Systemic Arterial Blood Pressure Targets and Extracorporeal Membrane Oxygenation or Death in Persistent Pulmonary Hypertension of Newborns: A Cohort Analysis

Introduction: Persistent pulmonary hypertension of the newborn (PPHN) is a life-threatening condition requiring intensive cardiopulmonary support. The optimal systemic blood pressure target in this population remains unknown. We evaluated the association between clinician-selected mean arterial pressure (MAP) targets and in-hospital outcomes in infants with PPHN. Methods: We conducted a retrospective cohort study of infants ≥35 weeks’ gestation with PPHN treated with inhaled nitric oxide (iNO) who had a clinician-documented MAP target within the first 48 hours of age. Infants were classified as having a MAP target <50 mmHg or ≥50 mmHg. The primary outcome was the composite of extracorporeal membrane oxygenation (ECMO) and/or death. Results: Among 109 infants, 82 (75%) were in the MAP target group < 50 mmHg and 27 (25%) were in the ≥ 50 mmHg MAP target group. Compared with a < 50 mmHg MAP target, a ≥ 50 mmHg MAP target was associated with higher rates of ECMO cannulation (33% vs 11%, p=0.01) and ECMO/death (48% vs 20%, p<0.01). Use of epinephrine and hydrocortisone, use of more than two vasoactive agents, and the vasoactive-inotropic score were also higher in the ≥ 50 mmHg MAP target group. After adjustment for HIE, pneumothorax, and initial oxygenation index, the ≥ 50 mmHg MAP target remained associated with ECMO cannulation (aOR 4.8; 95% CI 1.6, 15.0) and ECMO/death (aOR 5.9; 95% CI 2.0, 17.3). Conclusion: Among neonates treated with iNO for PPHN, clinician-selected MAP targets ≥ 50 mmHg were independently associated with ECMO cannulation and ECMO/death. Randomized trials are needed to define safe MAP targets in PPHN.