & LV shape, Tricuspid Annular Plane Systolic Excursion (TAPSE) with assessment of the tricuspid valve inflow velocities (Early (E), Late (A), and ratio (E/A)) during diastole by TDI.
This study showed that cases group had statistical significant decrease of TVI values of Septal and lateral TV leaflets at 3rd and 7th days when compared to control group associated with statistical significant increase in RV: LV ratio diameter values at 3rd, 7th and pre-discharge days when compared with control group also Cases group had statistical significant increase in TAPSE values at 3rd, 7th days when compared with control group
Assessment of Cardiac Output which includes Left Ventricle, Right Ventricle and Superior Vena Cava blood flow assessment.
The current study results showed that cases group had statistical significant decrease in LV and RV output at 3rd and 7th days when compared to control groups associated with statistical significant lower SVC outflow at 3rd and 7th days.
Our results also showed that there was significant increase in CPI in cases group compared with control group at 3rd, 7th and pre-discharge days. There was no statistically significant correlation between CPI and IVCCI, IVCDI, PASP, RV output and SVC outflow at 3rd day while, there was statistically significant negative correlation between CPI and IVCCI, RV output and SVC outflow at 7th day while no statistically significant correlation was found with IVCDI and PASP and at pre-discharge day there was statistically significant negative correlation found between CPI and SVC outflow; while no statistically significant correlation found with IVCCI, IVCDI, PASP and RV output changes.
Our results showed that IVH was detected in 36 cases (66.7%); with Grade I (58.3%), Grade II (27.8%), Grade III (2.8 %) and Grade IV (11.1%). 72.2% were ventilated. 53.7% needed conventional MV while 16.7 % needed HFOV with duration of MV ranging from 1.5–11 days. While, duration of NICU admission among cases group ranged from 6 up to 32 days. 64.8 % were discharged and 35.2 % died.